Cost Effectiveness of On-site versus Off-site Depression Collaborative Care in Rural Federally Qualified Health Centers

PubMed Central

Pyne, Jeffrey M.; Fortney, John C.; Mouden, Sip; Lu, Liya; Hudson, Teresa J; Mittal, Dinesh

2018-01-01

Objective Collaborative care for depression is effective and cost-effective in primary care settings. However, there is minimal evidence to inform the choice of on-site versus off-site models. This study examined the cost-effectiveness of on-site practice-based collaborative care (PBCC) versus off-site telemedicine-based collaborative care (TBCC) for depression in Federally Qualified Health Centers (FQHCs). Methods Multi-site randomized pragmatic comparative cost-effectiveness trial. 19,285 patients were screened for depression, 14.8% (n=2,863) screened positive (PHQ9 ≥10) and 364 were enrolled. Telephone interview data were collected at baseline, 6-, 12-, and 18-months. Base case analysis used Arkansas FQHC healthcare costs and secondary analysis used national cost estimates. Effectiveness measures were depression-free days and quality-adjusted life years (QALYs) derived from depression-free days, Medical Outcomes Study SF-12, and Quality of Well Being scale (QWB). Nonparametric bootstrap with replacement methods were used to generate an empirical joint distribution of incremental costs and QALYs and acceptability curves. Results Mean base case FQHC incremental cost-effectiveness ratio (ICER) using depression-free days was $10.78/depression-free day. Mean base case ICERs using QALYs ranged from $14,754/QALY (depression-free day QALY) to $37,261/QALY (QWB QALY). Mean secondary national ICER using depression-free days was $8.43/depression-free day and using QALYs ranged from $11,532/QALY (depression-free day QALY) to $29,234/QALY (QWB QALY). Conclusions These results support the cost-effectiveness of the TBCC intervention in medically underserved primary care settings. Results can inform the decision about whether to insource (make) or outsource (buy) depression care management in the FQHC setting within the current context of Patient-Centered Medical Home, value-based purchasing, and potential bundled payments for depression care. The www.clinicaltrials.gov # for this study is NCT00439452. PMID:25686811

Toddlers' and Preschoolers' Experience in Family Day Care: Age Differences and Behavioral Correlates

ERIC Educational Resources Information Center

Kryzer, Erin M.; Kovan, Nikki; Phillips, Deborah A.; Domagall, Lindsey A.; Gunnar, Megan R.

2007-01-01

One hundred and twelve children, 56 toddlers and 56 preschoolers, were observed in their family child care settings to determine whether toddlers cared for in settings that also included preschoolers were, relative to the preschoolers, receiving more or less high-quality care and/or whether their functioning at child care appeared to be more or…

Caring Spaces, Learning Places: Children's Environments That Work.

ERIC Educational Resources Information Center

Greenman, Jim

This book is intended as a resource for those who create, adapt, and cope with settings for young children. It focuses particularly on all-day child care settings. Part 1, "Understanding Children's Settings," explores the power of the environment, or the "landscape" of children's lives--the array of settings they inhabit--and analyzes the…

Length of day-care attendance and attachment behavior in eighteen-month-old infants.

PubMed

Schwartz, P

1983-08-01

Differences in the attachment behavior of 18-month-old full-time, part-time, and non-day-care infants from intact middle-class homes were compared. Mothers of the day-care infants had made arrangements to return to work before their infants' birth, and all the infants had been placed in day-care homes before 9 months of age. The study involved 2 sessions: a home observation and the strange-situation procedure in a laboratory setting. The home-observation and rating scale scores of maternal behaviors directed at the child yielded few group differences. More full-time day-care children (but not part-time children) were found to display avoidance of the mother during the final reunion episode of the strange-situation procedure than did non-day-care children. The length of the daily separation appears to be an important determinant of day-care effects on infant-mother attachment.

Shared decision-making for people living with dementia in extended care settings: a systematic review

PubMed Central

Bunn, Frances; Goodman, Claire

2018-01-01

Background Shared decision-making is recognised as an important element of person-centred dementia care. Objectives The aim of this review was to explore how people living with dementia and cognitive impairment can be included in day-to-day decisions about their health and care in extended care settings. Design A systematic review including primary research relating to shared decision-making, with cognitively impaired adults in (or transferrable to) extended care settings. Databases searched were: CINAHL, PubMed, the Cochrane Library, NICE Evidence, OpenGrey, Autism Data, Google Scholar, Scopus and Medicines Complete (June to October 2016 and updated 2018) for studies published in the last 20 years. Results Of the 19 included studies 15 involved people with living dementia, seven in extended care settings. People living with cognitive impairment often have the desire and ability to participate in decision-making about their everyday care, although this is regularly underestimated by their staff and family care partners. Shared decision-making has the potential to improve quality of life for both the person living with dementia and those who support them. How resources to support shared decision-making are implemented in extended care settings is less well understood. Conclusions Evidence suggests that people living with cognitive impairment value opportunities to be involved in everyday decision-making about their care. How these opportunities are created, understood, supported and sustained in extended care settings remains to be determined. Trial registration number CRD42016035919 PMID:29886439

Health Update: CMV and Child Care Prgrams.

ERIC Educational Resources Information Center

Aronson, Susan S.

1988-01-01

Discusses appropriate steps to be taken in a day care setting to minimize the known risks associated with cytomegalovirus (CMV). Explains what CMV is; why people should worry about CMV; how it is spread; and how it can be treated and prevented. Suggests a number of hygiene practices for use in day care centers. (RWB)

[Setting up of a day group service system for severely disabled children, the "Koala Club"].

PubMed

Ozawa, Hiroshi; Kubota, Masaya; Tanaka, Yoshiko; Atsumi, So; Arimoto, Kiyoshi; Kimiya, Satoshi

2006-01-01

This is a report of the setting up of a day group service system for severely disabled children, the "Koala Club". The "Koala Club" was started in 1993, and has been running outside of the hospital since 1997. A support group for the "Koala Club" was established in 1999. Currently 13 children attend the "Koala Club". The staff of the "Koala Club" consists of one coordinater, four nurses and eight care workers. The medical care is fulfilled by nurses. The "Koala Club" open two days a week. It has been supervised by a doctor and a case worker. There is an important role for physicians in the regional care of disabled children.

CTEPP-OH DATA COLLECTED ON FORM 01: RECRUITMENT SURVEY FOR DAY CARE CENTER SAMPLE SUBJECTS

EPA Science Inventory

This data set contains data for CTEPP-OH concerning the eligiblity of preschool children who attended day care during the day and were recruited them into the study.

The Children’s Total Exposure to Persistent Pesticides and Other Persistent Pollutant (CTEPP) study was one of...

CTEPP NC DATA COLLECTED ON FORM 01: RECRUITMENT SURVEY FOR DAY CARE CENTER SAMPLE SUBJECTS

EPA Science Inventory

This data set contains data concerning the eligiblity of preschool children who attended day care during the day and were recruited them into the study.

The Children’s Total Exposure to Persistent Pesticides and Other Persistent Pollutant (CTEPP) study was one of the largest ...

Integrating Behavioral Psychology Services into Adult Day Programming for Individuals with Dementia

ERIC Educational Resources Information Center

LeBlanc, Linda A.

2010-01-01

Many individuals with dementia and problem behavior are served in nursing home settings long before health issues necessitate constant medical care. Alternative community-based adult day health care programs allow individuals with dementia to remain in their home with their families at a substantially reduced cost; however, many adult day programs…

Motor and Cognitive Functional Status Are Associated with 30-day Unplanned Rehospitalization Following Post-Acute Care in Medicare Fee-for-Service Beneficiaries.

PubMed

Middleton, Addie; Graham, James E; Lin, Yu-Li; Goodwin, James S; Bettger, Janet Prvu; Deutsch, Anne; Ottenbacher, Kenneth J

2016-12-01

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood. To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care. This was a retrospective cohort study. Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013. Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406). Not applicable. Thirty-day unplanned rehospitalization following post-acute rehabilitation. The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %). The functional domains identified in the IMPACT Act were associated with 30-day unplanned rehospitalization following post-acute care in this large national sample. Further research is needed to better understand and improve the functional measures, and to determine if their association with rehospitalizations varies across post-acute settings, patient populations, or episodes of care.

Shared decision-making for people living with dementia in extended care settings: a systematic review.

PubMed

Daly, Rachel Louise; Bunn, Frances; Goodman, Claire

2018-06-09

Shared decision-making is recognised as an important element of person-centred dementia care. The aim of this review was to explore how people living with dementia and cognitive impairment can be included in day-to-day decisions about their health and care in extended care settings. A systematic review including primary research relating to shared decision-making, with cognitively impaired adults in (or transferrable to) extended care settings. Databases searched were: CINAHL, PubMed, the Cochrane Library, NICE Evidence, OpenGrey, Autism Data, Google Scholar, Scopus and Medicines Complete (June to October 2016 and updated 2018) for studies published in the last 20 years. Of the 19 included studies 15 involved people with living dementia, seven in extended care settings. People living with cognitive impairment often have the desire and ability to participate in decision-making about their everyday care, although this is regularly underestimated by their staff and family care partners. Shared decision-making has the potential to improve quality of life for both the person living with dementia and those who support them. How resources to support shared decision-making are implemented in extended care settings is less well understood. Evidence suggests that people living with cognitive impairment value opportunities to be involved in everyday decision-making about their care. How these opportunities are created, understood, supported and sustained in extended care settings remains to be determined. CRD42016035919. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Constructing a Measure of Private-pay Nursing Home Days.

PubMed

Thomas, Kali S; Silver, Benjamin; Gozalo, Pedro L; Dosa, David; Grabowski, David C; Makineni, Rajesh; Mor, Vincent

2018-05-01

Nursing home (NH) care is financed through multiple sources. Although Medicaid is the predominant payer for NH care, over 20% of residents pay out-of-pocket for their care. Despite this large percentage, an accepted measure of private-pay NH occupancy has not been established and little is known about the types of facilities and the long-term care markets that cater to this population. To describe 2 novel measures of private-pay utilization in the NH setting, including the proportion of privately financed residents and resident days, and examine their construct validity. Retrospective descriptive analysis of US NHs in 2007-2009. We used Medicare claims, Medicare Enrollment records, and the Minimum Data Set to create measures of private-pay resident prevalence and proportion of privately financed NH days. We compared our estimates of private-pay utilization to payer data collected in the NH annual certification survey and evaluated the relationships of our measures with facility characteristics. Our measures of private-pay resident prevalence and private-pay days are highly correlated (r=0.83, P<0.001 and r=0.83, P<0.001, respectively) with the rate of "other payer" reported in the annual certification survey. We also observed a significantly higher proportion of private-pay residents and days in higher quality facilities. This new methodology provides estimates of private-pay resident prevalence and resident days. These measures were correlated with estimates using other data sources and validated against measures of facility quality. These data set the stage for additional work to examine questions related to NH payment, quality of care, and responses to changes in the long-term care market.

Overcoming roadblocks: current and emerging reimbursement strategies for integrated mental health services in primary care.

PubMed

O'Donnell, Allison N; Williams, Mark; Kilbourne, Amy M

2013-12-01

The Chronic Care Model (CCM) has been shown to improve medical and psychiatric outcomes for persons with mental disorders in primary care settings, and has been proposed as a model to integrate mental health care in the patient-centered medical home under healthcare reform. However, the CCM has not been widely implemented in primary care settings, primarily because of a lack of a comprehensive reimbursement strategy to compensate providers for day-to-day provision of its core components, including care management and provider decision support. Drawing upon the existing literature and regulatory guidelines, we provide a critical analysis of challenges and opportunities in reimbursing CCM components under the current fee-for-service system, and describe an emerging financial model involving bundled payments to support core CCM components to integrate mental health treatment into primary care settings. Ultimately, for the CCM to be used and sustained over time to integrate physical and mental health care, effective reimbursement models will need to be negotiated across payers and providers. Such payments should provide sufficient support for primary care providers to implement practice redesigns around core CCM components, including care management, measurement-based care, and mental health specialist consultation.

Curriculum Guide for Day Care Primary.

ERIC Educational Resources Information Center

Radke, Mary Ann

This curriculum, designed for severely retarded children in a primary day care setting, is divided into three sections: (1) Awareness of Body Parts, (2) Gross Motor Skills, and (3) Language Arts. Detailed activities are suggested to develop and reinforce various gross motor coordinations and learning skills. (CS)

The Effects on Children of the Organization and the Design of the Day Care Physical Environment: Appropriateness of the Federal Inter-Agency Day Care Requirements. Final Report.

ERIC Educational Resources Information Center

Kruvant, Charito; And Others

This paper presents a discussion of the impact of the physical design of day care settings on children and adults. Specifically addressed is the question of how the location and design of the facility, the arrangement of indoor and outdoor space, and the organization of the furniture and materials affect the behavior of the adults and children who…

Poststroke Rehabilitation and Restorative Care Utilization: A Comparison Between VA Community Living Centers and VA-contracted Community Nursing Homes.

PubMed

Jia, Huanguang; Pei, Qinglin; Sullivan, Charles T; Cowper Ripley, Diane C; Wu, Samuel S; Bates, Barbara E; Vogel, W Bruce; Bidelspach, Douglas E; Wang, Xinping; Hoffman, Nannette

2016-03-01

Effective poststroke rehabilitation care can speed patient recovery and minimize patient functional disabilities. Veterans affairs (VA) community living centers (CLCs) and VA-contracted community nursing homes (CNHs) are the 2 major sources of institutional long-term care for Veterans with stroke receiving care under VA auspices. This study compares rehabilitation therapy and restorative nursing care among Veterans residing in VA CLCs versus those Veterans in VA-contracted CNHs. Retrospective observational. All Veterans diagnosed with stroke, newly admitted to the CLCs or CNHs during the study period who completed at least 2 Minimum Data Set assessments postadmission. The outcomes were numbers of days for rehabilitation therapy and restorative nursing care received by the Veterans during their stays in CLCs or CNHs as documented in the Minimum Data Set databases. For rehabilitation therapy, the CLC Veterans had lower user rates (75.2% vs. 76.4%, P=0.078) and fewer observed therapy days (4.9 vs. 6.4, P<0.001) than CNH Veterans. However, the CLC Veterans had higher adjusted odds for therapy (odds ratio=1.16, P=0.033), although they had fewer average therapy days (coefficient=-1.53±0.11, P<0.001). For restorative nursing care, CLC Veterans had higher user rates (33.5% vs. 30.6%, P<0.001), more observed average care days (9.4 vs. 5.9, P<0.001), higher adjusted odds (odds ratio=2.28, P<0.001), and more adjusted days for restorative nursing care (coefficient=5.48±0.37, P<0.001). Compared with their counterparts at VA-contracted CNHs, Veterans at VA CLCs had fewer average rehabilitation therapy days (both unadjusted and adjusted), but they were significantly more likely to receive restorative nursing care both before and after risk adjustment.

Expert Consensus on Metrics to Assess the Impact of Patient-Level Antimicrobial Stewardship Interventions in Acute-Care Settings

PubMed Central

Anderson, Deverick J.; Cochran, Ronda L.; Hicks, Lauri A.; Srinivasan, Arjun; Dodds Ashley, Elizabeth S.

2017-01-01

Antimicrobial stewardship programs (ASPs) positively impact patient care, but metrics to assess ASP impact are poorly defined. We used a modified Delphi approach to select relevant metrics for assessing patient-level interventions in acute-care settings for the purposes of internal program decision making. An expert panel rated 90 candidate metrics on a 9-point Likert scale for association with 4 criteria: improved antimicrobial prescribing, improved patient care, utility in targeting stewardship efforts, and feasibility in hospitals with electronic health records. Experts further refined, added, or removed metrics during structured teleconferences and re-rated the retained metrics. Six metrics were rated >6 in all criteria: 2 measures of Clostridium difficile incidence, incidence of drug-resistant pathogens, days of therapy over admissions, days of therapy over patient days, and redundant therapy events. Fourteen metrics rated >6 in all criteria except feasibility were identified as targets for future development. PMID:27927866

Updated recommendations for isolation of persons with mumps.

PubMed

2008-10-10

Mumps, an acute vaccine-preventable viral illness transmitted by respiratory droplets and saliva, has an incubation period most commonly of 16-18 days. The classic clinical presentation of mumps is parotitis, which can be preceded by several days of nonspecific prodromal symptoms; however, mumps also can be asymptomatic, especially in young children. Mumps transmission can occur from persons with subclinical or clinical infections and during the prodromal or symptomatic phases of illness. In 2006, during a mumps resurgence in the United States, the latest national recommendations from CDC and the American Academy of Pediatrics (AAP) stipulated that persons with mumps be maintained in isolation with standard precautions and droplet precautions for 9 days after onset of parotitis. However, the existence of conflicting guidance (i.e., that the infectious period of mumps extended through the fourth day after parotitis onset) led to confusion regarding the appropriate length of isolation. In addition, during the 2006 resurgence, compliance with recommendations for isolation in university settings was substantially lower for 9 days (65%) compared with 4-5 days (86%). In 2007, after a review of the evidence supporting the 9-day isolation guidance by AAP and CDC, AAP changed its isolation guidance for health-care workers in ambulatory settings from 9 days to 5 days. In February 2008, after review of data on mumps in health-care settings, mumps viral load, and mumps virus isolation, the Healthcare Infection Control Practices Advisory Committee (HICPAC) approved changes in its recommendations related to mumps in in-patient settings. As a result, CDC, AAP, and HICPAC all now recommend a 5-day period after onset of parotitis, both for isolation of persons with mumps in either community or health-care settings and for use of standard precautions and droplet precautions. This report summarizes the scientific basis for these changes in mumps isolation guidance.

KSC volunteers help paint Baxley Manor as part of Days of Caring '99

NASA Technical Reports Server (NTRS)

1999-01-01

Volunteers for Days of Caring '99 set up the paint trays for painting at Baxley Manor, an apartment building for senior citizens on Merritt Island. Coordinated by the KSC Community Relations Council, Days of Caring provides an opportunity for employees to volunteer their services in projects such as painting, planting flowers, reading to school children, and more. Organizations accepting volunteers include The Embers, Yellow Umbrella, Serene Harbor, Domestic Violence Program, the YMCA of Brevard County, and others.

Physician office vs retail clinic: patient preferences in care seeking for minor illnesses.

PubMed

Ahmed, Arif; Fincham, Jack E

2010-01-01

Retail clinics are a relatively new phenomenon in the United States, offering cheaper and convenient alternatives to physician offices for minor illness and wellness care. The objective of this study was to investigate the effects of cost of care and appointment wait time on care-seeking decisions at retail clinics or physician offices. As part of a statewide random-digit-dial survey of households, adult residents of Georgia were interviewed to conduct a discrete choice experiment with 2 levels each of 4 attributes: price ($59; $75), appointment wait time (same day; 1 day or longer), care setting-clinician combination (nurse practitioner in retail clinic; physician in private office), and acute illness (urinary tract infection [UTI]; influenza). The respondents indicated whether they would seek care under each of the 16 resulting choice scenarios. A cooperation rate of 33.1% yielded 493 completed telephone interviews. The respondents preferred to seek care for both conditions; were less likely to seek care for UTI (beta = -0.149; P = .008); preferred to seek care from a physician (beta = 1.067; P < .001) and receive same day care (beta = -2.789; P < .001). All else equal, cost savings of $31.42 would be required for them to seek care at a retail clinic and $82.12 to wait 1 day or more. Time and cost savings offered by retail clinics are attractive to patients, and they are likely to seek care there given sufficient cost savings. Appointment wait time is the most important factor in care-seeking decisions and should be considered carefully in setting appointment policies in primary care practices.

Growing up Active: A Study into Physical Activity in Long Day Care Centers

ERIC Educational Resources Information Center

Cashmore, Aaron W.; Jones, Sandra C.

2008-01-01

The child care center is an ideal setting in which to implement strategies to promote physical activity and healthy weight, but there is a paucity of empirical evidence on factors that influence physical activity in these settings. The current study gathered initial qualitative data to explore these factors. Child care workers from five long day…

CTEPP NC DATA COLLECTED ON FORM 03:HOUSE/BUILDING CHARACTERISTICS OBSERVATION SURVEY FOR THE DAY CARE CENTER

EPA Science Inventory

This data set contains data concerning the physical characteristics of the day care center and identified possible sources of pollutants.

The Children’s Total Exposure to Persistent Pesticides and Other Persistent Pollutant (CTEPP) study was one of the largest aggregate exposu...

Assessing the economic value of avoiding hospital admissions by shifting the management of gram+ acute bacterial skin and skin-structure infections to an outpatient care setting.

PubMed

Ektare, V; Khachatryan, A; Xue, M; Dunne, M; Johnson, K; Stephens, J

2015-01-01

To estimate, from a US payer perspective, the cost offsets of treating gram positive acute bacterial skin and skin-structure infections (ABSSSI) with varied hospital length of stay (LOS) followed by outpatient care, as well as the cost implications of avoiding hospital admission. Economic drivers of care were estimated using a literature-based economic model incorporating inpatient and outpatient components. The model incorporated equal efficacy, adverse events (AE), resource use, and costs from literature. Costs of once- and twice-daily outpatient infusions to achieve a 14-day treatment were analyzed. Sensitivity analyses were performed. Costs were adjusted to 2015 US$. Total non-drug medical cost for treatment of ABSSSI entirely in the outpatient setting to avoid hospital admission was the lowest among all scenarios and ranged from $4039-$4924. Total non-drug cost for ABSSSI treated in the inpatient setting ranged from $9813 (3 days LOS) to $18,014 (7 days LOS). Inpatient vs outpatient cost breakdown was: 3 days inpatient ($6657)/11 days outpatient ($3156-$3877); 7 days inpatient ($15,017)/7 days outpatient ($2495-$2997). Sensitivity analyses revealed a key outpatient cost driver to be peripherally inserted central catheter (PICC) costs (average per patient cost of $873 for placement and $205 for complications). Drug and indirect costs were excluded and resource use was not differentiated by ABSSSI type. It was assumed that successful ABSSSI treatment takes up to 14 days per the product labels, and that once-daily and twice-daily antibiotics have equal efficacy. Shifting ABSSSI care to outpatient settings may result in medical cost savings greater than 53%. Typical outpatient scenarios represent 14-37% of total medical cost, with PICC accounting for 28-43% of the outpatient burden. The value of new ABSSSI therapies will be driven by eliminating the need for PICC line, reducing length of stay and the ability to completely avoid a hospital stay.

[Mobile geriatric rehabilitation in nursing homes, in short-term care facilities and private homes : Setting-specific analysis of nationwide treatment documentation (Part 2)].

PubMed

Pippel, Kristina; Meinck, M; Lübke, N

2017-06-01

Mobile geriatric rehabilitation can be provided in the setting of nursing homes, short-term care (STC) facilities and exclusively in private homes. This study analyzed the common features and differences of mobile rehabilitation interventions in various settings. Stratified by setting 1,879 anonymized mobile geriatric rehabilitation treatments between 2011 and 2014 from 11 participating institutions were analyzed with respect to patient, process and outcome-related features. Significant differences between the settings nursing home (n = 514, 27 %), STC (n = 167, 9 %) and private homes (n = 1198, 64 %) were evident for mean age (83 years, 83 years and 80 years, respectively), percentage of women (72 %, 64 % and 55 %), degree of dependency on pre-existing care (92 %, 76 % and 64 %), total treatment sessions (TS, 38 TS, 42 TS and 41 TS), treatment duration (54 days, 61 days and 58 days) as well as the Barthel index at the start of rehabilitation (34 points, 39 points and 46 points) and the gain in the Barthel index (15 points, 21 points and 18 points), whereby the gain in the capacity for self-sufficiency was significant in all settings. The setting-specific evaluation of mobile geriatric rehabilitation showed differences for relevant patient, process and outcome-related features. Compared to inpatient rehabilitation mobile rehabilitation in all settings made an above average contribution to the rehabilitation of patients with pre-existing dependency on care. The gains in the capacity for self-sufficiency achieved in all settings support the efficacy of mobile geriatric rehabilitation under the current prerequisites for applicability.

Keeping Kids Healthy.

ERIC Educational Resources Information Center

Mays, Sharon; And Others

This pamphlet offers a collection of items relating to child health in the day care setting. Included is an overview of a collaborative project to develop a comprehensive set of national standards for health, nutrition, safety, and sanitation in child care programs. Contents of the project's resource kit, "Keeping Kids Healthy and Parents at…

Importation, Antibiotics, and Clostridium difficile Infection in Veteran Long-Term Care: A Multilevel Case-Control Study.

PubMed

Brown, Kevin A; Jones, Makoto; Daneman, Nick; Adler, Frederick R; Stevens, Vanessa; Nechodom, Kevin E; Goetz, Matthew B; Samore, Matthew H; Mayer, Jeanmarie

2016-06-21

Although clinical factors affecting a person's susceptibility to Clostridium difficile infection are well-understood, little is known about what drives differences in incidence across long-term care settings. To obtain a comprehensive picture of individual and regional factors that affect C difficile incidence. Multilevel longitudinal nested case-control study. Veterans Health Administration health care regions, from 2006 through 2012. Long-term care residents. Individual-level risk factors included age, number of comorbid conditions, and antibiotic exposure. Regional risk factors included importation of cases of acute care C difficile infection per 10 000 resident-days and antibiotic use per 1000 resident-days. The outcome was defined as a positive result on a long-term care C difficile test without a positive result in the prior 8 weeks. 6012 cases (incidence, 3.7 cases per 10 000 resident-days) were identified in 86 regions. Long-term care C difficile incidence (minimum, 0.6 case per 10 000 resident-days; maximum, 31.0 cases per 10 000 resident-days), antibiotic use (minimum, 61.0 days with therapy per 1000 resident-days; maximum, 370.2 days with therapy per 1000 resident-days), and importation (minimum, 2.9 cases per 10 000 resident-days; maximum, 341.3 cases per 10 000 resident-days) varied substantially across regions. Together, antibiotic use and importation accounted for 75% of the regional variation in C difficile incidence (R2 = 0.75). Multilevel analyses showed that regional factors affected risk together with individual-level exposures (relative risk of regional antibiotic use, 1.36 per doubling [95% CI, 1.15 to 1.60]; relative risk of importation, 1.23 per doubling [CI, 1.14 to 1.33]). Case identification was based on laboratory criteria. Admission of residents with recent C difficile infection from non-Veterans Health Administration acute care sources was not considered. Only 25% of the variation in regional C difficile incidence in long-term care remained unexplained after importation from acute care facilities and antibiotic use were accounted for, which suggests that improved infection control and antimicrobial stewardship may help reduce the incidence of C difficile in long-term care settings. U.S. Department of Veterans Affairs and Centers for Disease Control and Prevention.

Integrating palliative care across settings: A retrospective cohort study of a hospice home care programme for cancer patients.

PubMed

Tan, Woan Shin; Lee, Angel; Yang, Sze Yee; Chan, Susan; Wu, Huei Yaw; Ng, Charis Wei Ling; Heng, Bee Hoon

2016-07-01

Terminally ill patients at the end-of-life do transit between care settings due to their complex care needs. Problems of care fragmentation could result in poor quality of care. We aimed to evaluate the impact of an integrated hospice home care programme on acute care service usage and on the share of home deaths. The retrospective study cohort comprised patients who were diagnosed with cancer, had an expected prognosis of 1 year or less, and were referred to a home hospice. The intervention group comprised deceased patients enrolled in the integrated hospice home care programme between September 2012 and June 2014. The historical comparison group comprised deceased patients who were referred to other home hospices between January 2007 and January 2011. There were 321 cases and 593 comparator subjects. Relative to the comparator group, the share of hospital deaths was significantly lower for programme participants (12.1% versus 42.7%). After adjusting for differences at baseline, the intervention group had statistically significantly lower emergency department visits at 30 days (incidence rate ratio: 0.38; 95% confidence interval: 0.31-0.47), 60 days (incidence rate ratio: 0.61; 95% confidence interval: 0.54-0.69) and 90 days (incidence rate ratio: 0.69; 95% confidence interval: 0.62-0.77) prior to death. Similar results held for the number of hospitalisations at 30 days (incidence rate ratio: 0.48; 95% confidence interval: 0.40-0.58), 60 days (incidence rate ratio: 0.71; 95% confidence interval: 0.62-0.82) and 90 days (incidence rate ratio: 0.77; 95% confidence interval: 0.68-0.88) prior to death. Our results demonstrated that by integrating services between acute care and home hospice care, a reduction in acute care service usage could occur. © The Author(s) 2016.

"Looking and Listening-In": A Methodological Approach to Generating Insights into Infants' Experiences of Early Childhood Education and Care Settings

ERIC Educational Resources Information Center

Sumsion, Jennifer; Goodfellow, Joy

2012-01-01

In this article, we describe an observational approach, "looking and listening-in," that we have used to try to understand the experience of an infant in an Australian family day-care home. The article is drawn from a larger study of infants' experiences of early childhood education and care settings. In keeping with the mosaic…

The Burn-Out Syndrome in the Day Care Setting

ERIC Educational Resources Information Center

Maslach, Christina; Pines, Ayala

1977-01-01

Results of a study of personal job-stress factors among day care center personnel focus on impact of staff-child ratio, working hours, time out, staff meetings and program structure. Recommended institutional changes for prevention of staff "burn-out" involve reduction in amount of direct staff-child contact, development of social-professional…

Maternal and Child Health Issues and Female Labor Force Participation.

ERIC Educational Resources Information Center

Howze, Dorothy C.; And Others

Reviewing health related "costs" of female labor force participation, this paper examines four highly salient maternal and child health issues. Discussion of acute illness in day care settings begins with an overview of studies on day care and illness and focuses on hepatitis A, appropriate sanitation, and indications of research on…

Whose Culture?: Monolithic Cultures and Subcultures in Early Childhood Settings

ERIC Educational Resources Information Center

Halttunen, Leena

2017-01-01

In Finland, day care centre directors have traditionally led only a single unit, but after the recent merging of many units, most directors simultaneously lead several, physically separate units. These organizations are called distributed organizations. This study was carried out in two distributed day care organizations. The findings are based on…

CTEPP-OH DATA COLLECTED ON FORM 03:HOUSE/BUILDING CHARACTERISTICS OBSERVATION SURVEY FOR THE DAY CARE CENTER

EPA Science Inventory

This data set contains data concerning the physical characteristics of the day care center and identified possible sources of pollutants for CTEPP-OH.

The Children’s Total Exposure to Persistent Pesticides and Other Persistent Pollutant (CTEPP) study was one of the largest agg...

Acute care alternate-level-of-care days due to delayed discharge for traumatic and non-traumatic brain injuries.

PubMed

Amy, Chen; Zagorski, Brandon; Chan, Vincy; Parsons, Daria; Vander Laan, Rika; Colantonio, Angela

2012-05-01

Alternate-level-of-care (ALC) days represent hospital beds that are taken up by patients who would more appropriately be cared for in other settings. ALC days have been found to be costly and may result in worse functional outcomes, reduced motor skills and longer lengths of stay in rehabilitation. This study examines the factors that are associated with acute care ALC days among patients with acquired brain injury (ABI). We used the Discharge Abstract Database to identify patients with ABI using International Classification of Disease-10 codes. From fiscal years 2007/08 to 2009/10, 17.5% of patients with traumatic and 14% of patients with non-traumatic brain injury had at least one ALC day. Significant predictors include having a psychiatric co-morbidity, increasing age and length of stay in acute care. These findings can inform planning for care of people with ABI in a publicly funded healthcare system.

Sex Differences in Young Children's Responses to an Infant: An Observation Within a Day Care Setting.

ERIC Educational Resources Information Center

Berman, Phyllis W.

A sample of 43 boys and 43 girls (aged 32 to 63 months) was observed during interactions with a 13-month-old infant in a structured situation in a day care center. Attendance in an area surrounding an empty playpen, and behaviors in that area, were recorded on four preliminary days to adapt children to observers and measure baseline behavior; on…

Cuidado de Ninos con Necesidades Especiales en el Hogar: Manual de Estrategias y Actividades para Proveedores que Cuidan Ninos en Sus Hogares (Children with Special Needs in Family Day Care Homes: A Handbook of Approaches and Activities for Family Day Care Home Providers).

ERIC Educational Resources Information Center

de la Brosse, Beatrice

Practical information and sample teaching activities for child caregivers who work with young developmentally disabled children in family day care settings are provided in this manual. Each chapter shares a typical experience a caregiver may have with a particular child. Chapter 1 focuses on getting to know a new child, initial expectations, and…

Patient subjective experience and satisfaction during the perioperative period in the day surgery setting: a systematic review.

PubMed

Rhodes, Lenore; Miles, Gail; Pearson, Alan

2006-08-01

This systematic review used the Joanna Briggs Institute Qualitative Assessment and Review Instrument to manage, appraise, analyse and synthesize textual data in order to present the best available information in relation to how patients experience nursing interventions and care during the perioperative period in the day surgery setting. Some of the significant findings that emerged from the systematic review include the importance of pre-admission contact, provision of relevant, specific education and information, improving communication skills and maintaining patient privacy throughout their continuum of care.

Burden of allergy diets in Finnish day care reduced by change in practices.

PubMed

Erkkola, M; Saloheimo, T; Hauta-Alus, H; Kukkonen, A K; Virta, S; Kronberg-Kippilä, C; Vaara, E; Pelkonen, A S; Fogelholm, M; Mäkelä, M J

2016-10-01

Nonessential allergy diets in children with mild symptoms may harm the development of immunological tolerance and impose a burden on families and day care. We aimed to reduce the high prevalence of allergy diets in day care by reforming the practices for inquiring about need of special diets from parents. We developed a new special diet form and an information leaflet based on the new allergy guidelines. The new form was implemented into 40 Finnish day care centres in the capital region in 2013-2015. The questionnaires on practices concerning special diets in day care centres and allergy knowledge were collected from the personnel. After 2 years, the new special diet form was used by 64% of families with food-allergic children, and the prevalence of allergy diets in day care centres decreased by 43% to 4.3% (IQ range 3.05-5.96). A significant decrease was found in the prevalence of all basic (milk, grains, egg) and most other allergy diets (P for trend < 0.01). The new practice was well accepted by day care and kitchen personnel. Lack of updated allergy knowledge was noted among day care personnel. The burden of allergy diets in day care settings could be decreased by simple pragmatic changes based on current allergy guidelines. Old allergy attitudes persisted among day care personnel, indicating the need for continuous education. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Multicultural Issues in Child Care.

ERIC Educational Resources Information Center

Gonzalez-Mena, Janet

This volume focuses on cultural differences relevant to all child-care-giving settings, including day care, nursery, and preschool programs. Based on respect for cultural pluralism, this concise supplementary text is designed to increase caregiver sensitivity to different cultural child-care practices and values and to improve communication and…

Quality indicators for care of cancer patients in their last days of life: literature update and experts' evaluation.

PubMed

Raijmakers, Natasja; Galushko, Maren; Domeisen, Franzisca; Beccaro, Monica; Lundh Hagelin, Carina; Lindqvist, Olav; Popa-Velea, Ovidiu; Romotzky, Vanessa; Schuler, Stefanie; Ellershaw, John; Ostgathe, Christoph

2012-03-01

Quality indicators (QIs) are needed to monitor and to improve palliative care. Care of patients in the last days of life is a discrete phase of palliative care and therefore specific QIs are needed. This study aimed to identify and evaluate current QIs against which to measure future care of patients in the last days of life. To identify QIs for patients in the last days of life an update of the literature and national guidelines was conducted. Subsequently, an international panel of palliative care experts was asked to evaluate the identified QIs: how well they describe care and how applicable they are for care in the last days of life. Also additional QIs were asked. In total, 34 QIs for care in the last days were identified in the literature and guidelines. The experts (response rate 58%) agreed with seven QIs as being good descriptors and applicable: concerning a home visit for the family following a patient's death, the presence of a dedicated family room, limited patients receiving chemotherapy, limited need for pain control, gastrointestinal symptoms, and communication from professional to patient and family. The experts also suggested 18 additional topics for QIs for the last days of life. Currently no definite set of QIs exist to describe quality of care of patients in their last days of life. New QIs that are focused on care for patients in their last days of life, their relatives, as well as their professional caregivers are needed.

C. P. A. Youth Motivation through Day Care Demonstration. Final Evaluation.

ERIC Educational Resources Information Center

Pittman, Audrey; McWhorter, Schelysture

The Real Experiences for Alternatives in Living Program (REAL) employs three components in an attempt to alter positively the lives of inner-city male youths and to provide indigenous role models within a day care setting to school-age children enrolled therein. These components are informal and formal on-the-job inservice training in child…

Physical Activity Programs in Long Day Care and Family Day Care Settings

ERIC Educational Resources Information Center

Lawlis, Tanya; Mikhailovich, Katja; Morrison, Paul

2008-01-01

In the past 10 years the prevalence of childhood obesity has increased considerably and there is growing recognition of the need to establish positive attitudes to healthy lifestyle practices from an early age if this trend is to be reversed. Childcare centres provide ideal environments from which to develop these positive attitudes. A literature…

CTEPP NC DATA COLLECTED ON FORM 10 (PERIODS 1-3): DAY CARE CENTER CHILD ACTIVITY DIARY AND FOOD SURVEY

EPA Science Inventory

This data set contains data concerning the child’s activities at the day care center over the 48-h monitoring period. The diary was divided into three time periods over the 48-h monitoring interval. The Food Survey collected information on the frequency and types of fruits, veget...

Challenges in the management of nutritional disorders and communicable diseases in child day care centers: a quantitative and qualitative approach.

PubMed

Konstantyner, Tulio; Konstantyner, Thais Cláudia Roma de Oliveira; Toloni, Maysa Helena Aguiar; Longo-Silva, Giovana; Taddei, José Augusto de Aguiar Carrazedo

2017-03-01

In Brazil, although many children from low income families attend day care centers with appropriate hygiene practices and food programs, they have nutritional disorders and communicable diseases. This quantitative and qualitative cross-sectional study identified staff challenges in child day care centers and suggested alternative activity management to prevent nutritional disorders and communicable diseases. The study included 71 nursery teachers and 270 children from public and philanthropic day care centers (teacher to child ratios of 1:2.57 and 1:6.40, respectively). Interviews and focus groups were conducted with teachers and parents, and anthropometry and blood samples were drawn from the children by digital puncture. Children in philanthropic child day care centers were more likely to be hospitalized due to communicable diseases. Teachers from philanthropic child day care centers had lower age, income and education and higher work responsibilities based on the number of children and working time. The focus groups characterized institutions with organized routines, standard food practices, difficulties with caretaking, and lack of training to provide healthcare to children. Strategies to improve children's health in day care settings should focus on training of teachers about healthcare and nutrition.

Appropriateness of bed usage for inpatients admitted as emergencies to internal medicine services.

PubMed

Armstrong, S H; Peden, N R; Nimmo, S; Alcorn, M

2001-11-01

To establish the appropriateness of bed usage for acute care within the medical directorates of two district general hospitals using a validated assessment tool, the Emergency Admission Review (EAR). This tool assesses the appropriateness of day of care against strict criteria and allows classification of care as either acute or non-acute. Prospectively, 200 medical emergency admissions, 100 in each of the hospitals, were selected. Following identification patients were assessed every two days during the first fortnight of admission or until discharge. Those patients staying longer than two weeks were then assessed weekly until conclusion of the audit period or discharge whichever was reached first. The medical directorates of two District General Hospitals within one acute NHS trust. All patients admitted as medical emergencies, who were 14 years or older and had a length of stay of 24 hours or more. A total of 787 acute in-patient bed days were analysed in Hospital A of which 363 (46%) were deemed inappropriate for acute care. In Hospital B 810 bed days were analysed and 44% (363) were deemed inappropriate. In Hospital A the most common reason for bed-days not meeting the acute care criteria was short-term waiting, accounting for 60% (217 days) of the total bed days deemed non-acute. In Hospital B the most common reason for patients receiving non-acute care was that they were having active rehabilitation. This accounted for 29% (105 days) of the total number of non-acute care days. In Hospital B three patients accounted for 28% of the total occupied bed days. The use of the EAR is a systematic and objective approach to the assessment of appropriateness of acute care. It applies strict criteria to determine the reason for a patient's continued hospital stay. From the results it is clear that a significant proportion of medical emergency admissions in both Hospital A and B remain in hospital for care that is deemed non-acute and therefore in theory could be performed in another setting. This information has significant potential in identifying the opportunities for streamlining services within hospitals to reduce short-term delays and also to inform the development of intermediate care services both within and outwith the acute hospital setting.

Child Care and Work Absences: Trade-Offs by Type of Care

ERIC Educational Resources Information Center

Gordon, Rachel A.; Kaestner, Robert; Korenman, Sanders

2008-01-01

Parents face a trade-off in the effect of child-care problems on employment. Whereas large settings may increase problems because of child illness, small group care may relate to provider unavailability. Analyzing the NICHD Study of Early Child Care, we find that child-care centers and large family day care lead to mothers' greater work absences…

Assessment of Needs of Adults with Developmental Disabilities in Skilled Nursing and Intermediate Care Facilities in Illinois.

ERIC Educational Resources Information Center

Uehara, Edwina S.; And Others

1991-01-01

This study evaluated 2,815 adults with developmental disabilities in 328 Illinois intermediate care and skilled nursing facilities. Only 10 percent were determined to be appropriately placed in medical settings; 27 percent were enrolled in day training programs; and many individuals recommended for alternative residential settings had medical and…

Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children

PubMed Central

Poppy, Amy; Retamal-Munoz, Claudia; Cree-Green, Melanie; Wood, Colleen; Davis, Shanlee; Clements, Scott A.; Majidi, Shideh; Steck, Andrea K.; Alonso, G. Todd; Chambers, Christina; Rewers, Arleta

2018-01-01

OBJECTIVE Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital. METHODS Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines. RESULTS After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days. CONCLUSIONS Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved. PMID:27317577

Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children.

PubMed

Poppy, Amy; Retamal-Munoz, Claudia; Cree-Green, Melanie; Wood, Colleen; Davis, Shanlee; Clements, Scott A; Majidi, Shideh; Steck, Andrea K; Alonso, G Todd; Chambers, Christina; Rewers, Arleta

2016-07-01

Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital. Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines. After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days. Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved. Copyright © 2016 by the American Academy of Pediatrics.

Economic and clinical benefit of collagenase ointment compared to a hydrogel dressing for pressure ulcer debridement in a long-term care setting.

PubMed

Waycaster, Curtis; Milne, Catherine

2013-06-01

The purpose of this study is to determine the cost-effectiveness of collagenase ointment relative to autolysis with a hydrogel dressing when debriding necrotic pressure ulcers in a long-term care setting. A Markov decision process model with 2 states (necrotic nonviable wound bed transitioning to a granulated viable wound bed) was developed using data derived from a prospective, randomized, 6-week, single-center trial of 27 institutionalized subjects with pressure ulcers that were ≥ 85% necrotic nonviable tissue. Direct medical costs from the payer perspective included study treatments, wound treatment supplies, and nursing time. Clinical benefit was measured as "granulation days" and was derived from the time-dependent debridement rates of the alternative products. The average cost per patient for 42 days of pressure ulcer care was $1,817 in 2012 for the collagenase group and $1,611 for the hydrogel group. Days spent with a granulated wound were 3.6 times higher for collagenase (23.4 vs 6.5) than with the hydrogel. The estimated cost per granulation day was > 3.2 times higher for hydrogel ($249) vs collagenase ($78). In this economic analysis based on a randomized, controlled clinical trial, collagenase ointment resulted in a faster time to complete debridement and was more cost-effective than hydrogel autolysis for pressure ulcers in a long-term care setting. Even though collagenase ointment has a higher acquisition cost than hydrogel, the clinical benefit offsets the initial cost difference, resulting in lower cost per granulation day to the nursing home over the course of the 42-day analysis.

Physician organization care management capabilities associated with effective inpatient utilization management: a fuzzy set qualitative comparative analysis.

PubMed

Sheehy, Thomas J; Thygeson, N Marcus

2014-12-03

We studied the relationship between physician organization (PO) care management capabilities and inpatient utilization in order to identify PO characteristics or capabilities associated with low inpatient bed-days per thousand. We used fuzzy-set qualitative comparative analysis (fsQCA) to conduct an exploratory comparative case series study. Data about PO capabilities were collected using structured interviews with medical directors at fourteen California POs that are delegated to provide inpatient utilization management (UM) for HMO members of a California health plan. Health plan acute hospital claims from 2011 were extracted from a reporting data warehouse and used to calculate inpatient utilization statistics. Supplementary analyses were conducted using Fisher's Exact Test and Student's T-test. POs with low inpatient bed-days per thousand minimized length of stay and surgical admissions by actively engaging in concurrent review, discharge planning, and surgical prior authorization, and by contracting directly with hospitalists to provide UM-related services. Disease and case management were associated with lower medical admissions and readmissions, respectively, but not lower bed-days per thousand. Care management methods focused on managing length of stay and elective surgical admissions are associated with low bed-days per thousand in high-risk California POs delegated for inpatient UM. Reducing medical admissions alone is insufficient to achieve low bed-days per thousand. California POs with high bed-days per thousand are not applying care management best practices.

Family Day Care: Guidelines Designed to Enhance Cognitive Learning within the Home Environment Based on Piagetian Theory.

ERIC Educational Resources Information Center

Parr, Carolyn M.

The purpose of this guidebook is to help persons interested in establishing a family day care program in their homes set up a quality learning environment that enhances children's cognitive development through play. Following a literature review showing the importance of play in Piaget's theory of child development, the author describes a…

The Need for Privacy and the Application of Privacy to the Day Care Setting.

ERIC Educational Resources Information Center

Jacobs, Ellen

This paper, focusing on young children's need for privacy, describes a study conducted to determine the manner in which children in day care centers resolve the problem of reduced space and time for privacy. A pilot study revealed that children displayed three privacy seeking behaviors: (1) verbal and nonverbal territorial behavior (use or defense…

CTEPP-OH DATA COLLECTED ON FORM 10 (PERIODS 1-3): DAY CARE CENTER CHILD ACTIVITY DIARY AND FOOD SURVEY

EPA Science Inventory

This data set contains data for CTEPP-OH concerning the child’s activities at the day care center over the 48-h monitoring period. The diary was divided into three time periods over the 48-h monitoring interval. The Food Survey collected information on the frequency and types of ...

State of the art and recommendations. Kangaroo mother care: application in a high-tech environment.

PubMed

Nyqvist, K H; Anderson, G C; Bergman, N; Cattaneo, A; Charpak, N; Davanzo, R; Ewald, U; Ludington-Hoe, S; Mendoza, S; Pallás-Allonso, C; Peláez, J G; Sizun, J; Wiström, A M

2010-11-01

Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low-income settings, the original KMC modelis implemented. This consists of continuous (24 h/day; 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding and, adequate follow up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC modelin all types of settings was discussed at the 7th International Workshop on KMC Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents'role, modification of the NICU environment, performance of care in KMC, and KMCin case of infant instability. Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.

State of the art and recommendations. Kangaroo mother care: application in a high-tech environment.

PubMed

Nyqvist, K H; Anderson, G C; Bergman, N; Cattaneo, A; Charpak, N; Davanzo, R; Ewald, U; Ludington-Hoe, S; Mendoza, S; Pallás-Allonso, C; Peláez, J G; Sizun, J; Widström, A-M

2010-06-01

Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low income settings, the original KMC model is implemented. This consists of continuous (24 h/day, 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding; and, adequate follow-up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC model in all types of settings was discussed at the 7th International Workshop on KMC. Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents' role, modification of the NICU environment, performance of care in KMC, and KMC in case of infant instability. Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.

Computer-generated reminders and quality of pediatric HIV care in a resource-limited setting.

PubMed

Were, Martin C; Nyandiko, Winstone M; Huang, Kristin T L; Slaven, James E; Shen, Changyu; Tierney, William M; Vreeman, Rachel C

2013-03-01

To evaluate the impact of clinician-targeted computer-generated reminders on compliance with HIV care guidelines in a resource-limited setting. We conducted this randomized, controlled trial in an HIV referral clinic in Kenya caring for HIV-infected and HIV-exposed children (<14 years of age). For children randomly assigned to the intervention group, printed patient summaries containing computer-generated patient-specific reminders for overdue care recommendations were provided to the clinician at the time of the child's clinic visit. For children in the control group, clinicians received the summaries, but no computer-generated reminders. We compared differences between the intervention and control groups in completion of overdue tasks, including HIV testing, laboratory monitoring, initiating antiretroviral therapy, and making referrals. During the 5-month study period, 1611 patients (49% female, 70% HIV-infected) were eligible to receive at least 1 computer-generated reminder (ie, had an overdue clinical task). We observed a fourfold increase in the completion of overdue clinical tasks when reminders were availed to providers over the course of the study (68% intervention vs 18% control, P < .001). Orders also occurred earlier for the intervention group (77 days, SD 2.4 days) compared with the control group (104 days, SD 1.2 days) (P < .001). Response rates to reminders varied significantly by type of reminder and between clinicians. Clinician-targeted, computer-generated clinical reminders are associated with a significant increase in completion of overdue clinical tasks for HIV-infected and exposed children in a resource-limited setting.

Training Family Day Care Providers to Use Behavior Modification Procedures: A Case Study.

ERIC Educational Resources Information Center

Powers, Michael D.

Effects of brief time out on the biting behavior of a 21- month-old boy enrolled in a day care setting was examined. The Motivation Assessment Scale (MAS; Durand, 1983) was used to determine the function of the child's biting. A parent report survey, the MAS assesses disruptive behavior using a Likert-type scale and discriminates the function of a…

The Development of a Prototype Infant, Preschool and Child Day Care Center in Metropolitan Toronto. Year I Progress Report: Program Development.

ERIC Educational Resources Information Center

Fowler, William; And Others

The project reported on is designed to develop a model program of infant and child day care in a municipal setting. The development of the program is discussed under the following topics: (1) physical caregiving routines; (2) guided learning through play; (3) supervising children in free play; (4) staff guidance and communication: inservice…

Reflective Dialogues in Community Music Engagement: An Exploratory Experience in a Singapore Nursing Home and Day-Care Centre for Senior Citizens

ERIC Educational Resources Information Center

Lum, Chee-Hoo

2011-01-01

This study documents a reflective journey of a community music programme initiated by a university music education faculty member and an occupational therapist within the setting of a nursing home and day-care centre in Singapore. Weekly music interaction sessions in conjunction with reminiscence therapy were conducted over a period of five…

Cost-effectiveness of on-site versus off-site collaborative care for depression in rural FQHCs.

PubMed

Pyne, Jeffrey M; Fortney, John C; Mouden, Sip; Lu, Liya; Hudson, Teresa J; Mittal, Dinesh

2015-05-01

Collaborative care for depression in primary care settings is effective and cost-effective. However, there is minimal evidence to support the choice of on-site versus off-site models. This study examined the cost-effectiveness of on-site practice-based collaborative care (PBCC) versus off-site telemedicine-based collaborative care (TBCC) for depression in federally qualified health centers (FQHCs). In a multisite, randomized, pragmatic comparative cost-effectiveness trial, 19,285 patients were screened for depression, 2,863 (14.8%) screened positive, and 364 were enrolled. Telephone interview data were collected at baseline and at six, 12, and 18 months. Base case analysis used Arkansas FQHC health care costs, and secondary analysis used national cost estimates. Effectiveness measures were depression-free days and quality-adjusted life years (QALYs) derived from depression-free days, the 12-Item Short-Form Survey, and the Quality of Well-Being (QWB) Scale. Nonparametric bootstrap with replacement methods were used to generate an empirical joint distribution of incremental costs and QALYs and acceptability curves. The TBCC intervention resulted in more depression-free days and QALYs but at a greater cost than the PBCC intervention. The disease-specific (depression-free day) and generic (QALY) incremental cost-effectiveness ratios (ICERs) were below their respective ICER thresholds for implementation, suggesting that the TBCC intervention was more cost effective than the PBCC intervention. These results support the cost-effectiveness of TBCC in medically underserved primary care settings. Information about whether to insource (make) or outsource (buy) depression care management is important, given the current interest in patient-centered medical homes, value-based purchasing, and bundled payments for depression care.

Volume of hydration in terminal cancer patients.

PubMed

Bruera, E; Belzile, M; Watanabe, S; Fainsinger, R L

1996-03-01

In this retrospective study we reviewed the volume and modality of hydration of consecutive series of terminal cancer patients in two different settings. In a palliative care unit 203/290 admitted patients received subcutaneous hydration for 12 +/- 8 days at a daily volume of 1015 +/- 135 ml/day. At the cancer center, 30 consecutive similar patients received intravenous hydration for 11.5 +/- 5 days (P > 0.2) but at a daily volume of 2080 +/- 720 ml/day (P < 0.001). None of the palliative care unit patients required discontinuation of hydration because of complications. Hypodermoclysis was administered mainly as a continuous infusion, an overnight infusion, or in one to three 1-h boluses in 62 (31%), 98 (48%) and 43 (21%) patients, respectively. Our findings suggest that, in some settings, patients may be receiving excessive volumes of hydration by less comfortable routes such as the intravenous route. Increased education and research in this area are badly needed.

The Emergency Care of Patients With Cancer: Setting the Research Agenda.

PubMed

Brown, Jeremy; Grudzen, Corita; Kyriacou, Demetrios N; Obermeyer, Ziad; Quest, Tammie; Rivera, Donna; Stone, Susan; Wright, Jason; Shelburne, Nonniekaye

2016-12-01

To identify research priorities and appropriate resources and to establish the infrastructure required to address the emergency care of patients with cancer, the National Institutes of Health's National Cancer Institute and the Office of Emergency Care Research sponsored a one-day workshop, "Cancer and Emergency Medicine: Setting the Research Agenda," in March 2015 in Bethesda, MD. Participants included leading researchers and clinicians in the fields of oncology, emergency medicine, and palliative care, and representatives from the National Institutes of Health. Attendees were charged with identifying research opportunities and priorities to advance the understanding of the emergency care of cancer patients. Recommendations were made in 4 areas: the collection of epidemiologic data, care of the patient with febrile neutropenia, acute events such as dyspnea, and palliative care in the emergency department setting. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Inpatient Palliative Care Consultation and 30-Day Readmissions in Oncology.

PubMed

DiMartino, Lisa D; Weiner, Bryan J; Hanson, Laura C; Weinberger, Morris; Birken, Sarah A; Reeder-Hayes, Katherine; Trogdon, Justin G

2018-01-01

Prior research indicates that hospice and palliative care delivered in outpatient settings are associated with reduced hospital readmissions for cancer patients. However, little is known about how inpatient palliative care affects readmissions in oncology. To examine associations among inpatient palliative care consultation, hospice use (discharge), and 30-day readmissions among patients with solid tumor cancers. We identified all live discharges from a large tertiary cancer hospital between 2010 and 2016. Palliative care consult data were abstracted from medical charts and linked to hospital encounter data. Propensity scores were used to match palliative care consult to usual care encounters. Modified Poisson regression models estimated adjusted relative risk (aRR) and 95% confidence intervals (CI) of 30-day readmissions and hospice discharge. We compared predicted probabilities of readmission for palliative care consultation with hospice discharge, without hospice discharge, and usual care. Of 8085 eligible encounters, 753 involved a palliative care consult. The likelihood of having a 30-day readmission did not differ between palliative care consult and usual care groups (p > 0.05). However, the palliative care consult group was more likely than usual care to have a hospice discharge (aRR = 4.09, 95% CI: 3.07-5.44). The predicted probability of 30-day readmission was lower when palliative care consultation was combined with hospice discharge compared to usual care or consultation with discharge to nonhospice postacute care (p < 0.001). The effect of inpatient palliative care on readmissions in oncology is largely driven by hospice enrollment. Strategies that combine palliative care consultation with hospice discharge may decrease hospital readmissions and improve cancer care quality.

Special Programs for Individual Needs (SPIN). Handicapped Children Early Education Program: P.L. 91-230 Title VI, Part C. Final Report, July 1, 1974 to June 30, 1977.

ERIC Educational Resources Information Center

Wight, Byron W.

The document contains the final report of the Special Programs for Individualized Needs (SPIN) program designed to develop a demonstration model for training day care personnel to identify developmentally delayed or emotionally disturbed children and to program for them within the regular day care setting. Major objectives were to develop…

Developing a Set of Uniform Outcome Measures for Adult Day Services.

PubMed

Anderson, Keith A; Geboy, Lyn; Jarrott, Shannon E; Missaelides, Lydia; Ogletree, Aaron M; Peters-Beumer, Lisa; Zarit, Steven H

2018-06-01

Adult day services (ADS) provide care to adults with physical, functional, and/or cognitive limitations in nonresidential, congregate, community-based settings. ADS programs have emerged as a growing and affordable approach within the home and community-based services sector. Although promising, the growth of ADS has been hampered by a lack of uniform outcome measures and data collection protocols. In this article, the authors detail a recent effort by leading researchers and practitioners in ADS to develop a set of uniform outcome measures. Based upon three recent efforts to develop outcome measures, selection criteria were established and an iterative process was conducted to debate the merits of outcome measures across three domains-participant well-being, caregiver well-being, and health care utilization. The authors conclude by proposing a uniform set of outcome measures to (a) standardize data collection, (b) aid in the development of programming, and (c) facilitate the leveraging of additional funding for ADS.

Negotiated risk and resident autonomy: Frontline care staff perspectives on culture change in long term care in Nova Scotia, Canada.

PubMed

Roberts, Emily

2016-08-12

Regulating risk, freedom of action, and autonomy in decision making are problems shared by both caregivers and residents in long term care settings, and may become the subject of tension and constant negotiation. This study focuses on long term care staff and management perceptions of day to day life in a care community which has gone through a culture change transition, where small residentially scaled households replace large instutional models of care. In each household, the setting is considered to be home for the 8-12 residents, creating a major shift of roles for the caregivers; they are, in essence, coming into a home rather than institutional environment as a place of work. This potentially changes the dynamics of both patterns of work for caregivers and patterns of daily living for residents. Participant observations and care staff interviews. Several key themes emrged which include: teamwork; the culture of care; regulating risk; the physical environment and care staff empowerment. An unexpected outcome was the consensus among care staff that it is they who feel at home while working in the care households, leading to empowerment in their work roles and a deeper understanding of the importance of their role in the lives of the residents.

Profiling for primary-care presentation, investigation and referral for liver cancers: evidence from a national audit.

PubMed

Hughes, Daniel L; Neal, Richard D; Lyratzopoulos, Georgios; Rubin, Greg

2016-04-01

The incidence of liver cancer across Europe is increasing. There is a lack of evidence within the current literature on the identification and investigation of liver cancer within primary care. We aimed to profile liver cancer recognition and assessment as well as the timeliness of liver cancer diagnosis from within the primary-care setting in the UK. Data were obtained from the National Audit of Cancer Diagnosis in Primary Care 2009-2010 and analysed. We calculated the patient interval, the primary-care interval and the number of prereferral consultations for liver cancer. We then compared these data with prior data on the respective indicators for other common cancers. The median patient interval was 9 days (interquartile range 0-31 days), and the median primary-care interval for liver cancer was 11 days (interquartile range 0-40 days). Of the 90 patients, 21 (23.3%) had three or more consultations with their general practitioner before specialist referral. For the three metrics (patient interval, primary-care interval and number of prereferral consultations), liver cancer has average or longer intervals when compared with other cancers. The most common symptomatic presentation of liver cancer within the primary-care setting was right upper quadrant pain (11%), followed by decompensated liver failure (9%). Of the patients, 12% were diagnosed with liver cancer on the basis of an incidental finding of an abnormal liver function test. This study provides a detailed and thorough overview of the recognition of liver cancer and the promptness of liver cancer identification in an English context, and should inform strategies for improving the timeliness of diagnosis.

Effect of Offering Same-Day ART vs Usual Health Facility Referral During Home-Based HIV Testing on Linkage to Care and Viral Suppression Among Adults With HIV in Lesotho: The CASCADE Randomized Clinical Trial.

PubMed

Labhardt, Niklaus D; Ringera, Isaac; Lejone, Thabo I; Klimkait, Thomas; Muhairwe, Josephine; Amstutz, Alain; Glass, Tracy R

2018-03-20

Home-based HIV testing is a frequently used strategy to increase awareness of HIV status in sub-Saharan Africa. However, with referral to health facilities, less than half of those who test HIV positive link to care and initiate antiretroviral therapy (ART). To determine whether offering same-day home-based ART to patients with HIV improves linkage to care and viral suppression in a rural, high-prevalence setting in sub-Saharan Africa. Open-label, 2-group, randomized clinical trial (February 22, 2016-September 17, 2017), involving 6 health care facilities in northern Lesotho. During home-based HIV testing in 6655 households from 60 rural villages and 17 urban areas, 278 individuals aged 18 years or older who tested HIV positive and were ART naive from 268 households consented and enrolled. Individuals from the same household were randomized into the same group. Participants were randomly assigned to be offered same-day home-based ART initiation (n = 138) and subsequent follow-up intervals of 1.5, 3, 6, 9, and 12 months after treatment initiation at the health facility or to receive usual care (n = 140) with referral to the nearest health facility for preparatory counseling followed by ART initiation and monthly follow-up visits thereafter. Primary end points were rates of linkage to care within 3 months (presenting at the health facility within 90 days after the home visit) and viral suppression at 12 months, defined as a viral load of less than 100 copies/mL from 11 through 14 months after enrollment. Among 278 randomized individuals (median age, 39 years [interquartile range, 28.0-52.0]; 180 women [65.7%]), 274 (98.6%) were included in the analysis (137 in the same-day group and 137 in the usual care group). In the same-day group, 134 (97.8%) indicated readiness to start ART that day and 2 (1.5%) within the next few days and were given a 1-month supply of ART. At 3 months, 68.6% (94) in same-day group vs 43.1% (59) in usual care group had linked to care (absolute difference, 25.6%; 95% CI, 13.8% to 36.3%; P < .001). At 12 months, 50.4% (69) in the same-day group vs 34.3% (47) in usual care group achieved viral suppression (absolute difference, 16.0%; 4.4%-27.2%; P = .007). Two deaths (1.5%) were reported in the same-day group, none in usual care group. Among adults in rural Lesotho, a setting of high HIV prevalence, offering same-day home-based ART initiation to individuals who tested positive during home-based HIV testing, compared with usual care and standard clinic referral, significantly increased linkage to care at 3 months and HIV viral suppression at 12 months. These findings support the practice of offering same-day ART initiation during home-based HIV testing. clinicaltrials.gov Identifier: NCT02692027.

Students with Specialized Health Care Needs. ERIC Digest #458.

ERIC Educational Resources Information Center

Sirvis, Barbara

Students with specialized health care needs require specialized technological health care procedures for life support and/or health support during the school day. They may or may not require special education. These children were previously unserved in educational settings. Estimation of their numbers is difficult, but as many as 100,000 infants…

Outpatient Palliative Care and Aggressiveness of End-of-Life Care in Patients with Metastatic Colorectal Cancer.

PubMed

Lee, Si Won; Jho, Hyun Jung; Baek, Ji Yeon; Shim, Eun Kyung; Kim, Hyun Mi; Ku, Ji Yeon; Nam, Eun Jung; Chang, Yoon-Jung; Choi, Hye Jin; Kim, Sun Young

2018-01-01

Palliative care in outpatient setting has been shown to promote better symptom management and transition to hospice care among patients with advanced cancer. Nevertheless, specialized palliative care is rarely provided at cancer centers in Korea. Herein, we aimed to assess aggressiveness of end-of-life care for patients with metastatic colorectal cancer according to the use of outpatient palliative care (OPC) at a single cancer center in Korea. We performed a retrospective medical record review for 132 patients with metastatic colorectal cancer who died between 2011 and 2014. Fifty patients used OPC (OPC group), while 82 patients did not (non-OPC group). Indicators of aggressiveness of end-of-life care including chemotherapy use, emergency department visits, hospitalization, and utilization of hospice care were analyzed according to the use of OPC. More patients in the OPC group were admitted to hospice than those in the non-OPC group (32% vs 17%, P = .047). The mean of inpatient days within 30 days of death was shorter for the OPC group than the non-OPC group (4.02 days vs 7.77 days, respectively, P = .032). There were no differences in the proportions of patients who received chemotherapy and visited the emergency department within 30 days from death. Among patients with metastatic colorectal cancer, OPC was associated with shorter inpatient days near death and greater hospice utilization. Further prospective studies are needed to evaluate the impact of OPC on end-of-life care in Korea.

Feasibility of Training Early Childhood Educators in a Community Child Care Setting Using a Caregiver-Mediated Intervention for Toddlers with Autism Spectrum Disorder

ERIC Educational Resources Information Center

Brian, Jessica; Bernardi, Kate; Dowds, Erin; Easterbrook, Rachel; MacWilliam, Stacey; Bryson, Susan

2017-01-01

Parent-mediated intervention programs have demonstrated benefits for toddlers with autism spectrum disorder (ASD). Interest is emerging in other community-level models, such as those that can be integrated into child care settings. These programs have the potential to reach a wide range of high-risk toddlers who spend the majority of their day in…

Economic, Social and Policy Aspects of Child Care: A Quantitative Analysis of Child Care Arrangements of Working Mothers. Report of a Study.

ERIC Educational Resources Information Center

Angrist, Shirley S.; Lave, Judith R.

To determine what child care arrangements are made by employed mothers, how much they spend for child care, and their potential use of other arrangements including day care, a study was conducted in the Pittsburgh area early in 1973. Included were four work settings which employ women in a variety of occupations. A structured questionnaire was…

KSC-99pp1246

NASA Image and Video Library

1999-10-22

Volunteers for Days of Caring '99 set up the paint trays for painting at Baxley Manor, an apartment building for senior citizens on Merritt Island. Coordinated by the KSC Community Relations Council, Days of Caring provides an opportunity for employees to volunteer their services in projects such as painting, planting flowers, reading to school children, and more. Organizations accepting volunteers include The Embers, Yellow Umbrella, Serene Harbor, Domestic Violence Program, the YMCA of Brevard County, and others

Comparative Analysis of Resource Utilization and Safety of Outpatient Management Following Intensive AML Induction/Salvage Chemotherapy

PubMed Central

Vaughn, Jennifer E.; Othus, Megan; Powell, Morgan A.; Gardner, Kelda M.; Rizzuto, Donelle L.; Hendrie, Paul C.; Becker, Pamela S.; Pottinger, Paul S.; Estey, Elihu H.; Walter, Roland B.

2016-01-01

Importance Adults with acute myeloid leukemia (AML) typically remain hospitalized after induction or salvage chemotherapy until blood count recovery, with resulting prolonged inpatient stays being a primary driver of healthcare cost. Pilot studies suggest that outpatient management following chemotherapy might be safe and could reduce cost for these patients. Objective To compare safety, resource utilization, infections and cost between adults discharged early following AML induction or salvage chemotherapy and inpatient controls. Design Non-randomized phase 2 study. Setting Single center study conducted at the University of Washington Medical Center in Seattle, WA. Participants Over a 43-month period (January 1, 2011 – July 31, 2014), 178 adults receiving intensive AML chemotherapy were enrolled. After completion of chemotherapy, 107 met pre-designated medical and logistical criteria for early discharge (ED), while 29 met medical criteria only and served as inpatient controls. Interventions for Clinical Trials ED patients were discharged from the hospital at the completion of chemotherapy, and supportive care was provided in the outpatient setting until count recovery (median 21 days, range 2–45 days). Controls received inpatient supportive care (median 16 days, range 3–42 days). Main Outcome Measures 1) differences in early mortality 2) differences in resource utilization (ICU days, transfusions/study-day and IV antibiotics/study-day) 3) numbers of infections and 3) total and inpatient charges/study-day between early discharge patients and controls. Results Four patients discharged early (4%) but no controls died within 30 days of enrollment (p=0.58). Nine patients discharged early (8%) but no controls required intensive care unit-level care (p=0.20). No differences were noted in the average daily number of red blood cell (p=0.55) or platelet (p=0.31) transfusions. Patients discharged early did have more positive blood cultures (p=0.04) but required fewer days of IV antibiotics (p=0.007). Overall, daily charges among discharged patients were significantly lower (median $3,840 vs. $5,852; p<0.001) despite increased charges per inpatient day when readmitted (median $7,405 vs. $6,267; p<0.001). Conclusions and Relevance Early dischargefollowing intensive AML chemotherapy can reduce cost and use of IV antibiotics, but attention should be paid to complications that may occur in the outpatient setting. This study was registered at www.ClinicalTrials.gov (NCT01235572). PMID:26355382

The frequency of outdoor play for preschool age children cared for at home-based child care settings.

PubMed

Tandon, Pooja S; Zhou, Chuan; Christakis, Dimitri A

2012-01-01

Given that more than 34% of U.S. children are cared for in home-based child care settings and outdoor play is associated with physical activity and other health benefits, we sought to characterize the outdoor play frequency of preschoolers cared for at home-based child care settings and factors associated with outdoor play. Cross-sectional study of 1900 preschoolers (representing approximately 862,800 children) cared for in home-based child care settings (including relative and nonrelative care) using the nationally representative Early Childhood Longitudinal Study, Birth Cohort. Only 50% of home-based child care providers reported taking the child outside to walk or play at least once/day. More than one-third of all children did not go outside to play daily with either their parent(s) or home-based child care provider. There were increased odds of going outside daily for children cared for by nonrelatives in the child's home compared with care from a relative. Children with ≥3 regular playmates had greater odds of being taken outdoors by either the parents or child care provider. We did not find statistically significant associations between other child level (age, sex, screen-time), family level (highest education in household, mother's race, employment, exercise frequency), and child care level (hours in care, provider's educational attainment, perception of neighborhood safety) factors and frequency of outdoor play. At a national level, the frequency of outdoor play for preschoolers cared for in home-based child care settings is suboptimal. Further study and efforts to increase outdoor playtime for children in home-based child care settings are needed. Copyright © 2012 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Influence of Structured Group Experience on Moral Judgments of Preschoolers.

ERIC Educational Resources Information Center

Moran, James D., III; O'Brien, Gayle

This study examines the influence of social experiences received in a group-care setting on the development of moral reasoning in young children. Thirty-five children approximately 4 years old, participated in the study. Twenty of the subjects attended day care or nursery school; the remaining 15 did not attend any group-care programs. Each child…

Building compassion literacy: Enabling care in primary health care nursing.

PubMed

Burridge, Letitia Helen; Winch, Sarah; Kay, Margaret; Henderson, Amanda

This paper introduces the concept of compassion literacy and discusses its place in nursing within the general practice setting. Compassion literacy is a valuable competency for sustaining the delivery of high quality care. Being compassion literate enables practice nurses to provide compassionate care to their patients and to recognise factors that may constrain this. A compassion literate practice nurse may be more protected from compassion fatigue and its negative consequences. Understanding how to enable self-compassion and how to support the delivery of compassionate care within the primary care team can enhance the care experienced by the patient while improving the positive engagement and satisfaction of the health professionals. The capacity to deliver compassionate care can be depleted by the day-to-day demands of the clinical setting. Compassion literacy enables the replenishing of compassion, but the development of compassion literacy can be curtailed by personal and workplace barriers. This paper articulates why compassion literacy should be an integral aspect of practice nursing and considers strategies for enabling compassion literacy to develop and thrive within the workplace environment. Compassion literacy is also a valuable opportunity for practice nurses to demonstrate their key role within the multidisciplinary team of general practice, directly enhancing the quality of the care delivered.

A partnership model for implementing electronic health records in resource-limited primary care settings: experiences from two nurse-managed health centers

PubMed Central

Dennehy, Patricia; White, Mary P; Hamilton, Andrew; Pohl, Joanne M; Tanner, Clare; Onifade, Tiffiani J

2011-01-01

Objective To present a partnership-based and community-oriented approach designed to ease provider anxiety and facilitate the implementation of electronic health records (EHR) in resource-limited primary care settings. Materials and Methods The approach, referred to as partnership model, was developed and iteratively refined through the research team's previous work on implementing health information technology (HIT) in over 30 safety net practices. This paper uses two case studies to illustrate how the model was applied to help two nurse-managed health centers (NMHC), a particularly vulnerable primary care setting, implement EHR and get prepared to meet the meaningful use criteria. Results The strong focus of the model on continuous quality improvement led to eventual implementation success at both sites, despite difficulties encountered during the initial stages of the project. Discussion There has been a lack of research, particularly in resource-limited primary care settings, on strategies for abating provider anxiety and preparing them to manage complex changes associated with EHR uptake. The partnership model described in this paper may provide useful insights into the work shepherded by HIT regional extension centers dedicated to supporting resource-limited communities disproportionally affected by EHR adoption barriers. Conclusion NMHC, similar to other primary care settings, are often poorly resourced, understaffed, and lack the necessary expertise to deploy EHR and integrate its use into their day-to-day practice. This study demonstrates that implementation of EHR, a prerequisite to meaningful use, can be successfully achieved in this setting, and partnership efforts extending far beyond the initial software deployment stage may be the key. PMID:21828225

High-Value, Cost-Conscious Care: Iterative Systems-Based Interventions to Reduce Unnecessary Laboratory Testing.

PubMed

Sadowski, Brett W; Lane, Alison B; Wood, Shannon M; Robinson, Sara L; Kim, Chin Hee

2017-09-01

Inappropriate testing contributes to soaring healthcare costs within the United States, and teaching hospitals are vulnerable to providing care largely for academic development. Via its "Choosing Wisely" campaign, the American Board of Internal Medicine recommends avoiding repetitive testing for stable inpatients. We designed systems-based interventions to reduce laboratory orders for patients admitted to the wards at an academic facility. We identified the computer-based order entry system as an appropriate target for sustainable intervention. The admission order set had allowed multiple routine tests to be ordered repetitively each day. Our iterative study included interventions on the automated order set and cost displays at order entry. The primary outcome was number of routine tests controlled for inpatient days compared with the preceding year. Secondary outcomes included cost savings, delays in care, and adverse events. Data were collected over a 2-month period following interventions in sequential years and compared with the year prior. The first intervention led to 0.97 fewer laboratory tests per inpatient day (19.4%). The second intervention led to sustained reduction, although by less of a margin than order set modifications alone (15.3%). When extrapolating the results utilizing fees from the Centers for Medicare and Medicaid Services, there was a cost savings of $290,000 over 2 years. Qualitative survey data did not suggest an increase in care delays or near-miss events. This series of interventions targeting unnecessary testing demonstrated a sustained reduction in the number of routine tests ordered, without adverse effects on clinical care. Published by Elsevier Inc.

Changing practice in residential aged care using participatory methods.

PubMed

Lindeman, M A; Black, K; Smith, R; Gough, J; Bryce, A; Gilsenan, B; Hill, K; Stewart, A

2003-03-01

Residential aged care staff play a significant role in the day-to-day lives of residents yet are faced with many barriers to providing care that promotes resident wellbeing. Action research is a useful approach for clarifying issues, identifying education and training needs, and identifying, and in some cases overcoming, organizational barriers to change. The Well for Life project aimed to enhance the social and physical health and well being of residents of aged care settings by empowering the staff of facilities to make change. The project had a particular focus on nutrition and physical activity. This paper reports on the action research group process undertaken during Phase I of the Well for Life project. Five residential aged care settings participated in the action research process facilitated by project staff independent of the facilities. The action plan and outcomes from one of these settings is used to illustrate the process and outcomes. The main findings of the project indicate that using a process that encourages staff involvement in identification of issues and actions can facilitate change in the practice of resident care. The action research groups identified specific gaps in knowledge and skill leading to targeted education that addressed areas of need. The importance of presenting information and learning opportunities for staff in a variety of formats was also recognized, as was the importance of organizational context, management support and empowerment of staff to make change.

Feasibility of implementing oral health guidelines in residential care settings: views of nursing staff and residential care workers.

PubMed

Hilton, Shaylee; Sheppard, Justine Joan; Hemsley, Bronwyn

2016-05-01

To determine the views of nurses and on the feasibility of implementing current evidence-based guidelines for oral care, examining barriers and facilitators to implementation. This mixed-methods study involved an online survey of 35 nurses and residential care workers, verified and expanded upon by one focus group of six residential care workers. Results reflected that nurses and residential care workers (a) have little or no training in recommended oral care techniques, and (b) lack access to the equipment and professional supports needed to provide adequate oral care. Basic oral care might be performed less than once per day in some settings and patients with problematic behaviours, dysphagia, or sensitivities associated with poor oral health might be less likely to receive oral care. While lack of time was highlighted as a barrier in the survey findings, focus group members considered that time should not be a barrier to prioritising oral care practices on a daily basis in residential care settings. There are several important discrepancies between the recommendations made in evidence-based guidelines for oral care and the implementation of such practices in residential care settings. Nursing and residential care staff considered adequate oral care to be feasible if access, funding and training barriers are removed and facilitators enhanced. Copyright © 2015 Elsevier Inc. All rights reserved.

Volunteers in Specialist Palliative Care: A Survey of Adult Services in the United Kingdom

PubMed Central

Burbeck, Rachel; Low, Joe; Sampson, Elizabeth L.; Bravery, Ruth; Hill, Matthew; Morris, Sara; Ockenden, Nick; Payne, Sheila

2014-01-01

Abstract Background: Worldwide, the demand for specialist palliative care is increasing but funding is limited. The role of volunteers is underresearched, although their contribution reduces costs significantly. Understanding what volunteers do is vital to ensure services develop appropriately to meet the challenges faced by providers of palliative care. Objective: The study's objective is to describe current involvement of volunteers with direct patient/family contact in U.K. specialist palliative care. Design: An online survey was sent to 290 U.K. adult hospices and specialist palliative care services involving volunteers covering service characteristics, involvement and numbers of volunteers, settings in which they are involved, extent of involvement in care services, specific activities undertaken in each setting, and use of professional skills. Results: The survey had a 67% response rate. Volunteers were most commonly involved in day care and bereavement services. They entirely ran some complementary therapy, beauty therapy/hairdressing, and pastoral/faith-based care services, and were involved in a wide range of activities, including sitting with dying patients. Conclusions: This comprehensive survey of volunteer activity in U.K. specialist palliative care provides an up-to-date picture of volunteer involvement in direct contact with patients and their families, such as providing emotional care, and the extent of their involvement in day and bereavement services. Further research could focus on exploring their involvement in bereavement care. PMID:24475743

Does community health care require different competencies from physicians and nurses?

PubMed Central

2014-01-01

Background Recently competency approach in Health Professionals’ Education (HPE) has become quite popular and for an effective competency based HPE, it is important to design the curriculum around the health care needs of the population to be served and on the expected roles of the health care providers. Unfortunately, in community settings roles of health providers tend to be described less clearly, particularly at the Primary Health Care (PHC) level where a multidisciplinary and appropriately prepared health team is generally lacking. Moreover, to tailor the education on community needs there is no substantial evidence on what specific requirements the providers must be prepared for. Methods This study has explored specific tasks of physicians and nurses employed to work in primary or secondary health care units in a context where there is a structural scarcity of community health care providers. In-depth Interviews of 11 physicians and 06 nurses working in community settings of Pakistan were conducted along with review of their job descriptions. Results At all levels of health settings, physicians’ were mostly engaged with diagnosing and prescribing medical illness of patients coming to health center and nurses depending on their employer were either providing preventive health care activities, assisting physicians or occupied in day to day management of health center. Geographical location or level of health facility did not have major effect on the roles being expected or performed, however the factors that determined the roles performed by health providers were employer expectations, preparation of health providers for providing community based care, role clarity and availability of resources including health team at health facilities. Conclusions Exploration of specific tasks of physicians and nurses working in community settings provide a useful framework to map competencies, and can help educators revisit the curricula and instructional designs accordingly. Furthermore, in community settings there are many synergies between the roles of physicians and nurses which could be simulated as learning activities; at the same time these two groups of health providers offer distinct sets of services, which must be harnessed to build effective, non-hierarchal, collaborative health teams. PMID:24387322

Social Context of Work Injury Among Undocumented Day Laborers in San Francisco

PubMed Central

Walter, Nicholas; Bourgois, Philippe; Loinaz, H Margarita; Schillinger, Dean

2002-01-01

OBJECTIVE To identify ways in which undocumented day laborers' social context affects their risk for occupational injury, and to characterize the ways in which these workers' social context influences their experience of disability. DESIGN Qualitative study employing ethnographic techniques of participant-observation, supplemented by semistructured in-depth interviews. SETTINGS Street corners in San Francisco's Mission District, a homeless shelter, and a nonprofit day labor hiring hall. PARTICIPANTS Thirty-eight Mexican and Central American male day laborers, 11 of whom had been injured. PRIMARY THEMES Anxiety over the potential for work injury is omnipresent for day laborers. They work in dangerous settings, and a variety of factors such as lack of training, inadequate safety equipment, and economic pressures further increase their risk for work injury. The day laborers are isolated from family and community support, living in a local context of homelessness, competition, and violence. Injuries tend to have severe emotional, social, and economic ramifications. Day laborers frequently perceive injury as a personal failure that threatens their masculinity and their status as patriarch of the family. Their shame and disappointment at failing to fulfill culturally defined masculine responsibilities leads to intense personal stress and can break family bonds. Despite the high incidence of work injuries and prevalence of work-related health conditions, day laborers are frequently reluctant to use health services due to anxiety regarding immigration status, communication barriers, and economic pressure. IMPLICATIONS On the basis of these ethnographic data, we recommend strategies to improve ambulatory care services to day laborers in 3 areas: structural changes in ambulatory care delivery, clinical interactions with individual day laborers, and policymaking around immigration and health care issues. PMID:11929509

Cardiac acute care nurse practitioner and 30-day readmission.

PubMed

David, Daniel; Britting, Lorraine; Dalton, Joanne

2015-01-01

The utilization outcomes of nurse practitioners (NPs) in the acute care setting have not been widely studied. The purpose of this study was to determine the impact on utilization outcomes of NPs on medical teams who take care of patients admitted to a cardiovascular intensive care unit. A retrospective 2-group comparative design was used to evaluate the outcomes of 185 patients with ST- or non ST-segment elevation myocardial infarction or heart failure who were admitted to a cardiovascular intensive care unit in an urban medical center. Patients received care from a medical team that included a cardiac acute care NP (n = 109) or medical team alone (n = 76). Patient history, cardiac assessment, medical interventions, discharge disposition, discharge time, and 3 utilization outcomes (ie, length of stay, 30-day readmission, and time of discharge) were compared between the 2 treatment groups. Logistic regression was used to identify predictors of 30-day readmission. Patients receiving care from a medical team that included an NP were rehospitalized approximately 50% less often compared with those receiving care from a medical team without an NP. Thirty-day hospital readmission (P = .011) and 30-day return rates to the emergency department (P = .021) were significantly lower in the intervention group. Significant predictors for rehospitalization included diagnosis of heart failure versus myocardial infarction (odds ratio [OR], 3.153, P = 0.005), treatment by a medical team without NP involvement (OR, 2.905, P = 0.008), and history of diabetes (OR, 2.310, P = 0.032). The addition of a cardiac acute care NP to medical teams caring for myocardial infarction and heart failure patients had a positive impact on 30-day emergency department return and hospital readmission rates.

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2011 CFR

2011-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2012 CFR

2012-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2013 CFR

2013-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2014 CFR

2014-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

Identifying models of delivery, care domains and quality indicators relevant to palliative day services: a scoping review protocol.

PubMed

O'Connor, Seán R; Dempster, Martin; McCorry, Noleen K

2017-05-16

With an ageing population and increasing numbers of people with life-limiting illness, there is a growing demand for palliative day services. There is a need to measure and demonstrate the quality of these services, but there is currently little agreement on which aspects of care should be used to do this. The aim of the scoping review will be to map the extent, range and nature of the evidence around models of delivery, care domains and existing quality indicators used to evaluate palliative day services. Electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials) will be searched for evidence using consensus development methods; randomised or quasi-randomised controlled trials; mixed methods; and prospective, longitudinal or retrospective case-control studies to develop or test quality indicators for evaluating palliative care within non-residential settings, including day hospices and community or primary care settings. At least two researchers will independently conduct all searches, study selection and data abstraction procedures. Meta-analyses and statistical methods of synthesis are not planned as part of the review. Results will be reported using numerical counts, including number of indicators in each care domain and by using qualitative approach to describe important indicator characteristics. A conceptual model will also be developed to summarise the impact of different aspects of quality in a palliative day service context. Methodological quality relating to indicator development will be assessed using the Appraisal of Indicators through Research and Evaluation (AIRE) tool. Overall strength of evidence will be assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Final decisions on quality assessment will be made via consensus between review authors. Identifying, developing and implementing evidence-based quality indicators is critical to the evaluation and continued improvement of palliative care. Review findings will be used to support clinicians and policymakers make decisions on which quality indicators are most appropriate for evaluating day services at the patient and service level, and to identify areas for further research.

Development of Sex-Typed Play Behavior in Toddlers.

ERIC Educational Resources Information Center

O'Brien, Marion; Huston, Aletha C.

1985-01-01

Observed play of 52 toddlers with a set of socially stereotyped masculine, feminine, and neutral toys in a day care setting over 14 months to (1) determine the age at which toddlers consistently exhibit sex-stereotyped toy choices in a natural setting and (2) investigate relation of parents' expectations and the children's own knowledge of gender…

[Intensive care and radio, two universes that feed of each other].

PubMed

Houguet, Morgan

2014-04-01

The discovery of the healthcare environment can be a stupefying and sometimes difficult process. It is a setting where life rubs shoulders with death every day and where laughter and tears are equally commonplace. Morgan Houguet, a young nurse, shares the humanity of his practice in intensive care.

School-Age Ideas and Activities for After School Programs.

ERIC Educational Resources Information Center

Haas-Foletta, Karen; Cogley, Michele

This guide describes activities for school-age children in after-school day care programs. These activities may also be used in other settings. An introductory section discusses program philosophy, room arrangement, multicultural curriculum, program scheduling, summer programs and holiday care, field trips and special programs, age grouping,…

Parents' Perceptions of Preschool Activities: Exploring Outdoor Play

ERIC Educational Resources Information Center

Jayasuriya, Avanthi; Williams, Marcia; Edwards, Todd; Tandon, Pooja

2016-01-01

Research Findings: Outdoor play is important for children's health and development, yet many preschool-age children in child care settings do not receive the recommended 60 min/day of outdoor play. Child care providers have previously described parent-related barriers to increasing outdoor playtime, including parents not providing appropriate…

Homeopathic and conventional treatment for acute respiratory and ear complaints: A comparative study on outcome in the primary care setting

PubMed Central

Haidvogl, Max; Riley, David S; Heger, Marianne; Brien, Sara; Jong, Miek; Fischer, Michael; Lewith, George T; Jansen, Gerard; Thurneysen, André E

2007-01-01

Background The aim of this study was to assess the effectiveness of homeopathy compared to conventional treatment in acute respiratory and ear complaints in a primary care setting. Methods The study was designed as an international, multi-centre, comparative cohort study of non-randomised design. Patients, presenting themselves with at least one chief complaint: acute (≤ 7 days) runny nose, sore throat, ear pain, sinus pain or cough, were recruited at 57 primary care practices in Austria (8), Germany (8), the Netherlands (7), Russia (6), Spain (6), Ukraine (4), United Kingdom (10) and the USA (8) and given either homeopathic or conventional treatment. Therapy outcome was measured by using the response rate, defined as the proportion of patients experiencing 'complete recovery' or 'major improvement' in each treatment group. The primary outcome criterion was the response rate after 14 days of therapy. Results Data of 1,577 patients were evaluated in the full analysis set of which 857 received homeopathic (H) and 720 conventional (C) treatment. The majority of patients in both groups reported their outcome after 14 days of treatment as complete recovery or major improvement (H: 86.9%; C: 86.0%; p = 0.0003 for non-inferiority testing). In the per-protocol set (H: 576 and C: 540 patients) similar results were obtained (H: 87.7%; C: 86.9%; p = 0.0019). Further subgroup analysis of the full analysis set showed no differences of response rates after 14 days in children (H: 88.5%; C: 84.5%) and adults (H: 85.6%; C: 86.6%). The unadjusted odds ratio (OR) of the primary outcome criterion was 1.40 (0.89–2.22) in children and 0.92 (0.63–1.34) in adults. Adjustments for demographic differences at baseline did not significantly alter the OR. The response rates after 7 and 28 days also showed no significant differences between both treatment groups. However, onset of improvement within the first 7 days after treatment was significantly faster upon homeopathic treatment both in children (p = 0.0488) and adults (p = 0.0001). Adverse drug reactions occurred more frequently in adults of the conventional group than in the homeopathic group (C: 7.6%; H: 3.1%, p = 0.0032), whereas in children the occurrence of adverse drug reactions was not significantly different (H: 2.0%; C: 2.4%, p = 0.7838). Conclusion In primary care, homeopathic treatment for acute respiratory and ear complaints was not inferior to conventional treatment. PMID:17335565

Rethinking transitions of care: An interprofessional transfer triage protocol in post-acute care.

PubMed

Patel, Radha V; Wright, Lauri; Hay, Brittany

2017-09-01

Readmissions to hospitals from post-acute care (PAC) units within long-term care settings have been rapidly increasing over the past decade, and are drivers of increased healthcare costs. With an average of $11,000 per admission, there is a need for strategies to reduce 30-day preventable hospital readmission rates. In 2018, incentives and penalties will be instituted for long-term care facilities failing to meet all-cause, all-condition hospital readmission rate performance measures. An interprofessional team (IPT) developed and implemented a Transfer Triage Protocol used in conjunction with the INTERACT programme to enhance clinical decision-making and assess the potential to reduce the facility's 30-day preventable hospital readmission rates by 10% within 6 weeks of implementation. Results from quantitative analysis demonstrated an overall 35.2% reduction in the 30-day preventable hospital readmission rate. Qualitative analysis revealed the need for additional staff education, improved screening and communication upon admission and prior to hospital transfer, and the need for more IPT on-site availability. This pilot study demonstrates the benefits and implications for practice of an IPT to improve the quality of care within PAC and decrease 30-day preventable hospital readmissions.

Building Literacy. Beginnings Workshop.

ERIC Educational Resources Information Center

Lombardi, Joan; Curry-Rood, Leah; Racin, Jean Berry; Schickedanz, Judith A.; Allison, Jeanette

1999-01-01

Presents five articles discussing aspects of literacy promotion in the day care center setting: "Promoting Language, Literacy, and a Love of Learning Makes a Difference (Joan Lombardi); "Creating Readers" (Leah Curry-Rood); "Family Literacy" (Jean Berry Racin); "Setting the Stage for Literacy Events in the Classroom" (Judith A. Schickedanz); and…

Mortality related to acute illness and injury in rural Uganda: task shifting to improve outcomes.

PubMed

Chamberlain, Stacey; Stolz, Uwe; Dreifuss, Bradley; Nelson, Sara W; Hammerstedt, Heather; Andinda, Jovita; Maling, Samuel; Bisanzo, Mark

2015-01-01

Due to the dual critical shortages of acute care and healthcare workers in resource-limited settings, many people suffer or die from conditions that could be easily treated if existing resources were used in a more timely and effective manner. In order to address this preventable morbidity and mortality, a novel emergency midlevel provider training program was developed in rural Uganda. This is the first study that assesses this unique application of a task-shifting model to acute care by evaluating the outcomes of 10,105 patients. Nurses participated in a two-year training program to become midlevel providers called Emergency Care Practitioners at a rural district hospital. This is a retrospective analysis of the Emergency Department's quality assurance database, including three-day follow-up data. Case fatality rates (CFRs) are reported as the percentage of cases with a specific diagnosis that died within three days of their Emergency Department visit. Overall, three-day mortality was 2.0%. The most common diagnoses of patients who died were malaria (n=60), pneumonia (n=51), malnutrition (n=21), and trauma (n=18). Overall and under-five CFRs were as follows: malaria, 2.0% and 1.9%; pneumonia, 5.5% and 4.1%; and trauma, 1.2% and 1.6%. Malnutrition-related fatality (all cases <18 years old) was 6.5% overall and 6.8% for under-fives. This study describes the outcomes of emergency patients treated by midlevel providers in a resource-limited setting. Our fatality rates are lower than previously published regional rates. These findings suggest this model of task-shifting can be successfully applied to acute care in order to address the shortage of emergency care services in similar settings as part of an integrated approach to health systems strengthening.

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

Recognition and assessment of resident' deterioration in the nursing home setting: A critical ethnography.

PubMed

Laging, Bridget; Kenny, Amanda; Bauer, Michael; Nay, Rhonda

2018-04-01

To explore the recognition and assessment of resident deterioration in the nursing home setting. There is a dearth of research exploring how nurses and personal-care-assistants manage a deteriorating nursing home resident. Critical ethnography. Observation and semi-structured interviews with 66 participants (general medical practitioners, nurses, personal-care-assistants, residents and family members) in two Australian nursing homes. The study has been reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines. The value of nursing assessment is poorly recognised in the nursing home setting. A lack of clarity regarding the importance of nursing assessments associated with resident care has contributed to a decreasing presence of registered nurses and an increasing reliance on personal-care-assistants who had inadequate skills and knowledge to recognise signs of deterioration. Registered nurses experienced limited organisational support for autonomous decision-making and were often expected to undertake protocol-driven decisions that contributed to potentially avoidable hospital transfers. Nurses need to demonstrate the importance of assessment, in association with day-to-day resident care and demand standardised, regulated, educational preparation of an appropriate workforce who are competent in undertaking this role. Workforce structures that enhance familiarity between nursing home staff and residents could result in improved resident outcomes. The value of nursing assessment, in guiding decisions at the point of resident deterioration, warrants further consideration. © 2018 John Wiley & Sons Ltd.

Building the capacity of family day care educators to promote children's social and emotional wellbeing: an exploratory cluster randomised controlled trial.

PubMed

Davis, Elise; Williamson, Lara; Mackinnon, Andrew; Cook, Kay; Waters, Elizabeth; Herrman, Helen; Sims, Margaret; Mihalopoulos, Cathrine; Harrison, Linda; Marshall, Bernard

2011-11-03

Childhood mental health problems are highly prevalent, experienced by one in five children living in socioeconomically disadvantaged families. Although childcare settings, including family day care are ideal to promote children's social and emotional wellbeing at a population level in a sustainable way, family day care educators receive limited training in promoting children's mental health. This study is an exploratory wait-list control cluster randomised controlled trial to test the appropriateness, acceptability, cost, and effectiveness of "Thrive," an intervention program to build the capacity of family day care educators to promote children's social and emotional wellbeing. Thrive aims to increase educators' knowledge, confidence and skills in promoting children's social and emotional wellbeing. This study involves one family day care organisation based in a low socioeconomic area of Melbourne. All family day care educators (term used for registered carers who provide care for children for financial reimbursement in the carers own home) are eligible to participate in the study. The clusters for randomisation will be the fieldworkers (n = 5) who each supervise 10-15 educators. The intervention group (field workers and educators) will participate in a variety of intervention activities over 12 months, including workshops; activity exchanges with other educators; and focused discussion about children's social and emotional wellbeing during field worker visits. The control group will continue with their normal work practice. The intervention will be delivered to the intervention group and then to the control group after a time delay of 15 months post intervention commencement. A baseline survey will be conducted with all consenting educators and field workers (n = ~70) assessing outcomes at the cluster and individual level. The survey will also be administered at one month, six months and 12 months post-intervention commencement. The survey consists of questions measuring perceived levels of knowledge, confidence and skills in promoting children's social and emotional wellbeing. As much of this intervention will be delivered by field workers, field worker-family day care educator relationships are key to its success and thus supervisor support will also be measured. All educators will also have an in-home quality of care assessment at baseline, one month, six months and 12 months post-intervention commencement. Process evaluation will occur at one month, six months and 12 months post-intervention commencement. Information regarding intervention fidelity and economics will also be assessed in the survey. A capacity building intervention in child mental health promotion for family day care is an essential contribution to research, policy and practice. This initiative is the first internationally, and essential in building an evidence base of interventions in this extremely policy-timely setting. 343312.

Building the capacity of family day care educators to promote children's social and emotional wellbeing: an exploratory cluster randomised controlled trial

PubMed Central

2011-01-01

Background Childhood mental health problems are highly prevalent, experienced by one in five children living in socioeconomically disadvantaged families. Although childcare settings, including family day care are ideal to promote children's social and emotional wellbeing at a population level in a sustainable way, family day care educators receive limited training in promoting children's mental health. This study is an exploratory wait-list control cluster randomised controlled trial to test the appropriateness, acceptability, cost, and effectiveness of "Thrive," an intervention program to build the capacity of family day care educators to promote children's social and emotional wellbeing. Thrive aims to increase educators' knowledge, confidence and skills in promoting children's social and emotional wellbeing. Methods/Design This study involves one family day care organisation based in a low socioeconomic area of Melbourne. All family day care educators (term used for registered carers who provide care for children for financial reimbursement in the carers own home) are eligible to participate in the study. The clusters for randomisation will be the fieldworkers (n = 5) who each supervise 10-15 educators. The intervention group (field workers and educators) will participate in a variety of intervention activities over 12 months, including workshops; activity exchanges with other educators; and focused discussion about children's social and emotional wellbeing during field worker visits. The control group will continue with their normal work practice. The intervention will be delivered to the intervention group and then to the control group after a time delay of 15 months post intervention commencement. A baseline survey will be conducted with all consenting educators and field workers (n = ~70) assessing outcomes at the cluster and individual level. The survey will also be administered at one month, six months and 12 months post-intervention commencement. The survey consists of questions measuring perceived levels of knowledge, confidence and skills in promoting children's social and emotional wellbeing. As much of this intervention will be delivered by field workers, field worker-family day care educator relationships are key to its success and thus supervisor support will also be measured. All educators will also have an in-home quality of care assessment at baseline, one month, six months and 12 months post-intervention commencement. Process evaluation will occur at one month, six months and 12 months post-intervention commencement. Information regarding intervention fidelity and economics will also be assessed in the survey. Discussion A capacity building intervention in child mental health promotion for family day care is an essential contribution to research, policy and practice. This initiative is the first internationally, and essential in building an evidence base of interventions in this extremely policy-timely setting. Trial Registration number 343312 PMID:22047600

Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care.

PubMed

Nyqvist, K H; Anderson, G C; Bergman, N; Cattaneo, A; Charpak, N; Davanzo, R; Ewald, U; Ibe, O; Ludington-Hoe, S; Mendoza, S; Pallás-Allonso, C; Ruiz Peláez, J G; Sizun, J; Widström, A-M

2010-06-01

The hallmark of Kangaroo Mother Care (KMC) is the kangaroo position: the infant is cared for skin-to-skin vertically between the mother's breasts and below her clothes, 24 h/day, with father/substitute(s) participating as KMC providers. Intermittent KMC (for short periods once or a few times per day, for a variable number of days) is commonly employed in high-tech neonatal intensive care units. These two modalities should be regarded as a progressive adaptation of the mother-infant dyad, ideally towards continuous KMC, starting gradually and progressively with intermittent KMC. The other components in KMC are exclusive breastfeeding (ideally) and early discharge in kangaroo position with strict follow-up. Current evidence allows the following general statements about KMC in affluent and low-income settings: KMC enhances bonding and attachment; reduces maternal postpartum depression symptoms; enhances infant physiologic stability and reduces pain, increases parental sensitivity to infant cues; contributes to the establishment and longer duration of breastfeeding and has positive effects on infant development and infant/parent interaction. Therefore, intrapartum and postnatal care in all types of settings should adhere to a paradigm of nonseparation of infants and their mothers/families. Preterm/low-birth-weight infants should be regarded as extero-gestational foetuses needing skin-to-skin contact to promote maturation. Kangaroo Mother Care should begin as soon as possible after birth, be applied as continuous skin-to-skin contact to the extent that this is possible and appropriate and continue for as long as appropriate.

Kangaroo Mother Care (KMC) in LBW infants--a western Rajasthan experience.

PubMed

Gupta, Mukesh; Jora, Rakesh; Bhatia, Ravi

2007-08-01

This study was taken to study the various beneficial effects of KMC in LBW babies. 50 LBW babies (birth weight> 2 kg) two who delivered at Umaid Hospital, RIMCH Jodhpur included in this study and they have given KMC 4-6 hours/day in 3-4 settings. Maternal & Neonatal characteristics and complications prospectively recorded. Of 50 LBW babies enrolled, M:F ratio was 1.5:1 and mean birth weight was 1.487 +/- 0.175 kg. The mean age at which KMC started was 4+/-1.738 days. The mean weight gain was 29 +/- 3.52 g, mean age of discharge 23.6 +/- 3.52 days and mean duration of hospital stay was 15.5 +/- 11.3 days. KMC is effective and safe in stable preterm infants and as effective on traditional care with incubators. KMC because of its simplicity may have a place in home care of LBW babies.

Character Development: Encouraging Self-Esteem & Self-Discipline in Infants, Toddlers, and Two-Year-Olds.

ERIC Educational Resources Information Center

Greenberg, Polly

With the goal of maintaining settings most conducive to helping each child develop optimally, the essays in this book delve into realistic ways in which child care providers can move from providing inadequate or merely adequate day care to providing high quality center-based or family child care. Most of the 12 essays begin with a question or…

3 N.J. Community Colleges Set Up New Programs as Part of State's Plans for Welfare Reform.

ERIC Educational Resources Information Center

Jaschik, Scott

1987-01-01

Bergen Community College, Middlesex County College, and Union County College are setting up (1) counseling programs to help welfare recipients determine their job interests and skills, (2) job-training courses, and (3) day-care centers for participants children. (MLW)

Confidence Bounds and Power for the Reliability of Observational Measures on the Quality of a Social Setting

ERIC Educational Resources Information Center

Shin, Yongyun; Raudenbush, Stephen W.

2012-01-01

Social scientists are frequently interested in assessing the qualities of social settings such as classrooms, schools, neighborhoods, or day care centers. The most common procedure requires observers to rate social interactions within these settings on multiple items and then to combine the item responses to obtain a summary measure of setting…

Effectiveness of app-based relaxation for patients with chronic low back pain (Relaxback) and chronic neck pain (Relaxneck): study protocol for two randomized pragmatic trials.

PubMed

Blödt, Susanne; Pach, Daniel; Roll, Stephanie; Witt, Claudia M

2014-12-15

Chronic low back pain (LBP) and neck pain (NP) are highly prevalent conditions resulting in high economic costs. Treatment guidelines recommend relaxation techniques, such as progressive muscle relaxation, as adjuvant therapies. Self-care interventions could have the potential to reduce costs in the health care system, but their effectiveness, especially in a usual care setting, is unclear. The aim of these two pragmatic randomized studies is to evaluate whether an additional app-delivered relaxation is more effective in the reduction of chronic LBP or NP than usual care alone. Each pragmatic randomized two-armed study aims to include a total of 220 patients aged 18 to 65 years with chronic (>12 weeks) LBP or NP and an average pain intensity of ≥ 4 on a numeric rating scale (NRS) in the 7 days before recruitment. The participants will be randomized into an intervention and a usual care group. The intervention group will be instructed to practice one of these 3 relaxation techniques on at least 5 days/week for 15 minutes/day over a period of 6 months starting on the day of randomization: autogenic training, mindfulness meditation, or guided imagery. Instructions and exercises will be provided using a smartphone app, baseline information will be collected using paper and pencil. Follow-up information (daily, weekly, and after 3 and 6 months) will be collected using electronic diaries and questionnaires included in the app. The primary outcome measure will be the mean LBP or NP intensity during the first 3 months of intervention based on daily pain intensity measurements on a NRS (0 = no pain, 10 = worst possible pain). The secondary outcome parameters will include the mean pain intensity during the first 6 months after randomization based on daily measurements, the mean pain intensity measured weekly as the average pain intensity of the previous 7 days over 3 and 6 months, pain acceptance, 'LBP- and NP-related' stress, sick leave days, pain medication intake, adherence, suspected adverse reaction, and serious adverse events. The designed studies reflect a usual self-care setting and will provide evidence on a pragmatic self-care intervention that is easy to combine with care provided by medical professionals. ClinicalTrials.gov identifier Relaxback NCT02019498, Relaxneck NCT02019134 registered on 18 December 2013.

HIV testing, care referral and linkage to care intervals affect time to engagement in care for newly diagnosed HIV-infected adolescents in fifteen adolescent medicine clinics in the United States

PubMed Central

Philbin, Morgan M.; Tanner, Amanda E.; DuVal, Anna; Ellen, Jonathan M.; Xu, Jiahong; Kapogiannis, Bill; Bethel, Jim; Fortenberry, J. Dennis

2016-01-01

Objective To examine how the time from HIV testing to care referral and from referral to care linkage influenced time to care engagement for newly diagnosed HIV-infected adolescents. Methods We evaluated the Care Initiative, a care linkage and engagement program for HIV-infected adolescents in 15 U.S. clinics. We analyzed client-level factors, provider type and intervals from HIV testing to care referral and from referral to care linkage as predictors of care engagement. Engagement was defined as a second HIV-related medical visit within 16 weeks of initial HIV-related medical visit (linkage). Results At 32 months, 2,143 youth had been referred. Of these, 866 were linked to care through the Care Initiative within 42 days and thus eligible for study inclusion. Of the linked youth, 90.8% were ultimately engaged in care. Time from HIV testing to referral (e.g., ≤7 days versus >365 days) was associated with engagement (AOR=2.91; 95% CI: 1.43–5.94) and shorter time to engagement (Adjusted HR=1.41; 95% CI: 1.11–1.79). Individuals with shorter care referral to linkage intervals (e.g., ≤7 days versus 22–42 days) engaged in care faster (Adjusted HR=2.90; 95% CI: 2.34–3.60) and more successfully (AOR=2.01; 95% CI: 1.04–3.89). Conclusions These data address a critical piece of the care continuum, and can offer suggestions of where and with whom to intervene in order to best achieve the care engagement goals outlined in the U.S. National HIV/AIDS Strategy. These results may also inform programs and policies that set concrete milestones and strategies for optimal care linkage timing for newly diagnosed adolescents. PMID:26885804

What Do Older People Learn from Young People? Intergenerational Learning in "Day Centre" Community Settings in Malta

ERIC Educational Resources Information Center

Spiteri, Damian

2016-01-01

This study analyses what motivates older people to attend "day centres" in Malta and what they believe that they derive from young people who carry out their placements at these day "centres" These young people, who are aged 16-17, attend a vocational college in Malta and are studying health and social care. The study is based…

Unmet Needs of Children with Special Health Care Needs in a Specialized Day School Setting

ERIC Educational Resources Information Center

Aruda, Mary M.; Kelly, Mary; Newinsky, Karina

2011-01-01

Children with Special Health Care Needs (CSHCN) represent a significant component of the pediatric population. They often present to schools with multiple and increasingly complex health issues, including medical technology dependency. Their daily variation in health status requires close monitoring and communication among caregivers. Limited…

Aesthetics in Asian Child Care Settings.

ERIC Educational Resources Information Center

Honig, Alice S.

This speech presents observations, made on a trip in June 1976, of the aesthetic environments of children in China, Japan, and Hong Kong. Home, school and day care environments are compared in terms of living and play space, room decor, the presence of art and toys, dramatic play and performance, music, nature and outdoor appreciation, food and…

Developing Clinical Leaders in Primary Care: The US Air Force Diabetes Champion Course

DTIC Science & Technology

2017-04-03

The US Air Force Diabetes Center of Excellence designed the Diabetes Champion Course (DCC), a semi-annual, 3-day course, to train primary care teams ...and patient flow in a team -based setting. Each team is tasked to identify local deficits and make a Plan of Action (POA) for implementation.

HIV-positive pregnant women attending the prevention of mother-to-child transmission of HIV/AIDS (PMTCT) services in Ethiopia: economic productivity losses across urban-rural settings.

PubMed

Zegeye, Elias Asfaw; Mbonigaba, Josue; Kaye, Sylvia Blanche

2018-06-01

HIV/AIDS impacts significantly on pregnant women and on children in Ethiopia. This impact has a multiplier effect on household economies and on productivity losses, and is expected to vary across rural and urban settings. Applying the human capital approach to data collected from 131 respondents, this study estimated productivity losses per HIV-positive pregnant woman-infant pair across urban and rural health facilities in Ethiopia, which in turn were used to estimate the national productivity loss. The study found that the annual productivity loss per woman-infant pair was Ethiopian birr (ETB) 7,433 or United States dollar (US$) 378 and ETB 625 (US$ 32) in urban and rural settings, respectively. The mean patient days lost per year due to inpatient admission at hospitals/health centres was 11 in urban and 22 in rural health facilities. On average, urban home care-givers spent 20 (SD = 21) days annually providing home care services, while their rural counterparts spent 23 days (SD = 26). The productivity loss accounted for 16% and 7% of household income in urban and rural settings, respectively. These high and varying productivity losses require preventive interventions that are appropriate to each setting to ensure the welfare of women and children in Ethiopia.

Adjustment of inpatient care reimbursement for nursing intensity.

PubMed

Welton, John M; Zone-Smith, Laurie; Fischer, Mary H

2006-11-01

The Centers for Medicare and Medicaid Services has begun an ambitious recalibration of the inpatient prospective payment system, the first since its introduction in 1983. Unfortunately, inpatient nursing care has been overlooked in the new payment system and continues to be treated as a fixed cost and billed at a set per-diem "room and board" fee despite the known variability of nursing intensity across different care settings and diagnoses. This article outlines the historical influences regarding costing, billing, and reimbursement of inpatient nursing care and provides contemporary evidence about the variability of nursing intensity and costs at acute care hospitals in the United States. A remedy is proposed to overcome the existing limitations of the Inpatient Prospective Payment System by creating a new nursing cost center and nursing intensity adjustment by DRG for each routine-and intensive-care day of stay to allow independent costing, billing, and reimbursement of inpatient nursing care.

Total direct cost, length of hospital stay, institutional discharges and their determinants from rehabilitation settings in stroke patients.

PubMed

Saxena, S K; Ng, T P; Yong, D; Fong, N P; Gerald, K

2006-11-01

Length of hospital stay (LOHS) is the largest determinant of direct cost for stroke care. Institutional discharges (acute care and nursing homes) from rehabilitation settings add to the direct cost. It is important to identify potentially preventable medical and non-medical reasons determining LOHS and institutional discharges to reduce the direct cost of stroke care. The aim of the study was to ascertain the total direct cost, LOHS, frequency of institutional discharges and their determinants from rehabilitation settings. Observational study was conducted on 200 stroke patients in two rehabilitation settings. The patients were examined for various socio-demographic, neurological and clinical variables upon admission to the rehabilitation hospitals. Information on total direct cost and medical complications during hospitalization were also recorded. The outcome variables measured were total direct cost, LOHS and discharges to institutions (acute care and nursing home facility) and their determinants. The mean and median LOHS in our study were 34 days (SD = 18) and 32 days respectively. LOHS and the cost of hospital stay were significantly correlated. The significant variables associated with LOHS on multiple linear regression analysis were: (i) severe functional impairment/functional dependence Barthel Index < or = 50, (ii) medical complications, (iii) first time stroke, (iv) unplanned discharges and (v) discharges to nursing homes. Of the stroke patients 19.5% had institutional discharges (22 to acute care and 17 to nursing homes). On multivariate analysis the significant predictors of discharges to institutions from rehabilitation hospitals were medical complications (OR = 4.37; 95% CI 1.01-12.53) and severe functional impairment/functional dependence. (OR = 5.90, 95% CI 2.32-14.98). Length of hospital stay and discharges to institutions from rehabilitation settings are significantly determined by medical complications. Importance of adhering to clinical pathway/protocol for stroke care is further discussed.

Perceived Benefits, Barriers, and Drivers of Telemedicine From the Perspective of Skilled Nursing Facility Administrative Staff Stakeholders.

PubMed

Driessen, Julia; Castle, Nicholas G; Handler, Steven M

2018-01-01

Potentially avoidable hospitalizations (PAHs) of skilled nursing facility (SNF) patients are common and costly. Telemedicine represents a unique approach to manage and potentially reduce PAHs in SNFs, having been used in a variety of settings to improve coordination of care and enhance access to providers. Nonetheless, broad implementation and use of telemedicine lags in SNFs relative to other health care settings. To understand why, we surveyed SNF administrative staff attending a 1-day telemedicine summit. Participants saw the highest value of telemedicine in improving the quality of care and reducing readmissions. They identified hospital and managed care telemedicine requirements as primary drivers of adoption. The most significant barrier to adoption was the initial investment required. A joint research-policy effort to improve the evidence base around telemedicine in SNFs and introduce incentives may improve adoption and continued use of telemedicine in this setting.

Spinal surgery: variations in health care costs and implications for episode-based bundled payments.

PubMed

Ugiliweneza, Beatrice; Kong, Maiying; Nosova, Kristin; Huang, Kevin T; Babu, Ranjith; Lad, Shivanand P; Boakye, Maxwell

2014-07-01

Retrospective, observational. To simulate what episodes of care in spinal surgery might look like in a bundled payment system and to evaluate the associated costs and characteristics. Episode-based payment bundling has received considerable attention as a potential method to help curb the rise in health care spending and is being investigated as a new payment model as part of the Affordable Care Act. Although earlier studies investigated bundled payments in a number of surgical settings, very few focused on spine surgery, specifically. We analyzed data from MarketScan. Patients were included in the study if they underwent cervical or lumbar spinal surgery during 2000-2009, had at least 2-year preoperative and 90-day postoperative follow-up data. Patients were grouped on the basis of their diagnosis-related group (DRG) and then tracked in simulated episodes-of-care/payment bundles that lasted for the duration of 30, 60, and 90 days after the discharge from the index-surgical hospitalization. The total cost associated with each episode-of-care duration was measured and characterized. A total of 196,918 patients met our inclusion criteria. Significant variation existed between DRGs, ranging from $11,180 (30-day bundle, DRG 491) to $107,642 (30-day bundle, DRG 456). There were significant cost variations within each individual DRG. Postdischarge care accounted for a relatively small portion of overall bundle costs (range, 4%-8% in 90-day bundles). Total bundle costs remained relatively flat as bundle-length increased (total average cost of 30-day bundle: $33,522 vs. $35,165 for 90-day bundle). Payments to hospitals accounted for the largest portion of bundle costs (76%). There exists significant variation in total health care costs for patients who undergo spinal surgery, even within a given DRG. Better characterization of impacts of a bundled payment system in spine surgery is important for understanding the costs of index procedure hospital, physician services, and postoperative care on potential future health care policy decision making. N/A.

Are we prepared for Affordable Care Act provisions of care coordination? Case managers' self-assessments and views on physicians' roles.

PubMed

Moreo, Kathleen; Moreo, Natalie; Urbano, Frank L; Weeks, Matthew; Greene, Laurence

2014-01-01

Care coordination, traditionally the purview of the case management field, is recognized as a national priority for improving health care delivery and patient outcomes. With reforms of the Affordable Care Act (ACA) of 2010, case managers face new challenges and opportunities in providing care coordination services. The evolving roles of case managers as members of interprofessional care teams will be influenced by new policies that enable physicians to be reimbursed for care coordination. This qualitative study aimed to evaluate case managers' self-assessed readiness for ACA reforms of care coordination and their perceptions of physicians' understanding of case management and ability to lead care coordination efforts in evolving models. Provisions of care coordination in the ACA affect case managers in all practice settings. The majority of this study's participants represented hospital and managed care settings. An invitation to complete an 11-item online survey was sent by e-mail to 8,110 case managers in an opt-in database maintained by a health care continuing education company. Survey questions were designed to assess respondents' (1) self-reported levels of knowledge and preparation for ACA care coordination provisions and (2) beliefs about the readiness and abilities of physicians to administer care coordination services. In addition, demographic data and open-ended comments regarding physicians' roles in conducting care coordination were collected. Over a restricted 9-day period, 834 case managers representing various health care settings responded to the survey. The majority of respondents (63%) indicated that more than 50% of their day is dedicated to performing care coordination activities. However, 80% of all respondents reported being "not at all knowledgeable" or only "somewhat knowledgeable" about the new care coordination provisions in the ACA. Only 8% admitted to being "very prepared" to implement ACA changes. The majority of respondents (68%) perceive their case management departments to be at least "somewhat prepared" to implement necessary changes. Whereas 67% of respondents expect physicians to have at least a "moderate role" in implementing care coordination services, only 12% believe that physicians have more than "some" understanding of the processes of care coordination and case managers' roles. These qualitative study findings suggest that case managers from multiple practice settings perceive a lack of preparedness, knowledge, and understanding among themselves and physicians regarding ACA reforms that may significantly affect the delivery of care coordination services. The findings call for new initiatives in interprofessional education to address the knowledge gaps and enhance understanding of the collaborative roles among case managers and physicians.

The Day-to-Day Co-Production of Ageing in Place.

PubMed

Procter, Rob; Greenhalgh, Trisha; Wherton, Joe; Sugarhood, Paul; Rouncefield, Mark; Hinder, Sue

We report findings from a study that set out to explore the experience of older people living with assisted living technologies and care services. We find that successful 'ageing in place' is socially and collaboratively accomplished - 'co-produced' - day-to-day by the efforts of older people, and their formal and informal networks of carers (e.g. family, friends, neighbours). First, we reveal how 'bricolage' allows care recipients and family members to customise assisted living technologies to individual needs. We argue that making customisation easier through better design must be part of making assisted living technologies 'work'. Second, we draw attention to the importance of formal and informal carers establishing and maintaining mutual awareness of the older person's circumstances day-to-day so they can act in a concerted and coordinated way when problems arise. Unfortunately, neither the design of most current assisted living technologies, nor the ways care services are typically configured, acknowledges these realities of ageing in place. We conclude that rather than more 'advanced' technologies, the success of ageing in place programmes will depend on effortful alignments in the technical, organisational and social configuration of support.

Reducing hospital readmission through team-based primary care: A 7-week pilot study integrating behavioral health and pharmacy.

PubMed

DeCaporale-Ryan, Lauren N; Ahmed-Sarwar, Nabila; Upham, Robbyn; Mahler, Karen; Lashway, Katie

2017-06-01

A team-based service delivery model was applied to provide patients with biopsychosocial care following hospital discharge to reduce hospital readmission. Most previous interventions focused on transitions of care occurred in the inpatient setting with attention to predischarge strategies. These interventions have not considered psychosocial stressors, and few have explored management in primary care settings. A 7-week team-based service delivery model was implemented in a family medicine practice emphasizing a biopsychosocial approach. A physician, psychologist, pharmacist, care managers, and interdisciplinary trainees worked with 17 patients following hospital discharge. This comprehensive evaluation assessed patients' mood, cognitive abilities, and self-management of health behaviors. Modifications were made to improve ease of access to outpatient care and to improve patient understanding of the therapeutic plan. This pilot study was conducted to determine the utility of the model. Of 17 patients, 15 individuals avoided readmission at 30- and 90-day intervals. Other substantial benefits were noted, including reduced polypharmacy, engagement in specialty care, and reduction of environmental stressors to improve access to care. The clinic in which this was implemented is currently making efforts to maintain this model of care based on observed success. Although this work only represents a small sample, results are encouraging. This model can be replicated in other primary care settings with specialty clinicians on site. Specifically, approaches that promote a team-based delivery in a primary care setting may support improved patient outcomes and reduced overall systems' costs. Recommendations for research in a clinical setting are also offered. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Regional variations in the use of home care services in Ontario, 1993/95

PubMed Central

Coyte, P C; Young, W

1999-01-01

BACKGROUND: Although regional variations in the use of many health care services have been reported, little attention has been devoted to home care practices. Given the dramatic shift in care settings from hospitals to private homes, it is important to determine the extent to which home care practices vary by geographic region. METHODS: Data from the Canadian Institute for Health Information and the Ontario Home Care Administration System database were used to assess regional variations in rates of home care use following inpatient care and same-day surgery for the fiscal years 1993, 1994 and 1995. Various measures of regional variation were employed. RESULTS: Of the 2,870,695 inpatient separations and 1,803,307 same-day surgery separations during the study period, 359,972 and 64,541, respectively, were followed by home care. The rate of home care use per 100 separations was 12.5 for inpatients and 3.6 for same-day surgery patients. There was a a 3.5-fold regional variation in the rates of home care use following inpatient care and a 7-fold variation in rates of use following same-day surgery. Additional home care funding to attain calculated target rates was estimated to be $48.9 million (30% of expenditures for patients recently discharged from hospital over the study period). For a 20% increase in service provision it was estimated that an additional injection of $42.2 million is required. INTERPRETATION: The wide regional variations in rates of home care use highlight the importance of modifying home care funding to ensure that all residents of Ontario have equal access to services. To achieve this our estimates suggest that a substantial increase in home care funding is warranted. PMID:10478160

Health Care Systems Support to Enhance Patient-Centered Care: Lessons from a Primary Care-Based Chronic Pain Management Initiative.

PubMed

Elder, Charles R; Debar, Lynn L; Ritenbaugh, Cheryl; Rumptz, Maureen H; Patterson, Charlotte; Bonifay, Allison; Cowan, Penney; Lancaster, Lindsay; Deyo, Richard A

2017-01-01

Supporting day-to-day self-care activities has emerged as a best practice when caring for patients with chronic pain, yet providing this support may introduce challenges for both patients and primary care physicians. It is essential to develop tools that help patients identify the issues and outcomes that are most important to them and to communicate this information to primary care physicians at the point of care. We describe our process to engage patients, primary care physicians, and other stakeholders in the context of a pilot randomized controlled trial of a patient-centered assessment process implemented in an everyday practice setting. We identify lessons on how to engage stakeholders and improve patient-centered care for those with chronic conditions within the primary care setting. A qualitative analysis of project minutes, interviews, and focus groups was conducted to evaluate stakeholder experiences. Stakeholders included patients, caregivers, clinicians, medical office support staff, health plan administrators, an information technology consultant, and a patient advocate. Our stakeholders included many patients with no prior experience with research. This approach enriched the applicability of feedback but necessitated extra time for stakeholder training and meeting preparation. Types of stakeholders varied over the course of the project, and more involvement of medical assistants and Information Technology staff was required than originally anticipated. Meaningful engagement of patient and physician stakeholders must be solicited in a well-coordinated manner with broad health care system supports in place to ensure full execution of patient-centered processes.

Physician Professional Satisfaction and Area of Clinical Practice: Evidence from an Integrated Health Care Delivery System.

PubMed

Caloyeras, John P; Kanter, Michael; Ives, Nicole; Kim, Chong Y; Kanzaria, Hemal K; Berry, Sandra H; Brook, Robert H

2016-01-01

For health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties. To assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system. Cross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers. Primary measure was satisfaction with one's day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income. Of the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2-9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income. It is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction.

Physician Professional Satisfaction and Area of Clinical Practice: Evidence from an Integrated Health Care Delivery System

PubMed Central

Caloyeras, John P; Kanter, Michael; Ives, Nicole; Kim, Chong Y; Kanzaria, Hemal K; Berry, Sandra H; Brook, Robert H

2016-01-01

Context: For health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties. Objective: To assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system. Design: Cross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers. Main Outcome Measures: Primary measure was satisfaction with one’s day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income. Results: Of the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2–9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income. Conclusion: It is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction. PMID:27057819

Children diagnosed with type 1 diabetes: a randomized controlled trial comparing hospital versus home-based care.

PubMed

Tiberg, Irén; Katarina, Steen Carlsson; Carlsson, Annelie; Hallström, Inger

2012-10-01

  To compare two different regimens for children diagnosed with type 1 diabetes: hospital-based care or hospital-based home care (HBHC), referring to specialist care in a home-based setting.   The trial took place in Sweden with a randomized controlled design and included 60 children, aged 3-15 years. After 2-3 days with hospital-based care, children were randomized to either continued hospital-based care or to HBHC for 6 days. The primary outcome was the child's metabolic control after 2 years. Secondary outcomes were set to evaluate the family and child situation as well as the healthcare services. This article presents data 6 months after diagnosis.   Results showed equivalence between groups in terms of metabolic control, insulin dose, parents' employment and working hours as well as parents' and significant others' absence from work related to the child's diabetes. Parents in the HBHC were more satisfied with the received health care and showed less subsequent healthcare resource use. The level of risk for the family's psychosocial distress assessed at diagnosis was associated with the subsequent use of resources, but not with metabolic control.   HBHC was found to be an equally safe and effective way of providing care as hospital-based care at the onset of type 1 diabetes for children who are medically stable. © 2012 The Author(s)/Acta Paediatrica © 2012 Foundation Acta Paediatrica.

Physician Office vs Retail Clinic: Patient Preferences in Care Seeking for Minor Illnesses

PubMed Central

Ahmed, Arif; Fincham, Jack E.

2010-01-01

PURPOSE Retail clinics are a relatively new phenomenon in the United States, offering cheaper and convenient alternatives to physician offices for minor illness and wellness care. The objective of this study was to investigate the effects of cost of care and appointment wait time on care-seeking decisions at retail clinics or physician offices. METHODS As part of a statewide random-digit-dial survey of households, adult residents of Georgia were interviewed to conduct a discrete choice experiment with 2 levels each of 4 attributes: price ($59; $75), appointment wait time (same day; 1 day or longer), care setting–clinician combination (nurse practitioner in retail clinic; physician in private office), and acute illness (urinary tract infection [UTI]; influenza). The respondents indicated whether they would seek care under each of the 16 resulting choice scenarios. A cooperation rate of 33.1% yielded 493 completed telephone interviews. RESULTS The respondents preferred to seek care for both conditions; were less likely to seek care for UTI (β =−0.149; P = .008); preferred to seek care from a physician (β =1.067; P <.001) and receive same day care (β =−2.789; P<.001). All else equal, cost savings of $31.42 would be required for them to seek care at a retail clinic and $82.12 to wait 1 day or more. CONCLUSIONS Time and cost savings offered by retail clinics are attractive to patients, and they are likely to seek care there given sufficient cost savings. Appointment wait time is the most important factor in care-seeking decisions and should be considered carefully in setting appointment policies in primary care practices. PMID:20212298

Child care choices, food intake, and children's obesity status in the United States.

PubMed

Mandal, Bidisha; Powell, Lisa M

2014-07-01

This article studies two pathways in which selection into different types of child care settings may affect likelihood of childhood obesity. Frequency of intake of high energy-dense and low energy-dense food items may vary across care settings, affecting weight outcomes. We find that increased use of paid and regulated care settings, such as center care and Head Start, is associated with higher consumption of fruits and vegetables. Among children from single-mother households, the probability of obesity increases by 15 percentage point with an increase in intake of soft drinks from four to six times a week to daily consumption and by 25 percentage point with an increase in intake of fast food from one to three times a week to four to six times a week. Among children from two-parent households, eating vegetables one additional time a day is associated with 10 percentage point decreased probability of obesity, while one additional drink of juice a day is associated with 10 percentage point increased probability of obesity. Second, variation across care types could be manifested through differences in the structure of the physical environment not captured by differences in food intake alone. This type of effect is found to be marginal and is statistically significant among children from two-parent households only. Data are used from the Early Childhood Longitudinal Study - Birth Cohort surveys (N=10,700; years=2001-2008). Children's age ranged from four to six years in the sample. Copyright © 2014 Elsevier B.V. All rights reserved.

Wound-healing outcomes using standardized assessment and care in clinical practice.

PubMed

Bolton, Laura; McNees, Patrick; van Rijswijk, Lia; de Leon, Jean; Lyder, Courtney; Kobza, Laura; Edman, Kelly; Scheurich, Anne; Shannon, Ron; Toth, Michelle

2004-01-01

Wound-healing outcomes applying standardized protocols have typically been measured within controlled clinical trials, not natural settings. Standardized protocols of wound care have been validated for clinical use, creating an opportunity to measure the resulting outcomes. Wound-healing outcomes were explored during clinical use of standardized validated protocols of care based on patient and wound assessments. This was a prospective multicenter study of wound-healing outcomes management in real-world clinical practice. Healing outcomes from March 26 to October 31, 2001, were recorded on patients in 3 long-term care facilities, 1 long-term acute care hospital, and 12 home care agencies for wounds selected by staff to receive care based on computer-generated validated wound care algorithms. After diagnosis, wound dimensions and status were assessed using a tool adapted from the Pressure Sore Status Toolfor use on all wounds. Wound, ostomy, and continence nursing professionals accessed consistent protocols of care, via telemedicine in home care or paper forms in long-term care. A physician entered assessments into a desktop computer in the wound clinic. Based on evidence that healing proceeds faster with fewer infections in environments without gauze, the protocols generally avoided gauze dressings. Most of the 767 wounds selected to receive the standardized-protocols of care were stage III-IV pressure ulcers (n = 373; mean healing time 62 days) or full-thickness venous ulcers (n = 124; mean healing time 57 days). Partial-thickness wounds healed faster than same-etiology full-thickness wounds. These results provide benchmarks for natural-setting healing outcomes and help to define and address wound care challenges. Outcomes primarily using nongauze protocols of care matched or surpassed best previously published results on similar wounds using gauze-based protocols of care, including protocols applying gauze impregnated with growth factors or other agents.

Strengthening pharmaceutical systems for palliative care services in resource limited settings: piloting a mHealth application across a rural and urban setting in Uganda.

PubMed

Namisango, Eve; Ntege, Chris; Luyirika, Emmanuel B K; Kiyange, Fatia; Allsop, Matthew J

2016-02-19

Medicine availability is improving in sub-Saharan Africa for palliative care services. There is a need to develop strong and sustainable pharmaceutical systems to enhance the proper management of palliative care medicines, some of which are controlled. One approach to addressing these needs is the use of mobile technology to support data capture, storage and retrieval. Utilizing mobile technology in healthcare (mHealth) has recently been highlighted as an approach to enhancing palliative care services but development is at an early stage. An electronic application was implemented as part of palliative care services at two settings in Uganda; a rural hospital and an urban hospice. Measures of the completeness of data capture, time efficiency of activities and medicines stock and waste management were taken pre- and post-implementation to identify changes to practice arising from the introduction of the application. Improvements in all measures were identified at both sites. The application supported the registration and management of 455 patients and a total of 565 consultations. Improvements in both time efficiency and medicines management were noted. Time taken to collect and report pharmaceuticals data was reduced from 7 days to 30 min and 10 days to 1 h at the urban hospice and rural hospital respectively. Stock expiration reduced from 3 to 0.5% at the urban hospice and from 58 to 0% at the rural hospital. Additional observations relating to the use of the application across the two sites are reported. A mHealth approach adopted in this study was shown to improve existing processes for patient record management, pharmacy forecasting and supply planning, procurement, and distribution of essential health commodities for palliative care services. An important next step will be to identify where and how such mHealth approaches can be implemented more widely to improve pharmaceutical systems for palliative care services in resource limited settings.

Effect of Dynamic Light Application on Cognitive Performance and Well-being of Intensive Care Nurses.

PubMed

Simons, Koen S; Boeijen, Enzio R K; Mertens, Marlies C; Rood, Paul; de Jager, Cornelis P C; van den Boogaard, Mark

2018-05-01

Exposure to bright light has alerting effects. In nurses, alertness may be decreased because of shift work and high work pressure, potentially reducing work performance and increasing the risk for medical errors. To determine whether high-intensity dynamic light improves cognitive performance, self-reported depressive signs and symptoms, fatigue, alertness, and well-being in intensive care unit nurses. In a single-center crossover study in an intensive care unit of a teaching hospital in the Netherlands, 10 registered nurses were randomly divided into 2 groups. Each group worked alternately for 3 to 4 days in patients' rooms with dynamic light and 3 to 4 days in control lighting settings. High-intensity dynamic light was administered through ceiling-mounted fluorescent tubes that delivered bluish white light up to 1700 lux during the daytime, versus 300 lux in control settings. Cognitive performance, self-reported depressive signs and symptoms, fatigue, and well-being before and after each period were assessed by using validated cognitive tests and questionnaires. Cognitive performance, self-reported depressive signs and symptoms, and fatigue did not differ significantly between the 2 light settings. Scores of subjective well-being were significantly lower after a period of working in dynamic light. Daytime lighting conditions did not affect intensive care unit nurses' cognitive performance, perceived depressive signs and symptoms, or fatigue. Perceived quality of life, predominantly in the psychological and environmental domains, was lower for nurses working in dynamic light. © 2018 American Association of Critical-Care Nurses.

Resource Utilization and Safety of Outpatient Management Following Intensive Induction or Salvage Chemotherapy for Acute Myeloid Leukemia or Myelodysplastic Syndrome: A Nonrandomized Clinical Comparative Analysis.

PubMed

Vaughn, Jennifer E; Othus, Megan; Powell, Morgan A; Gardner, Kelda M; Rizzuto, Donelle L; Hendrie, Paul C; Becker, Pamela S; Pottinger, Paul S; Estey, Elihu H; Walter, Roland B

2015-11-01

Adults with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) typically remain hospitalized after induction or salvage chemotherapy until blood cell count recovery, with resulting prolonged inpatient stays being a primary driver of health care costs. Pilot studies suggest that outpatient management following chemotherapy might be safe and could reduce costs for these patients. To compare safety, resource utilization, infections, and costs between adults discharged early following AML or MDS induction or salvage chemotherapy and inpatient controls. Nonrandomized, phase 2, single-center study conducted at the University of Washington Medical Center. Over a 43-month period (January 1, 2011, through July 31, 2014), 178 adults receiving intensive AML or MDS chemotherapy were enrolled. After completion of chemotherapy, 107 patients met predesignated medical and logistical criteria for early discharge, while 29 met medical criteria only and served as inpatient controls. Early-discharge patients were released from the hospital at the completion of chemotherapy, and supportive care was provided in the outpatient setting until blood cell count recovery (median, 21 days; range, 2-45 days). Controls received inpatient supportive care (median, 16 days; range, 3-42 days). We analyzed differences in early mortality, resource utilization including intensive care unit (ICU) days, transfusions per study day, and use of intravenous (IV) antibiotics per study day), numbers of infections, and total and inpatient charges per study day among early-discharge patients vs controls. Four of the 107 early-discharge patients and none of the 29 control patients died within 30 days of enrollment (P=.58). Nine early-discharge patients (8%) but no controls required ICU-level care (P=.20). No differences were noted in the median daily number of transfused red blood cell units (0.27 vs 0.29; P=.55) or number of transfused platelet units (0.26 vs 0.29; P=.31). Early-discharge patients had more positive blood cultures (37 [35%] vs 4 [14%]; P=.04) but required fewer IV antibiotic days per study day (0.48 vs 0.71; P=.01). Overall, daily charges among early-discharge patients were significantly lower than for inpatients (median, $3840 vs $5852; P<.001) despite increased charges per inpatient day when readmitted (median, $7405 vs $5852; P<.001). Early discharge following intensive AML or MDS chemotherapy can reduce costs and use of IV antibiotics, but attention should be paid to complications that may occur in the outpatient setting.

Healthcare provider perceptions of the role of interprofessional care in access to and outcomes of primary care in an underserved area.

PubMed

Wan, Shaowei; Teichman, Peter G; Latif, David; Boyd, Jennifer; Gupta, Rahul

2018-03-01

To meet the needs of an aging population who often have multiple chronic conditions, interprofessional care is increasingly adopted by patient-centred medical homes and Accountable Care Organisations to improve patient care coordination and decrease costs in the United States, especially in underserved areas with primary care workforce shortages. In this cross-sectional survey across multiple clinical settings in an underserved area, healthcare providers perceived overall outcomes associated with interprofessional care teams as positive. This included healthcare providers' beliefs that interprofessional care teams improved patient outcomes, increased clinic efficiency, and enhanced care coordination and patient follow-up. Teams with primary care physician available each day were perceived as better able to coordinate care and follow up with patients (p = .031), while teams that included clinical pharmacists were perceived as preventing medication-associated problems (p < .0001). Healthcare providers perceived the interprofessional care model as a useful strategy to improve various outcomes across different clinical settings in the context of a shortage of primary care physicians.

Research without billing data. Econometric estimation of patient-specific costs.

PubMed

Barnett, P G

1997-06-01

This article describes a method for computing the cost of care provided to individual patients in health care systems that do not routinely generate billing data, but gather information on patient utilization and total facility costs. Aggregate data on cost and utilization were used to estimate how costs vary with characteristics of patients and facilities of the US Department of Veterans Affairs. A set of cost functions was estimated, taking advantage of the department-level organization of the data. Casemix measures were used to determine the costs of acute hospital and long-term care. Hospitalization for medical conditions cost an average of $5,642 per US Health Care Financing Administration diagnosis-related group weight; surgical hospitalizations cost $11,836. Nursing home care cost $197.33 per day, intermediate care cost $280.66 per day, psychiatric care cost $307.33 per day, and domiciliary care cost $111.84 per day. Outpatient visits cost an average of $90.36. These estimates include the cost of physician services. The econometric method presented here accounts for variation in resource use caused by casemix that is not reflected in length of stay and for the effects of medical education, research, facility size, and wage rates. Data on non-Veteran's Affairs hospital stays suggest that the method accounts for 40% of the variation in acute hospital care costs and is superior to cost estimates based on length of stay or diagnosis-related group weight alone.

Workplace health and safety intervention for child care staff: Rationale, design, and baseline results from the CARE cluster randomized control trial.

PubMed

Ward, Dianne S; Vaughn, Amber E; Hales, Derek; Viera, Anthony J; Gizlice, Ziya; Bateman, Lori A; Grummon, Anna H; Arandia, Gabriela; Linnan, Laura A

2018-05-01

Low-wage workers suffer disproportionately high rates of chronic disease and are important targets for workplace health and safety interventions. Child care centers offer an ideal opportunity to reach some of the lowest paid workers, but these settings have been ignored in workplace intervention studies. Caring and Reaching for Health (CARE) is a cluster-randomized controlled trial evaluating efficacy of a multi-level, workplace-based intervention set in child care centers that promotes physical activity and other health behaviors among staff. Centers are randomized (1:1) into the Healthy Lifestyles (intervention) or the Healthy Finances (attention control) program. Healthy Lifestyles is delivered over six months including a kick-off event and three 8-week health campaigns (magazines, goal setting, behavior monitoring, tailored feedback, prompts, center displays, director coaching). The primary outcome is minutes of moderate and vigorous physical activity (MVPA); secondary outcomes are health behaviors (diet, smoking, sleep, stress), physical assessments (body mass index (BMI), waist circumference, blood pressure, fitness), and workplace supports for health and safety. In total, 56 centers and 553 participants have been recruited and randomized. Participants are predominately female (96.7%) and either Non-Hispanic African American (51.6%) or Non-Hispanic White (36.7%). Most participants (63.4%) are obese. They accumulate 17.4 (±14.2) minutes/day of MVPA and consume 1.3 (±1.4) and 1.3 (±0.8) servings/day of fruits and vegetables, respectively. Also, 14.2% are smokers; they report 6.4 (±1.4) hours/night of sleep; and 34.9% are high risk for depression. Baseline data demonstrate several serious health risks, confirming the importance of workplace interventions in child care. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Workplace health and safety intervention for child care staff: Rationale, design, and baseline results from the CARE cluster randomized control trial

PubMed Central

Ward, Dianne S.; Vaughn, Amber E.; Hales, Derek; Viera, Anthony J.; Gizlice, Ziya; Bateman, Lori A.; Grummon, Anna H.; Arandia, Gabriela; Linnan, Laura A.

2018-01-01

Background Low-wage workers suffer disproportionately high rates of chronic disease and are important targets for workplace health and safety interventions. Child care centers offer an ideal opportunity to reach some of the lowest paid workers, but these settings have been ignored in workplace intervention studies. Methods Caring and Reaching for Health (CARE) is a cluster-randomized controlled trial evaluating efficacy of a multi-level, workplace-based intervention set in child care centers that promotes physical activity and other health behaviors among staff. Centers are randomized (1:1) into the Healthy Lifestyles (intervention) or the Healthy Finances (attention control) program. Healthy Lifestyles is delivered over six months including a kick-off event and three 8-week health campaigns (magazines, goal setting, behavior monitoring, tailored feedback, prompts, center displays, director coaching). The primary outcome is minutes of moderate and vigorous physical activity (MVPA); secondary outcomes are health behaviors (diet, smoking, sleep, stress), physical assessments (body mass index (BMI), waist circumference, blood pressure, fitness), and workplace supports for health and safety. Results In total, 56 centers and 553 participants have been recruited and randomized. Participants are predominately female (96.7%) and either Non-Hispanic African American (51.6%) or Non-Hispanic White (36.7%). Most participants (63.4%) are obese. They accumulate 17.4 ( ± 14.2) minutes/day of MVPA and consume 1.3 ( ± 1.4) and 1.3 ( ± 0.8) servings/day of fruits and vegetables, respectively. Also, 14.2% are smokers; they report 6.4 ( ± 1.4) hours/night of sleep; and 34.9% are high risk for depression. Conclusions Baseline data demonstrate several serious health risks, confirming the importance of workplace interventions in child care. PMID:29501740

Obesity prevention in the family day care setting: impact of the Romp & Chomp intervention on opportunities for children's physical activity and healthy eating.

PubMed

de Silva-Sanigorski, A; Elea, D; Bell, C; Kremer, P; Carpenter, L; Nichols, M; Smith, M; Sharp, S; Boak, R; Swinburn, B

2011-05-01

The Romp & Chomp intervention reduced the prevalence of overweight/obesity in pre-school children in Geelong, Victoria, Australia through an intervention promoting healthy eating and active play in early childhood settings. This study aims to determine if the intervention successfully created more health promoting family day care (FDC) environments. The evaluation had a cross-sectional, quasi-experimental design with the intervention FDC service in Geelong and a comparison sample from 17 FDC services across Victoria. A 45-item questionnaire capturing nutrition- and physical activity-related aspects of the policy, socio-cultural and physical environments of the FDC service was completed by FDC care providers (in 2008) in the intervention (n= 28) and comparison (n= 223) samples. Select results showed intervention children spent less time in screen-based activities (P= 0.03), organized active play (P < 0.001) and free inside play (P= 0.03) than comparison children. There were more rules related to healthy eating (P < 0.001), more care provider practices that supported children's positive meal experiences (P < 0.001), fewer unhealthy food items allowed (P= 0.05), higher odds of staff being trained in nutrition (P= 0.04) and physical activity (P < 0.001), lower odds of having set minimum times for outside (P < 0.001) and organized (P= 0.01) active play, and of rewarding children with food (P < 0.001). Romp & Chomp improved the FDC service to one that discourages sedentary behaviours and promotes opportunities for children to eat nutritious foods. Ongoing investment to increase children's physical activity within the setting and improving the capacity and health literacy of care providers is required to extend and sustain the improvements. © 2011 Blackwell Publishing Ltd.

The Checklist of Unit Behaviours (CUB): Validation within a Canadian outpatient day hospital programme.

PubMed

Taube-Schiff, M; El Morr, C; Counsell, A; Mehak, Adrienne; Gollan, J

2018-05-01

WHAT IS KNOWN ON THE SUBJECT?: The psychometrics of the CUB measure have been tested within an inpatient psychiatric setting. Results show that the CUB has two factors that reflect patients' approach and avoidance of dimensions of the treatment milieu, and that an increase of approach and decrease of avoidance are correlated with discharge. No empirical research has examined the validity of the CUB in a day hospital programme. WHAT THIS ARTICLE ADDS TO EXISTING KNOWLEDGE?: This study was the first to address the validity of this questionnaire within a psychiatric day hospital setting. This now allows other mental health service providers to use this questionnaire following administration of patient engagement interventions (such as behavioural activation), which are routinely used within this type of a setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our results can enable healthcare providers to employ an effective and psychometrically validated tool in a day hospital setting to measure treatment outcomes and provide reflections of patients' approach behaviours and avoidance behaviours. Introduction We evaluated the Checklist of Unit Behaviours (CUBs) questionnaire in a novel mental health setting: a day hospital within a large acute care general hospital. No empirical evidence exists, as of yet, to look at the validity of this measure in this type of a treatment setting. The CUB measures two factors, avoidance or approach, of the patients' engagement with the treatment milieu within the previous 24 hr. Aim A confirmatory factor analysis (CFA) was conducted to validate the CUB's original two factor structure in an outpatient day programme. Methods Psychiatric outpatients (n = 163) completed the CUB daily while participating in a day hospital programme in Toronto, Canada. Results A CFA was used to confirm the CUB factors but resulted in a poor fitting model for our sample, χ 2 (103) = 278.59, p < .001, CFI = 0.80, RMSEA = 0.10, SRMR = 0.10. Questions 5, 8 and 10 had higher loadings on a third factor revealed through exploratory factor analysis. We believe this factor, "Group Engagement," reflects the construct of group-related issues. Discussion The CUB was a practical and useful tool in our psychiatric day hospital setting at a large acute care general hospital. Implications for practice Our analysis identified group engagement, a critical variable in day programmes, as patients have autonomy regarding staying or leaving the programme. © 2017 John Wiley & Sons Ltd.

In the Child's Best Interest: A Primer on the U.N. Convention on the Rights of the Child. New Edition-Revised Text.

ERIC Educational Resources Information Center

Castelle, Kay

The purpose of this book is to explain the United Nations Convention on the Rights of the Child, which sets standards for the protection and care of children. No country protects the rights of all its children or provides them with an adequate standard of health care, education, day care, housing and nutrition, or properly protects them from…

Avoiding costly hospitalisation at end of life: findings from a specialist palliative care pilot in residential care for older adults.

PubMed

Chapman, Michael; Johnston, Nikki; Lovell, Clare; Forbat, Liz; Liu, Wai-Man

2018-03-01

Specialist palliative care is not a standardised component of service delivery in nursing home care in Australia. Specialist palliative care services can increase rates of advance care planning, decrease hospital admissions and improve symptom management in such facilities. New approaches are required to support nursing home residents in avoiding unnecessary hospitalisation and improving rates of dying in documented preferred place of death. This study examined whether the addition of a proactive model of specialist palliative care reduced resident transfer to the acute care setting, and achieved a reduction in hospital deaths. A quasi-experimental design was adopted, with participants at 4 residential care facilities. The intervention involved a palliative care nurse practitioner leading 'Palliative Care Needs Rounds' to support clinical decision-making, education and training. Participants were matched with historical decedents using propensity scores based on age, sex, primary diagnosis, comorbidities and the Aged Care Funding Instrument rating. Outcome measures included participants' hospitalisation in the past 3 months of life and the location of death. The data demonstrate that the intervention is associated with a substantial reduction in the length of hospital stays and a lower incidence of death in the acute care setting. While rates of hospitalisation were unchanged on average, length of admission was reduced by an average of 3.22 days (p<0.01 and 95% CI -5.05 to -1.41), a 67% decrease in admitted days. The findings have significant implications for promoting quality outcomes through models of palliative care service delivery in residential facilities. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Portraits of Whole Language Classrooms: Learning for All Ages.

ERIC Educational Resources Information Center

Mills, Heidi, Ed.; Clyde, Jean Anne, Ed.

Highlighting typical days in a variety of whole-language classrooms, this book describes learners of all ages, beginning with a home day-care setting through preschool programs and elementary classrooms to a junior high and high school. The book also describes a special education site and an English-as-a-Second Language classroom, and concludes in…

Electronic palliative care coordination systems: Devising and testing a methodology for evaluating documentation

PubMed Central

Allsop, Matthew J; Kite, Suzanne; McDermott, Sarah; Penn, Naomi; Millares-Martin, Pablo; Bennett, Michael I

2016-01-01

Background: The need to improve coordination of care at end of life has driven electronic palliative care coordination systems implementation across the United Kingdom and internationally. No approaches for evaluating electronic palliative care coordination systems use in practice have been developed. Aim: This study outlines and applies an evaluation framework for examining how and when electronic documentation of advance care planning is occurring in end of life care services. Design: A pragmatic, formative process evaluation approach was adopted. The evaluation drew on the Project Review and Objective Evaluation methodology to guide the evaluation framework design, focusing on clinical processes. Setting/participants: Data were extracted from electronic palliative care coordination systems for 82 of 108 general practices across a large UK city. All deaths (n = 1229) recorded on electronic palliative care coordination systems between April 2014 and March 2015 were included to determine the proportion of all deaths recorded, median number of days prior to death that key information was recorded and observations about routine data use. Results: The evaluation identified 26.8% of all deaths recorded on electronic palliative care coordination systems. The median number of days to death was calculated for initiation of an electronic palliative care coordination systems record (31 days), recording a patient’s preferred place of death (8 days) and entry of Do Not Attempt Cardiopulmonary Resuscitation decisions (34 days). Where preferred and actual place of death was documented, these were matching for 75% of patients. Anomalies were identified in coding used during data entry on electronic palliative care coordination systems. Conclusion: This study reports the first methodology for evaluating how and when electronic palliative care coordination systems documentation is occurring. It raises questions about what can be drawn from routine data collected through electronic palliative care coordination systems and outlines considerations for future evaluation. Future evaluations should consider work processes of health professionals using electronic palliative care coordination systems. PMID:27507636

75 FR 35947 - Father's Day, 2010

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-23

... step-father, a grandfather, or caring guardian. We owe a special debt of gratitude for those parents..., with all the love and gratitude they deserve. IN WITNESS WHEREOF, I have hereunto set my hand this...

Acceptability and clinical outcomes of first- and second-trimester surgical abortion by suction aspiration in Colombia.

PubMed

DePiñeres, Teresa; Baum, Sarah; Grossman, Daniel

2014-09-01

Since partial decriminalization of abortion in Colombia, Oriéntame has provided legal abortion services through 15 weeks gestation in an outpatient primary care setting. We sought to document the safety and acceptability of the second trimester compared to the first-trimester surgical abortion in this setting. This was a prospective cohort study using a consecutive sample of 100 women undergoing surgical first-trimester abortion (11 weeks 6 days gestational age or less) and 200 women undergoing second-trimester abortion (12 weeks 0 days-15 weeks 0 days) over a 5-month period in 2012. After obtaining informed consent, a trained interviewer collected demographic and clinical information from direct observation and the patient's clinical chart. The interviewer asked questions after the procedure regarding satisfaction with the procedure, physical pain and emotional discomfort. Fifteen days later, the interviewer assessed satisfaction with the procedure and any delayed complications. There were no major complications and seven minor complications. Average measured blood loss was 37.87 mL in the first trimester and 109 mL in the second trimester (p<.001). Following the procedure, more second-trimester patients reported being very satisfied (81% vs. 94%, p=.006). Satisfaction was similar between groups at follow-up. There were no differences in reported emotional discomfort after the procedure or at follow-up, with the majority reporting no emotional discomfort. The majority of women (99%) stated that they would recommend the clinic to a friend or family member. Second-trimester surgical abortion in an outpatient primary care setting in Colombia can be provided safely, and satisfaction with these services is high. This is one of the first studies from Latin America, a region with a high proportion of maternal mortality due to unsafe abortion, which documents the safety and acceptability of surgical abortion in an outpatient primary care setting. Findings could support increased access to safe abortion services, particularly in the second trimester. Copyright © 2014 Elsevier Inc. All rights reserved.

Building skill in heart failure self-care among community dwelling older adults: results of a pilot study.

PubMed

Dickson, Victoria Vaughan; Melkus, Gail D'Eramo; Katz, Stuart; Levine-Wong, Alissa; Dillworth, Judy; Cleland, Charles M; Riegel, Barbara

2014-08-01

Most of the day-to-day care for heart failure (HF) is done by the patient at home and requires skill in self-care. In this randomized controlled trial (RCT) we tested the efficacy of a community-based skill-building intervention on HF self-care, knowledge and health-related quality of life (HRQL) at 1- and 3-months. An ethnically diverse sample (n=75) of patients with HF (53% female; 32% Hispanic, 27% Black; mean age 69.9±10 years) was randomized to the intervention group (IG) or a wait-list control group (CG). The protocol intervention focused on tactical and situational HF self-care skill development delivered by lay health educators in community senior centers. Data were analyzed using mixed (between-within subjects) ANOVA. There was a significant improvement in self-care maintenance [F(2,47)=3.42, p=.04, (Cohen's f=.38)], self-care management [F(2,41)=4.10, p=.02, (Cohen's f=.45) and HF knowledge [F(2,53)=8.00, p=.001 (Cohen's f=.54)] in the IG compared to the CG. The skill-building intervention improved self-care and knowledge but not HRQL in this community-dwelling sample. Delivering an intervention in a community setting using lay health educators provides an alternative to clinic- or home-based teaching that may be useful across diverse populations and geographically varied settings. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Children and youth with non-traumatic brain injury: a population based perspective.

PubMed

Chan, Vincy; Pole, Jason D; Keightley, Michelle; Mann, Robert E; Colantonio, Angela

2016-07-20

Children and youth with non-traumatic brain injury (nTBI) are often overlooked in regard to the need for post-injury health services. This study provided population-based data on their burden on healthcare services, including data by subtypes of nTBI, to provide the foundation for future research to inform resource allocation and healthcare planning for this population. A retrospective cohort study design was used. Children and youth with nTBI in population-based healthcare data were identified using International Classification of Diseases Version 10 codes. The rate of nTBI episodes of care, demographic and clinical characteristics, and discharge destinations from acute care and by type of nTBI were identified. The rate of pediatric nTBI episodes of care was 82.3 per 100,000 (N = 17,977); the average stay in acute care was 13.4 days (SD = 25.6 days) and 35% were in intensive care units. Approximately 15% were transferred to another inpatient setting and 6% died in acute care. By subtypes of nTBI, the highest rates were among those with a diagnosis of toxic effect of substances (22.7 per 100,000), brain tumours (18.4 per 100,000), and meningitis (15.4 per 100,000). Clinical characteristics and discharge destinations from the acute care setting varied by subtype of nTBI; the proportion of patients that spent at least one day in intensive care units and the proportion discharged home ranged from 25.9% to 58.2% and from 50.6% to 76.4%, respectively. Children and youth with nTBI currently put an increased demand on the healthcare system. Active surveillance of and in-depth research on nTBI, including subtypes of nTBI, is needed to ensure that timely, appropriate, and targeted care is available for this pediatric population.

Effectiveness of a transitional home care program in reducing acute hospital utilization: a quasi-experimental study.

PubMed

Low, Lian Leng; Vasanwala, Farhad Fakhrudin; Ng, Lee Beng; Chen, Cynthia; Lee, Kheng Hock; Tan, Shu Yun

2015-03-14

Improving healthcare utilization is essential as health systems around the world grapple with the escalating demands for acute hospital resources. Evidence suggests that transitional care programs are effective to improve utilization of healthcare. However, the evidence for transitional care programs that enhance the home medical care model and provide multi-disciplinary patient-centered care is not well established. We evaluated if a transitional home care program operated by the Singapore General Hospital was effective in reducing acute hospital utilization. We performed a quasi-experimental study using a pre-post design to evaluate the effectiveness of a transitional home care program in reducing hospital admissions and emergency department attendances of medically complex patients enrolled into the program in a tertiary hospital in Singapore. Patients received a comprehensive needs assessment performed by the physician and a nurse case manager in the home setting, followed by an individualized care plan that included medical and nursing care, patient education and coordination of care with hospital specialists and community services. Primary study outcomes were emergency department attendances and hospital admissions to all hospitals. These were extracted from hospital administrative data and national health records. Wilcoxon Signed Ranks Test was used for assess differences in pre and post continuous data. Overall, 262 patients were enrolled into the program and 259 were analyzed. Patients had a 51.6% and 52.8% reduction in hospital admissions in the three-month and six-month post enrollment, respectively. Similarly, a 47.1% and 48.2% reduction was observed for emergency department attendances in the three and six months post enrollment, respectively. The average difference in per patient hospital bed days in the pre- and post-enrollment periods were 12.05 days and 20.03 days at the 3-month and 6-month periods, respectively. Patients enrolled in the transitional home care program had significantly lower acute hospital utilization through the reduction of emergency department attendances and hospital admissions. A comprehensive assessment of patients' medical and social needs in the home setting and formulation of an individualized care plan optimized post-discharge care for medically complex patients.

The effect of rapid response teams on end-of-life care: A retrospective chart review

PubMed Central

Tam, Benjamin; Salib, Mary; Fox-Robichaud, Alison

2014-01-01

BACKGROUND: A subset of critically ill patients have end-of-life (EOL) goals that are unclear. Rapid response teams (RRTs) may aid in the identification of these patients and the delivery of their EOL care. OBJECTIVES: To characterize the impact of RRT discussion on EOL care, and to examine how a preprinted order (PPO) set for EOL care influenced EOL discussions and outcomes. METHODS: A single-centre retrospective chart review of all RRT calls (January 2009 to December 2010) was performed. The effect of RRT EOL discussions and the effect of a hospital-wide PPO set on EOL care was examined. Charts were from the Ontario Ministry of Health and Long-Term Care Critical Care Information Systemic database, and were interrogated by two reviewers. RESULTS: In patients whose EOL status changed following RRT EOL discussion, there were fewer intensive care unit (ICU) transfers (8.4% versus 17%; P<0.001), decreased ICU length of stay (5.8 days versus 20 days; P=0.08), increased palliative care consultations (34% versus 5.3%; P<0.001) and an increased proportion who died within 24 h of consultation (25% versus 8.3%; P<0.001). More patients experienced a change in EOL status following the introduction of an EOL PPO, from 20% (before) to 31% (after) (P<0.05). CONCLUSIONS: A change in EOL status following RRT-led EOL discussion was associated with reduced ICU transfers and enhanced access to palliative care services. Further study is required to identify and deconstruct barriers impairing timely and appropriate EOL discussions. PMID:25299222

Pilot randomized trial of therapeutic hypothermia with serial cranial ultrasound and 18-22 month follow-up for neonatal encephalopathy in a low resource hospital setting in Uganda: study protocol.

PubMed

Robertson, Nicola J; Hagmann, Cornelia F; Acolet, Dominique; Allen, Elizabeth; Nyombi, Natasha; Elbourne, Diana; Costello, Anthony; Jacobs, Ian; Nakakeeto, Margaret; Cowan, Frances

2011-06-04

There is now convincing evidence that in industrialized countries therapeutic hypothermia for perinatal asphyxial encephalopathy increases survival with normal neurological function. However, the greatest burden of perinatal asphyxia falls in low and mid-resource settings where it is unclear whether therapeutic hypothermia is safe and effective. Under the UCL Uganda Women's Health Initiative, a pilot randomized controlled trial in infants with perinatal asphyxia was set up in the special care baby unit in Mulago Hospital, a large public hospital with ~20,000 births in Kampala, Uganda to determine:(i) The feasibility of achieving consent, neurological assessment, randomization and whole body cooling to a core temperature 33-34°C using water bottles(ii) The temperature profile of encephalopathic infants with standard care(iii) The pattern, severity and evolution of brain tissue injury as seen on cranial ultrasound and relation with outcome(iv) The feasibility of neurodevelopmental follow-up at 18-22 months of age Ethical approval was obtained from Makerere University and Mulago Hospital. All infants were in-born. Parental consent for entry into the trial was obtained. Thirty-six infants were randomized either to standard care plus cooling (target rectal temperature of 33-34°C for 72 hrs, started within 3 h of birth) or standard care alone. All other aspects of management were the same. Cooling was performed using water bottles filled with tepid tap water (25°C). Rectal, axillary, ambient and surface water bottle temperatures were monitored continuously for the first 80 h. Encephalopathy scoring was performed on days 1-4, a structured, scorable neurological examination and head circumference were performed on days 7 and 17. Cranial ultrasound was performed on days 1, 3 and 7 and scored. Griffiths developmental quotient, head circumference, neurological examination and assessment of gross motor function were obtained at 18-22 months. We will highlight differences in neonatal care and infrastructure that need to be taken into account when considering a large safety and efficacy RCT of therapeutic hypothermia in low and mid resource settings in the future. Current controlled trials ISRCTN92213707.

Mobile phone intervention reduces perinatal mortality in zanzibar: secondary outcomes of a cluster randomized controlled trial.

PubMed

Lund, Stine; Rasch, Vibeke; Hemed, Maryam; Boas, Ida Marie; Said, Azzah; Said, Khadija; Makundu, Mkoko Hassan; Nielsen, Birgitte Bruun

2014-03-26

Mobile phones are increasingly used in health systems in developing countries and innovative technical solutions have great potential to overcome barriers of access to reproductive and child health care. However, despite widespread support for the use of mobile health technologies, evidence for its role in health care is sparse. We aimed to evaluate the association between a mobile phone intervention and perinatal mortality in a resource-limited setting. This study was a pragmatic, cluster-randomized, controlled trial with primary health care facilities in Zanzibar as the unit of randomization. At their first antenatal care visit, 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary health care facilities were included in this study and followed until 42 days after delivery. Twenty-four primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text message and voucher component. Secondary outcome measures included stillbirth, perinatal mortality, and death of a child within 42 days after birth as a proxy of neonatal mortality. Within the first 42 days of life, 2482 children were born alive, 54 were stillborn, and 36 died. The overall perinatal mortality rate in the study was 27 per 1000 total births. The rate was lower in the intervention clusters, 19 per 1000 births, than in the control clusters, 36 per 1000 births. The intervention was associated with a significant reduction in perinatal mortality with an odds ratio (OR) of 0.50 (95% CI 0.27-0.93). Other secondary outcomes showed an insignificant reduction in stillbirth (OR 0.65, 95% CI 0.34-1.24) and an insignificant reduction in death within the first 42 days of life (OR 0.79, 95% CI 0.36-1.74). Mobile phone applications may contribute to improved health of the newborn and should be considered by policy makers in resource-limited settings. ClinicalTrials.gov NCT01821222; http://www.clinicaltrials.gov/ct2/show/NCT01821222 (Archived by WebCite at http://www.webcitation.org/6NqxnxYn0).

Toddlers’ transition to out-of-home day care: Settling into a new care environment

PubMed Central

Datler, Wilfried; Ereky-Stevens, Katharina; Hover-Reisner, Nina; Malmberg, Lars-Erik

2012-01-01

This study investigates toddlers’ initial reaction to day care entry and their behaviour change over the first few months in care. One hundred and four toddlers (10–33 months of age) in Viennese childcare centres participated in the study. One-hour video observations were carried out at 3 time points during the first 4 months in the setting and coded into a total of 36 5-min observation segments. Multilevel models (observation segments nested within children) with an autoregressive error structure fitted data well. Two weeks after entry into care, toddlers’ levels of affect and interaction were low. Overall, changes in all areas of observed behaviour were less than expected. There were considerable individual differences in change over time, mostly unrelated to child characteristics. Significant associations between children's positive affect, their dynamic interactions and their explorative and investigative interest were found. PMID:22721743

Peer-Delivered Linkage Case Management and Same-Day ART Initiation for Men and Young Persons with HIV Infection - Eswatini, 2015-2017.

PubMed

MacKellar, Duncan; Williams, Daniel; Bhembe, Bonsile; Dlamini, Makhosazana; Byrd, Johnita; Dube, Lenhle; Mazibuko, Sikhathele; Ao, Trong; Pathmanathan, Ishani; Auld, Andrew F; Faura, Pamela; Lukhele, Nomthandazo; Ryan, Caroline

2018-06-15

To achieve epidemic control of human immunodeficiency virus (HIV) infection, sub-Saharan African countries are striving to diagnose 90% of HIV infections, initiate and retain 90% of HIV-diagnosed persons on antiretroviral therapy (ART), and achieve viral load suppression* for 90% of ART recipients (90-90-90) (1). In Eswatini (formerly Swaziland), the country with the world's highest estimated HIV prevalence (27.2%), achieving 90-90-90 depends upon improving access to early ART for men and young adults with HIV infection, two groups with low ART coverage (1-3). Although community-based strategies test many men and young adults with HIV infection in Eswatini, fewer than one third of all persons who test positive in community settings enroll in HIV care within 6 months of diagnosis after receiving standard referral services (4,5). To evaluate the effectiveness of peer-delivered linkage case management † in improving early ART initiation for persons with HIV infection diagnosed in community settings in Eswatini, CDC analyzed data on 651 participants in CommLink, a community-based, mobile HIV-testing, point-of-diagnosis HIV care, and peer-delivered linkage case management demonstration project, and found that after diagnosis, 635 (98%) enrolled in care within a median of 5 days (interquartile range [IQR] = 2-8 days), and 541 (83%) initiated ART within a median of 6 days (IQR = 2-14 days), including 402 (74%) on the day of their first clinic visit (same-day ART). After expanding ART eligibility to all persons with HIV infection on October 1, 2016, 96% of 225 CommLink clients initiated ART, including 87% at their first clinic visit. Compared with women and adult clients aged ≥30 years, similar high proportions of men and persons aged 15-29 years enrolled in HIV care and received same-day ART. To help achieve 90-90-90 by 2020, the United States President's Emergency Plan for AIDS Relief (PEPFAR) is supporting the national scale-up of CommLink in Eswatini and recommending peer-delivered linkage case management as a potential strategy for countries to achieve >90% early enrollment in care and ART initiation after diagnosis of HIV infection (6).

Estimating Time Physicians and Other Health Care Workers Spend with Patients in an Intensive Care Unit Using a Sensor Network.

PubMed

Butler, Rachel; Monsalve, Mauricio; Thomas, Geb W; Herman, Ted; Segre, Alberto M; Polgreen, Philip M; Suneja, Manish

2018-04-09

Time and motion studies have been used to investigate how much time various health care professionals spend with patients as opposed to performing other tasks. However, the majority of such studies are done in outpatient settings, and rely on surveys (which are subject to recall bias) or human observers (which are subject to observation bias). Our goal was to accurately measure the time physicians, nurses, and critical support staff in a medical intensive care unit spend in direct patient contact, using a novel method that does not rely on self-report or human observers. We used a network of stationary and wearable mote-based sensors to electronically record location and contacts among health care workers and patients under their care in a 20-bed intensive care unit for a 10-day period covering both day and night shifts. Location and contact data were used to classify the type of task being performed by health care workers. For physicians, 14.73% (17.96%) of their time in the unit during the day shift (night shift) was spent in patient rooms, compared with 40.63% (30.09%) spent in the physician work room; the remaining 44.64% (51.95%) of their time was spent elsewhere. For nurses, 32.97% (32.85%) of their time on unit was spent in patient rooms, with an additional 11.34% (11.79%) spent just outside patient rooms. They spent 11.58% (13.16%) of their time at the nurses' station and 23.89% (24.34%) elsewhere in the unit. From a patient's perspective, we found that care times, defined as time with at least one health care worker of a designated type in their intensive care unit room, were distributed as follows: 13.11% (9.90%) with physicians, 86.14% (88.15%) with nurses, and 8.14% (7.52%) with critical support staff (eg, respiratory therapists, pharmacists). Physicians, nurses, and critical support staff spend very little of their time in direct patient contact in an intensive care unit setting, similar to reported observations in both outpatient and inpatient settings. Not surprisingly, nurses spend far more time with patients than physicians. Additionally, physicians spend more than twice as much time in the physician work room (where electronic medical record review and documentation occurs) than the time they spend with all of their patients combined. Copyright © 2018 Elsevier Inc. All rights reserved.

Clinical and economic benefit of enzymatic debridement of pressure ulcers compared to autolytic debridement with a hydrogel dressing.

PubMed

Waycaster, Curtis; Milne, Catherine T

2013-07-01

The purpose of this study was to determine the cost-effectiveness of enzymatic debridement using collagenase relative to autolytic debridement with a hydrogel dressing for the treatment of pressure ulcers. A 3-stage Markov model was used to determine the expected costs and outcomes of wound care for collagenase and hydrogel dressings. Outcome data used in the analysis were taken from a randomized clinical trial that directly compared collagenase and hydrogel dressings. The primary outcome in the clinical trial was the proportion of patients achieving a closed epithelialized wound. Transition probabilities for the Markov states were estimated from the clinical trial. A 1-year time horizon was used to determine the expected number of closed wound days and the expected costs for the two alternative debridement therapies. Resource utilization was based on the wound care treatment regimen used in the clinical trial. Resource costs were derived from standard cost references and medical supply wholesalers. The economic perspective taken was that of the long-term care facility. No cost discounting was performed due to the short time horizon of the analysis. A deterministic sensitivity analysis was conducted to analyze economic uncertainty. The number of expected wound days for the collagenase and hydrogel cohorts are estimated at 48 and 147, respectively. The expected direct cost per patient for pressure ulcer care was $2003 for collagenase and $5480 for hydrogel debridement. The number of closed wound days was 1.5-times higher for collagenase (317 vs 218 days) than with the hydrogel. The estimated cost/closed wound day was 4-times higher for the hydrogel ($25) vs collagenase ($6). In this Markov model based on a randomized trial of pressure ulcer care in a long-term care setting collagenase debridement was economically dominant over autolytic debridement, yielding better outcomes at a lower total cost. Since it was a single institution study with a small sample size, the results should be interpreted with caution. Specifically, the findings may not necessarily be generalized to other hydrogel dressings, healthcare settings, age groups, or to wounds of other etiologies.

Complementary and Integrative Interventions for Chronic Neurologic Conditions Encountered in the Primary Care Office.

PubMed

Bega, Danny

2017-06-01

Chronic neurologic conditions are frequently managed in the primary care setting, and patients with these conditions are increasingly seeking nonconventional treatment options. This article provides a review and summary of the evidence for some of the most commonly studied and most frequently used complementary and integrative interventions for 3 conditions managed every day in primary care offices - diabetic neuropathy, migraine, and dementia. Copyright © 2017 Elsevier Inc. All rights reserved.

Improving Patient Care Through the Prism of Psychology: application of Maslow’s Hierarchy to Sedation, Delirium and Early Mobility in the ICU

PubMed Central

Jackson, James C.; Santoro, Michael J.; Ely, Taylor M.; Boehm, Leanne; Kiehl, Amy L; Anderson, Lindsay S.; Ely, E. Wesley

2016-01-01

The Intensive Care Unit is not only a place where lives are saved; it is also a site of harm and iatrogenic injury for millions of people treated in this setting globally every year. Increasingly, hospitals admit only the sickest patients, and, while the overall number of hospital beds remains stable in the U.S., the percentage of that total devoted to ICU beds is rising. These two realities engender a demographic imperative to address patient safety in the critical care setting. This manuscript addresses the medical community’s resistance to adopting a culture of safety in critical care with regard to issues surrounding sedation, delirium, and early mobility. Although there is currently much research and quality improvement in this area, most of what we know from these data and published guidelines has not become reality in the day-to-day management of ICU patients. This manuscript is not intended to provide a comprehensive review of the literature, but rather a framework to rethink our currently outdated culture of critical care by employing Maslow’s Hierarchy of Needs, along with a few novel analogies. Application of Maslow’s Hierarchy will help propel healthcare professionals toward comprehensive care of the whole person, not merely for survival, but toward restoration of pre-illness function of mind, body, and spirit. PMID:24636724

Psychological, Behavioral, and Educational Considerations for Children with Classified Disabilities and Diabetes within the School Setting

ERIC Educational Resources Information Center

Wyckoff, Leah; Hanchon, Timothy; Gregg, S. Renee

2015-01-01

School nurses are answering a call to action to provide day-to-day care for an increasing number of students diagnosed with chronic illnesses. Diabetes mellitus is one of the most prevalent chronic health conditions identified among school-age children and presents a host of complex challenges for the school nurse, educators, and other support…

Elective ambulatory surgical care in Ireland-why it needs to be better coded, classified and managed.

PubMed

Keane, Frank; Hammond, Laura; Kelliher, Gerry; Mealy, Ken

2017-12-12

In the year to July 2017, surgical disciplines accounted for 73% of the total national inpatient and day case waiting list and, of these, day cases accounted for 72%. Their proper classification is therefore important so that patients can be managed and treated in the most suitable and efficient setting. We set out to sub-classify the different elective surgical day cases treated in Irish public hospitals in order to assess their need to be managed as day cases and the consistency of practice between hospitals. We analysed all elective day cases that came under the care of surgeons between January 2014 and December 2016 and sub-classified them into those that were (A) true day case surgical procedures; (B) minor surgery or outpatient procedures; (C) gastrointestinal endoscopies; (D) day case, non-surgical interventions and (E) unclassified or having no primary procedure identified. Of 813,236 day case surgical interventions performed over 3 years, 26% were adjudged to accord with group A, 41% with B, 23% with C, 5% with D and 5% with E. The ratio of A to B procedures did not vary significantly across the range of hospital types. However, there were some notable variations in coding and practices between hospitals. Our findings show that many day cases should have been performed as outpatient procedures and that there were variations in coding and practices between hospitals that could not be easily explained. Outpatient procedure coding and a better, more consistent, classification of day cases are both required to better manage this group of patients.

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.

Home care--a safe and attractive alternative to inpatient administration of intensive chemotherapies.

PubMed

Lüthi, François; Fucina, Nadia; Divorne, Nathalie; Santos-Eggimann, Brigitte; Currat-Zweifel, Christine; Rollier, Patricia; Wasserfallen, Jean-Blaise; Ketterer, Nicolas; Leyvraz, Serge

2012-03-01

The objective of this study was to evaluate feasibility, safety, perception, and costs of home care for the administration of intensive chemotherapies. Patients receiving sequential chemotherapy in an inpatient setting, living within 30 km of the hospital, and having a relative to care for them were offered home care treatment. Chemotherapy was administered by a portable, programmable pump via an implantable catheter. The main endpoints were safety, patient's quality of life [Functional Living Index-Cancer (FLIC)], satisfaction of patients and relatives, and costs. Two hundred days of home care were analysed, representing a total of 46 treatment cycles of intensive chemotherapy in 17 patients. Two cycles were complicated by technical problems that required hospitalisation for a total of 5 days. Three major medical complications (heart failure, angina pectoris, and major allergic reaction) could be managed at home. Grades 1 and 2 nausea and vomiting occurring in 36% of patients could be treated at home. FLIC scores remained constant throughout the study. All patients rated home care as very satisfactory or satisfactory. Patient benefits of home care included increased comfort and freedom. Relatives acknowledged better tolerance and less asthenia of the patient. Home care resulted in a 53% cost benefit compared to hospital treatment (€420 ± 120/day vs. €896 ± 165/day). Administration of intensive chemotherapy regimens at home was feasible and safe. Quality of life was not affected; satisfaction of patients and relatives was very high. A psychosocial benefit was observed for patients and relatives. Furthermore, a cost-benefit of home care compared to hospital treatment was demonstrated.

An Educational Intervention to Evaluate Nurses' Knowledge of Heart Failure.

PubMed

Sundel, Siobhan; Ea, Emerson E

2018-07-01

Nurses are the main providers of patient education in inpatient and outpatient settings. Unfortunately, nurses may lack knowledge of chronic medical conditions, such as heart failure. The purpose of this one-group pretest-posttest intervention was to determine the effectiveness of teaching intervention on nurses' knowledge of heart failure self-care principles in an ambulatory care setting. The sample consisted of 40 staff nurses in ambulatory care. Nurse participants received a focused education intervention based on knowledge deficits revealed in the pretest and were then resurveyed within 30 days. Nurses were evaluated using the valid and reliable 20-item Nurses Knowledge of Heart Failure Education Principles Survey tool. The results of this project demonstrated that an education intervention on heart failure self-care principles improved nurses' knowledge of heart failure in an ambulatory care setting, which was statistically significant (p < .05). Results suggest that a teaching intervention could improve knowledge of heart failure, which could lead to better patient education and could reduce patient readmission for heart failure. J Contin Educ Nurs. 2018;49(7):315-321. Copyright 2018, SLACK Incorporated.

Temporal distribution of deaths in cancer patients during the day in different settings.

PubMed

Gonçalves, José Ferraz; Fonseca, Eugénia; Alvarenga, Margarida; Morais, Maria Rosa

2005-06-01

All living organisms perform their functions normally according to circadian rhythms. Certain diseases, such as ischemic heart disease and asthma, produce symptoms that are distributed during the day in a nonrandom fashion. Chronomodulated therapy with some regimens of chemotherapy and other drugs produce better results than traditional schedules. Even death is not evenly distributed during the day. Significant differences in the time of death through the day could influence the work planning and care activities. To determine whether timing of death from a population of cancer patients admitted at our Oncology Institute varied during the day and according to different settings: at home (H), at the palliative care unit (PCU), and at other services (OS) of the hospital. Comparing the timing of deaths from different settings can give some clues about the possible existence of a circadian rhythm and the influence of external circumstances in the time of death of cancer patients. We conducted a retrospective study of the records of time of death at the different settings. The study involved 772 patients from the PCU and 997 from OS who died between May 25, 1996, and May 24, 2000, and 347 patients who died at H between April 1, 1999, and December 31, 2001. A statistically significant difference was found in the distribution of time of death in patients at the PCU (p <.001), but not at OS or at H. There were two peaks between 08:00 and 10:00 and between 00:00 and 02:00, and one trough between 04:00 and 08:00. This suggests that a temporal variation occurs in the time of death of cancer patients dying in the PCU, but not in other settings. The clinical relevance of the results obtained in this study would depend on the amplitude of the eventual variation detected in the number of deaths during the day. Therefore, although there was a statistically significant variation at the time of death during the day, its amplitude is not high enough to make it clinically significant. The differences observed among the various settings suggest that, even if circadian rhythms exist at the time of death in cancer patients, external factors can overcome these rhythms.

Is There Extra Cost of Institutional Care for MS Patients?

PubMed Central

Noyes, Katia; Bajorska, Alina; Weinstock-Guttman, Bianca

2013-01-01

Throughout life, patients with multiple sclerosis (MS) require increasing levels of support, rehabilitative services, and eventual skilled nursing facility (SNF) care. There are concerns that access to SNF care for MS patients is limited because of perceived higher costs of their care. This study compares costs of caring for an MS patient versus those of a typical SNF patient. We merged SNF cost report data with the 2001–2006 Nursing Home Minimum Data Set (MDS) to calculate percentage of MS residents-days and facility case-mix indices (CMIs). We estimated the average facility daily cost using hybrid cost functions, adjusted for facility ownership, average facility wages, CMI-adjusted number of SNF days, and percentage of MS residents-days. We describe specific characteristics of SNF with high and low MS volumes and examine any sources of variation in cost. MS patients were no longer more costly than typical SNF patients. A greater proportion of MS patients had no significant effect on facility daily costs (P = 0.26). MS patients were more likely to receive care in government-owned facilities (OR = 1.904) located in the Western (OR = 2.133) and Midwestern (OR = 1.3) parts of the USA (P < 0.05). Cost of SNF care is not a likely explanation for the perceived access barriers that MS patients face. PMID:24163769

Various contract settings and their impact on the cost of medical services.

PubMed

Magnezi, R; Dankner, R; Kedem, R; Reuveni, H

2007-03-01

This study analyzes the effect of outsourcing healthcare on career soldiers in the Israel Defense Forces (IDF) in different settings, so as to develop a model for predicting per capita medical costs Demographic information and data on healthcare utilization and costs were gathered from three computerized billing database systems: The IDF Medical Corps; a civilian hospital; and a healthcare fund, providing services to 3,746; 3,971; and 6,400 career soldiers, respectively. Visits to primary care physicians and specialists, laboratory and imaging exams, number of sick-leave days, and hospitalization days, were totaled for men and women separately for each type of clinic. A uniform cost was assigned to each type of treatment to create an average annual per capita cost for medical services of career soldiers. Significantly more visits were recorded to primary care physician and to specialists, as well as imaging examinations by Leumit Healthcare Services (LHS), than visits and tests in hospitals or in military clinics (p < 0.001). The number of referrals to emergency rooms and sick-leave days were lowest in the LHS as compared to the hospital and military clinics (p < 0.001). The medical cost per capita/year was lowest in LHS as well. Outsourcing primary care for career soldiers to a civilian healthcare fund represents a major cost effective change, lowest consumption and lower cost of medical care. Co-payment should be integrated into every agreement with the medical corps.

Limits on same-day billing in Medicaid hinders integration of behavioral health into the medical home model.

PubMed

Roby, Dylan H; Jones, Erynne E

2016-02-01

The potential expansion of insurance coverage through the Patient Protection and Affordable Care Act of 2010 can facilitate the reduction of access barriers and improved quality for behavioral health care. More than 5 million of the newly insured are expected to have mental health and substance use disorders. In addition, state and federal efforts to integrate behavioral and medical health needs through patient-centered medical home models and innovations in payment strategies provide an unprecedented opportunity to use federal financial support to improve not only access to care, but also improve quality through active care coordination, use of interdisciplinary teams, colocating services, and engaging in warm hand-offs between providers in the same setting. These potential advances are hindered in 24 different states because of Medicaid payment policy, with 7 explicitly limiting the ability to reimburse for physical health and behavioral health services on the same day for all providers. Without the ability for providers to be reimbursed for different services on the same day to improve behavioral and medical health care coordination, these states could be limited in their ability to improve care via patient-centered approaches and interdisciplinary team-based care that would involve physicians, clinical psychologists, psychiatrists, and other mental health professionals. Limits on same-day billing in Medicaid programs could impact up to 36.7 million people in 24 states, which is approximately 52.6% of all Medicaid enrollees. (c) 2016 APA, all rights reserved).

Missing the Target: We Need to Focus on Informal Care Rather than Preschool. Evidence Speaks Reports, Vol 1, #19

ERIC Educational Resources Information Center

Loeb, Susanna

2016-01-01

Despite the widely-recognized benefits of early childhood experiences in formal settings that enrich the social and cognitive environments of children, many children--particularly infants and toddlers--spend their days in unregulated (or very lightly regulated) "informal" childcare settings. Over half of all one- and two-year-olds are…

Building a dream: creating an oncology day/evening hospital.

PubMed

Fletcher, K; Painter, V

2002-01-01

The demand for inpatient beds has reached and often exceeds capacity producing waiting lists for cancer care. There is a need to explore alternative approaches to oncology treatment. The Oncology Day/Evening Hospital (ODEH), originally envisioned in 1995 as a joint project between an ambulatory cancer centre and a large teaching hospital, is an important cancer treatment initiative offering extended hours of ambulatory oncology treatment on days, evenings, weekends and statutory holidays. A review of current inpatient treatment modalities revealed that many patients receiving inpatient therapy could be safely and effectively managed in the ambulatory setting if treatment regimens were modified and if ambulatory hours of operation were extended. Healthcare improvements expected were: appropriate movement of inpatient activity to the ambulatory setting; more opportunities for patient choice in treatment time thereby allowing for maintenance of normal living; better quality of life for patients through prevention of hospitalization; decrease in treatment waiting times; consolidation of patients into an ambulatory oncology treatment setting as opposed to utilization of adult medicine units; and more rational inpatient bed utilization with reduction of admissions and intra-treatment transfers. This article describes our experience in building a dream, the challenges and lessons learned in implementing a better way to deliver oncology care in an environment of rapid change and staff shortages.

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.

Retainment incentives in three rural practice settings: variations in job satisfaction among staff registered nurses.

PubMed

Stratton, T D; Dunkin, J W; Juhl, N; Geller, J M

1995-05-01

Researchers have demonstrated repeatedly the importance of the relationship linking job satisfaction to employee retention. In rural areas of the country, where a persistent maldistribution of nurses continues to hamper health care delivery, the potential benefits of bolstering retention via enhancements in job satisfaction are of utmost utility to administrators and providers alike. Data were gathered from a multistate survey of registered nurses (RNs) practicing in rural hospitals, skilled nursing facilities, and community/public health settings (N = 1,647; response rate = 40.3%). The investigators found that the use of tuition reimbursement corresponded significantly with increased levels of job satisfaction among nurses in all three practice environments, as did day care services for nurses in acute care settings. Also, among hospital-based RNs, level of nursing education was found to be a significant factor in the relationship between tuition reimbursement and job satisfaction, with the highest level occurring among diploma-prepared nurses.

A retrospective comparison of clinical outcomes and Medicare expenditures in skilled nursing facility residents with chronic wounds.

PubMed

DaVanzo, Joan E; El-Gamil, Audrey M; Dobson, Allen; Sen, Namrata

2010-09-01

Medicare skilled nursing facility (SNF) residents with chronic wounds require more resources and have relatively high healthcare expenditures compared to Medicare patients without wounds. A retrospective cohort study was conducted using 2006 Medicare Chronic Condition Warehouse claims data for SNF, inpatient, outpatient hospital, and physician supplier settings along with 2006 Long-Term Care Minimum Data Set (MDS) information to compare Medicare expenditures between two groups of SNF residents with a diagnosis of pressure, venous, ischemic, or diabetic ulcers whose wounds healed during the 10-month study period. The study group (n = 372) was managed using a structured, comprehensive wound management protocol provided by an external wound management team. The matched comparison group consisted of 311 SNF residents who did not receive care from the wound management team. Regression analyses indicate that after controlling for resident comorbidities and wound severity, study group residents experienced lower rates of wound-related hospitalization per day (0.08% versus 0.21%, P < 0.01) and shorter wound episodes (94 days versus 115 days, P < 0.01) than comparison group patients. Total Medicare costs were $21,449.64 for the study group and $40,678.83 for the comparison group (P < 0.01) or $229.07 versus $354.26 (P < 0.01) per resident episode day. Additional studies including wounds that do not heal are warranted. Increasing the number of SNF residents receiving the care described in this study could lead to significant Medicare cost savings. Incorporating wound clinical outcomes into a pay-for-performance measures for SNFs could increase broader SNF adoption of comprehensive wound care programs to treat chronic wounds.

Effects of Nasal Continuous Positive Airway Pressure and Cannula Use in the Neonatal Intensive Care Unit Setting

PubMed Central

Jatana, Kris R.; Oplatek, Agnes; Stein, Melanie; Phillips, Gary; Kang, D. Richard; Elmaraghy, Charles A.

2013-01-01

Objective To investigate the effects of nasal continuous positive airway pressure (CPAP) and cannula use in the neonatal intensive care unit. Design Cross-sectional study. Setting Tertiary care children’s hospital. Patients One hundred patients (200 nasal cavities), younger than 1 year, who received at least 7 days of nasal CPAP (n = 91) or cannula supplementation (n = 9) in the neonatal intensive care unit. Interventions External nasal examination and anterior nasal endoscopy with photographic documentation. Main Outcome Measures The incidence and characteristics of internal and external nasal findings of patients with nasal CPAP or cannula use. Results Nasal complications were seen in 12 of the 91 patients (13.2%) with at least 7 days of nasal CPAP exposure, while no complications were seen in the 9 patients with nasal cannula use alone. The external nasal finding of columellar necrosis, seen in 5 patients (5.5%), occurred as early as 10 days after nasal CPAP use. Incidence of intranasal findings attributed to CPAP use, in the 182 nostrils examined, included ulceration in 6 nasal cavities (3.3%), granulation in 3 nasal cavities (1.6%), and vestibular stenosis in 4 nasal cavities (2.2%). Intranasal complications were seen as early as 8 to 9 days after nasal CPAP administration. Nasal complications from CPAP were associated with lower Apgar scores at 1 (P = .02) and 5 (P = .06) minutes. Conclusions External or internal complications of nasal CPAP can be relatively frequent (13.2%) and can occur early, and patients with lower Apgar scores may be at higher risk. Close surveillance for potential complications should be considered during nasal CPAP use. PMID:20231649

Feasibility of community-based careHPV for cervical cancer prevention in rural Thailand.

PubMed

Trope, Lee A; Chumworathayi, Bandit; Blumenthal, Paul D

2013-07-01

This study aimed to assess the safety, acceptability and feasibility of primary human papillomavirus (HPV) testing for cervical cancer prevention at the community level in a low-resource setting. After training a technician to run specimens on the careHPV unit, the study team traveled to a different village each day in rural Roi-et Province, Thailand. Women were tested for HPV using self-swab, followed by careHPV testing. Those with positive result were assessed immediately by visual inspection with acetic acid. Women positive for HPV and visual inspection with acetic acid were offered cryotherapy. Safety was determined by monitoring adverse events. Exit surveys assessed acceptability and feasibility. Feasibility was also assessed by measuring testing and triage throughputs. Technician training required 2.5 days to achieve competency. A total of 431 women were screened in 14 days, with an average of 31 women screened daily. No adverse events were reported. Women deemed the program overwhelmingly acceptable: 90.5% reported that they would take the self-swab again, 71.3% preferred the self-swab to a clinician swab. The program was also feasible: 99.8% of eligible women agreed to testing, 94.8% returned for same-day follow-up, and women only spent 30 to 50 minutes of their total time with the program from screening to results. Cervical cancer prevention programs based on self-swab HPV testing could be safe, acceptable, feasible, and effective at the community level in low-resource settings.

Choosing wisely and the use of antibiotics in ophthalmic surgery: There is more than meets the eye.

PubMed

Grosso, Andrea; Ceruti, Piero; Scarpa, Giuseppe; Giardini, Franco; Marchini, Giorgio; Aragona, Emanuela; Bert, Fabrizio; Bandello, Francesco; Siliquini, Roberta

2018-02-01

One of the directions of modern ophthalmology is toward an odontoiatric model, and new settings of eye care are becoming the standard of care: one day surgery and also office-based therapies. Retrospective analysis of three tertiary-care centers in Italy and analysis of the literature. We provide readers with state-of-the-art measures of prophylaxis in ophthalmic surgery. Role of antibiotics is criticized in the light of stewardship antimicrobial paradigm.

Process of Transition for Congenital Heart Patients: Preventing Loss to Follow-up.

PubMed

Habibi, Hajar; Emmanuel, Yaso; Chung, Natali

The aim of this article is to provide an overview of our nurse-led transition clinic provided to congenital heart disease patients moving from pediatric into adult care setting. Nurse-led transition clinic was analyzed at various stages of young adult care from an early stage of 12 to 14 years to entering adult setting at 16 years or older. Overview of current transition service for young adults being transferred from pediatric into adult services highlights the integral role of clinical nurse specialist as a coordinator of care. The result of the service overview indicates that nurse-led transition service enables patients to build on their knowledge. This is achieved by providing them time and the opportunities to develop an understanding of their condition and the attitudes required to engage with the adult care setting as indicated in the psychology questionnaire from transition day. A nurse-led transition clinic enhances long-term care of patients by supporting the young adults and their family/carer through the transition and transfer of the care to promote the young adult's understanding of their condition and to prevent any lost to follow-up.

Diet, smoking and cardiovascular risk in schizophrenia in high and low care supported housing.

PubMed

Gupta, Avirup; Craig, Tom K J

2009-01-01

People suffering from schizophrenia have markedly increased physical morbidity and mortality. A poor diet and sedentary lifestyle make a significant contribution to this ill health. Healthcare professionals need to include assessments of diet and to promote a 'healthy living' lifestyle. To describe the dietary habits and cardiovascular risk factors of people with chronic schizophrenia living in supported accommodation and to audit the provision of cardiovascular health screening in this population. The dietary habits of 69 people with chronic schizophrenia living in community settings were assessed. Tobacco smoking, body mass indices and waist circumference were also measured. The dietary behaviour of patients living in high care settings with care staff present every day was compared with those in low care settings. Residents in both levels of care made poor dietary choices. Patients in high care were consuming more fast food than those in low care. The dietary habits of men and women in both levels of care were worse than reported by surveys of the general population in England. All patients had seen their GP in the previous year though only 3 had received diabetes screening and fewer than half had lipid profiles. People with schizophrenia do not improve their diet just by the provision of healthy food as was the case in high care settings. Secondary care services must address physical health monitoring as well as mental health if the increased mortality of patients with schizophrenia is to be addressed effectively. More effective interventions are necessary to improve and sustain a healthy diet.

The Milieu Manager: A Nursing Staffing Strategy to Reduce Observer Use in the Acute Psychiatric Inpatient Setting.

PubMed

Triplett, Patrick; Dearholt, Sandra; Cooper, Mary; Herzke, John; Johnson, Erin; Parks, Joyce; Sullivan, Patricia; Taylor, Karin F; Rohde, Judith

Rising acuity levels in inpatient settings have led to growing reliance on observers and increased the cost of care. Minimizing use of observers, maintaining quality and safety of care, and improving bed access, without increasing cost. Nursing staff on two inpatient psychiatric units at an academic medical center pilot-tested the use of a "milieu manager" to address rising patient acuity and growing reliance on observers. Nursing cost, occupancy, discharge volume, unit closures, observer expense, and incremental nursing costs were tracked. Staff satisfaction and reported patient behavioral/safety events were assessed. The pilot initiatives ran for 8 months. Unit/bed closures fell to zero on both units. Occupancy, patient days, and discharges increased. Incremental nursing cost was offset by reduction in observer expense and by revenue from increases in occupancy and patient days. Staff work satisfaction improved and measures of patient safety were unchanged. The intervention was effective in reducing observation expense and improved occupancy and patient days while maintaining patient safety, representing a cost-effective and safe approach for management of acuity on inpatient psychiatric units.

Seeking to reduce nonbeneficial treatment in the ICU: an exploratory trial of proactive ethics intervention*.

PubMed

Andereck, William S; McGaughey, J Westly; Schneiderman, Lawrence J; Jonsen, Albert R

2014-04-01

To investigate whether the proactive intervention of a clinical ethicist in cases of prolonged lengths of stay in a critical care setting reduces nonbeneficial treatment while increasing perceived patient/surrogate and provider satisfaction and reducing associated costs. Nonbeneficial treatment is defined here as the use of life-sustaining treatments delivered to patients who had been in the ICU for 5 days and did not survive to discharge. Prospective randomized exploratory trial from October 2007 to February 2010 in the adult ICU of a large, urban, not-for-profit community hospital. Medical/surgical ICU of California Pacific Medical Center, a large tertiary not-for-profit hospital in San Francisco, CA. Three hundred eighty-four patients with ICU lengths of stay of five days or greater. Patients were randomized to either an intervention arm (Proactive Ethics Intervention) (n = 174) or control arm (n = 210). There were 56 patients in the intervention arm and 52 patients in the control arm who did not survive to discharge. Proactive ethics intervention involves a trained bioethicist in the care of all ICU patients with a length of stay greater than or equal to 5 days. The intervention used a nine step process model designed to look for manifest or latent ethics conflicts and address them. The primary outcome measures were days in the ICU; overall length of hospital stay; mortality; nonbeneficial treatments, for example, provision of nutritional support; surrogate and survivor satisfaction, and cost. The intervention and control arms showed no significant difference in mortality. Proactive Ethics Intervention, at the 95% CI, was not associated with reductions of overall length of stay (23 d for intervention and 21 d for control, p = 0.74), ICU days (11 in each arm, p = 0.91), life-sustaining treatments (days on ventilator: intervention, 14.6; control, 13.7; p = 0.74; days receiving artificial nutrition and hydration: intervention, 16.5; control, 15.9; p = 0.85), or cost ($167,350.00 for intervention and $164,670.00 for control, p =0.92) in patients who did not survive to discharge. Perceptions of quality of care by patients and providers showed no difference between intervention and control arms. Our study finds that Proactive Ethics Intervention, provided to all patients in a critical care setting for 5 days, and before an ethical conflict has been recognized, is ineffective in reducing overall length of hospital stay, ICU days, nonbeneficial treatments, or hospital costs. It is also not effective in increasing perceptions of quality of care by patients or providers.

Costs and Effects of an Ambulatory Geriatric Unit (the AGe-FIT Study): A Randomized Controlled Trial.

PubMed

Ekdahl, Anne W; Wirehn, Ann-Britt; Alwin, Jenny; Jaarsma, Tiny; Unosson, Mitra; Husberg, Magnus; Eckerblad, Jeanette; Milberg, Anna; Krevers, Barbro; Carlsson, Per

2015-06-01

To examine costs and effects of care based on comprehensive geriatric assessment (CGA) provided by an ambulatory geriatric care unit (AGU) in addition to usual care. Assessor-blinded, single-center randomized controlled trial. AGU in an acute hospital in southeastern Sweden. Community-dwelling individuals aged 75 years or older who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion and randomized to the intervention group (IG; n = 208) or control group (CG; n = 174). Mean age (SD) was 82.5 (4.9) years. Participants in the IG received CGA-based care at the AGU in addition to usual care. The primary outcome was number of hospitalizations. Secondary outcomes were days in hospital and nursing home, mortality, cost of public health and social care, participant' sense of security in care, and health-related quality of life (HRQoL). Baseline characteristics did not differ between groups. The number of hospitalizations did not differ between the IG (2.1) and CG (2.4), but the number of inpatient days was lower in the IG (11.1 vs 15.2; P = .035). The IG showed trends of reduced mortality (hazard ratio 1.51; 95% confidence interval [CI] 0.988-2.310; P = .057) and an increased sense of security in care interaction. No difference in HRQoL was observed. Costs for the IG and CG were 33,371 £ (39,947 £) and 30,490 £ (31,568 £; P = .432). This study of CGA-based care was performed in an ambulatory care setting, in contrast to the greater part of studies of the effects of CGA, which have been conducted in hospital settings. This study confirms the superiority of this type of care to elderly people in terms of days in hospital and sense of security in care interaction and that a shift to more accessible care for older people with multimorbidity is possible without increasing costs. This study can aid the planning of future interventions for older people. clinicaltrials.gov identifier: NCT01446757. Copyright © 2015 AMDA - The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

An Integrated Care Initiative to Improve Patient Outcome in Schizophrenia.

PubMed

Mayer-Amberg, Norbert; Woltmann, Rainer; Walther, Stefanie

2015-01-01

The optimal treatment of schizophrenia patients requires integration of medical and psychosocial inputs. In Germany, various health-care service providers and institutions are involved in the treatment process. Early and continuous treatment is important but often not possible because of the fragmented medical care system in Germany. The Integrated Care Initiative Schizophrenia has implemented a networked care concept in the German federal state of Lower Saxony that integrates various stakeholders of the health care system. In this initiative, office-based psychiatrists, specialized nursing staff, psychologists, social workers, hospitals, psychiatric institutional outpatient's departments, and other community-based mental health services work together in an interdisciplinary approach. Much emphasis is placed on psychoeducation. Additional efforts cover socio-therapy, visiting care, and family support. During the period from October 2010 (start of the initiative) to December 2012, first experiences and results of quality indicators were collected of 713 registered patients and summarized in a quality monitoring report. In addition, standardized patient interviews were conducted, and duration of hospital days was recorded in 2013. By the end of 2012, patients had been enrolled for an average of 18.7 months. The overall patient satisfaction measured in a patient survey in June 2013 was high and the duration of hospital days measured in a pre-post analysis in July 2013 was reduced by 44%. Two years earlier than planned, the insurance fund will continue the successfully implemented Integrated Care Initiative and adopt it in the regular care setting. This initiative can serve as a learning case for how to set up and measure integrated care systems that may improve outcomes for patients suffering from schizophrenia.

The impact of inpatient palliative care on end of life care among older trauma patients who die after hospital discharge.

PubMed

Lilley, Elizabeth J; Lee, Katherine C; Scott, John W; Krumrei, Nicole J; Haider, Adil H; Salim, Ali; Gupta, Rajan; Cooper, Zara

2018-05-30

Palliative care is associated with lower intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care, however the impact of PC on healthcare utilization at the end of life has yet to be characterized in older trauma patients. This retrospective cohort study using 2006-2011 national Medicare claims included trauma patients ≥65 years who died within 180 days after discharge. The exposure of interest was inpatient palliative care during the trauma admission. A non-PC control group was developed by exact-matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We employed logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility (SNF) or long-term acute care hospital (LTACH) admission, death in an institutional setting, and intensive care unit (ICU) admission or receipt of life-sustaining treatments (LST) during a subsequent hospitalization. Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [95% confidence interval] = 3.80 [3.54-4.09]) and reduced odds of rehospitalization (0.17[0.15-0.20]), SNF/LTACH admission (0.43[0.39-0.47]), death in an institutional setting (0.34[0.30-0.39]), subsequent ICU admission (0.51[0.36-0.72]), or receiving LST (0.56[0.39-0.80]). Inpatient palliative care is associated with lower intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underutilized among those who die within 6 months after discharge. Level III STUDY TYPE: Prognostic.

Cultural/Favorite Recipe Day: Strengthening Approaches to Increase Culturally Diverse Foods Served in Head Start Meals

ERIC Educational Resources Information Center

Hoffman, Jessica A.; Agrawal, Tara; Carter, Sonia; Grinder, AnnMarie; Castaneda-Sceppa, Carmen

2012-01-01

One approach to halting the childhood obesity epidemic has been the modification of foods available to children during the school day. In recent years there has been an increased focus on obesity prevention efforts among children ages birth to 5 and the role of child care settings in prevention efforts. Head Start serves as an important venue for…

Association between shift work and being overweight or obese among health care workers in a clinical setting in Medellin, Colombia.

PubMed

Gomez-Parra, Myrna; Romero-Arrieta, Lydis; Vasquez-Trespalacios, Elsa Maria; Palacio-Jaramillo, Veronica; Valencia-Martinez, Andrea

2016-11-22

Shift work is common in health care settings and has been hypothesized as a risk factor for being overweight or obese. We examined the relation between shift work and being overweight or obese, adjusting for stress and lifestyle habits in Colombian health care workers. The aim of this study was to assess the association between shift work and being overweight/obese in employees of a health care setting in Medellin, Colombia. This cross-sectional study was carried out among 200 workers in a health care setting. Participants completed a demographic, occupational, work-related stress and life style questionnaire. Their Body Mass Index (BMI) and waist to hip ratio were also measured. The study sample consisted of 160 (80%) females and 40 (20%) males. Mean age was 35.1±9.1 years and mean BMI was 25±3.9. After adjusting for potential confounders, multivariate logistic regression revealed no statistically significant association between being overweight, being obese or waist to hip ratio and shift work; 95% CI OR: 1.08 (0.62-1.89), 1.33 (0.44-3.99) and 1.2 (0.8-1.9), respectively. Day workers were statistically more likely to smoke, work more hours, and have a higher educational level than shift workers. No significant associations between shift work and being overweight/obese were observed in health care workers in a Colombian setting. These findings need to be confirmed through longitudinal studies.

Objectively Measured Activity Patterns among Adults in Residential Aged Care

PubMed Central

Reid, Natasha; Eakin, Elizabeth; Henwood, Timothy; Keogh, Justin W. L.; Senior, Hugh E.; Gardiner, Paul A.; Winkler, Elisabeth; Healy, Genevieve N.

2013-01-01

Objectives: To determine the feasibility of using the activPAL3TM activity monitor, and, to describe the activity patterns of residential aged care residents. Design: Cross-sectional. Setting: Randomly selected aged care facilities within 100 km of the Gold Coast, Queensland, Australia. Participants: Ambulatory, older (≥60 years) residential aged care adults without cognitive impairment. Measurements: Feasibility was assessed by consent rate, sleep/wear diary completion, and through interviews with staff/participants. Activity patterns (sitting/lying, standing, and stepping) were measured via activPAL3TM monitors worn continuously for seven days. Times spent in each activity were described and then compared across days of the week and hours of the day using linear mixed models. Results: Consent rate was 48% (n = 41). Activity patterns are described for the 31 participants (mean age 84.2 years) who provided at least one day of valid monitor data. In total, 14 (45%) completed the sleep/wear diary. Participants spent a median (interquartile range) of 12.4 (1.7) h sitting/lying (with 73% of this accumulated in unbroken bouts of ≥30 min), 1.9 (1.3) h standing, and 21.4 (36.7) min stepping during their monitored waking hours per day. Activity did not vary significantly by day of the week (p ≥ 0.05); stepping showed significant hourly variation (p = 0.018). Conclusions: Older adults in residential aged care were consistently highly sedentary. Feasibility considerations for objective activity monitoring identified for this population include poor diary completion and lost monitors. PMID:24304508

Variation in the prevalence of urinary catheters: a profile of National Health Service patients in England.

PubMed

Shackley, David Clifford; Whytock, Cameron; Parry, Gareth; Clarke, Laurence; Vincent, Charles; Harrison, Abigail; John, Amber; Provost, Lloyd; Power, Maxine

2017-06-23

Harm from catheter-associated urinary tract infections is a common, potentially avoidable, healthcare complication. Variation in catheter prevalence may exist and provide opportunity for reducing harm, yet to date is poorly understood. This study aimed to determine variation in the prevalence of urinary catheters between patient groups, settings, specialities and over time. A prospective study (July 2012 to April 2016) of National Health Service (NHS) patients surveyed by healthcare professionals, following a standardised protocol to determine the presence of a urinary catheter and duration of use, on 1 day per month using the NHS Safety Thermometer. 1314 organisations (253 NHS trusts) and 9 266 284 patients were included. Overall, 12.9% of patients were catheterised, but utilisation varied. There was higher utilisation of catheters in males (15.7% vs 10.7% p<0.001) and younger people (18-70 year 14.0% vs >70 year 12.8% p<0.001), utilisation was highest in hospital settings (18.6% p<0.001), particularly in critical care (76.6% p<0.001). Most catheters had been in situ <28 days (72.9% p<0.001). No clinically significant changes were seen over time in any setting or specialty. Catheter prevalence in patients receiving NHS-funded care varies according to gender, age, setting and specialty, being most prevalent in males, younger people, hospitals and critical care. Utilisation has changed only marginally over 46 months, and further guidance is indicated to provide clarity for clinicians on the insertion and removal of catheters to supplement the existing guidance on care. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Five fruit and vegetables and five praises a day: the case for a proactive approach.

PubMed

Sutton, Carole; Herbert, Martin

2008-04-01

The government has adopted the five outcomes of Every Child Matters as guiding principles for all those caring for and working with children. One of the ways in which efforts are being made to help children achieve good physical health is to encourage them to eat 'five fruit and vegetables a day'. This article sets out the case that practitioners can help children achieve good mental health by encouraging parents and those who care for children to give them at least'five praises a day'. Babies are predisposed from birth to make close social and emotional attachments with their main caregivers, and typically receive generous and loving admiration and appreciation. However, we know that some parents may not understand how infants and toddlers continue to need active nurturing attention, praise and positive messages from those who care for them as they grow. The authors seek to develop their inter-professional campaign to extend the 'five fruit and vegetables a day' maxim to include'five praises a day' for children. Health visitors are uniquely placed to help parents, to explain and encourage the contribution that praise and positive feedback make toward children's general wellbeing and sound mental health.

Validation of the 3-day rule for stool bacterial tests in Japan.

PubMed

Kobayashi, Masanori; Sako, Akahito; Ogami, Toshiko; Nishimura, So; Asayama, Naoki; Yada, Tomoyuki; Nagata, Naoyoshi; Sakurai, Toshiyuki; Yokoi, Chizu; Kobayakawa, Masao; Yanase, Mikio; Masaki, Naohiko; Takeshita, Nozomi; Uemura, Naomi

2014-01-01

Stool cultures are expensive and time consuming, and the positive rate of enteric pathogens in cases of nosocomial diarrhea is low. The 3-day rule, whereby clinicians order a Clostridium difficile (CD) toxin test rather than a stool culture for inpatients developing diarrhea >3 days after admission, has been well studied in Western countries. The present study sought to validate the 3-day rule in an acute care hospital setting in Japan. Stool bacterial and CD toxin test results for adult patients hospitalized in an acute care hospital in 2008 were retrospectively analyzed. Specimens collected after an initial positive test were excluded. The positive rate and cost-effectiveness of the tests were compared among three patient groups. The adult patients were divided into three groups for comparison: outpatients, patients hospitalized for ≤3 days and patients hospitalized for ≥4 days. Over the 12-month period, 1,597 stool cultures were obtained from 992 patients, and 880 CD toxin tests were performed in 529 patients. In the outpatient, inpatient ≤3 days and inpatient ≥4 days groups, the rate of positive stool cultures was 14.2%, 3.6% and 1.3% and that of positive CD toxin tests was 1.9%, 7.1% and 8.5%, respectively. The medical costs required to obtain one positive result were 9,181, 36,075 and 103,600 JPY and 43,200, 11,333 and 9,410 JPY, respectively. The 3-day rule was validated for the first time in a setting other than a Western country. Our results revealed that the "3-day rule" is also useful and cost-effective in Japan.

Readmission to Acute Care Hospital during Inpatient Rehabilitation for Traumatic Brain Injury

PubMed Central

Hammond, Flora M.; Horn, Susan D.; Smout, Randall J.; Beaulieu, Cynthia L.; Barrett, Ryan S.; Ryser, David K.; Sommerfeld, Teri

2015-01-01

Objective To investigate frequency, reasons, and factors associated with readmission to acute care (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI). Design Prospective observational cohort. Setting Inpatient rehabilitation. Participants 2,130 consecutive admissions for TBI rehabilitation. Interventions Not applicable. Main Outcome Measure(s) RTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location. Results 183 participants (9%) experienced RTAC for a total 210 episodes. 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. Mean days from rehabilitation admission to first RTAC was 22 days (SD 22). Mean duration in acute care during RTAC was 7 days (SD 8). 84 participants (46%) had >1 RTAC episode for medical reasons, 102 (56%) had >1 RTAC for surgical reasons, and RTAC reason was unknown for 6 (3%) participants. Most common surgical RTAC reasons were: neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurologic (23%), and cardiac (12%). Older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission predicted patients with RTAC. RTAC was less likely for patients with higher admission Functional Independence Measure Motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home. Conclusion(s) Approximately 9% of patients with TBI experience RTAC during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation due to RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting. PMID:26212405

Patients' view of retail clinics as a source of primary care: boon for nurse practitioners?

PubMed

Ahmed, Arif; Fincham, Jack E

2011-04-01

To estimate consumer utilities associated with major attributes of retail clinics (RCs). A discrete choice experiment (DCE) with 383 adult residents of the metropolitan statistical areas in Georgia conducted via Random Digit Dial survey of households. The DCE had two levels each of four attributes: price ($59; $75), appointment wait time (same day; 1 day or more), care setting-provider combination (nurse practitioner [NP]-RC; physician-private office), and acute illness (urinary tract infection; influenza), resulting in 16 choice scenarios. The respondents indicated whether they would seek care under each scenario. Cost savings and convenience offered by RCs are attractive to urban patients, and given sufficient cost savings they are likely to seek care there. All else equal, one would require cost savings of at least $30.21 to seek care from an NP at RC rather than a physician at private office, and $83.20 to wait one day or more. Appointment wait time is a major determinant of care-seeking decisions for minor illnesses. The size of the consumer utility associated with the convenience feature of RCs indicates that there is likely to be further growth and employment opportunities for NPs in these clinics. ©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.

Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial.

PubMed

Bruce, Martha L; Lohman, Matthew C; Greenberg, Rebecca L; Bao, Yuhua; Raue, Patrick J

2016-11-01

To determine whether a depression care management intervention in Medicare home health recipients decreases risk of hospitalization. Cluster-randomized trial. Nurse teams were randomized to intervention (12 teams) or enhanced usual care (EUC; 9 teams). Six home health agencies from distinct geographic regions. Home health recipients were interviewed at home and over the telephone. Individuals aged 65 and older who screened positive for depression on nurse assessments (N = 755) and a subset who consented to interviews (n = 306). The Depression CARE for PATients at Home (CAREPATH) guides nurses in managing depression during routine home visits. Clinical functions include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. Researchers conducted telephone conferences with team supervisors every 2 weeks. Hospitalization while receiving home health services was assessed using data from the home health record. Hospitalization within 30 days of starting home health, regardless of how long recipients received home health services, was assessed using data from the home care record and research assessments. The relative hazard of being admitted to the hospital directly from home health was 35% lower within 30 days of starting home health care (hazard ratio (HR) = 0.65, P = .01) and 28% lower within 60 days (HR = 0.72, P = .03) for CAREPATH participants than for participants receiving EUC. In participants referred to home health directly from the hospital, the relative hazard of being rehospitalized was approximately 55% lower (HR = 0.45, P = .001) for CAREPATH participants. Integrating CAREPATH depression care management into routine nursing practice reduces hospitalization and rehospitalization risk in older adults receiving Medicare home health nursing services. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

The diverse landscape of palliative care clinics.

PubMed

Smith, Alexander K; Thai, Julie N; Bakitas, Marie A; Meier, Diane E; Spragens, Lynn H; Temel, Jennifer S; Weissman, David E; Rabow, Michael W

2013-06-01

Many health care organizations are interested in instituting a palliative care clinic. However, there are insufficient published data regarding existing practices to inform the development of new programs. Our objective was to obtain in-depth information about palliative care clinics. We conducted a cross-sectional survey of 20 outpatient palliative care practices in diverse care settings. The survey included both closed- and open-ended questions regarding practice size, utilization of services, staffing, referrals, services offered, funding, impetus for starting, and challenges. Twenty of 21 (95%) practices responded. Practices self-identified as: hospital-based (n=7), within an oncology division/cancer center (n=5), part of an integrated health system (n=6), and hospice-based (n=2). The majority of referred patients had a cancer diagnosis. Additional common diagnoses included chronic obstructive pulmonary disease, neurologic disorders, and congestive heart failure. All practices ranked "pain management" and "determining goals of care" as the most common reasons for referrals. Twelve practices staffed fewer than 5 half-days of clinic per week, with 7 operating only one half-day per week. Practices were staffed by a mixture of physicians, advanced practice nurses or nurse practitioners, nurses, or social workers. Eighteen practices expected their practice to grow within the next year. Eleven practices noted a staffing shortage and 8 had a wait time of a week or more for a new patient appointment. Only 12 practices provide 24/7 coverage. Billing and institutional support were the most common funding sources. Most practices described starting because inpatient palliative providers perceived poor quality outpatient care in the outpatient setting. The most common challenges included: funding for staffing (11) and being overwhelmed with referrals (8). Once established, outpatient palliative care practices anticipate rapid growth. In this context, outpatient practices must plan for increased staffing and develop a sustainable financial model.

Nursing delegation and medication administration in assisted living.

PubMed

Mitty, Ethel; Resnick, Barbara; Allen, Josh; Bakerjian, Debra; Hertz, Judith; Gardner, Wendi; Rapp, Mary Pat; Reinhard, Susan; Young, Heather; Mezey, Mathy

2010-01-01

Assisted living (AL) residences are residential long-term care settings that provide housing, 24-hour oversight, personal care services, health-related services, or a combination of these on an as-needed basis. Most residents require some assistance with activities of daily living and instrumental activities of daily living, such as medication management. A resident plan of care (ie, service agreement) is developed to address the health and psychosocial needs of the resident. The amount and type of care provided, and the individual who provides that care, vary on the basis of state regulations and what services are provided within the facility. Some states require that an RN hold a leadership position to oversee medication management and other aspects of care within the facility. A licensed practical nurse/licensed vocational nurse can supervise the day-to-day direct care within the facility. The majority of direct care in AL settings is provided by direct care workers (DCWs), including certified nursing assistants or unlicensed providers. The scope of practice of a DCW varies by state and the legal structure within that state. In some states, the DCW is exempt from the nurse practice act, and in some states, the DCW may practice within a specific scope such as being a medication aide. In most states, however, the DCW scope of practice is conscribed, in part, by the delegation of responsibilities (such as medication administration) by a supervising RN. The issue of RN delegation has become the subject of ongoing discussion for AL residents, facilities, and regulators and for the nursing profession. The purpose of this article is to review delegation in AL and to provide recommendations for future practice and research in this area.

Case-Mix, Care Processes, and Outcomes in Medically-Ill Patients Receiving Mechanical Ventilation in a Low-Resource Setting from Southern India: A Prospective Clinical Case Series.

PubMed

Karthikeyan, Balasubramanian; Kadhiravan, Tamilarasu; Deepanjali, Surendran; Swaminathan, Rathinam Palamalai

2015-01-01

Mechanical ventilation is a resource intensive organ support treatment, and historical studies from low-resource settings had reported a high mortality. We aimed to study the outcomes in patients receiving mechanical ventilation in a contemporary low-resource setting. We prospectively studied the characteristics and outcomes (disease-related, mechanical ventilation-related, and process of care-related) in 237 adults mechanically ventilated for a medical illness at a teaching hospital in southern India during February 2011 to August 2012. Vital status of patients discharged from hospital was ascertained on Day 90 or later. Mean age of the patients was 40 ± 17 years; 140 (51%) were men. Poisoning and envenomation accounted for 98 (41%) of 237 admissions. In total, 87 (37%) patients died in-hospital; 16 (7%) died after discharge; 115 (49%) were alive at 90-day assessment; and 19 (8%) were lost to follow-up. Weaning was attempted in 171 (72%) patients; most patients (78 of 99 [79%]) failing the first attempt could be weaned off. Prolonged mechanical ventilation was required in 20 (8%) patients. Adherence to head-end elevation and deep vein thrombosis prophylaxis were 164 (69%) and 147 (62%) respectively. Risk of nosocomial infections particularly ventilator-associated pneumonia was high (57.2 per 1,000 ventilator-days). Higher APACHE II score quartiles (adjusted HR [95% CI] quartile 2, 2.65 [1.19-5.89]; quartile 3, 2.98 [1.24-7.15]; quartile 4, 5.78 [2.45-13.60]), and new-onset organ failure (2.98 [1.94-4.56]) were independently associated with the risk of death. Patients with poisoning had higher risk of reintubation (43% vs. 20%; P = 0.001) and ventilator-associated pneumonia (75% vs. 53%; P = 0.001). But, their mortality was significantly lower compared to the rest (24% vs. 44%; P = 0.002). The case-mix considerably differs from other settings. Mortality in this low-resource setting is similar to high-resource settings. But, further improvements in care processes and prevention of nosocomial infections are required.

Intensity of Care at the End of Life Among Older Adults in Korea.

PubMed

Kim, Su Hyun; Kang, Sangwook; Song, Mi-Kyung

2018-01-01

To examine the intensity of care at the end of life among older adults in Korea and to identify the individual and institutional factors associated with care intensity. This secondary data analysis included a sample of 6278 decedents aged 65 years or older who were identified from the 2009 to 2010 Korean National Health Insurance Service-National Sample Cohort Claims data. We examined the medical care received by the cohort in the last 30 days of their lives. Overall, 36.5% of the sample received at least 1 intensive care procedure in the last 30 days of their lives; 26.3% of patients experienced intensive care unit admission, with an average stay of 7.45 days, 19.5% received mechanical ventilation, 12.3% received cardiopulmonary resuscitation, and 15.5% had a feeding tube placement. A statistical analysis using a multiple logistic regression model with random effects showed that younger age, higher household income, primary diagnoses of diseases (ischemic heart disease, infectious disease, chronic lung disease, or chronic heart disease), and characteristics of care setting (large hospitals and facilities located in metropolitan areas) were significantly associated with the likelihood of receiving high-intensity care at the end of life. A substantial number of older adults in Korea experienced high-intensity end-of-life care. Both individual and institutional factors were associated with the likelihood of receiving high-intensity care. Gaining an understanding of the intensity of care at the end of life and the impact of the determinants would advance efforts to improve quality of care at the end of life for older adults in Korea.

The effectiveness of Nurse Practitioners working at a GP cooperative: a study protocol

PubMed Central

2012-01-01

Background In many countries out-of-hours care faces serious challenges, including shortage of general practitioners, a high workload, reduced motivation to work out of hours, and increased demand for out-of-hours care. One response to these challenges is the introduction of nurse practitioner as doctor substitutes, in order to maintain the (high) accessibility and safety of out of hours care. Although nurse practitioners have proven to provide equally safe and efficient care during daytime primary care, it is unclear whether substitution is effective and efficient in the more complex out of hours primary care. This study aims to assess the effects of substitution of care from general practitioners to nurse practitioners in an out of hours primary care setting. Design A quasi experimental study is undertaken at one “general practitioner cooperative” to offer out-of-hours care for 304.000 people in the South East of the Netherlands. In the experimental condition patient care is provided by a team of one nurse practitioner and four general practitioners; where the nurse practitioner replaces one general practitioner during one day of the weekend from 10 am to 5 pm. In the control condition patient care is provided by a team of five general practitioners during the other day of the weekend, also from 10 am to 5 pm. The study period last 15 months, from April 2011 till July 2012. Methods Data will be collected on number of different outcomes using a range of methods. Our primary outcome is substitution of care. This is calculated using the number and characteristics of patients that have a consultation at the GP cooperative. We compare the number of patients seen by both professionals, type of complaints, resource utilization (e.g. prescription, tests, investigations, referrals) and waiting times in the experimental condition and control condition. This data is derived from patient electronic medical records. Secondary outcomes are: patient satisfaction; general practitioners workload; quality and safety of care and barriers and facilitators. Discussion The study will provide evidence whether substitution of care in out-of-hours setting is safe and efficient and give insight into barriers and facilitators related to the introduction of nurse practitioners in out-of-hours setting. Trial registration ClinicalTrials.gov ID NCT01388374 PMID:22870898

The effectiveness of nurse practitioners working at a GP cooperative: a study protocol.

PubMed

Wijers, Nancy; Schoonhoven, Lisette; Giesen, Paul; Vrijhoef, Hubertus; van der Burgt, Regi; Mintjes, Joke; Wensing, Michel; Laurant, Miranda

2012-08-07

In many countries out-of-hours care faces serious challenges, including shortage of general practitioners, a high workload, reduced motivation to work out of hours, and increased demand for out-of-hours care. One response to these challenges is the introduction of nurse practitioner as doctor substitutes, in order to maintain the (high) accessibility and safety of out of hours care. Although nurse practitioners have proven to provide equally safe and efficient care during daytime primary care, it is unclear whether substitution is effective and efficient in the more complex out of hours primary care. This study aims to assess the effects of substitution of care from general practitioners to nurse practitioners in an out of hours primary care setting. A quasi experimental study is undertaken at one "general practitioner cooperative" to offer out-of-hours care for 304.000 people in the South East of the Netherlands. In the experimental condition patient care is provided by a team of one nurse practitioner and four general practitioners; where the nurse practitioner replaces one general practitioner during one day of the weekend from 10 am to 5 pm. In the control condition patient care is provided by a team of five general practitioners during the other day of the weekend, also from 10 am to 5 pm. The study period last 15 months, from April 2011 till July 2012. Data will be collected on number of different outcomes using a range of methods. Our primary outcome is substitution of care. This is calculated using the number and characteristics of patients that have a consultation at the GP cooperative. We compare the number of patients seen by both professionals, type of complaints, resource utilization (e.g. prescription, tests, investigations, referrals) and waiting times in the experimental condition and control condition. This data is derived from patient electronic medical records. Secondary outcomes are: patient satisfaction; general practitioners workload; quality and safety of care and barriers and facilitators. The study will provide evidence whether substitution of care in out-of-hours setting is safe and efficient and give insight into barriers and facilitators related to the introduction of nurse practitioners in out-of-hours setting. ClinicalTrials.gov ID NCT01388374.

Creation of an Internal Teledermatology Store-and-Forward System in an Existing Electronic Health Record

PubMed Central

Carter, Zachary A.; Goldman, Shauna; Anderson, Kristen; Li, Xiaxiao; Hynan, Linda S.; Chong, Benjamin F.

2017-01-01

Importance External store-and-forward (SAF) teledermatology systems operate separately from the primary health record and have many limitations, including care fragmentation, inadequate communication among clinicians, and privacy and security concerns, among others. Development of internal SAF workflows within existing electronic health records (EHRs) should be the standard for large health care organizations for delivering high-quality dermatologic care, improving access, and capturing other telemedicine benchmark data. Epic EHR software (Epic Systems Corporation) is currently one of the most widely used EHR system in the United States, and development of a successful SAF workflow within it is needed. Objectives To develop an SAF teledermatology workflow within the Epic system, the existing EHR system of Parkland Health and Hospital System (Dallas, Texas), assess its effectiveness in improving access to care, and validate its reliability; and to evaluate the system’s ability to capture meaningful outcomes. Design, Setting, and Participants Electronic consults were independently evaluated by 2 board-certified dermatologists, who provided diagnoses and treatment plans to primary care physicians (PCPs). Results were compared with in-person referrals from May to December 2013 from the same clinic (a community outpatient clinic in a safety-net public hospital system). Patients were those 18 years or older with dermatologic complaints who would have otherwise been referred to dermatology clinic. Main Outcomes and Measures Median time to evaluation; percentage of patients evaluated by a dermatologist through either teledermatology or in-person compared with the previous year. Results Seventy-nine teledermatology consults were placed by 6 PCPs from an outpatient clinic between May and December 2014; 57 (74%) were female and their mean (SD) age was 47.0 (12.4) years. Teledermatology reduced median time to evaluation from 70.0 days (interquartile range [IQR], 33.25-83.0 days) to 0.5 days (IQR, 0.172-0.94 days) and median time to treatment from 73.5 to 3.0 days compared with in-person dermatology visits. Overall, a greater percentage of patients (120 of 144 [83.3%]) were evaluated by a dermatologist through either teledermatology or in-person during the 2014 study period compared with the previous year (111 of 173 [64.2%]). Primary care physicians followed management recommendations 93% of the time. Conclusions and Relevance Epic-based SAF teledermatology can improve access to dermatologic care in a public safety-net hospital setting. We hope that the system will serve as a model for other health care organizations wanting to create SAF teledermatology workflows within the Epic EHR system. PMID:28423156

Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials.

PubMed

Rollins, Katie E; Lobo, Dileep N

2016-03-01

To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols. Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality. A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66-0.89, P = 0.0007), hospital length of stay (LOS; mean difference -1.55 days, 95% CI -2.73 to -0.36, P = 0.01), intensive care LOS (mean difference -0.63 days, 95% CI -1.18 to -0.09, P = 0.02), and time to passage of feces (mean difference -0.90 days, 95% CI -1.48 to -0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference -0.63 days, 95% CI -0.94 to -0.32, P < 0.0001) and time to passage of feces (mean difference -1.09 days, 95% CI -2.03 to -0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to -0.84, P = 0.0002) and total hospital LOS (mean difference -2.14, 95% CI -4.15 to -0.13, P = 0.04). GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting.

Knowledge Confidence and Desire for Further Diabetes-Management Education among Nurses and Personal Support Workers in Long-Term Care.

PubMed

Vincent, Corita; Hall, Peter; Ebsary, Sally; Hannay, Scott; Hayes-Cardinal, Lynn; Husein, Nadira

2016-06-01

Diabetes care in the long-term care (LTC) setting is complicated by increased prevalence of comorbidities, age-related changes in medication tolerance, frailty and limited resources. Registered nurses (RNs), registered practical nurses (RPNs) and personal support workers (PSWs) are responsible for front-line diabetes care; however, there is limited formal diabetes education in this setting. The current study aimed to assess the knowledge confidence and desire for additional diabetes education among nurses and PSWs in the LTC setting. We studied 89 RNs, RPNs and PSWs (Mage=43.6, 94.3% female) in 2 LTC facilities in the Kitchener-Waterloo area who participated in an online survey assessing knowledge and confidence in 6 key areas of diabetes care (nutrition, insulin, oral medications, hypoglycemia, hyperglycemia and sick-day management). Interest in further diabetes education was also explored. Self-rated knowledge and confidence were generally moderate to high, ranging from 46% to 79% being moderately to very knowledgeable and from 61% to 74% being moderately to very confident. Knowledge and confidence was highest for nutrition and management of hypo- and hyperglycemia and lower for sick-day management, oral medications and insulin. There were significant differences between clinicians such that PSWs reported less knowledge and confidence than RNs and RPNs on most parameters. Among the whole sample, 85% wanted education about diabetes, and this rate did not vary by occupation. The most commonly reported areas for additional education concerning diabetes were for management of hypo- and hyperglycemia (30% to 31%) and insulin (31%). Overall, the findings indicate moderate levels of self-rated knowledge across diabetes care areas; however, most clinicians feel there is room for more diabetes-care education, particularly regarding insulin and management of hypo- and hyperglycemia. Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

Characterizing emergency admissions of patients with sickle cell crisis in NHS brent: observational study

PubMed Central

Green, Stuart A; AlJuburi, Ghida; Majeed, Azeem; Okoye, Ogo; Amobi, Carole; Banarsee, Ricky; Phekoo, Karen J

2012-01-01

Objectives To characterize emergency admissions for patients with sickle cell crisis in NHS Brent and to determine which patients and practices may benefit most from primary care intervention. Design Observational study Setting Emergency departments attended by residents of the London borough of Brent Participants Patients with sickle cell disease registered with a general practitioner (GP) in the borough of Brent Main outcome measures Analysis of admissions between January 2008 and July 2010 that included length of stay (average and <2 days versus ≥2 days) by age group and registered GP practice. Results Thirty six percent of sickle cell disease admission spells resulted in a length of stay of less than two days. Seventy four percent of total bed days are associated with patients with more than one admission during the period of analysis, i.e. multiple admissions. Two general practices in Brent were identified as having the highest number of patients admitted to the emergency department for sickle cell crisis and may benefit most from primary care intervention. Discussion Patients with short length of stay and multiple admissions may be potentially amenable to primary care intervention. The practices which have the highest numbers of sickle cell disease patients who frequently seek emergency care will be earmarked for an education intervention designed to help further engage general practitioners in the care and management of their sickle cell patients. PMID:22768371

A project investigating music therapy referral trends within palliative care: an Australian perspective.

PubMed

Horne-Thompson, Anne; Daveson, Barbara; Hogan, Bridgit

2007-01-01

The purpose of this project is to analyze music therapy (MT) referral trends from palliative care team members across nine Australian inpatient and community-based palliative care settings. For each referral 6 items were collected: referral source, reason and type; time from Palliative Care Program (PCP) admission to MT referral; time from MT referral to death/discharge; and profile of referred patient. Participants (196 female, 158 male) were referred ranging in age from 4-98 years and most were diagnosed with cancer (91%, n = 323). Nurses (47%, n = 167) referred most frequently to music therapy. The mean average time in days for all referrals from PCP admission to MT referral was 11.47 and then 5.19 days to time of death. Differences in length of time to referral ranged from 8.19 days (allied health staff) to 43.75 days (families). Forty-eight percent of referrals (48.5%, n = 172) were completed when the patient was rated at an Eastern Cooperative Oncology Group Performance (ECOG) of three. Sixty-nine percent (n = 244) were living with others at the time of referral and most were Australian born. Thirty-six percent (36.7%, n = 130) were referred for symptom-based reasons, and 24.5% (n = 87) for support and coping. Implications for service delivery of music therapy practice, interdisciplinary care and benchmarking of music therapy services shall be discussed.

Determining level of care appropriateness in the patient journey from acute care to rehabilitation

PubMed Central

2011-01-01

Background The selection of patients for rehabilitation, and the timing of transfer from acute care, are important clinical decisions that impact on care quality and patient flow. This paper reports utilization review data on inpatients in acute care with stroke, hip fracture or elective joint replacement, and other inpatients referred for rehabilitation. It examines reasons why acute level of care criteria are not met and explores differences in decision making between acute care and rehabilitation teams around patient appropriateness and readiness for transfer. Methods Cohort study of patients in a large acute referral hospital in Australia followed with the InterQual utilization review tool, modified to also include reasons why utilization criteria are not met. Additional data on team decision making about appropriateness for rehabilitation, and readiness for transfer, were collected on a subset of patients. Results There were 696 episodes of care (7189 bed days). Days meeting acute level of care criteria were 56% (stroke, hip fracture and joint replacement patients) and 33% (other patients, from the time of referral). Most inappropriate days in acute care were due to delays in processes/scheduling (45%) or being more appropriate for rehabilitation or lower level of care (30%). On the subset of patients, the acute care team and the utilization review tool deemed patients ready for rehabilitation transfer earlier than the rehabilitation team (means of 1.4, 1.3 and 4.0 days from the date of referral, respectively). From when deemed medically stable for transfer by the acute care team, 28% of patients became unstable. From when deemed stable by the rehabilitation team or utilization review, 9% and 11%, respectively, became unstable. Conclusions A high proportion of patient days did not meet acute level of care criteria, due predominantly to inefficiencies in care processes, or to patients being more appropriate for an alternative level of care, including rehabilitation. The rehabilitation team was the most accurate in determining ongoing medical stability, but at the cost of a longer acute stay. To avoid inpatients remaining in acute care in a state of 'terra nullius', clinical models which provide rehabilitation within acute care, and more efficient movement to a rehabilitation setting, is required. Utilization review could have a decision support role in the determination of medical stability. PMID:22040281

Independence, institutionalization, death and treatment costs 18 months after rehabilitation of older people in two different primary health care settings.

PubMed

Johansen, Inger; Lindbak, Morten; Stanghelle, Johan K; Brekke, Mette

2012-11-14

The optimal setting and content of primary health care rehabilitation of older people is not known. Our aim was to study independence, institutionalization, death and treatment costs 18 months after primary care rehabilitation of older people in two different settings. Eighteen months follow-up of an open, prospective study comparing the outcome of multi-disciplinary rehabilitation of older people, in a structured and intensive Primary care dedicated inpatient rehabilitation (PCDIR, n=202) versus a less structured and less intensive Primary care nursing home rehabilitation (PCNHR, n=100). 302 patients, disabled from stroke, hip-fracture, osteoarthritis and other chronic diseases, aged ≥65years, assessed to have a rehabilitation potential and being referred from general hospital or own residence. Primary: Independence, assessed by Sunnaas ADL Index(SI). Secondary: Hospital and short-term nursing home length of stay (LOS); institutionalization, measured by institutional residence rate; death; and costs of rehabilitation and care. Statistical tests: T-tests, Correlation tests, Pearson's χ2, ANCOVA, Regression and Kaplan-Meier analyses. Overall SI scores were 26.1 (SD 7.2) compared to 27.0 (SD 5.7) at the end of rehabilitation, a statistically, but not clinically significant reduction (p=0.003 95%CI(0.3-1.5)). The PCDIR patients scored 2.2points higher in SI than the PCNHR patients, adjusted for age, gender, baseline MMSE and SI scores (p=0.003, 95%CI(0.8-3.7)). Out of 49 patients staying >28 days in short-term nursing homes, PCNHR-patients stayed significantly longer than PCDIR-patients (mean difference 104.9 days, 95%CI(0.28-209.6), p=0.05). The institutionalization increased in PCNHR (from 12%-28%, p=0.001), but not in PCDIR (from 16.9%-19.3%, p= 0.45). The overall one year mortality rate was 9.6%. Average costs were substantially higher for PCNHR versus PCDIR. The difference per patient was 3528€ for rehabilitation (p<0.001, 95%CI(2455-4756)), and 10134€ for the at-home care (p=0.002, 95%CI(4066-16202)). The total costs of rehabilitation and care were 18702€ (=1.6 times) higher for PCNHR than for PCDIR. At 18 months follow-up the PCDIR-patients maintained higher levels of independence, spent fewer days in short-term nursing homes, and did not increase the institutionalization compared to PCNHR. The costs of rehabilitation and care were substantially lower for PCDIR. More communities should consider adopting the PCDIR model. Clinicaltrials.gov ID NCT01457300.

Clinical Pharmacy Consultations Provided by American and Kenyan Pharmacy Students During an Acute Care Advanced Pharmacy Practice Experience

PubMed Central

Pastakia, Sonak D.; Manji, Imran; Kamau, Evelyn; Schellhase, Ellen M.

2011-01-01

Objective To compare the clinical consultations provided by American and Kenyan pharmacy students in an acute care setting in a developing country. Methods The documented pharmacy consultation recommendations made by American and Kenyan pharmacy students during patient care rounds on an advanced pharmacy practice experience at a referral hospital in Kenya were reviewed and classified according to type of intervention and therapeutic area. Results The Kenyan students documented more interventions than American students (16.7 vs. 12.0 interventions/day) and provided significantly more consultations regarding human immunodeficiency virus (HIV) and antibiotics. The top area of consultations provided by American students was cardiovascular diseases. Conclusions American and Kenyan pharmacy students successfully providing clinical pharmacy consultations in a resource-constrained, acute-care practice setting suggests an important role for pharmacy students in the reconciliation of prescriber orders with medication administration records and in providing drug information. PMID:21655396

The Relationship Among Heart Failure Disease Management, Quality of Care, and Hospitalizations.

PubMed

Chung, Eugene S; Bartone, Cheryl; Daly, Kathleen; Menon, Santosh; McDonald, Mark

2015-01-01

Heart failure (HF) affects 5.1 million adult patients, accounting for over 1 million hospitalizations, 1.8 million office visits, and nearly 680,000 emergency department visits annually. HF hospitalizations have been incorporated into a national measure of hospital and provider quality, with associated financial penalties based on the 30-day readmission rate after an index hospitalization for HF. However, it is not clear whether the number of HF-related hospitalizations or 30-day readmissions is consistently related to quality of care. The relationships between various measures of HF care quality and hospitalization rates were evaluated by performing a cohort study of an HF disease management program in a clinical practice setting. Following the statistical analyses assessing outcomes and survival, the conclusion was that an HF disease management program in clinical practice associated with improved utilization of evidence-based medical and device therapies tends to improve ejection fraction and survival, and reduce sex and race disparities, but not with an associated reduction in hospitalizations or total hospital days.

Clinical Nursing Leadership Education in Long-Term Care: Intervention Design and Evaluation.

PubMed

Fiset, Valerie; Luciani, Tracy; Hurtubise, Alyssa; Grant, Theresa L

2017-04-01

The main objective of the current case study was to investigate the perceived leadership learning needs and feasibility of delivering leadership education to registered staff involved in direct care in long-term care (LTC) homes. The study was conducted in Ontario, Canada, and participants included RNs, registered practical nurses, and nursing administrators. Phase 1 bilingual web-based survey and bilingual focus group needs assessment data supported a preference for external training along with in-house mentoring to support sustainability. An intervention designed using insights gained from Phase 1 data was delivered via a 2-day, in-person workshop. Phases 2 and 3 evaluation survey data identified aspects of leadership training for LTC that require ongoing refinement. Findings suggest that communication skills and managing day-to-day nursing demands in the context of regulatory frameworks were areas of particular interest for leadership training in the LTC setting. [Journal of Gerontological Nursing, 43(4), 49-56.]. Copyright 2017, SLACK Incorporated.

Cost-effectiveness of Skin Cancer Referral and Consultation Using Teledermoscopy in Australia.

PubMed

Snoswell, Centaine L; Caffery, Liam J; Whitty, Jennifer A; Soyer, H Peter; Gordon, Louisa G

2018-06-01

International literature has shown that teledermoscopy referral may be a viable method for skin cancer referral; however, no economic investigations have occurred in Australia. To assess the cost-effectiveness of teledermoscopy as a referral mechanism for skin cancer diagnosis and management in Australia. Cost-effectiveness analysis using a decision-analytic model of Australian primary care, informed by publicly available data. We compared the costs of teledermoscopy referral (electronic referral containing digital dermoscopic images) vs usual care (a written referral letter) for specialist dermatologist review of a suspected skin cancer. Cost and time in days to clinical resolution, where clinical resolution was defined as diagnosis by a dermatologist or excision by a general practitioner. Probabilistic sensitivity analysis was performed to examine the uncertainty of the main results. Findings from the decision-analytic model showed that the mean time to clinical resolution was 9 days (range, 1-50 days) with teledermoscopy referral compared with 35 days (range, 0-138 days) with usual care alone (difference, 26 days; 95% credible interval [CrI], 13-38 days). The estimated mean cost difference between teledermoscopy referral (A$318.39) vs usual care (A$263.75) was A$54.64 (95% CrI, A$22.69-A$97.35) per person. The incremental cost per day saved to clinical resolution was A$2.10 (95% CrI, A$0.87-A$5.29). Using teledermoscopy for skin cancer referral and triage in Australia would cost A$54.64 extra per case on average but would result in clinical resolution 26 days sooner than usual care. Implementation recommendations depend on the preferences of the Australian health system decision makers for either lower cost or expedited clinical resolution. Further research around the clinical significance of expedited clinical resolution and its importance for patients could inform implementation recommendations for the Australian setting.

Care homes and the Mental Capacity Act 2005: Changes in understanding and practice over time.

PubMed

Manthorpe, Jill; Samsi, Kritika

2016-07-01

The Mental Capacity Act 2005 provides the legal framework in England and Wales for the making of decisions in respect of people who have never had or have lost decision-making capacity. As part of a 5-year research program investigating the implementation and adoption of the Mental Capacity Act in dementia practice, we interviewed staff working in different care homes at two time points (32 staff at Time 1 in 2008 and 27 staff at Time 2 in 2012) in South East England. At baseline Time 1, daily practice seemed to resonate with Mental Capacity Act principles of respecting decisions and trying to act in a person's best interests. This paper reports Time 2 findings. We found that few care home staff interviewed specifically reported finding the Mental Capacity Act helpful in crystallizing the legal basis of their work. Most continued to offer illustrations of day-to-day practice in which they paid attention to individual choices, took account of the wishes of residents' families, and tried to act in residents' best interests but referred major decisions to their seniors. This study highlights the potential of referring to specific day-to-day practice in care homes when offering training or scrutinizing practice in dementia care more generally so that the work is set in its legal as well as moral framework. Care home staff in this study reported that advanced planning and pre-specifying preferences were more common among new care home residents, especially those with dementia, indicating that greater understanding of these is required by staff. © The Author(s) 2014.

Real association of factors with inappropriate hospital days.

PubMed

Huet, Bernard; Cauterman, Maxime

2005-01-01

Several studies of inappropriate (in the sense of the AEP) hospital days highlighted associations between two factors (rate of inappropriateness and reasons for inappropriateness, rate of inappropriateness and appropriate setting of care,..). The aim of this communication is to present a study on real associations, at constant factor, between five factors associated with hospital inappropriate days: medical management process, reason for inappropriateness, scheduled admission, rate of inappropriateness, length of stay. We used the European version of Appropriateness Evaluation Protocol for evaluation of inappropriate days and the French protocol ;for analysis of inappropriate days. The study set in three Parisian hospitals, four clinical departments, three specialities. 523 patients were included in the study, 5663 days were evaluated on a wide variety of pathologies: 27 Medical Management Processes. Results show that there are real associations (elimination of transitive associations) between five factors : medical management process and discharge processes, reason for inappropriateness, scheduled admission, rate of inappropriate days, length of stay. Multiple Correspondence Analysis on all "groups of contiguous days related with the same reason for inappropriateness" shows five profiles of queues integrating various medical management processes.

Standardizing communication from acute care providers to primary care providers on critically ill adults.

PubMed

Ellis, Kerri A; Connolly, Ann; Hosseinnezhad, Alireza; Lilly, Craig M

2015-11-01

To increase the frequency of communication of patient information between acute and primary care providers. A secondary objective was to determine whether higher rates of communication were associated with lower rates of hospital readmission 30 days after discharge. A validated instrument was used for telephone surveys before and after an intervention designed to increase the frequency of communication among acute care and primary care providers. The communication intervention was implemented in 3 adult intensive care units from 2 campuses of an academic medical center. The frequency of communication among acute care and primary care providers, the perceived usefulness of the intervention, and its association with 30-day readmission rates were assessed for 202 adult intensive care episodes before and 100 episodes after a communication intervention. The frequency of documented communication increased significantly (5/202 or 2% before to 72/100 or 72% after the intervention; P < .001) and the communication was considered useful by every participating primary care provider. Rates of rehospitalization at 30 days were lower for the intervention group than the preintervention group, but the difference was not statistically significant (41/202 or 23% vs 16/88 or 18% of discharged patients; P = .45; power 0.112 at P = .05). The frequency of communication episodes that provide value can be increased through standardized processes. The key aspects of this effective intervention were setting the expectation that communication should occur, documenting when communication has occurred, and reviewing that documentation during multiprofessional rounds. ©2015 American Association of Critical-Care Nurses.

Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs

PubMed Central

Kim, Minchul; Franciskovich, Chris M.; Weinberg, Jason E.; Svendsen, Jessica D.; Fehr, Linda S.; Funk, Amy; Sawicki, Robert; Asche, Carl V.

2018-01-01

Abstract Background: Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options. Objective: To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care. Design: This was a case–control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs. Setting/subjects: Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases. Measurements: The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare. Results: We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6–54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02–1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (−0.37 admissions, 95% CI −0.66 to −0.08), and inpatient days (−3.66 days, 95% CI −6.23 to −1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI −$16,207 to −$2,793). Conclusions: ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients. PMID:29206564

Another Setting for Stewardship: High Rate of Unnecessary Antimicrobial Use in a VA Long-Term Care Facility

PubMed Central

Peron, Emily P.; Hirsch, Amy A.; Jury, Lucy A.; Jump, Robin L.P.; Donskey, Curtis J.

2015-01-01

BACKGROUND/OBJECTIVE Antimicrobials are frequently prescribed in long-term care facilities (LTCFs). In order to develop effective stewardship interventions, there is a need for data on current patterns of unnecessary antimicrobial prescribing among LTCF residents. The objective of this study was to examine the frequency of, reasons for, and adverse effects of unnecessary antimicrobial use in our Veterans Affairs (VA) LTCF. DESIGN Retrospective chart review. SETTING Cleveland VA Medical Center LTCF. PARTICIPANTS Randomly selected patients receiving antimicrobial therapy from October 1, 2008 to March 31, 2009. MEASUREMENTS Days of necessary and unnecessary antimicrobial therapy determined using Infectious Diseases Society of America guidelines, syndromes treated with unnecessary antimicrobials, and the frequency of development of Clostridium difficile infection (CDI), colonization or infection with antimicrobial resistant pathogens, and other adverse effects. RESULTS Of 1351 days of therapy prescribed in 100 regimens, 575 days (42.5%) were deemed unnecessary. Of the 575 unnecessary days of therapy, 334 (58%) were for antimicrobial regimens that were entirely unnecessary (n=42). Asymptomatic bacteriuria was the most common reason for entirely unnecessary regimens (n=21), resulting in 173 days of unnecessary therapy. Regimens that were partially unnecessary resulted in 241 (42%) days of unnecessary therapy, with longer than recommended treatment duration accounting for 226 (94%) unnecessary days of therapy. Within 30 days of completing the antimicrobial regimens, 5 patients developed CDI, 5 had colonization or infection with antimicrobial-resistant pathogens, and 10 experienced other adverse drug events. CONCLUSIONS In our VA LTCF, 43% of all days of antimicrobial therapy were unnecessary. Our findings suggest that antimicrobial stewardship interventions in LTCFs should focus on improving adherence to recommended treatment durations and eliminating inappropriate treatment of asymptomatic bacteriuria. PMID:23405923

Survival and detection of rotaviruses on environmental surfaces in day care centers.

PubMed Central

Keswick, B H; Pickering, L K; DuPont, H L; Woodward, W E

1983-01-01

Previously, we demonstrated that children in day care centers commonly experience diarrhea due to rotavirus, giardia, and bacterial pathogens. Multiple agents frequently coexist, and the environment is heavily contaminated with enteric bacteria during outbreaks. A study of environmental surface contamination with rotavirus was performed during three non-outbreak periods. Of 25 samples collected from environmental surfaces and teachers hands at a day care center, 4 (16%) were positive for rotavirus antigen when a fluorescence assay was used. We also examined the survival of two animal viruses, rotavirus SA-11 and poliovirus type 1, and bacteriophage 12 on similar environmental surfaces in a laboratory. Poliovirus type 1 and bacteriophage f2 were more resistant to drying than rotavirus SA-11 and could be recovered after a 90-min exposure on a dry surface. Rotavirus SA-11 could be detected for 30 min. All three viruses survived longer when they were suspended in fecal material than when they were suspended in distilled water. These data suggest that several agents, including rotavirus, can remain viable on contaminated surfaces long enough to be transmitted to susceptible children. This finding helps explain why rotavirus shows a mode of spread like that of parasitic and bacterial agents within day care center settings. PMID:6314896

A Modified Collagen Gel Enhances Healing Outcome in a Pre-Clinical Swine Model of Excisional Wounds

PubMed Central

Elgharably, Haytham; Roy, Sashwati; Khanna, Savita; Abas, Motaz; DasGhatak, Piya; Das, Amitava; Mohammed, Kareem; Sen, Chandan K.

2013-01-01

Collagen-based dressings are of great interest in wound care. However, evidence supporting their mechanism of action in a wound setting in vivo is scanty. This work providesfirst results from a pre-clinical swine model of excisional wounds elucidating the mechanism of action of a modified collagen gel (MCG) dressing. Following wounding, wound-edge tissue was collected at specific time intervals (3, 7, 14, and 21 days post-wounding). On day 7, histological analysis showed significant increase in the length of rete ridges suggesting improved biomechanical properties of the healing wound tissue. Rapid and transient mounting of inflammation is necessary for efficient healing. MCG significantly accelerated neutrophil and macrophages recruitment to the wound site on day 3 and day 7 with successful resolution of inflammation on day 21. MCG induced MCP-1 expression in neutrophil-like HL-60 cells in vitro. In vivo, MCG treated wound tissue displayed elevated VEGF expression. Consistently, MCG-treated wounds displayed significantly higher abundance of endothelial cells with increased blood flow to the wound area indicating improved vascularization. This observation was explained by the finding that MCG enhanced proliferation of wound-site endothelial cells. In MCG-treated wound tissue, Masson’s Trichrome and Picrosirius red staining showed higher abundance of collagen and increased collagen type I:III ratio. This work presents first evidence from a pre-clinical experimental setting explaining how a collagen-based dressing may improve wound closure by targeting multiple key mechanisms as compared to standard of care i.e., Tegadem treated wounds. The current findings warrant additional studies to determine whether the responses to the MCG are different from other modified or unmodified collagen based products used in clinical setting. PMID:23607796

Distribution of outbreak reporting in health care institutions by day of the week.

PubMed

Amirov, Chingiz; Walton, Ryan N; Ahmed, Sarah; Binns, Malcolm A; Van Toen, Jane E; Candon, Heather L

2012-12-01

The notion that outbreaks are more likely to occur on Friday is prevalent among staff in health care institutions. However, there is little evidence to support or discredit this notion. We postulated that outbreaks were no more likely to be reported on any particular day of the week. A total of 901 institutional outbreaks in Toronto health care facilities were tabulated according to type, outbreak setting, and day of the week reported. A χ(2) goodness-of-fit test compared daily values for 7-day per week and 5-day per week periods. Post hoc partitioning was used to pinpoint specific day(s) of the week that differed significantly. Fewer outbreaks were reported on Saturdays and Sundays. Further analysis examined the distribution of outbreak reporting specifically focusing on the Monday to Friday weekday period. Among the weekdays, higher proportions of outbreaks were reported on Mondays and Fridays. Our null hypothesis was rejected. Overall, Mondays and Fridays had the highest occurrence of outbreak reporting. We suggest that this might be due to "deadline" and "catch-up" reporting related to the "weekend effect," whereby structural differences in weekend staffing affect detection of outbreaks. Such delays warrant reexamination of surveillance processes for timely outbreak detection independent of calendar cycle. Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

Role strain among male RNs in the critical care setting: Perceptions of an unfriendly workplace.

PubMed

Carte, Nicholas S; Williams, Collette

2017-12-01

Traditionally, nursing has been a female-dominated profession. Men employed as registered nurses have been in the minority and little is known about the experiences of this demographic. The purpose of this descriptive, quantitative study was to understand the relationship between the variables of demographics and causes of role strain among male nurses in critical care settings. The Sherrod Role Strain Scale assesses role strain within the context of role conflict, role overload, role ambiguity and role incongruity. Data analysis of the results included descriptive and inferential statistics. Inferential statistics involved the use of repeated measures ANOVA testing for significant difference in the causes of role strain between male nurses employed in critical care settings and a post hoc comparison of specific demographic data using multivariate analyses of variance (MANOVAs). Data from 37 male nurses in critical care settings from the northeast of the United States were used to calculate descriptive statistics standard deviation, mean of the data analysis and results of the repeated ANOVA and the post hoc secondary MANOVA analysis. The descriptive data showed that all participants worked full-time. There was an even split from those participants who worked day shift (46%) vs. night shift (43%), most the participants indicated they had 15 years or more experience as an registered nurse (54%). Significant findings of this study include two causes of role strain in male nurses employed in critical care settings which are: role ambiguity and role overload based on ethnicity. Consistent with previous research findings, the results of this study suggest that male registered nurses employed in critical care settings do experience role strain. The two main causes of role strain in male nurses are role ambiguity and role overload. Copyright © 2017. Published by Elsevier Ltd.

Docetaxel chemotherapy in metastatic castration-resistant prostate cancer: cost of care in Medicare and commercial populations.

PubMed

Armstrong, A; Bui, C; Fitch, K; Sawhney, T Goss; Brown, B; Flanders, S; Balk, M; Deangelis, J; Chambers, J

2017-06-01

To estimate the healthcare costs and characteristics of docetaxel chemotherapy episodes of care for men with metastatic castration-resistant prostate cancer (mCRPC). This study used the Medicare 5% sample and MarketScan Commercial (2010-2013) claims data sets to identify men with mCRPC and initial episodes of docetaxel treatment. Docetaxel episodes included docetaxel claim costs from the first claim until 30 days after the last claim, with earlier termination for death, insurance disenrollment, or the end of a 24-month look-forward period from initial docetaxel index date. Docetaxel drug claim costs were adjusted for 2011 generic docetaxel introduction, while other costs were adjusted to 2015 values using the national average annual unit cost increase. This study identified 281 Medicare-insured and 155 commercially insured men, with 325 and 172 docetaxel episodes, respectively. The average number of cycles (unique docetaxel infusion days) per episode was 6.9 for Medicare and 6.3 for commercial cohorts. The average cost per episode was $28,792 for Medicare and $67,958 for commercial cohorts, with docetaxel drug costs contributing $2,588 and $13,169 per episode, respectively. The average cost per episode on docetaxel infusion days was $8,577 (30%) for Medicare and $28,412 (42%) for commercial. Non-docetaxel infusion day costs included $7,074 (25%) for infused or injected drugs for Medicare, $10,838 (16%) for commercial cohorts, and $6,875 (24%) and $9,324 (14%) for inpatient admissions, respectively. The applicability is only to the metastatic castration-resistance clinical setting, rather than the metastatic hormone-sensitive setting, and the lack of data on the cost effectiveness of different sequencing strategies of a range of systemic therapies including enzalutamide, abiraterone, radium-223, and taxane chemotherapy. The majority of docetaxel episode costs in Medicare and commercial mCRPC populations were non-docetaxel drug costs. Future research should evaluate the total cost of care in mCPRC.

The adaptation of the Sheffield Profile for Assessment and Referral for Care (SPARC) to the Polish clinical setting for needs assessment of advanced cancer patients.

PubMed

Leppert, Wojciech; Majkowicz, Mikolaj; Ahmedzai, Sam H

2012-12-01

Assessment of the needs of advanced cancer patients is a very important issue in palliative care. The aim of the study was to adapt the Sheffield Profile for Assessment and Referral for Care (SPARC) to the Polish environment and evaluate its usefulness in needs assessment of patients with advanced cancer. A forward-back translation of the SPARC to Polish was done. The SPARC was used once in 58 consecutive patients with advanced cancer during follow-up. The patients were enrolled from a palliative care unit (25 patients), home care (18 patients), and a day care center (15 patients). The reliability was evaluated by establishing the internal consistency using Cronbach's alpha coefficients. Content validity was analyzed in accordance with the theories of needs by Murray and Maslow as a nonstatistical method of validity assessment. Factor analysis with principal components extraction and varimax rotation of raw data was used to reduce the set of data and assess the construct validity. There were differences regarding religious and spiritual issues and independence and activity between patients in the palliative care unit (worse results) and those at the day care center (better scores). Communication and need for more information items were associated with psychological, social, spiritual, and treatment issues. Cronbach's alpha coefficients and factor analysis demonstrated, respectively, satisfactory reliability and construct validity of the tool. The study demonstrated that the Polish version of the SPARC is a valid and reliable tool recommended for the needs assessment and symptom evaluation of patients with advanced cancer. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Provider perceptions of the value of same-day, electronic patient-reported measures for use in clinical HIV care

PubMed Central

Fredericksen, RJ; Tufano, J; Ralston, J; McReynolds, J; Stewart, M; Lober, WB; Mayer, K; Mathews, WC; Mugavero, M; Crane, PK; Crane, HM

2016-01-01

Strong evidence suggests that patient-reported outcomes (PROs) aid in managing chronic conditions, reduce omissions in care, and improve patient-provider communication. However, provider acceptability of PROs and their use in clinical HIV care is not well known. We interviewed providers (n=27) from four geographically diverse HIV and community care clinics in the U.S. that have integrated PROs into routine HIV care, querying perceived value, challenges, and use of PRO data. Perceived benefits included the ability of PROs to identify less-observable behaviors and conditions, particularly suicidal ideation, depression, and substance use; usefulness in agenda-setting prior to a visit; and reduction of social desirability bias in patient-provider communication. Challenges included initial flow integration issues and ease of interpretation of PRO feedback. Providers value same-day, electronic patient-reported measures for use in clinical HIV care with the condition that PROs are 1) tailored to be the most clinically relevant to their population; 2) well-integrated into clinic flow; 3) easy to interpret, highlighting chief patient concerns and changes over time. PMID:27237187

Tele-ICU "myth busters".

PubMed

Venditti, Angelo; Ronk, Chanda; Kopenhaver, Tracey; Fetterman, Susan

2012-01-01

Tele-intensive care unit (ICU) technology has been proven to bridge the gap between available resources and quality care for many health care systems across the country. Tele-ICUs allow the standardization of care and provide a second set of eyes traditionally not available in the ICU. A growing body of literature supports the use of tele-ICUs based on improved outcomes and reduction in errors. To date, the literature has not effectively outlined the limitations of this technology related to response to changes in patient care, interventions, and interaction with the care team. This information can potentially have a profound impact on service expectations. Some misconceptions about tele-ICU technology include the following: tele-ICU is "watching" 24 hours a day, 7 days a week; tele-ICU is a telemetry unit; tele-ICU is a stand-alone crisis intervention tool; tele-ICU decreases staffing at the bedside; tele-ICU clinical roles are clearly defined and understood; and tele-ICUs are not cost-effective to operate. This article outlines the purpose of tele-ICU technology, reviews outcomes, and "busts" myths about tele-ICU technology.

Use of the Environment and Policy Evaluation and Observation as a Self-Report Instrument (EPAO-SR) to measure nutrition and physical activity environments in child care settings: validity and reliability evidence.

PubMed

Ward, Dianne S; Mazzucca, Stephanie; McWilliams, Christina; Hales, Derek

2015-09-26

Early care and education (ECE) centers are important settings influencing young children's diet and physical activity (PA) behaviors. To better understand their impact on diet and PA behaviors as well as to evaluate public health programs aimed at ECE settings, we developed and tested the Environment and Policy Assessment and Observation - Self-Report (EPAO-SR), a self-administered version of the previously validated, researcher-administered EPAO. Development of the EPAO-SR instrument included modification of items from the EPAO, community advisory group and expert review, and cognitive interviews with center directors and classroom teachers. Reliability and validity data were collected across 4 days in 3-5 year old classrooms in 50 ECE centers in North Carolina. Center teachers and directors completed relevant portions of the EPAO-SR on multiple days according to a standardized protocol, and trained data collectors completed the EPAO for 4 days in the centers. Reliability and validity statistics calculated included percent agreement, kappa, correlation coefficients, coefficients of variation, deviations, mean differences, and intraclass correlation coefficients (ICC), depending on the response option of the item. Data demonstrated a range of reliability and validity evidence for the EPAO-SR instrument. Reporting from directors and classroom teachers was consistent and similar to the observational data. Items that produced strongest reliability and validity estimates included beverages served, outside time, and physical activity equipment, while items such as whole grains served and amount of teacher-led PA had lower reliability (observation and self-report) and validity estimates. To overcome lower reliability and validity estimates, some items need administration on multiple days. This study demonstrated appropriate reliability and validity evidence for use of the EPAO-SR in the field. The self-administered EPAO-SR is an advancement of the measurement of ECE settings and can be used by researchers and practitioners to assess the nutrition and physical activity environments of ECE settings.

Views and experiences of using integrated care pathways (ICPs) for caring for people in the last days to hours of life: results from a cross-sectional survey of UK professionals.

PubMed

Collins, K A; Hughes, P M; Ibbotson, R; Foy, G; Brooks, D

2016-09-01

To determine the views and experiences of health and social care professionals on using integrated care pathways (ICPs)for caring for people in the last days to hours of life. Online cross-sectional questionnaire survey of UK professionals working in UK primary and secondary care settings. 1331 professionals returned completed questionnaires. Ninety-three per cent (1138/1228) of respondents used the Liverpool Care Pathway (LCP) or local variant. Eighty-eight (1089/1234) felt ICPs enabled professionals to provide better care for individuals and their families/carers. ICPs were viewed as promoting patient-centred holistic care, improving pain and symptom control, providing guidance and standards and improving communication with patients/families. Sixty-two per cent (770/1234) had no concerns regarding the use of ICPs. Areas of concern included incorrect use and implementation of the ICP, poor communication with families, junior level staff making decisions and insufficient education and support. There was strong support for using ICPs for caring for people in the last days to hours of life. ICPs were viewed as supporting high-quality patient-centred holistic care. Given the recommendations of the More Care Less Pathway report, those that develop the guidance and support that replace the LCP need to incorporate the aspects of this that have resulted in the benefits seen by professionals within this survey, but also learn from the instances where ICPs have failed to prevent poor care, or worse, have contributed to it. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Proposing an Empirically Justified Reference Threshold for Blood Culture Sampling Rates in Intensive Care Units

PubMed Central

Castell, Stefanie; Schwab, Frank; Geffers, Christine; Bongartz, Hannah; Brunkhorst, Frank M.; Gastmeier, Petra; Mikolajczyk, Rafael T.

2014-01-01

Early and appropriate blood culture sampling is recommended as a standard of care for patients with suspected bloodstream infections (BSI) but is rarely taken into account when quality indicators for BSI are evaluated. To date, sampling of about 100 to 200 blood culture sets per 1,000 patient-days is recommended as the target range for blood culture rates. However, the empirical basis of this recommendation is not clear. The aim of the current study was to analyze the association between blood culture rates and observed BSI rates and to derive a reference threshold for blood culture rates in intensive care units (ICUs). This study is based on data from 223 ICUs taking part in the German hospital infection surveillance system. We applied locally weighted regression and segmented Poisson regression to assess the association between blood culture rates and BSI rates. Below 80 to 90 blood culture sets per 1,000 patient-days, observed BSI rates increased with increasing blood culture rates, while there was no further increase above this threshold. Segmented Poisson regression located the threshold at 87 (95% confidence interval, 54 to 120) blood culture sets per 1,000 patient-days. Only one-third of the investigated ICUs displayed blood culture rates above this threshold. We provided empirical justification for a blood culture target threshold in ICUs. In the majority of the studied ICUs, blood culture sampling rates were below this threshold. This suggests that a substantial fraction of BSI cases might remain undetected; reporting observed BSI rates as a quality indicator without sufficiently high blood culture rates might be misleading. PMID:25520442

Outpatient total elbow arthroplasty: 90-day outcomes.

PubMed

Stone, Michael A; Singh, Paramjit; Rosario, Santano L; Omid, Reza

2018-05-14

Interest in outpatient arthroplasty has grown in response to increasing emphasis on the efficient delivery of safe, high-quality medical care. This study evaluated 90-day episode-of-care complications after outpatient total elbow arthroplasty (TEA). We retrospectively evaluated 28 patients discharged the same day after primary TEA for 90-day episode-of-care complications, reoperations, and readmissions. Postoperative complications and elbow range of motion measurements were recorded and evaluated at the latest follow-up. All patients were contacted and given a satisfaction survey to assess their outpatient experience. Univariate logistic regression was performed for each risk factor to evaluate the risk for major and minor complications. Statistical significance was set as P < .05. Final follow-up data were available for 28 patients at an average of 14 months. Major complications within 90 days of surgery occurred in 7.1% of patients, ulnar nerve paresthesias occurred in 42.8% of patients, and minor wound problems occurred in 39.2% of patients. Five reoperations occurred after the 90-day postoperative period. All ulnar paresthesias and minor wound complications had resolved by the latest follow-up. Univariate regression analysis revealed a significant correlation between smoking and minor wound complications (P = .038). The satisfaction survey had an 85.7% response rate, with 91.7% of patients stating they were happy they went home the same day, and 95.8% feeling more confident and in control of their lives. The risk profile of carefully selected patients undergoing same-day discharge after TEA is acceptable when combined with close follow-up. Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Post-Discharge Care Duration, Charges, and Outcomes Among Medicare Patients After Primary Total Hip and Knee Arthroplasty.

PubMed

Ponnusamy, Karthikeyan E; Naseer, Zan; El Dafrawy, Mostafa H; Okafor, Louis; Alexander, Clayton; Sterling, Robert S; Khanuja, Harpal S; Skolasky, Richard L

2017-06-07

In April 2016, the U.S. Centers for Medicare & Medicaid Services initiated mandatory 90-day bundled payments for total hip and knee arthroplasty for much of the country. Our goal was to determine duration of care, 90-day charges, and readmission rates by discharge disposition and U.S. region after hip or knee arthroplasty. Using the 2008 Medicare Provider Analysis and Review database 100% sample, we identified patients who had undergone elective primary total hip or knee arthroplasty. We collected data on patient age, sex, comorbidities, U.S. Census region, discharge disposition, duration of care, 90-day charges, and readmission. Multivariate regression was used to assess factors associated with readmission (logistic) and charges (linear). Significance was set at p < 0.01. Patients undergoing 138,842 total hip arthroplasties were discharged to home (18%), home health care (34%), extended-care facilities (35%), and inpatient rehabilitation (13%); patients undergoing 329,233 total knee arthroplasties were discharged to home (21%), home health care (38%), extended-care facilities (31%), and inpatient rehabilitation (10%). Patients in the Northeast were more likely to be discharged to extended-care facilities or inpatient rehabilitation than patients in other regions. Patients in the West had the highest 90-day charges. Approximately 70% of patients were discharged home from extended-care facilities, whereas after inpatient rehabilitation, >50% of patients received home health care. Among those discharged to home, 90-day readmission rates were highest in the South (9.6%) for patients undergoing total hip arthroplasty and in the Midwest (8.7%) and the South (8.5%) for patients undergoing total knee arthroplasty. Having ≥4 comorbidities, followed by discharge to inpatient rehabilitation or an extended-care facility, had the strongest associations with readmission, whereas the region of the West and the discharge disposition to inpatient rehabilitation had the strongest association with higher charges. Among Medicare patients, discharge disposition and number of comorbidities were most strongly associated with readmission. Inpatient rehabilitation and the West region had the strongest associations with higher charges. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Identifying Opportunities to Increase HIV Testing among Mexican Migrants: A Call to Step Up Efforts in Health Care and Detention Settings

PubMed Central

Martínez-Donate, Ana P.; Rangel, Maria Gudelia; Rhoads, Natalie; Zhang, Xiao; Hovell, Melbourne; Magis-Rodriguez, Carlos; González-Fagoaga, Eduardo

2015-01-01

HIV testing and counseling is a critical component of HIV prevention efforts and core element of current “treatment as prevention” strategies. Mobility, low education and income, and limited access to health care put Latino migrants at higher risk for HIV and represent barriers for adequate levels of HIV testing in this population. We examined correlates of, and missed opportunities to increase, HIV testing for circular Mexican migrants in the U.S. We used data from a probability-based survey of returning Mexican migrants (N=1161) conducted in the border city of Tijuana, Mexico. We estimated last 12-months rates of HIV testing and the percentage of migrants who received other health care services or were detained in an immigration center, jail, or prison for 30 or more days in the U.S., but were not tested for HIV. Twenty-two percent of migrants received HIV testing in the last 12 months. In general, utilization of other health care services or detention for 30 or more days in the U.S. was a significant predictor of last 12-months HIV testing. Despite this association, we found evidence of missed opportunities to promote testing in healthcare and/or correctional or immigration detention centers. About 27.6% of migrants received other health care and/or were detained at least 30 days but not tested for HIV. Health care systems, jails and detention centers play an important role in increasing access to HIV testing among circular migrants, but there is room for improvement. Policies to offer opt-out, confidential HIV testing and counseling to Mexican migrants in these settings on a routine and ethical manner need to be designed and pilot tested. These policies could increase knowledge of HIV status, facilitate engagement in HIV treatment among a highly mobile population, and contribute to decrease incidence of HIV in the host and receiving communities. PMID:25860261

Identifying opportunities to increase HIV testing among mexican migrants: a call to step up efforts in health care and detention settings.

PubMed

Martínez-Donate, Ana P; Rangel, Maria Gudelia; Rhoads, Natalie; Zhang, Xiao; Hovell, Melbourne; Magis-Rodriguez, Carlos; González-Fagoaga, Eduardo

2015-01-01

HIV testing and counseling is a critical component of HIV prevention efforts and core element of current "treatment as prevention" strategies. Mobility, low education and income, and limited access to health care put Latino migrants at higher risk for HIV and represent barriers for adequate levels of HIV testing in this population. We examined correlates of, and missed opportunities to increase, HIV testing for circular Mexican migrants in the U.S. We used data from a probability-based survey of returning Mexican migrants (N=1161) conducted in the border city of Tijuana, Mexico. We estimated last 12-months rates of HIV testing and the percentage of migrants who received other health care services or were detained in an immigration center, jail, or prison for 30 or more days in the U.S., but were not tested for HIV. Twenty-two percent of migrants received HIV testing in the last 12 months. In general, utilization of other health care services or detention for 30 or more days in the U.S. was a significant predictor of last 12-months HIV testing. Despite this association, we found evidence of missed opportunities to promote testing in healthcare and/or correctional or immigration detention centers. About 27.6% of migrants received other health care and/or were detained at least 30 days but not tested for HIV. Health care systems, jails and detention centers play an important role in increasing access to HIV testing among circular migrants, but there is room for improvement. Policies to offer opt-out, confidential HIV testing and counseling to Mexican migrants in these settings on a routine and ethical manner need to be designed and pilot tested. These policies could increase knowledge of HIV status, facilitate engagement in HIV treatment among a highly mobile population, and contribute to decrease incidence of HIV in the host and receiving communities.

Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement.

PubMed

Snow, Richard; Granata, Jaymes; Ruhil, Anirudh V S; Vogel, Karen; McShane, Michael; Wasielewski, Ray

2014-10-01

Health-care costs following acute hospital care have been identified as a major contributor to regional variation in Medicare spending. This study investigated the associations of preoperative physical therapy and post-acute care resource use and its effect on the total cost of care during primary hip or knee arthroplasty. Historical claims data were analyzed using the Centers for Medicare & Medicaid Services Limited Data Set files for Diagnosis Related Group 470. Analysis included descriptive statistics of patient demographic characteristics, comorbidities, procedures, and post-acute care utilization patterns, which included skilled nursing facility, home health agency, or inpatient rehabilitation facility, during the ninety-day period after a surgical hospitalization. To evaluate the associations, we used bivariate and multivariate techniques focused on post-acute care use and total episode-of-care costs. The Limited Data Set provided 4733 index hip or knee replacement cases for analysis within the thirty-nine-county Medicare hospital referral cluster. Post-acute care utilization was a significant variable in the total cost of care for the ninety-day episode. Overall, 77.0% of patients used post-acute care services after surgery. Post-acute care utilization decreased if preoperative physical therapy was used, with only 54.2% of the preoperative physical therapy cohort using post-acute care services. However, 79.7% of the non-preoperative physical therapy cohort used post-acute care services. After adjusting for demographic characteristics and comorbidities, the use of preoperative physical therapy was associated with a significant 29% reduction in post-acute care use, including an $871 reduction of episode payment driven largely by a reduction in payments for skilled nursing facility ($1093), home health agency ($527), and inpatient rehabilitation ($172). The use of preoperative physical therapy was associated with a 29% decrease in the use of any post-acute care services. This association was sustained after adjusting for comorbidities, demographic characteristics, and procedural variables. Health-care providers can use this methodology to achieve an integrative, cost-effective, patient care pathway using preoperative physical therapy. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.

Coverage, quality of and barriers to postnatal care in rural Hebei, China: a mixed method study.

PubMed

Chen, Li; Qiong, Wu; van Velthoven, Michelle Helena; Yanfeng, Zhang; Shuyi, Zhang; Ye, Li; Wei, Wang; Xiaozhen, Du; Ting, Zhang

2014-01-18

Postnatal care is an important link in the continuum of care for maternal and child health. However, coverage and quality of postnatal care are poor in low- and middle-income countries. In 2009, the Chinese government set a policy providing free postnatal care services to all mothers and their newborns in China. Our study aimed at exploring coverage, quality of care, reasons for not receiving and barriers to providing postnatal care after introduction of this new policy. We carried out a mixed method study in Zhao County, Hebei Province, China from July to August 2011. To quantify the coverage, quality of care and reasons for not using postnatal care, we conducted a household survey with 1601 caregivers of children younger than two years of age. We also conducted semi-structured interviews with 24 township maternal and child healthcare workers to evaluate their views on workload, in-service training and barriers to postnatal home visits. Of 1442 (90% of surveyed caregivers) women who completed the postnatal care survey module, 8% received a timely postnatal home visit (within one week after delivery) and 24% of women received postnatal care within 42 days after delivery. Among women who received postnatal care, 37% received counseling or guidance on infant feeding and 32% on cord care. 24% of women reported that the service provider checked jaundice of their newborns and 18% were consulted on danger signs and thermal care of their newborns. Of 991 mothers who did not seek postnatal care within 42 days after birth, 65% of them said that they did not knew about postnatal care and 24% of them thought it was unnecessary. Qualitative findings revealed that staff shortages and inconvenient transportation limited maternal and child healthcare workers in reaching out to women at home. In addition, maternal and child healthcare workers said that in-service training was inadequate and more training on postnatal care, hands-on practice, and supervision were needed. Coverage and quality of postnatal care were low in rural Hebei Province and far below the targets set by Chinese government. We identified barriers both from the supply and demand side.

Evaluating patient care communication in integrated care settings: application of a mixed method approach in cerebral palsy programs.

PubMed

Gulmans, J; Vollenbroek-Hutten, M M R; Van Gemert-Pijnen, J E W C; Van Harten, W H

2009-02-01

In this study, we evaluated patient care communication in the integrated care setting of children with cerebral palsy in three Dutch regions in order to identify relevant communication gaps experienced by both parents and involved professionals. A three-step mixed method approach was used starting with a questionnaire to identify communication links in which parents experienced gaps. In subsequent in-depth interviews with parents and focus group meetings with professionals underlying factors were evaluated. In total, 197 parents completed the questionnaire (response 67%); 6% scored negative on parent-professional communication, whereas 17% scored negative on inter-professional communication, especially between the rehabilitation physician and primary care physiotherapy (16%) and (special) education/day care (15%). In-depth interviews among a subset of 20 parents revealed various sources of dissatisfaction such as lack of cooperation and patient centeredness, inappropriate amount of information exchange and professional use of parents as messenger of information. Focus group meetings revealed that professionals recognized these gaps. They attributed them to capacity problems, lack of interdisciplinary guidelines and clear definition of roles, but also a certain hesitance for contact due to unfamiliarity with involved professionals in the care network. Parents particularly identified gaps in inter-professional communication between (rehabilitation) hospitals and primary care settings. Involved professionals recognized these gaps and primarily attributed them to organizational factors. Improvement initiatives should focus on these factors as well as facilitation of low-threshold contact across the patient's care network.

Simulated Disaster Day: Benefit From Lessons Learned Through Years of Transformation From Silos to Interprofessional Education.

PubMed

Livingston, Laura L; West, Courtney A; Livingston, Jerry L; Landry, Karen A; Watzak, Bree C; Graham, Lori L

2016-08-01

Disaster Day is a simulation event that began in the College of Nursing and has increased exponentially in size and popularity for the last 8 years. The evolution has been the direct result of reflective practice and dedicated leadership in the form of students, faculty, and administration. Its development and expansion into a robust interprofessional education activity are noteworthy because it gives health care professions students an opportunity to work in teams to provide care in a disaster setting. The "authentic" learning situation has enhanced student knowledge of roles and responsibilities and seems to increase collaborative efforts with other disciplines. The lessons learned and modifications made in our Disaster Day planning, implementation, and evaluation processes are shared in an effort to facilitate best practices for other institutions interested in a similar activity.

COMPARISON OF MEDICAL COSTS AND CARE OF APPENDECTOMY PATIENTS BETWEEN FEE-FOR-SERVICE AND SET FEE FOR DIAGNOSIS-RELATED GROUP SYSTEMS IN 20 CHINESE HOSPITALS.

PubMed

Zhang, Yin-hua; He, Guo-ping; Liu, Jing-wei

2016-09-01

The objective of this study was to compare the fee-for-service and set fee for diagnosis-related group systems with regard to quality of medical care and cost to appendectomy patients. We conducted a retrospective study of 208 inpatients (from 20 hospitals) who undergone appendectomy in Changsha, China during 2013. Data were obtained from databases of medical insurance information systems directly connected to the hospital information systems. We collected and compared patient ages, length of study, and total medical costs for impatient appendectomies between patients using fee-for-service and set fee for diagnosisrelated group systems. One hundred thirty-three patients used the fee for service system and 75 used the set fee diagnosis related group system. For those using the diagnosis-related group system, the mean length of hospitalization (6.2 days) and mean number of prescribed antimicrobials (2.4) per patient were significantly lower than those of the patients who used the fee-for-service system (7.3 days and 3.0, respectively; p = 0.018; p < 0.05) and were accompanied by lower medical costs and cost of antimicrobials (RMB 2,518 versus RMB 4,484 and RMB476 versus RMB1,108, respectively; p = 0.000, p = 0.000). There were no significant differences in post-surgical complications between the two systems. The diagnosis-related group system had significantly medical costs for appendectomy compared to the fee-for-service system, without sacrificing quality of medical care.

Interventions for Challenging Behavior in Residential Settings.

ERIC Educational Resources Information Center

Stancliffe, Roger J.; Lakin, K. Charlie; Hayden, Mary F.

1999-01-01

A study investigated the use of different interventions for 151 individuals with mental retardation in residential care: Individualized Habilitation Plan objectives concerning challenging behavior, one-to-one crisis intervention in the preceding 30 days, and behavior management professional services in the preceding 6 months. Externalized…

Same-day antiretroviral therapy (ART) initiation in pregnancy is not associated with viral suppression or engagement in care: A cohort study.

PubMed

Langwenya, Nontokozo; Phillips, Tamsin K; Brittain, Kirsty; Zerbe, Allison; Abrams, Elaine J; Myer, Landon

2018-06-01

Many prevention of mother-to-child HIV transmission programmes across Africa initiate HIV-infected (HIV positive) pregnant women on lifelong antiretroviral therapy (ART) on the first day of antenatal care ("same-day" initiation). However, there are concerns that same-day initiation may limit patient preparation before starting ART and contribute to subsequent non-adherence, disengagement from care and raised viral load. We examined if same-day initiation was associated with viral suppression and engagement in care during pregnancy. Consecutive ART-eligible pregnant women making their first antenatal care (ANC) visit at a primary care facility in Cape Town, South Africa were enrolled into a prospective cohort between March 2013 and June 2014. Before July 2013, ART eligibility was based on CD4 cell count ≤350 cells/μL ("Option A"), with a 1 to 2 week delay from the first ANC visit to ART initiation for patient preparation; thereafter all women were eligible regardless of CD4 cell count ("Option B+") and offered ART on the same day as first ANC visit. Women were followed with viral load testing conducted separately from routine ART services, and engagement in ART services was measured using routinely collected clinic, pharmacy and laboratory records through 12 months postpartum. Among 628 HIV-positive women (median age, 28 years; median gestation at ART start, 21 weeks; 55% newly diagnosed with HIV), 73% initiated ART same-day; this proportion was higher under Option B+ versus Option A (85% vs. 20%). Levels of viral suppression (viral load <50 copies/mL) at delivery (74% vs. 82%) and 12 months postpartum (74% vs. 71%) were similar under same-day versus delayed initiation respectively. Findings were consistent when viral suppression was defined at <1000 copies/mL, after adjustment for demographic/clinical measures and across subgroups of age, CD4 and timing of HIV diagnosis. Time to first viral rebound following initial suppression did not differ by timing of ART initiation nor did engagement in care through 12 months postpartum (same-day = 73%, delayed = 73%, p = 0.910). These data suggest that same-day ART initiation during pregnancy is not associated with lower levels of engagement in care or viral suppression through 12 months post-delivery in this setting, providing reassurance to ART programmes implementing Option B+. © 2018 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.

Emergency medical systems in low- and middle-income countries: recommendations for action.

PubMed Central

Kobusingye, Olive C.; Hyder, Adnan A.; Bishai, David; Hicks, Eduardo Romero; Mock, Charles; Joshipura, Manjul

2005-01-01

Emergency medical care is not a luxury for rich countries or rich individuals in poor countries. This paper makes the point that emergency care can make an important contribution to reducing avoidable death and disability in low- and middle-income countries. But emergency care needs to be planned well and supported at all levels--at the national, provincial and community levels--and take into account the entire spectrum of care, from the occurrence of an acute medical event in the community to the provision of appropriate care at the hospital. The mix of personnel, materials, and health-system infrastructure can be tailored to optimize the provision of emergency care in settings with different levels of resource availability. The misconception that emergency care cannot be cost effective in low-income settings is demonstrably inaccurate. Emergencies occur everywhere, and each day they consume resources regardless of whether there are systems capable of achieving good outcomes. With better planning, the ongoing costs of emergency care can result in better outcomes and better cost-effectiveness. Every country and community can and should provide emergency care regardless of their place in the ratings of developmental indices. We make the case for universal access to emergency care and lay out a research agenda to fill the gaps in knowledge in emergency care. PMID:16184282

CDC-funded HIV testing, HIV positivity, and linkage to HIV medical care in non-health care settings among young men who have sex with men (YMSM) in the United States.

PubMed

Seth, Puja; Walker, Tanja; Figueroa, Argelia

2017-07-01

In the United States, HIV infection disproportionately affects young gay, bisexual, and other men who have sex with men, aged 13-24 years (collectively referred to as YMSM), specifically black YMSM. Knowledge of HIV status is the first step for timely and essential prevention and treatment services. Because YMSM are disproportionately affected by HIV, the number of CDC-funded HIV testing events, overall and newly diagnosed HIV positivity, and linkage to HIV medical care among YMSM in non-health care settings were examined from 61 health department jurisdictions. Differences by age and race/ethnicity were analyzed. Additionally, trends in number of HIV testing events and newly diagnosed HIV positivity were examined from 2011 to 2015. In 2015, 42,184 testing events were conducted among YMSM in non-health care settings; this represents only 6% of tests in non-health care settings. Overall and newly diagnosed HIV positivity was 2.8% and 2.1%, respectively, with black/African-American YMSM being disproportionately affected (5.6% for overall; 4% for newly diagnosed); 71% of YMSM were linked within 90 days. The newly diagnosed HIV positivity among YMSM decreased from 2.8% in 2011 to 2.4% in 2015, and the number of newly diagnosed YMSM also decreased. Further targeted testing efforts among YMSM are needed to identify undiagnosed YMSM, specifically black YMSM.

Improving the Capture of Fall Events in Hospitals: Combining a Service for Evaluating Inpatient Falls with an Incident Report System

PubMed Central

Shorr, Ronald I.; Mion, Lorraine C.; Chandler, A. Michelle; Rosenblatt, Linda C.; Lynch, Debra; Kessler, Lori A.

2008-01-01

OBJECTIVES To determine the utility of a fall evaluation service to improve the ascertainment of falls in acute care. DESIGN Six-month observational study. SETTING Sixteen adult nursing units (349 beds) in an urban, academically affiliated, community hospital. PARTICIPANTS Patients admitted to the study units during the study period. INTERVENTION Nursing staff identifying falls were instructed to notify, using a pager, a trained nurse ‘‘fall evaluator.’’ Fall evaluators provided 24-hour-per-day 7-day-per-week coverage throughout the study. Data on patient falls gathered by fall evaluators were compared with falls data obtained through the hospital’s incident reporting system. RESULTS During 51,180 patient-days of observation, 191 falls were identified according to incident reports (3.73 falls/1,000 patient-days), whereas the evaluation service identified 228 falls (4.45 falls/1,000 patient-days). Combining falls reported from both data sources yielded 266 falls (5.20 falls/1,000 patient-days), a 39% relative rate increase compared with incident reports alone (P<.001). For falls with injury, combining data from both sources yielded 79 falls (1.54 injurious falls/1,000 patient-days), compared with 57 falls (1.11 injurious falls/1,000 patient-days) filed in incident reports—a 28% increase (P = .06). In the 16 nursing units, the relative percentage increase of captured fall events using the combined data sources versus the incident reporting system alone ranged from 13% to 125%. CONCLUSION Incident reports significantly underestimate both injurious and noninjurious falls in acute care settings and should not be used as the sole source of data for research or quality improvement initiatives. PMID:18205761

Cost-effectiveness of Collaborative Care for Depression in Human Immunodeficiency Virus Clinics

PubMed Central

Fortney, John C; Gifford, Allen L; Rimland, David; Monson, Thomas; Rodriguez-Barradas, Maria C.; Pyne, Jeffrey M

2015-01-01

Objective To examine the cost-effectiveness of the HITIDES intervention. Design Randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care. Setting Three Veterans Health Administration (VHA) HIV clinics in the Southern US. Subjects 249 HIV-infected patients completed the baseline interview; 123 were randomized to the intervention and 126 to usual care. Intervention HITIDES consisted of an off-site HIV depression care team that delivered up to 12 months of collaborative care. The intervention used a stepped-care model for depression treatment and specific recommendations were based on the Texas Medication Algorithm Project and the VA/Department of Defense Depression Treatment Guidelines. Main outcome measure(s) Quality-adjusted life years (QALYs) were calculated using the 12-Item Short Form Health Survey, the Quality of Well Being Scale, and by converting depression-free days to QALYs. The base case analysis used outpatient, pharmacy, patient, and intervention costs. Cost-effectiveness was calculated using incremental cost effectiveness ratios (ICERs) and net health benefit (NHB). ICER distributions were generated using nonparametric bootstrap with replacement sampling. Results The HITIDES intervention was more effective and cost-saving compared to usual care in 78% of bootstrapped samples. The intervention NHB was positive and therefore deemed cost-effective using an ICER threshold of $50,000/QALY. Conclusions In HIV clinic settings this intervention was more effective and cost-saving compared to usual care. Implementation of off-site depression collaborative care programs in specialty care settings may be a strategy that not only improves outcomes for patients, but also maximizes the efficient use of limited healthcare resources. PMID:26102447

Early primary care follow-up after ED and hospital discharge - does it affect readmissions?

PubMed

Sinha, Sanjai; Seirup, Joanna; Carmel, Amanda

2017-04-01

After hospitalization, timely discharge follow-up has been linked to reduced readmissions in the heart failure population, but data from general inpatients has been mixed. The objective of this study was to determine if there was an association between completed follow-up appointments within 14 days of hospital discharge and 30-day readmission amongst primary care patients at an urban academic medical center. Index discharges included both inpatient and emergency room settings. A secondary objective was to identify patient factors associated with completed follow-up appointments within 14 days. We conducted a retrospective review of primary care patients at an urban academic medical center who were discharged from either the emergency department (ED) or inpatient services at the Weill Cornell Medical Center/New York Presbyterian Hospital from 1 January 2014-31 December 2014. Cox proportional hazard models were used to identify the relationship between follow-up in primary care within 14 days and readmission within 30 days. Logistic regression was used to evaluate the association of patient factors with 14-day follow-up. Among 9,662 inpatient and ED discharges, multivariable analysis (adjusting for age, gender, race/ethnicity, insurance, number of diagnoses on problem list, length of stay, and discharge service) showed that follow-up with primary care within 14 days was not associated with a lower hazard of readmission within 30 days (HR = 0.78; 95% CI 0.56-1.09). A higher number of diagnoses on the problem list was associated with greater odds of follow-up for both inpatient and emergency department discharges (inpatient: HR = 1.03, 95% CI 1.02-1.04; ED: HR = 1.02, 95% CI 1.00-1.04). For inpatient discharges, each additional day in length of stay was associated with 3% lower odds of follow-up (HR = 0.97, 95% CI 0.96-0.99). Early follow-up within 14 days after discharge from general inpatient services was associated with a trend toward lower hazard of 30-day readmission though this finding was not significant. Future studies should focus on identifying additional cohorts of patients in which readmission is reduced by early follow-up, so that access to primary care appointments is not compromised.

Intensive point-of-care ultrasound training with long-term follow-up in a cohort of Rwandan physicians.

PubMed

Henwood, Patricia C; Mackenzie, David C; Rempell, Joshua S; Douglass, Emily; Dukundane, Damas; Liteplo, Andrew S; Leo, Megan M; Murray, Alice F; Vaillancourt, Samuel; Dean, Anthony J; Lewiss, Resa E; Rulisa, Stephen; Krebs, Elizabeth; Raja Rao, A K; Rudakemwa, Emmanuel; Rusanganwa, Vincent; Kyanmanywa, Patrick; Noble, Vicki E

2016-12-01

We delivered a point-of-care ultrasound training programme in a resource-limited setting in Rwanda, and sought to determine participants' knowledge and skill retention. We also measured trainees' assessment of the usefulness of ultrasound in clinical practice. This was a prospective cohort study of 17 Rwandan physicians participating in a point-of-care ultrasound training programme. The follow-up period was 1 year. Participants completed a 10-day ultrasound course, with follow-up training delivered over the subsequent 12 months. Trainee knowledge acquisition and skill retention were assessed via observed structured clinical examinations (OSCEs) administered at six points during the study, and an image-based assessment completed at three points. Trainees reported minimal structured ultrasound education and little confidence using point-of-care ultrasound before the training. Mean scores on the image-based assessment increased from 36.9% (95% CI 32-41.8%) before the initial 10-day training to 74.3% afterwards (95% CI 69.4-79.2; P < 0.001). The mean score on the initial OSCE after the introductory course was 81.7% (95% CI 78-85.4%). The mean OSCE performance at each subsequent evaluation was at least 75%, and the mean OSCE score at the 58-week follow up was 84.9% (95% CI 80.9-88.9%). Physicians providing acute care in a resource-limited setting demonstrated sustained improvement in their ultrasound knowledge and skill 1 year after completing a clinical ultrasound training programme. They also reported improvements in their ability to provide patient care and in job satisfaction. © 2016 John Wiley & Sons Ltd.

Combinations of long-term care insurance services and associated factors in Japan: a classification tree model.

PubMed

Igarashi, Ayumi; Ishibashi, Tomoaki; Shinozaki, Tomohiro; Yamamoto-Mitani, Noriko

2014-09-10

To develop a quality community-based care management system, it is important to identify the actual use of long-term care insurance (LTCI) services and the most frequent combinations of services. It is also important to determine the factors associated with the use of such combinations. This study was conducted in 10 care management agencies in the urban area around Tokyo, Japan. The assessment and services data of 983 clients using the Minimum Data Set for Home Care were collected from the agencies. We categorized combination patterns of services from descriptive data analysis of service use and conducted chi-squared automatic interaction detection (CHAID) analysis to identify the primary variables determining the combinations of the services used. We identified nine patterns of service use: day care only (16.5%); day care and assistive devices (14.4%); day care, home helper, and assistive devices (13.2%); home helper and assistive devices (11.8%); assistive devices only (10.9%); home helper only (8.7%); day care and home helper (7.7%); home helper, visiting nurse, and assistive devices (5.4%); and others (11.3%). The CHAID dendrogram illustrated the relative importance of significant independent variables in determining combination use; the most important variables in predicting combination use were certified care need level, living arrangements, cognitive function, and need for medical procedures. The characteristics of care managers and agencies were not associated with the combinations. This study clarified patterns of community-based service use in the LTCI system in Japan. The combinations of services were more related to the physical and psychosocial status of older adults than to the characteristics of agencies and care managers. Although we found no association between service use and the characteristics of agencies and care managers, further examination of possible bias in the use of services should be included in future studies. Researchers and policymakers can use these combinations identified in this study to categorize the use of community-based care service and measure the outcomes of care interventions.

Physical Activity Patterns of Acute Stroke Patients Managed in a Rehabilitation Focused Stroke Unit

PubMed Central

2013-01-01

Background. Comprehensive stroke unit care, incorporating acute care and rehabilitation, may promote early physical activity after stroke. However, previous information regarding physical activity specific to the acute phase of stroke and the comprehensive stroke unit setting is limited to one stroke unit. This study describes the physical activity undertaken by patients within 14 days after stroke admitted to a comprehensive stroke unit. Methods. This study was a prospective observational study. Behavioural mapping was used to determine the proportion of the day spent in different activities. Therapist reports were used to determine the amount of formal therapy received on the day of observation. The timing of commencement of activity out of bed was obtained from the medical records. Results. On average, patients spent 45% (SD 25) of the day in some form of physical activity and received 58 (SD 34) minutes per day of physiotherapy and occupational therapy combined. Mean time to first mobilisation out of bed was 46 (SD 32) hours post-stroke. Conclusions. This study suggests that commencement of physical activity occurs earlier and physical activity is at a higher level early after stroke in this comprehensive stroke unit, when compared to studies of other acute stroke models of care. PMID:24024192

Implementation Research to Inform the Use of Xpert MTB/RIF in Primary Health Care Facilities in High TB and HIV Settings in Resource Constrained Settings.

PubMed

Muyoyeta, Monde; Moyo, Maureen; Kasese, Nkatya; Ndhlovu, Mapopa; Milimo, Deborah; Mwanza, Winfridah; Kapata, Nathan; Schaap, Albertus; Godfrey Faussett, Peter; Ayles, Helen

2015-01-01

The current cost of Xpert MTB RIF (Xpert) consumables is such that algorithms are needed to select which patients to prioritise for testing with Xpert. To evaluate two algorithms for prioritisation of Xpert in primary health care settings in a high TB and HIV burden setting. Consecutive, presumptive TB patients with a cough of any duration were offered either Xpert or Fluorescence microscopy (FM) test depending on their CXR score or HIV status. In one facility, sputa from patients with an abnormal CXR were tested with Xpert and those with a normal CXR were tested with FM ("CXR algorithm"). CXR was scored automatically using a Computer Aided Diagnosis (CAD) program. In the other facility, patients who were HIV positive were tested using Xpert and those who were HIV negative were tested with FM ("HIV algorithm"). Of 9482 individuals pre-screened with CXR, Xpert detected TB in 2090/6568 (31.8%) with an abnormal CXR, and FM was AFB positive in 8/2455 (0.3%) with a normal CXR. Of 4444 pre-screened with HIV, Xpert detected TB in 508/2265 (22.4%) HIV positive and FM was AFB positive in 212/1920 (11.0%) in HIV negative individuals. The notification rate of new bacteriologically confirmed TB increased; from 366 to 620/ 100,000/yr and from 145 to 261/100,000/yr at the CXR and HIV algorithm sites respectively. The median time to starting TB treatment at the CXR site compared to the HIV algorithm site was; 1(IQR 1-3 days) and 3 (2-5 days) (p<0.0001) respectively. Use of Xpert in a resource-limited setting at primary care level in conjunction with pre-screening tests reduced the number of Xpert tests performed. The routine use of Xpert resulted in additional cases of confirmed TB patients starting treatment. However, there was no increase in absolute numbers of patients starting TB treatment. Same day diagnosis and treatment commencement was achieved for both bacteriologically confirmed and empirically diagnosed patients where Xpert was used in conjunction with CXR.

Implementation Research to Inform the Use of Xpert MTB/RIF in Primary Health Care Facilities in High TB and HIV Settings in Resource Constrained Settings

PubMed Central

Muyoyeta, Monde; Moyo, Maureen; Kasese, Nkatya; Ndhlovu, Mapopa; Milimo, Deborah; Mwanza, Winfridah; Kapata, Nathan; Schaap, Albertus; Godfrey Faussett, Peter; Ayles, Helen

2015-01-01

Background The current cost of Xpert MTB RIF (Xpert) consumables is such that algorithms are needed to select which patients to prioritise for testing with Xpert. Objective To evaluate two algorithms for prioritisation of Xpert in primary health care settings in a high TB and HIV burden setting. Method Consecutive, presumptive TB patients with a cough of any duration were offered either Xpert or Fluorescence microscopy (FM) test depending on their CXR score or HIV status. In one facility, sputa from patients with an abnormal CXR were tested with Xpert and those with a normal CXR were tested with FM (“CXR algorithm”). CXR was scored automatically using a Computer Aided Diagnosis (CAD) program. In the other facility, patients who were HIV positive were tested using Xpert and those who were HIV negative were tested with FM (“HIV algorithm”). Results Of 9482 individuals pre-screened with CXR, Xpert detected TB in 2090/6568 (31.8%) with an abnormal CXR, and FM was AFB positive in 8/2455 (0.3%) with a normal CXR. Of 4444 pre-screened with HIV, Xpert detected TB in 508/2265 (22.4%) HIV positive and FM was AFB positive in 212/1920 (11.0%) in HIV negative individuals. The notification rate of new bacteriologically confirmed TB increased; from 366 to 620/ 100,000/yr and from 145 to 261/100,000/yr at the CXR and HIV algorithm sites respectively. The median time to starting TB treatment at the CXR site compared to the HIV algorithm site was; 1(IQR 1-3 days) and 3 (2-5 days) (p<0.0001) respectively. Conclusion Use of Xpert in a resource-limited setting at primary care level in conjunction with pre-screening tests reduced the number of Xpert tests performed. The routine use of Xpert resulted in additional cases of confirmed TB patients starting treatment. However, there was no increase in absolute numbers of patients starting TB treatment. Same day diagnosis and treatment commencement was achieved for both bacteriologically confirmed and empirically diagnosed patients where Xpert was used in conjunction with CXR. PMID:26030301

Protocolized treatment is associated with decreased organ dysfunction in pediatric severe sepsis

PubMed Central

Balamuth, Fran; Weiss, Scott L.; Fitzgerald, Julie C.; Hayes, Katie; Centkowski, Sierra; Chilutti, Marianne; Grundmeier, Robert W.; Lavelle, Jane; Alpern, Elizabeth R.

2016-01-01

Objective To determine whether treatment with a protocolized sepsis guideline in the emergency department (ED) was associated with a lower burden of organ dysfunction (OD) by hospital day 2 compared to non-protocolized usual care in pediatric patients with severe sepsis. Design Retrospective cohort study Setting Tertiary care children’s hospital from January 1, 2012–March 31, 2014. Measurements and Main Results Subjects with international consensus defined severe sepsis and pediatric intensive care unit (PICU) admission within 24 hours of ED arrival were included. The exposure was the use of a protocolized ED sepsis guideline. The primary outcome was complete resolution of OD by hospital day 2. One hundred eighty nine subjects were identified during the study period. Of these, 121 (64%) were treated with the protocolized ED guideline and 68 were not. There were no significant differences between the groups in age, sex, race, number of comorbid conditions, ED triage level, or OD on arrival to the ED. Patients treated with protocolized ED care were more likely to be free of OD on hospital day 2 after controlling for sex, comorbid condition, indwelling central venous catheter, PIM-2 score, and timing of antibiotics and intravenous fluids (adjusted OR 4.2, 95% CI 1.7, 10.4). Conclusions Use of a protocolized ED sepsis guideline was independently associated with resolution of OD by hospital day 2 compared to non-protocolized usual care. These data indicate that morbidity outcomes in children can be improved with the use of protocolized care. PMID:27455114

Primary Care-Mental Health Integration in the Veterans Affairs Health System: Program Characteristics and Performance.

PubMed

Cornwell, Brittany L; Brockmann, Laurie M; Lasky, Elaine C; Mach, Jennifer; McCarthy, John F

2018-06-01

The Veterans Health Administration (VHA) has achieved substantial national implementation of primary care-mental health integration (PC-MHI) services. However, little is known regarding program characteristics, variation in characteristics across settings, or associations between program fidelity and performance. This study identified core elements of PC-MHI services and evaluated their associations with program characteristics and performance. A principal-components analysis (PCA) of reports from 349 sites identified factors associated with PC-MHI fidelity. Analyses assessed the correlation among factors and between each factor and facility type (medical center or community-based outpatient clinic), primary care population size, and performance indicators (receipt of PC-MHI services, same-day access to mental health and primary care services, and extended duration of services). PCA identified seven factors: core implementation, care management (CM) assessments and supervision, CM supervision receipt, colocated collaborative care (CCC) by prescribing providers, CCC by behavioral health providers, participation in patient aligned care teams (PACTs) for special populations, and treatment of complex mental health conditions. Sites serving larger populations had greater core implementation scores. Medical centers and sites serving larger populations had greater scores for CCC by prescribing providers, CM assessments and supervision, and participation in PACTs. Greater core implementation scores were associated with greater same-day access. Sites with greater scores for CM assessments and supervision had lower scores for treatment of complex conditions. Outpatient clinics and sites serving smaller populations experienced challenges in integrated care implementation. To enhance same-day access, VHA should continue to prioritize PC-MHI implementation. Providing brief, problem-focused care may enhance CM implementation.

Relation Between Hospital Length of Stay and Quality of Care in Patients With Acute Coronary Syndromes (from the American Heart Association's Get With the Guidelines--Coronary Artery Disease Data Set).

PubMed

Tickoo, Sumit; Bhardwaj, Adarsh; Fonarow, Gregg C; Liang, Li; Bhatt, Deepak L; Cannon, Christopher P

2016-01-15

Worries regarding short length of stay (LOS) adversely impacting quality of care prompted us to assess the relation between hospital LOS and inpatient guideline adherence in patients with acute coronary syndrome. We used the American Heart Association's Get with The Guidelines (GWTG)--Coronary Artery Disease data set. Data were collected from January 2, 2000, to March 21, 2010, for patients with acute coronary syndrome from 405 different sites. Of the 119,398 patients in the study, the mean LOS was 5.5 days with a median of 4 days. There was no difference in the LOS on the basis of hospital size, hospital type, or cardiac surgery availability. The population with an LOS <4 days were younger (63.8 ± 14.1 vs 70 ± 14.5, p <0.0001), men (63.8% vs 55.3%, p <0.0001) and had fewer clinical co-morbidities. The overall adherence was high in the GWTG participating hospitals. Those with the LOS <4 days were more likely to receive aspirin (adjusted odds ratio [OR] 1.12, 95% CI 1.06 to 1.19; p <0.001), clopidogrel (OR 1.77, 95% CI 1.60 to 1.95; p <0.001), lipid-lowering therapy if indicated (OR 1.13, 95% CI 1.05 to 1.21; p <0.001), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for left ventricular systolic dysfunction (OR 1.10, 95% CI 1.01 to 1.21; p = 0.04) and smoking cessation counseling (OR 1.17, 95% CI 1.1 to 1.24; p <0.001) compared to those with the LOS ≥ 4 days. In contrast, those with the LOS <4 days were less likely to receive beta blockers (OR 0.88, 95% CI 0.84 to 0.93; p <0.001). The odds of receiving defect-free care were greater for patients with the LOS <4 days (OR 1.15, 95% CI 1.1 to 1.21; p <0.001). In conclusion, in GWTG participating hospitals, a shorter LOS did not appear to adversely affect adherence to discharge quality of care measures. Copyright © 2016 Elsevier Inc. All rights reserved.

Effect of time and day of admission on hospital care quality for patients with chronic obstructive pulmonary disease exacerbation in England and Wales: single cohort study

PubMed Central

Roberts, Christopher Michael; Lowe, Derek; Skipper, Emma; Steiner, Michael C; Jones, Rupert; Gelder, Colin; Hurst, John R; Lowrey, Gillian E; Thompson, Catherine; Stone, Robert A

2017-01-01

Objective To evaluate if observed increased weekend mortality was associated with poorer quality of care for patients admitted to hospital with chronic obstructive pulmonary disease (COPD) exacerbation. Design Prospective case ascertainment cohort study. Setting 199 acute hospitals in England and Wales, UK. Participants Consecutive COPD admissions, excluding subsequent readmissions, from 1 February to 30 April 2014 of whom 13 414 cases were entered into the study. Main outcomes Process of care mapped to the National Institute for Health and Care Excellence clinical quality standards, access to specialist respiratory teams and facilities, mortality and length of stay, related to time and day of the week of admission. Results Mortality was higher for weekend admissions (unadjusted OR 1.20, 95% CI 1.00 to 1.43), and for case-mix adjusted weekend mortality when calculated for admissions Friday morning through to Monday night (adjusted OR 1.19, 95% CI 1.00 to 1.43). Median time to death was 6 days. Some clinical processes were poorer on Mondays and during normal working hours but not weekends or out of hours. Specialist respiratory care was less available and less prompt for Friday and Saturday admissions. Admission to a specialist ward or high dependency unit was less likely on a Saturday or Sunday. Conclusions Increased mortality observed in weekend admissions is not easily explained by deficiencies in early clinical guideline care. Further study of out-of-hospital factors, specialty care and deaths later in the admission are required if effective interventions are to be made to reduce variation by day of the week of admission. PMID:28882909

Effect of kangaroo mother care on vital physiological parameters of the low birth weight newborn.

PubMed

Bera, Alpanamayi; Ghosh, Jagabandhu; Singh, Arun Kumarendu; Hazra, Avijit; Som, Tapas; Munian, Dinesh

2014-10-01

Low birth weight (LBW; <2500 g), which is often associated with preterm birth, is a common problem in India. Both are recognized risk factors for neonatal mortality. Kangaroo mother care (KMC) is a non-conventional, low-cost method for newborn care based upon intimate skin-to-skin contact between mother and baby. Our objective was to assess physiological state of LBW babies before and after KMC in a teaching hospital setting. Study cohort comprised in-born LBW babies and their mothers - 300 mother-baby pairs were selected through purposive sampling. Initially, KMC was started for 1 hour duration (at a stretch) on first day and then increased by 1 hour each day for next 2 days. Axillary temperature, respiration rate (RR/ min), heart rate (HR/ min), and oxygen saturation (SpO2) were assessed for 3 consecutive days, immediately before and after KMC. Data from 265 mother-baby pairs were analyzed. Improvements occurred in all 4 recorded physiological parameters during the KMC sessions. Mean temperature rose by about 0.4°C, RR by 3 per minute, HR by 5 bpm, and SpO2 by 5% following KMC sessions. Although modest, these changes were statistically significant on all 3 days. Individual abnormalities (e.g. hypothermia, bradycardia, tachycardia, low SpO2) were often corrected during the KMC sessions. Babies receiving KMC showed modest but statistically significant improvement in vital physiological parameters on all 3 days. Thus, without using special equipment, the KMC strategy can offer improved care to LBW babies. These findings support wider implementation of this strategy.

Peripherally Inserted Central Venous Catheters in Pediatric Hematology/Oncology Patients in Tertiary Care Setting: A Developing Country Experience.

PubMed

Fadoo, Zehra; Nisar, Muhammad I; Iftikhar, Raza; Ali, Sajida; Mushtaq, Naureen; Sayani, Raza

2015-10-01

Peripherally inserted central venous catheters (PICC) have been successfully used to provide central access for chemotherapy and frequent transfusions. The purpose of this study was to assess the feasibility of PICCs and determine PICC-related complications in pediatric hematology/oncology patients in a resource-poor setting. All pediatric patients (age below 16 y) with hematologic and malignant disorders who underwent PICC line insertion at Aga Khan University Hospital from January 2008 to June 2010 were enrolled in the study. Demographic features, primary diagnosis, catheter days, complications, and reasons for removal of device were recorded. Total of 36 PICC lines were inserted in 32 pediatric patients. Complication rate of 5.29/1000 catheter days was recorded. Our study showed comparable complication profile such as infection rate, occlusion, breakage, and dislodgement. The median catheter life was found to be 69 days. We conclude that PICC lines are feasible in a resource-poor setting and recommend its use for chemotherapy administration and prolonged venous access.

Cost consequences of point-of-care troponin T testing in a Swedish primary health care setting

PubMed Central

Andersson, Agneta; Janzon, Magnus; Karlsson, Jan-Erik; Levin, Lars-Åke

2014-01-01

Abstract Objective. To evaluate the safety and cost-effectiveness of point-of-care troponin T testing (POCT-TnT) for the management of patients with chest pain in primary care. Design. Prospective observational study with follow-up. Setting. Three primary health care (PHC) centres using POCT-TnT and four PHC centres not using POCT-TnT in south-east Sweden. Patients. All patients ≥ 35 years of age, contacting one of the PHC centres for chest pain, dyspnoea on exertion, unexplained weakness and/or fatigue, with no other probable cause than cardiac, were included. Symptoms must have commenced or worsened during the previous seven days. Main outcome measures. Emergency referral rates, diagnoses of acute myocardial infarction (AMI) or unstable angina (UA), and costs were collected for 30 days after the patient sought care at the PHC centre. Results. A total of 196 patients with chest pain were included: 128 in PHC centres with POCT-TnT and 68 in PHC centres without POCT-TnT. Fewer patients from the PHC centres with POCT-TnT (n = 32, 25%) were emergently referred to hospital than from centres without POCT-TnT (n = 29, 43%; p = 0.011). Eight patients (6.2%) from PHC centres with POCT-TnT were diagnosed with AMI or UA compared with six patients (8.8%) from centres without POCT-TnT (p = 0.565). Two patients with AMI or UA were classified as missed cases from PHC centres with POCT-TnT and there were no missed cases from PHC centres without POCT-TnT. SKr290 000 was saved per missed case of AMI or UA. Conclusion. The use of POCT-TnT in primary care may be cost saving but at the expense of missed cases. PMID:25434410

Quality of care and variability in lung cancer management across Belgian hospitals: a population-based study using routinely available data.

PubMed

Vrijens, France; De Gendt, Cindy; Verleye, Leen; Robays, Jo; Schillemans, Viki; Camberlin, Cécile; Stordeur, Sabine; Dubois, Cécile; Van Eycken, Elisabeth; Wauters, Isabelle; Van Meerbeeck, Jan P

2018-05-01

To evaluate the quality of care for all patients diagnosed with lung cancer in Belgium based on a set of evidence-based quality indicators and to study the variability of care between hospitals. A retrospective study based on linked data from the cancer registry, insurance claims and vital status for all patients diagnosed with lung cancer between 2010 and 2011. Evidence-based quality indicators were identified from a systematic literature search. A specific algorithm to attribute patients to a centre was developed, and funnel plots were used to assess variability of care between centres. None. The proportion of patients who received appropriate care as defined by the indicator. Secondary outcome included the variability of care between centres. Twenty indicators were measured for a total of 12 839 patients. Good results were achieved for 60-day post-surgical mortality (3.9%), histopathological confirmation of diagnosis (93%) and for the use of PET-CT before treatment with curative intent (94%). Areas to be improved include the reporting of staging information to the Belgian Cancer Registry (80%), the use of brain imaging for clinical stage III patients eligible for curative treatment (79%), and the time between diagnosis and start of first active treatment (median 20 days). High variability between centres was observed for several indicators. Twenty-three indicators were found relevant but could not be measured. This study highlights the feasibility to develop a multidisciplinary set of quality indicators using population-based data. The main advantage of this approach is that not additional registration is required, but the non-measurability of many relevant indicators is a hamper. It allows however to easily point to areas of large variability in care.

Blended care; development of a day treatment program for medically unexplained physical symptoms (MUPS) in the Dutch Armed Forces.

PubMed

Zeylemaker, M M P; Linn, F H H; Vermetten, E

2015-01-01

A subgroup of servicemen can be identified that seek a disproportionally amount of health care in comparison to diagnostic and therapeutic perspectives. This group can be identified on the basis of an absence of a structural medical explanation for their symptoms. The symptoms manifest predominantly as fatigue and pain, and are often chronic. Patients with medical unexplained medical symptoms (MUPS) often have multiple and complex problems that would be best treated by a multidisciplinary team of medical specialists and paramedics. The military is characterized by high loyalty towards peers and leadership, leading to neglect for personal care. While consensus on the biological basis for these complaints is lacking, awareness on the need for effective treatments for this patient group is high. Based on reviews, expert recommendations and clinical demand, a specialized treatment program for soldiers with MUPS has recently been developed and implemented in the system of health care in the Netherlands Armed Forces. We developed a functional rehabilitation program with blended care elements of cognitive behavioral therapy (CBT), physical therapy, case management, and psychoeducation, embedded in a day treatment setting. The program received high scores on participant as well as team satisfaction. The program is illustrated by two clinical vignettes. The blended care program for MUPS that focused on allostatic load awareness offered a more holistic and preventive approach that contributed to a reduction of unnecessary medical consumption, and increased job participation. We recommend that the development of guidelines for diagnoses and treatment of these complaints in military settings will improve the quality of patient care, reduce disability, facilitate reintegration, and encourage scientific research.

NATURAL HISTORY OF DENTAL PLAQUE ACCUMULATION IN MECHANICALLY VENTILATED ADULTS: A DESCRIPTIVE CORRELATIONAL STUDY

PubMed Central

Jones, Deborah J.; Munro, Cindy L.; Grap, Mary Jo

2011-01-01

Summary Objective The purpose of this study was to describe the pattern of dental plaque accumulation in mechanically ventilated adults. Accumulation of dental plaque and bacterial colonization of the oropharynx is associated with a number of systemic diseases including ventilator associated pneumonia. Research Methodology/Design Data were collected from mechanically ventilated critically ill adults (n=137), enrolled within 24 hours of intubation. Dental plaque, counts of decayed, missing and filled teeth and systemic antibiotic use was assessed on study days 1, 3, 5 and 7. Dental plaque averages per study day, tooth type and tooth location were analyzed. Setting Medical Respiratory, Surgical Trauma and Neuroscience ICU’s of a large tertiary care center in the southeast United States. Results Plaque: All surfaces > 60% plaque coverage from day 1 to day 7; Molars and Premolars contained greatest plaque average >70%. Systemic antibiotic use on day 1 had no significant effect on plaque accumulation on day 3 (p=0.73). Conclusions Patients arrive in critical care units with preexisting oral hygiene issues. Dental plaque tends to accumulate in the posterior teeth (molars and premolars) that may be hard for nurses to visualize and reach; this problem may be exacerbated by endotracheal tubes and other equipment. Knowing accumulation trends of plaque will guide the development of effective oral care protocols. PMID:22014582

38 CFR 59.160 - Adult day health care requirements.

Code of Federal Regulations, 2010 CFR

2010-07-01

... multipurpose room or area for group activities, including dining, with adequate table setting space. (2) Rehabilitation rooms or an area for individual and group treatments for occupational therapy, physical therapy... individual room for counseling and interviewing participants and family members. (10) A reception area. (11...

A Control-Based Multidimensional Approach to the Role of Optimism in the Use of Dementia Day Care Services.

PubMed

Contador, Israel; Fernández-Calvo, Bernardino; Palenzuela, David L; Campos, Francisco Ramos; Rivera-Navarro, Jesús; de Lucena, Virginia Menezes

2015-11-01

We examined whether grounded optimism and external locus of control are associated with admission to dementia day care centers (DCCs). A total of 130 informal caregivers were recruited from the Alzheimer's Association in Salamanca (northwest Spain). All caregivers completed an assessment protocol that included the Battery of Generalized Expectancies of Control Scales (BEEGC-20, acronym in Spanish) as well as depression and burden measures. The decision of the care setting at baseline assessment (own home vs DCC) was considered the main outcome measure in the logistic regression analyses. Grounded optimism was a preventive factor for admission (odds ratio [OR]: 0.34 and confidence interval [CI]: 0.15-0.75), whereas external locus of control (OR: 2.75, CI: 1.25-6.03) increased the probabilities of using DCCs. Depression mediated the relationship between optimism and DCCs, but this effect was not consistent for burden. Grounded optimism promotes the extension of care at home for patients with dementia. © The Author(s) 2013.

Changing Patient Expectations Decreases Length of Stay in an Enhanced Recovery Program for THA.

PubMed

Tanzer, Dylan; Smith, Karen; Tanzer, Michael

2018-02-01

The implementation of care pathways in hip arthroplasty programs has been shown to result in a decreased length of stay (LOS), but often multiple elements of a care pathway are implemented at the same time. As a result, it is difficult to understand the impact each of the individual modifications has made to the patient's prepathway care. In particular, it is unknown what the role of patient expectations pertaining to anticipated LOS alone is on the LOS after primary THA. (1) Does changing the patient's expectations regarding his or her anticipated LOS, without intentionally changing the rest of the care pathway, result in a change in the patient's LOS after primary THA? (2) Is the resultant LOS associated with the patient's age, gender, or day of the week the surgery was performed? We retrospectively compared the LOS in 100 consecutive patients undergoing THA immediately after the implementation of a 4-day care pathway (4-day Group) with 100 consecutive patients, 3 months later, who were also in the same pathway but were told by their surgeon preoperatively and in the hospital to expect a LOS of 2 days (2-day Group). Aside from reeducation by the surgeon, there was no difference in the surgery or intentional changes to the intraoperative or postoperative management of the two groups. Only the patient and the surgeon were made aware of the accelerated discharge plan. We compared the LOS between the two groups and the number of patients who met their discharge goal. As well, the ability to meet the discharge goal for each group was further determined based on age, gender, and day of the week the surgery was performed. Overall, patients in the 2-day Group had a shorter LOS than those in the 4-day Group (2.9 ± 0.88 days versus 3.9 ± 1.71 days; mean difference 1 day; 95% confidence interval [CI], 0.60-1.36; p = 0.001). In the 2-day Group, the LOS was 2 days in 32% compared with 8% in the 4-day Group (odds ratio, 4.0; 95% CI, 1.76-9.11; p < 0.001). Men in the 4-day Group had a shorter LOS than women (3.4 ± 1.22 days versus 4.2 ± 1.89 days; mean difference 0.8 days; 95% CI, 0.17-1.78; p = 0.019), but there was no difference in LOS by gender in the 2-day Group (2.8 ± 0.81 days versus 3.1 ± 0.93 days; mean difference 0.3 days; 95% CI, -0.14 to 0.61; p = 0.219). For all patients > 40 years and < 90 years of age, a greater percentage of patients in the 2-day Group went home by postoperative day 2 than those in the 4-day Group (32% compared with 7%; odds ratio, 4.6; p < 0.001). In both groups, there was no difference in the LOS if the surgery was on Friday compared with an earlier day of the week (4-day Group: 3.4 ± 0.67 days versus 4.0 ± 1.80 days; p = 0.477 and 2-day Group: 2.8 ± 0.62 days versus 3.0 ± 0.93 days; p = 0.547). We found that a surgeon who sets a clear expectation in terms of LOS could achieve a reduction in this parameter. Although it is impossible to be certain in the context of a retrospective study whether other caregivers adjusted the pathway in response to the surgeon's preferences, and we suspect this probably did occur, this still points to an opportunity on the topic of expectations setting that future studies should explore. This study highlights the influence patient education and expectations has on the effectiveness of care pathways in THA as well as the importance of continuous reinforcement of discharge planning both preoperatively and in the hospital. Level III, therapeutic study.

Consultant Input in Acute Medical Admissions and Patient Outcomes in Hospitals in England: A Multivariate Analysis

PubMed Central

Bell, Derek; Lambourne, Adrian; Percival, Frances; Laverty, Anthony A.; Ward, David K.

2013-01-01

Recent recommendations for physicians in the UK outline key aspects of care that should improve patient outcomes and experience in acute hospital care. Included in these recommendations are Consultant patterns of work to improve timeliness of clinical review and improve continuity of care. This study used a contemporaneous validated survey compared with clinical outcomes derived from Hospital Episode Statistics, between April 2009 and March 2010 from 91 acute hospital sites in England to evaluate systems of consultant cover for acute medical admissions. Clinical outcomes studied included adjusted case fatality rates (aCFR), including the ratio of weekend to weekday mortality, length of stay and readmission rates. Hospitals that had an admitting Consultant presence within the Acute Medicine Unit (AMU, or equivalent) for a minimum of 4 hours per day (65% of study group) had a lower aCFR compared with hospitals that had Consultant presence for less than 4 hours per day (p<0.01) and also had a lower 28 day re-admission rate (p<0.01). An ‘all inclusive’ pattern of Consultant working, incorporating all the guideline recommendations and which included the minimum Consultant presence of 4 hours per day (29%) was associated with reduced excess weekend mortality (p<0.05). Hospitals with >40 acute medical admissions per day had a lower aCFR compared to hospitals with fewer than 40 admissions per day (p<0.03) and had a lower 7 day re-admission rate (p<0.02). This study is the first large study to explore the potential relationships between systems of providing acute medical care and clinical outcomes. The results show an association between well-designed systems of Consultant working practices, which promote increased patient contact, and improved patient outcomes in the acute hospital setting. PMID:23613858

Consultant input in acute medical admissions and patient outcomes in hospitals in England: a multivariate analysis.

PubMed

Bell, Derek; Lambourne, Adrian; Percival, Frances; Laverty, Anthony A; Ward, David K

2013-01-01

Recent recommendations for physicians in the UK outline key aspects of care that should improve patient outcomes and experience in acute hospital care. Included in these recommendations are Consultant patterns of work to improve timeliness of clinical review and improve continuity of care. This study used a contemporaneous validated survey compared with clinical outcomes derived from Hospital Episode Statistics, between April 2009 and March 2010 from 91 acute hospital sites in England to evaluate systems of consultant cover for acute medical admissions. Clinical outcomes studied included adjusted case fatality rates (aCFR), including the ratio of weekend to weekday mortality, length of stay and readmission rates. Hospitals that had an admitting Consultant presence within the Acute Medicine Unit (AMU, or equivalent) for a minimum of 4 hours per day (65% of study group) had a lower aCFR compared with hospitals that had Consultant presence for less than 4 hours per day (p<0.01) and also had a lower 28 day re-admission rate (p<0.01). An 'all inclusive' pattern of Consultant working, incorporating all the guideline recommendations and which included the minimum Consultant presence of 4 hours per day (29%) was associated with reduced excess weekend mortality (p<0.05). Hospitals with >40 acute medical admissions per day had a lower aCFR compared to hospitals with fewer than 40 admissions per day (p<0.03) and had a lower 7 day re-admission rate (p<0.02). This study is the first large study to explore the potential relationships between systems of providing acute medical care and clinical outcomes. The results show an association between well-designed systems of Consultant working practices, which promote increased patient contact, and improved patient outcomes in the acute hospital setting.

Measuring Nursing Care Time and Tasks in Long-Term Services and Supports: One Size Does Not Fit All

PubMed Central

Sochalski, Julie A.; Foust, Janice B.; Zubritsky, Cynthia D.; Hirschman, Karen B.; Abbott, Katherine M.; Naylor, Mary D.

2015-01-01

Background Although nursing care personnel comprise the majority of staff in long-term care services and supports (LTSS), a method for measuring the provision of nursing care has not yet been developed. Purpose/Methods We sought to understand the challenges of measuring nursing care across different types of LTSS using a qualitative approach that included the triangulation of data from three unique sources. Results Six primary challenges to measuring nursing care across LTSS emerged: level of detail about time of day, amount of time, or type of tasks varied by type of nursing and organization; time and tasks were documented in clinical records and administrative databases; data existed both on paper and electronically; several sources of information were needed to create the fullest picture of nursing care; data was inconsistently available for contracted providers; documentation of informal caregiving was unavailable. Differences were observed for assisted living facilities and home and community based services compared to nursing homes and across organizations within a setting. A commonality across settings and organizations was the availability of an electronically stored care plan specifying individual needs but not necessarily how these would be met. Conclusions The findings demonstrate the variability of data availability and specificity across three distinct LTSS settings. This study is an initial step toward establishing a process for measuring the provision of nursing care across LTSS to be able to explore the range of nursing care needs of LTSS recipients and how these needs are fulfilled. PMID:22902975

Rapid research and implementation priority setting for wound care uncertainties.

PubMed

Gray, Trish A; Dumville, Jo C; Christie, Janice; Cullum, Nicky A

2017-01-01

People with complex wounds are more likely to be elderly, living with multimorbidity and wound related symptoms. A variety of products are available for managing complex wounds and a range of healthcare professionals are involved in wound care, yet there is a lack of good evidence to guide practice and services. These factors create uncertainty for those who deliver and those who manage wound care. Formal priority setting for research and implementation topics is needed to more accurately target the gaps in treatment and services. We solicited practitioner and manager uncertainties in wound care and held a priority setting workshop to facilitate a collaborative approach to prioritising wound care-related uncertainties. We recruited healthcare professionals who regularly cared for patients with complex wounds, were wound care specialists or managed wound care services. Participants submitted up to five wound care uncertainties in consultation with their colleagues, via an on-line survey and attended a priority setting workshop. Submitted uncertainties were collated, sorted and categorised according professional group. On the day of the workshop, participants were divided into four groups depending on their profession. Uncertainties submitted by their professional group were viewed, discussed and amended, prior to the first of three individual voting rounds. Participants cast up to ten votes for the uncertainties they judged as being high priority. Continuing in the professional groups, the top 10 uncertainties from each group were displayed, and the process was repeated. Groups were then brought together for a plenary session in which the final priorities were individually scored on a scale of 0-10 by participants. Priorities were ranked and results presented. Nominal group technique was used for generating the final uncertainties, voting and discussions. Thirty-three participants attended the workshop comprising; 10 specialist nurses, 10 district nurses, seven podiatrists and six managers. Participants had been qualified for a mean of 20.7 years with a mean of 16.8 years of wound care experience. One hundred and thirty-nine uncertainties were submitted electronically and a further 20 were identified on the day of the workshop following lively, interactive group discussions. Twenty-five uncertainties from the total of 159 generated made it to the final prioritised list. These included six of the 20 new uncertainties. The uncertainties varied in focus, but could be broadly categorised into three themes: service delivery and organisation, patient centred care and treatment options. Specialist nurses were more likely to vote for service delivery and organisation topics, podiatrists for patient centred topics, district nurses for treatment options and operational leads for a broad range. This collaborative priority setting project is the first to engage front-line clinicians in prioritising research and implementation topics in wound care. We have shown that it is feasible to conduct topic prioritisation in a short time frame. This project has demonstrated that with careful planning and rigor, important questions that are raised in the course of clinicians' daily decision making can be translated into meaningful research and implementation initiatives that could make a difference to service delivery and patient care.

Rapid research and implementation priority setting for wound care uncertainties

PubMed Central

Dumville, Jo C.; Christie, Janice; Cullum, Nicky A.

2017-01-01

Introduction People with complex wounds are more likely to be elderly, living with multimorbidity and wound related symptoms. A variety of products are available for managing complex wounds and a range of healthcare professionals are involved in wound care, yet there is a lack of good evidence to guide practice and services. These factors create uncertainty for those who deliver and those who manage wound care. Formal priority setting for research and implementation topics is needed to more accurately target the gaps in treatment and services. We solicited practitioner and manager uncertainties in wound care and held a priority setting workshop to facilitate a collaborative approach to prioritising wound care-related uncertainties. Methods We recruited healthcare professionals who regularly cared for patients with complex wounds, were wound care specialists or managed wound care services. Participants submitted up to five wound care uncertainties in consultation with their colleagues, via an on-line survey and attended a priority setting workshop. Submitted uncertainties were collated, sorted and categorised according professional group. On the day of the workshop, participants were divided into four groups depending on their profession. Uncertainties submitted by their professional group were viewed, discussed and amended, prior to the first of three individual voting rounds. Participants cast up to ten votes for the uncertainties they judged as being high priority. Continuing in the professional groups, the top 10 uncertainties from each group were displayed, and the process was repeated. Groups were then brought together for a plenary session in which the final priorities were individually scored on a scale of 0–10 by participants. Priorities were ranked and results presented. Nominal group technique was used for generating the final uncertainties, voting and discussions. Results Thirty-three participants attended the workshop comprising; 10 specialist nurses, 10 district nurses, seven podiatrists and six managers. Participants had been qualified for a mean of 20.7 years with a mean of 16.8 years of wound care experience. One hundred and thirty-nine uncertainties were submitted electronically and a further 20 were identified on the day of the workshop following lively, interactive group discussions. Twenty-five uncertainties from the total of 159 generated made it to the final prioritised list. These included six of the 20 new uncertainties. The uncertainties varied in focus, but could be broadly categorised into three themes: service delivery and organisation, patient centred care and treatment options. Specialist nurses were more likely to vote for service delivery and organisation topics, podiatrists for patient centred topics, district nurses for treatment options and operational leads for a broad range. Conclusions This collaborative priority setting project is the first to engage front-line clinicians in prioritising research and implementation topics in wound care. We have shown that it is feasible to conduct topic prioritisation in a short time frame. This project has demonstrated that with careful planning and rigor, important questions that are raised in the course of clinicians’ daily decision making can be translated into meaningful research and implementation initiatives that could make a difference to service delivery and patient care. PMID:29206884

Applicability of the National Comprehensive Cancer Network/Multinational Association of Supportive Care in Cancer Guidelines for Prevention and Management of Chemotherapy-Induced Nausea and Vomiting in Southeast Asia: A Consensus Statement.

PubMed

Chan, Alexandre; Abdullah, Matin M; Ishak, Wan Zamaniah B Wan; Ong-Cornel, Annielyn B; Villalon, Antonio H; Kanesvaran, Ravindran

2017-12-01

A meeting of regional experts was convened in Manila, Philippines, to develop a resource-stratified chemotherapy-induced nausea and vomiting (CINV) management guideline. In patients treated with highly emetogenic chemotherapy in general clinical settings, triple therapy with a serotonin (5-hydroxytryptamine-3 [5-HT 3 ]) antagonist (preferably palonosetron), dexamethasone, and aprepitant is recommended for acute CINV prevention. In resource-restricted settings, triple therapy is still recommended, although a 5-HT 3 antagonist other than palonosetron may be used. In both general and resource-restricted settings, dual therapy with dexamethasone (days 2 to 4) and aprepitant (days 2 to 3) is recommended to prevent delayed CINV. In patients treated with moderately emetogenic chemotherapy, dual therapy with a 5-HT 3 antagonist, preferably palonosetron, and dexamethasone is recommended for acute CINV prevention in general settings; any 5-HT 3 antagonist can be combined with dexamethasone in resource-restricted environments. In general settings, for the prevention of delayed CINV associated with moderately emetogenic chemotherapy, corticosteroid monotherapy on days 2 and 3 is recommended. If aprepitant is used on day 1, it should be continued on days 2 and 3. Prevention of delayed CINV with corticosteroids is preferred in resource-restricted settings. The expert panel also developed CINV management guidelines for anthracycline plus cyclophosphamide combination schedules, multiday cisplatin, and chemotherapy with low or minimal emetogenic potential, and its recommendations are detailed in this review. Overall, these regional guidelines provide definitive guidance for CINV management in general and resource-restricted settings. These consensus recommendations are anticipated to contribute to collaborative efforts to improve CINV management in Southeast Asia.

Applicability of the National Comprehensive Cancer Network/Multinational Association of Supportive Care in Cancer Guidelines for Prevention and Management of Chemotherapy-Induced Nausea and Vomiting in Southeast Asia: A Consensus Statement

PubMed Central

Abdullah, Matin M.; Ishak, Wan Zamaniah B. Wan; Ong-Cornel, Annielyn B.; Villalon, Antonio H.; Kanesvaran, Ravindran

2017-01-01

A meeting of regional experts was convened in Manila, Philippines, to develop a resource-stratified chemotherapy-induced nausea and vomiting (CINV) management guideline. In patients treated with highly emetogenic chemotherapy in general clinical settings, triple therapy with a serotonin (5-hydroxytryptamine-3 [5-HT3]) antagonist (preferably palonosetron), dexamethasone, and aprepitant is recommended for acute CINV prevention. In resource-restricted settings, triple therapy is still recommended, although a 5-HT3 antagonist other than palonosetron may be used. In both general and resource-restricted settings, dual therapy with dexamethasone (days 2 to 4) and aprepitant (days 2 to 3) is recommended to prevent delayed CINV. In patients treated with moderately emetogenic chemotherapy, dual therapy with a 5-HT3 antagonist, preferably palonosetron, and dexamethasone is recommended for acute CINV prevention in general settings; any 5-HT3 antagonist can be combined with dexamethasone in resource-restricted environments. In general settings, for the prevention of delayed CINV associated with moderately emetogenic chemotherapy, corticosteroid monotherapy on days 2 and 3 is recommended. If aprepitant is used on day 1, it should be continued on days 2 and 3. Prevention of delayed CINV with corticosteroids is preferred in resource-restricted settings. The expert panel also developed CINV management guidelines for anthracycline plus cyclophosphamide combination schedules, multiday cisplatin, and chemotherapy with low or minimal emetogenic potential, and its recommendations are detailed in this review. Overall, these regional guidelines provide definitive guidance for CINV management in general and resource-restricted settings. These consensus recommendations are anticipated to contribute to collaborative efforts to improve CINV management in Southeast Asia. PMID:29244998

A novel point-of-care testing strategy for sexually transmitted infections among pregnant women in high-burden settings: results of a feasibility study in Papua New Guinea.

PubMed

Badman, Steven G; Vallely, Lisa M; Toliman, Pamela; Kariwiga, Grace; Lote, Bomesina; Pomat, William; Holmer, Caroline; Guy, Rebecca; Luchters, Stanley; Morgan, Chris; Garland, Suzanne M; Tabrizi, Sepehr; Whiley, David; Rogerson, Stephen J; Mola, Glen; Wand, Handan; Donovan, Basil; Causer, Louise; Kaldor, John; Vallely, Andrew

2016-06-06

Sexually transmitted and genital infections in pregnancy are associated with an increased risk of adverse maternal and neonatal health outcomes. High prevalences of sexually transmitted infections have been identified among antenatal attenders in Papua New Guinea. Papua New Guinea has amongst the highest neonatal mortality rates worldwide, with preterm birth and low birth weight major contributors to neonatal mortality. The overall aim of our study was to determine if a novel point-of-care testing and treatment strategy for the sexually transmitted and genital infections Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV) and Bacterial vaginosis (BV) in pregnancy is feasible in the high-burden, low-income setting of Papua New Guinea. Women attending their first antenatal clinic visit were invited to participate. CT/NG and TV were tested using the GeneXpert platform (Cepheid, USA), and BV tested using BVBlue (Gryphus Diagnostics, USA). Participants received same-day test results and antibiotic treatment as indicated. Routine antenatal care including HIV and syphilis screening were provided. Point-of-care testing was provided to 125/222 (56 %) of women attending routine antenatal care during the three-month study period. Among the 125 women enrolled, the prevalence of CT was 20.0 %; NG, 11.2 %; TV, 37.6 %; and BV, 17.6 %. Over half (67/125, 53.6 %) of women had one or more of these infections. Most women were asymptomatic (71.6 %; 47/67). Women aged 24 years and under were more likely to have one or more STI compared with older women (odds ratio 2.38; 95 % CI: 1.09, 5.21). Most women with an STI received treatment on the same day (83.6 %; 56/67). HIV prevalence was 1.6 % and active syphilis 4.0 %. Point-of-care STI testing and treatment using a combination of novel, newly-available assays was feasible during routine antenatal care in this setting. This strategy has not previously been evaluated in any setting and offers the potential to transform STI management in pregnancy and to prevent their associated adverse health outcomes.

Is Specialized Integrated Treatment for Comorbid Anxiety, Depression and Alcohol Dependence Better than Treatment as Usual in a Public Hospital Setting?

PubMed

Morley, K C; Baillie, A; Leung, S; Sannibale, C; Teesson, M; Haber, P S

2016-07-01

To assess the effectiveness of a 12 week specialized, integrated intervention for alcohol dependence with comorbid anxiety and/or mood disorder using a randomized design in an outpatient hospital setting. Out of 86 patients meeting the inclusion criteria for alcohol dependence with suspicion of comorbid anxiety and/or depressive disorder, 57 completed a 3-week stabilization period (abstinence or significantly reduced consumption). Of these patients, 37 (65%) met a formal diagnostic assessment of an anxiety and/or depressive disorder and were randomized to either (a) integrated intervention (cognitive behavioural therapy) for alcohol, anxiety and/or depression, or (b) usual counselling care for alcohol problems. Intention-to-treat analyses revealed a beneficial treatment effect of integrated treatment relative to usual counselling care for the number of days to relapse (χ(2) = 6.42, P < 0.05) and lapse (χ(2) = 10.73, P < 0.01). In addition, there was a significant interaction effect of treatment and time for percentage days of abstinence (P < 0.05). For heavy drinking days, the treatment effect was mediated by changes in DASS anxiety (P < 0.05). There were no significant treatment interaction effects for DASS depression or anxiety symptoms. These results provide support for integrated care in improving drinking outcomes for patients with alcohol dependence and comorbid depression/anxiety disorder. ClinicalTrials.gov Identifier: NCT01941693. © The Author 2015. Medical Council on Alcohol and Oxford University Press. All rights reserved.

Impact of a nutrition award scheme on the food and nutrient intakes of 2- to 4-year-olds attending long day care.

PubMed

Bell, Lucinda K; Hendrie, Gilly A; Hartley, Jo; Golley, Rebecca K

2015-10-01

Early childhood settings are promising avenues to intervene to improve children's nutrition. Previous research has shown that a nutrition award scheme, Start Right - Eat Right (SRER), improves long day care centre policies, menus and eating environments. Whether this translates into improvements in children's dietary intake is unknown. The present study aimed to determine whether SRER improves children's food and nutrient intakes. Pre-post cohort study. Twenty long day care centres in metropolitan Adelaide, South Australia, Australia. Children aged 2-4 years (n 236 at baseline, n 232 at follow-up). Dietary intake (morning tea, lunch, afternoon tea) was assessed pre- and post-SRER implementation using the plate wastage method. Centre nutrition policies, menus and environments were evaluated as measures of intervention fidelity. Comparisons between baseline and follow-up were made using t tests. At follow-up, 80 % of centres were fully compliant with the SRER award criteria, indicating high scheme implementation and adoption. Intake increased for all core food groups (range: 0·2-0·4 servings/d, P<0·001) except for vegetable intake. Energy intake increased and improvements in intakes of eleven out of the nineteen nutrients evaluated were observed. SRER is effective in improving children's food and nutrient intakes at a critical time point when dietary habits and preferences are established and can inform future public health nutrition interventions in this setting.

RecoverNow: Feasibility of a Mobile Tablet-Based Rehabilitation Intervention to Treat Post-Stroke Communication Deficits in the Acute Care Setting

PubMed Central

Corbett, Dale; Finestone, Hillel M.; Hatcher, Simon; Lumsden, Jim; Momoli, Franco; Shamy, Michel C. F.; Stotts, Grant; Swartz, Richard H.; Yang, Christine

2016-01-01

Background Approximately 40% of patients diagnosed with stroke experience some degree of aphasia. With limited health care resources, patients’ access to speech and language therapies is often delayed. We propose using mobile-platform technology to initiate early speech-language therapy in the acute care setting. For this pilot, our objective was to assess the feasibility of a tablet-based speech-language therapy for patients with communication deficits following acute stroke. Methods We enrolled consecutive patients admitted with a stroke and communication deficits with NIHSS score ≥1 on the best language and/or dysarthria parameters. We excluded patients with severe comprehension deficits where communication was not possible. Following baseline assessment by a speech-language pathologist (SLP), patients were provided with a mobile tablet programmed with individualized therapy applications based on the assessment, and instructed to use it for at least one hour per day. Our objective was to establish feasibility by measuring recruitment rate, adherence rate, retention rate, protocol deviations and acceptability. Results Over 6 months, 143 patients were admitted with a new diagnosis of stroke: 73 had communication deficits, 44 met inclusion criteria, and 30 were enrolled into RecoverNow (median age 62, 26.6% female) for a recruitment rate of 68% of eligible participants. Participants received mobile tablets at a mean 6.8 days from admission [SEM 1.6], and used them for a mean 149.8 minutes/day [SEM 19.1]. In-hospital retention rate was 97%, and 96% of patients scored the mobile tablet-based communication therapy as at least moderately convenient 3/5 or better with 5/5 being most “convenient”. Conclusions Individualized speech-language therapy delivered by mobile tablet technology is feasible in acute care. PMID:28002479

Differential Family Experience of Palliative Sedation Therapy in Specialized Palliative or Critical Care Units.

PubMed

Shen, Hui-Shan; Chen, Szu-Yin; Cheung, Denise Shuk Ting; Wang, Shu-Yi; Lee, Jung Jae; Lin, Chia-Chin

2018-02-21

No study has examined the varying family experience of palliative sedation therapy (PST) for terminally ill patients in different settings. To examine and compare family concerns about PST use and its effect on the grief suffered by terminally ill patients' families in palliative care units (PCUs) or intensive care units (ICUs). A total of 154 family members of such patients were recruited in Taiwan, of whom 143 completed the study, with 81 from the PCU and 62 from the ICU. Data were collected on their concerns regarding PST during recruitment. Grief levels were assessed at three days and one month after the patient's death with the Texas Revised Inventory of Grief. Families' major concern about sedated patients in the PCU was that "there might be other ways to relieve symptoms" (90.2%), whereas families of ICU sedated patients gave the highest ratings to "feeling they still had something more to do" (93.55%), and "the patient's sleeping condition was not dignified" (93.55%). Family members recruited from the ICU tended to experience more grief than those from the PCU (P = 0.005 at Day 3 and < 0.001 at Month 1). PST use predicted higher levels of grief in family members recruited from the PCU (P < 0.001 at Day 3 and Month 1). Family experiences with the use of PST in terminally ill patients varied in different settings. Supportive care should address family concerns about PST use, and regular attention should be paid to the grief of individuals at higher risk. Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital.

PubMed

Agulnik, Asya; Mora Robles, Lupe Nataly; Forbes, Peter W; Soberanis Vasquez, Doris Judith; Mack, Ricardo; Antillon-Klussmann, Federico; Kleinman, Monica; Rodriguez-Galindo, Carlos

2017-08-01

Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in resource-limited settings. Pediatric early warning systems (PEWS) aid in the early identification of clinical deterioration; however, there are limited data regarding their feasibility or impact in low-resource settings. This study describes the successful implementation of PEWS at the Unidad Nacional de Oncología Pediátrica (UNOP), a pediatric oncology hospital in Guatemala, resulting in improved inpatient outcomes. A modified PEWS was implemented at UNOP with systems to track errors, transfers to a higher level of care, and high scores. A retrospective cohort study was used to evaluate clinical deterioration events in the year before and after PEWS implementation. After PEWS implementation at UNOP, there was 100% compliance with PEWS documentation and an error rate of <10%. Implementation resulted in 5 high PEWS per week, with 30% of patients transferring to a higher level of care. Among patients requiring transfer to the pediatric intensive care unit (PICU), 93% had an abnormal PEWS before transfer. The rate of clinical deterioration events decreased after PEWS implementation (9.3 vs 6.5 per 1000-hospitalpatient-days, p = .003). Despite an 18% increase in total hospital patient-days, PICU utilization for inpatient transfers decreased from 1376 to 1088 PICU patient-days per year (21% decrease; P<.001). This study describes the successful implementation of PEWS in a pediatric oncology hospital in Guatemala, resulting in decreased inpatient clinical deterioration events and PICU utilization. This work demonstrates that PEWS is a feasible and effective quality improvement measure to improve hospital care for children with cancer in hospitals with limited resources. Cancer 2017;123:2965-74. © 2017 American Cancer Society. © 2017 American Cancer Society.

RecoverNow: Feasibility of a Mobile Tablet-Based Rehabilitation Intervention to Treat Post-Stroke Communication Deficits in the Acute Care Setting.

PubMed

Mallet, Karen H; Shamloul, Rany M; Corbett, Dale; Finestone, Hillel M; Hatcher, Simon; Lumsden, Jim; Momoli, Franco; Shamy, Michel C F; Stotts, Grant; Swartz, Richard H; Yang, Christine; Dowlatshahi, Dar

2016-01-01

Approximately 40% of patients diagnosed with stroke experience some degree of aphasia. With limited health care resources, patients' access to speech and language therapies is often delayed. We propose using mobile-platform technology to initiate early speech-language therapy in the acute care setting. For this pilot, our objective was to assess the feasibility of a tablet-based speech-language therapy for patients with communication deficits following acute stroke. We enrolled consecutive patients admitted with a stroke and communication deficits with NIHSS score ≥1 on the best language and/or dysarthria parameters. We excluded patients with severe comprehension deficits where communication was not possible. Following baseline assessment by a speech-language pathologist (SLP), patients were provided with a mobile tablet programmed with individualized therapy applications based on the assessment, and instructed to use it for at least one hour per day. Our objective was to establish feasibility by measuring recruitment rate, adherence rate, retention rate, protocol deviations and acceptability. Over 6 months, 143 patients were admitted with a new diagnosis of stroke: 73 had communication deficits, 44 met inclusion criteria, and 30 were enrolled into RecoverNow (median age 62, 26.6% female) for a recruitment rate of 68% of eligible participants. Participants received mobile tablets at a mean 6.8 days from admission [SEM 1.6], and used them for a mean 149.8 minutes/day [SEM 19.1]. In-hospital retention rate was 97%, and 96% of patients scored the mobile tablet-based communication therapy as at least moderately convenient 3/5 or better with 5/5 being most "convenient". Individualized speech-language therapy delivered by mobile tablet technology is feasible in acute care.

Measuring newborn foot length to identify small babies in need of extra care: a cross sectional hospital based study with community follow-up in Tanzania.

PubMed

Marchant, Tanya; Jaribu, Jennie; Penfold, Suzanne; Tanner, Marcel; Armstrong Schellenberg, Joanna

2010-10-19

Neonatal mortality because of low birth weight or prematurity remains high in many developing country settings. This research aimed to estimate the sensitivity and specificity, and the positive and negative predictive values of newborn foot length to identify babies who are low birth weight or premature and in need of extra care in a rural African setting. A cross-sectional study of newborn babies in hospital, with community follow-up on the fifth day of life, was carried out between 13 July and 16 October 2009 in southern Tanzania. Foot length, birth weight and gestational age were estimated on the first day and foot length remeasured on the fifth day of life. In hospital 529 babies were recruited and measured within 24 hours of birth, 183 of whom were also followed-up at home on the fifth day. Day one foot length <7 cm at birth was 75% sensitive (95%CI 36-100) and 99% specific (95%CI 97-99) to identify very small babies (birth weight <1500 grams); foot length <8 cm had sensitivity and specificity of 87% (95%CI 79-94) and 60% (95%CI 55-64) to identify those with low birth weight (<2500 grams), and 93% (95%CI 82-99) and 58% (95%CI 53-62) to identify those born premature (<37 weeks). Mean foot length on the first day was 7.8 cm (standard deviation 0.47); the mean difference between first and fifth day foot lengths was 0.1 cm (standard deviation 0.3): foot length measured on or before the fifth day of life identified more than three-quarters of babies who were born low birth weight. Measurement of newborn foot length for home births in resource poor settings has the potential to be used by birth attendants, community volunteers or parents as a screening tool to identify low birth weight or premature newborns in order that they can receive targeted interventions for improved survival.

Dynamic allocation of same-day requests in multi-physician primary care practices in the presence of prescheduled appointments.

PubMed

Balasubramanian, Hari; Biehl, Sebastian; Dai, Longjie; Muriel, Ana

2014-03-01

Appointments in primary care are of two types: 1) prescheduled appointments, which are booked in advance of a given workday; and 2) same-day appointments, which are booked as calls come during the workday. The challenge for practices is to provide preferred time slots for prescheduled appointments and yet see as many same-day patients as possible during regular work hours. It is also important, to the extent possible, to match same-day patients with their own providers (so as to maximize continuity of care). In this paper, we present a mathematical framework (a stochastic dynamic program) for same-day patient allocation in multi-physician practices in which calls for same-day appointments come in dynamically over a workday. Allocation decisions have to be made in the presence of prescheduled appointments and without complete demand information. The objective is to maximize a weighted measure that includes the number of same-day patients seen during regular work hours as well as the continuity provided to these patients. Our experimental design is motivated by empirical data we collected at a 3-provider family medicine practice in Massachusetts. Our results show that the location of prescheduled appointments - i.e. where in the day these appointments are booked - has a significant impact on the number of same-day patients a practice can see during regular work hours, as well as the continuity the practice is able to provide. We find that a 2-Blocks policy which books prescheduled appointments in two clusters - early morning and early afternoon - works very well. We also provide a simple, easily implementable policy for schedulers to assign incoming same-day requests to appointment slots. Our results show that this policy provides near-optimal same-day assignments in a variety of settings.

Outcome after failure of allogeneic hematopoietic stem cell transplantation in children with acute leukemia: a study by the société Francophone de greffe de moelle et de thérapie cellulaire (SFGM-TC).

PubMed

Roux, C; Tifratene, K; Socié, G; Galambrun, C; Bertrand, Y; Rialland, F; Jubert, C; Pochon, C; Paillard, C; Sirvent, A; Nelken, B; Vannier, J P; Freycon, C; Beguin, Y; Raus, N; Yakoub-Agha, I; Mohty, M; Dalle, J-H; Michel, G; Pradier, C; Peffault de Latour, R; Rohrlich, P-S

2017-05-01

Allogeneic hematopoietic stem cell transplantation (SCT) contributes to improved outcome in childhood acute leukemia (AL). However, therapeutic options are poorly defined in the case of post-transplantation relapse. We aimed to compare treatment strategies in 334 consecutive children with acute leukemia relapse or progression after SCT in a recent 10-year period. Data could be analyzed in 288 patients (157 ALL, 123 AML and 8 biphenotypic AL) with a median age of 8.16 years at transplantation. The median delay from first SCT to relapse or progression was 182 days. The treatment consisted of chemotherapy alone (n=108), chemotherapy followed by second SCT (n=70), supportive/palliative care (n=67), combination of chemotherapy and donor lymphocyte infusion (DLI; n=30), or isolated reinfusion of donor lymphocytes (DLI; n=13). The median OS duration after relapse was 164 days and differed according to therapy: DLI after chemotherapy=385 days, second allograft=391 days, chemotherapy=174 days, DLI alone=140 days, palliative care=43 days. A second SCT or a combination of chemotherapy and DLI yielded similar outcome (hazard ratio (HR)=0.85, P=0.53) unlike chemotherapy alone (HR=1.43 P=0.04), palliative care (HR=4.24, P<0.0001) or isolated DLI (HR=1,94, P<0.04). Despite limitations in this retrospective setting, strategies including immunointervention appear superior to other approaches, mostly in AML.

Perceived quality in Day Surgery Units Proposal of an enquiry postoperative questionnaire.

PubMed

Palumbo, Piergaspare; Perotti, Bruno; Amatucci, Chiara; Pangrazi, Maria Pia; Leuzzi, Barbara; Vietri, Francesco; Illuminati, Giulio

2016-01-01

Assessing patient satisfaction could be particularly useful in Day Surgery Units, as it helps maintaining and increasing medical care demand. Moreover, it provides feedback that turns out useful for improving quality in departments, and for assessing competence and skill of the whole staff. Background and aim - The purpose of this study was to evaluate the quality perceived in a day surgery unit through a questionnaire, covering the 10 main aspects of the care pathway. The results of a questionnaire filled by patients undergoing Day Surgery between January 2007 and December 2012 were retrospectively reviewed. Patients undergoing surgery between 2007 and 2009 filled up the questionnaire at the time of the discharge, whereas those operated on between 2009 and 2012 filled up the same questionnaire 30 days after discharge. The results were good in terms of number of returned questionnaires, underlining its comprehensibility and suitability to be filled out. The questionnaires' scores were good in both groups, although quality perceived by the group that completed it in 30 days after surgery were lightly better than the other group's. The advantages of the questionnaire consisted of an overall improvement of the quality of care, whereas limitations consisted of the difficulty in setting up the questionnaire accurately, interpreting patients' answers correctly, and dispensing the questionnaire in a timely fashion, in order to evaluate the quality perceived by the patients without any bias related to delay, pain and anxiety. Day Surgery, Nursing, Questionnaire, Quality.

Infection Surveillance Protocol for a Multicountry Population-based Study in South Asia to Determine the Incidence, Etiology and Risk Factors for Infections Among Young Infants of 0 to 59 Days Old.

PubMed

Islam, Mohammad Shahidul; Baqui, Abdullah H; Zaidi, Anita K; Bhutta, Zulfiqar A; Panigrahi, Pinaki; Bose, Anuradha; Soofi, Sajid B; Kazi, Abdul Momin; Mitra, Dipak K; Isaac, Rita; Nanda, Pritish; Connor, Nicholas E; Roth, Daniel E; Qazi, Shamim A; El Arifeen, Shams; Saha, Samir K

2016-05-01

Insufficient knowledge of the etiology and risk factors for community-acquired neonatal infection in low-income countries is a barrier to designing appropriate intervention strategies for these settings to reduce the burden and treatment of young infant infection. To address these gaps, we are conducting the Aetiology of Neonatal Infection in South Asia (ANISA) study among young infants in Bangladesh, India and Pakistan. The objectives of ANISA are to establish a comprehensive surveillance system for registering newborns in study catchment areas and collecting data on bacterial and viral etiology and associated risk factors for infections among young infants aged 0-59 days. We are conducting active surveillance in 1 peri-urban and 4 rural communities. During 2 years of surveillance, we expect to enroll an estimated 66,000 newborns within 7 days of their birth and to follow-up them until 59 days of age. Community health workers visit each young infant in the study area 3 times in the first week of life and once a week thereafter. During these visits, community health workers assess the newborns using a clinical algorithm and refer young infants with signs of suspected infection to health care facilities where study physicians reassess them and provide care if needed. On physician confirmation of suspected infection, blood and respiratory specimens are collected and tested to identify the etiologic agent. ANISA is one of the largest initiatives ever undertaken to understand the etiology of young infant infection in low-income countries. The data generated from this surveillance will help guide evidence-based decision making to improve health care in similar settings.

Resident-Assisted Montessori Programming (RAMP): use of a small group reading activity run by persons with dementia in adult day health care and long-term care settings.

PubMed

Skrajner, Michael J; Camp, Cameron J

2007-01-01

Six persons in the early to middle stages of dementia ("leaders") were trained in Resident-Assisted Montessori Programming (RAMP) to lead a reading activity for 22 persons with more advanced dementia ("participants") in an adult day health center (ADHC) and a special care unit (SCU) in a skilled nursing facility. Researchers assessed the leaders' abilities to learn and follow the procedures of leading a group, as well as their satisfaction with their roles. In addition, participants' engagement and affect were measured, both during standard activities programming and during client-led activities. Results of this study suggest that persons with dementia can indeed successfully lead small group activities, if several important prerequisites are met. Furthermore, the engagement and affect of participants was more positive in client-led activities than in standard activities programming.

Independence, institutionalization, death and treatment costs 18 months after rehabilitation of older people in two different primary health care settings

PubMed Central

2012-01-01

Background The optimal setting and content of primary health care rehabilitation of older people is not known. Our aim was to study independence, institutionalization, death and treatment costs 18 months after primary care rehabilitation of older people in two different settings. Methods Eighteen months follow-up of an open, prospective study comparing the outcome of multi-disciplinary rehabilitation of older people, in a structured and intensive Primary care dedicated inpatient rehabilitation (PCDIR, n=202) versus a less structured and less intensive Primary care nursing home rehabilitation (PCNHR, n=100). Participants: 302 patients, disabled from stroke, hip-fracture, osteoarthritis and other chronic diseases, aged ≥65years, assessed to have a rehabilitation potential and being referred from general hospital or own residence. Outcome measures: Primary: Independence, assessed by Sunnaas ADL Index(SI). Secondary: Hospital and short-term nursing home length of stay (LOS); institutionalization, measured by institutional residence rate; death; and costs of rehabilitation and care. Statistical tests: T-tests, Correlation tests, Pearson’s χ2, ANCOVA, Regression and Kaplan-Meier analyses. Results Overall SI scores were 26.1 (SD 7.2) compared to 27.0 (SD 5.7) at the end of rehabilitation, a statistically, but not clinically significant reduction (p=0.003 95%CI(0.3-1.5)). The PCDIR patients scored 2.2points higher in SI than the PCNHR patients, adjusted for age, gender, baseline MMSE and SI scores (p=0.003, 95%CI(0.8-3.7)). Out of 49 patients staying >28 days in short-term nursing homes, PCNHR-patients stayed significantly longer than PCDIR-patients (mean difference 104.9 days, 95%CI(0.28-209.6), p=0.05). The institutionalization increased in PCNHR (from 12%-28%, p=0.001), but not in PCDIR (from 16.9%-19.3%, p= 0.45). The overall one year mortality rate was 9.6%. Average costs were substantially higher for PCNHR versus PCDIR. The difference per patient was 3528€ for rehabilitation (p<0.001, 95%CI(2455–4756)), and 10134€ for the at-home care (p=0.002, 95%CI(4066–16202)). The total costs of rehabilitation and care were 18702€ (=1.6 times) higher for PCNHR than for PCDIR. Conclusions At 18 months follow-up the PCDIR-patients maintained higher levels of independence, spent fewer days in short-term nursing homes, and did not increase the institutionalization compared to PCNHR. The costs of rehabilitation and care were substantially lower for PCDIR. More communities should consider adopting the PCDIR model. Trial registration Clinicaltrials.gov ID NCT01457300 PMID:23150906

Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting

PubMed Central

Hurley, Hermione J.; Knepper, Bryan C.; Price, Connie S.; Mehler, Philip S.; Burman, William J.; Jenkins, Timothy C.

2014-01-01

Background Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotics. A detailed understanding of current prescribing practices is necessary to optimize antibiotic use for these conditions. Methods This was a retrospective cohort study of children and adults treated in the ambulatory care setting for uncomplicated cellulitis, wound infection, or cutaneous abscess between March 1, 2010 and February 28, 2011. We assessed the frequency of avoidable antibiotic exposure, defined as: use of antibiotics with broad gram-negative activity, combination antibiotic therapy, or treatment for 10 or more days. Total antibiotic-days prescribed for the cohort were compared to antibiotic-days in four hypothetical short-course (5 – 7 days), single-antibiotic treatment models consistent with national guidelines. Results 364 cases were included for analysis (155 cellulitis, 41 wound infection, and 168 abscess). Antibiotics active against methicillin-resistant Staphylococcus aureus were prescribed in 61% of cases of cellulitis. Of 139 cases of abscess where drainage was performed, antibiotics were prescribed in 80% for a median of 10 (interquartile range 7 – 10) days. Of 292 total cases where complete prescribing data were available, avoidable antibiotic exposure occurred in 46%. This included use of antibiotics with broad gram-negative activity in 4%, combination therapy in 12%, and treatment for 10 or more days in 42%. Use of the short-course, single-antibiotic treatment strategies would have reduced prescribed antibiotic-days by 19 – 55%. Conclusions Nearly half of uncomplicated skin infections involved avoidable antibiotic exposure. Antibiotic use could be reduced through treatment approaches utilizing short courses of a single antibiotic. PMID:24262724

Single embryo transfer and IVF/ICSI outcome: a balanced appraisal.

PubMed

Gerris, Jan M R

2005-01-01

This review considers the value of single embryo transfer (SET) to prevent multiple pregnancies (MP) after IVF/ICSI. The incidence of MP (twins and higher order pregnancies) after IVF/ICSI is much higher (approximately 30%) than after natural conception (approximately 1%). Approximately half of all the neonates are multiples. The obstetric, neonatal and long-term consequences for the health of these children are enormous and costs incurred extremely high. Judicious SET is the only method to decrease this epidemic of iatrogenic multiple gestations. Clinical trials have shown that programmes with >50% of SET maintain high overall ongoing pregnancy rates ( approximately 30% per started cycle) while reducing the MP rate to <10%. Experience with SET remains largely European although the need to reduce MP is accepted worldwide. An important issue is how to select patients suitable for SET and embryos with a high putative implantation potential. The typical patient suitable for SET is young (aged <36 years) and in her first or second IVF/ICSI trial. Embryo selection is performed using one or a combination of embryo characteristics. Available evidence suggests that, for the overall population, day 3 and day 5 selection yield similar results but better than zygote selection results. Prospective studies correlating embryo characteristics with documented implantation potential, utilizing databases of individual embryos, are needed. The application of SET should be supported by other measures: reimbursement of IVF/ICSI (earned back by reducing costs), optimized cryopreservation to augment cumulative pregnancy rates per oocyte harvest and a standardized format for reporting results. To make SET the standard of care in the appropriate target group, there is a need for more clinical studies, for intensive counselling of patients, and for an increased sense of responsibility in patients, health care providers and health insurers.

Developing a set of consensus indicators to support maternity service quality improvement: using Core Outcome Set methodology including a Delphi process.

PubMed

Bunch, K J; Allin, B; Jolly, M; Hardie, T; Knight, M

2018-05-16

To develop a core metric set to monitor the quality of maternity care. Delphi process followed by a face-to-face consensus meeting. English maternity units. Three representative expert panels: service designers, providers and users. Maternity care metrics judged important by participants. Participants were asked to complete a two-phase Delphi process, scoring metrics from existing local maternity dashboards. A consensus meeting discussed the results and re-scored the metrics. In all, 125 distinct metrics across six domains were identified from existing dashboards. Following the consensus meeting, 14 metrics met the inclusion criteria for the final core set: smoking rate at booking; rate of birth without intervention; caesarean section delivery rate in Robson group 1 women; caesarean section delivery rate in Robson group 2 women; caesarean section delivery rate in Robson group 5 women; third- and fourth-degree tear rate among women delivering vaginally; rate of postpartum haemorrhage of ≥1500 ml; rate of successful vaginal birth after a single previous caesarean section; smoking rate at delivery; proportion of babies born at term with an Apgar score <7 at 5 minutes; proportion of babies born at term admitted to the neonatal intensive care unit; proportion of babies readmitted to hospital at <30 days of age; breastfeeding initiation rate; and breastfeeding rate at 6-8 weeks. Core outcome set methodology can be used to incorporate the views of key stakeholders in developing a core metric set to monitor the quality of care in maternity units, thus enabling improvement. Achieving consensus on core metrics for monitoring the quality of maternity care. © 2018 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.

Informing Transitions in the Early Years

ERIC Educational Resources Information Center

Dunlop, Aline-Wendy; Fabian, Hilary

2006-01-01

An increased emphasis on an early start in group day care and educational settings for young children means that by the time children enter statutory education, they may already have had several transitional experiences: each will have an impact. This book explores early transitions from a variety of international perspectives. Each chapter is…

Factors Influencing Child Engagement in Mainstream Settings.

ERIC Educational Resources Information Center

McWilliam, R. A.; Bailey, Donald B., Jr.

Effects of two environmental variables, activity type and age groupings, and two child variables, age and handicapping condition, were examined with respect to the engagement of toddlers and preschoolers in a mainstreaming day care center. The construct of engagement is predicated on the assumption that the more time an individual spends attending…

25 CFR 11.1108 - Date of hearing.

Code of Federal Regulations, 2013 CFR

2013-04-01

...-of-care petition, the children's court shall set a date for the hearing which shall not be more than 15 days after the children's court receives the petition from the presenting officer. If the... the presenting officer by reason of the unavailability of material evidence or witnesses and the...

25 CFR 11.1108 - Date of hearing.

Code of Federal Regulations, 2014 CFR

2014-04-01

...-of-care petition, the children's court shall set a date for the hearing which shall not be more than 15 days after the children's court receives the petition from the presenting officer. If the... the presenting officer by reason of the unavailability of material evidence or witnesses and the...

25 CFR 11.1108 - Date of hearing.

Code of Federal Regulations, 2010 CFR

2010-04-01

...-of-care petition, the children's court shall set a date for the hearing which shall not be more than 15 days after the children's court receives the petition from the presenting officer. If the... the presenting officer by reason of the unavailability of material evidence or witnesses and the...

25 CFR 11.1108 - Date of hearing.

Code of Federal Regulations, 2011 CFR

2011-04-01

...-of-care petition, the children's court shall set a date for the hearing which shall not be more than 15 days after the children's court receives the petition from the presenting officer. If the... the presenting officer by reason of the unavailability of material evidence or witnesses and the...

The Advocacy of Educators: Perspectives from Early Childhood

ERIC Educational Resources Information Center

Mevawalla, Zinnia; Hadley, Fay

2012-01-01

This article investigates early childhood educators' perceptions of advocacy in raising the professional status with multiple stakeholders in diverse contexts. The article reports on findings from a phenomenological study investigating the perceptions of 12 educators working full time in long-day-care settings across Sydney, New South Wales (NSW),…

Infants' Social-Emotional Adjustment within a Childcare Context of Korea

ERIC Educational Resources Information Center

Kim, Min-Hee; Moon, Hyukjun

2011-01-01

In a child day-care setting, the naturally occurring social-emotional behaviours and play interaction of 51 infants were observed and recorded. Individual differences in gender, age, temperament, and maternal parenting behaviours were examined to understand how these variables might be related to social-emotional adjustment of infants. The…

How Do Early Childhood Practitioners Define Professionalism in Their Interactions with Parents?

ERIC Educational Resources Information Center

Ward, Ute

2018-01-01

This study deepens the understanding of the interactions between early childhood practitioners and the parents of young children in English day care settings, nurseries and pre-schools. Using a phenomenological approach and semi-structured interviews with 17 experienced practitioners the study highlights practitioners' lived experiences and their…

CTEPP-OH DATA COLLECTED ON FORM 07: CHILD DAY CARE CENTER POST-MONITORING

EPA Science Inventory

This data set contains data concerning the child’s daily activities and potential exposures to pollutants at their homes for CTEPP-OH. It included questions on chemicals applied and cigarettes smoked at the home over the 48-h monitoring period. It also collected information on th...

CTEPP NC DATA COLLECTED ON FORM 07: CHILD DAY CARE CENTER POST-MONITORING

EPA Science Inventory

This data set contains data concerning the child’s daily activities and potential exposures to pollutants at their homes. It included questions on chemicals applied and cigarettes smoked at the home over the 48-h monitoring period. It also collected information on the child’s han...

Ready, Set, Grow! Health Education for 3-5 Year Olds.

ERIC Educational Resources Information Center

Peterson, Paula J.

Intended for use in family day care, preschool centers, professional preparation institutions, and in homes, this comprehensive health education curriculum for 3- through 5-year-old children contains units designed to sequentially teach concepts about physical health, mental health, family living, and safety. Contents include the following…

Counselor Training Manual for Resident Environmental Education Camp.

ERIC Educational Resources Information Center

Fortman, Kathleen J.

Designed for use with junior and senior high school students, this manual outlines procedures for recruiting and training counselors to work with upper elementary students in a resident outdoor education setting. Counselors can provide the additional leadership necessary when caring for large groups of students 24 hours a day. However, their…

A Population-Based Study of Preschoolers' Food Neophobia and Its Associations with Food Preferences

ERIC Educational Resources Information Center

Russell, Catherine Georgina; Worsley, Anthony

2008-01-01

Objective: This cross-sectional study was designed to investigate the relationships between food preferences, food neophobia, and children's characteristics among a population-based sample of preschoolers. Design: A parent-report questionnaire. Setting: Child-care centers, kindergartens, playgroups, day nurseries, and swimming centers. Subjects:…

Reduction of 30-Day Preventable Pediatric Readmission Rates With Postdischarge Phone Calls Utilizing a Patient- and Family-Centered Care Approach.

PubMed

Flippo, Renee; NeSmith, Elizabeth; Stark, Nancy; Joshua, Thomas; Hoehn, Michelle

2015-01-01

The purpose of this project was to evaluate the effectiveness of postdischarge phone calls on 30-day preventable readmission rates within the pediatric hospital setting. Because the unit of care identified was patients and their families, a patient- and family-centered care approach was used. The project used an exploratory design and was conducted at a 154-bed pediatric hospital facility. A sample of 15 patients meeting project inclusion criteria was selected before and after the intervention, and medical records were reviewed to identify if a 30-day preventable readmission had occurred. Medical record review revealed four preintervention readmissions, providing an overall preintervention readmission rate of 26%. Only one readmission was discovered after the intervention, yielding an overall postintervention readmission rate of 6%. The sample size was not large enough to show statistical significance, but clinical significance was seen, with readmission rates for the project target population decreasing below the rates recorded in 2012. Copyright © 2015 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.

Ultra-Short-Course Antibiotics for Patients With Suspected Ventilator-Associated Pneumonia but Minimal and Stable Ventilator Settings.

PubMed

Klompas, Michael; Li, Lingling; Menchaca, John T; Gruber, Susan

2017-04-01

Many patients started on antibiotics for possible ventilator-associated pneumonia (VAP) do not have pneumonia. Patients with minimal and stable ventilator settings may be suitable candidates for early antibiotic discontinuation. We compared outcomes among patients with suspected VAP but minimal and stable ventilator settings treated with 1-3 days vs >3 days of antibiotics. We identified consecutive adult patients started on antibiotics for possible VAP with daily minimum positive end-expiratory pressure of ≤5 cm H2O and fraction of inspired oxygen ≤40% for at least 3 days within a large tertiary care hospital between 2006 and 2014. We compared time to extubation alive vs ventilator death and time to hospital discharge alive vs hospital death using competing risks models among patients prescribed 1-3 days vs >3 days of antibiotics. All models were adjusted for patient demographics, comorbidities, severity of illness, clinical signs of infection, and pathogens. There were 1290 eligible patients, 259 treated for 1-3 days and 1031 treated for >3 days. The 2 groups had similar demographics, comorbidities, and clinical signs. There were no significant differences between groups in time to extubation alive (hazard ratio [HR], 1.16 for short- vs long-course treatment; 95% confidence interval [CI], .98-1.36), ventilator death (HR, 0.82 [95% CI, .55-1.22]), time to hospital discharge alive (HR, 1.07 [95% CI, .91-1.26]), or hospital death (HR, 0.99 [95% CI, .75-1.31]). Very short antibiotic courses (1-3 days) were associated with outcomes similar to longer courses (>3 days) in patients with suspected VAP but minimal and stable ventilator settings. Assessing serial ventilator settings may help clinicians identify candidates for early antibiotic discontinuation. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.

[Plastic surgery in the setting of a public hospital day care unit].

PubMed

Faga, A; Valdatta, L; Magnani, S; Thione, A

2000-09-01

The authors describe the advantages and disadvantages of plastic surgery performed in a day-care public hospital unit. A retrospective study was made of the day-surgery activities over 16 months (1998-1999) as part of a centralized system. Data were compared to day-surgery activities undertaken in 1997 using a non-centralized system. The study was based in the Macchi Foundation Hospital in Varese. A total of 179 patients were treated from all age group whose clinical, intellectual and social characteristics enabled them to be treated using a day-hospital regime. The pathologies treated can be classified into six groups: benign skin pathologies, malignant skin pathologies, scar pathologies, hand disorders, burns and others. All operations were performed as planned under general, local or regional anesthesia with the help of an anesthetist. The centralized system has a number of advantages of a social and technical kind; there are few disadvantages, mainly consisting in the impossibility of using this approach for emergency surgery and its overall rigidity. This form of surgery provides a service that stands out for its quality, organisational efficiency and low cost.

Prevalence of wounds in a community care setting in Ireland.

PubMed

McDermott-Scales, L; Cowman, S; Gethin, G

2009-10-01

To establish the prevalence of wounds and their management in a community care setting. A multi-site, census point prevalence wound survey was conducted in the following areas: intellectual disability, psychiatry, GP practices, prisons, long-term care private nursing homes, long-term care, public nursing homes and the community/public health (district) nursing services on one randomly selected day. Acute services were excluded. Formal ethical approval was obtained. Data were collected using a pre-piloted questionnaire. Education was provided to nurses recording the tool (n=148). Descriptive statistical analysis was performed. A 97.2% response rate yielded a crude prevalence rate of 15.6% for wounds across nursing disciplines (290/1,854 total census) and 0.2% for the community area (290/133,562 population statistics for the study area). Crude point prevalence ranged from 2.7% in the prison services (7/262 total prison population surveyed) to 33.5% in the intellectual disability services (72/215 total intellectual disability population surveyed). The most frequent wounds recorded were pressure ulcers (crude point prevalence 4%, 76/1,854 total census; excluding category l crude point prevalence was 2.6%, 49/1,854 total census), leg ulcers (crude point prevalence 2.9%, 55/1,854 total census), self-inflicted superficial abrasions (crude point prevalence 2.2%, 41/1,854 total census) and surgical wounds (crude point prevalence 1.7%, 32/1,854 total census). These results support previous international research in that they identify a high prevalence of wounds in the community. The true community prevalence of wounds is arguably much higher, as this study identified only wounds known to the nursing services and excluded acute settings and was conducted on one day.

The Relationship Between Index Hospitalizations, Sepsis, and Death or Transition to Hospice Care During 30-Day Hospital Readmissions.

PubMed

Dietz, Brett W; Jones, Tiffanie K; Small, Dylan S; Gaieski, David F; Mikkelsen, Mark E

2017-04-01

Hospital readmissions are common, expensive, and increasingly used as a metric for assessing quality of care. The relationship between index hospitalizations and specific outcomes among those readmitted remains largely unknown. Identify risk factors present during the index hospitalization associated with death or transition to hospice care during 30-day readmissions and examine the contribution of infection in readmissions resulting in death. Retrospective cohort study. A total of 17,716 30-day readmissions in an academic health system. We used mixed-effects multivariable logistic regression models to identify risk factors associated with the primary outcome, in-hospital death, or transition to hospice during 30-day readmissions. Of 17,716 30-day readmissions, 1144 readmissions resulted in death or transition to hospice care (6.5%). Risk factors identified included: age, burden, and type of comorbid conditions, recent hospitalizations, nonelective index admission type, outside hospital transfer, low discharge hemoglobin, low discharge sodium, high discharge red blood cell distribution width, and disposition to a setting other than home. Sepsis (OR=1.33; 95% CI, 1.02-1.72; P=0.03) and shock (OR=1.78; 95% CI, 1.22-2.58; P=0.002) during the index admission were associated with the primary outcome, and in-hospital mortality specifically. In patients who died, infection was the primary cause for readmission in 51.6% of readmissions after sepsis and 28.6% of readmissions after a nonsepsis hospitalization (P=0.009). We identified factors, including sepsis and shock during the index hospitalization, associated with death or transition to hospice care during readmission. Infection was frequently implicated as the cause of a readmission that ended in death.

Effect of Intrafix® SafeSet infusion apparatus on phlebitis in a neurological intensive care unit: a case-control study.

PubMed

Liu, F; Chen, D; Liao, Y; Diao, L; Liu, Y; Wu, M; Xue, X; You, C; Kang, Y

2012-01-01

To investigate the effect of the Intrafix(®) SafeSet infusion apparatus on the incidence of phlebitis in patients being intravenously infused in a neurological intensive care unit (ICU). Patients aged > 12 years, with no history of diabetes mellitus and no existing phlebitis, requiring a daily peripheral intravenous infusion of ≥ 8 h with the total period lasting ≥ 3 days, were enrolled. Infusions were performed using the Intrafix(®) SafeSet or normal infusion apparatus. Incidence of phlebitis (scored according to the Infusion Nursing Standards of Practice of the American Infusion Nurses Society) was analysed. Patients (n = 1545) were allocated to Intrafix(®) SafeSet (n = 709) or normal infusion (n = 836) groups, matched for age, gender and preliminary diagnosis. Incidence of phlebitis was significantly higher using normal infusion apparatus compared with the Intrafix(®) SafeSet (23.4% versus 17.9%, respectively). Intrafix(®) SafeSet infusion apparatus significantly reduced the incidence of phlebitis in patients in the neurological ICU, compared with normal infusion apparatus, and may be suitable for use in routine clinical practice.

Advance Care Planning and the Quality of End-of-Life Care among Older Adults

PubMed Central

Bischoff, Kara E.; Sudore, Rebecca; Miao, Yinghui; Boscardin, W. John; Smith, Alexander K.

2013-01-01

Background Advance care planning is increasingly common, but whether it influences end-of-life quality of care remains controversial. Design Medicare data and survey data from the Health and Retirement Study were combined to determine whether advance care planning was associated with quality metrics. Setting The nationally representative Health and Retirement Study. Participants 4394 decedent subjects (mean age 82.6 years at death, 55% women). Measurements Advance care planning was defined as having an advance directive, durable power of attorney or having discussed preferences for end-of-life care with a next-of-kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in-hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice ≤3 days). Results Seventy-six percent of subjects engaged in advance care planning. Ninety-two percent of advance directives stated a preference to prioritize comfort. After adjustment, subjects who engaged in advance care planning were less likely to die in a hospital (adjusted RR 0.87, 95% CI 0.80-0.94), more likely to be enrolled in hospice (aRR 1.68, 1.43-1.97), and less likely to receive hospice for ≤3 days before death (aRR 0.88, 0.85-0.91). Having an advance directive, a durable-power-of-attorney or an advance care planning discussion were each independently associated with a significant increase in hospice use (p<0.01 for all). Conclusion Advance care planning was associated with improved quality of care at the end of life, including less in-hospital death and increased use of hospice. Having an advance directive, assigning a durable power of attorney and conducting advance care planning discussions are all important elements of advance care planning. PMID:23350921

Ventilator-associated pneumonia: the importance of oral care in intubated adults.

PubMed

Stonecypher, Karen

2010-01-01

Ventilator-associated pneumonia (VAP) occurs within 24 hours of intubation and mechanical ventilation. Health care costs related to increased patient mortality, extended length of stay, and patient well-being make treatment of VAP a priority in all health care settings. The Institute for Healthcare Improvements has developed the Ventilator Bundle as a group of interventions linked to ventilator care with demonstrated outcome improvements; removal of subglottic secretions is one of these recommendations. Dental plaque and bacterial colonization of pathogens is directly related to microaspiration of bacteria into the lungs. A moist environment in the mouth maintains normal oropharyngeal bacteria, preventing overgrowth of pathogenic bacteria. Frequent oral care to include twice-a-day brushing of the teeth found a 69% reduction in respiratory tract infections.

The Accuracy of Physicians' Clinical Predictions of Survival in Patients With Advanced Cancer.

PubMed

Amano, Koji; Maeda, Isseki; Shimoyama, Satofumi; Shinjo, Takuya; Shirayama, Hiroto; Yamada, Takeshi; Ono, Shigeki; Yamamoto, Ryo; Yamamoto, Naoki; Shishido, Hideki; Shimizu, Mie; Kawahara, Masanori; Aoki, Shigeru; Demizu, Akira; Goshima, Masahiro; Goto, Keiji; Gyoda, Yasuaki; Hashimoto, Kotaro; Otomo, Sen; Sekimoto, Masako; Shibata, Takemi; Sugimoto, Yuka; Morita, Tatsuya

2015-08-01

Accurate prognoses are needed for patients with advanced cancer. To evaluate the accuracy of physicians' clinical predictions of survival (CPS) and assess the relationship between CPS and actual survival (AS) in patients with advanced cancer in palliative care units, hospital palliative care teams, and home palliative care services, as well as those receiving chemotherapy. This was a multicenter prospective cohort study conducted in 58 palliative care service centers in Japan. The palliative care physicians evaluated patients on the first day of admission and followed up all patients to their death or six months after enrollment. We evaluated the accuracy of CPS and assessed the relationship between CPS and AS in the four groups. We obtained a total of 2036 patients: 470, 764, 404, and 398 in hospital palliative care teams, palliative care units, home palliative care services, and chemotherapy, respectively. The proportion of accurate CPS (0.67-1.33 times AS) was 35% (95% CI 33-37%) in the total sample and ranged from 32% to 39% in each setting. While the proportion of patients living longer than CPS (pessimistic CPS) was 20% (95% CI 18-22%) in the total sample, ranging from 15% to 23% in each setting, the proportion of patients living shorter than CPS (optimistic CPS) was 45% (95% CI 43-47%) in the total sample, ranging from 43% to 49% in each setting. Physicians tend to overestimate when predicting survival in all palliative care patients, including those receiving chemotherapy. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Prevalence and incidence studies of pressure ulcers in two long-term care facilities in Canada.

PubMed

Davis, C M; Caseby, N G

2001-11-01

A study was initiated to determine the prevalence and incidence of pressure ulcers in two long-term care facilities in Canada, one with 95 residents and the other with 92 residents. The prevalence study was conducted at both facilities on a single day. The incidence study was completed after 41 and 42 days, respectively, at each facility. Data were collected on demographics, medical information, and possible contributing factors. Each resident was assessed for the presence of a pressure ulcer. Each ulcer was staged and anatomical location was noted. The prevalence of pressure ulcers in the two long-term care facilities was 36.8% and 53.2%, respectively. The incidence of pressure ulcers in the two long-term care facilities was 11.7% and 11.6%, respectively. In conclusion, the pressure ulcer prevalence is higher than published figures for the long-term care setting. However, a pressure ulcer incidence of less than 12% in each facility suggests an equal and acceptable level of nursing care in both facilities. The disparity of pressure ulcer prevalence between the two facilities may be explained by a difference of case mix.

Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery

PubMed Central

Rollins, Katie E.; Lobo, Dileep N.

2016-01-01

Objectives: To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols. Methods: Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality. Results: A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66–0.89, P = 0.0007), hospital length of stay (LOS; mean difference −1.55 days, 95% CI −2.73 to −0.36, P = 0.01), intensive care LOS (mean difference −0.63 days, 95% CI −1.18 to −0.09, P = 0.02), and time to passage of feces (mean difference −0.90 days, 95% CI −1.48 to −0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference −0.63 days, 95% CI −0.94 to −0.32, P < 0.0001) and time to passage of feces (mean difference −1.09 days, 95% CI −2.03 to −0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to −0.84, P = 0.0002) and total hospital LOS (mean difference −2.14, 95% CI −4.15 to −0.13, P = 0.04). Conclusions: GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting. PMID:26445470

Giving them a good start: informatics support of newborn screening and clinical care.

PubMed

Wetter, T; Haschler, I; Ho, S; Hoffmann, G F; Linderkamp, O; Philipp, F; Skonetzki, S

2005-01-01

Newborns are a vulnerable population: Exposed to dramatically changing environmental conditions, potentially suffering from impairments that cannot realistically be diagnosed during pregnancy, with the risk that unfavorable conditions escalate fast. We have investigated informatics methods and tools to make screening for congenital diseases and containment of critical processes that start in the first days safer and more efficient. This poster present a set of three different methodological approaches that all aim at comprehensive improvement of neonatal care.

Priority setting in a Canadian surgical department: a case study using program budgeting and marginal analysis

PubMed Central

Mitton, Craig; Donaldson, Cam; Shellian, Barb; Pagenkopf, Cort

2003-01-01

Introduction A key mandate of Canadian regional health authorities is to set priorities and allocate resources within a limited funding envelope. The objective in this study was to determine how resources within a surgical program in a Canadian rural hospital might be reallocated to better meet the needs of the local community. Methods Early in 2001, at the Canmore General Hospital, Canmore, Alta., an expert-panel working group, consisting of a community health service leader, operating-room nurse clinician, acute care head nurse and a general surgeon, assisted by a research assistant and 2 health economists carried out a program budgeting and marginal analysis project to assess multiple data inputs into the decision-making process and to develop recommendations for service expansion and resource release. They considered the cost and benefits of altering the mix of resources used, based on Headwaters Health Authority activity and financial data, and local expert opinion. Results The primary recommendation was to implement an additional surgery day per week (38 days of major surgery and 12 days of minor surgery over a 50-week year). However, the total dollars to fund such an expansion could not be released from within the Canmore budget, and additional dollars were not forthcoming from the health region. A secondary objective of implementing an additional minor surgery day every 3 weeks was pursued and the required resources were obtained. Conclusions Due to resource constraints in health care, efforts by both clinicians and administrators should be made to better spend available resources. The marginal analysis process used in this study served as a useful framework for priority setting, which is generalizable to other surgical and nonsurgical programs in Canada. PMID:12585790

A role for social workers in improving care setting transitions: a case study.

PubMed

Barber, Ruth D; Coulourides Kogan, Alexis; Riffenburgh, Anne; Enguidanos, Susan

2015-01-01

High 30-day readmission rates are a major burden to the American medical system. Much attention is on transitional care to decrease financial costs and improve patient outcomes. Social workers may be uniquely qualified to improve care transitions and have not previously been used in this role. We present a case study of an older, dually eligible Latina woman who received a social work-driven transition intervention that included in-home and telephone contacts. The patient was not readmitted during the six-month study period, mitigated her high pain levels, and engaged in social outings once again. These findings suggest the value of a social worker in a transitional care role.

Economic burden to primary informal caregivers of hospitalized older adults in Mexico: a cohort study.

PubMed

López-Ortega, Mariana; García-Peña, Carmen; Granados-García, Víctor; García-González, José Juan; Pérez-Zepeda, Mario Ulises

2013-02-08

The burden of out of pocket spending for the Mexican population is high compared to other countries. Even patients insured by social security institutions have to face the cost of health goods, services or nonmedical expenses related to their illness. Primary caregivers, in addition, experience losses in productivity by taking up responsibilities in care giving activities. This situation represents a mayor economic burden in an acute care setting for elderly population. There is evidence that specialized geriatric services could represent lower overall costs in these circumstances and could help reduce these burdens.The aim of this study was to investigate economic burden differences in caregivers of elderly patients comparing two acute care services (Geriatric and Internal Medicine). Specifically, economic costs associated with hospitalization of older adults in these two settings by evaluating health care related out of pocket expenditures (OOPE), non-medical OOPE and indirect costs. A comparative analysis of direct and indirect costs in hospitalised elderly patients (60-year or older) and their primary informal caregivers in two health care settings, using a prospective cohort was performed. Economic burden was measured by out of pocket expenses and indirect costs (productivity lost) due to care giving activities. The analysis included a two-part model, the first one allowing the estimation of the probability of observing any health care related and non-medical OOPE; and the second one, the positive observations or expenditures. A total of 210 subjects were followed during their hospital stay. Of the total number of subjects 95% reported at least one non-medical OOPE, being daily transportation the most common expense. Regarding medical OOPE, medicines were the most common expense, and the mean numbers of days without income were 4.12 days. Both OOPE and indirect costs were significantly different between type of services, with less overall economic burden to the caregivers of elderly hospitalized in the geriatric unit. The final model showed that type of service and satisfaction had the largest coefficients (-0.68 and 0.662 respectively, p<0.001). This study allowed us to identify associated factors of economic burden in elderly hospitalized in acute care units. It opens as well, an issue that should not be overlooked in framing public policies regarding elderly health care.

Economic burden to primary informal caregivers of hospitalized older adults in Mexico: a cohort study

PubMed Central

2013-01-01

Background The burden of out of pocket spending for the Mexican population is high compared to other countries. Even patients insured by social security institutions have to face the cost of health goods, services or nonmedical expenses related to their illness. Primary caregivers, in addition, experience losses in productivity by taking up responsibilities in care giving activities. This situation represents a mayor economic burden in an acute care setting for elderly population. There is evidence that specialized geriatric services could represent lower overall costs in these circumstances and could help reduce these burdens. The aim of this study was to investigate economic burden differences in caregivers of elderly patients comparing two acute care services (Geriatric and Internal Medicine). Specifically, economic costs associated with hospitalization of older adults in these two settings by evaluating health care related out of pocket expenditures (OOPE), non-medical OOPE and indirect costs. Methods A comparative analysis of direct and indirect costs in hospitalised elderly patients (60-year or older) and their primary informal caregivers in two health care settings, using a prospective cohort was performed. Economic burden was measured by out of pocket expenses and indirect costs (productivity lost) due to care giving activities. The analysis included a two-part model, the first one allowing the estimation of the probability of observing any health care related and non-medical OOPE; and the second one, the positive observations or expenditures. Results A total of 210 subjects were followed during their hospital stay. Of the total number of subjects 95% reported at least one non-medical OOPE, being daily transportation the most common expense. Regarding medical OOPE, medicines were the most common expense, and the mean numbers of days without income were 4.12 days. Both OOPE and indirect costs were significantly different between type of services, with less overall economic burden to the caregivers of elderly hospitalized in the geriatric unit. The final model showed that type of service and satisfaction had the largest coefficients (-0.68 and 0.662 respectively, p<0.001). Conclusions This study allowed us to identify associated factors of economic burden in elderly hospitalized in acute care units. It opens as well, an issue that should not be overlooked in framing public policies regarding elderly health care. PMID:23391286

Neighborhood poverty rate and mortality in patients receiving critical care in the academic medical center setting.

PubMed

Zager, Sam; Mendu, Mallika L; Chang, Domingo; Bazick, Heidi S; Braun, Andrea B; Gibbons, Fiona K; Christopher, Kenneth B

2011-06-01

Poverty is associated with increased risk of chronic illness but its contribution to critical care outcome is not well defined. We performed a multicenter observational study of 38,917 patients, aged ≥ 18 years, who received critical care between 1997 and 2007. The patients were treated in two academic medical centers in Boston, Massachusetts. Data sources included 1990 US census and hospital administrative data. The exposure of interest was neighborhood poverty rate, categorized as < 5%, 5% to 10%, 10% to 20%, 20% to 40% and > 40%. Neighborhood poverty rate is the percentage of residents below the federal poverty line. Census tracts were used as the geographic units of analysis. Logistic regression examined death by days 30, 90, and 365 post-critical care initiation and in-hospital mortality. Adjusted ORs were estimated by multivariable logistic regression models. Sensitivity analysis was performed for 1-year postdischarge mortality among patients discharged to home. Following multivariable adjustment, neighborhood poverty rate was not associated with all-cause 30-day mortality: 5% to 10% OR, 1.05 (95% CI, 0.98-1.14; P = .2); 10% to 20% OR, 0.96 (95% CI, 0.87-1.06; P = .5); 20% to 40% OR, 1.08 (95% CI, 0.96-1.22; P = .2); > 40% OR, 1.20 (95% CI, 0.90-1.60; P = .2); referent in each is < 5%. Similar nonsignificant associations were noted at 90-day and 365-day mortality post-critical care initiation and in-hospital mortality. Among patients discharged to home, neighborhood poverty rate was not associated with 1-year-postdischarge mortality. Our study suggests that there is no relationship between the neighborhood poverty rate and mortality up to 1 year following critical care at academic medical centers.

A Novel Mental Health Crisis Service - Outcomes of Inpatient Data.

PubMed

Morrow, R; McGlennon, D; McDonnell, C

2016-01-01

Northern Ireland has high mental health needs and a rising suicide rate. Our area has suffered a 32% reduction of inpatient beds consistent with the national drive towards community based treatment. Taking these factors into account, a new Mental Health Crisis Service was developed incorporating a high fidelity Crisis Response Home Treatment Team (CRHTT), Acute Day Care facility and two inpatient wards. The aim was to provide alternatives to inpatient admission. The new service would facilitate transition between inpatient and community care while decreasing bed occupancy and increasing treatment in the community. All services and processes were reviewed to assess deficiencies in current care. There was extensive consultation with internal and external stakeholders and process mapping using the COBRAs framework as a basis for the service improvement model. The project team set the service criteria and reviewed progress. In the original service model, the average inpatient occupancy rate was 106.6%, admission rate was 48 patients per month and total length of stay was 23.4 days. After introducing the inpatient consultant hospital model, the average occupancy rate decreased to 90%, admissions to 43 per month and total length of stay to 22 days. The results further decreased to 83% occupancy, 32 admissions per month and total length of stay 12 days after CRHTT initiation. The Crisis Service is still being evaluated but currently the model has provided safe alternatives to inpatient care. Involvement with patients, carers and all multidisciplinary teams is maximised to improve the quality and safety of care. Innovative ideas including structured weekly timetable and regular interface meetings have improved communication and allowed additional time for patient care.

A Novel Mental Health Crisis Service – Outcomes of Inpatient Data

PubMed Central

McGlennon, D; McDonnell, C

2016-01-01

Introduction Northern Ireland has high mental health needs and a rising suicide rate. Our area has suffered a 32% reduction of inpatient beds consistent with the national drive towards community based treatment. Taking these factors into account, a new Mental Health Crisis Service was developed incorporating a high fidelity Crisis Response Home Treatment Team (CRHTT), Acute Day Care facility and two inpatient wards. The aim was to provide alternatives to inpatient admission. The new service would facilitate transition between inpatient and community care while decreasing bed occupancy and increasing treatment in the community. Methods All services and processes were reviewed to assess deficiencies in current care. There was extensive consultation with internal and external stakeholders and process mapping using the COBRAs framework as a basis for the service improvement model. The project team set the service criteria and reviewed progress. Results In the original service model, the average inpatient occupancy rate was 106.6%, admission rate was 48 patients per month and total length of stay was 23.4 days. After introducing the inpatient consultant hospital model, the average occupancy rate decreased to 90%, admissions to 43 per month and total length of stay to 22 days. The results further decreased to 83% occupancy, 32 admissions per month and total length of stay 12 days after CRHTT initiation. Discussion The Crisis Service is still being evaluated but currently the model has provided safe alternatives to inpatient care. Involvement with patients, carers and all multidisciplinary teams is maximised to improve the quality and safety of care. Innovative ideas including structured weekly timetable and regular interface meetings have improved communication and allowed additional time for patient care. PMID:27158159

Feeding tubes and health costs postinsertion in nursing home residents with advanced dementia.

PubMed

Hwang, Deborah; Teno, Joan M; Gozalo, Pedro; Mitchell, Susan

2014-06-01

The best evidence suggests that feeding tubes are ineffective in persons with advanced dementia. Little is known about their health care costs. To estimate Medicare costs attributable to inpatient care among nursing home (NH) residents with advanced dementia during the year following the placement of a percutaneous endoscopic gastrostomy (PEG) tube during an index hospitalization. Medicare claims (1999-2009) and Minimum Data Set data (1999-2009) were used to estimate Medicare costs attributable to inpatient care among NH residents with advanced dementia during the year following the placement of a PEG tube and compared with those who did not get a PEG tube. The study used a 3:1 propensity-matched cohort design. Matched residents with (n=1924, 68.9% female, 28.8% African American, average age 83.1 years) and without (weighted n=1924, unique n=4337) PEG insertion showed comparable sociodemographic characteristics, similar rates of feeding tube risk factors, and similar mortality (51.9% 180 day mortality among those with a feeding tube vs. 49.8% among those without a feeding tube, P=0.11). One year hospital costs were $2224 higher in NH residents with a feeding tube ($10,191 vs. $7967, 95% CI of difference=$1514, $2933), with those with a feeding tube likely to spend more time in an intensive care unit (1.92 vs. 1.29 days, 95% CI of difference=0.34, 0.92 days). In an analysis controlling for selection bias, PEG tube insertion is associated with a small but significant increase in annual inpatient health care costs, as well as in hospital and intensive care unit days, postinsertion. Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Impact of Homecare Electronic Health Record on Timeliness of Clinical Documentation, Reimbursement, and Patient Outcomes

PubMed Central

Bowles, K. H.; Adelsberger, M. C.; Chittams, J. L.; Liao, C.

2014-01-01

Summary Background Homecare is an important and effective way of managing chronic illnesses using skilled nursing care in the home. Unlike hospitals and ambulatory settings, clinicians visit patients at home at different times, independent of each other. Twenty-nine percent of 10,000 homecare agencies in the United States have adopted point-of-care EHRs. Yet, relatively little is known about the growing use of homecare EHRs. Objective Researchers compared workflow, financial billing, and patient outcomes before and after implementation to evaluate the impact of a homecare point-of-care EHR. Methods The design was a pre/post observational study embedded in a mixed methods study. The setting was a Philadelphia-based homecare agency with 137 clinicians. Data sources included: (1) clinician EHR documentation completion; (2) EHR usage data; (3) Medicare billing data; (4) an EHR Nurse Satisfaction survey; (5) clinician observations; (6) clinician interviews; and (7) patient outcomes. Results Clinicians were satisfied with documentation timeliness and team communication. Following EHR implementation, 90% of notes were completed within the 1-day compliance interval (n = 56,702) compared with 30% of notes completed within the 7-day compliance interval in the pre-implementation period (n = 14,563; OR 19, p <. 001). Productivity in the number of clinical notes documented post-implementation increased almost 10-fold compared to pre-implementation. Days to Medicare claims fell from 100 days pre-implementation to 30 days post-implementation, while the census rose. EHR implementation impact on patient outcomes was limited to some behavioral outcomes. Discussion Findings from this homecare EHR study indicated clinician EHR use enabled a sustained increase in productivity of note completion, as well as timeliness of documentation and billing for reimbursement with limited impact on improving patient outcomes. As EHR adoption increases to better meet the needs of the growing population of older people with chronic health conditions, these results can inform homecare EHR development and implementation. PMID:25024760

Evaluation of a cyanoacrylate dressing to manage peristomal skin alterations under ostomy skin barrier wafers.

PubMed

Milne, Catherine T; Saucier, Darlene; Trevellini, Chenel; Smith, Juliet

2011-01-01

Peristomal skin alterations under ostomy barrier wafers are a commonly reported problem. While a number of interventions to manage this issue have been reported, the use of a topically applied cyanoacrylate has received little attention. This case series describes the use of a topical cyanoacrylate for the management of peristomal skin alterations in persons living with an ostomy. Using a convenience sample, the topical cyanoacrylate dressing was applied to 11 patients with peristomal skin disruption under ostomy wafers in acute care and outpatient settings. The causes of barrier function interruption were also addressed to enhance outcomes. Patients were assessed for wound discomfort using a Likert Scale, time to healing, and number of appliance changes. Patient satisfaction was also examined. Average reported discomfort levels were 9.5 out of 10 at the initial peristomal irritation assessment visit decreased to 3.5 at the first wafer change and were absent by the second wafer change. Wafers had increasing wear time between changes in both settings with acute care patients responding faster. Epidermal resurfacing occurred within 10.2 days in outpatients and within 7 days in acute care patients. Because of the skin sealant action of this dressing, immediate adherence of the wafer was reported at all pouch changes.

Community Game Day: Using an End-of-Life Conversation Game to Encourage Advance Care Planning.

PubMed

Van Scoy, Lauren J; Reading, Jean M; Hopkins, Margaret; Smith, Brandi; Dillon, Judy; Green, Michael J; Levi, Benjamin H

2017-11-01

Advance care planning (ACP) is an important process that involves discussing and documenting one's values and preferences for medical care, particularly end-of-life treatments. This convergent, mixed-methods study assessed whether an end-of-life conversation card game is an acceptable and effective means for performing ACP for patients with chronic illness and/or their caregivers when deployed in a community setting. Twenty-two games (n = 93 participants) were held in community settings surrounding Hershey, PA in 2016. Participants were recruited using random sampling from patient databases and also convenience sampling (i.e., flyers). Quantitative questionnaires and qualitative focus group interviews were administered to assess the game experience and subsequent performance of ACP behaviors. Both quantitative and qualitative data found that Community Game Day was a well-received, positive experience for participants and 75% of participants performed ACP within three months post-intervention. These findings suggest that using a conversation game during community outreach is a useful approach for engaging patients and caregivers in ACP. The convergence of quantitative and qualitative data strongly supports the continued investigation of the game in randomized controlled trials. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Pressure Ulcers in Elderly Hip Fracture Patients Across the Continuum of Care

PubMed Central

Baumgarten, Mona; Margolis, David J.; Orwig, Denise L.; Shardell, Michelle D.; Hawkes, William G.; Langenberg, Patricia; Palmer, Mary H.; Jones, Patricia S.; McArdle, Patrick F.; Sterling, Robert; Kinosian, Bruce P.; Rich, Shayna E.; Sowinski, Janice; Magaziner, Jay

2012-01-01

Objectives The aim of this study was to identify care settings associated with increased pressure ulcer risk among elderly hip fracture patients in the post-fracture period. Design Prospective cohort study. Setting Nine hospitals that participate in the Baltimore Hip Studies network and 105 postacute facilities to which patients from these hospitals were discharged. Participants Hip fracture patients age ≥65 years who underwent surgery for hip fracture. Measurements A full-body skin examination was conducted at baseline (as soon as possible after hospital admission) and repeated on alternating days for 21 days. Patients were deemed to have an acquired pressure ulcer (APU) if they developed ≥1 new pressure ulcers stage 2 or higher following hospital admission. Results Among 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). Compared to home, the adjusted APU incidence rate was highest during the initial acute hospital stay (relative rate [RR] 2.2, 95% confidence interval [CI] 1.3–3.7) and during re-admission to the acute hospital (RR 2.2, 95% CI 1.1–4.2). The relative rates in rehabilitation and nursing home settings were 1.4 (95% CI 0.8–2.3) and 1.3 (95% CI 0.8–2.1), respectively. Conclusion Approximately one-third of hip fracture patients developed an APU during the study period. The rate was highest in the acute setting, a finding that is significant in light of Medicare’s policy of not reimbursing hospitals for the treatment of hospital-acquired pressure ulcers. Hip fracture patients constitute an important group to target for pressure ulcer prevention in hospitals. PMID:19484841

Health status of UK care home residents: a cohort study

PubMed Central

Gordon, Adam Lee; Franklin, Matthew; Bradshaw, Lucy; Logan, Pip; Elliott, Rachel; Gladman, John R.F.

2014-01-01

Background: UK care home residents are often poorly served by existing healthcare arrangements. Published descriptions of residents’ health status have been limited by lack of detail and use of data derived from surveys drawn from social, rather than health, care records. Aim: to describe in detail the health status and healthcare resource use of UK care home residents Design and setting: a 180-day longitudinal cohort study of 227 residents across 11 UK care homes, 5 nursing and 6 residential, selected to be representative for nursing/residential status and dementia registration. Method: Barthel index (BI), Mini-mental state examination (MMSE), Neuropsychiatric index (NPI), Mini-nutritional index (MNA), EuroQoL-5D (EQ-5D), 12-item General Health Questionnaire (GHQ-12), diagnoses and medications were recorded at baseline and BI, NPI, GHQ-12 and EQ-5D at follow-up after 180 days. National Health Service (NHS) resource use data were collected from databases of local healthcare providers. Results: out of a total of 323, 227 residents were recruited. The median BI was 9 (IQR: 2.5–15.5), MMSE 13 (4–22) and number of medications 8 (5.5–10.5). The mean number of diagnoses per resident was 6.2 (SD: 4). Thirty per cent were malnourished, 66% had evidence of behavioural disturbance. Residents had contact with the NHS on average once per month. Conclusion: residents from both residential and nursing settings are dependent, cognitively impaired, have mild frequent behavioural symptoms, multimorbidity, polypharmacy and frequently use NHS resources. Effective care for such a cohort requires broad expertise from multiple disciplines delivered in a co-ordinated and managed way. PMID:23864424

Use of peripherally inserted central catheters as an alternative to central catheters in neurocritical care units.

PubMed

DeLemos, Christi; Abi-Nader, Judy; Akins, Paul T

2011-04-01

Patients in neurological critical care units often have lengthy stays that require extended vascular access and invasive hemodynamic monitoring. The traditional approach for these patients has relied heavily on central venous and pulmonary artery catheters. The aim of this study was to evaluate peripherally inserted central catheters as an alternative to central venous catheters in neurocritical care settings. Data on 35 patients who had peripherally inserted central catheters rather than central venous or pulmonary artery catheters for intravascular access and monitoring were collected from a prospective registry of neurological critical care admissions. These data were cross-referenced with information from hospital-based data registries for peripherally inserted central catheters and subarachnoid hemorrhage. Complete data were available on 33 patients with Hunt-Hess grade IV-V aneurysmal subarachnoid hemorrhage. Catheters remained in place a total of 649 days (mean, 19 days; range, 4-64 days). One patient (3%) had deep vein thrombosis in an upper extremity. In 2 patients, central venous pressure measured with a peripherally inserted catheter was higher than pressure measured concurrently with a central venous catheter. None of the 33 patients had a central catheter bloodstream infection or persistent insertion-related complications. CONCLUSIONS Use of peripherally inserted central catheters rather than central venous catheters or pulmonary artery catheters in the neurocritical care unit reduced procedural and infection risk without compromising patient management.

Medical savings accounts make waves.

PubMed

Gardner, J

1995-02-27

MSAs: the theory. Medical savings account legislation would allow consumers to set aside pre-tax dollars to pay for day-to-day healthcare costs. The accounts are to be backed up by a catastropic policy with a deductible roughly equal to the maximum amount allowed in the MSA. The aim is to reduce healthcare cost inflation by making consumers more aware of the costs of healthcare than they are under comprehensive policies and enabling them to shop for the lowest-cost, highest-quality care.

Critical care: Are we customer friendly?

PubMed

Venkataraman, Ramesh; Ranganathan, Lakshmi; Rajnibala, V; Abraham, Babu K; Rajagopalan, Senthilkumar; Ramakrishnan, Nagarajan

2015-09-01

Assessing and enhancing family satisfaction are imperative for the provision of comprehensive intensive care. There is a paucity of Indian data exploring family's perception of Intensive Care Unit (ICU) patients. We wanted to explore family satisfaction and whether it differed in families of patients admitted under intensivists and nonintensivists in our semi-open ICU. We surveyed family members of 200 consecutive patients, between March and September 2009 who were in ICU for >3 days. An internationally validated family satisfaction survey was adapted and was administered to a family member, on day 4 of the patient's stay. The survey consisted of 15 questions in five categories - patient care, medical counseling, staff interaction, visiting hours, and facilities and was set to a Likert scale of 1-4. Mean, median, and proportions were computed to describe answers for each question and category. A total of 515 patients were admitted during the study period, of which 200 patients stayed in the ICU >3 days. One family member each of the 200 patients completed the survey with 100% response rate. Families reported the greatest satisfaction with patient care (94.5%) and least satisfaction with visiting hours (60.5%). Chi-square tests performed for each of the five categories revealed no significant difference between satisfaction scores of intensivists and nonintensivists' patients. Family members of ICU patients were satisfied with current care and communication, irrespective of whether they were admitted under intensivists or nonintensivists. Family members preferred open visiting hours policy than a time limited one.

Critical care: Are we customer friendly?

PubMed Central

Venkataraman, Ramesh; Ranganathan, Lakshmi; Rajnibala, V.; Abraham, Babu K.; Rajagopalan, Senthilkumar; Ramakrishnan, Nagarajan

2015-01-01

Objective: Assessing and enhancing family satisfaction are imperative for the provision of comprehensive intensive care. There is a paucity of Indian data exploring family's perception of Intensive Care Unit (ICU) patients. We wanted to explore family satisfaction and whether it differed in families of patients admitted under intensivists and nonintensivists in our semi-open ICU. Methodology: We surveyed family members of 200 consecutive patients, between March and September 2009 who were in ICU for >3 days. An internationally validated family satisfaction survey was adapted and was administered to a family member, on day 4 of the patient's stay. The survey consisted of 15 questions in five categories - patient care, medical counseling, staff interaction, visiting hours, and facilities and was set to a Likert scale of 1–4. Mean, median, and proportions were computed to describe answers for each question and category. Results: A total of 515 patients were admitted during the study period, of which 200 patients stayed in the ICU >3 days. One family member each of the 200 patients completed the survey with 100% response rate. Families reported the greatest satisfaction with patient care (94.5%) and least satisfaction with visiting hours (60.5%). Chi-square tests performed for each of the five categories revealed no significant difference between satisfaction scores of intensivists and nonintensivists' patients. Conclusion: Family members of ICU patients were satisfied with current care and communication, irrespective of whether they were admitted under intensivists or nonintensivists. Family members preferred open visiting hours policy than a time limited one. PMID:26430335

Effect of Kangaroo Mother Care on Vital Physiological Parameters of The Low Birth Weight Newborn

PubMed Central

Bera, Alpanamayi; Ghosh, Jagabandhu; Singh, Arun Kumarendu; Hazra, Avijit; Som, Tapas; Munian, Dinesh

2014-01-01

Objectives: Low birth weight (LBW; <2500 g), which is often associated with preterm birth, is a common problem in India. Both are recognized risk factors for neonatal mortality. Kangaroo mother care (KMC) is a non-conventional, low-cost method for newborn care based upon intimate skin-to-skin contact between mother and baby. Our objective was to assess physiological state of LBW babies before and after KMC in a teaching hospital setting. Materials and Methods: Study cohort comprised in-born LBW babies and their mothers - 300 mother-baby pairs were selected through purposive sampling. Initially, KMC was started for 1 hour duration (at a stretch) on first day and then increased by 1 hour each day for next 2 days. Axillary temperature, respiration rate (RR/ min), heart rate (HR/ min), and oxygen saturation (SpO2) were assessed for 3 consecutive days, immediately before and after KMC. Results: Data from 265 mother-baby pairs were analyzed. Improvements occurred in all 4 recorded physiological parameters during the KMC sessions. Mean temperature rose by about 0.4°C, RR by 3 per minute, HR by 5 bpm, and SpO2 by 5% following KMC sessions. Although modest, these changes were statistically significant on all 3 days. Individual abnormalities (e.g. hypothermia, bradycardia, tachycardia, low SpO2) were often corrected during the KMC sessions. Conclusions: Babies receiving KMC showed modest but statistically significant improvement in vital physiological parameters on all 3 days. Thus, without using special equipment, the KMC strategy can offer improved care to LBW babies. These findings support wider implementation of this strategy. PMID:25364150

Evaluating Quality Metrics and Cost After Discharge: A Population-based Cohort Study of Value in Health Care Following Elective Major Vascular Surgery.

PubMed

de Mestral, Charles; Salata, Konrad; Hussain, Mohamad A; Kayssi, Ahmed; Al-Omran, Mohammed; Roche-Nagle, Graham

2018-04-18

Early readmission to hospital after surgery is an omnipresent quality metric across surgical fields. We sought to understand the relative importance of hospital readmission among all health services received after hospital discharge. The aim of this study was to characterize 30-day postdischarge cost and risk of an emergency department (ED) visit, readmission, or death after hospitalization for elective major vascular surgery. This is a population-based retrospective cohort study of patients who underwent elective major vascular surgery - carotid endarterectomy, EVAR, open AAA repair, bypass for lower extremity peripheral arterial disease - in Ontario, Canada, between 2004 and 2015. The outcomes of interest included quality metrics - ED visit, readmission, death - and cost to the Ministry of Health, within 30 days of discharge. Costs after discharge included those attributable to hospital readmission, ED visits, rehab, physician billing, outpatient nursing and allied health care, medications, interventions, and tests. Multivariable regression models characterized the association of pre-discharge characteristics with the above-mentioned postdischarge quality metrics and cost. A total of 30,752 patients were identified. Within 30 days of discharge, 2588 (8.4%) patients were readmitted to hospital and 13 patients died (0.04%). Another 4145 (13.5%) patients visited an ED without requiring admission. Across all patients, over half of 30-day postdischarge costs were attributable to outpatient care. Patients at an increased risk of an ED visit, readmission, or death within 30 days of discharge differed from those patients with relatively higher 30-day costs. Events occurring outside the hospital setting should be integral to the evaluation of quality of care and cost after hospitalization for major vascular surgery.

Content and functional specifications for a standards-based multidisciplinary rounding tool to maintain continuity across acute and critical care.

PubMed

Collins, Sarah; Hurley, Ann C; Chang, Frank Y; Illa, Anisha R; Benoit, Angela; Laperle, Sarah; Dykes, Patricia C

2014-01-01

Maintaining continuity of care (CoC) in the inpatient setting is dependent on aligning goals and tasks with the plan of care (POC) during multidisciplinary rounds (MDRs). A number of locally developed rounding tools exist, yet there is a lack of standard content and functional specifications for electronic tools to support MDRs within and across settings. To identify content and functional requirements for an MDR tool to support CoC. We collected discrete clinical data elements (CDEs) discussed during rounds for 128 acute and critical care patients. To capture CDEs, we developed and validated an iPad-based observational tool based on informatics CoC standards. We observed 19 days of rounds and conducted eight group and individual interviews. Descriptive and bivariate statistics and network visualization were conducted to understand associations between CDEs discussed during rounds with a particular focus on the POC. Qualitative data were thematically analyzed. All analyses were triangulated. We identified the need for universal and configurable MDR tool views across settings and users and the provision of messaging capability. Eleven empirically derived universal CDEs were identified, including four POC CDEs: problems, plan, goals, and short-term concerns. Configurable POC CDEs were: rationale, tasks/'to dos', pending results and procedures, discharge planning, patient preferences, need for urgent review, prognosis, and advice/guidance. Some requirements differed between settings; yet, there was overlap between POC CDEs. We recommend an initial list of 11 universal CDEs for continuity in MDRs across settings and 27 CDEs that can be configured to meet setting-specific needs.

An International Standard Set of Patient-Centered Outcome Measures After Stroke.

PubMed

Salinas, Joel; Sprinkhuizen, Sara M; Ackerson, Teri; Bernhardt, Julie; Davie, Charlie; George, Mary G; Gething, Stephanie; Kelly, Adam G; Lindsay, Patrice; Liu, Liping; Martins, Sheila C O; Morgan, Louise; Norrving, Bo; Ribbers, Gerard M; Silver, Frank L; Smith, Eric E; Williams, Linda S; Schwamm, Lee H

2016-01-01

Value-based health care aims to bring together patients and health systems to maximize the ratio of quality over cost. To enable assessment of healthcare value in stroke management, an international standard set of patient-centered stroke outcome measures was defined for use in a variety of healthcare settings. A modified Delphi process was implemented with an international expert panel representing patients, advocates, and clinical specialists in stroke outcomes, stroke registers, global health, epidemiology, and rehabilitation to reach consensus on the preferred outcome measures, included populations, and baseline risk adjustment variables. Patients presenting to a hospital with ischemic stroke or intracerebral hemorrhage were selected as the target population for these recommendations, with the inclusion of transient ischemic attacks optional. Outcome categories recommended for assessment were survival and disease control, acute complications, and patient-reported outcomes. Patient-reported outcomes proposed for assessment at 90 days were pain, mood, feeding, selfcare, mobility, communication, cognitive functioning, social participation, ability to return to usual activities, and health-related quality of life, with mobility, feeding, selfcare, and communication also collected at discharge. One instrument was able to collect most patient-reported subdomains (9/16, 56%). Minimum data collection for risk adjustment included patient demographics, premorbid functioning, stroke type and severity, vascular and systemic risk factors, and specific treatment/care-related factors. A consensus stroke measure Standard Set was developed as a simple, pragmatic method to increase the value of stroke care. The set should be validated in practice when used for monitoring and comparisons across different care settings. © 2015 The Authors.

Benchmarking antibiotic use in Finnish acute care hospitals using patient case-mix adjustment.

PubMed

Kanerva, Mari; Ollgren, Jukka; Lyytikäinen, Outi

2011-11-01

It is difficult to draw conclusions about the prudence of antibiotic use in different hospitals by directly comparing usage figures. We present a patient case-mix adjustment model of antibiotic use to rank hospitals while taking patient characteristics into account. Data on antibiotic use were collected during the national healthcare-associated infection (HAI) prevalence survey in 2005 in Finland in all 5 tertiary care, all 15 secondary care and 10 (25% of 40) other acute care hospitals. The use of antibiotics was measured using use-days/100 patient-days during a 7day period and the prevalence of patients receiving at least two antimicrobials during the study day. Case-mix-adjusted antibiotic use was calculated by using multivariate models and an indirect standardization method. Parameters in the model included age, sex, severity of underlying diseases, intensive care, haematology, preceding surgery, respirator, central venous and urinary catheters, community-associated infection, HAI and contact isolation due to methicillin-resistant Staphylococcus aureus. The ranking order changed one position in 12 (40%) hospitals and more than two positions in 13 (43%) hospitals when the case-mix-adjusted figures were compared with those observed. In 24 hospitals (80%), the antibiotic use density observed was lower than expected by the case-mix-adjusted use density. The patient case-mix adjustment of antibiotic use ranked the hospitals differently from the ranking according to observed use, and may be a useful tool for benchmarking hospital antibiotic use. However, the best set of easily and widely available parameters that would describe both patient material and hospital activities remains to be determined.

A 10 year epidemiological study of paediatric burns at the Welsh Centre for burns and plastic surgery.

PubMed

Sanyaolu, Leigh; Javed, Muhammad Umair; Eales, Micheal; Hemington-Gorse, Sarah

2017-05-01

Paediatric burns make up a significant proportion of burn injured patients seen within the hospital setting and worldwide account for a significant proportion of unintentional deaths. Currently there is limited data on severe paediatric burns requiring intensive care support. Our study aimed primarily to describe the epidemiology of severe burns admitted to the intensive care unit at our centre receiving fluid resuscitation over a 10 year period. A secondary aim was to describe the referrals patterns in general over the same time period. A retrospective analysis was performed for paediatric patients referred to our centre receiving fluid resuscitation and intensive care support from 2003 to 2013. We also analysed the patterns of referrals, admissions and need for surgical intervention over the same time period retrospectively. Children less than 5 years old made up 65% of admissions to intensive care and scald injuries (56%) were the commonest aetiology. Both total length of stay (25 days in 2003 to 10 days in 2013) and intensive care length of stay (7.2 days in 2003 to 3 days in 2013) decreased during the study and less patients underwent operative intervention. Referrals to our centre increased from 261 in 2003 to 366 in 2013, however admission rates declined from 145 to 85 during that time period. Currently there is limited data on severe burns within the paediatric population. Our study provides epidemiological data in this area, an important step for developing future prevention strategies. Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.

Encouraging consumption of water in school and child care settings: access, challenges, and strategies for improvement.

PubMed

Patel, Anisha I; Hampton, Karla E

2011-08-01

Children and adolescents are not consuming enough water, instead opting for sugar-sweetened beverages (sodas, sports and energy drinks, milks, coffees, and fruit-flavored drinks with added sugars), 100% fruit juice, and other beverages. Drinking sufficient amounts of water can lead to improved weight status, reduced dental caries, and improved cognition among children and adolescents. Because children spend most of their day at school and in child care, ensuring that safe, potable drinking water is available in these settings is a fundamental public health measure. We sought to identify challenges that limit access to drinking water; opportunities, including promising practices, to increase drinking water availability and consumption; and future research, policy efforts, and funding needed in this area.

Safety Profile during Initiation of Propranolol for Treatment of Infantile Hemangiomas in an Ambulatory Day-Care Hospitalization Setting.

PubMed

Fogel, Itay; Ollech, Ayelet; Zvulunov, Alex; Valdman-Greenshpon, Yulia; Atar-Sagie, Vered; Friedland, Rivka; Lapidoth, Moshe; Ben-Amitai, Dan

2018-03-24

Propranolol is the mainstay of treatment for infantile hemangioma. Despite its good safety profile, it is not risk-free. Guidelines for propranolol initiation and monitoring have been suggested, but protocols vary among practitioners. This study sought to assess the prevalence of adverse events and clinically significant fluctuations in hemodynamic parameters in children with infantile hemangioma during initiation of treatment with propranolol in a day-hospitalization setting. Children with infantile hemangioma treated with propranolol in a day-hospitalization department of a tertiary pediatric medical center in 2008-2014 were identified retrospectively. The pretreatment evaluation included clinical examination by a pediatric dermatologist and electrocardiography, echocardiography, and clinical examination by a pediatric cardiologist. The propranolol dosage was escalated from 0.5mg/kg/day to 2mg/kg/day, divided into 3 doses/day, over 3 days. Heart rate, blood pressure, and blood glucose level were measured before treatment onset and 60 min after the first two doses each day. The third dose was given at home. The cohort included 220 children aged 1 month to 5 years. No severe treatment-related adverse events were documented; 27 patients had minor side effects. There was a significant decrease in heart rate each day after the first two doses (p<0.001), and in systolic blood pressure, on day 2 (1mg/kg/day) after the first dose (p=0.01). Blood glucose level remained stable. The hemodynamic changes were clinically asymptomatic and did not require intervention. Propranolol treatment (2mg/kg/day in three doses) for infantile hemangioma is well tolerated and safe and may be administered and monitored in an ambulatory setting. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Prioritizing the organization and management of intensive care services in the United States: the PrOMIS Conference.

PubMed

Barnato, Amber E; Kahn, Jeremy M; Rubenfeld, Gordon D; McCauley, Kathleen; Fontaine, Dorrie; Frassica, Joseph J; Hubmayr, Rolf; Jacobi, Judith; Brower, Roy G; Chalfin, Donald; Sibbald, William; Asch, David A; Kelley, Mark; Angus, Derek C

2007-04-01

Adult critical care services are a large, expensive part of U.S. health care. The current agenda for response to workforce shortages and rising costs has largely been determined by members of the critical care profession without input from other stakeholders. We sought to elicit the perceived problems and solutions to the delivery of critical care services from a broad set of U.S. stakeholders. A consensus process involving purposive sampling of identified stakeholders, preconference Web-based survey, and 2-day conference. Participants represented healthcare providers, accreditation and quality-oversight groups, federal sponsoring institutions, healthcare vendors, and institutional and individual payers. We identified 39 stakeholders for the field of critical care medicine. Thirty-six (92%) completed the preconference survey and 37 (95%) attended the conference. None. Participants expressed moderate to strong agreement with the concerns identified by the critical care professionals and additionally expressed consternation that the critical care delivery system was fragmented, variable, and not patient-centered. Recommended solutions included regionalizing the adult critical care system into "tiers" defined by explicit triage criteria and professional competencies, achieved through voluntary hospital accreditation, supported through an expanded process of competency certification, and monitored through process and outcome surveillance; implementing mechanisms for improved communication across providers and settings and between providers and patients/families; and conducting market research and a public education campaign regarding critical care's promises and limitations. This consensus conference confirms that agreement on solutions to complex healthcare delivery problems can be achieved and that problem and solution frames expand with broader stakeholder participation. This process can be used as a model by other specialties to address priority setting in an era of shifting demographics and increasing resource constraints.

Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs

PubMed Central

Richards, David A; Meakins, Joan; Tawfik, Jane; Godfrey, Lesley; Dutton, Evelyn; Richardson, Gerald; Russell, Daphne

2002-01-01

Objective To compare the workloads of general practitioners and nurses and costs of patient care for nurse telephone triage and standard management of requests for same day appointments in routine primary care. Design Multiple interrupted time series using sequential introduction of experimental triage system in different sites with repeated measures taken one week in every month for 12 months. Setting Three primary care sites in York. Participants 4685 patients: 1233 in standard management, 3452 in the triage system. All patients requesting same day appointments during study weeks were included in the trial. Main outcome measures Type of consultation (telephone, appointment, or visit), time taken for consultation, presenting complaints, use of services during the month after same day contact, and costs of drugs and same day, follow up, and emergency care. Results The triage system reduced appointments with general practitioner by 29-44%. Compared with standard management, the triage system had a relative risk (95% confidence interval) of 0.85 (0.72 to 1.00) for home visits, 2.41 (2.08 to 2.80) for telephone care, and 3.79 (3.21 to 4.48) for nurse care. Mean overall time in the triage system was 1.70 minutes longer, but mean general practitioner time was reduced by 2.45 minutes. Routine appointments and nursing time increased, as did out of hours and accident and emergency attendance. Costs did not differ significantly between standard management and triage: mean difference £1.48 more per patient for triage (95% confidence interval –0.19 to 3.15). Conclusions Triage reduced the number of same day appointments with general practitioners but resulted in busier routine surgeries, increased nursing time, and a small but significant increase in out of hours and accident and emergency attendance. Consequently, triage does not reduce overall costs per patient for managing same day appointments. What is already known on this topicNurse telephone triage is used to manage the increasing demand for same day appointments in general practiceEvidence that nurse telephone triage is effective is limitedWhat this study addsTriage resulted in 29-44% fewer same day appointments with general practitioners than standard managementNursing and overall time increased in the triage group as 40% of patients were managed by nursesTriage was not less costly than standard management because of increased costs for nursing, follow up, out of hours, and accident and emergency care PMID:12446539

The Costs of Waiting: Implications of the Timing of Palliative Care Consultation among a Cohort of Decedents at a Comprehensive Cancer Center.

PubMed

Scibetta, Colin; Kerr, Kathleen; Mcguire, Joseph; Rabow, Michael W

2016-01-01

Palliative care is recommended along with oncologic care for patients with advanced cancer. However, there are limited data about how the timing of palliative care affects quality and costs. Comparison of health care utilization and care quality for patients with cancer who died having received early versus late palliative care. Analysis of cancer registry, administrative, and billing databases. Patients with cancer who died having received specialty palliative care consultation. Comparing early (more than 90 days prior to death) versus late (less than 90 days prior to death) palliative care, outcome measures included rates of health care utilization and health care costs. Among 922 decedents, 297 (32.2%) had palliative care referrals, with 93 (10.1%) receiving early referrals and 204 (22.1%) late referrals. Compared to patients receiving late palliative care, early palliative care patients had lower rates of inpatient (33% versus 66%, p < 0.01), ICU (5% versus 20%, p < 0.01), and ED utilization (34% versus 54%, p = 0.04) in the last month of life. Direct costs of inpatient care in the last 6 months of life for patients with early palliative care were lower compared to late palliative care ($19,067 versus $25,754, p < 0.01), while direct outpatient costs were similar ($13,040 versus $11,549, p = 0.85). Early palliative care was predominantly delivered in the outpatient setting (84%) while late palliative care was mostly delivered in the hospital (82%). Early palliative care is associated with less intensive medical care, improved quality outcomes, and cost savings at the end of life for patients with cancer. Despite recommendations that early palliative care be offered to all patients with metastatic cancer, palliative care services remain underutilized.

Parent-to-parent support: a critical component of health care services for families.

PubMed

Hartman, A F; Radin, M B; McConnell, B

1992-01-01

Families of children with chronic medical conditions or disabilities face many unique difficulties. It is often necessary for them to assimilate technical medical information and participate in important decisions regarding their children's care before they have had time to adjust to their children's condition. Health care providers are not always available to help parents learn how to function in their dramatically changed roles. To adjust to their new parenting roles and work through feelings of confusion, denial, anxiety, guilt, anger, and depression, parents of children with special health care needs need opportunities to fully vent feelings, and to experience the grieving processes in their own way and at their own pace, in a nonthreatening, nonjudgmental environment. An informal support network is a powerful tool for accomplishing these tasks, for teaching day-to-day coping skills, and for supporting the establishment of new value systems that incorporate families' unique needs. The literature on family support documents ways in which parents of children with special health care needs are particularly qualified to help each other. This article briefly describes the philosophy of parent-to-parent support, its unique contributions in the health care setting, and the ways that health care providers can assist in creating an environment in which parents and professionals can work together more effectively.

Measuring fecundity with standardised estimates of expected pregnancies.

PubMed

Mikolajczyk, Rafael T; Stanford, Joseph B

2006-11-01

Approaches to measuring fecundity include the assessment of time to pregnancy and day-specific probabilities of conception (daily fecundities) indexed to a day of ovulation. In this paper, we develop an additional approach of calculating expected pregnancies based on daily fecundities indexed to the last day of the menstrual cycle. Expected pregnancies can thus be calculated while controlling for frequency and timing of coitus. Comparing observed pregnancies with expected pregnancies allows for a standardised comparison of fecundity between studies or groups within studies, and can be used to assess the effects of categorical covariates on the woman or couple level, and also on the cycle level. This can be accomplished in a minimal data set that does not necessarily require hormonal measurement or the explicit identification of ovulation. We demonstrate this approach by examining the effects of age and parity on fecundity in a data set from women monitoring their fertility cycles with the Creighton Model FertilityCare System.

Core Competencies in Integrative Pain Care for Entry-Level Primary Care Physicians.

PubMed

Tick, Heather; Chauvin, Sheila W; Brown, Michael; Haramati, Aviad

2015-11-01

The objective was to develop a set of core competencies for graduating primary care physicians in integrative pain care (IPC), using the Accreditation Council for Graduate Medical Education (ACGME) domains. These competencies build on previous work in competencies for integrative medicine, interprofessional education, and pain medicine and are proposed for inclusion in residency training. A task force was formed to include representation from various professionals who are involved in education, research, and the practice of IPC and who represent broad areas of expertise. The task force convened during a 1.5-day face-to-face meeting, followed by a series of surveys and other vetting processes involving diverse interprofessional groups, which led to the consensus of a final set of competencies. The proposed competencies focus on interprofessional knowledge, skills, and attitudes (KSAs) and are in line with recommendations by the Institute of Medicine, military medicine, and professional pain societies advocating the need for coordination and integration of services for effective pain care with reduced risk and cost and improved outcomes. These ACGME domain compatible competencies for physicians reflect the contributions of several disciplines that will need to be included in evolving interprofessional settings and underscore the need for collaborative care. These core competencies can guide the incorporation of KSAs within curricula. The learning experiences should enable medical educators and graduating primary care physicians to focus more on integrative approaches, interprofessional team-based, patient-centered care that use evidence-based, traditional and complementary disciplines and therapeutics to provide safe and effective treatments for people in pain. Wiley Periodicals, Inc.

Hospital care of children with a cleft in England

PubMed Central

Fitzsimons, Kate J; Copley, Lynn P; Deacon, Scott A; van der Meulen, Jan H

2013-01-01

Objective To analyse hospital admissions in the first 2 years of life among children with cleft lip and/or palate in England. Design Analysis of national administrative data of hospital admissions. Setting National Health Service hospitals. Patients Patients born alive between 1997 and 2008 who underwent surgical cleft repair. Outcome measures Number of admissions, including the birth episode, and days spent in hospital were examined. Children were analysed according to cleft type and whether or not they had additional congenital anomalies. Results 10 892 children were included. In their first 2 years, children without additional anomalies (n=8482) had on average 3.2 admissions and 13.2 days in hospital, which varied from 2.6 admissions and 9.2 days with cleft lip to 4.7 admissions and 19.7 days with bilateral cleft lip and palate (BCLP). Children with additional anomalies (n=2410) had on average 6.7 admissions and 51.4 days in hospital, which varied from 6.4 admissions and 48.5 days with cleft palate to 8.8 admissions and 67.5 days with BCLP. The mean number and duration of cleft-related admissions was similar in children without (1.6 admissions and 6.4 days) and in those with additional anomalies (1.5 admissions and 8.5 days). 35.2% of children without additional anomalies had at least one emergency admission, whereas the corresponding figure was 67.3% with additional anomalies. Conclusions The burden of hospital care in the first 2 years of life varied according to cleft type and presence of additional anomalies. However, cleft-specific hospital care did not differ between children with and without additional anomalies. PMID:23968774

Experience with Kangaroo mother care in a neonatal intensive care unit (NICU) in Chandigarh, India.

PubMed

Parmar, Veena Rani; Kumar, Ajay; Kaur, Rupinder; Parmar, Siddharth; Kaur, D; Basu, Srikant; Jain, Suksham; Narula, Sunny

2009-01-01

To study the feasibility and acceptability of Kangaroo mother care (KMC) on the low birth weight infants (LBWI) in the neonatal intensive care unit (NICU) by the mothers, family members and health care workers (HCW) and to observe its effect on the vital parameters of the babies. A observation in the NICU. A total of 135 babies (74 boys and 61 girls) who completed minimum of 4 hrs of KMC/day, were included. The mean birth weight and gestation were 1460 gm and 30 week respectively. 47% babies started KMC within first week of age. Mean duration of KMC was 7 days (3-48) days. The O(2) saturation improved by 2-3%, temperature ( degrees C) rose from 36.75 +/- 0.19 to 37.23 +/- 0.25, respiration stabilized (p<0.05 for all) and heart rate dropped by 3-5 beats. No episodes of hypothermia or apnea were observed during KMC. KMC was accepted by 96 % mothers, 82% fathers and 84% other family members. 94% HCW considered it to be safe and conservative method of care of LBWI. Benefits of KMC on the babies' behavior and on maternal confidence and lactation were reported by 57%, 94% and 80% respectively. A decline in use of heating devices in the NICU was reported by 85% and 79% said it did not increase their work load. KMC was found to be safe, effective and feasible method of care of LBWI even in the NICU settings. Positive attitudes were observed in mothers, families and HCW.

Interprofessional care collaboration for patients with heart failure.

PubMed

Boykin, Amanda; Wright, Danielle; Stevens, Lydia; Gardner, Lauren

2018-01-01

An innovative collaborative care model to improve transitions of care (TOC) for patients with heart failure (HF) is described. As part of a broad effort by New Hanover Regional Medical Center (NHRMC) to reduce avoidable 30-day hospital readmissions and decrease associated healthcare costs through a team-centered, value-based approach to patient care, an interprofessional team was formed to help reduce hospital readmissions among discharged patients with HF. The team consists of 5 TOC pharmacists, 4 community paramedics, and 4 advanced care practitioners (ACPs) who collaborate to coordinate care and prevent 30-day readmissions among patients with HF transitioning from the hospital to the community setting. Each team member plays an integral role in providing high-quality postdischarge care. The TOC pharmacist ensures that patients have access to all needed medications, provides in-home medication reconciliation services, makes medication recommendations, and alerts the team of potential medication-related issues. Community paramedics conduct home visits consisting of physical and mental health assessments, diet and disease state education, reviews of medication bottles and education on proper medication use, and administration of i.v. diuretics to correct volume status under provider orders. The ACPs offer close clinic follow-up (typically initiated within 7 days of discharge) as well as long-term HF management and education. At NHRMC, collaboration among healthcare professionals, including a TOC pharmacist, community paramedics, and ACPs, has assisted in the growth and expansion of services provided to patients with HF. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

"Observation-Projet": A Professional Tool for Caregivers. Two Experiences in Italian Day-Care Settings

ERIC Educational Resources Information Center

Molina, Paola; Marotta, Monica; Bulgarelli, Daniela

2016-01-01

Ability to reflect on practice is a key element of early childhood professionalism and is positively associated with the quality of educational services. "Observation-Projet" (Fontaine 2008, 2011b) is a method designed to support practitioners' reflection through the observational process. The method adapts the required scientific…

An Innovative Program in Social Work Education

ERIC Educational Resources Information Center

Peleg-Oren, Neta; Aran, Ofra; Even-Zahav, Ronit; Macgowan, Mark J.; Stanger, Varda

2007-01-01

This paper is a report of an innovative program in social work education to enrich field supervisors and students with the latest theories and practices related to social work practice in health care settings. This program consists of a study day organized jointly by academic faculty, field supervisors, and students, conducted once a year between…

CTEPP STANDARD OPERATING PROCEDURE FOR COLLECTION OF FIXED SITE INDOOR AND OUTDOOR AIR SAMPLES FOR PERSISTENT ORGANIC POLLUTANTS (SOP-2.12)

EPA Science Inventory

This SOP describes the procedures to set up, calibrate, initiate and terminate air sampling for persistent organic pollutants. This method is used to sample air, indoors and outdoors, at homes and at day care centers over a 48-hr period.

Teaching Third-Year Medical Students how to Care for Terminally Ill Patients.

ERIC Educational Resources Information Center

Martin, Robert W.; Wylie, Norma

1989-01-01

A successful seven-day course offered to third-year medical students is an integrated program for teaching them how to deal with terminal illness. The course uses lectures, audiovisual aids, and group and individual sessions to enhance self-awareness and practical application of the material in a clinical setting. (Author/MSE)

Preschool Inclusion: Navigating through Alphabet Soup

ERIC Educational Resources Information Center

Lytle, Rebecca; Bordin, Judith

2005-01-01

The number of preschool-aged children with disabilities who spend some part of their day in an inclusive school or child care setting has grown tremendously in the past ten years. Meeting the needs of these children is always challenging. However, Public Law 105-17 the Individuals with Disabilities Education Act (IDEA'97) mandates that children…

A Day at the Improv.... The Assessment and Treatment of Musculoskeletal Injuries in the Backcountry.

ERIC Educational Resources Information Center

Cochran, Brent

Outdoor leaders and those involved in personal outdoor adventure pursuits must be knowledgeable in the assessment, treatment, and prevention of musculoskeletal injuries in the backcountry. In the wilderness medicine setting, extended time periods of patient care, rugged terrain, severe environmental conditions, and limited resources create…

[Application of the Balance of Care model in decision-making regarding the best care for patients with dementia].

PubMed

Risco, Ester; Zabalegui, Adelaida; Miguel, Susana; Farré, Marta; Alvira, Carme; Cabrera, Esther

To describe the implementation of the Balance of Care model in decision-making regarding the best care for patients with dementia in Spain. The Balance of Care model was used, which consists of (1) describing the profile of the typical cases of people with dementia and their caregivers, (2) identifying the most suitable care setting for each of the cases (home-care or long-term care institution), (3) designing specific care plans for each case, and (4) evaluating the cost of the proposed care plans. A total of 1,641 people with dementia and their caregivers from eight European countries were used in the case design. The evaluation of cases was conducted by 20 experts in different medical fields of dementia. In Spain, the results indicated that initially the most suitable placement to take care of people with dementia was the home, however in cases with higher dependency in activities of daily living, the long-term care setting was the best option. For the best care plan, the following resources were chosen: professional help to perform basic activities; day center; multidisciplinary home care team; financial support; community nurse; and social worker. The Balance of Care method allows us to assess the most appropriate place of care for people with dementia systematically, objectively and with a multidisciplinary team. Other cost-effective interventions should be integrated in patients with dementia care in order to improve home care. Copyright © 2016 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

Mental health recovery on care farms and day centres: a qualitative comparative study of users' perspectives.

PubMed

Iancu, Sorana C; Zweekhorst, Marjolein B M; Veltman, Dick J; van Balkom, Anton J L M; Bunders, Joske F G

2014-01-01

Mental health services increasingly incorporate the vision of recovery. This qualitative study analysed and compared experiences of recovery on prevocational services, in order to assess if users make progress towards recovery, relative to a staged recovery model. Data were collected through semi-structured interviews with participants on care farms (n = 14), work (n = 7) and creative projects (n = 5). The transition from past to current lives was described as a progressive, non-linear process, with different stages guided by different goals. Participants on creative projects lacked clear goals, presented less interest in peers and high need for emotional support. Participants on work projects aimed for occupational rehabilitation, but struggled with the patient culture of the peer community. Participants on care farms aimed for daytime occupations and closer contact with society. They experienced care farms as open, real-life work settings where they could exercise responsibility and connect with people. Participants progressed towards recovery, as care farms, work- and creative projects empowered them to leave behind inactive, isolated or disorganized living. In day centres, users focused on self-reflection and personal development (creative projects) or on occupational performance (work projects), whereas on care farms, users fulfilled worker roles in a real-life, open community environment. Organized as open communities in real-life settings, care farms facilitate the reflection on personal and social responsibility, and therefore have the potential to help users internalize worker identities and improve their motivation to progress towards recovery. Supervisors on care farms are regarded by users as close contacts within the social networks they develop on the service, a position that allows supervisors to actively engage and promote users' progress towards recovery. Elements of the farm environment (such as the "normal life", presence of family members and visitors, and nature) can serve as anchors for supporting the progress towards recovery.

The relationship between nurses' stress and nurse staffing factors in a hospital setting.

PubMed

Purcell, Stacey R; Kutash, Mary; Cobb, Sarah

2011-09-01

The present study objective was to examine the relationships between nurses' stress and nurse staffing in a hospital setting. Nurses have many job-related stressors. There is a lack of research exploring the relationship between job stressors to staffing and day of week worked. The sample consisted of registered nurses (RNs) (N = 197) providing direct patient care. Data were collected via electronic software. Variables included demographic information, work setting information, Perceived Stress Scale (PSS) scores and Nursing Stress Scale (NSS) scores. Data analysis included descriptive statistics, correlations and analysis of variance. Among respondents, a positive correlation (r = 0.363, P  0.05) was found between the NSS and PSS and between age and patient work load (i.e. number of patients the nurse cared for) (r = 0.218, P < 0.05). A negative correlation (r = -0.142, P < 0.05) existed between NSS and respondents' age. Analysis of variance showed that younger nurses had more nursing stress than older nurses (F(1,195) = 4.283, P < 0.05). Age, patient work load and day of the week worked are important factors affecting nurses' stress levels. IMPLICATIONS FOR NURSING MANAGEMEN: Nurse managers should consider scheduling as a potential stressor for nurses. 2011 Blackwell Publishing Ltd.

Early identification of work-related stress predicted sickness absence in employed women with musculoskeletal or mental disorders: a prospective, longitudinal study in a primary health care setting.

PubMed

Holmgren, Kristina; Fjällström-Lundgren, Malin; Hensing, Gunnel

2013-03-01

The objectives were to identify work-related stress, and to analyse whether or not work-related stress served to predict sick-leave in a population of employed women who saw a doctor due to musculoskeletal or mental disorder at primary health care centres. This prospective study was based on data collected with the Work Stress Questionnaire (WSQ) at baseline 2008 and at follow-up 2009 in the primary health care centres in western Sweden. A total of 198 women participated. High perceived stress owing to indistinct organization and conflicts at baseline increased the risk for sick-leave 8 days or longer at follow-up. The adjusted relative risk (RR) was 2.50 (1.14-5.49). The combination of high stress perception owing to indistinct organization and high stress perception owing to individual demands and commitment increased the risk for sickness absence of 8 days or longer with an adjusted RR of 4.34 (1.72-10.99). Work-related stress predicted sick-leave during the follow-up at 12 months. The WSQ seemed to be useful in identifying women at risk of future sick-leave. Thus, it can be recommended to introduce questions and questionnaires on work-related stress in primary health care settings to early identify women with the need for preventive measures in order to decrease risk for sick-leave due to work-related stress.

Impact of an antimicrobial stewardship program with multidisciplinary cooperation in a community public teaching hospital in Taiwan.

PubMed

Lin, Yu-Shiuan; Lin, I-Fen; Yen, Yung-Feng; Lin, Pei-Ching; Shiu, Yu-Chih; Hu, Hsing-Yi; Yang, Ying-Pi

2013-11-01

Reports of antimicrobial stewardship programs (ASPs) in community hospitals are limited, with the major focus on specific agents, small settings, or short time periods. Here we present the outcomes of cost control, consumption restraint, and quality of care after a 3-year multidisciplinary ASP in a 415-bed community public teaching hospital. Three strategies for improving antimicrobial stewardship were implemented: education, clinical pharmacists-based intervention, and regular outcome announcement. The steering panel of the program was a committee composed of infection specialists, attending physicians, clinical pharmacists, nurses, and medical laboratorists. Semiannual data from July 2009 to June 2012 was analyzed. Antibiotic costs declined from $21,464 to $12,146 per 1,000 patient-days (-43.4%). Approximately $2.5 million was saved in 3 years, and estimated labor cost was $3,935 per month. Defined daily dose per 1,000 patient-days were diminished from 906.7 to 717.5 (-20.9%). Significant reductions were found in the consumption of aminoglycosides, first-generation cephalosporins, and aminopenicillins. However, through comprehensive auditing, increasing consumption of fourth-generation cephalosporins and fluoroquinolones was noticed. No significant difference in the quality of care (ie, length of stay, incidence of health care associated infections, and mortality) was observed. The multidisciplinary ASP was beneficial to reduce antibiotic cost and consumption. The strategies were practical and worthy to be recommended to community health care settings. Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition -- Heart Failure (BEAT-HF) Randomized Clinical Trial.

PubMed

Ong, Michael K; Romano, Patrick S; Edgington, Sarah; Aronow, Harriet U; Auerbach, Andrew D; Black, Jeanne T; De Marco, Teresa; Escarce, Jose J; Evangelista, Lorraine S; Hanna, Barbara; Ganiats, Theodore G; Greenberg, Barry H; Greenfield, Sheldon; Kaplan, Sherrie H; Kimchi, Asher; Liu, Honghu; Lombardo, Dawn; Mangione, Carol M; Sadeghi, Bahman; Sadeghi, Banafsheh; Sarrafzadeh, Majid; Tong, Kathleen; Fonarow, Gregg C

2016-03-01

It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization. To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF. We randomized 1437 patients hospitalized for HF between October 12, 2011, and September 30, 2013, to the intervention arm (715 patients) or to the usual care arm (722 patients) of the Better Effectiveness After Transition-Heart Failure (BEAT-HF) study and observed them for 180 days. The dates of our study analysis were March 30, 2014, to October 1, 2015. The setting was 6 academic medical centers in California. Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF. The intervention combined health coaching telephone calls and telemonitoring. Telemonitoring used electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. Centralized registered nurses conducted telemonitoring reviews, protocolized actions, and telephone calls. The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life at 30 and 180 days. Among 1437 participants, the median age was 73 years. Overall, 46.2% (664 of 1437) were female, and 22.0% (316 of 1437) were African American. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported. Among patients hospitalized for HF, combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions. clinicaltrials.gov Identifier: NCT01360203.

Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial)

PubMed Central

Goldberg, Sarah E; Bradshaw, Lucy E; Kearney, Fiona C; Russell, Catherine; Whittamore, Kathy H; Foster, Pippa E R; Mamza, Jil; Gladman, John R F; Jones, Rob G; Lewis, Sarah A; Porock, Davina

2013-01-01

Objective To develop and evaluate a best practice model of general hospital acute medical care for older people with cognitive impairment. Design Randomised controlled trial, adapted to take account of constraints imposed by a busy acute medical admission system. Setting Large acute general hospital in the United Kingdom. Participants 600 patients aged over 65 admitted for acute medical care, identified as “confused” on admission. Interventions Participants were randomised to a specialist medical and mental health unit, designed to deliver best practice care for people with delirium or dementia, or to standard care (acute geriatric or general medical wards). Features of the specialist unit included joint staffing by medical and mental health professionals; enhanced staff training in delirium, dementia, and person centred dementia care; provision of organised purposeful activity; environmental modification to meet the needs of those with cognitive impairment; delirium prevention; and a proactive and inclusive approach to family carers. Main outcome measures Primary outcome: number of days spent at home over the 90 days after randomisation. Secondary outcomes: structured non-participant observations to ascertain patients’ experiences; satisfaction of family carers with hospital care. When possible, outcome assessment was blind to allocation. Results There was no significant difference in days spent at home between the specialist unit and standard care groups (median 51 v 45 days, 95% confidence interval for difference −12 to 24; P=0.3). Median index hospital stay was 11 versus 11 days, mortality 22% versus 25% (−9% to 4%), readmission 32% versus 35% (−10% to 5%), and new admission to care home 20% versus 28% (−16% to 0) for the specialist unit and standard care groups, respectively. Patients returning home spent a median of 70.5 versus 71.0 days at home (−6.0 to 6.5). Patients on the specialist unit spent significantly more time with positive mood or engagement (79% v 68%, 2% to 20%; P=0.03) and experienced more staff interactions that met emotional and psychological needs (median 4 v 1 per observation; P<0.001). More family carers were satisfied with care (overall 91% v 83%, 2% to 15%; P=0.004), and severe dissatisfaction was reduced (5% v 10%, −10% to 0%; P=0.05). Conclusions Specialist care for people with delirium and dementia improved the experience of patients and satisfaction of carers, but there were no convincing benefits in health status or service use. Patients’ experience and carers’ satisfaction might be more appropriate measures of success for frail older people approaching the end of life. Trial registration Clinical Trials NCT01136148 PMID:23819964

IMPACT: Investigating the impact of Models of Practice for Allied health Care in subacuTe settings. A protocol for a quasi-experimental mixed methods study of cost effectiveness and outcomes for patients exposed to different models of allied health care.

PubMed

Coker, Freya; Williams, Cylie M; Taylor, Nicholas F; Caspers, Kirsten; McAlinden, Fiona; Wilton, Anita; Shields, Nora; Haines, Terry P

2018-05-10

This protocol considers three allied health staffing models across public health subacute hospitals. This quasi-experimental mixed-methods study, including qualitative process evaluation, aims to evaluate the impact of additional allied health services in subacute care, in rehabilitation and geriatric evaluation management settings, on patient, health service and societal outcomes. This health services research will analyse outcomes of patients exposed to different allied health models of care at three health services. Each health service will have a control ward (routine care) and an intervention ward (additional allied health). This project has two parts. Part 1: a whole of site data extraction for included wards. Outcome measures will include: length of stay, rate of readmissions, discharge destinations, community referrals, patient feedback and staff perspectives. Part 2: Functional Independence Measure scores will be collected every 2-3 days for the duration of 60 patient admissions.Data from part 1 will be analysed by linear regression analysis for continuous outcomes using patient-level data and logistic regression analysis for binary outcomes. Qualitative data will be analysed using a deductive thematic approach. For part 2, a linear mixed model analysis will be conducted using therapy service delivery and days since admission to subacute care as fixed factors in the model and individual participant as a random factor. Graphical analysis will be used to examine the growth curve of the model and transformations. The days since admission factor will be used to examine non-linear growth trajectories to determine if they lead to better model fit. Findings will be disseminated through local reports and to the Department of Health and Human Services Victoria. Results will be presented at conferences and submitted to peer-reviewed journals. The Monash Health Human Research Ethics committee approved this multisite research (HREC/17/MonH/144 and HREC/17/MonH/547). © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Parents are reluctant to use technological means of communication in pediatric day care.

PubMed

Murto, Kimmo; Bryson, Gregory L; Abushahwan, Ibrahim; King, Jim; Moher, David; El-Emam, Khaled; Splinter, William

2008-04-01

We hypothesized that advanced information and communication technology (ICT) would be acceptable to parents in a pediatric surgical, and diagnostic imaging day care setting. After Ethics Committee approval, we distributed surveys, over a one-month period, to parents of children arriving for day care surgery or diagnostic imaging. Parents indicated their acceptance of various proposed modes of postoperative discussion of healthcare i.e.; face-to-face, videophone, or telephone. Parents were also asked to describe their receptiveness to scheduling non-emergency hospital appointments online and to receiving electronic media describing their child's surgery and postoperative management. Parental education, income, and familiarity with the Internet were also assessed. A total of 451 surveys (84% response rate) were returned. Most parents (95%) had access to the Internet and 70% did their banking online. Forty-two percent of the parents had at least a university education and 63% had an annual family income > $50,000 Canadian. The majority of parents (98%) accepted face-to-face interaction, while only 35% and 37% of parents were receptive to videophone and telephone interviews, respectively. Computer availability (P = 0.001) and online banking (P = 0.011) were the only variables that predicted those parents who were in favour of using videophone technology. Parents were receptive to instruction electronic media (80%) and booking appointments online (61%). A well-educated and technologically sophisticated parent population does not favour advanced communication technologies over simple, face-to-face interaction in an in-hospital setting. These parents are prepared to receive technology-based information about their child's surgery and to schedule non-emergency hospital appointments online.

Legal Protections in Public Accommodations Settings: A Critical Public Health Issue for Transgender and Gender-Nonconforming People.

PubMed

Reisner, Sari L; Hughto, Jaclyn M White; Dunham, Emilia E; Heflin, Katherine J; Begenyi, Jesse Blue Glass; Coffey-Esquivel, Julia; Cahill, Sean

2015-09-01

Since 2012, Massachusetts law has provided legal protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not protect against discrimination based on gender identity in public accommodations settings such as transportation, retail stores, restaurants, health care facilities, and bathrooms. A 2013 survey of Massachusetts transgender and other gender minority adults found that in the past 12 months, 65% had experienced public accommodations discrimination since the law was passed. This discrimination was associated with a greater risk of adverse emotional and physical symptoms in the past 30 days. Nondiscrimination laws inclusive of gender identity should protect against discrimination in public accommodations settings to support transgender people's health and their ability to access health care. Gender minority people who are transgender or gender nonconforming experience widespread discrimination and health inequities. Since 2012, Massachusetts law has provided protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not, however, protect against discrimination in public accommodations (eg, hospitals, health centers, transportation, nursing homes, supermarkets, retail establishments). For this article, we examined the frequency and health correlates of public accommodations discrimination among gender minority adults in Massachusetts, with attention to discrimination in health care settings. In 2013, we recruited a community-based sample (n = 452) both online and in person. The respondents completed a 1-time, electronic survey assessing demographics, health, health care utilization, and discrimination in public accommodations venues in the past 12 months. Using adjusted multivariable logistic regression models, we examined whether experiencing public accommodations discrimination in health care was independently associated with adverse self-reported health, adjusting for discrimination in other public accommodations settings. Overall, 65% of respondents reported public accommodations discrimination in the past 12 months. The 5 most prevalent discrimination settings were transportation (36%), retail (28%), restaurants (26%), public gatherings (25%), and health care (24%). Public accommodations discrimination in the past 12 months in health care settings was independently associated with a 31% to 81% increased risk of adverse emotional and physical symptoms and a 2-fold to 3-fold increased risk of postponement of needed care when sick or injured and of preventive or routine health care, adjusting for discrimination in other public accommodations settings (which also conferred an additional 20% to 77% risk per discrimination setting endorsed). Discrimination in public accommodations is common and is associated with adverse health outcomes among transgender and gender-nonconforming adults in Massachusetts. Discrimination in health care settings creates a unique health risk for gender minority people. The passage and enforcement of transgender rights laws that include protections against discrimination in public accommodations-inclusive of health care-are a public health policy approach critically needed to address transgender health inequities. © 2015 Milbank Memorial Fund.

Ten clinician-driven strategies for maximising value of Australian health care.

PubMed

Scott, Ian

2014-05-01

To articulate the concept of high-value care (i.e. clinically relevant, patient-important benefit at lowest possible cost) and suggest strategies by which clinicians can promote such care in rendering the Australian healthcare system more affordable and sustainable. Strategies were developed by the author based on personal experience in clinical practice, evidence-based medicine and quality improvement. Relevant literature was reviewed in retrieving studies supporting each strategy. Ten strategies were developed: (1) minimise errors in diagnosis; (2) discontinue low- or no-value practices that provide little benefit or cause harm; (3) defer the use of unproven interventions; (4) select care options according to comparative cost-effectiveness; (5) target clinical interventions to those who derive greatest benefit; (6) adopt a more conservative approach nearing the end of life; (7) actively involve patients in shared decision making and self-management; (8) minimise day-to-day operational waste; (9) convert healthcare institutions into rapidly learning organisations; and (10) advocate for integrated patient care across all clinical settings. Clinicians and their professional organisations, in partnership with managers, can implement strategies capable of maximising value and sustainability of health care in Australia. What is known about this topic? Value-based care has emerged as a unitary concept that integrates quality and cost, and is being increasingly used to inform healthcare policy making and reform. What does this paper add? There is scant literature that translates the concept of high value care into actionable enhancement strategies for clinicians in everyday practice settings. This article provides 10 strategies with supporting studies in an attempt to fill this gap. What are the implications for practitioners? If all practitioners, in partnership with healthcare managers, attempted to enact all 10 strategies in their workplaces, a significant quantum of healthcare resources could be redirected from low- to high-value care, culminating in much greater health benefit from the healthcare dollars currently being spent. However, such reforms will require a shift in clinician thinking and practice away from volume-based care to value-based care.

[Continuing training plan in a clinical management unit].

PubMed

Gamboa Antiñolo, Fernando Miguel; Bayol Serradilla, Elia; Gómez Camacho, Eduardo

2011-01-01

Continuing Care Unit (UCA) focused the attention of frail patients, polypathological patients and palliative care. UCA attend patients at home, consulting, day unit, telephone consulting and in two hospitals of the health area. From 2002 UCA began as a management unit, training has been a priority for development. Key elements include: providing education to the workplace, including key aspects of the most prevalent health care problems in daily work, directing training to all staff including organizational aspects of patient safety and the environment, improved working environment, development of new skills and knowledge supported by the evidence-based care for the development of different skills. The unit can be the ideal setting to undertake the reforms necessary conceptual training of professionals to improve the quality of care. 2010 SESPAS. Published by Elsevier Espana. All rights reserved.

The Prehospital Sepsis Project: out-of-hospital physiologic predictors of sepsis outcomes.

PubMed

Baez, Amado Alejandro; Hanudel, Priscilla; Wilcox, Susan Renee

2013-12-01

Severe sepsis and septic shock are common, expensive and often fatal medical problems. The care of the critically sick and injured often begins in the prehospital setting; there is limited data available related to predictors and interventions specific to sepsis in the prehospital arena. The objective of this study was to assess the predictive effect of physiologic elements commonly reported in the out-of-hospital setting in the outcomes of patients transported with sepsis. This was a cross-sectional descriptive study. Data from the years 2004-2006 were collected. Adult cases (≥18 years of age) transported by Emergency Medical Services to a major academic center with the diagnosis of sepsis as defined by ICD-9-CM diagnostic codes were included. Descriptive statistics and standard deviations were used to present group characteristics. Chi-square was used for statistical significance and odds ratio (OR) to assess strength of association. Statistical significance was set at the .05 level. Physiologic variables studied included mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR) and shock index (SI). Sixty-three (63) patients were included. Outcome variables included a mean hospital length of stay (HLOS) of 13.75 days (SD = 9.97), mean ventilator days of 4.93 (SD = 7.87), in-hospital mortality of 22 out of 63 (34.9%), and mean intensive care unit length-of-stay (ICU-LOS) of 7.02 days (SD = 7.98). Although SI and RR were found to predict intensive care unit (ICU) admissions, [OR 5.96 (CI, 1.49-25.78; P = .003) and OR 4.81 (CI, 1.16-21.01; P = .0116), respectively] none of the studied variables were found to predict mortality (MAP <65 mmHg: P = .39; HR >90: P = .60; RR >20 P = .11; SI >0.7 P = .35). This study demonstrated that the out-of-hospital shock index and respiratory rate have high predictability for ICU admission. Further studies should include the development of an out-of-hospital sepsis score.

Intergenerational care: an exploration of consumer preferences and willingness to pay for care.

PubMed

Vecchio, N; Radford, K; Fitzgerald, J A; Comans, T; Harris, P; Harris, N

2017-05-25

To identify feasible models of intergenerational care programmes, that is, care of children and older people in a shared setting, to determine consumer preferences and willingness to pay. Feasible models were constructed in extensive consultations with a panel of experts using a Delphi technique (n = 23) and were considered based on their practical implementation within an Australian setting. This informed a survey tool that captured the preferences and willingness to pay for these models by potential consumers, when compared to the status quo. Information collected from the surveys (n = 816) was analysed using regression analysis to identify fundamental drivers of preferences and the prices consumers were willing to pay for intergenerational care programmes. The shared campus and visiting models were identified as feasible intergenerational care models. Key attributes of these models included respite day care; a common educational pedagogy across generations; screening; monitoring; and evaluation of participant outcomes. Although parents were more likely to take up intergenerational care compared to the status quo, adult carers reported a higher willingness to pay for these services. Educational attainment also influenced the likely uptake of intergenerational care. The results of this study show that there is demand for the shared campus and the visiting campus models among the Australian community. The findings support moves towards consumer-centric models of care, in line with national and international best practice. This consumer-centric approach is encapsulated in the intergenerational care model and enables greater choice of care to match different consumer demands.

Same day ART initiation versus clinic-based pre-ART assessment and counselling for individuals newly tested HIV-positive during community-based HIV testing in rural Lesotho - a randomized controlled trial (CASCADE trial).

PubMed

Labhardt, Niklaus Daniel; Ringera, Isaac; Lejone, Thabo Ishmael; Masethothi, Phofu; Thaanyane, T'sepang; Kamele, Mashaete; Gupta, Ravi Shankar; Thin, Kyaw; Cerutti, Bernard; Klimkait, Thomas; Fritz, Christiane; Glass, Tracy Renée

2016-04-14

Achievement of the UNAIDS 90-90-90 targets in Sub-Sahara Africa is challenged by a weak care-cascade with poor linkage to care and retention in care. Community-based HIV testing and counselling (HTC) is widely used in African countries. However, rates of linkage to care and initiation of antiretroviral therapy (ART) in individuals who tested HIV-positive are often very low. A frequently cited reason for non-linkage to care is the time-consuming pre-ART assessment often requiring several clinic visits before ART-initiation. This two-armed open-label randomized controlled trial compares in individuals tested HIV-positive during community-based HTC the proposition of same-day community-based ART-initiation to the standard of care pre-ART assessment at the clinic. Home-based HTC campaigns will be conducted in catchment areas of six clinics in rural Lesotho. Households where at least one individual tested HIV positive will be randomized. In the standard of care group individuals receive post-test counselling and referral to the nearest clinic for pre-ART assessment and counselling. Once they have started ART the follow-up schedule foresees monthly clinic visits. Individuals randomized to the intervention group receive on the spot point-of-care pre-ART assessment and adherence counselling with the proposition to start ART that same day. Once they have started ART, follow-up clinic visits will be less frequent. First primary outcome is linkage to care (individual presents at the clinic at least once within 3 months after the HIV test). The second primary outcome is viral suppression 12 months after enrolment in the study. We plan to enrol a minimum of 260 households with 1:1 allocation and parallel assignment into both arms. This trial will show if in individuals tested HIV-positive during community-based HTC campaigns the proposition of same-day ART initiation in the community, combined with less frequent follow-up visits at the clinic could be a pragmatic approach to improve the care cascade in similar settings. NCT02692027 , registered February 21, 2016.

Effectiveness and feasibility of the early start denver model implemented in a group-based community childcare setting.

PubMed

Vivanti, Giacomo; Paynter, Jessica; Duncan, Ed; Fothergill, Hannah; Dissanayake, Cheryl; Rogers, Sally J

2014-12-01

A recent study documented the efficacy of the Early Start Denver Model (ESDM) delivered in a 1:1 fashion. In the current study we investigated the effectiveness and feasibility of the ESDM in the context of a long-day care community service, with a child-staff ratio of 1:3. Outcomes of 27 preschoolers with ASD undergoing 15-25 h per week of ESDM over 12 months were compared to those of 30 peers with ASD undergoing a different intervention program delivered in a similar community long-day care service. Children in both groups made gains in cognitive, adaptive and social skills. Participants in the ESDM group showed significantly higher gains in developmental rate and receptive language.

[Handover between home and respite care facilities : Delphi survey within the context of continuity of care for people with dementia].

PubMed

Kuske, S; Roes, M; Bartholomeyczik, S

2016-07-01

Criteria for the handover between healthcare settings were identified based on a review and on results of empirical data. This study was carried out to select the most relevant criteria for defining the quality of continuity of care of people with dementia (PwD) in the context of the handover between care at home and respite care facilities. A modified classical two-step Delphi design was used in combination with a group Delphi design. A total of 28 core criteria with a consensus strength of > 60 % are presented. Safety-relevant information, especially the personal habits of PwD and the role of informal caregivers in the handover between care settings are important. Furthermore, the following general principles to ensure the quality of continuity of the care of PwD were deduced: completeness, verification, multipath communication, timeliness and topicality, accessibility and defined responsibilities, roles and standardization. A successful transition of PwD to respite care facilities relies on the provision of relevant information, considering personal habits, before the day of transition. Furthermore, a timely preparation for discharge is important. The individual needs of the informal caregivers with regard to their support should be considered. Professionals who are responsible in handover processes should have solid communication competence in order to collect relevant information from informal caregivers, who have a strong individual care experience with the PwD.

Family Day Care in the United States: Family Day Care Systems. Final Report of the National Day Care Home Study. Volume 5.

ERIC Educational Resources Information Center

Grasso, Janet; Fosburg, Steven

Fifth in a series of seven volumes reporting the design, methodology, and findings of the 4-year National Day Care Home Study (NDCHS), this volume presents a descriptive and statistical analysis of the day care institutions that administer day care systems. These systems, such as Learning Unlimited in Los Angeles and the family day care program of…

Dental assessment prior to stem cell transplant: treatment need and barriers to care.

PubMed

Durey, K; Patterson, H; Gordon, K

2009-05-09

To assess the treatment needs of patients undergoing pre-haematopoietic stem cell transplant (HSCT) dental assessment, to collate the examination findings and treatment provided and to define the management issues impacting on care. Single centre retrospective analysis. Salaried Primary Care Dental Service, Western General Hospital, Edinburgh, UK. One hundred and sixteen available charts of patients who attended for pre-transplant dental assessment during April 2004-June 2007 were examined. Ninety-four patients, 52 men (55.3%) and 42 women (43.6%), were included. Patients were referred a mean of 31.5 (SD 18.82) days before admission for transplant. Dental assessment occurred, on average, 7.88 days (SD 6.78) following referral. Eighty-eight (93.6%) patients were dentate, while six (6.3%) were edentulous. Eighty-eight (93.6%) patients presented with oral disease; 89 (94.7%) patients received dental care. Issues impacting on care were medical (n = 88, 93.6%), time constraints (n = 73, 77.7%), no GDP (n = 25, 26.7%), dental complexity (n = 5, 5.3%) and anxiety management (n = 1, 1.1%). The majority of patients required dental care, most of which, for healthy adults, would normally be completed within a primary care setting. However, the issues surrounding the care of patients destined for HSCT indicate that there is a place for a dedicated dental service as part of the multidisciplinary team.

Effectiveness of the Certificate Course in Essentials of Palliative Care Program on the Knowledge in Palliative Care among the Participants: A Cross-sectional Interventional Study.

PubMed

Bhatnagar, Sushma; Patel, Anuradha

2018-01-01

Palliative medicine is an upcoming new specialty aimed at relieving suffering, improving quality of life and comfort care. There are many challenges and barriers in providing palliative care to our patients. The major challenge is lack of knowledge, attitude and skills among health-care providers. Evaluate the effectiveness of the certificate course in essentials of palliative care (CCEPC) program on the knowledge in palliative care among the participants. All participants ( n = 29) of the CCEPC at All India Institute of Medical Sciences, Delhi, giving consent for pretest and posttest were recruited in the study. This educational lecture of 15 h was presented to all the participants following pretest and participants were given same set of questionnaire to be filled as postintervention test. In pretest, 7/29 (24.1%) had good knowledge which improved to 24/29 (82.8%) after the program. In pretest, 62.1% had average knowledge and only 13.8% had poor knowledge. There was also improvement in communication skills, symptom management, breaking bad news, and pain assessment after completion of the program. The CCEPC is an effective program and improving the knowledge level about palliative care among the participants. The participants should implement this knowledge and the skills in their day-to-day practice to improve the quality of life of patients.

A randomized, controlled trial of diathermy hemorrhoidectomy vs. stapled hemorrhoidectomy in an intended day-care setting with longer-term follow-up.

PubMed

Cheetham, M J; Cohen, C R G; Kamm, M A; Phillips, R K S

2003-04-01

Hemorrhoidectomy is the most effective long-term treatment for hemorrhoids. Although it is possible to perform hemorrhoidectomy as a day case with a high degree of patient satisfaction, patients take an average of 14 days off work after surgery. Stapled hemorrhoidectomy is believed to be less painful than conventional hemorrhoidectomy and should allow an earlier return to work. The aim of this study was to compare both the immediate and the long-term results of stapled hemorrhoidectomy with diathermy hemorrhoidectomy in patients with prolapsing internal hemorrhoids in an intended day-care setting. Thirty-one patients were randomly assigned to undergo diathermy hemorrhoidectomy (n = 16) or stapled hemorrhoidectomy performed with a purpose-designed endoluminal stapling device, PPH01T (n = 15). All operations were planned as day or short-stay cases. All patients received lactulose, commenced preoperatively, together with postoperative topical glyceryl trinitrate and oral metronidazole. Patients were assessed by structured interview to assess their symptoms before and after surgery, with an intended follow-up of six months. All patients completed a 10-cm visual analog pain scale daily for the first ten days after surgery. The total pain score (sum of all pain scores) was significantly higher in the diathermy group (50 (range, 9.8-79.9) vs. 19.6 (range, 1.3-89.5), P = 0.03). Patients took a median of 14 (range, 3-21) days off work after diathermy hemorrhoidectomy compared with 10 (range, 3-38) days for the patients undergoing stapled hemorrhoidectomy (P = 0.15). At long-term follow-up, three patients (all in the stapled group) developed new symptoms of fecal urgency and anal pain, and three patients required further surgery to remove symptomatic external hemorrhoids after stapled hemorrhoidectomy. Although stapled hemorrhoidectomy is less painful in the short term, this does not lead to a significantly earlier return to work, and some patients develop new symptoms at long-term follow-up.

Day Care: A Program in Search of a Policy.

ERIC Educational Resources Information Center

Bikales, Gerda

This report examines current issues relating to day care and challenges many of the policy assumptions that underlie a major public program of subsidized day care for children. A historical perspective of day care is presented and various types of day care are described. The costs and benefits of day care are examined and the relation of day care…

Patients' perception of types of errors in palliative care - results from a qualitative interview study.

PubMed

Kiesewetter, Isabel; Schulz, Christian; Bausewein, Claudia; Fountain, Rita; Schmitz, Andrea

2016-08-11

Medical errors have been recognized as a relevant public health concern and research efforts to improve patient safety have increased. In palliative care, however, studies on errors are rare and mainly focus on quantitative measures. We aimed to explore how palliative care patients perceive and think about errors in palliative care and to generate an understanding of patients' perception of errors in that specialty. A semistructured qualitative interview study was conducted with patients who had received at least 1 week of palliative care in an inpatient or outpatient setting. All interviews were transcribed verbatim and analysed according to qualitative content analysis. Twelve patients from two centers were interviewed (7 women, median age 63.5 years, range 22-90 years). Eleven patients suffered from a malignancy. Days in palliative care ranged from 10 to 180 days (median 28 days). 96 categories emerged which were summed up under 11 umbrella terms definition, difference, type, cause, consequence, meaning, recognition, handling, prevention, person causing and affected person. A deductive model was developed assigning umbrella terms to error-theory-based factor levels (definition, type and process-related factors). 23 categories for type of error were identified, including 12 categories that can be considered as palliative care specific. On the level of process-related factors 3 palliative care specific categories emerged (recognition, meaning and consequence of errors). From the patients' perspective, there are some aspects of errors that could be considered as specific to palliative care. As the results of our study suggest, these palliative care-specific aspects seem to be very important from the patients' point of view and should receive further investigation. Moreover, the findings of this study can serve as a guide to further assess single aspects or categories of errors in palliative care in future research.

Pressure ulcers in elderly patients with hip fracture across the continuum of care.

PubMed

Baumgarten, Mona; Margolis, David J; Orwig, Denise L; Shardell, Michelle D; Hawkes, William G; Langenberg, Patricia; Palmer, Mary H; Jones, Patricia S; McArdle, Patrick F; Sterling, Robert; Kinosian, Bruce P; Rich, Shayna E; Sowinski, Janice; Magaziner, Jay

2009-05-01

To identify care settings associated with greater pressure ulcer risk in elderly patients with hip fracture in the postfracture period. Prospective cohort study. Nine hospitals that participate in the Baltimore Hip Studies network and 105 postacute facilities to which patients from these hospitals were discharged. Hip fracture patients aged 65 and older who underwent surgery for hip fracture. A full-body skin examination was conducted at baseline (as soon as possible after hospital admission) and repeated on alternating days for 21 days. Patients were deemed to have an acquired pressure ulcer (APU) if they developed one or more new stage 2 or higher pressure ulcers after hospital admission. In 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). The adjusted APU incidence rate was highest during the initial acute hospital stay (relative risk (RR)=2.2, 95% confidence interval (CI)=1.3-3.7) and during re-admission to the acute hospital (RR=2.2, 95% CI=1.1-4.2). The relative risks in rehabilitation and nursing home settings were 1.4 (95% CI=0.8-2.3) and 1.3 (95% CI=0.8-2.1), respectively. Approximately one-third of hip fracture patients developed an APU during the study period. The rate was highest in the acute setting, a finding that is significant in light of Medicare's policy of not reimbursing hospitals for the treatment of hospital-APUs. Hip fracture patients constitute an important group to target for pressure ulcer prevention in hospitals.

Walk-in Model for Ill Care in an Urban Academic Pediatric Clinic.

PubMed

Warrick, Stephen; Morehous, John; Samaan, Zeina M; Mansour, Mona; Huentelman, Tracy; Schoettker, Pamela J; Iyer, Srikant

2018-04-01

Since the Institute of Medicine's 2001 charge to reform health care, there has been a focus on the role of the medical home. Access to care in the proper setting and at the proper time is central to health care reform. We aimed to increase the volume of patients receiving care for acute illnesses within the medical home rather than the emergency department or urgent care center from 41% to 60%. We used quality improvement methods to create a separate nonemergency care stream in a large academic primary care clinic serving 19,000 patients (90% Medicaid). The pediatric primary care (PPC) walk-in clinic opened in July 2013 with service 4 hours per day and expanded to an all-day clinic in October 2013. Statistical process control methods were used to measure the change over time in the volume of ill patients and visits seen in the PPC walk-in clinic. Average weekly walk-in nonemergent ill-care visits increased from 61 to 158 after opening the PPC walk-in clinic. The percentage of nonemergent ill-care visits in the medical home increased from 41% to 45%. Visits during regular clinic hours increased from 55% to 60%. Clinic cycle time remained unchanged. Implementation of a walk-in care stream for acute illness within the medical home has allowed us to provide ill care to a higher proportion of patients, although we have not yet achieved our predicted volume. Matching access to demand is key to successfully meeting patient needs. Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, 2000-2015.

PubMed

Teno, Joan M; Gozalo, Pedro; Trivedi, Amal N; Bunker, Jennifer; Lima, Julie; Ogarek, Jessica; Mor, Vincent

2018-06-25

End-of-life care costs are high and decedents often experience poor quality of care. Numerous factors influence changes in site of death, health care transitions, and burdensome patterns of care. To describe changes in site of death and patterns of care among Medicare decedents. Retrospective cohort study among a 20% random sample of 1 361 870 decedents who had Medicare fee-for-service (2000, 2005, 2009, 2011, and 2015) and a 100% sample of 871 845 decedents who had Medicare Advantage (2011 and 2015) and received care at an acute care hospital, at home or in the community, at a hospice inpatient care unit, or at a nursing home. Secular changes between 2000 and 2015. Medicare administrative data were used to determine site of death, place of care, health care transitions, which are changes in location of care, and burdensome patterns of care. Burdensome patterns of care were based on health care transitions during the last 3 days of life and multiple hospitalizations for infections or dehydration during the last 120 days of life. The site of death and patterns of care were studied among 1 361 870 decedents who had Medicare fee-for-service (mean [SD] age, 82.8 [8.4] years; 58.7% female) and 871 845 decedents who had Medicare Advantage (mean [SD] age, 82.1 [8.5] years; 54.0% female). Among Medicare fee-for-service decedents, the proportion of deaths that occurred in an acute care hospital decreased from 32.6% (95% CI, 32.4%-32.8%) in 2000 to 19.8% (95% CI, 19.6%-20.0%) in 2015, and deaths in a home or community setting that included assisted living facilities increased from 30.7% (95% CI, 30.6%-30.9%) in 2000 to 40.1% (95% CI, 39.9%-30.3% ) in 2015. Use of the intensive care unit during the last 30 days of life among Medicare fee-for-service decedents increased from 24.3% (95% CI, 24.1%-24.4%) in 2000 and then stabilized between 2009 and 2015 at 29.0% (95% CI, 28.8%-29.2%). Among Medicare fee-for-service decedents, health care transitions during the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) in 2000 to a high of 14.2% (95% CI, 14.0%-14.3%) in 2009 and then decreased to 10.8% (95% CI, 10.6%-10.9%) in 2015. The number of decedents enrolled in Medicare Advantage during the last 90 days of life increased from 358 600 in 2011 to 513 245 in 2015. Among decedents with Medicare Advantage, similar patterns in the rates for site of death, place of care, and health care transitions were observed. Among Medicare fee-for-service beneficiaries who died in 2015 compared with 2000, there was a lower likelihood of dying in an acute care hospital, an increase and then stabilization of intensive care unit use during the last month of life, and an increase and then decline in health care transitions during the last 3 days of life.

Training unemployed women for adult day care in Izmir, Turkey: a program evaluation.

PubMed

Hussein, Shereen; Oğlak, Sema

2014-01-01

The proportion of older people in Turkey is increasing steadily with a subsequent growth of long-term care (LTC) needs. There is a scarcity of formal care provisions for residential and particularly nonresidential settings. Thus, formal caregiving is not meeting LTC needs nor attracting workers as a labor option. The authors examine the hypothesis that LTC may offer work opportunities for women unfamiliar with caregiving as an occupation, and also examine the need and acceptance of different types of LTC beyond residential care. The authors evaluate an innovative project introducing these two elements to 76 women in İzmir, Turkey, using an analysis framework that incorporates factors related to applications and progression; management assessment; trainees' self-assessment reflecting on their views on aging; and older people's perception of the experience and its impact on their well-being. Trainees reported a major positive shift in their attitudes toward working in LTC and toward the aging process. Users reported discovering a new dimension to care, which directly affected their quality of life. Overall, this community-based initiative appeared effective in enhancing the awareness of the concept of adult day centers providing a social model of care, and appears promising in addressing the growing need for formal LTC in Turkey.

'Being a conduit' between hospital and home: stakeholders' views and perceptions of a nurse-led Palliative Care Discharge Facilitator Service in an acute hospital setting.

PubMed

Venkatasalu, Munikumar Ramasamy; Clarke, Amanda; Atkinson, Joanne

2015-06-01

To explore and critically examine stakeholders' views and perceptions concerning the nurse-led Palliative Care Discharge Service in an acute hospital setting and to inform sustainability, service development and future service configuration. The drive in policy and practice is to enable individuals to achieve their preferred place of care during their last days of life. However, most people in UK die in acute hospital settings against their wishes. To facilitate individuals' preferred place of care, a large acute hospital in northeast England implemented a pilot project to establish a nurse-led Macmillan Palliative Care Discharge Facilitator Service. A pluralistic evaluation design using qualitative methods was used to seek stakeholders' views and perceptions of this service. In total, 12 participants (five bereaved carers and seven health professionals) participated in the evaluation. Semi-structured interviews were conducted with bereaved carers who used this service for their relatives. A focus group and an individual interview were undertaken with health professionals who had used the service since its inception. Individual interviews were also conducted with the Discharge Facilitator and service manager. Analysis of all data was guided by Framework Analysis. Four key themes emerged relating to the role of the Discharge Facilitator Service: achieving preferred place of care; the Discharge Facilitator as the 'conduit' between hospital and community settings; delays in hospital discharge and stakeholders' perceptions of the way forward for the service. The Discharge Facilitator Service acted as a reliable resource and support for facilitating the fast-tracking of end-of-life patients to their preferred place of care. Future planning for hospital-based palliative care discharge facilitating services need to consider incorporating strategies that include: increased profile of the service, expansion of service provision and the Discharge Facilitator's earlier involvement in the discharge process. © 2015 John Wiley & Sons Ltd.

Public Health Stops at the School House Door

PubMed Central

Paulson, Jerome A.; Barnett, Claire L.

2016-01-01

Summary: In the United States, all children of appropriate age are required to attend school, and many parents send their children to child care. Many school and day care buildings have been found to have environmental health problems that impact children’s health and diminish their ability to learn. No federal agency has the capacity or authority to identify, track, or remediate these problems. A recent meeting, coordinated by Healthy Schools Network, Inc., has developed a set of recommendations to begin to deal with the issue of environmental health problems in schools. PMID:27689395

Encouraging Consumption of Water in School and Child Care Settings: Access, Challenges, and Strategies for Improvement

PubMed Central

Hampton, Karla E.

2011-01-01

Children and adolescents are not consuming enough water, instead opting for sugar-sweetened beverages (sodas, sports and energy drinks, milks, coffees, and fruit-flavored drinks with added sugars), 100% fruit juice, and other beverages. Drinking sufficient amounts of water can lead to improved weight status, reduced dental caries, and improved cognition among children and adolescents. Because children spend most of their day at school and in child care, ensuring that safe, potable drinking water is available in these settings is a fundamental public health measure. We sought to identify challenges that limit access to drinking water; opportunities, including promising practices, to increase drinking water availability and consumption; and future research, policy efforts, and funding needed in this area. PMID:21680941

Announcement: Get Smart About Antibiotics Week - November 14-20, 2016.

PubMed

2016-11-11

Get Smart About Antibiotics Week is November 14-20, 2016. This annual observance is intended to engage health care providers, professional societies, advocacy groups, for-profit companies, state and local health departments, the general public, the media, and others in an effort to improve antibiotic stewardship in outpatient, inpatient, nursing home, and animal health settings. During this week, participants will raise awareness of the threat of antibiotic resistance and emphasize the importance of appropriate antibiotic use across all health care settings. Get Smart About Antibiotics Week coincides with the World Health Organization's World Antibiotic Awareness Week and European Antibiotic Awareness Day (November 18). In addition to the United States and European Union, other participating countries and international organizations include Australia, Canada, and the Pan American Health Organization.

Health in Day Care: A Training Guide for Day Care Providers.

ERIC Educational Resources Information Center

Pokorni, Judith L.; Kaufmann, Roxane K.

Written for trainers of day care staff, this guide provides help in communicating to day care personnel the information presented in "Health in Day Care: A Manual for Day Care Providers," originally developed by a division of the Massachusetts Department of Health and adapted for national use by the Georgetown University Child Development Center.…

Child Development: Day Care. Administration, Number 7.

ERIC Educational Resources Information Center

Host, Malcolm S.; Heller, Pearl B.

The organizing and administering of day care services are the focus of this handbook. The three parts of the handbook are: (1) Organizing Day Care Services (Starting a Day Care Program, The Board of Directors, and The Staff); (2) Components of Day Care Services (Purpose, Objectives and Evaluation of Day Care Programs; Health and Medical Program;…

DRG migration: A novel measure of inefficient surgical care in a value-based world.

PubMed

Hughes, Byron D; Mehta, Hemalkumar B; Sieloff, Eric; Shan, Yong; Senagore, Anthony J

2018-03-01

Diagnosis-Related Group (DRG) migration, DRG 331 to 330, is defined by the assignment to a higher cost DRG due only to post admission comorbidity or complications (CC). We assessed the 5% national Medicare data set (2011-2014) for colectomy (DRG's 331/330), excluding present on admission CC's and selecting patients with one or more CC's post-admission to define the impact on payments, cost, and length of stay (LOS). The incidence of DRG migration was 14.2%. This was associated with statistically significant increases in payments, hospital cost, and LOS compared to DRG 331 patients. When DRG migration rate was extrapolated to the entire at risk population, the results were an increase of Centers for Medicare and Medicaid Services (CMS) cost by $98 million, hospital cost by $418 million, and excess hospital days equaling 68,669 days. These negative outcomes represent potentially unnecessary variations in the processes of care, and therefore a unique economic concept defining inefficient surgical care. Copyright © 2017 Elsevier Inc. All rights reserved.

Chronic obstructive pulmonary disease readmissions at minority-serving institutions.

PubMed

Prieto-Centurion, Valentin; Gussin, Hélène A; Rolle, Andrew J; Krishnan, Jerry A

2013-12-01

About 20% of patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations are readmitted within 30 days. High 30-day risk-standardized readmission rates after COPD exacerbations will likely place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services starting in fiscal year 2015. Factors contributing to hospital readmissions include healthcare quality, access to care, coordination of care between hospital and ambulatory settings, and factors linked to socioeconomic resources (e.g., social support, stable housing, transportation, and food). These concerns are exacerbated at minority-serving institutions, which provide a disproportionate share of care to patients with low socioeconomic resources. Solutions tailored to the needs of minority-serving institutions are urgently needed. We recommend research that will provide the evidence base for strategies to reduce readmissions at minority-serving institutions. Promising innovative approaches include using a nontraditional healthcare workforce, such as community health workers and peer-coaches, and telemedicine. These strategies have been successfully used in other conditions and need to be studied in patients with COPD.

Auto TeleCare -- understanding the failures and successes of small business in telehealth.

PubMed

McMahon, David

2005-01-01

Auto TeleCare provided an automatic daily telephone service for people living alone. The business used an interactive voice response (IVR) system to call clients at a set time each day. The clients were required to press a button on their telephone to listen to a message (e.g. joke of the day), thereby indicating that they were alright. If the client did not respond, staff would call the given list of contacts to check on the client's welfare. The service was first offered in December 2003 and there was a lot of interest from clients and health-care groups. Although the technology was sophisticated, it was very simple for the clients to use. However, it was the marketing and advertising costs of the business that in the end proved to be too costly. The number of clients required for commercial viability was calculated to be 3,000, and after nearly 15 months of business it was decided to close the business.

In the right words: addressing language and culture in providing health care.

PubMed

2003-08-01

As part of its continuing mission to serve trustees, executives, and staff of health foundations and corporate giving programs, Grantmakers In Health (GIH) convened a group of experts from philanthropy, research, health care practice, and policy on April 4, 2003, to discuss the roles of language and culture in providing effective health care. During this Issue Dialogue, In the Right Words: Addressing Language and Culture in Providing Health Care, health grantmakers and experts from policy and practice participated in an open exchange of ideas and perspectives on language access and heard from fellow grantmakers who are funding innovative programs in this area. Together they explored ways to effectively support comprehensive language services, including the use of interpreters and translation of written materials. This Issue Brief synthesizes key points from the day's discussion with a background paper previously prepared for Issue Dialogue participants. It focuses on the challenges and opportunities involved with ensuring language access for the growing number of people who require it. Sections include: recent immigration trends and demographic changes; the effect of language barriers on health outcomes and health care processes; laws and policies regarding the provision of language services to patients, including an overview of public financing mechanisms; strategies for improving language access, including enhancing access in delivery settings, promoting advocacy and policy change, improving interpreter training, and advancing research; and roles for foundations in supporting improved language access, including examples of current activities. The Issue Dialogue focused mainly on activities and programs that ensure linguistic access to health care for all patients. Although language and culture are clearly inseparable, a full exploration of the field of cultural competence and initiatives that promote its application to the health care setting are beyond the scope of this Issue Brief. The day's discussion did, however, raise provocative issues of culture that are reflected throughout this report.

Quality of Care in Hip Fracture Patients: The Relationship Between Adherence to National Standards and Improved Outcomes.

PubMed

Farrow, Luke; Hall, Andrew; Wood, Adrian D; Smith, Rik; James, Kate; Holt, Graeme; Hutchison, James; Myint, Phyo K

2018-05-02

Optimizing the perioperative care of patients with a hip fracture is a key health-care priority. We aimed to determine whether adherence to the Scottish Standards of Care for Hip Fracture Patients (SSCHFP) was associated with improved patient outcomes. In this retrospective cohort study of prospectively collected data from the Scottish National Hip Fracture Audit, we assessed adherence to the SSCHFP in 21 Scottish hospitals over a 9-month period in 2014 and examined the effect of the guidelines on 30 and 120-day mortality, length of hospital stay, and discharge destination. A total of 1,162 patients who were ≥50 years old and admitted with a hip fracture were included. There was a significant association between low adherence to the SSCHFP and increased mortality at 30 and 120 days (odds ratio [OR], 3.58 [95% confidence interval (CI), 1.75 to 7.32; p < 0.001] and 2.01 [95% CI, 1.28 to 3.12; p = 0.003], respectively). Low adherence was associated with a reduced likelihood of a short length of stay (OR, 0.58; 95% CI, 0.42 to 0.78; p < 0.0001), but increased odds of discharge to a high-care setting (OR, 1.63; 95% CI, 1.12 to 2.36; p = 0.01). Early physiotherapy input and occupational therapy input were associated with a reduced likelihood of discharge to a high-care setting (OR, 0.64 [95% CI, 0.44 to 0.98; p = 0.04] and 0.34 [95% CI, 0.23 to 0.48; p <0.001], respectively). Adherence to the SSCHFP is associated with better patient outcomes. These findings confirm the clinical utility of the SSCHFP and support their use as a benchmarking tool to improve quality of care for hip fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Content and functional specifications for a standards-based multidisciplinary rounding tool to maintain continuity across acute and critical care

PubMed Central

Collins, Sarah; Hurley, Ann C; Chang, Frank Y; Illa, Anisha R; Benoit, Angela; Laperle, Sarah; Dykes, Patricia C

2014-01-01

Background Maintaining continuity of care (CoC) in the inpatient setting is dependent on aligning goals and tasks with the plan of care (POC) during multidisciplinary rounds (MDRs). A number of locally developed rounding tools exist, yet there is a lack of standard content and functional specifications for electronic tools to support MDRs within and across settings. Objective To identify content and functional requirements for an MDR tool to support CoC. Materials and methods We collected discrete clinical data elements (CDEs) discussed during rounds for 128 acute and critical care patients. To capture CDEs, we developed and validated an iPad-based observational tool based on informatics CoC standards. We observed 19 days of rounds and conducted eight group and individual interviews. Descriptive and bivariate statistics and network visualization were conducted to understand associations between CDEs discussed during rounds with a particular focus on the POC. Qualitative data were thematically analyzed. All analyses were triangulated. Results We identified the need for universal and configurable MDR tool views across settings and users and the provision of messaging capability. Eleven empirically derived universal CDEs were identified, including four POC CDEs: problems, plan, goals, and short-term concerns. Configurable POC CDEs were: rationale, tasks/‘to dos’, pending results and procedures, discharge planning, patient preferences, need for urgent review, prognosis, and advice/guidance. Discussion Some requirements differed between settings; yet, there was overlap between POC CDEs. Conclusions We recommend an initial list of 11 universal CDEs for continuity in MDRs across settings and 27 CDEs that can be configured to meet setting-specific needs. PMID:24081019

Developing an Inclusive Approach to Preschool Education: A Discussion of Issues and Strategies, with Implications Focussing on Quebec.

ERIC Educational Resources Information Center

Potter, Annie; Jacques, Marie

1997-01-01

Examines cultural conditions necessary for children's development in day care settings, using Bronfenbrenner's Ecology of Human Development. Considers the parental role in this context; also the relationship between educators and parents, with a view to creating culturally appropriate conditions for the developing child. Discusses policies and…

Study of Programs To Meet the Developmental Needs of Young Children. Report to the Legislature.

ERIC Educational Resources Information Center

Minnesota State Dept. of Education, St. Paul. Div. of Development and Partnership.

Committees discussed six educational program options for 4- and 5-year-old children, in terms of curriculum, staff and licensure, cost and school facilities, coordination with existing resources, public opinion, and school-age day care. The curriculum committee developed a set of goals, outlined a program design, and considered the possible…

Allergens in School Settings: Results of Environmental Assessments in 3 City School Systems

ERIC Educational Resources Information Center

Abramson, Stuart L.; Turner-Henson, Anne; Anderson, Lise; Hemstreet, Mary P.; Bartholomew, L. Kay; Joseph, Christine L. M.; Tang, Shenghui; Tyrrell, Shellie; Clark, Noreen M.; Ownby, Dennis

2006-01-01

Environmental allergens are major triggers for pediatric asthma. While children's greatest exposure to indoor allergens is in the home, other public places where children spend a large amount of time, such as school and day care centers, may also be sources of significant allergen encounters. The purpose of this article is to describe schoolroom…

[Intensive care anaesthesia practice in the prison environment. Can a prisoner benefit from ambulatory anaesthesia].

PubMed

Manaouil, C; Montpellier, D; Sannier, O; Defouilloy, C; Radji, M; Jardé, O; Dupont, H

2010-01-01

Ambulatory anaesthesia is an anesthesia allowing the return of the patient home the same day. Even if the ambulatory hospitalization can, in theory, be applied to a prisoner as to every patient, caution is essential in such approach. Every anaesthetist reanimator doctor practicing in public hospitals may give care to patient prisoners while he is far from dominating all features of the prison world and while he must put down his therapeutic indications. The ambulatory anaesthesia in prison environment does not guarantee full security for the patient. Procedures could be set up between hospital complexes, caretakers practicing within penal middle (Unit of Consultation and Ambulatory Care [UCAC]) the prison service and hospital, the prefecture, to identify possible ambulatory interventions for a patient prisoner and to set up all guarantees of patient follow-up care in his return in prison environment. The development of interregional secure hospital units (ISHU) within teaching hospitals, allows an easier realization of interventions to the prisoners, but exists only in seven teaching hospitals in France. Copyright 2009 Elsevier Masson SAS. All rights reserved.

Reduction of health care-associated infection indicators by copper oxide-impregnated textiles: Crossover, double-blind controlled study in chronic ventilator-dependent patients.

PubMed

Marcus, Esther-Lee; Yosef, Hana; Borkow, Gadi; Caine, Yehezkel; Sasson, Ady; Moses, Allon E

2017-04-01

Copper oxide has potent wide-spectrum biocidal properties. The purpose of this study is to determine if replacing hospital textiles with copper oxide-impregnated textiles reduces the following health care-associated infection (HAI) indicators: antibiotic treatment initiation events (ATIEs), fever days, and antibiotic usage in hospitalized chronic ventilator-dependent patients. A 7-month, crossover, double-blind controlled trial including all patients in 2 ventilator-dependent wards in a long-term care hospital. For 3 months (period 1), one ward received copper oxide-impregnated textiles and the other received untreated textiles. After a 1-month washout period of using regular textiles, for 3 months (period 2) the ward that received the treated textiles received the control textiles and vice versa. The personnel were blinded to which were treated or control textiles. There were no differences in infection control measures during the study. There were reductions of 29.3% (P = .002), 55.5% (P < .0001), 23.0% (P < .0001), and 27.5% (P < .0001) in the ATIEs, fever days (>37.6°C), days of antibiotic treatment, and antibiotic defined daily dose per 1,000 hospitalization days, respectively, when using the copper oxide-impregnated textiles. Use of copper oxide-impregnated biocidal textiles in a long-term care ward of ventilator-dependent patients was associated with a significant reduction of HAI indicators and antibiotic utilization. Using copper oxide-impregnated biocidal textiles may be an important measure aimed at reducing HAIs in long-term care medical settings. Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Scottish urban versus rural trauma outcome study.

PubMed

McGuffie, A Crawford; Graham, Colin A; Beard, Diana; Henry, Jennifer M; Fitzpatrick, Michael O; Wilkie, Stewart C; Kerr, Gary W; Parke, Timothy R J

2005-09-01

Outcome following trauma and health care access are important components of health care planning. Resources are limited and quality information is required. We set the objective of comparing the outcomes for patients suffering significant trauma in urban and rural environments in Scotland. The study was designed as a 2 year prospective observational study set in the west of Scotland, which has a population of 2.58 million persons. Primary outcome measures were defined as the total number of inpatient days, total number of intensive care unit days, and mortality. The participants were patients suffering moderate (ISS 9-15) and major (ISS>15) trauma within the region. The statistical analysis consisted of chi square test for categorical data and Mann Whitney U test for comparison of medians. There were 3,962 urban (85%) and 674 rural patients (15%). Urban patients were older (50 versus 46 years, p = 0.02), were largely male (62% versus 57%, p = 0.02), and suffered more penetrating traumas (9.9% versus 1.9%, p < 0.001). All prehospital times are significantly longer for rural patients (p < 0.001), include more air ambulance transfers (p < 0.001), and are characterized by greater paramedic presence (p < 0.001). Excluding neurosurgical and spinal injuries transfers, there was a higher proportion of transfers in the rural major trauma group (p = 0.002). There were more serious head injuries in the urban group (p = 0.04), and also a higher proportion of urban patients with head injuries transferred to the regional neurosurgical unit (p = 0.037). There were no differences in length of total inpatient stay (median 8 days, p = 0.7), total length of stay in the intensive care unit (median two days, p = 0.4), or mortality (324 deaths, moderate trauma, p = 0.13; major trauma, p = 0.8). Long prehospital times in the rural environment were not associated with differences in mortality or length of stay in moderately and severely injured patients in the west of Scotland. This may lend support to a policy of rationalization of trauma services in Scotland.

The contributions of family care-givers at end of life: A national post-bereavement census survey of cancer carers' hours of care and expenditures.

PubMed

Rowland, Christine; Hanratty, Barbara; Pilling, Mark; van den Berg, Bernard; Grande, Gunn

2017-04-01

Family members provide vital care at end of life, enabling patients to remain at home. Such informal care contributes significantly to the economy while supporting patients' preferences and government policy. However, the value of care-givers' contributions is often underestimated or overlooked in evaluations. Without information on the activities and expenditures involved in informal care-giving, it is impossible to provide an accurate assessment of carers' contribution to end-of-life care. The aim of this study was to investigate the contributions and expenditure of informal, family care-giving in end-of-life cancer care. A national census survey of English cancer carers was conducted. Survey packs were mailed to 5271 people who registered the death of a relative to cancer during 1-16 May 2015. Data were collected on decedents' health and situation, care support given, financial expenditure resulting from care, carer well-being and general background information. In all, 1504 completed surveys were returned (28.5%). Over 90% of respondents reported spending time on care-giving in the last 3 months of the decedent's life, contributing a median 69 h 30 min of care-giving each week. Those who reported details of expenditure (72.5%) spent a median £370 in the last 3 months of the decedent's life. Carers contribute a great deal of time and money for day-to-day support and care of patients. This study has yielded a unique, population-level data set of end-of-life care-giving and future analyses will provide estimates of the economic value of family care-givers' contributions.

Hand hygiene: Back to the basics of infection control

PubMed Central

Mathur, Purva

2011-01-01

Health care associated infections are drawing increasing attention from patients, insurers, governments and regulatory bodies. This is not only because of the magnitude of the problem in terms of the associated morbidity, mortality and cost of treatment, but also due to the growing recognition that most of these are preventable. The medical community is witnessing in tandem unprecedented advancements in the understanding of pathophysiology of infectious diseases and the global spread of multi-drug resistant infections in health care set-ups. These factors, compounded by the paucity of availability of new antimicrobials have necessitated a re-look into the role of basic practices of infection prevention in modern day health care. There is now undisputed evidence that strict adherence to hand hygiene reduces the risk of cross-transmission of infections. With “Clean Care is Safer Care” as a prime agenda of the global initiative of WHO on patient safety programmes, it is time for developing countries to formulate the much-needed policies for implementation of basic infection prevention practices in health care set-ups. This review focuses on one of the simplest, low cost but least accepted from infection prevention: hand hygiene. PMID:22199099

Prevalence of key care indicators of pressure injuries, incontinence, malnutrition, and falls among older adults living in nursing homes in New Zealand.

PubMed

Carryer, Jenny; Weststrate, Jan; Yeung, Polly; Rodgers, Vivien; Towers, Andy; Jones, Mark

2017-12-01

Pressure injuries, incontinence, malnutrition, and falls are important indicators of the quality of care in healthcare settings, particularly among older people, but there is limited information on their prevalence in New Zealand (NZ). The aim of this study was to establish the prevalence of these four problems among older people in nursing home facilities. The cross-sectional study was an analysis of data collected on a single day for the 2016 National Care Indicators Programme-New Zealand (NCIP-NZ). The sample included 276 people ages 65 and older who were residents in 13 nursing home facilities in a geographically diverse area of central NZ. Data were analyzed with descriptive statistics. Prevalence rates in these nursing home settings was pressure injuries 8%; urinary incontinence 57%; fecal incontinence 26%; malnutrition 20%, and falls 13%, of which half resulted in injuries. As people age, complex health issues can lead to increasing care dependency and more debilitating and costly health problems. Measuring the prevalence of basic care problems in NZ healthcare organizations and contributing to a NZ database can enable monitoring of the effectiveness of national and international guidelines. © 2017 Wiley Periodicals, Inc.

Geriatric Hip Fracture Care: Fixing a Fragmented System.

PubMed

Anderson, Mary E; Mcdevitt, Kelly; Cumbler, Ethan; Bennett, Heather; Robison, Zachary; Gomez, Bryan; Stoneback, Jason W

2017-01-01

Fragmentation in geriatric hip fracture care is a growing concern because of the aging population. Patients with hip fractures at our institution historically were admitted to multiple different services and units, leading to unnecessary variation in inpatient care. Such inconsistency contributed to delays in surgery, discharge, and functional recovery; hospital-acquired complications; failure to adhere to best practices in osteoporosis management; and poor coordination with outpatient practitioners. To describe a stepwise approach to systems redesign for this patient population. We designed and implemented a comprehensive geriatric hip fracture program for patients aged 65 years and older at our academic Medical Center in October 2014. Key interventions included admission of all ward-status patients to the Orthopedics Service with hospitalist comanagement; geographic placement on the Orthopedics Unit; and standardized, evidence-based electronic order sets bundling geriatric best practices and a streamlined workflow for discharge planning. Hospital length of stay. We identified 271 admissions among 267 patients between January 1, 2012, and March 31, 2016; of those, 154 were before and 117 were after program implementation. Mean hospital length of stay significantly improved from 6.4 to 5.5 days (p = 0.004). The 30-day all-cause readmission rate and discharge disposition remained stable. The percentage of patients receiving osteoporosis evaluation and treatment increased significantly. The rate of completed 30-day outpatient follow-up also improved. Our comprehensive geriatric hip fracture program achieved and sustained gains in the quality and efficiency of care by improving fragmentation in the health care system.

[Age discrimination. Point of view of the professionals].

PubMed

Ribera Casado, Jose Manuel; Bustillos, Antonio; Guerra Vaquero, Ana Ilenia; Huici Casal, Carmen; Fernández-Ballesteros, Rocío

2016-01-01

It is generally believed that legislation is an essential resource in the prevention of discriminatory behaviour against older people. This study first examines the Spanish legislation for potential age discrimination and then uses the C-EVE-D questionnaire to ask professionals in social work and health care settings the extent to what certain ageist behaviours described in the questionnaire are observed in practice. The field study was carried out with professionals in geriatrics and gerontology, who are members of Spanish Society for Geriatrics and Gerontology (SEGG). The EVE discrimination questionnaire consists of 28 items which investigate the existence of age discrimination in medical and social care contexts. A total of 174 people (63% women; mean age: 45.6 years) took part in the study, with a mean professional experience of 17.2 years. Doctors made up 59% of the sample, psychologists 19%, with the rest coming from other professions. The first 20 discrimination items of the EVE-D questionnaire were significantly positively reported by more than 60% of the sample. Although Spanish legislation, from the constitution down to the rules that govern social and health care settings, clearly prohibits any kind of discrimination with regard to age, our results show that Spanish professionals most closely involved in the care of older people perceive both direct and indirect age discrimination. Furthermore, evidence was found of prejudice in the treatment of older people as a phenomenon in day-to-day health and social services care, both when analysing medical cases and, to a greater extent, cases of a more general nature and/or relating to co-existence. Copyright © 2016 SEGG. Publicado por Elsevier España, S.L.U. All rights reserved.

Cost of delivering secondary-level health care services through public sector district hospitals in India.

PubMed

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

2017-09-01

Despite an impetus for strengthening public sector district hospitals for provision of secondary health care in India, there is lack of robust evidence on cost of services provided through these district hospitals. In this study, an attempt was made to determine the unit cost of an outpatient visit consultation, inpatient bed-day of hospitalization, surgical procedure and overall per-capita cost of providing secondary care through district hospitals. Economic costing of five randomly selected district hospitals in two north Indian States - Haryana and Punjab, was undertaken. Cost analysis was done using a health system perspective and employing bottom-up costing methodology. Quantity of all resources - capital or recurrent, used for delivering services was measured and valued. Median unit costs were estimated along with their 95 per cent confidence intervals. Sensitivity analysis was undertaken to assess the effect of uncertainties in prices and other assumptions; and to generalize the findings for Indian set-up. The overall annual cost of delivering secondary-level health care services through a public sector district hospital in north India was ' 11,44,13,282 [US Dollars (USD) 2,103,185]. Human resources accounted for 53 per cent of the overall cost. The unit cost of an inpatient bed-day, surgical procedure and outpatient consultation was ' 844 (USD 15.5), ' 3481 (USD 64) and ' 170 (USD 3.1), respectively. With the current set of resource allocation, per-capita cost of providing health care through district hospitals in north India was ' 139 (USD 2.5). The estimates obtained in our study can be used for Fiscal planning of scaling up secondary-level health services. Further, these may be particularly useful for future research such as benefit-incidence analysis, cost-effectiveness analysis and national health accounts including disease-specific accounts in India.

Extending “Continuity of Care” to include the Contribution of Family Carers

PubMed Central

Parsons, John; Sheridan, Nicolette; Kenealy, Timothy; Peckham, Allie

2017-01-01

Background: Family carers, as a “shadow workforce”, are foundational to the day-to-day integration of health service delivery for older family members living with complex health needs. This paper utilises Haggerty’s model of continuity of care to explore the contribution of family carers’ to the provision of care and support for an older family member’s chronic condition within the context of health service delivery. Methods: We analysed data from interviews of 13 family carers in a case study of primary health care in New Zealand – a Maori Provider Organisation – to determine the alignment of family caregiving with the three levels of continuity of care (relational continuity, informational continuity, and management continuity). Results: We found alignment of family caregiving tasks, responsibilities, and relationships with the three levels of continuity of care. Family carers 1) partnered with providers to extend chronic care to the home; 2) transferred and contributed information from one provider/service to another; 3) supported consistent and flexible management of care. Discussion: The Maori Provider Organisation supported family carer-provider partnership enabled by shared Maori cultural values and social mandate of building family-centred wellbeing. Relational continuity was the most important level of continuity of care; it sets precedence for family carers and providers to establish the other levels – informational and management – continuity of care for their family member cared for. Family carers need to be considered as active partners working alongside responsive primary health care providers and organisation in the implementation of chronic care. PMID:28970752

Care work in changing welfare states: Nordic care workers' experiences.

PubMed

Trydegård, Gun-Britt

2012-06-01

This article focuses on Nordic eldercare workers and their experiences of working conditions in times of change and reorganisation. In recent years New Public Management-inspired ideas have been introduced to increase efficiency and productivity in welfare services. These reforms have also had an impact on day-to-day care work, which has become increasingly standardized and set out in detailed contracts, leading to time-pressure and an undermining of care workers' professional discretion and autonomy. The empirical data comes from a survey of unionised eldercare workers in home care and residential care in Denmark, Finland, Norway and Sweden ( N  = 2583) and was analysed by bi- and multi-variate methods. The care workers reported that they found their working conditions physically and mentally arduous. They had to a great extent experienced changes for the worse in terms of working conditions and in their opportunity to provide good quality care. In addition, the majority felt they did not receive support from their managers. An alarming finding was that one out of three care workers declared that they had seriously considered quitting their jobs. Care workers with multiple problems at work were much more likely to consider quitting, and the likelihood was increasing with the number of problems reported. Furthermore, care workers lacking support from their managers had double odds of wanting to quit. The Nordic welfare states with growing older populations are facing challenges in retaining care staff in the eldercare services and ensuring they have good working conditions and support in their demanding work.

Pressure Injuries in Inpatient Care Facilities in the Czech Republic: Analysis of a National Electronic Database.

PubMed

Pokorná, Andrea; Benešová, Klára; Jarkovský, Jirˇí; Mužík, Jan; Beeckman, Dimitri

The purpose of this study was to analyze pressure injury (PI) occurrence upon admission and at any time during the hospital course inpatients care facilities in the Czech Republic. Secondary aims were to evaluate demographic and clinical data of patients with PI and the impact of a PI on length of stay (LOS) in the hospital. Retrospective, cross-sectional analysis. The sample comprised data of hospitalized patients entered into the National Register of Hospitalized Patients (NRHOSP) database of the Czech Republic between 2007 and 2014 with a diagnosis L89 (pressure ulcer of unspecified site based on the International Classification of Diseases, Tenth Revision, ICD-10). Electronic records of 17,762,854 hospitalizations were reviewed. Data from the NRHOSP from all acute and non-acute care hospitals in the Czech Republic were analyzed. Specifically, we analyzed patients admitted to acute and non-acute care facilities with a primary or secondary diagnosis of PI. The NRHOSP database included 17,762,854 cases, of which 46,224 cases (33,342 cases in acute care hospitals; 12,882 in non-acute care hospitals) had the L89 diagnosis (0.3%). The mean age of patients admitted with a PI was 73.8 ± 15.3 years (mean ± SD), and their average LOS was 33.2 ± 76.9 days. The mean LOS of patients hospitalized with L89 code as a primary diagnosis (n = 6877) was significantly longer compared to those patients for whom L89 code was a secondary diagnosis (25.8 vs 20.2 days, P < .001) in acute care facilities. In contrast, we found no difference in the mean LOS for patients hospitalized in non-acute care facility (58.7 days vs 65.1 days; P = .146) with ICD code L89. Pressure injuries were associated with significant LOS in both acute and non-acute care settings in the Czech Republic. Despite the valuable insights we obtained from the analysis of NRHOSP data, we advocate creation of a more valid and reliable electronic reporting system that enables policy makers to evaluate the quality and safety concerning PI and its impact on patients and the healthcare system.

Excess Length of Stay Attributable to Clostridium difficile Infection (CDI) in the Acute Care Setting: A Multistate Model.

PubMed

Stevens, Vanessa W; Khader, Karim; Nelson, Richard E; Jones, Makoto; Rubin, Michael A; Brown, Kevin A; Evans, Martin E; Greene, Tom; Slade, Eric; Samore, Matthew H

2015-09-01

Standard estimates of the impact of Clostridium difficile infections (CDI) on inpatient lengths of stay (LOS) may overstate inpatient care costs attributable to CDI. In this study, we used multistate modeling (MSM) of CDI timing to reduce bias in estimates of excess LOS. A retrospective cohort study of all hospitalizations at any of 120 acute care facilities within the US Department of Veterans Affairs (VA) between 2005 and 2012 was conducted. We estimated the excess LOS attributable to CDI using an MSM to address time-dependent bias. Bootstrapping was used to generate 95% confidence intervals (CI). These estimates were compared to unadjusted differences in mean LOS for hospitalizations with and without CDI. During the study period, there were 3.96 million hospitalizations and 43,540 CDIs. A comparison of unadjusted means suggested an excess LOS of 14.0 days (19.4 vs 5.4 days). In contrast, the MSM estimated an attributable LOS of only 2.27 days (95% CI, 2.14-2.40). The excess LOS for mild-to-moderate CDI was 0.75 days (95% CI, 0.59-0.89), and for severe CDI, it was 4.11 days (95% CI, 3.90-4.32). Substantial variation across the Veteran Integrated Services Networks (VISN) was observed. CDI significantly contributes to LOS, but the magnitude of its estimated impact is smaller when methods are used that account for the time-varying nature of infection. The greatest impact on LOS occurred among patients with severe CDI. Significant geographic variability was observed. MSM is a useful tool for obtaining more accurate estimates of the inpatient care costs of CDI.

Probiotics for respiratory tract infections in children attending day care centers-a systematic review.

PubMed

Laursen, Rikke Pilmann; Hojsak, Iva

2018-05-12

Probiotics have been suggested to have a preventive effect on respiratory tract infections (RTIs), but limited evidence exist on strain-specific effects. The main aim of this systematic review and meta-analysis was to evaluate strain-specific probiotic effects on RTIs in children attending day care. We included 15 RCTs with 5121 children in day care settings (aged 3 months to 7 years), but due to high diversity in reported outcomes, different number of RCTs were available for evaluated outcomes. Twelve RCTs (n = 4527) reported results which could be compared in at least one outcome of the meta-analysis. Compared to placebo, Lactobacillus rhamnosus GG (LGG) significantly reduced duration of RTIs (three RCTs, n = 1295, mean difference - 0.78 days, 95% confidence interval (CI) - 1.46; - 0.09), whereas no effect was found on other evaluated outcomes. Based on the results from two studies (n = 343), Bifidobacterium animalis subsp. lactis BB-12 showed no effect on duration of RTIs or on absence from day care. Meta-analyses on other strains or their combination were not possible due to limited data and different outcome measures. LGG is modestly effective in decreasing the duration of RTIs. More RCTs investigating specific probiotic strains or their combinations in prevention of RTIs are needed. What is known: • Previously published systematic reviews have suggested that probiotics may have a preventive effect on respiratory infections, but limited data exist on strain specific effects. What is new: • This systematic review showed that use of Lactobacillus rhamnosus GG modestly reduces the duration of respiratory tract infections.

Interprofessional Teamwork Innovation Model (ITIM) to promote communication and patient-centred, coordinated care.

PubMed

Li, Jing; Talari, Preetham; Kelly, Andrew; Latham, Barbara; Dotson, Sherri; Manning, Kim; Thornsberry, Lisa; Swartz, Colleen; Williams, Mark V

2018-02-14

Despite recommendations and the need to accelerate redesign of delivery models to be team-based and patient-centred, professional silos and cultural and structural barriers that inhibit working together and communicating effectively still predominate in the hospital setting. Aiming to improve team-based rounding, we developed, implemented and evaluated the Interprofessional Teamwork Innovation Model (ITIM). This quality improvement (QI) study was conducted at an academic medical centre. We followed the system's QI framework, FOCUS-PDSA, with Lean as guiding principles. Primary outcomes included 30-day all-cause same-hospital readmissions and 30-day emergency department (ED) visits. The intervention group consisted of patients receiving care on two hospitalist ITIM teams, and patients receiving care from other hospitalist teams were matched with a control group. Outcomes were assessed using difference-in-difference analysis. Team members reported enhanced communication and overall time savings. In multivariate modelling, patients discharged from hospitalist teams using the ITIM approach were associated with reduced 30-day same-hospital readmissions with an estimated point OR of 0.56 (95% CI 0.34 to 0.92), but there was no impact on 30-day same-hospital ED visits. Difference-in-difference analysis showed that ITIM was not associated with changes in average total direct costs nor average cost per patient day, after adjusting for all other covariates in the models, despite the addition of staff resources in the ITIM model. The ITIM approach facilitates a collaborative environment in which patients and their family caregivers, physicians, nurses, pharmacists, case managers and others work and share in the process of care. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Mentalising skills in generic mental healthcare settings: can we make our day-to-day interactions more therapeutic?

PubMed

Welstead, H J; Patrick, J; Russ, T C; Cooney, G; Mulvenna, C M; Maclean, C; Polnay, A

2018-06-01

Aims and methodCaring for patients with personality disorder is one of the biggest challenges in psychiatric work. We investigated whether mentalisation-based treatment skills (MBT-S) teaching improves clinicians' understanding of mentalising and attitudes towards personality disorder. Self-report questionnaires (Knowledge and Application of MBT (KAMQ) and Attitudes to Personality Disorder (APDQ)) were completed at baseline and after a 2-day MBT-S workshop. Ninety-two healthcare professionals completed questionnaires before and after training. The mean within-participant increase in scores from baseline to end-of-programme was 11.6 points (95% CI 10.0-13.3) for the KAMQ and 4.0 points (1.8-6.2) for the APDQ.Clinical implicationsMBT-S is a short intervention that is effective in improving clinicians' knowledge of personality disorder and mentalisation. That attitudes to personality disorder improved overall is encouraging in relation to the possibility of deeper learning in staff and, ultimately, improved care for patients with personality disorder.Declaration of interestNone.

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

Effects of Self-Management Support on Structure, Process, and Outcomes Among Vulnerable Patients With Diabetes

PubMed Central

Schillinger, Dean; Handley, Margaret; Wang, Frances; Hammer, Hali

2009-01-01

OBJECTIVE Despite the importance of self-management support (SMS), few studies have compared SMS interventions, involved diverse populations, or entailed implementation in safety net settings. We examined the effects of two SMS strategies across outcomes corresponding to the Chronic Care Model. RESEARCH DESIGN AND METHODS A total of 339 outpatients with poorly controlled diabetes from county-run clinics were enrolled in a three-arm trial. Participants, more than half of whom spoke limited English, were uninsured, and/or had less than a high school education, were randomly assigned to usual care, interactive weekly automated telephone self-management support with nurse follow-up (ATSM), or monthly group medical visits with physician and health educator facilitation (GMV). We measured 1-year changes in structure (Patient Assessment of Chronic Illness Care [PACIC]), communication processes (Interpersonal Processes of Care [IPC]), and outcomes (behavioral, functional, and metabolic). RESULTS Compared with the usual care group, the ATSM and GMV groups showed improvements in PACIC, with effect sizes of 0.48 and 0.50, respectively (P < 0.01). Only the ATSM group showed improvements in IPC (effect sizes 0.40 vs. usual care and 0.25 vs. GMV, P < 0.05). Both SMS arms showed improvements in self-management behavior versus the usual care arm (P < 0.05), with gains being greater for the ATSM group than for the GMV group (effect size 0.27, P = 0.02). The ATSM group had fewer bed days per month than the usual care group (−1.7 days, P = 0.05) and the GMV group (−2.3 days, P < 0.01) and less interference with daily activities than the usual care group (odds ratio 0.37, P = 0.02). We observed no differences in A1C change. CONCLUSIONS Patient-centered SMS improves certain aspects of diabetes care and positively influences self-management behavior. ATSM seems to be a more effective communication vehicle than GMV in improving behavior and quality of life. PMID:19131469

The implementation and evaluation of therapeutic touch in burn patients: an instructive experience of conducting a scientific study within a non-academic nursing setting.

PubMed

Busch, Martine; Visser, Adriaan; Eybrechts, Maggie; van Komen, Rob; Oen, Irma; Olff, Miranda; Dokter, Jan; Boxma, Han

2012-12-01

Evaluation of therapeutic touch (TT) in the nursing of burn patients; post hoc evaluation of the research process in a non-academic nursing setting. 38 burn patients received either TT or nursing presence. On admission, days 2, 5 and 10 of hospitalization, data were collected on anxiety for pain, salivary cortisol, and pain medication. Interviews with nurses were held concerning research in a non-academic setting. Anxiety for pain was more reduced on day 10 in the TT-group. The TT-group was prescribed less morphine on day 1 and 2. On day 2 cortisol level before dressing changes was higher in the TT-group. The situational challenges of this study led to inconsistencies in data collection and a high patient attrition rate, weakening its statistical power. Conducting an effect study within daily nursing practice should not be done with a nursing staff inexperienced in research. Analysis of the remaining data justifies further research on TT for burn patients with pain, anxiety for pain, and cortisol levels as outcomes. Administering and evaluating TT during daily care requires nurses experienced both in TT and research, thus leading to less attrition and missing data, increasing the power of future studies. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Can the care transitions measure predict rehospitalization risk or home health nursing use of home healthcare patients?

PubMed

Ryvicker, Miriam; McDonald, Margaret V; Trachtenberg, Melissa; Peng, Timothy R; Sridharan, Sridevi; Feldman, Penny H

2013-01-01

The Care Transitions Measure (CTM) was designed to assess the quality of patient transitions from the hospital. Many hospitals are using the measure to inform their efforts to improve transitional care. We sought to determine if the measure would have utility for home healthcare providers by predicting newly admitted patients at heightened risk for emergency department use, rehospitalization, or increased home health nursing visits. The CTM was administered to 495 home healthcare patients shortly after hospital discharge and home healthcare admission. Follow-up interviews were completed 30 and 60 days post hospital discharge. Interview data were supplemented with agency assessment and service use data. We did not find evidence that the CTM could predict home healthcare patients having an elevated risk for emergent care, rehospitalization, or higher home health nursing use. Because Medicare/Medicaid-certified home healthcare providers already use a comprehensive, mandated start of care assessment, the CTM may not provide them additional crucial information. Process and outcome measurement is increasingly becoming part of usual care. Selection of measures appropriate for each service setting requires thorough site-specific evaluation. In light of our findings, we cannot recommend the CTM as an additional measure in the home healthcare setting. © 2013 National Association for Healthcare Quality.

Non-operative advances: what has happened in the last 50 years in paediatric surgery?

PubMed

Holland, Andrew J A; McBride, Craig A

2015-01-01

Paediatric surgeons remain paediatric clinicians who have the unique skill set to treat children with surgical problems that may require operative intervention. Many of the advances in paediatric surgical care have occurred outside the operating theatre and have involved significant input from medical, nursing and allied health colleagues. The establishment of neonatal intensive care units, especially those focusing on the care of surgical infants, has greatly enhanced the survival rates and long-term outcomes of those infants with major congenital anomalies requiring surgical repair. Educational initiatives such as the advanced trauma life support and emergency management of severe burns courses have facilitated improved understanding and clinical care. Paediatric surgeons have led with the non-operative management of solid organ injury following blunt abdominal trauma. Nano-crystalline burn wound dressings have enabled a reduced frequency of painful dressing changes in addition to effective antimicrobial efficacy and enhanced burn wound healing. Burns care has evolved so that many children may now be treated almost exclusively in an ambulatory care setting or as day case-only patients, with novel technologies allowing accurate prediction of burn would outcome and planning of elective operative intervention to achieve burn wound closure. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Effects of automated immunization registry reporting via an electronic health record deployed in community practice settings.

PubMed

Merrill, J; Phillips, A; Keeling, J; Kaushal, R; Senathirajah, Y

2013-01-01

Among the expected benefits of electronic health records (EHRs) is increased reporting of public health information, such as immunization status. State and local immunization registries aid control of vaccine-preventable diseases and help offset fragmentation in healthcare, but reporting is often slow and incomplete. The Primary Care Information Project (PCIP), an initiative of the NYC Department of Health and Mental Hygiene, has implemented EHRs with immunization reporting capability in community settings. To evaluate the effect of automated reporting via an EHR on use and efficiency of reporting to the NY Citywide Immunization Registry, we conducted a secondary analysis of 1.7 million de-identified records submitted between January 2007 and June 2011 by 217 primary care practices enrolled in PCIP, pre and post launch of automated reporting via an EHR. We examined differences in records submitted per day, lag time, and documentation of eligibility for subsidized vaccines. Mean submissions per day did not change. Automated submissions of new and historical records increased by 18% and 98% respectively. Submissions within 14 days increased from 84% to 87%, and within 2 days increased from 60% to 77%. Median lag time decreased from 13 to 10 days. Documentation of eligibility decreased. Results are significant at p<0.001. Significant improvements in registry use and efficiency of reporting were found after launch of automated reporting via an EHR. A decrease in eligibility documentation was attributed to EHR workflow. The limitations to comprehensive evaluation found in these data, which were extracted from a registry initiated prior to widespread EHR implementation suggests that reliable evaluation of immunization reporting via the EHR may require modifications to legacy registry databases.

Sleep Quality and Vigilance Differ Among Inpatient Nurses Based on the Unit Setting and Shift Worked.

PubMed

Surani, Salim; Hesselbacher, Sean; Guntupalli, Bharat; Surani, Sara; Subramanian, Shyam

2015-12-01

Sleepiness in nurses has been shown to impact patient care and safety. The objectives of this study are to measure sleep quality, sleepiness, fatigue, and vigilance in inpatient nurses and to assess how setting (intensive care unit versus the general floor) and shift worked (day versus night) affect these measures. Nurses from both the ICU and floor were included in the study. Participants completed questionnaires assessing self-reported sleep quality (Pittsburgh Sleep Quality Index, PSQI), sleepiness (Stanford Sleepiness Scale and Epworth Sleepiness Scale, ESS), and fatigue (Fatigue Severity Scale, FSS). Vigilance was measured by means of the psychomotor vigilance test (PVT), before and after a 12-hour duty shift. The ESS was abnormal in 22% of all nurses, the FSS was abnormal in 33%, and the global PSQI was abnormal in 63%. More ICU nurses than floor nurses reported abnormal sleep quality (component 5) on the PSQI. Sleep medication use (PSQI component 6) was higher in night shift nurses. The FSS was greater in night shift nurses. On preshift PVT testing, day-shift nurses overall provided faster mean reaction time (RT) than night-shift nurses. ICU nurses working the day shift made more than twice as many total errors and false starts than day shift floor nurses. Floor nurses demonstrated a significant decrease from preshift to postshift in the mean of the fastest 10% RT. Our data indicate that a significant number of inpatient nurses have impaired sleep quality, excessive sleepiness, and abnormal fatigue, which may place them at a greater risk of making medical errors and harming patients; these problems are especially pronounced in night shift workers. PVT results were inconsistent, but floor and day shift nurses performed better on some tasks than ICU and night shift nurses.

Early prediction of intensive care unit-acquired weakness using easily available parameters: a prospective observational study.

PubMed

Wieske, Luuk; Witteveen, Esther; Verhamme, Camiel; Dettling-Ihnenfeldt, Daniela S; van der Schaaf, Marike; Schultz, Marcus J; van Schaik, Ivo N; Horn, Janneke

2014-01-01

An early diagnosis of Intensive Care Unit-acquired weakness (ICU-AW) using muscle strength assessment is not possible in most critically ill patients. We hypothesized that development of ICU-AW can be predicted reliably two days after ICU admission, using patient characteristics, early available clinical parameters, laboratory results and use of medication as parameters. Newly admitted ICU patients mechanically ventilated ≥2 days were included in this prospective observational cohort study. Manual muscle strength was measured according to the Medical Research Council (MRC) scale, when patients were awake and attentive. ICU-AW was defined as an average MRC score <4. A prediction model was developed by selecting predictors from an a-priori defined set of candidate predictors, based on known risk factors. Discriminative performance of the prediction model was evaluated, validated internally and compared to the APACHE IV and SOFA score. Of 212 included patients, 103 developed ICU-AW. Highest lactate levels, treatment with any aminoglycoside in the first two days after admission and age were selected as predictors. The area under the receiver operating characteristic curve of the prediction model was 0.71 after internal validation. The new prediction model improved discrimination compared to the APACHE IV and the SOFA score. The new early prediction model for ICU-AW using a set of 3 easily available parameters has fair discriminative performance. This model needs external validation.

A Cost Analysis of Day Care in Denmark.

ERIC Educational Resources Information Center

Wagner, Marsden G.

A cost analysis of day care in Denmark was initiated to determine what day care services cost, who pays for them, and how these costs relate to the quality of day care services. Some of the findings are: (1) group day care is considerably more expensive for children 0-3 years of age than for children 3-7 years of age; (2) group day care centers…

7 CFR 226.18 - Day care home provisions.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 4 2014-01-01 2014-01-01 false Day care home provisions. 226.18 Section 226.18... care home provisions. (a) Day care homes shall have current Federal, State or local licensing or approval to provide day care services to children. Day care homes which cannot obtain their license because...

7 CFR 226.18 - Day care home provisions.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 4 2013-01-01 2013-01-01 false Day care home provisions. 226.18 Section 226.18... care home provisions. (a) Day care homes shall have current Federal, State or local licensing or approval to provide day care services to children. Day care homes which cannot obtain their license because...

7 CFR 226.18 - Day care home provisions.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 7 Agriculture 4 2012-01-01 2012-01-01 false Day care home provisions. 226.18 Section 226.18... care home provisions. (a) Day care homes shall have current Federal, State or local licensing or approval to provide day care services to children. Day care homes which cannot obtain their license because...

Impact of 4.0% chlorhexidine cleansing of the umbilical cord on mortality and omphalitis among newborns of Sylhet, Bangladesh: design of a community-based cluster randomized trial.

PubMed

Mullany, Luke C; El Arifeen, Shams; Winch, Peter J; Shah, Rasheduzzaman; Mannan, Ishtiaq; Rahman, Syed M; Rahman, Mohammad R; Darmstadt, Gary L; Ahmed, Saifuddin; Santosham, Mathuram; Black, Robert E; Baqui, Abdullah H

2009-10-21

The World Health Organization recommends dry cord care for newborns but this recommendation may not be optimal in low resource settings where most births take place in an unclean environment and infections account for up to half of neonatal deaths. A previous trial in Nepal indicated that umbilical cord cleansing with 4.0% chlorhexidine could substantially reduce mortality and omphalitis risk, but policy changes await additional community-based data. The Projahnmo Chlorhexidine study was a three-year, cluster-randomized, community-based trial to assess the impact of three cord care regimens on neonatal mortality and omphalitis. Women were recruited mid-pregnancy, received a basic package of maternal and neonatal health promotion messages, and were followed to pregnancy outcome. Newborns were visited at home by local village-based workers whose areas were randomized to either 1) single- or 2) 7-day cord cleansing with 4.0% chlorhexidine, or 3) promotion of dry cord care as recommended by WHO. All mothers received basic messages regarding hand-washing, clean cord cutting, and avoidance of harmful home-base applications to the cord. Death within 28 days and omphalitis were the primary outcomes; these were monitored directly through home visits by community health workers on days 1, 3, 6, 9, 15, and 28 after birth. Due to report in early 2010, the Projahnmo Chlorhexidine Study examines the impact of multiple or single chlorhexidine cleansing of the cord on neonatal mortality and omphalitis among newborns of rural Sylhet District, Bangladesh. The results of this trial will be interpreted in conjunction with a similarly designed trial previously conducted in Nepal, and will have implications for policy guidelines for optimal cord care of newborns in low resource settings in Asia. ClinicalTrials.gov (NCT00434408).

Primary care challenges of an obscure case of "Alice in Wonderland" syndrome in a patient with severe malaria in a resource-constrained setting: a case report.

PubMed

Kadia, Benjamin Momo; Ekabe, Cyril Jabea; Agborndip, Ettamba

2017-12-22

"Alice in Wonderland" syndrome (AIWS) is a rare neurological abnormality characterized by distortions of visual perceptions, body schema and experience of time. AIWS has been reported in patients with various infections such as infectious mononucleosis, H1N1 influenza, Cytomegalovirus encephalitis, and typhoid encephalopathy. However, AIWS occurring in a patient with severe malaria is less familiar and could pose serious primary care challenges in a low-income context. A 9-year-old male of black African ethnicity was brought by his parents to our primary care hospital because for 2 days he had been experiencing intermittent sudden perceptions of his parents' heads and objects around him either "shrinking" or "expanding". The visual perceptions were usually brief and resolved spontaneously. One week prior to the onset of the visual problem, he had developed an intermittent high grade fever that was associated with other severe constitutional symptoms. Based on the historical and clinical data that were acquired, severe malaria was suspected and this was confirmed by hyperparasitaemia on blood film analysis. The patient was treated with quinine for 10 days. Apart from a single episode of generalized tonic-clonic seizures that was observed on the first day of treatment, the overall clinical progress was good. The visual illusions completely resolved and no further abnormalities were recorded during 3 months of follow-up. Symptoms of AIWS usually resolve spontaneously or after treatment of an underlying cause. In our case, the successful treatment of severe malaria coincided with a complete regression of AIWS whose aetiology was poorly-elucidated given the resource constraints. In any case, the good outcome of our patient aligns with previous reports on acute AIWS that highlight a limited need for excessive investigation and treatment modalities which are, in passing, predominantly unaffordable in resource-limited primary care settings.

Should Breast Cancer Surgery Be Done in an Outpatient Setting?: Health Economics From the Perspective of Service Providers.

PubMed

Formago, Margaret; Schrauder, Michael G; Rauh, Claudia; Hack, Carolin C; Jud, Sebastian M; Hildebrandt, Thomas; Schulz-Wendtland, Rüdiger; Frentz, S; Graubert, S; Beckmann, Matthias W; Lux, Michael P

2017-08-01

The care of patients with breast cancer is extremely complex and requires interdisciplinary care in certified facilities. These specialized facilities provide numerous services without being correspondingly remunerated. The question whether breast cancer surgery should be performed in an outpatient setting to reduce costs is increasingly being debated. This study compares inpatient surgical treatment with a model of the same surgery performed on an outpatient basis to examine the potential financial impact. A theoretical model was developed and the DRG fees for surgical interventions to treat primary breast cancer were calculated. A theoretical 1-day DRG was then calculated to permit comparisons with outpatient procedures. The costs of outpatient surgery were calculated based on the remuneration rates of the AOP (Outpatient Surgery) Contract and the EBM (Uniform Assessment Scale) and compared to the costs of the 1-day DRG. The DRG fee for both breast-conserving surgery and mastectomy is higher than the fee paid in the context of the EBM system, although the same procedures were carried out in both systems. If a hospital were to carry out breast-conserving surgery as an outpatient procedure, the fee would be € 1313.81; depending on the type of surgery, the hospital would therefore only receive between 39.20% and 52.82% of the DRG fee. This was the case even for a 1-day treatment. Compared to the real DRG fees the difference would be even more striking. Carrying out breast cancer surgery as an outpatient procedure would result in a significant shortfall of revenues. Additional services from certified centers, such as the interdisciplinary planning of treatment, psycho-oncological and social-medical care with the involvement of relatives, detailed documentation, etc., which are currently provided without surcharge or adequate remuneration, could no longer be maintained. The quality of processes and excellent results which have been achieved and ultimately the care given by certified facilities would be significantly at risk.

Language-concordant automated telephone queries to assess medication adherence in a diverse population: a cross-sectional analysis of convergent validity with pharmacy claims.

PubMed

Ratanawongsa, Neda; Quan, Judy; Handley, Margaret A; Sarkar, Urmimala; Schillinger, Dean

2018-04-06

Clinicians have difficulty accurately assessing medication non-adherence within chronic disease care settings. Health information technology (HIT) could offer novel tools to assess medication adherence in diverse populations outside of usual health care settings. In a multilingual urban safety net population, we examined the validity of assessing adherence using automated telephone self-management (ATSM) queries, when compared with non-adherence using continuous medication gap (CMG) on pharmacy claims. We hypothesized that patients reporting greater days of missed pills to ATSM queries would have higher rates of non-adherence as measured by CMG, and that ATSM adherence assessments would perform as well as structured interview assessments. As part of an ATSM-facilitated diabetes self-management program, low-income health plan members typed numeric responses to rotating weekly ATSM queries: "In the last 7 days, how many days did you MISS taking your …" diabetes, blood pressure, or cholesterol pill. Research assistants asked similar questions in computer-assisted structured telephone interviews. We measured continuous medication gap (CMG) by claims over 12 preceding months. To evaluate convergent validity, we compared rates of optimal adherence (CMG ≤ 20%) across respondents reporting 0, 1, and ≥ 2 missed pill days on ATSM and on structured interview. Among 210 participants, 46% had limited health literacy, 57% spoke Cantonese, and 19% Spanish. ATSM respondents reported ≥1 missed day for diabetes (33%), blood pressure (19%), and cholesterol (36%) pills. Interview respondents reported ≥1 missed day for diabetes (28%), blood pressure (21%), and cholesterol (26%) pills. Optimal adherence rates by CMG were lower among ATSM respondents reporting more missed days for blood pressure (p = 0.02) and cholesterol (p < 0.01); by interview, differences were significant for cholesterol (p = 0.01). Language-concordant ATSM demonstrated modest potential for assessing adherence. Studies should evaluate HIT assessments of medication beliefs and concerns in diverse populations. NCT00683020 , registered May 21, 2008.

A randomized trial of an acid-peptic disease management program in a managed care environment.

PubMed

Ofman, Joshua J; Segal, Richard; Russell, Wayne L; Cook, Deborah J; Sandhu, Meenu; Maue, Susan K; Lowenstein, Edward H; Pourfarzib, Ray; Blanchette, Erv; Ellrodt, Gray; Weingarten, Scott R

2003-06-01

To study the effectiveness of a disease management program for patients with acid-related disorders. A cluster-randomized clinical trial of 406 patients comparing a disease management program with "usual practice." Enrolled patients included those presenting with new dyspepsia and chronic users of antisecretory drugs in 8 geographically separate physician offices associated with the Orlando Health Care Group. There were 35 providers in the intervention group and 48 in the control group. The disease management program included evidence-based practice guidelines implemented by using physician champions, academic detailing, and multidisciplinary teams. Processes of care, patient symptoms, quality of life, costs, and work days lost were measured 6 months after patient enrollment. Compared with usual practice, disease management was associated with improvements in Helicobacter pylori testing (61% vs 9%; P = .001), use of recommended H pylori treatment regimens (96% vs 10%; P = .001), and discontinuation rates of proton pump therapy after treatment (70% vs 36%; P = .04). There were few differences in patient quality of life or symptoms between the 2 study groups. Disease management resulted in fewer days of antisecretory therapy (71.7 vs 88.1 days; P = .02) but no difference in total costs. This disease management program for patients with acid-related disorders led to improved processes of care. The effectiveness of such a program in other settings requires further study.

Online social network use by health care providers in a high traffic patient care environment.

PubMed

Black, Erik; Light, Jennifer; Paradise Black, Nicole; Thompson, Lindsay

2013-05-17

The majority of workers, regardless of age or occupational status, report engaging in personal Internet use in the workplace. There is little understanding of the impact that personal Internet use may have on patient care in acute clinical settings. The objective of this study was to investigate the volume of one form of personal Internet use-online social networking (Facebook)-generated by workstations in the emergency department (ED) in contrast to measures of clinical volume and severity. The research team analyzed anonymous network utilization records for 68 workstations located in the emergency medicine department within one academic medical center for 15 consecutive days (12/29/2009 to 1/12/2010). This data was compared to ED work index (EDWIN) data derived by the hospital information systems. Health care workers spent an accumulated 4349 minutes (72.5 hours) browsing Facebook, staff cumulatively visited Facebook 9369 times and spent, on average, 12.0 minutes per hour browsing Facebook. There was a statistically significant difference in the time spent on Facebook according to time of day (19.8 minutes per hour versus 4.3 minutes per hour, P<.001). There was a significant, positive correlation between EDWIN scores and time spent on Facebook (r=.266, P<.001). Facebook use constituted a substantive percentage of staff time during the 15-day observation period. Facebook use increased with increased patient volume and severity within the ED.

Anterior cervical discectomy and fusion in the outpatient ambulatory surgery setting compared with the inpatient hospital setting: analysis of 1000 consecutive cases.

PubMed

Adamson, Tim; Godil, Saniya S; Mehrlich, Melissa; Mendenhall, Stephen; Asher, Anthony L; McGirt, Matthew J

2016-06-01

OBJECTIVE In an era of escalating health care costs and pressure to improve efficiency and cost of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options for many surgical therapies. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed, and the frequency of its performance is rapidly increasing as the aging population grows. Although ASCs offer significant cost advantages over hospital-based surgical centers, concern over the safety of outpatient ACDF has slowed its adoption. The authors intended to 1) determine the safety of the first 1000 consecutive ACDF surgeries performed in their outpatient ASC, and 2) compare the safety of these outpatient ACDFs with that of consecutive ACDFs performed during the same time period in the hospital setting. METHODS A total of 1000 consecutive patients who underwent ACDF in an ACS (outpatient ACDF) and 484 consecutive patients who underwent ACDF at Vanderbilt University Hospital (inpatient ACDF) from 2006 to 2013 were included in this retrospective study of patients' medical records. Data were collected on patient demographics, comorbidities, operative details, and perioperative and 90-day morbidity. Perioperative morbidity and hospital readmission were compared between the outpatient and inpatient ACDF groups. RESULTS Of the first 1000 outpatient ACDF cases performed in the authors' ASC, 629 (62.9%) were 1-level and 365 (36.5%) were 2-level ACDFs. Mean patient age was 49.5 ± 8.6, and 484 (48.4%) were males. All patients were observed postoperatively at the ASC postanesthesia care unit (PACU) for 4 hours before being discharged home. Eight patients (0.8%) were transferred from the surgery center to the hospital postoperatively (for pain control [n = 3], chest pain and electrocardiogram changes [n = 2], intraoperative CSF leak [n = 1], postoperative hematoma [n = 1], and profound postoperative weakness and surgical reexploration [n = 1]). No perioperative deaths occurred. The 30-day hospital readmission rate was 2.2%. All 90-day surgical morbidity was similar between outpatient and inpatient cohorts for both 1-level and 2-level ACDFs. CONCLUSIONS An analysis of 1000 consecutive patients who underwent ACDF in an outpatient setting demonstrates that surgical complications occur at a low rate (1%) and can be appropriately diagnosed and managed in a 4-hour ASC PACU window. Comparison with an inpatient ACDF surgery cohort demonstrated similar results, highlighting that ACDF can be safely performed in the outpatient ambulatory surgery setting without compromising surgical safety. In an effort to decrease costs of care, surgeons can safely perform 1- and 2-level ACDFs in an ASC environment.

The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: a prospective randomized crossover trial.

PubMed

Tan, Xueli; Yowler, Charles J; Super, Dennis M; Fratianne, Richard B

2010-01-01

The purpose of this study was to explore the efficacy of two music therapy protocols on pain, anxiety, and muscle tension levels during dressing changes in burn patients. Twenty-nine inpatients participated in this prospective, crossover randomized controlled trial. On two consecutive days, patients were randomized to receive music therapy services either on the first or second day of the study. On control days, they received no music. On music days, patients practiced music-based imagery (MBI), a form of music-assisted relaxation with patient-specific mental imagery before and after dressing changes. Also, on music days during dressing changes, the patients engaged in music alternate engagement (MAE), which consisted of active participation in music making. The dependent variables were the patients' subjective ratings of their pain and anxiety levels and the research nurse's objective ratings of their muscle tension levels. Two sets of data were collected before, three sets during, and another two sets after dressing changes. The results showed significant decrease in pain levels before (P < .025), during (P < .05), and after (P < .025) dressing changes on days the patients received music therapy in contrast to control days. Music therapy was also associated with a decrease in anxiety and muscle tension levels during the dressing changes (P < .05) followed by a reduction in muscle tension levels after dressing changes (P < .025). Music therapy significantly decreases the acute procedural pain, anxiety, and muscle tension levels associated with daily burn care.

Depressive Mood, Anger, and Daily Cortisol of Caregivers on High- and Low-Stress Days.

PubMed

Leggett, Amanda N; Zarit, Steven H; Kim, Kyungmin; Almeida, David M; Klein, Laura Cousino

2015-11-01

This study examines the association of daily cortisol with depressive mood and anger. Depressive mood, anger and 2 markers of cortisol, area under the curve (AUC), and cortisol awakening response (CAR) were examined for caregivers (N = 164) of individuals with dementia (IWDs) across 8 days, some of which IWDs attended an adult day service (ADS) program. Caregivers were primarily female (86.7%) with a mean age of 61.99. First, multilevel models were run with CAR and AUC each as separate covariates of anger and depressive mood. A second set of models examined contextual factors of caregivers (i.e., care-related stressors and amount of ADS use) were added to the models for anger and depressive mood (Model 2). On days where caregivers had AUCs below their average they expressed higher anger scores. However in Model 2, anger was associated with more care-related stressors, but not ADS use or daily cortisol. Caregivers who on average had smaller CARs were more likely to be depressed. In Model 2, depressed mood was associated with more care-related stressors and a low average CAR. We found that hypocortisol patterns, reflective of chronic stress experienced by caregivers, are associated with negative mood. © The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Interventional radiology in infancy.

PubMed

Barnacle, Alex M

2014-11-01

Interventional radiology (IR) is an emerging sub-speciality within paediatric medicine. In adult care, IR is largely centred on the management of vascular disease but in paediatric practice, IR applications are varied and increasingly innovative, making this an exciting field to be a part of. IR has a central role both in the day to day care of sick children, from long term IV access provision to feeding tube insertions, and in the acute management of critically ill infants, such as those with overwhelming liver disease, neonatal tumours and vascular malformations. Paediatric IR faces a unique set of challenges, developing or modifying techniques and equipment for use in very small patients, training professionals to take the speciality forward and, most importantly, convincing paediatricians and healthcare institutions to create opportunities for IR to make a difference. Copyright © 2014 Elsevier Ltd. All rights reserved.

Nutrition and physical activity in child care centers: the impact of a wellness policy initiative on environment and policy assessment and observation outcomes, 2011.

PubMed

Lyn, Rodney; Maalouf, Joyce; Evers, Sarah; Davis, Justin; Griffin, Monica

2013-05-23

The child care environment has emerged as an ideal setting in which to implement policies that promote healthy body weight of children. The purpose of this study was to assess the effect of a wellness policy and training program on the physical activity and nutrition environment in 24 child care centers in Georgia. We used the Environment and Policy Assessment and Observation instrument to identify changes to foods served, staff behaviors, and physical activity opportunities. Observations were performed over 1 day, beginning with breakfast and concluding when the program ended for the day. Observations were conducted from February 2010 through April 2011 for a total of 2 observations in each center. Changes to nutrition and physical activity in centers were assessed on the basis of changes in scores related to the physical activity and nutrition environment documented in the observations. Paired t test analyses were performed to determine significance of changes. Significant improvements to total nutrition (P < .001) and physical activity scores (P < .001) were observed. Results indicate that centers significantly improved the physical activity environments of centers by enhancing active play (P = .02), the sedentary environment (P = .005), the portable environment (P = .002), staff behavior (P = .004), and physical activity training and education (P < .001). Significant improvements were found for the nutrition environment (P < .001), and nutrition training and education (P < .001). Findings from this study suggest that implementing wellness policies and training caregivers in best practices for physical activity and nutrition can promote healthy weight for young children in child care settings.

Helping mothers survive bleeding after birth: an evaluation of simulation-based training in a low-resource setting.

PubMed

Nelissen, Ellen; Ersdal, Hege; Ostergaard, Doris; Mduma, Estomih; Broerse, Jacqueline; Evjen-Olsen, Bjørg; van Roosmalen, Jos; Stekelenburg, Jelle

2014-03-01

To evaluate "Helping Mothers Survive Bleeding After Birth" (HMS BAB) simulation-based training in a low-resource setting. Educational intervention study. Rural referral hospital in Northern Tanzania. Clinicians, nurse-midwives, medical attendants, and ambulance drivers involved in maternity care. In March 2012, health care workers were trained in HMS BAB, a half-day simulation-based training, using a train-the-trainer model. The training focused on basic delivery care, active management of third stage of labor, and treatment of postpartum hemorrhage, including bimanual uterine compression. Evaluation questionnaires provided information on course perception. Knowledge, skills, and confidence of facilitators and learners were tested before and after training. Four master trainers trained eight local facilitators, who subsequently trained 89 learners. After training, all facilitators passed the knowledge test, but pass rates for the skills test were low (29% pass rate for basic delivery and 0% pass rate for management of postpartum hemorrhage). Evaluation revealed that HMS BAB training was considered acceptable and feasible, although more time should be allocated for training, and teaching materials should be translated into the local language. Knowledge, skills, and confidence of learners increased significantly immediately after training. However, overall pass rates for skills tests of learners after training were low (3% pass rate for basic delivery and management of postpartum hemorrhage). The HMS BAB simulation-based training has potential to contribute to education of health care providers. We recommend a full day of training and validation of the facilitators to improve the training. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

The economic cost of stroke-associated pneumonia in a UK setting.

PubMed

Ali, A N; Howe, J; Majid, A; Redgrave, J; Pownall, S; Abdelhafiz, A H

2018-04-01

Introduction Stroke-associated pneumonia (SAP) is common, however, data on the economic impact of SAP are scarce. This study aimed to prospectively evaluate the impact of SAP on acute stroke care costs in a UK setting. Methods Prospective cohort study of 213 consecutive patients with stroke (196 ischemic, 17 hemorrhagic) was admitted to a UK hospital over 1 year. Socio demographic and clinical characteristics were recorded along with all treatments and rehabilitation activity. Patients were classified as having SAP if they fulfilled criteria for "probable" or "definite" respiratory tract infection according to the Centres for Disease Control and Prevention definition, within the first seven days following stroke. Resource use was calculated using a "bottom up" approach of cumulative unit costs. Univariate and multivariate regression analyses were used to establish independent predictors of direct costs. Results Probable or definite SAP occurred in 13.2% (28/213) of patients. Patients with SAP experienced greater inpatient stays (31 days vs. 9 days, p ≤ 0.001) and higher in-hospital mortality (29.2% vs. 10.2%, p = 0.007). Mean (SD) acute care costs per patient was £7035 (6767), but costs were significantly greater for patients with SAP than without [£14,371 (9484) versus £6,103 (5,735); p ≤ 0.001]. SAP was an independent predictor of costs along with increasing stroke severity (NIHSS) and age. Occurrence of SAP resulted in an adjusted incremental additional cost of £5817 (95% CI 4945-6689; p = 0.001) per patient. Conclusions SAP increased acute care costs for stroke by approximately 80%. This provides further impetus for research aimed at reducing SAP, and will inform cost-effectiveness analyses of potential therapeutic strategies.

Urinary versus plasma neutrophil gelatinase-associated lipocalin (NGAL) as a predictor of mortality for acute kidney injury in intensive care unit patients.

PubMed

Mahmoodpoor, Ata; Hamishehkar, Hadi; Fattahi, Vahid; Sanaie, Sarvin; Arora, Pradeep; Nader, Nader D

2018-02-01

To examine urinary and plasma neutrophil gelatinase-associated lipocalin (NGAL) levels in predicting ICU mortality. Prospective observational. University Critical Care setting. 50 patients with acute kidney injury (AKI). None. Serial urinary and plasma concentrations of NGAL were measured. Twenty-five patients had early progression (EP) and 25 patients had early improvement (EI) of AKI. Plasma concentrations of NGAL in the EP group (N=25) were significantly higher than those in the EI group (129 [IQR; 20] vs. 111 [IQR; 32] ng/mL; P=0.009), while urine NGAL levels on admission were similar in both groups (61 [IQR; 20] vs. 65 [IQR; 20] ng/mL; P=0.767). Plasma NGAL concentrations rapidly decreased to 87 [32] ng/mL in the EI group (P<0.001) and while it remained elevated in the EP group (138 [21] ng/mL). Within 28-days, 50% of the patients died in the EP group, whereas no patient died in the EI group (P<0.001). Plasma NGAL was a fair predictor for progression of AKI (AUC; 0.719±0.063; P=0.006). 48-hour changes in plasma NGAL levels predicted death within 28-days of ICU admission (AUC; 0.874±0.048; P<0.001). Early progression of AKI was associated with more death within 28 and 90days. While one time measurement of plasma NGAL levels at the time ICU admission may represent the kidney health status in critical care settings, it does not reliably predict mortality. On the other hand, changes in plasma NGAL within 48h of admission improve the value of this biomarker in predicting ICU mortality. Published by Elsevier Inc.

Interprofessional oral health initiative in a nondental, American Indian setting.

PubMed

Murphy, Kate L; Larsson, Laura S

2017-12-01

Tooth decay is the most common chronic childhood disease and American Indian (AI) children are at increased risk. Pediatric primary care providers are in an opportune position to reduce tooth decay. The purpose of this study was to integrate and evaluate a pediatric oral health project in an AI, pediatric primary care setting. The intervention set included caregiver education, caries risk assessment, and a same-day dental home referral. All caregiver/child dyads age birth to 5 years presenting to the pediatric clinic were eligible (n = 47). Most children (n = 35, 91.1%) were scored as high risk for caries development. Of those with first tooth eruption (n = 36), ten had healthy teeth (27.8%) and seven had seen a dentist in the past 3 months (19.4%). All others were referred to a dentist (n = 29) and 21 families (72.4%) completed the referral. In fewer than 5 min per appointment (x = 4.73 min), the primary care provider integrated oral health screening, education, and referral into the well-child visit. Oral health is part of total health, and thus should be incorporated into routine well-child visits. ©2017 American Association of Nurse Practitioners.

Family Day Care: Some Observations.

ERIC Educational Resources Information Center

Saunders, Minta M.; Keister, Mary Elizabeth

A study comparing family and group day care was conducted. Data were collected over a two-year period on 12 children in a Greensboro, N. C., family day care program and 10 children in the UNC-G Demonstration Center for Infant-Toddler Care, a group day care center. Results, which disproved many assumptions cited as advantages of family day care,…

Non-native Speech Perception Training Using Vowel Subsets: Effects of Vowels in Sets and Order of Training

PubMed Central

Nishi, Kanae; Kewley-Port, Diane

2008-01-01

Purpose Nishi and Kewley-Port (2007) trained Japanese listeners to perceive nine American English monophthongs and showed that a protocol using all nine vowels (fullset) produced better results than the one using only the three more difficult vowels (subset). The present study extended the target population to Koreans and examined whether protocols combining the two stimulus sets would provide more effective training. Method Three groups of five Korean listeners were trained on American English vowels for nine days using one of the three protocols: fullset only, first three days on subset then six days on fullset, or first six days on fullset then three days on subset. Participants' performance was assessed by pre- and post-training tests, as well as by a mid-training test. Results 1) Fullset training was also effective for Koreans; 2) no advantage was found for the two combined protocols over the fullset only protocol, and 3) sustained “non-improvement” was observed for training using one of the combined protocols. Conclusions In using subsets for training American English vowels, care should be taken not only in the selection of subset vowels, but also for the training orders of subsets. PMID:18664694

A Descriptive Analysis of Incidents Reported by Community Aged Care Workers.

PubMed

Tariq, Amina; Douglas, Heather E; Smith, Cheryl; Georgiou, Andrew; Osmond, Tracey; Armour, Pauline; Westbrook, Johanna I

2015-07-01

Little is known about the types of incidents that occur to aged care clients in the community. This limits the development of effective strategies to improve client safety. The objective of the study was to present a profile of incidents reported in Australian community aged care settings. All incident reports made by community care workers employed by one of the largest community aged care provider organizations in Australia during the period November 1, 2012, to August 8, 2013, were analyzed. A total of 356 reports were analyzed, corresponding to a 7.5% incidence rate per client year. Falls and medication incidents were the most prevalent incident types. Clients receiving high-level care and those who attended day therapy centers had the highest rate of incidents with 14% to 20% of these clients having a reported incident. The incident profile indicates that clients on higher levels of care had higher incident rates. Incident data represent an opportunity to improve client safety in community aged care. © The Author(s) 2014.

Urine Culture Follow-up and Antimicrobial Stewardship in a Pediatric Urgent Care Network.

PubMed

Saha, Dipanwita; Patel, Jimisha; Buckingham, Don; Thornton, David; Barber, Terry; Watson, Joshua R

2017-04-01

Empiric antibiotic therapy for presumed urinary tract infection (UTI) leads to unnecessary antibiotic exposure in many children whose urine culture results fail to confirm the diagnosis. The objective of this quality improvement study was to improve follow-up management of negative urine culture results in the off-campus urgent care network of Nationwide Children's Hospital to reduce inappropriate antibiotic exposure in children. A multidisciplinary task force developed and implemented a protocol for routine nurse and clinician follow-up of urine culture results, discontinuation of unnecessary antibiotics, and documentation in the electronic medical record. Monthly antibiotic discontinuation rates were tracked in empirically treated patients with negative urine culture results from July 2013 through December 2015. Statistical process control methods were used to track improvement over time. Fourteen-day return visits for UTIs were monitored as a balancing measure. During the study period, 910 patients received empiric antibiotic therapy for UTIs but had a negative urine culture result. The antibiotic discontinuation rate increased from 4% to 84%, avoiding 3429 (40%) of 8648 antibiotic days prescribed. Among patients with discontinued antibiotics, none was diagnosed with a UTI within 14 days of the initial urgent care encounter. Implementation of a standard protocol for urine culture follow-up and discontinuation of unnecessary antibiotics was both effective and safe in a high-volume pediatric urgent care network. Urine culture follow-up management is an essential opportunity for improved antimicrobial stewardship in the outpatient setting that will affect many patients by avoiding a substantial number of antibiotic days. Copyright © 2017 by the American Academy of Pediatrics.

Antenatal iron/folic acid supplements, but not postnatal care, prevents neonatal deaths in Indonesia: analysis of Indonesia Demographic and Health Surveys 2002/2003–2007 (a retrospective cohort study)

PubMed Central

Titaley, Christiana Rialine; Dibley, Michael John

2012-01-01

Objective This study aimed to assess the contribution of postnatal services to the risk of neonatal mortality, and the relative contributions of antenatal iron/folic acid supplements and postnatal care in preventing neonatal mortality in Indonesia. Design Retrospective cohort study. Setting and participants Data used in this study were the 2002–2007 Indonesia Demographic and Health Surveys, nationally representative surveys. The pooled data provided survival information of 26 591 most recent live-born infants within the 5-years prior to each interview. Primary outcomes Primary outcomes were early neonatal mortality, that is, deaths in the first week, and all neonatal mortality, that is, deaths in the first month of life. Exposures were antenatal iron/folic acid supplementation and postnatal care from days 1 to 7. Potential confounders were community, socio-economic status and birthing characteristics and perinatal healthcare. Cox regression was used to assess the association between study factors and neonatal mortality. Results Postnatal care services were not associated with newborn survival. Postnatal care on days 1–7 after birth did not reduce neonatal death (HR=1.00, 95% CI 0.55 to 1.83, p=1.00) and early postnatal care on day 1 was associated with an increased risk of early neonatal death (HR=1.27, 95% CI 0.69 to 2.32, p=0.44) possibly reflecting referral of ill newborns. Early postnatal care on day 1 was not protective for neonatal deaths on days 2–7 whether provided by doctors (HR 3.61, 95% CI 1.54 to 8.45, p<0.01), or by midwives or nurses (HR 1.38, 95% CI 0.53 to 3.57, p=0.512). In mothers who took iron/folic acid supplements during pregnancy, the risk of early neonatal death was reduced by 51% (HR=0.49, 95% CI 0.30 to 0.79, p<0.01). Conclusions We found no protective effect of postnatal care against neonatal deaths in Indonesia. However, important reductions in the risk of neonatal death were found for women who reported use of antenatal iron/folic acid supplements during pregnancy. PMID:23117564

Teleradiology in southern Sweden--a tool for reorganization of health care and for education.

PubMed

Pettersson, H; Holmer, N G

1998-01-01

The county organization, including health care, is reorganized in the province of Scania in southern Sweden. As part of the restructuring of health care, a program for digitalization of the departments of diagnostic imaging, as well as for teleradiology, has been set up. Standards for network, radiology information systems, and workstations have been settled, and teleradiology links both for on-call consultations and for on-line consultations day-time have been implemented, mainly running at 10 Mb/s. Further digitalization and implementation of teleradiology is planned for the nearest years. Parallel to this, a video conference system including several disciplines, hospitals and health care levels in the whole of southern Sweden has been implemented. The links are now also used for education, both in the province and internationally.

Effectiveness of locomotion training in a home visit preventive care project: one-group pre-intervention versus post-intervention design study.

PubMed

Ito, Shinya; Hashimoto, Mari; Aduma, Saori; Yasumura, Seiji

2015-11-01

Locomotion training in a home visit-type preventive-care program has been reported elsewhere. However, continuation of appropriate exercises in a home setting is difficult, and few reports are available on locomotion training in a home setting. The objective of this study was to evaluate the effectiveness of locomotion training over 3 months in a home visit-type preventive-care program for improvement of motor function among elderly people. Nine hundred and fifty-eight elderly people in Tendo City in Japan who were not currently attending any preventive-care program were invited to participate in the study, and 87 were enrolled. In the pre-intervention and post-intervention assessments, we administered an interview survey (the Kihon Checklist), the timed one-leg standing test with eyes open and the sit-to-stand test, at the participants' homes. The intervention involved one set of training exercises with the participants standing on each leg for 1 min and squatting five or six times. The participants were asked to repeat one set of the exercises three times a day at home. In addition, the participants were regularly asked over the telephone about their performance of the exercises. Physical strength, cognitive function, and total scores of the Kihon Checklist were significantly lower after the intervention than before. In addition, the one-leg standing test time was significantly longer after the intervention (mean ± SD, 23.9 ± 35.4) than before (15.7 ± 20.5), and the sit-to-stand test time was significantly shorter after the intervention (13.0 ± 6.2) than before (14.8 ± 8.3). Locomotion training in a home-visit preventive-care program with telephone support effectively improved the motor function of elderly people who were not currently attending any preventive-care program organized by the long-term care insurance system.

Is socially integrated community day care for people with dementia associated with higher user satisfaction and a higher job satisfaction of staff compared to nursing home-based day care?

PubMed

Marijke van Haeften-van Dijk, A; Hattink, Bart J J; Meiland, Franka J M; Bakker, Ton J E M; Dröes, Rose-Marie

2017-06-01

To investigate whether community-based (CO) day care with carer support according to the proven effective Meeting Centres Support Programme model is associated with higher satisfaction of people with dementia (PwD) and their informal caregivers (CG) and with a higher job satisfaction among care staff compared to traditional nursing home-based (NH) day care. Data were collected in 11 NH day care centres and 11 CO day care centres. User satisfaction of PwD and CG was evaluated in the 11 NH day care centres (n PwD = 41, n CG = 39) and 11 CO day care centres (n PwD = 28, n CG = 36) with a survey after six months of participation. Job satisfaction was measured only in the six NH day care centres that recently transformed to CO day care, with two standard questionnaires before (n STAFF = 35), and six months after the transition (n STAFF = 35). PwD were more positive about the communication and listening skills of staff and the atmosphere and activities at the CO day care centre. Also, CG valued the communication with, and expertise of, staff in CO day care higher, and were more satisfied with the received emotional, social and practical support. After the transition, satisfaction of staff with the work pace increased, but satisfaction with learning opportunities decreased. PwD and CG were more satisfied about the communication with the staff and the received support in CO day care than in NH day care. Overall job satisfaction was not higher, except satisfaction about work pace.

Hysteroscopic Endometrial Polypectomy: Clinical and Economic Data in Decision Making.

PubMed

Franchini, Mario; Lippi, Giuseppe; Calzolari, Stefano; Giarrè, Giovanna; Gubbini, Giampietro; Catena, Ursula; Di Spiezio Sardo, Attilio; Florio, Pasquale

To compare the costs of hysteroscopic polypectomy using mechanical and electrosurgical systems in the hospital operating room and an office-based setting. Retrospective cohort study (Canadian Task Force classification II-2). Tertiary referral hospital and center for gynecologic care. Seven hundred and fifty-four women who underwent endometrial polypectomy between January 20, 2015, and April 27, 2016. Hysteroscopic endometrial polypectomy performed in the same-day hospital setting or office setting using one of the following: bipolar electrode, loop electrode, mechanical device, or hysteroscopic tissue removal system. The various costs associated with the 2 clinical settings at Palagi Hospital, Florence, Italy were compiled, and a direct cost comparison was made using an activity-based cost-management system. The costs for using reusable loop electrode resection-16 or loop electrode resection-26 were significantly less expensive than using disposable loop electrode resection-27, the tissue removal system, or bipolar electrode resection (p = .0002). Total hospital costs for polypectomy with all systems were significantly less expensive in an office setting compared with same-day surgery in the hospital setting (p = .0001). Office-based hysteroscopic tissue removal was associated with shorter operative time compared with the other procedures (p = .0002) CONCLUSION: The total cost of hysteroscopic polypectomy is markedly higher when using disposable equipment compared with reusable equipment, both in the hospital operating room and the office setting. Same-day hospital or office-based surgery with reusable loop electrode resection is the most cost-effective approach in each settings, but requires experienced surgeons. Finally, the shorter surgical time should be taken into consideration for patients undergoing vaginal polypectomy in the office setting, owing more to patient comfort than to cost savings. Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.

Family Day Care Training Curriculum (Lao).

ERIC Educational Resources Information Center

Nakatsu, Gail

California's Family Day Care Training Program was designed to recruit and train, in 7 weeks, Lao, Vietnamese, and Chinese refugees to establish their own state-licensed, family day care homes. Topics in the program's curriculum include an introduction to family day care, state licenses for family day care, state licensing requirements for family…

Family Day Care Training Curriculum.

ERIC Educational Resources Information Center

Nakatsu, Gail

California's Family Day Care Training Program was designed to recruit and train in 7 weeks, Lao, Vietnamese, and Chinese refugees to establish their own state-licensed, family day care homes. Topics in the program's curriculum include an introduction to family day care, state licenses for family day care, state licensing requirements for family…

Day Care: Scientific and Social Policy Issues.

ERIC Educational Resources Information Center

Zigler, Edward F., Ed.; Gordon, Edmund W., Ed.

In this book of articles on day care, policy analyses of day care delivery are combined with recent research on the effects of day care. The authors include experimental psychologists, psychiatrists, economists, public health workers, pediatricians, and early childhood educators. Among the issues investigated are the influence of day care on…

Pain medication management processes used by oncology outpatients and family caregivers part I: health systems contexts.

PubMed

Schumacher, Karen L; Plano Clark, Vicki L; West, Claudia M; Dodd, Marylin J; Rabow, Michael W; Miaskowski, Christine

2014-11-01

Oncology patients with persistent pain treated in outpatient settings and their family caregivers have significant responsibility for managing pain medications. However, little is known about their practical day-to-day experiences with pain medication management. The aim was to describe day-to-day pain medication management from the perspectives of oncology outpatients and their family caregivers who participated in a randomized clinical trial of a psychoeducational intervention called the Pro-Self(©) Plus Pain Control Program. In this article, we focus on pain medication management by patients and family caregivers in the context of multiple complex health systems. We qualitatively analyzed audio-recorded intervention sessions that included extensive dialogue between patients, family caregivers, and nurses about pain medication management during the 10-week intervention. The health systems context for pain medication management included multiple complex systems for clinical care, reimbursement, and regulation of analgesic prescriptions. Pain medication management processes particularly relevant to this context were getting prescriptions and obtaining medications. Responsibilities that fell primarily to patients and family caregivers included facilitating communication and coordination among multiple clinicians, overcoming barriers to access, and serving as a final safety checkpoint. Significant effort was required of patients and family caregivers to insure safe and effective pain medication management. Health systems issues related to access to needed analgesics, medication safety in outpatient settings, and the effort expended by oncology patients and their family caregivers require more attention in future research and health-care reform initiatives. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Using key performance indicators as knowledge-management tools at a regional health-care authority level.

PubMed

Berler, Alexander; Pavlopoulos, Sotiris; Koutsouris, Dimitris

2005-06-01

The advantages of the introduction of information and communication technologies in the complex health-care sector are already well-known and well-stated in the past. It is, nevertheless, paradoxical that although the medical community has embraced with satisfaction most of the technological discoveries allowing the improvement in patient care, this has not happened when talking about health-care informatics. Taking the above issue of concern, our work proposes an information model for knowledge management (KM) based upon the use of key performance indicators (KPIs) in health-care systems. Based upon the use of the balanced scorecard (BSC) framework (Kaplan/Norton) and quality assurance techniques in health care (Donabedian), this paper is proposing a patient journey centered approach that drives information flow at all levels of the day-to-day process of delivering effective and managed care, toward information assessment and knowledge discovery. In order to persuade health-care decision-makers to assess the added value of KM tools, those should be used to propose new performance measurement and performance management techniques at all levels of a health-care system. The proposed KPIs are forming a complete set of metrics that enable the performance management of a regional health-care system. In addition, the performance framework established is technically applied by the use of state-of-the-art KM tools such as data warehouses and business intelligence information systems. In that sense, the proposed infrastructure is, technologically speaking, an important KM tool that enables knowledge sharing amongst various health-care stakeholders and between different health-care groups. The use of BSC is an enabling framework toward a KM strategy in health care.

Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care.

PubMed

Bray, Benjamin D; Cloud, Geoffrey C; James, Martin A; Hemingway, Harry; Paley, Lizz; Stewart, Kevin; Tyrrell, Pippa J; Wolfe, Charles D A; Rudd, Anthony G

2016-07-09

Studies in many health systems have shown evidence of poorer quality health care for patients admitted on weekends or overnight than for those admitted during the week (the so-called weekend effect). We postulated that variation in quality was dependent on not only day, but also time, of admission, and aimed to describe the pattern and magnitude of variation in the quality of acute stroke care across the entire week. We did this nationwide, registry-based, prospective cohort study using data from the Sentinel Stroke National Audit Programme. We included all adult patients (aged >16 years) admitted to hospital with acute stroke (ischaemic or primary intracerebral haemorrhage) in England and Wales between April 1, 2013, and March 31, 2014. Our outcome measure was 30 day post-admission survival. We estimated adjusted odds ratios for 13 indicators of acute stroke-care quality by fitting multilevel multivariable regression models across 42 4-h time periods per week. The study cohort comprised 74,307 patients with acute stroke admitted to 199 hospitals. Care quality varied across the entire week, not only between weekends and weekdays, with different quality measures showing different patterns and magnitudes of temporal variation. We identified four patterns of variation: a diurnal pattern (thrombolysis, brain scan within 12 h, brain scan within 1 h, dysphagia screening), a day of the week pattern (stroke physician assessment, nurse assessment, physiotherapy, occupational therapy, and assessment of communication and swallowing by a speech and language therapist), an off-hours pattern (door-to-needle time for thrombolysis), and a flow pattern whereby quality changed sequentially across days (stroke-unit admission within 4 h). The largest magnitude of variation was for door-to-needle time within 60 min (range in quality 35-66% [16/46-232/350]; coefficient of variation 18·2). There was no difference in 30 day survival between weekends and weekdays (adjusted odds ratio 1·03, 95% CI 0·95-1·13), but patients admitted overnight on weekdays had lower odds of survival (0·90, 0·82-0·99). The weekend effect is a simplification, and just one of several patterns of weekly variation occurring in the quality of stroke care. Weekly variation should be further investigated in other health-care settings, and quality improvement should focus on reducing temporal variation in quality and not only the weekend effect. None. Copyright © 2016 Elsevier Ltd. All rights reserved.

What proportion of patients at the end of life contact out-of-hours primary care? A data linkage study in Oxfordshire

PubMed Central

Brettell, Rachel; Fisher, Rebecca; Hunt, Helen; Garland, Sophie; Hayward, Gail

2018-01-01

Objectives Out-of-hours (OOH) primary care services are a key element of community care at the end of life, yet there have been no previous attempts to describe the scope of this activity. We aimed to establish the proportion of Oxfordshire patients who were seen by the OOH service within the last 30 days of life, whether they were documented in a palliative phase of care and the demographic and clinical features of these groups. Design Population-based study linking a database of patient contacts with OOH primary care with the register of all deaths within Oxfordshire (600 000 population) during 13 months. Setting Oxfordshire. Participants Between 1 December 2014 and 30 November 2015 there were 102 877 OOH contacts made by 67 943 patients with the OOH service. Main outcome measures Proportion of patients dying in the Oxfordshire population who were seen by the OOH service within the last 30 days of life. Demographic and clinical features of these contacts. Results 29.5% of all population deaths were seen by the OOH service in the last 30 days of life. Among the 1530 patients seen, patients whose palliative phase was documented (n=577, 36.4%) were slightly younger (median age=83.5 vs 85.2 years, P<0.001) and were seen closer to death (median days to death=2 vs 8, P<0.001). More were assessed at home (59.8% vs 51.9%, P<0.001) and less were admitted to hospital (2.7% vs 18.0%, P<0.001). Conclusions OOH services see around one-third of all patients who die in a population. Most patients at the end of life are not documented as palliative by OOH services and are less likely to receive ongoing care at home. PMID:29712691

Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs.

PubMed

Bond, William F; Kim, Minchul; Franciskovich, Chris M; Weinberg, Jason E; Svendsen, Jessica D; Fehr, Linda S; Funk, Amy; Sawicki, Robert; Asche, Carl V

2018-04-01

Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options. To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care. This was a case-control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs. Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases. The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare. We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6-54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02-1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (-0.37 admissions, 95% CI -0.66 to -0.08), and inpatient days (-3.66 days, 95% CI -6.23 to -1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI -$16,207 to -$2,793). ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients.

Current practice and usual care of major cervical disorders in Korea

PubMed Central

Choi, A Ryeon; Shin, Joon-Shik; Lee, Jinho; Lee, Yoon Jae; Kim, Me-riong; Oh, Min-seok; Lee, Eun-Jung; Kim, Sungchul; Kim, Mia; Ha, In-Hyuk

2017-01-01

Abstract Neck pain is a highly common condition and is the 4th major cause of years lived with disability. Previous literature has focused on the effect of specific treatments, and observations of actual practice are lacking to date. This study examined Korean health insurance review and assessment service (HIRA) claims data to the aim of assessing prevalence and comparing current medical practice and costs of cervical disorders in Korea. Current practice trends were determined through assessment of prevalence, total expenses, per-patient expense, average days in care, average days of visits, sociodemographic characteristics, distribution of medical costs, and frequency of treatment types of high frequency cervical disorders (cervical sprain/strain, cervical intervertebral disc displacement [IDD], and cervicalgia). Although the number of cervical IDD patients was few, total expenses, per-patient expense, average days in care, and average days of visits were highest. The proportion of women was higher than men in all 3 groups with highest prevalence in the ≥50s middle-aged population for IDD compared to sprain/strain. Primary care settings were commonly used for ambulatory care, of which approximately 70% chose orthopedic specialist treatment. In analysis of medical expenditure distribution, costs of visit (consultation) (22%–34%) and physical therapy (14%–16%) were in the top 3 for all 3 disorders. Although heat and electrical therapies were the most frequently used physical therapies, traction use was high in the cervical IDD group. In nonnarcotics, aceclofenac and diclofenac were the most commonly used NSAIDs, and pethidine was their counterpart in narcotics. This study investigated practice trends and cost distribution of treatment regimens for major cervical disorders, providing current usage patterns to healthcare policy decision makers, and the detailed treatment reports are expected to be of use to clinicians and researchers in understanding current usual care. PMID:29145327

Current practice and usual care of major cervical disorders in Korea: A cross-sectional study of Korean health insurance review and assessment service national patient sample data.

PubMed

Choi, A Ryeon; Shin, Joon-Shik; Lee, Jinho; Lee, Yoon Jae; Kim, Me-Riong; Oh, Min-Seok; Lee, Eun-Jung; Kim, Sungchul; Kim, Mia; Ha, In-Hyuk

2017-11-01

Neck pain is a highly common condition and is the 4th major cause of years lived with disability. Previous literature has focused on the effect of specific treatments, and observations of actual practice are lacking to date. This study examined Korean health insurance review and assessment service (HIRA) claims data to the aim of assessing prevalence and comparing current medical practice and costs of cervical disorders in Korea.Current practice trends were determined through assessment of prevalence, total expenses, per-patient expense, average days in care, average days of visits, sociodemographic characteristics, distribution of medical costs, and frequency of treatment types of high frequency cervical disorders (cervical sprain/strain, cervical intervertebral disc displacement [IDD], and cervicalgia).Although the number of cervical IDD patients was few, total expenses, per-patient expense, average days in care, and average days of visits were highest. The proportion of women was higher than men in all 3 groups with highest prevalence in the ≥50s middle-aged population for IDD compared to sprain/strain. Primary care settings were commonly used for ambulatory care, of which approximately 70% chose orthopedic specialist treatment. In analysis of medical expenditure distribution, costs of visit (consultation) (22%-34%) and physical therapy (14%-16%) were in the top 3 for all 3 disorders. Although heat and electrical therapies were the most frequently used physical therapies, traction use was high in the cervical IDD group. In nonnarcotics, aceclofenac and diclofenac were the most commonly used NSAIDs, and pethidine was their counterpart in narcotics.This study investigated practice trends and cost distribution of treatment regimens for major cervical disorders, providing current usage patterns to healthcare policy decision makers, and the detailed treatment reports are expected to be of use to clinicians and researchers in understanding current usual care.

Effectiveness of the Certificate Course in Essentials of Palliative Care Program on the Knowledge in Palliative Care among the Participants: A Cross-sectional Interventional Study

PubMed Central

Bhatnagar, Sushma; Patel, Anuradha

2018-01-01

Background: Palliative medicine is an upcoming new specialty aimed at relieving suffering, improving quality of life and comfort care. There are many challenges and barriers in providing palliative care to our patients. The major challenge is lack of knowledge, attitude and skills among health-care providers. Objectives: Evaluate the effectiveness of the certificate course in essentials of palliative care (CCEPC) program on the knowledge in palliative care among the participants. Subjects and Methods: All participants (n = 29) of the CCEPC at All India Institute of Medical Sciences, Delhi, giving consent for pretest and posttest were recruited in the study. This educational lecture of 15 h was presented to all the participants following pretest and participants were given same set of questionnaire to be filled as postintervention test. Results: In pretest, 7/29 (24.1%) had good knowledge which improved to 24/29 (82.8%) after the program. In pretest, 62.1% had average knowledge and only 13.8% had poor knowledge. There was also improvement in communication skills, symptom management, breaking bad news, and pain assessment after completion of the program. Conclusion: The CCEPC is an effective program and improving the knowledge level about palliative care among the participants. The participants should implement this knowledge and the skills in their day-to-day practice to improve the quality of life of patients. PMID:29440814

Health Behaviors, Nutritional Status, and Anthropometric Parameters of Roma and Non-Roma Mothers and Their Infants in the Czech Republic

ERIC Educational Resources Information Center

Rambouskova, Jolana; Dlouhy, Pavel; Krizova, Eva; Prochazka, Bohumir; Hrncirova, Dana; Andel, M

2009-01-01

Objective: To compare maternal health behaviors, maternal nutritional status, and infant size at birth of Romas and non-Romas in the Czech Republic. Design: Maternal interviews and food frequency questionnaire, maternal blood samples, physical measurements of mothers and infants. Setting: Hospital, maternal/child care center; 2-4 days postpartum.…

The Relationship between Early Language, Cognitive and Social Development through a Longitudinal Study of Autistic Children.

ERIC Educational Resources Information Center

Ogura, Tamiko

The development of and relationship between early language, symbolic play, sensorimotor skills, and social development were examined in a longitudinal study conducted in Japan with two young autistic males who were observed from the approximate ages of 2 to 4 years in clinic, day care, and home settings. One child acquired speech; the other did…

Human Papillomavirus Vaccine Uptake in Texas Pediatric Care Settings: A Statewide Survey of Healthcare Professionals.

PubMed

Javaid, Mehwish; Ashrawi, Dana; Landgren, Rachel; Stevens, Lori; Bello, Rosalind; Foxhall, Lewis; Mims, Melissa; Ramondetta, Lois

2017-02-01

The purpose of this study was to identify barriers to and facilitators of human papillomavirus (HPV) vaccination in children aged 9-17 years across Texas. A literature review informed the development of a web-based survey designed for people whose work involves HPV vaccination in settings serving pediatric patients. The survey was used to examine current HPV vaccine recommendation practices among healthcare providers, barriers to HPV vaccination, reasons for parent/caregiver vaccine refusal, staff and family education practices, utilization of reminder and recall systems and status of vaccine administration (payment, ordering and stocking). 1132 responses were received representing healthcare providers, administrative and managerial staff. Respondents identified perceived barriers to HPV vaccination as parental beliefs about lack of necessity of vaccination prior to sexual debut, parental concerns regarding safety and/or side effects, parental perceptions that their child is at low risk for HPV-related disease, and parental lack of knowledge that the vaccine is a series of three shots. Of responding healthcare providers, 94 % (n = 582) reported they recommend the vaccine for 9-12 year olds; however, same-day acceptance of the vaccine is low with only 5 % (n = 31) of providers reporting the HPV vaccine is "always" accepted the same day the recommendation is made. Healthcare providers and multidisciplinary care teams in pediatric care settings must work to identify gaps between recommendation and uptake to maximize clinical opportunities. Training in methods to communicate an effective HPV recommendation and patient education tailored to address identified barriers may be helpful to reduce missed opportunities and increase on-time HPV vaccinations.

A Pilot Study to Examine Maturation of Body Temperature Control in Preterm Infants

PubMed Central

Knobel, Robin B.; Levy, Janet; Katz, Laurence; Guenther, Bob; Holditch-Davis, Diane

2013-01-01

Objective To test instrumentation and develop analytic models to use in a larger study to examine developmental trajectories of body temperature and peripheral perfusion from birth in extremely low birth weight (EBLW) infants. Design A case study design. Setting The study took place in a level four neonatal intensive care unit (NICU) in North Carolina. Participants Four ELBW infants, less than 29 weeks gestational age at birth. Methods Physiologic data were measured every minute for the first 5 days of life: peripheral perfusion using perfusion index by Masimo and body temperature using thermistors. Body temperature was also measured using infrared thermal imaging. Stimulation and care events were recorded over the first 5 days using video which was coded with Noldus Observer software. Novel analytical models using the state space approach to time series analysis were developed to explore maturation of neural control over central and peripheral body temperature. Results/Conclusion Results from this pilot study confirmed the feasibility of using multiple instruments to measure temperature and perfusion in ELBW infants. This approach added rich data to our case study design and set a clinical context with which to interpret longitudinal physiological data. PMID:24004312

Collaboration, facilities and communities in day care services for older people.

PubMed

Adams, John

2001-05-01

Similarities and differences between day hospitals, run by the NHS, and day centres, run by local authorities or charitable organisations, have been widely discussed in the literature of gerontology for many years. The authors of this paper have undertaken a single blind, randomised-controlled trial to compare rehabilitation outcomes in the two settings, which was published in 1999. This research project involved augmenting the staff of day centres by visiting therapists. In addition to quantitative findings, their project also generated much qualitative data from interviews with health service and social service staff which provides the thought-provoking content. The themes identified included the reluctance of some patients to accept referral to a day centre, and the difficulties associated with discharging patients. Positive aspects included the opportunity to share skills, knowledge and resources. 29 references.

Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities.

PubMed

Seal, Karen H; Bertenthal, Daniel; Miner, Christian R; Sen, Saunak; Marmar, Charles

2007-03-12

Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) have endured high combat stress and are eligible for 2 years of free military service-related health care through the Department of Veterans Affairs (VA) health care system, yet little is known about the burden and clinical circumstances of mental health diagnoses among OEF/OIF veterans seen at VA facilities. US veterans separated from OEF/OIF military service and first seen at VA health care facilities between September 30, 2001 (US invasion of Afghanistan), and September 30, 2005, were included. Mental health diagnoses and psychosocial problems were assessed using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The prevalence and clinical circumstances of and subgroups at greatest risk for mental health disorders are described herein. Of 103 788 OEF/OIF veterans seen at VA health care facilities, 25 658 (25%) received mental health diagnosis(es); 56% of whom had 2 or more distinct mental health diagnoses. Overall, 32 010 (31%) received mental health and/or psychosocial diagnoses. Mental health diagnoses were detected soon after the first VA clinic visit (median of 13 days), and most initial mental health diagnoses (60%) were made in nonmental health clinics, mostly primary care settings. The youngest group of OEF/OIF veterans (age, 18-24 years) were at greatest risk for receiving mental health or posttraumatic stress disorder diagnoses compared with veterans 40 years or older. Co-occurring mental health diagnoses and psychosocial problems were detected early and in primary care medical settings in a substantial proportion of OEF/OIF veterans seen at VA facilities. Targeted early detection and intervention beginning in primary care settings are needed to prevent chronic mental illness and disability.

Standardized network order sets in rural Ontario: a follow-up report on successes and sustainability.

PubMed

Rawn, Andrea; Wilson, Katrina

2011-01-01

Unifying, implementing and sustaining a large order set project requires strategic placement of key organizational professionals to provide ongoing user education, communication and support. This article will outline the successful strategies implemented by the Grey Bruce Health Network, Evidence-Based Care Program to reduce length of stay, increase patient satisfaction and increase the use of best practices resulting in quality outcomes, safer practice and better allocation of resources by using standardized Order Sets within a network of 11 hospital sites. Audits conducted in 2007 and again in 2008 revealed a reduced length of stay of 0.96 in-patient days when order sets were used on admission and readmission for the same or a related diagnosis within one month decreased from 5.5% without order sets to 3.5% with order sets.

Does neonatal pain management in intensive care units differ between night and day? An observational study

PubMed Central

Guedj, Romain; Danan, Claude; Daoud, Patrick; Zupan, Véronique; Renolleau, Sylvain; Zana, Elodie; Aizenfisz, Sophie; Lapillonne, Alexandre; de Saint Blanquat, Laure; Granier, Michèle; Durand, Philippe; Castela, Florence; Coursol, Anne; Hubert, Philippe; Cimerman, Patricia; Anand, K J S; Khoshnood, Babak; Carbajal, Ricardo

2014-01-01

Objective To determine whether analgesic use for painful procedures performed in neonates in the neonatal intensive care unit (NICU) differs during nights and days and during each of the 6 h period of the day. Design Conducted as part of the prospective observational Epidemiology of Painful Procedures in Neonates study which was designed to collect in real time and around-the-clock bedside data on all painful or stressful procedures. Setting 13 NICUs and paediatric intensive care units in the Paris Region, France. Participants All 430 neonates admitted to the participating units during a 6-week period between September 2005 and January 2006. Data collection During the first 14 days of admission, data were collected on all painful procedures and analgesic therapy. The five most frequent procedures representing 38 012 of all 42 413 (90%) painful procedures were analysed. Intervention Observational study. Main outcome assessment We compared the use of specific analgesic for procedures performed during each of the 6 h period of a day: morning (7:00 to 12:59), afternoon, early night and late night and during daytime (morning+afternoon) and night-time (early night+late night). Results 7724 of 38 012 (20.3%) painful procedures were carried out with a specific analgesic treatment. For morning, afternoon, early night and late night, respectively, the use of analgesic was 25.8%, 18.9%, 18.3% and 18%. The relative reduction of analgesia was 18.3%, p<0.01, between daytime and night-time and 28.8%, p<0.001, between morning and the rest of the day. Parental presence, nurses on 8 h shifts and written protocols for analgesia were associated with a decrease in this difference. Conclusions The substantial differences in the use of analgesics around-the-clock may be questioned on quality of care grounds. PMID:24556241

A smartphone application to support recovery from alcoholism: A randomized controlled trial

PubMed Central

Gustafson, David H.; McTavish, Fiona M.; Chih, Ming-Yuan; Atwood, Amy K.; A. Johnson, Roberta; G. Boyle, Michael; S. Levy, Michael; Driscoll, Hilary; M. Chisholm, Steven; Dillenburg, Lisa; Isham, Andrew; Shah, Dhavan

2014-01-01

Importance: Patients leaving treatment for alcohol-use disorders (AUDs) are not typically offered evidence-based continuing care, although research suggests that continuing care is associated with better outcomes. A smartphone-based application could provide effective continuing care. Objective: To determine whether patients leaving residential treatment for AUDs with a smartphone application to support recovery have fewer risky drinking days than control-group patients. Design: An un-blinded randomized controlled trial. Patients were randomized to treatment as usual or treatment as usual plus a smartphone with A-CHESS, an application designed to improve continuing care for AUDs. “A-CHESS” stands for Addiction – Comprehensive Health Enhancement Support System. Setting: Three residential programs operated by one treatment organization in the Midwestern US and 2 residential programs operated by one organization in the Northeastern US. Participants: 349 patients who met the criteria for DSM-IV alcohol dependence when they entered residential treatment. 179 were randomized to the control group and 170 to the treatment group. Intervention: Treatment as usual varied across programs; none offered patients coordinated continuing care after discharge. A-CHESS provides monitoring, information, communication, and support services to patients, including ways for patients and counselors to stay in contact. The intervention lasted 8 months and the follow-up period lasted 4 months. Main Outcome Measure: Risky drinking days—the number of days during which a patient’s drinking in a 2-hour period exceeded, for men, 4 standard drinks and for women, 3 standard drinks. Patients were asked to report their risky drinking days in the previous 30 days on surveys taken 4, 8, and 12 months after discharge from residential treatment. Results: For the 8 months of the intervention and 4 months of follow-up, patients in the A-CHESS group reported significantly fewer risky drinking days than patients in the control group (M = 1.39 vs. 2.75, respectively; P = .003; 95% CI [.46, 2.27]). Conclusions and Relevance: The findings suggest that a multi-featured smartphone application may have significant benefit to patients in continuing care for AUDs. Trial registration: clinicaltrials.gov Identifier: NCT01003119 PMID:24671165

Bio-Medical Waste Managment in a Tertiary Care Hospital: An Overview.

PubMed

Pandey, Anita; Ahuja, Sanjiv; Madan, Molly; Asthana, Ajay Kumar

2016-11-01

Bio-Medical Waste (BMW) management is of utmost importance as its improper management poses serious threat to health care workers, waste handlers, patients, care givers, community and finally the environment. Simultaneously, the health care providers should know the quantity of waste generated in their facility and try to reduce the waste generation in day-to-day work because lesser amount of BMW means a lesser burden on waste disposal work and cost saving. To have an overview of management of BMW in a tertiary care teaching hospital so that effective interventions and implementations can be carried out for better outcome. The observational study was carried out over a period of five months from January 2016 to May 2016 in Chhatrapati Shivaji Subharti Hospital, Meerut by the Infection Control Team (ICT). Assessment of knowledge was carried out by asking set of questions individually and practice regarding awareness of BMW Management among the Health Care Personnel (HCP) was carried out by direct observation in the workplace. Further, the total BMW generated from the present setup in kilogram per bed per day was calculated by dividing the mean waste generated per day by the number of occupied beds. Segregation of BMW was being done at the site of generation in almost all the areas of the hospital in color coded polythene bags as per the hospital protocol. The different types of waste being collected were infectious solid waste in red bag, soiled infectious waste in yellow bag and sharp waste in puncture proof container and blue bag. Though awareness (knowledge) about segregation of BMW was seen in 90% of the HCP, 30%-35% did not practice. Out of the total waste generated (57912 kg.), 8686.8 kg. (15%) was infectious waste. Average infectious waste generated was 0.341 Kg per bed per day. The transport, treatment and disposal of each collected waste were outsourced and carried out by 'Synergy' waste management Pvt. Ltd. The practice of BMW Management was lacking in 30-35% HCP which may lead to mixing of the 15% infectious waste with the remaining non-infectious. Therefore, training courses and awareness programs about BMW management will be carried out every month targeting smaller groups.

Self-management priority setting and decision-making in adults with multimorbidity: A narrative review of literature

PubMed Central

Bratzke, Lisa C.; Muehrer, Rebecca J.; Kehl, Karen A.; Lee, Kyoung Suk; Ward, Earlise C.; Kwekkeboom, Kristine L.

2014-01-01

Objectives The purpose of this narrative review was to synthesize current research findings related to self-management, in order to better understand the processes of priority setting and decision-making in among adults with multimorbidity. Design A narrative literature review was undertaken, synthesizing findings from published, peer-reviewed empirical studies that addressed priority setting and/or decision-making in self-management of multimorbidity. Data sources A search of PubMed, PsychINFO, CINAHL and SocIndex databases was conducted from database inception through December 2013. References lists from selected empirical studies and systematic reviews were evaluated to identify any additional relevant articles. Review methods Full text of potentially eligible articles were reviewed and selected for inclusion if they described empirical studies that addressed priority setting or decision-making in self-management of multimorbidity among adults. Two independent reviewers read each selected article and extracted relevant data to an evidence table. Processes and factors and processes of multimorbidity self-management were identified and sorted into categories of priority setting, decision-making, and facilitators/barriers. Results Thirteen articles were selected for inclusion; most were qualitative studies describing processes, facilitators, and barriers of multimorbidity self-management. The findings revealed that patients prioritize a dominant chronic illness and re-prioritize over time as conditions and treatments change; that multiple facilitators (e.g. support programs) and barriers (e.g. lack of financial resources) impact individuals’ self-management priority setting and decision-making ability; as do individual beliefs, preferences, and attitudes (e.g., perceived personal control, preferences regarding treatment). Conclusions Health care providers need to be cognizant that individuals with multimorbidity engage in day-to-day priority setting and decision-making among their multiple chronic illnesses and respective treatments. Researchers need to develop and test interventions that support day-to-day priority setting and decision-making and improve health outcomes for individuals with multimorbidity. PMID:25468131

Self-management priority setting and decision-making in adults with multimorbidity: a narrative review of literature.

PubMed

Bratzke, Lisa C; Muehrer, Rebecca J; Kehl, Karen A; Lee, Kyoung Suk; Ward, Earlise C; Kwekkeboom, Kristine L

2015-03-01

The purpose of this narrative review was to synthesize current research findings related to self-management, in order to better understand the processes of priority setting and decision-making among adults with multimorbidity. A narrative literature review was undertaken, synthesizing findings from published, peer-reviewed empirical studies that addressed priority setting and/or decision-making in self-management of multimorbidity. A search of PubMed, PsychINFO, CINAHL and SocIndex databases was conducted from database inception through December 2013. References lists from selected empirical studies and systematic reviews were evaluated to identify any additional relevant articles. Full text of potentially eligible articles were reviewed and selected for inclusion if they described empirical studies that addressed priority setting or decision-making in self-management of multimorbidity among adults. Two independent reviewers read each selected article and extracted relevant data to an evidence table. Processes and factors of multimorbidity self-management were identified and sorted into categories of priority setting, decision-making, and facilitators/barriers. Thirteen articles were selected for inclusion; most were qualitative studies describing processes, facilitators, and barriers of multimorbidity self-management. The findings revealed that patients prioritize a dominant chronic illness and re-prioritize over time as conditions and treatments change; that multiple facilitators (e.g. support programs) and barriers (e.g. lack of financial resources) impact individuals' self-management priority setting and decision-making ability; as do individual beliefs, preferences, and attitudes (e.g., perceived personal control, preferences regarding treatment). Health care providers need to be cognizant that individuals with multimorbidity engage in day-to-day priority setting and decision-making among their multiple chronic illnesses and respective treatments. Researchers need to develop and test interventions that support day-to-day priority setting and decision-making and improve health outcomes for individuals with multimorbidity. Copyright © 2014 Elsevier Ltd. All rights reserved.

The role of support staff in promoting the social inclusion of persons with an intellectual disability.

PubMed

McConkey, R; Collins, S

2010-08-01

Past studies have found that people supported in more individualised housing options tend to have levels of community participation and wider social networks than those in other accommodation options. Yet, the contribution of support staff in facilitating social inclusion has received relatively scant attention. In all 245 staff working in either supported living schemes, or shared residential and group homes, or in day centres completed a written questionnaire in which they rated in terms of priority to their job, 16 tasks that were supportive of social inclusion and a further 16 tasks that related to the care of the person they supported. In addition staff identified those tasks that they considered were not appropriate to their job. Across all three service settings, staff rated more care tasks as having higher priority than they did the social inclusion tasks. However, staff in supported living schemes rated more social inclusion tasks as having high priority than did staff in the other two service settings. Equally the staff who were most inclined to rate social inclusion tasks as not being applicable to their job were those working day centres; female rather than male staff, those in front-line staff rather than senior staff, and those in part-time or relief positions rather than full-time posts. However, within each service settings, there were wide variations in how staff rated the social inclusion tasks. Staff working in more individualised support arrangements tend to give greater priority to promoting social inclusion although this can vary widely both across and within staff teams. Nonetheless, staff gave greater priority to care tasks especially in congregated service settings. Service managers may need to give more emphasis to social inclusion tasks and provide the leadership, training and resources to facilitate support staff to re-assess their priorities.

Increasing the efficiency of autopsy reporting.

PubMed

Siebert, Joseph R

2009-12-01

-When autopsy reports are delayed, clinicians and families do not receive information in a timely fashion. -Using lean principles derived from the Toyota Production System, we set out to streamline our autopsy reporting process. -In a formal workshop setting, we identified the steps involved in producing an autopsy report, then sought to eliminate, abbreviate, or reschedule them into a more efficient format. We established intermediate deadlines for each case, taking care to make them visible; we initiated a weekly quality assurance review, giving attention to both scientific issues and approaching deadlines. -By adopting a more standardized approach, eliminating redundancy, and improving the visibility of tasks, we improved the mean completion time of autopsy reports from 53 days (N = 47 cases) to 25 days (N = 47 cases). Previously, 17% of reports were completed by 30 days and 71% by 60 days; in the 15 months following initiation of the program, 72% of reports were completed by 30 days and 100% by 60 days. A follow-up survey of attending physicians revealed continuing appreciation for the autopsy and timely communication, with no perceived diminution in the quality of reports. -This approach was of great benefit in our laboratory and may assist others in reducing the turnaround time of their autopsy reports. It may also benefit other areas of the laboratory.

Optimizing Infant Development: Strategies for Day Care.

ERIC Educational Resources Information Center

Chambliss, Catherine

This guide for infant day care providers examines the importance of early experience for brain development and strategies for providing optimal infant care. The introduction discusses the current devaluation of day care and idealization of maternal care and identifies benefits of quality day care experience for intellectual development, sleep…

38 CFR 52.61 - General requirements for adult day health care program.

Code of Federal Regulations, 2011 CFR

2011-07-01

... adult day health care program. 52.61 Section 52.61 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS (CONTINUED) PER DIEM FOR ADULT DAY HEALTH CARE OF VETERANS IN STATE HOMES Standards § 52.61 General requirements for adult day health care program. Adult day health care must be a...

38 CFR 52.61 - General requirements for adult day health care program.

Code of Federal Regulations, 2012 CFR

2012-07-01

... adult day health care program. 52.61 Section 52.61 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS (CONTINUED) PER DIEM FOR ADULT DAY HEALTH CARE OF VETERANS IN STATE HOMES Standards § 52.61 General requirements for adult day health care program. Adult day health care must be a...

38 CFR 52.61 - General requirements for adult day health care program.

Code of Federal Regulations, 2010 CFR

2010-07-01

... adult day health care program. 52.61 Section 52.61 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS (CONTINUED) PER DIEM FOR ADULT DAY HEALTH CARE OF VETERANS IN STATE HOMES Standards § 52.61 General requirements for adult day health care program. Adult day health care must be a...

38 CFR 52.61 - General requirements for adult day health care program.

Code of Federal Regulations, 2013 CFR

2013-07-01

... adult day health care program. 52.61 Section 52.61 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS (CONTINUED) PER DIEM FOR ADULT DAY HEALTH CARE OF VETERANS IN STATE HOMES Standards § 52.61 General requirements for adult day health care program. Adult day health care must be a...

38 CFR 52.61 - General requirements for adult day health care program.

Code of Federal Regulations, 2014 CFR

2014-07-01

... adult day health care program. 52.61 Section 52.61 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS (CONTINUED) PER DIEM FOR ADULT DAY HEALTH CARE OF VETERANS IN STATE HOMES Standards § 52.61 General requirements for adult day health care program. Adult day health care must be a...

Influence of hang time and location on bacterial contamination of intravenous bags in a veterinary emergency and critical care setting.

PubMed

Guillaumin, Julien; Olp, Nichole M; Magnusson, Karissa D; Butler, Amy L; Daniels, Joshua B

2017-09-01

To assess the rate of bacterial contamination of fluid and ports in intravenous bags in a veterinary emergency room (ER) and intensive care unit (ICU). Experimental model. Ninety intravenous fluid bags of lactated balanced-electrolytes solution (1 L) hung in a university hospital. Bags were hung in 2 different locations in the ER (sink and bins) and one location in the ICU (sink) for 11 days. Bags were punctured 3 times daily with a sterile needle to simulate clinical use. Injection ports were swabbed and 50 mL of fluid were collected in duplicates on days 0, 2, 4, 7, and 10. Aerobic bacterial cultures were performed on the fluid and injection port. Contamination was defined as bacterial growth of a similar phenotype across 2 consecutive times. Increase in the fluid contamination rate from day 0 was tested using an exact binomial test. Port contamination rate between locations was tested using Fisher's exact test. Combined bacterial growth on injection ports reached a mean (95% confidence interval) of 8.1 (0.005-16.2) cfu/port on day 10. The combined port contamination was 3.3%, 11.1%, 17.8%, and 31.1% on days 0, 2, 4, and 7, respectively. Port contamination was similar between ER and ICU. However, port contamination was higher in the sink versus the bins area (38.3% vs 16.7%, P = 0.032). No fluid bag was contaminated at days 0 and 2. The contamination rate of fluid bag was 1.1% and 4.4% on days 4 and 7, respectively. All bags with contaminated fluid were in the ER (6.7%, 95% exact binomial confidence interval 1.9-16.2%). Injection port contamination reached 31.1% on day 7. Contamination was more likely when the bags were hung next to a sink. In our model of bag puncture, fluid contamination occurred between days 2 and 4. © Veterinary Emergency and Critical Care Society 2017.

Association between aggressive care and bereaved families' evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities.

PubMed

Ersek, Mary; Miller, Susan C; Wagner, Todd H; Thorpe, Joshua M; Smith, Dawn; Levy, Cari R; Gidwani, Risha; Faricy-Anderson, Katherine; Lorenz, Karl A; Kinosian, Bruce; Mor, Vincent

2017-08-15

To the authors' knowledge, little is known regarding the relationship between patients' and families' satisfaction with aggressive end-of-life care. Herein, the authors examined the associations between episodes of aggressive care (ie, chemotherapy, mechanical ventilation, acute hospitalizations, and intensive care unit admissions) within the last 30 days of life and families' evaluations of end-of-life care among patients with non-small cell lung cancer (NSCLC). A total of 847 patients with NSCLC (34% of whom were aged <65 years) who died in a nursing home or intensive care, acute care, or hospice/palliative care (HPC) unit at 1 of 128 Veterans Affairs Medical Centers between 2010 and 2012 were examined. Data sources included Veterans Affairs administrative and clinical data, Medicare claims, and the Bereaved Family Survey. The response rate for the Bereaved Family Survey was 62%. Greater than 72% of veterans with advanced lung cancer who died in an inpatient setting had at least 1 episode of aggressive care and 31% received chemotherapy within the last 30 days of life. For all units except for HPC, when patients experienced at least 1 episode of aggressive care, bereaved families rated care lower compared with when patients did not receive any aggressive care. For patients dying in an HPC unit, the associations between overall ratings of care and ≥2 inpatient admissions or any episode of aggressive care were not found to be statistically significant. Rates of aggressive care were not associated with age, and family ratings of care were similar for younger and older patients. Aggressive care within the last month of life is common among patients with NSCLC and is associated with lower family evaluations of end-of-life care. Specialized care provided within an HPC unit may mitigate the negative effects of aggressive care on these outcomes. Cancer 2017;123:3186-94. © 2017 American Cancer Society. © 2017 American Cancer Society.

38 CFR 17.111 - Copayments for extended care services.

Code of Federal Regulations, 2011 CFR

2011-07-01

... amount per day: (i) Adult day health care—$15. (ii) Domiciliary care—$5. (iii) Institutional respite care... each day that adult day health care, non-institutional geriatric evaluation, and non-institutional... the day of discharge. (c) Definitions. For purposes of this section: (1) Adult day health care is a...

Plasma concentrations of fentanyl with subcutaneous infusion in palliative care patients.

PubMed

Miller, R S; Peterson, G M; Abbott, F; Maddocks, I; Parker, D; McLean, S

1995-12-01

1. Plasma concentrations of fentanyl were measured by g.c. in 20 patients (median age: 75 years and range: 54-86 years; eight females) in palliative care receiving the drug by continuous s.c. infusion (median rate: 1200 micrograms day-1 and range: 100-5000 micrograms day-1). 2. The infusion rate was significantly related to the duration of therapy (Spearman rho = 0.56, P < 0.05). The total steady-state plasma concentrations of fentanyl ranged between 0.1 and 9 ng ml-1, with a median of 1 ng ml-1. The unbound fraction of fentanyl in the plasma ranged from 17.8 to 44.4%, with a median value of 33.6%. Infusion rates and both total and unbound plasma concentrations of fentanyl were correlated (Spearman rho = 0.92, P < 0.05 in each case). Even with standardization for dosage, there was an eightfold variation in total plasma concentrations and 3.5-fold variation in unbound plasma concentrations of fentanyl. 3. There is considerable inter-patient variability in the pharmacokinetics of fentanyl with s.c. infusion in the palliative care setting, which necessitates careful titration of dosage according to individual clinical response.

Drivers of Inpatient Hospital Experience Using the HCAHPS Survey in a Canadian Setting.

PubMed

Kemp, Kyle A; Chan, Nancy; McCormack, Brandi; Douglas-England, Kathleen

2015-08-01

To identify factors associated with patients' overall rating of inpatient hospital care. Two years of patient interview data (April 1, 2011 to March 31, 2013), linked to inpatient administrative records. Patients rated their overall health on a scale of 0 (worst care) to 10 (best care) using the HCAHPS instrument administered via telephone, up to 42 days postdischarge. Logistic regression was used to generate odds ratios for each independent predictor. HCAHPS data were linked to inpatient records based on health care numbers and dates of service. The outcome (overall health experience) was collapsed into two groups (10 vs. 0-9). Overall hospital experience of 0-9 was associated with younger age, male gender, higher level of education, being born in Canada, urgent admission, not having a family practitioner as the most responsible provider service, and not being discharged home. A length of stay of less than 3 days was protective. The c-statistic for the multivariate model was 0.635. Our results are novel in the Canadian population. Several questions for future research have been generated, in addition to opportunities for quality improvement within our own organization. © Health Research and Educational Trust.

Public Health Surveillance via Template Management in Electronic Health Records: Tri-Service Workflow's Rapid Response to an Infectious Disease Crisis.

PubMed

Berkley, Holly; Barnes, Matthew; Carnahan, David; Hayhurst, Janet; Bockhorst, Archie; Neville, James

2017-03-01

To describe the use of template-based screening for risk of infectious disease exposure of patients presenting to primary care medical facilities during the 2014 West African Ebola virus outbreak. The Military Health System implemented an Ebola risk-screening tool in primary care settings in order to create early notifications and early responses to potentially infected persons. Three time-sensitive, evidence-based screening questions were developed and posted to Tri-Service Workflow (TSWF) AHLTA templates in conjunction with appropriate training. Data were collected in January 2015, to assess the adoption of the TSWF-based Ebola risk-screening tool. Among encounters documented using TSWF templates, 41% of all encounters showed use of the TSWF-based Ebola risk-screening questions by the fourth day. The screening rate increased over the next 3 weeks, and reached a plateau at approximately 50%. This report demonstrates the MHS capability to deploy a standardized, globally applicable decision support aid that could be seen the same day by all primary care clinics across the military health direct care system, potentially improving rapid compliance with screening directives. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

The relation between household income and surgical outcome in the Dutch setting of equal access to and provision of healthcare.

PubMed

Ultee, Klaas H J; Tjeertes, Elke K M; Bastos Gonçalves, Frederico; Rouwet, Ellen V; Hoofwijk, Anton G M; Stolker, Robert Jan; Verhagen, Hence J M; Hoeks, Sanne E

2018-01-01

The impact of socioeconomic disparities on surgical outcome in the absence of healthcare inequality remains unclear. Therefore, we set out to determine the association between socioeconomic status (SES), reflected by household income, and overall survival after surgery in the Dutch setting of equal access and provision of care. Additionally, we aim to assess whether SES is associated with cause-specific survival and major 30-day complications. Patients undergoing surgery between March 2005 and December 2006 in a general teaching hospital in the Netherlands were prospectively included. Adjusted logistic and cox regression analyses were used to assess the independent association of SES-quantified by gross household income-with major 30-day complications and long-term postoperative survival. A total of 3929 patients were included, with a median follow-up of 6.3 years. Low household income was associated with worse survival in continuous analysis (HR: 1.05 per 10.000 euro decrease in income, 95% CI: 1.01-1.10) and in income quartile analysis (HR: 1.58, 95% CI: 1.08-2.31, first [i.e. lowest] quartile relative to the fourth quartile). Similarly, low income patients were at higher risk of cardiovascular death (HR: 1.26 per 10.000 decrease in income, 95% CI: 1.07-1.48, first income quartile: HR: 3.10, 95% CI: 1.04-9.22). Household income was not independently associated with cancer-related mortality and major 30-day complications. Low SES, quantified by gross household income, is associated with increased overall and cardiovascular mortality risks among surgical patients. Considering the equality of care provided by this study setting, the associated survival hazards can be attributed to patient and provider factors, rather than disparities in healthcare. Increased physician awareness of SES as a risk factor in preoperative decision-making and focus on improving established SES-related risk factors may improve surgical outcome of low SES patients.