Why are hospital doctors not referring to Consultation-Liaison Psychiatry? - a systemic review.

PubMed

Chen, Kai Yang; Evans, Rebecca; Larkins, Sarah

2016-11-09

Consultation-Liaison Psychiatry (CLP) is a subspecialty of psychiatry that provides care to inpatients under non-psychiatric care. Despite evidence of benefits of CLP for inpatients with psychiatric comorbidities, referral rates from hospital doctors remain low. This review aims to understand barriers to CLP inpatient referral as described in the literature. We searched on Medline, PsychINFO, CINAHL and SCOPUS, using MESH and the following keywords: 1) Consultation-Liaison Psychiatry, Consultation Liaison Psychiatry, Consultation Psychiatry, Liaison Psychiatry, Hospital Psychiatry, Psychosomatic Medicine, the 2) Referral, Consultation, Consultancy and 3) Inpatient, Hospitalized patient, Hospitalized patient. We considered papers published between 1 Jan 1965 and 30 Sep 2015 and all articles written in English that contribute to understanding of barriers to CLP referral were included. Thirty-five eligible articles were found and they were grouped thematically into three categories: (1) Systemic factors; (2) Referrer factors; (3) Patient factors. Systemic factors that improves referrals include a dedicated CLP service, active CLP consultant and collaborative screening of patients. Referrer factors that increases referrals include doctors of internal medicine specialty and comfortable with CLP. Patients more likely to be referred tend to be young, has psychiatric history, live in an urban setting or has functional psychosis. This is the first systematic review that examines factors that influence CLP inpatient referrals. Although there is research in this area, it is of limited quality. Education could be provided to hospital doctors to better recognise mental illness. Collaborative screening of vulnerable groups could prevent inpatients from missing out on psychiatric care. CLP clinicians should use the knowledge gained in this review to provide quality engagement with referrers.

Diagnostic accuracy of rapid urine dipstick test to predict urinary tract infection among pregnant women in Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia.

PubMed

Demilie, Tazebew; Beyene, Getenet; Melaku, Selabat; Tsegaye, Wondewosen

2014-07-29

Untreated bacteriuria during pregnancy has been shown to be associated with low birth-weight and premature delivery. Therefore, routine screening for bacteriuria is advocated. The decision about how to screen pregnant women for bacteriuria has always been a balance between the cost of screening versus the sensitivity and specificity. This study was designed to evaluate the diagnostic accuracy of the rapid dipstick test to predict urinary tract infection in pregnancy against the gold standard urine culture. A total of 367 mid stream urine samples were collected, inoculated on MacConkey, Manitol salt agar (MSA) and blood agar and incubated aerobically at 37°C for overnight. Specimens were classified as "positive" for urinary tract infection (UTI) if the growth of the pathogen(s) was at a count ≥ 10(5) colony-forming units per milliliter (cfu/mL) of urine and classified as "negative" with growth of <10(5) cfu/mL. Urine samples were tested for the presence of nitrite and leukocyte esterase using dipstick rapid test in accordance to the manufacturer's instructions. From the total study participants, 37 pregnant women were symptomatic and the remaining 330 pregnant women were asymptomatic. The sensitivity and specificity of dipstick tests of leukocyte esterase was 50% and 89.1% for pregnant women with asymptomatic UTI(ABU) and 71.4% and 86.7% for symptomatic UTI respectively and for nitrite 35.7% and 98.0% for ABU and 57.1% and 96.7% symptomatic UTI. This study revealed that the use of dipstick leukocyte esterase and nitrite for screening UTI particularly asymptomatic bacteriuria was associated with many false positive and negative results when it was compared against the gold standard culture method. The low sensitivity and positive predictive value of urine dipstick test proved that culture should be used for the diagnosis of UTI.

Disease patterns and clinical outcomes of patients admitted in intensive care units of tertiary referral hospitals of Tanzania.

PubMed

Sawe, Hendry R; Mfinanga, Juma A; Lidenge, Salum J; Mpondo, Boniventura C T; Msangi, Silas; Lugazia, Edwin; Mwafongo, Victor; Runyon, Michael S; Reynolds, Teri A

2014-09-23

In sub-Saharan Africa the availability of intensive care unit (ICU) services is limited by a variety of factors, including lack of financial resources, lack of available technology and well-trained staff. Tanzania has four main referral hospitals, located in zones so as to serve as tertiary level referral centers. All the referral hospitals have some ICU services, operating at varying levels of equipment and qualified staff. We analyzed and describe the disease patterns and clinical outcomes of patients admitted in ICUs of the tertiary referral hospitals of Tanzania. This was a retrospective analysis of ICU patient records, for three years (2009 to 2011) from all tertiary referral hospitals of Tanzania, namely Muhimbili National Hospital (MNH), Kilimanjaro Christian Medical Centre (KCMC), Mbeya Referral Hospital (MRH) and Bugando Medical Centre (BMC). MNH is the largest of the four referral hospitals with 1300 beds, and MRH is the smallest with 480 beds. The ratio of hospital beds to ICU beds is 217:1 at MNH, 54:1 at BMC, 39:1 at KCMC, and 80:1 at MRH. KCMC had no infusion pumps. None of the ICUs had a point-of-care (POC) arterial blood gas (ABG) analyzer. None of the ICUs had an Intensive Care specialist or a nutritionist. A masters-trained critical care nurse was available only at MNH. From 2009-2011, the total number of patients admitted to the four ICUs was 5627, male to female ratio 1.4:1, median age of 34 years. Overall, Trauma (22.2%) was the main disease category followed by infectious disease (19.7%). Intracranial injury (12.5%) was the leading diagnosis in all age groups, while pneumonia (11.7%) was the leading diagnosis in pediatric patients (<18 years). Patients with tetanus (2.4%) had the longest median length ICU stay: 8 (5,13) days. The overall in-ICU mortality rate was 41.4%. The ICUs in tertiary referral hospitals of Tanzania are severely limited in infrastructure, personnel, and resources, making it difficult or impossible to provide optimum care to critically ill patients and likely contributing to the dauntingly high mortality rates.

Disease severity does not affect the interval between IBD diagnosis and the development of CRC: results from two large, Dutch case series.

PubMed

Mooiweer, Erik; Baars, Judith E; Lutgens, Maurice W M D; Vleggaar, Frank; van Oijen, Martijn; Siersema, Peter D; Kuipers, Ernst J; van der Woude, C Janneke; Oldenburg, Bas

2012-05-01

The increased risk of colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) is well established. The incidence of IBD-related CRC however, differs markedly between cohorts from referral centers and population-based studies. In the present study we aimed to identify characteristics potentially explaining these differences in two cohorts of patients with IBD-related CRC. PALGA, a nationwide pathology network and registry in The Netherlands, was used to search for patients with IBD-associated CRC between 1990 and 2006. Patients from 7 referral hospitals and 78 general hospitals were included. Demographic and disease specific parameters were collected retrospectively using patient charts. A total of 281 patients with IBD-associated CRC were identified. Patients from referral hospitals had a lower median age at IBD diagnosis (26 years vs. 28 years (p=0.02)), while having more IBD-relapses before CRC diagnosis than patients from general hospitals (3.8 vs. 1.5 (p<0.01)). In patients from referral hospitals, CRC was diagnosed at a younger age (47 years vs. 51 years (p=0.01)). However, the median interval between IBD diagnosis and diagnosis of CRC was similar in both cohorts (19 years in referral hospitals vs. 17 years in general hospitals (p=0.13)). IBD patients diagnosed with CRC treated in referral hospitals in The Netherlands are younger at both the diagnosis of IBD and CRC than IBD patients with CRC treated in general hospitals. Although patients from referral centers appeared to have a more severe course of IBD, the interval between IBD and CRC diagnosis was similar. Copyright © 2011 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

Primary care referral management: a marketing strategy for hospitals.

PubMed

Bender, A D; Geoghegan, S S; Lundquist, S H; Cantone, J M; Krasnick, C J

1990-06-01

With increasing competition among hospitals, primary care referral development and management programs offer an opportunity for hospitals to increase their admissions. Such programs require careful development, the commitment of the hospital staff to the strategy, an integration of hospital activities, and an understanding of medical practice management.

An Australian hospital's training program and referral pathway within a multi-disciplinary health-justice partnership addressing family violence.

PubMed

Forsdike, Kirsty; Humphreys, Cathy; Diemer, Kristin; Ross, Stuart; Gyorki, Linda; Maher, Helena; Vye, Penelope; Llewelyn, Fleur; Hegarty, Kelsey

2018-06-01

An innovative health-justice partnership was established to deliver legal assistance to women experiencing family violence who attended an Australian hospital. This paper reports on a multifaceted response to build capacity and willingness of health professionals to identify signs of family violence and engage with referral pathways to on-site legal assistance. A Realistic Evaluation analysed health professionals' knowledge and attitudes towards identification, response and referral for family violence before and after training; and use of referral pathways. Of 123 health professionals participating in training, 67 completed baseline and follow-up surveys. Training improved health professionals' self-reported knowledge of, and confidence in, responding to family violence and understanding of lawyers' roles in hospitals. Belief that patients should be referred to on-site legal services increased. Training did not correspond to actual increased referrals to legal assistance. The program built capacity and willingness of health professionals to identify signs of, and respond to, family violence. Increase in referral rates to legal assistance was not shown. Potential improvements include better data capture and greater availability of legal services. Implications for public health: Strong hospital system supports and reliable recording of family violence referrals need to be in place before introducing such partnerships to other hospitals. © 2017 The Authors.

Does an in-house internist at a GP practice result in reduced referrals to hospital-based specialist care?

PubMed

Quanjel, Tessa C C; Winkens, Anne; Spreeuwenberg, Marieke D; Struijs, Jeroen N; Winkens, Ron A G; Baan, Caroline A; Ruwaard, Dirk

2018-03-01

Consistent evidence on the effects of specialist services in the primary care setting is lacking. Therefore, this study evaluated the effects of an in-house internist at a GP practice on the number of referrals to specialist care in the hospital setting. Additionally, the involved GPs and internist were asked to share their experiences with the intervention. A retrospective interrupted times series study. Two multidisciplinary general practitioner (GP) practices. An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings. The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting. The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period. It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period. This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting. Key Points An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting. The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.

Referral Finder: Saving Time and Improving The Quality of In-hospital Referrals.

PubMed

Cathcart, Jennifer; Cowan, Neil; Tully, Vicki

2016-01-01

Making referrals to other hospital specialties is one of the key duties of the foundation doctor, which can be difficult and time consuming. In Ninewells hospital, Scotland, in our experience the effectiveness of referrals is limited by contact details not being readily accessible and foundation doctors not knowing what information is relevant to each specialty. We surveyed foundation doctors on their experience of the existing referral process to identify where we needed to focus to improve the process. The doctors reported significant delays in obtaining contact details from the operator, and found they did not know the specific information needed in each referral. To increase the information available to foundation doctors, we set up a page on the staff intranet called 'Referral Finder'. This page includes contact details, guidelines for referral, and links to relevant protocols for each specialty. By making this information readily accessible our objective was to increase the speed and quality of referrals. When surveyed two months after the web page was established, foundation doctors reported a reduction in calls to operator from baseline and reported achieving more effective referrals. When asked to comment, many doctors asked if the page could include details for other hospitals in our health board and provide more specialty specific information. This feedback prompted us to extend the scope of the page to include the district general hospital in our region, and update many of the existing details. Doctors were then surveyed after the updates, 100% agreed that the website saved time and there was a 49.3% reduction in doctors who reported not knowing the specific information needed for a referral. Having adequate information improved referrals and resulted in time saved. This would allow more time for patient care. The quality improvement project was praised among doctors as a useful, innovative and replicable project.

Referral Finder: Saving Time and Improving The Quality of In-hospital Referrals

PubMed Central

Cathcart, Jennifer; Cowan, Neil; Tully, Vicki

2016-01-01

Making referrals to other hospital specialties is one of the key duties of the foundation doctor, which can be difficult and time consuming. In Ninewells hospital, Scotland, in our experience the effectiveness of referrals is limited by contact details not being readily accessible and foundation doctors not knowing what information is relevant to each specialty. We surveyed foundation doctors on their experience of the existing referral process to identify where we needed to focus to improve the process. The doctors reported significant delays in obtaining contact details from the operator, and found they did not know the specific information needed in each referral. To increase the information available to foundation doctors, we set up a page on the staff intranet called ‘Referral Finder’. This page includes contact details, guidelines for referral, and links to relevant protocols for each specialty. By making this information readily accessible our objective was to increase the speed and quality of referrals. When surveyed two months after the web page was established, foundation doctors reported a reduction in calls to operator from baseline and reported achieving more effective referrals. When asked to comment, many doctors asked if the page could include details for other hospitals in our health board and provide more specialty specific information. This feedback prompted us to extend the scope of the page to include the district general hospital in our region, and update many of the existing details. Doctors were then surveyed after the updates, 100% agreed that the website saved time and there was a 49.3% reduction in doctors who reported not knowing the specific information needed for a referral. Having adequate information improved referrals and resulted in time saved. This would allow more time for patient care. The quality improvement project was praised among doctors as a useful, innovative and replicable project. PMID:27158494

Utilization of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan, Nigeria.

PubMed

Olaleye, Olubukola Adebisi; Lawal, Zainab Iyabo

2017-03-01

To investigate the pattern of referral for and utilisation of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan, Nigeria. Referral notes and medical records of patients admitted in the University College Hospital, Ibadan with a clinical diagnosis of stroke between January, 2009 and December, 2013 were retrospectively reviewed. Information on age, sex, type of stroke, length of hospital stay, referral for physiotherapy and utilisation of physiotherapy were retrieved. Data were summarised using descriptive statistics and analysed using Chi-square test. A total of 783 patients with stroke were admitted in the hospital during the period under study. The in-patient mortality rate was 37.2%. The mean Length of Hospital Stay (LoHS) was 16.17±12.34 days. Referral rate for physiotherapy was high (75.8%) and the mean time from admission to referral for physiotherapy was three days. Majority of patients referred utilised physiotherapy (63.4%) and mean number of physiotherapy sessions received during in-patient care was 8.69±6.45. There was a significant association between LoHS and utilisation of in-patientphysiotherapy (p=0.02). The referral rate of stroke patients for physiotherapy was relatively high. Utilisation of in-patient physiotherapy reduced length of hospital stay among patients with stroke. Utilisation of out-patient physiotherapy was low. Strategies to enhance out-patient utilisation should be explored.

Physician Referral Patterns and Race Differences in Receipt of Coronary Angiography

PubMed Central

LaVeist, Thomas A; Morgan, Athol; Arthur, Melanie; Plantholt, Stephen; Rubinstein, Michael

2002-01-01

Objective This study addresses the following research questions: (1) Is race a predictor of obtaining a referral for coronary angiography (CA) among patients who are appropriate candidates for the procedure? (2) Is there a race disparity in obtaining CA among patients who obtain a referral for the procedure? Study Setting Three community hospitals in Baltimore, Maryland. Study Design We abstracted hospital records of 7,927 patients from three hospitals to identify 2,653 patients who were candidates for CA. Patients were contacted by telephone to determine if they received a referral for CA. Logistic regression was used to assess whether racial differences in obtaining a referral were affected by adjustment for several potential confounders. A second set of analyses examined race differences in use of the procedure among a subsample of patients that obtained a referral. Principal Findings After controlling for having been hospitalized at a hospital with in-house catheterization facilities, ACC/AHA (American College of Cardiology/American Heart Association) classification, sex, age, and health insurance status, race remained a significant determinant of referral (OR=3.0, p<.05). Additionally, we found no significant race differences in receipt of the procedure among patients who obtained a referral. Conclusions Our results demonstrate that race differences in utilization of CA tend to occur during the process of determining the course of treatment. Once a referral is obtained, African American patients are not less likely than white patients to follow through with the procedure. Thus, future research should seek to better understand the process by which the decision is made to refer or not refer patients. PMID:12236392

Why do Families of Sick Newborns Accept Hospital Care? A Community-Based Cohort Study in Karachi, Pakistan

PubMed Central

Owais, Aatekah; Sultana, Shazia; Stein, Aryeh D.; Bashir, Nasira H.; Awaldad, Razia; Zaidi, Anita K M

2011-01-01

Objective Sick young infants are at high risk of mortality in developing countries but families often decline hospital referral. Our objective was to identify the predictors of acceptance of referral for hospital care among families of severely ill newborns and infants <59 days old in three low-income communities of Karachi, Pakistan. Study design A cohort of 541 newborns and infants referred from home by community health workers doing household surveillance, and diagnosed with a serious illness at local community clinics between January 1 and December 31, 2007, was followed-up within 1 month of referral to the public hospital. Results Only 24% of families accepted hospital referral. Major reasons for refusal were financial difficulties (67%) and father/elder denying permission (65%). Religious/cultural beliefs were cited by 20% of families. Referral acceptance was higher with recognition of severity of the illness by mother (OR=12.7; 95% CI=4.6–35.2), family’s ability to speak the dominant language at hospital (OR=2.0; 95% CI=1.3–3.1), presence of grunting in the infant (OR=3.3; 95% CI=1.2–9.0), and infant temperature <35.5°C (OR=4.1; 95% CI=2.3–7.4). No gender differential was observed. Conclusion Refusal of hospital referral for sick young infants is very common. Interventions that encourage appropriate care seeking, as well as community-based management of young infant illnesses when referral is not feasible are needed to improve neonatal survival in low-income countries. PMID:21273989

Education and referral criteria: impact on oncology referrals to palliative care.

PubMed

Reville, Barbara; Reifsnyder, JoAnne; McGuire, Deborah B; Kaiser, Karen; Santana, Abbie J

2013-07-01

To describe a quality improvement project involving education and referral criteria to influence oncology provider referrals to a palliative care service. A single group post-test only quasi-experimental design was used to evaluate palliative care service (PCS) referrals following an intervention consisting of a didactic presentation, education outreach visits (EOV) to key providers, and referral criteria. Data on patient demographics, cancer types, consult volume, reasons for referral, pre-consult length of stay, overall hospital stay, and discharge disposition were collected pre-intervention, then post-intervention for 7.5 months and compared. Attending oncologists, nurse practitioner, and house staff from the solid tumor division at a 700-bed urban teaching hospital participated in the project. Two geriatricians, a palliative care nurse practitioner, and rotating geriatric fellows staffed the PCS. The percentage of oncology referrals to PCS increased significantly following the intervention (χ(2) = 6.108, p = .013). 24.9% (390) patients were referred in the 4.6 years pre-intervention and 31.5% (106) patients were referred during 7.5 months post-intervention. The proportion of consults for pain management was significantly greater post-intervention (χ(2) = 5.378, p = .02), compared to pre-intervention, when most referrals were related to end-of-life issues. Lung, pancreatic, and colon were the most common cancer types at both periods, and there were no significant differences in patient demographics, pre-referral length of hospitalization or overall hospital days. There was a trend toward more patients being discharged alive following the intervention. A quality improvement project supported the use of education and referral criteria to influence both the frequency and reasons for palliative care referral by oncology providers.

Does an in-house internist at a GP practice result in reduced referrals to hospital-based specialist care?

PubMed Central

Quanjel, Tessa C. C.; Winkens, Anne; Spreeuwenberg, Marieke D.; Struijs, Jeroen N.; Winkens, Ron A. G.; Baan, Caroline A.; Ruwaard, Dirk

2018-01-01

Objective Consistent evidence on the effects of specialist services in the primary care setting is lacking. Therefore, this study evaluated the effects of an in-house internist at a GP practice on the number of referrals to specialist care in the hospital setting. Additionally, the involved GPs and internist were asked to share their experiences with the intervention. Design A retrospective interrupted times series study. Setting Two multidisciplinary general practitioner (GP) practices. Intervention An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings. Subjects The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting. Main outcome measures The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period. Results It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period. Conclusions This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting. Key Points An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting. The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues. PMID:29376458

Applying Task-Technology Fit Model to the Healthcare Sector: a Case Study of Hospitals' Computed Tomography Patient-Referral Mechanism.

PubMed

Chen, Ping-Shun; Yu, Chun-Jen; Chen, Gary Yu-Hsin

2015-08-01

With the growth in the number of elderly and people with chronic diseases, the number of hospital services will need to increase in the near future. With myriad of information technologies utilized daily and crucial information-sharing tasks performed at hospitals, understanding the relationship between task performance and information system has become a critical topic. This research explored the resource pooling of hospital management and considered a computed tomography (CT) patient-referral mechanism between two hospitals using the information system theory framework of Task-Technology Fit (TTF) model. The TTF model could be used to assess the 'match' between the task and technology characteristics. The patient-referral process involved an integrated information framework consisting of a hospital information system (HIS), radiology information system (RIS), and picture archiving and communication system (PACS). A formal interview was conducted with the director of the case image center on the applicable characteristics of TTF model. Next, the Icam DEFinition (IDEF0) method was utilized to depict the As-Is and To-Be models for CT patient-referral medical operational processes. Further, the study used the 'leagility' concept to remove non-value-added activities and increase the agility of hospitals. The results indicated that hospital information systems could support the CT patient-referral mechanism, increase hospital performance, reduce patient wait time, and enhance the quality of care for patients.

Collaboration across organizational boarders, the referral case.

PubMed

Heimly, Vigdis

2010-01-01

Referrals are requests for medical examination and evaluation by a specialist, outpatient clinic or a hospital. The referral can be sent from a GP, specialist or from one hospital to another. The referral transfers fully or partly the responsibility for further treatment of the patient. The diffusion of electronic referrals in the health sector has been slow in many countries despite the fact that EHR-systems, referral standards and technical infrastructure are available. This paper addresses shortcomings that have been seen in the Norwegian deployment process, and how collaboration can support, and be supported by, the involved actors in different organizations. Special attention is paid to how GPs that work in part time positions as practice consultants in Hospitals can act as boundary spanners in order to improve the collaborating actors understanding of each other's needs and work processes. Practice consultant should also be used actively in design of ICT-systems that support collaboration across organizational boarders in health care.

Initiating a Standardized Regional Referral and Counter-Referral System in Guatemala: A Mixed-Methods Study.

PubMed

Kapoor, Rupa; Avendaño, Leslie; Sandoval, Maria Antonieta; Cruz, Andrea T; Sampayo, Esther M; Soto, Miguel A; Camp, Elizabeth A; Crouse, Heather L

2017-01-01

Background: Few data exist for referral processes in resource-limited settings. We utilized mixed-methods to evaluate the impact of a standardized algorithm and training module developed for locally identified needs in referral/counter-referral procedures between primary health centers (PHCs) and a Guatemalan referral hospital. Methods : PHC personnel and hospital physicians participated in surveys and focus groups pre-implementation and 3, 6, and 12 months post-implementation to evaluate providers' experience with the system. Referred patient records were reviewed to evaluate system effectiveness. Results : A total of 111 initial focus group participants included 96 (86.5%) from PHCs and 15 from the hospital. Of these participants, 53 PHC physicians and nurses and 15 hospital physicians initially completed written surveys. Convenience samples participated in follow-up. Eighteen focus groups achieved thematic saturation. Four themes emerged: effective communication; provision of timely, quality patient care with adequate resources; educational opportunities; and development of empowerment and relationships. Pre- and post-implementation surveys demonstrated significant improvement at the PHCs ( P < .001) and the hospital ( P = .02). Chart review included 435 referrals, 98 (22.5%) pre-implementation and 337 (77.5%) post-implementation. There was a trend toward an increased percentage of appropriately referred patients requiring medical intervention (30% vs 40%, P = .08) and of patients requiring intervention who received it prior to transport (55% vs 73%, P = .06). Conclusions : Standardizing a referral/counter-referral system improved communication, education, and trust across different levels of pediatric health care delivery. This model may be used for extension throughout Guatemala or be modified for use in other countries. Mixed-methods research design can evaluate complex systems in resource-limited settings.

Gaps in referral to cardiac rehabilitation of patients undergoing percutaneous coronary intervention in the United States.

PubMed

Aragam, Krishna G; Dai, Dadi; Neely, Megan L; Bhatt, Deepak L; Roe, Matthew T; Rumsfeld, John S; Gurm, Hitinder S

2015-05-19

Rates of referral to cardiac rehabilitation after percutaneous coronary intervention (PCI) have been historically low despite the evidence that rehabilitation is associated with lower mortality in PCI patients. This study sought to determine the prevalence of and factors associated with referral to cardiac rehabilitation in a national PCI cohort, and to assess the association between insurance status and referral patterns. Consecutive patients who underwent PCI and survived to hospital discharge in the National Cardiovascular Data Registry between July 1, 2009 and March 31, 2012 were analyzed. Cardiac rehabilitation referral rates, and patient and institutional factors associated with referral were evaluated for the total study population and for a subset of Medicare patients presenting with acute myocardial infarction. Patients who underwent PCI (n = 1,432,399) at 1,310 participating hospitals were assessed. Cardiac rehabilitation referral rates were 59.2% and 66.0% for the overall population and the AMI/Medicare subgroup, respectively. In multivariable analyses, presentation with ST-segment elevation myocardial infarction (odds ratio 2.99; 95% confidence interval: 2.92 to 3.06) and non-ST-segment elevation myocardial infarction (odds ratio: 1.99; 95% confidence interval: 1.94 to 2.03) were associated with increased odds of referral to cardiac rehabilitation. Models adjusted for insurance status showed significant site-specific variability in referral rates, with more than one-quarter of all hospitals referring <20% of patients. Approximately 60% of patients undergoing PCI in the United States are referred for cardiac rehabilitation. Site-specific variation in referral rates is significant and is unexplained by insurance coverage. These findings highlight the potential need for hospital-level interventions to improve cardiac rehabilitation referral rates after PCI. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Trends in Use of Referral Hospital Services for Care of Sick Newborns in a Community-based Intervention in Tangail District, Bangladesh

PubMed Central

Bari, Sanwarul; Mannan, Ishtiaq; Rahman, Mohammed Anisur; Darmstadt, Gary L.; Seraji, M. Habibur R.; Baqui, Abdullah H.; Arifeen, Shams El; Rahman, Syed Moshfiqur; Saha, Samir K.; Ahmed, A.S.M. Nawshad Uddin; Ahmed, Saifuddin; Santosham, Mathuram; Black, Robert E.

2006-01-01

The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns. PMID:17591349

Appealing to an important customer. Physicians should be the target of marketing.

PubMed

Weiss, R

1989-05-01

Although many healthcare professionals are turning to the general public to increase market share and referrals, they should be directing their attention to physicians instead. One of the major challenges facing hospitals is determining physician needs. A survey may be necessary to identify physicians' perceptions, attitudes, values, expectations, market, and hospital loyalty. Another important research document is the physician profile, which includes each doctor by age, specialty, office location, admitting and outpatient referral activity, financial contribution, and referral and other affiliations. Surveying should not end with the physician. One of the best means of evaluating patient and physician satisfaction is by questioning physicians' office staff. To centralize physician services, a number of hospitals have established physician liaison programs, which bridge the gap between the hospital and the physician's office, heighten physician satisfaction, and increase referrals. Physician orientation is a key element of most outreach programs, providing an opportunity to develop relationships with new physicians. Other means of directly aiding physicians are physician referral services and practice enhancement and assistance.

A mechanism of institutional isomorphism in referral networks among hospitals in Seoul, South Korea.

PubMed

Jung, Minsoo; Choi, Mankyu

2010-01-01

Hospitals engage in medical referral system relations voluntarily, by virtue of their own service capacities. These capacities include medical technology, equipment supply, and patient management, which are assessed individually by medical institutions in efforts to control costs and maintain efficiency in tertiary hospitals. This study assessed referral networks according to the institutional isomorphism theory of new economic sociology. As a result, the referral networks were shown to exhibit emergent structural hierarchy via cumulative clustering by established year and were not affected by attributive variables such as region, bed number, and year of establishment. In particular, the networks evidenced institutional isomorphism with certain central hospitals. As a consequence, personal indices were shown to decrease in accordance with its period, and only the structural index increased. Normative pressures cause organizations to become hierarchically homogenized, in accordance with the principle of organizational learning in specialized fields. Therefore, normative isomorphism on the basis of public domains should be considered an inherent factor in the development of referral networks.

What Would Be the Effect of Referral to High-Volume Hospitals in a Largely Rural State?

ERIC Educational Resources Information Center

Ward, Marcia M.; Jaana, Mirou; Wakefield, Douglas S.; Ohsfeldt, Robert L.; Schneider, John E.; Miller, Thomas; Lei, Yang

2004-01-01

Volume of certain surgical procedures has been linked to patient outcomes. The Leapfrog Group and others have recommended evidence-based referral using specific volume thresholds for nonemergent cases. The literature is limited on the effect of such referral on hospitals, especially in rural areas. To examine the impact of evidence-based referral…

Referral patterns and service utilization in a pediatric hospital-wide intimate partner violence program.

PubMed

Cruz, Mario; Cruz, Patricia B; Weirich, Christine; McGorty, Ryan; McColgan, Maria D

2013-08-01

To describe the referral patterns and utilization of on-site intimate partner violence (IPV) services in both inpatient and outpatient settings at a large urban children's hospital. Retrospective review of case records from IPV victims referred to an on-site IPV counselor between September 2005 and February 2010. Descriptive statistics were used to examine IPV victim demographics, number of referrals per hospital department, referral source (type of staff member), time spent by IPV counselor for initial consultation, and services provided to IPV victims. A total of 453 unique referrals were made to the IPV counselor: 81% were identified by universal screening and 19% by risk-based screening. Thirty-six percent of IPV victims were referred from primary care clinics; 26% from inpatient units; 13% from outpatient subspecialty clinics; 12.5% from the emergency department; 5% from the Child Protection Program; and 4% were employee self-referrals. Social workers generated the most referrals (55%), followed by attending physicians (17%), residents (13%), nurses (7%), and other individuals (self-referrals) (4%). The median initial IPV intervention required 42 minutes. Supportive counseling and safety planning were the services most often utilized by IPV victims. IPV screening can be successfully integrated in both inpatient and outpatient settings by a multidisciplinary group of hospital staff. Most referrals were generated by universal screening outside of the primary care setting. IPV victims generally desired supportive counseling and safety planning over immediate housing relocation. Many IPV screening opportunities were missed by using verbal screening alone. Copyright © 2013 Elsevier Ltd. All rights reserved.

Referral by outreach specialist reduces hospitalisation costs of rural patients with digestive tract cancer: a report from medical consortium in China.

PubMed

Shi, Ge; Zhou, Bin; Cai, Zhi-Chang; Wu, Tao; Li, Xian-Feng; Xu, Weiguo

2014-01-01

The authors examined the effect of referrals from outreach specialists on total hospitalisation costs of rural Chinese patients receiving surgical treatment for digestive tract cancer at a tertiary hospital within a vertically integrated medical consortium. A retrospective cohort study was conducted within the Taiyuan Central Hospital medical consortium between January 2008 and December 2010. This consortium consists of Taiyuan Central Hospital (a tertiary hospital) and three county hospitals in Taiyuan city, the capital of Shanxi province in China. Patients admitted for surgery to treat digestive tract cancer (N=359) were assigned to control (direct admission without referral), referral by local doctor (RL), or referral by outreach specialist (RO) groups according to referral type. Length of stay (LOS) and hospitalisation costs were examined. Regression-adjusted costs were estimated by a multivariate model that controlled for gender, age, type of cancer, Charlson Comorbidity Index (CCI) score, and referral type. Significant differences were found between the three groups (p<0.001) for LOS and total hospitalisation costs. Both were highest for the control group, followed by RL and then the RO groups (LOS: 28.3 ± 4.9, 24.2 ± 5.9, and 19.2 ± 3.7 days; hospitalisation cost: Chinese yuan (CNY)35,087.87 ± 6208.30, 32,853.38 ± 5195.40, and 29,794.56 ± 5250.20). A strong association was found between RO and substantially reduced hospitalisation costs in patients receiving digestive tract cancer surgery within the medical consortium as compared to RL. This finding suggests that the strengthened collaboration between outreach specialists and local doctors, herein referred to as the green referral channel, is the key factor leading to reduced hospitalisation costs.

Routine diversion of patients with STEMI to high-volume PCI centres: modelling the financial impact on referral hospitals.

PubMed

Pathak, Elizabeth Barnett; Comins, Meg M; Forsyth, Colin J; Strom, Joel A

2015-01-01

To quantify possible revenue losses from proposed ST-elevation myocardial infarction (STEMI) patient diversion policies for small hospitals that lack high-volume percutaneous coronary intervention (PCI) capability status (ie, 'STEMI referral hospitals'). Negative financial impacts on STEMI referral hospitals have been discussed as an important barrier to implementing regional STEMI bypass/transfer protocols. However, there is little empirical data available that directly quantifies this potential financial impact. Using detailed financial charges from Florida hospital discharge data, we examined the potential negative financial impact on 112 STEMI referral hospitals from losing all inpatient STEMI revenue. The main outcome was projected revenue loss (PRL), defined as total annual patient with STEMI charges as a proportion of total annual charges for all patients. We hypothesised that for most community hospitals (>90%), STEMI revenue represented only a small fraction of total revenue (<1%). We further examined the financial impact of the 'worst case' scenario of loss of all acute coronary syndrome (ACS) (ie, chest pain) patients. PRLs were $0.33 for every $100 of patient revenue statewide for STEMI and $1.73 for ACS. At the individual hospital level, the 90th centile PRL was $0.74 for STEMI and $2.77 for ACS. PRLs for STEMI were not greater in rural areas compared with major metropolitan areas. Hospital revenue centres that would be most impacted by loss of patients with STEMI were cardiology procedures and intensive care units. Loss of patient with STEMI revenues would result in only a small financial impact on STEMI referral hospitals in Florida under proposed STEMI diversion/rapid transfer protocols. However, spillover loss of patients with ACS would increase revenue loss for many hospitals.

Outcomes of domestic violence screening at an acute London trust: are there missed opportunities for intervention?

PubMed

Warren-Gash, Charlotte; Bartley, Angela; Bayly, Jude; Dutey-Magni, Peter; Edwards, Sarah; Madge, Sara; Miller, Charlotte; Nicholas, Rachel; Radhakrishnan, Sheila; Sathia, Leena; Swarbrick, Helen; Blaikie, Dee; Rodger, Alison

2016-01-04

Domestic violence screening is advocated in some healthcare settings. Evidence that it increases referral to support agencies or improves health outcomes is limited. This study aimed to (1) investigate the proportion of hospital patients reporting domestic violence, (2) describe characteristics and previous hospital attendances of affected patients and (3) assess referrals to an in-house domestic violence advisor from Camden Safety Net. A series of observational studies. Three outpatient clinics at the Royal Free London NHS Foundation Trust. 10,158 patients screened for domestic violence in community gynaecology, genitourinary medicine (GUM) and HIV medicine clinics between 1 October 2013 and 30 June 2014. Also 2253 Camden Safety Net referrals over the same period. (1) Percentage reporting domestic violence by age group gender, ethnicity and clinic. (2) Rates of hospital attendances in the past 3 years for those screening positive and negative. (3) Characteristics, uptake and risk assessment results for hospital in-house domestic violence referrals compared with Camden Safety Net referrals from other sources. Of the 10,158 patients screened, 57.4% were female with a median age of 30 years. Overall, 7.1% reported ever-experiencing domestic violence, ranging from 5.7% in GUM to 29.4% in HIV services. People screening positive for domestic violence had higher rates of previous emergency department attendances (rate ratio (RR) 1.63, 95% CI 1.09 to 2.48), emergency inpatient admissions (RR 2.27, 95% CI 1.37 to 3.84) and day-case admissions (RR 2.03, 95% CI 1.23 to 3.43) than those screening negative. The 77 hospital referrals to the hospital-based domestic violence advisor during the study period were more likely to be taken up and to be classified as high risk than referrals from elsewhere. Selective screening for domestic violence in high-risk hospital clinic populations has the potential to identify affected patients and promote good uptake of referrals for in-house domestic violence support. 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/

Outcomes of domestic violence screening at an acute London trust: are there missed opportunities for intervention?

PubMed Central

Warren-Gash, Charlotte; Bartley, Angela; Bayly, Jude; Dutey-Magni, Peter; Edwards, Sarah; Madge, Sara; Miller, Charlotte; Nicholas, Rachel; Radhakrishnan, Sheila; Sathia, Leena; Swarbrick, Helen; Blaikie, Dee; Rodger, Alison

2016-01-01

Objectives Domestic violence screening is advocated in some healthcare settings. Evidence that it increases referral to support agencies or improves health outcomes is limited. This study aimed to (1) investigate the proportion of hospital patients reporting domestic violence, (2) describe characteristics and previous hospital attendances of affected patients and (3) assess referrals to an in-house domestic violence advisor from Camden Safety Net. Design A series of observational studies. Setting Three outpatient clinics at the Royal Free London NHS Foundation Trust. Participants 10 158 patients screened for domestic violence in community gynaecology, genitourinary medicine (GUM) and HIV medicine clinics between 1 October 2013 and 30 June 2014. Also 2253 Camden Safety Net referrals over the same period. Main outcome measures (1) Percentage reporting domestic violence by age group gender, ethnicity and clinic. (2) Rates of hospital attendances in the past 3 years for those screening positive and negative. (3) Characteristics, uptake and risk assessment results for hospital in-house domestic violence referrals compared with Camden Safety Net referrals from other sources. Results Of the 10 158 patients screened, 57.4% were female with a median age of 30 years. Overall, 7.1% reported ever-experiencing domestic violence, ranging from 5.7% in GUM to 29.4% in HIV services. People screening positive for domestic violence had higher rates of previous emergency department attendances (rate ratio (RR) 1.63, 95% CI 1.09 to 2.48), emergency inpatient admissions (RR 2.27, 95% CI 1.37 to 3.84) and day-case admissions (RR 2.03, 95% CI 1.23 to 3.43) than those screening negative. The 77 hospital referrals to the hospital-based domestic violence advisor during the study period were more likely to be taken up and to be classified as high risk than referrals from elsewhere. Conclusions Selective screening for domestic violence in high-risk hospital clinic populations has the potential to identify affected patients and promote good uptake of referrals for in-house domestic violence support. PMID:26729380

Why do women not adhere to advice on maternal referral in rural Tanzania? Narratives of women and their family members.

PubMed

Pembe, Andrea B; Mbekenga, Columba K; Olsson, Pia; Darj, Elisabeth

2017-01-01

In most low-income countries, many women with high-risk pregnancies and complications do not reach the referral hospitals despite the provision of referral advice. To explore how antenatal maternal referral advice is understood and handled in a rural Tanzanian community. Individual in-depth interviews were conducted with six women who did not go to hospital and 13 people who were involved in the referral advice. Narrative analysis was used to describe and create meanings out of the decision-making process. In all interviews, not following the referral advice was greatly influenced by close family members. Three main traits of how referral advice was understood emerged: convinced referral is not necessary, accepting referral advice but delayed by others, and passive and moving with the wind. The main reasons given for declining the referral advice included discrediting midwives' advice, citing previous successful deliveries despite referral advice; being afraid of undergoing surgery; lack of support for care of siblings at home; and high costs incurred during referral. Declining maternal referral advice centred around the pregnant women's position and their dependence on the family members around them, with a decreased ability to show autonomy. If they were socially and economically empowered, women could positively influence decision making during maternal referrals.

Post-acute referral patterns for hospitals and implications for bundled payment initiatives.

PubMed

Lau, Christopher; Alpert, Abby; Huckfeldt, Peter; Hussey, Peter; Auerbach, David; Liu, Hangsheng; Sood, Neeraj; Mehrotra, Ateev

2014-09-01

Under new bundled payment models, hospitals are financially responsible for post-acute care delivered by providers such as skilled nursing facilities (SNFs) and home health agencies (HHAs). The hope is that hospitals will use post-acute care more prudently and better coordinate care with post-acute providers. However, little is known about existing patterns in hospitals׳ referrals to post-acute providers. Post-acute provider referrals were identified using SNF and HHA claims within 14 days following hospital discharge. Hospital post-acute care network size and concentration were estimated across hospital types and regions. The 2008 Medicare Provider Analysis and Review claims for acute hospitals and SNFs, and the 100% HHA Standard Analytic Files were used. The mean post-acute care network size for U.S. hospitals included 57.9 providers with 37.5 SNFs and 23.4 HHAs. The majority of these providers (65.7% of SNFs, 60.9% of HHAs) accounted for 1 percent or less of a hospital׳s referrals and classified as "low-volume". Other post-acute providers we classified as routine. The mean network size for routine providers was greater for larger hospitals, teaching hospitals and in regions with higher per capita post-acute care spending. The average hospital works with over 50 different post-acute providers. Moreover, the size of post-acute care networks varies considerably geographically and by hospital characteristics. These results provide context on the complex task hospitals will face in coordinating care with post-acute providers and cutting costs under new bundled payment models. Copyright © 2014 Elsevier Inc. All rights reserved.

Timeliness of lung cancer care in Victoria: a retrospective cohort study.

PubMed

Evans, Sue M; Earnest, Arul; Bower, Wendy; Senthuren, Meera; McLaughlin, Peta; Stirling, Rob

2016-02-01

To assess factors associated with second-line delays in the management of patients diagnosed with lung cancer. A retrospective cohort study, conducted in six public and two private Victorian hospitals, of 1417 patients aged 18 years or more who were diagnosed between July 2011 and October 2014 with an incident case of lung cancer identified by International Classification of Diseases, 10th revision codes (C34.0-C34.9, Z85.1, Z85.2) on the basis of either a clinical or pathological diagnosis. Time intervals between referral, diagnosis and initial definitive management. The median time from referral to diagnosis was 15 days (interquartile range [IQR], 5-36); from diagnosis to initial definitive management, 30 days (IQR, 6-84); and from referral to initial definitive management, 53 days (IQR, 25-106). Factors that were significantly associated with delay between referral and initial definitive management include declining or not being referred to palliative care (hazard ratio [HR], v patients referred for palliation, 0.73; 95% CI, 0.62-0.86; P < 0.001), and being treated in a public hospital (HR, v patients managed in a private hospital, 0.55; 95% CI, 0.48-0.64; P < 0.001). The median time from referral to initial definitive management in public and private hospitals was 61 days (IQR, 35-118) and 30 days (IQR, 13-76) respectively; 48% of patients in public hospitals waited longer than the British National Health Service target of a maximum 62 days between referral and first definitive treatment. There are significant delays at various stages of the patient journey after referral for initial definitive management. Having a greater understanding of these delays will enable strategies to be developed that improve the timeliness of care for patients with lung cancer.

Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison.

PubMed

Christiaens, Wendy; Gouwy, Anneleen; Bracke, Piet

2007-07-12

The Belgian and Dutch societies present many similarities but differ with regard to the organisation of maternity care. The Dutch way of giving birth is well known for its high percentage of home births and its low medical intervention rate. In contrast, home births in Belgium are uncommon and the medical model is taken for granted. Dutch and Belgian maternity care systems are compared with regard to the influence of being referred to specialist care during pregnancy or intrapartum while planning for a home birth. We expect that a referral will result in lower satisfaction with childbirth, especially in Belgium. Two questionnaires were filled out by 605 women, one at 30 weeks of pregnancy and one within the first two weeks after childbirth, either at home or in a hospital. Of these, 563 questionnaires were usable for analysis. Women were invited to participate in the study by independent midwives and obstetricians during antenatal visits in 2004-2005. Satisfaction with childbirth was measured by the Mackey Satisfaction with Childbirth Rating Scale, which takes into account the multidimensional nature of the concept. Belgian women are more satisfied than Dutch women and home births are more satisfying than hospital births. Women who are referred to the hospital while planning for a home birth are less satisfied than women who planned to give birth in hospital and did. A referral has a greater negative impact on satisfaction for Dutch women. There is no reason to believe Dutch women receive hospital care of lesser quality than Belgian women in case of a referral. Belgian and Dutch attach different meaning to being referred, resulting in a different evaluation of childbirth. In the Dutch maternity care system home births lead to higher satisfaction, but once a referral to the hospital is necessary satisfaction drops and ends up lower than satisfaction with hospital births that were planned in advance. We need to understand more about referral processes and how women experience them.

Predictors of CD4 count over time among HIV patients initiated ART in Felege Hiwot Referral Hospital, northwest Ethiopia: multilevel analysis.

PubMed

Gezie, Lemma Derseh

2016-07-30

The response of HIV patients to antiretroviral therapy could be measured by its strong predictor, the CD4+ T cell (CD4) count for the initiation of antiretroviral therapy and proper management of disease progress. However, in addition to HIV, there are other factors which can influence the CD4 cell count. Patient's socio-economic, demographic, and behavioral variables, accessibility, duration of treatment etc., can be used to predict CD4 count. A retrospective cohort study was conducted to examine the predictors of CD4 count among ART users enrolled in the first 6 months of 2010 and followed upto mid 2014. The covariance components model was employed to determine the predictors of CD4 count over time. A total of 1196 ART attendants were used to analyze their data descriptively. Eight hundred sixty-one of the attendants had two or more CD4 count measurements and were used in modeling their data using the linear mixed method. Thus, the mean rates of incensement of CD4 counts for patients with ambulatory/bedridden and working baseline functional status were 17.4 and 30.6 cells/mm(3) per year, respectively. After adjusting for other variables, for each additional baseline CD4 count, the gain in CD4 count during treatment was 0.818 cells/mm(3) (p value <0.001). Patient's age and baseline functional status were also statistically significantly associated with CD4 count. In this study, higher baseline CD4 count, younger age, working functional status, and time in treatment contributed positively to the increment of the CD4 count. However, the observed increment at 4 year was unsatisfactory as the proportion of ART users who reached the normal range of CD4 count was very low. To see their long term treatment outcome, it requires further research with a sufficiently longer follow up data. In line with this, the local CD4 count for HIV negative persons should also be investigated for better comparison and proper disease management.

Obstetric referrals from a rural clinic to a community hospital in Honduras.

PubMed

Josyula, Srirama; Taylor, Kathryn K; Murphy, Blair M; Rodas, Dairamise; Kamath-Rayne, Beena D

2015-11-01

referrals between health care facilities are important in low-resource settings, particularly in maternal and child health, to transfer pregnant patients to the appropriate level of obstetric care. Our aim was to characterise the obstetrical referrals from a rural clinic to a community referral hospital in Honduras, to identify barriers in effective transport/referral, and to describe subsequent patient outcomes. we performed a descriptive retrospective study of patients referred during a 9-month period. We reviewed patient charts to review diagnosis, referral, and treatment times at both sites to understand the continuity of care. ninety-two pregnant patients were referred from the rural clinic to the community hospital. Twenty six pregnant patients (28%) did not have complete and accurate medical records and were excluded from the study. The remaining 66 patients were our study population. Of the 66 patients, 54 (82%) received antenatal care with an average of 5.5±2.4 visits. The most common diagnoses requiring referral were non-reassuring fetal status, hypertensive disorders of pregnancy, and preterm labour. The time spent in the rural clinic until transfer was 7.35±8.60 hours, and transport times were 4.42±1.07 hours. Of the 66 women transferred, 24 (36%) had different primary diagnoses and 16 (24%) had additional diagnoses after evaluation in the community hospital, whereas the remaining 26 (40%) had diagnoses that remained the same. No system was in place to give feedback to the referring clinic doctors regarding their primary diagnoses. our results demonstrate challenges seen in obstetric transport from a rural clinic to a community hospital in Honduras. Further research is needed for reform of emergency obstetric care management, targeting both healthcare personnel and medical referral infrastructure. The example of Honduras can be taken to motivate change in other resource-limited areas. Copyright © 2015 Elsevier Ltd. All rights reserved.

Frequency and predictors of seasonal influenza vaccination and reasons for refusal among patients at a large tertiary referral hospital.

PubMed

Masnick, Max; Leekha, Surbhi

2015-07-01

We assessed frequency and predictors of seasonal influenza vaccination acceptance among inpatients at a large tertiary referral hospital, as well as reasons for vaccination refusal. Over 5 seasons, >60% of patients unvaccinated on admission refused influenza vaccination while hospitalized; "believes not at risk" was the reason most commonly given.

A study to assess the quality of information in referral letters to the orthodontic department at Kingston Hospital, Surrey.

PubMed

Izadi, Maryam; Gill, Daljit S; Naini, Farhad B

2010-04-01

To assess the quality of information included in referral letters sent to the orthodontic department at Kingston Hospital, Surrey, UK. Referral letters sent by both general dental practitioners (GDPs) and specialist orthodontists were analysed retrospectively in order to ascertain the percentage meeting the inclusion criteria as suggested by Mossey (2006) and the British Orthodontic Society (2008) for the quality of information included in an ideal orthodontic referral letter. Thirty-five consecutive letters sent between May and September 2005 and 206 letters sent in the same period in 2008 were collected by hand and analysed against the inclusion criteria. The numbers of referral letters received from GDPs, specialist orthodontists, and others sources were also determined. Most of the referrals sent in 2005 and 2008 included 40-50% of the referral inclusion points. This was despite an almost twofold increase in the number of referral letters received from specialist orthodontic practitioners in 2008. The majority of the letters, from both GDPs and specialists, did not include details of the oral hygiene or caries status of the patient, or an indication of their motivation towards treatment. None of the referral letters included a plaque score. The main weaknesses in the quality of information provided in referral letters were that in more than 80% of the letters there was no mention of the patient's medical history and no comment on caries status, the standard of oral hygiene, patient motivation for treatment, or an Index of Orthodontic Treatment Need score. The quality of information included in referral letters sent to Kingston Hospital orthodontic department needs to be improved.

Referral to treatment for hospitalized medical patients with an alcohol use disorder: A proof-of-concept brief intervention study.

PubMed

Berger, Lisa; Hernandez-Meier, Jennifer; Hyatt, John; Brondino, Michael

2017-01-01

Substance misuse intervention in healthcare settings is becoming a US national priority, especially in the dissemination and implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT). Yet, the referral to treatment component of SBIRT is understudied. This proof-of-concept investigation tested an enhanced coordinated hospital-community two session brief intervention designed to facilitate the referral to treatment of hospitalized medical patients with an alcohol use disorder. Participants (N = 9) attended the second session of the brief intervention held in the community in most cases (56%), while one out of three (33%) received some level of post-brief intervention alcohol and/or other drug treatment. Alcohol use and alcohol-related problems also statistically improved. Based, in part, on the results plus the widespread dissemination of SBIRT, next step investigations of brief interventions to help bridge hospitalized medical patients in need to community substance abuse treatment are warranted.

Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial.

PubMed

Dumont, Alexandre; Fournier, Pierre; Abrahamowicz, Michal; Traoré, Mamadou; Haddad, Slim; Fraser, William D

2013-07-13

Maternal mortality is higher in west Africa than in most industrialised countries, so the development and validation of effective interventions is essential. We did a trial to assess the effect of a multifaceted intervention to promote maternity death reviews and onsite training in emergency obstetric care in referral hospitals with high maternal mortality rates in Senegal and Mali. We did a pragmatic cluster-randomised controlled trial, with hospitals as the units of randomisation and patients as the unit of analysis. 46 public first-level and second-level referral hospitals with more than 800 deliveries a year were enrolled, stratified by country and hospital type, and randomly assigned to either the intervention group (n=23) or the control group with no external intervention (n=23). All women who delivered in each of the participating facilities during the baseline and post-intervention periods were included. The intervention, implemented over a period of 2 years at the hospital level, consisted of an initial interactive workshop and quarterly educational clinically-oriented and evidence-based outreach visits focused on maternal death reviews and best practices implementation. The primary outcome was reduction of risk of hospital-based mortality. Analysis was by intention-to-treat and relied on the generalised estimating equations extension of the logistic regression model to account for clustering of women within hospitals. This study is registered with ClinicalTrials.gov, number ISRCTN46950658. 191,167 patients who delivered in the participating hospitals were analysed (95,931 in the intervention groups and 95,236 in the control groups). Overall, mortality reduction in intervention hospitals was significantly higher than in control hospitals (odds ratio [OR] 0·85, 95% CI 0·73-0·98, p=0·0299), but this effect was limited to capital and district hospitals, which mainly acted as first-level referral hospitals in this trial. There was no effect in second-level referral (regional) hospitals outside the capitals (OR 1·02, 95% CI 0·79-1·31, p=0·89). No hospitals were lost to follow-up. Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals. Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions. Maternal death reviews, combined with best practices implementation, are effective in reducing hospital-based mortality in first-level referral hospitals. Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals. Canadian Institutes of Health Research. Copyright © 2013 Elsevier Ltd. All rights reserved.

Referring physician satisfaction: toward a better understanding of hospital referrals.

PubMed

Ponzurick, T G; France, K R; Logar, C M

1998-01-01

Customer satisfaction literature has contributed significantly to the development of marketing strategies in the health-care arena. The research has led to the development of hospital-driven relationship marketing programs. This study examines the inclusion of referring physicians as partners in the hospital's relationship marketing program. In exploring this relationship, medical and hospital facility characteristics that referring physicians find important in making patient referrals to specialty care hospitals are identified and analyzed. The results lead to the development of strategic initiatives which hospital marketers should consider when developing relationship marketing programs designed to satisfy their referring physicians.

Survey of the Statewide Impact of Payer Source on Referral of Small Burns to Burn Centers.

PubMed

Penny, Rachel; Coffey, Rebecca; Jones, Larry; Bailey, J Kevin

It is generally agreed that patients with large burns will be referred to organized burn centers, however, the referral of patients with smaller burns is less certain. A two-part survey was conducted to identify referral patterns for burn patients that meet American Burn Association referral criteria, and any effect insurance type might have on the referral patterns. The emergency departments of our state hospital association's member hospitals were contacted seeking a referral for a fictitious patient with a third-degree scald of the dominant hand. The referral sites were contacted twice, first stating that the patient had commercial insurance, next stating that the patient had Medicaid. Data collected included wait time for an appointment or reasons for denial of an appointment. Of 218 hospitals, 46 were excluded because they did not offer emergency care, and eight because they were listed as burn centers on the American Burn Association website. Of the remaining 164, 119 (73%) would refer to a burn center, 21 (13%) to a plastic surgeon, 10 (6%) to a hand surgeon, 7 (4%) to a wound center, 7 (4%) to another nonburn physician resource. There was no difference in wait time to the first available appointment with regards to insurance type (6.56 ± 4.68 vs 6.53 ± 5.05 days). Our state's referral pattern gives us insight into the regional referral pattern. This information will be used to guide a focused education and communication program to provide better service for the burn victims of our state.

Trends in diarrhea hospitalizations among infants at three hospitals in Tanzania before and after rotavirus vaccine introduction.

PubMed

Lyamuya, Faraja; Michael, Fausta; Jani, Bhavin; Fungo, Yohana; Chambo, Alfred; Chami, Inviolatha; Bulali, Regina; Mpamba, Amina; Cholobi, Happy; Kallovya, Dotto; Kamugisha, Christopher; Mwenda, Jason M; Cortese, Margaret M

2018-04-11

The Tanzania Ministry of Health introduced monovalent human rotavirus vaccine in January 2013, to be administered at ages 6 and 10 weeks. Data suggest there was high vaccine uptake. We used hospital ward registers from 3 hospitals to examine trends in diarrhea hospitalizations among infants before and after vaccine introduction. Ward registers from Dodoma Regional Referral Hospital (Central Tanzania), and two hospitals in Mbeya (Southwest area), Mbeya Zonal Referral Hospital and Mbalizi Hospital, were used to tally admissions for diarrhea among children by age group, month and year. Rotavirus surveillance had started at these hospitals in early 2013; the proportion of infants enrolled and rotavirus-EIA positive were examined by month to determine peak periods of rotavirus disease post-vaccine introduction. Registers were available for 2-4 prevaccine years and 2-3 post introduction years. At Dodoma Regional Referral Hospital, compared with the mean of 2011 and 2012, diarrhea hospitalizations among infants were 26% lower in 2015 and 58% lower in 2016. The diarrhea peak shifted later in the year first by 1 and then by 2-3 months from prevaccine. At the Mbeya hospitals, the number of diarrhea admissions in prevaccine period varied substantially by year. At Mbeya Referral Hospital, diarrhea hospitalizations among infants were lower by 25-37% in 2014 and 11-26% in 2015, while at Mbalizi Hospital, these hospitalizations were 4% lower in 2014 and 14% higher in 2015. Rotavirus testing data demonstrated a lowering of the prevaccine peak, a shift in timing of the peak months and indicated that other diarrheal peaks in post-introduction years were not due to rotavirus. In this ecological evaluation, total diarrhea hospitalizations among infants were lower (≥25% lower in ≥1 year) following introduction in 2 of 3 hospitals. There are challenges in using ward registers to ascertain possible impact of rotavirus vaccine introduction on trends in hospitalizations for treatment of all diarrheal illness. Published by Elsevier Ltd.

Access to cardiac rehabilitation among South-Asian patients by referral method: a qualitative study.

PubMed

Grewal, Keerat; Leung, Yvonne W; Safai, Parissa; Stewart, Donna E; Anand, Sonia; Gupta, Milan; Parsons, Cynthia; Grace, Sherry L

2010-01-01

People of South-Asian origin have an increased prevalence of coronary artery disease. Although cardiac rehabilitation (CR) is effective, South Asians are among the least likely people to participate in these programs. Automatic referral increases CR use and may reduce access inequalities. This study qualitatively explored whether CR referral knowledge and access varied among South-Asian patients. Participants were South-Asian cardiac patients receiving treatment at hospitals in Ontario, Canada. Each hospital refers to CR via one offour methods: automatically through paper or electronically, through discussion with allied health professionals (liaison referral), or through referral at the physician's discretion. Data were collected via interviews and analyzed using interpretive-descriptive analysis. Four themes emerged: the importance of predischarge CR discussions with healthcare providers, limited knowledge of CR, ease of the referral process for facilitators of CR attendance, and participants'needs for personal autonomy regarding their decision to attend CR. Liaison referral was perceived to be the most suitable referral method for participants. It facilitated communication between patients and providers, ensuring improved understanding of CR. Automatic referral may not be as well suited to this population because of reduced patient-provider communication.

Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study.

PubMed

Grace, Sherry L; Russell, Kelly L; Reid, Robert D; Oh, Paul; Anand, Sonia; Rush, James; Williamson, Karen; Gupta, Milan; Alter, David A; Stewart, Donna E

2011-02-14

Although cardiac rehabilitation (CR) has been shown to reduce mortality and is a recommended component in clinical practice guidelines, CR referral and utilization rates remain low. Referral strategies have been implemented to increase CR use but have yet to be compared concurrently. To determine the optimal strategy to maximize CR referral, enrollment, and participation, we evaluated 3 referral strategies compared with usual care: "automatic" only via discharge order or electronic record, health care provider liaison only, or a combined approach. In this prospective controlled study, 2635 inpatients with coronary artery disease from 11 Ontario, Canada, hospitals using 1 of the 4 referral strategies completed a sociodemographic survey, and clinical data were extracted from medical charts. One year later, 1809 participants completed a mailed survey that assessed CR utilization. Referral strategies were compared using generalized estimating equations to control for effect of hospital. Adjusted analyses revealed referral strategy was significantly related to CR referral and enrollment (P<.001). Combined automatic and liaison referral resulted in the greatest CR use (odds ratio [OR], 8.41; 85.8% referral, 73.5% enrollment), followed by automatic only (OR, 3.27; 70.2% referral, 60.0% enrollment), and liaison only (OR, 3.35; 59.0% referral, 50.6% enrollment), compared with usual referral (32.2% referral, 29.0% enrollment). The degree of CR participation did not differ by referral strategy among referred participants (mean [SD] percentage of classes attended, 82.87% [27.20%]; P=.88). Automatic referral combined with a patient discussion can achieve among the highest rates of CR referral reported. Wider adoption of such strategies could ensure that 45% more patients being treated for cardiac disease would have access to and realize the benefits of CR. ©2011 American Medical Association. All rights reserved.

Criteria-based audit to improve a district referral system in Malawi: a pilot study.

PubMed

Kongnyuy, Eugene J; Mlava, Grace; van den Broek, Nynke

2008-09-22

To study the feasibility of using criteria-based audit to improve a district referral system. A criteria-based audit was used to assess the Salima District referral system in Malawi. A retrospective review of 60 obstetric emergencies referred from 12 health centres was conducted and compared with prior established standards for optimal referral of emergencies. Recommendations were made and implemented. Three months later, a re-audit was conducted (62 cases). There were significant improvements in 4 out of 7 standards: adequate resuscitation before referral (33.3% vs 88.7%; p = 0.001); delay of less than 2 hours from the time the ambulance is called to when the ambulance brought the patient to the hospital (42.8% vs 88.3%; p = 0.014); clinician attends to patient within 30 minutes of arrival to hospital (30.8% vs 92.6%; p = 0.001) and feedback given to the referring health centres (1.7% vs 91.9%; p <0.001). The rest of the three standards showed a high level of attainment (>95%) in both the initial audit and the re-audit: referred patients accompanied by a referral form; ambulances are available at all times and the district hospital is informed through short-wave radio by the health centre when a patient is referred. Criteria-based audit can improve the ability of a district referral system to handle obstetric emergencies in countries with limited resources.

Effect of referral strategies on access to cardiac rehabilitation among women.

PubMed

Gravely, Shannon; Anand, Sonia S; Stewart, Donna E; Grace, Sherry L

2014-08-01

Despite its proven benefits and need, women's access to cardiac rehabilitation (CR) is suboptimal. Referral strategies, such as systematic referral, have been advocated to improve access to CR. This study examined sex differences in CR referral and enrollment by referral strategies; and the impact of referral strategies for referral and enrollment concordance among women. Prospective cohort study. This prospective study included 2635 coronary artery disease inpatients from 11 Ontario hospitals that utilized one of four referral strategies. Participants completed a sociodemographic survey, and clinical data were extracted from charts. One year later, 1809 participants (452 (25%) women) completed a mailed survey that assessed CR utilization. Referral strategies were compared among women using generalized estimating equations to control for the effect of hospital. Overall, significantly more men than women were referred (67.2% and 57.8% respectively, p < 0.001), and enrolled in CR (58.6% and 49.3% respectively, p = 0.001). Of the retained women, combined systematic and liaison-facilitated referral resulted in significantly greater CR referral (OR 10.3, 95% CI 4.11-25.58) and enrollment (OR 6.6, 95% CI 4.34-9.92) among women when compared with usual referral. Conversely, concordance between referral and enrollment was greatest following usual referral (K = 0.85), and decreased with referral intensity. While a lower proportion of referred patients enroll, systematic and liaison-facilitated inpatient referral strategies result in the greatest CR enrollment rates among women. Such strategies have the potential to improve access among women, and reduce 'cherry picking' of patients for referral. © The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

What proportion of adult allergy referrals to secondary care could be dealt with in primary care by a GP with special interest?

PubMed

Smith, H E; Wade, J; Frew, A J

2015-01-01

The concept of a General Practitioner with Special Interest (GPwSI) was first proposed in the 2000 National Health Service Plan, as a way of providing specialised treatment closer to the patient's home and reducing hospital waiting times. Given the patchy and inadequate provision of allergy services in the UK the introduction of GPwSIs might reduce the pressure on existing specialist services. This study assessed what proportion of referrals to a specialist allergy clinic could be managed in a GPwSI allergy service with a predefined range of facilities and expertise (accurate diagnosis and management of allergy; skin prick testing; provision of advice on allergen avoidance; ability to assess suitability for desensitisation). 100 consecutive GP referrals to a hospital allergy clinic were reviewed to determine whether patients could be seen in a community-based clinic led by a general practitioner with special interest (GPwSI) allergy. The documentation relating to each referral was independently assessed by three allergy specialists. The referrals were judged initially on the referral letter alone and then re-assessed with the benefit of information summarised in the clinic letter, to determine whether appropriate triage decisions could be made prospectively. The proportion of referrals suitable for a GPwSI was calculated and their referral characteristics identified. 29 % referrals were judged unanimously appropriate for management by a GPwSI and an additional 30 % by 2 of the 3 reviewers. 18 % referrals were unsuitable for a GPwSI service because of the complexity of the presenting problem, patient co-morbidity or the need for specialist knowledge or facilities. At least a quarter, and possibly half, of allergy referrals to our hospital-based service could be dealt with in a GPwSI clinic, thereby diversifying the patient pathway, allowing specialist services to focus on more complex cases and reducing the waiting time for first appointments.

[Obstetric care in Mali: effect of organization on in-hospital maternal mortality].

PubMed

Zongo, A; Traoré, M; Faye, A; Gueye, M; Fournier, P; Dumont, A

2012-08-01

Maternal mortality is still too high in sub-Saharan Africa, particularly in referral hospitals. Solutions exist but their implementation is a great issue in the poor-resources settings. The objective of this study is to assess the effect of the organization of obstetric care services on maternal mortality in referral hospitals in Mali. This is a multicentric observational survey in 22 referral hospitals. Clinical data on 42,929 women delivering in the 22 hospitals within the 2007 to 2008 study period were collected. Organization evaluation was based on explicit criteria defined by an expert committee. The effect of the organization on in-hospital mortality adjusted on individual and institutional characteristics was estimated using multi-level logistic regression models. The results show that an optimal organization of obstetric care services based on eight explicit criteria reduced in-hospital maternal mortality by 41% compared with women delivering in a referral hospital with sub-optimal organization defined as non-compliance with at least one of the eight criteria (ORa=0.59; 95% CI=0.34-0.92). Furthermore, local policies that improved financial access to emergency obstetric care had a significant impact on maternal outcome. Criteria for optimal organization include the management of labor and childbirth by qualified personnel, an organization of human resources that allows timely management of obstetric emergencies, routine use of partography for all patients and availability of guidelines for the management of complications. These conditions could be easily implemented in the context of Mali to reduce in-hospital maternal mortality. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Participation Rates, Process Monitoring, and Quality Improvement Among Cardiac Rehabilitation Programs in the United States: A NATIONAL SURVEY.

PubMed

Pack, Quinn R; Squires, Ray W; Lopez-Jimenez, Francisco; Lichtman, Steven W; Rodriguez-Escudero, Juan P; Lindenauer, Peter K; Thomas, Randal J

2015-01-01

Although strategies exist for improving cardiac rehabilitation (CR) participation rates, it is unclear how frequently these strategies are used and what efforts are being made by CR programs to improve participation rates. We surveyed all CR program directors in the American Association of Cardiovascular and Pulmonary Rehabilitation's database. Data collection included program characteristics, the use of specific referral and recruitment strategies, and self-reported program participation rates. Between 2007 and 2012, 49% of programs measured referral of inpatients from the hospital, 21% measured outpatient referral from office/clinic, 71% measured program enrollment, and 74% measured program completion rates. Program-reported participation rates (interquartile range) were 68% (32-90) for hospital referral, 35% (15-60) for office/clinic referral, 70% (46-80) for enrollment, and 75% (62-82) for program completion. The majority of programs utilized a hospital-based systematic referral, liaison-facilitated referral, or inpatient CR program referral (64%, 68%, and 60% of the time, respectively). Early appointments (<2 weeks) were utilized by 35%, and consistent phone call appointment reminders were utilized by 50% of programs. Quality improvement (QI) projects were performed by about half of CR programs. Measurement of participation rates was highly correlated with performing QI projects (P < .0001.) : Although programs are aware of participation rate gaps, the monitoring of participation rates is suboptimal, QI initiatives are infrequent, and proven strategies for increasing patient participation are inconsistently utilized. These issues likely contribute to the national CR participation gap and may prove to be useful targets for national QI initiatives.

Old boys' network in general practitioners' referral behavior?

PubMed

Hackl, Franz; Hummer, Michael; Pruckner, Gerald J

2015-09-01

We analyzed the impact of social networks on general practitioners' (GPs) referral behavior based on administrative panel data from 2,684,273 referrals to specialists made between 1998 and 2007. For the definition of social networks, we used information on the doctors' place and time of study and their hospital work history. We found that GPs referred more patients to specialists within their personal networks and that patients referred within a social network had fewer follow-up consultations and less inpatient days thereafter. The effects on patient outcomes (e.g. waiting periods, days in hospital) of referrals within personal networks and affinity-based networks differed. Specifically, whereas empirical evidence showed a concentration on high-quality specialists for referrals within the personal network, suggesting that referrals within personal networks overcome information asymmetry with respect to specialists' abilities, the empirical evidence for affinity-based networks was different and less clear. Same-gender networks tended to refer patients to low-quality specialists. Copyright © 2015 Elsevier B.V. All rights reserved.

Epidemiology of Pediatric Critical Care Transport in Northern Alberta and the Western Arctic.

PubMed

Kawaguchi, Atsushi; Nielsen, Charlene C; G Guerra, Gonzalo; Saunders, L Duncan; Yasui, Yutaka; DeCaen, Allan

2018-06-01

Specialized pediatric critical care transport teams are essential to pediatric retrieval systems. This study aims to describe the contemporary transports performed by a Canadian pediatric critical care transport team and to compare the treatment and outcomes of children referred from high-level care (hospitals offering pediatric services where an adult ICU exists) and nonhigh-level care (all other hospitals) hospitals. A descriptive cohort study. The Stollery Children's Hospital in Edmonton, Alberta, Western Canada. Children younger than 17 years old transported by the transport team from referral hospitals within the Stollery Children's Hospital catchment area to Stollery Children's Hospital between 1998 and 2015. None. Characteristics of transports, patient demographics presenting vital signs, and outcomes were described overall and compared by transport-related time and referral hospital types (high-level care and nonhigh-level care). In total, 3,352 transports met the inclusion criteria; 1,049 were retrieved from eight high-level care hospitals and 2,303 from 53 nonhigh-level care hospitals; the median one-way transport distance was 383 kilometers, and 70% of the transports were air transports. The annual number of transports has increased during the study period. The PICU admission rate was between 40% and 55%. Transports from high-level care hospitals had significantly higher odds of being admitted to the PICU (odds ratio, 1.96; 95% CI, 1.31-2.93). The odds of intubation at the referral hospital were higher in the high-level care group, but the odds of intubation upon PICU admission was similar between the two groups. Mortality during or after transport was not significantly different between high-level care and nonhigh-level care hospitals. The current transport system has multiple priorities with regard to efficiency and quality. The medical services at referral hospitals may affect the likelihood of PICU admission and subsequent PICU length of stay; however, no negative impact was observed in other outcomes including mortality.

Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal.

PubMed

Fleming, Matthew; King, Caroline; Rajeev, Sindhya; Baruwal, Ashma; Schwarz, Dan; Schwarz, Ryan; Khadka, Nirajan; Pande, Sami; Khanal, Sumesh; Acharya, Bibhav; Benton, Adia; Rogers, Selwyn O; Panizales, Maria; Gyorki, David; McGee, Heather; Shaye, David; Maru, Duncan

2017-09-25

Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems. We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization's Health Systems Framework. We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district's per capita income. We identified and mapped challenges according to the World Health Organization's Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity. The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.

Frequency, cost and impact of inter-island referrals in the Solomon Islands.

PubMed

Negin, Joel; Martiniuk, Alexandra L C; Farrell, Penny; Dalipanda, Tenneth

2012-01-01

Providing quality health services to people living in remote areas is central to global efforts to achieve universal access to health care. Effective referral systems are especially critical in resource-limited countries where small populations are separated by considerable distances, geographic challenges and the limitations of human resources for health. This study aimed to build an evidence base on inter-island referrals in the Solomon Islands, in particular regarding the number of referrals, reasons for referrals, and cost, to ultimately provide recommendations regarding referral practice effectiveness and efficiency. Data were taken from the referral database collected and maintained by the National Referral Hospital (NRH) in the capital, Honiara. Data included age, sex, ward or department visited, date of travel back to home port, home port and province. Data were available and included for 2008, 6 months of 2009, all of 2010 and 1 month of 2011; a total of 31 months. Travel costs were taken from NRH administrative information and included in the analysis. In addition, 10 qualitative interviews were conducted with clinicians and policy-makers in the tertiary hospital and one provincial hospital to gather information regarding inter-island referrals, their appropriateness and challenges faced. In the Solomon Islands, referrals from outer islands to the NRH are substantial and are gradually increasing over time. The two most populous provinces outside of the capital, Western and Malaita, represented 51% of all referrals in the study period. Of those referred, 21% were less than 15 years of age - even though 40% of the country's population is under 15 - with 30% being young adults of 15-24 years. Orthopaedic conditions comprised the largest number of referrals, with obstetric and gynaecological conditions a close second. The cost of referrals is rapidly increasing and was almost US$350,000 per year for the NRH alone. The amount budgeted for patient travel from the provinces to the NRH was a fraction of what is needed to cover the current number of referrals leading to a substantial budget shortfall. There did not appear to be a clear link between number of doctors in each province and the rate of referrals. Improving the appropriateness of referrals can have a substantial impact on access, quality of care and costs. Improvements in equipment in remote facilities, in human resources for health and in information technology can strengthen the quality of care in outer islands. Reducing the burden on referral facilities will allow them to provide appropriate care to those most in need while building public trust in all layers of the health system.

Improving neurosurgical communication and reducing risk and registrar burden using a novel online database referral platform.

PubMed

Matloob, Samir A; Hyam, Jonathan A; Thorne, Lewis; Bradford, Robert

2016-01-01

Documentation of urgent referrals to neurosurgical units and communication with referring hospitals is critical for effective handover and appropriate continuity of care within a tertiary service. Referrals to our neurosurgical unit were audited and we found that the majority of referrals were not documented and this led to more calls to the on-call neurosurgery registrar regarding old referrals. We implemented a new referral system in an attempt to improve documentation of referrals, communication with our referring hospitals and to professionalise the service we offer them. During a 14-day period, number of bleeps, missed bleeps, calls discussing new referrals and previously processed referrals were recorded. Whether new referrals were appropriately documented and referrers received a written response was also recorded. A commercially provided secure cloud-based data archiving telecommunications and database platform for referrals was subsequently introduced within the Trust and the questionnaire repeated during another 14-day period 1 year after implementation. Missed bleeps per day reduced from 16% (SD ± 6.4%) to 9% (SD ± 4.8%; df = 13, paired t-tests p = 0.007) and mean calls per day clarifying previous referrals reduced from 10 (SD ± 4) to 5 (SD ± 3.5; df = 13, p = 0.003). Documentation of new referrals increased from 43% (74/174) to 85% (181/210), and responses to referrals increased from 74% to 98%. The use of a secure cloud-based data archiving telecommunications and database platform significantly increased the documentation of new referrals. This led to fewer missed bleeps and fewer calls about old referrals for the on call registrar. This system of documenting referrals results in improved continuity of care for neurosurgical patients, a significant reduction in risk for Trusts and a more efficient use of Registrar time.

Reducing variation in general practitioner referral rates through clinical engagement and peer review of referrals: a service improvement project.

PubMed

Evans, Elizabeth; Aiking, Harry; Edwards, Adrian

2011-01-01

General practitioner (GP) referral rates to hospital services vary widely, without clearly identified explanatory factors, introducing important quality and patient safety issues. Referrals are rising everywhere year on year; some of these may be more appropriately redirected to lower technology services. To use peer review with consultant engagement to influence GPs to improve the quality and effectiveness of their referrals. Service development project. Ten out of 13 GP practices in Torfaen, Gwent; consultants from seven specialties in Gwent Healthcare NHS Trust; project designed and managed within Torfaen Local Health Board between 2008 and 2009. GPs discussed the appropriateness of referrals in selected specialties, including referral information and compatibility with local guidelines, usually on a weekly basis and were provided with regular feedback of 'benchmarked' referral rates. Six-weekly 'cluster groups', involving GPs, hospital specialists and community health practitioners discussed referral pathways and appropriate management in community based services. Overall there was a reduction in variation in individual GP referral rates (from 2.6-7.7 to 3.0-6.5 per 1000 patients per quarter) and a related reduction in overall referral rate (from 5.5 to 4.3 per 1000 patients per quarter). Both reductions appeared sustainable whilst the intervention continued, and referral rates rose in keeping with local trends once the intervention finished. This intervention appeared acceptable to GPs because of its emphasis on reviewing appropriateness and quality of referrals and was effective and sustainable while the investment in resources continued. Consultant involvement in discussions appeared important. The intervention's cost-effectiveness requires evaluation for consideration of future referral management strategies.

Hospital or general practice? Results of two experiments limiting the number of self referrals of patients with injuries to hospitals in The Netherlands.

PubMed Central

Sixma, H J; de Bakker, D H

1996-01-01

OBJECTIVE: To describe the results of two Dutch experiments aimed at limiting the number of self referrals to accident and emergency (A&E) departments of a newly opened hospital. METHODS: Basic design for both field experiments was a one group test-retest study, with the opening of a new hospital being the experimental factor. Data refer (1) to the number of patient contacts for acute somatic and non-somatic professional help with traumata and intoxications filled in on contact registration forms, and (2) to patient reports based on written questionnaires and interviews by telephone. RESULTS: Both studies show that it is possible to limit the number of self referrals, although it is important to be aware of possible side effects. The solution chosen in one of the cities, with patients visiting the A&E department being sent back to a general practitioner, was highly effective but resulted in a series of complaints from the public. This forced the authorities to abandon their original policy. The model chosen in the other city, with two specialized health centres serving as an alternative for the free A&E department of the new hospital, was somewhat less successful in preventing patients from going directly to a hospital, but was much more acceptable for the public. CONCLUSIONS: Both studies showed that controlling the number of self referrals to the A&E departments of hospitals is possible. However, the more rigid the model, the more difficult it will be to have this model accepted by patients. Based on arguments like cost-effectiveness, a better solution might be not to discourage people from going to the hospital with minor injuries, but to integrate primary health care (PHC) and hospital facilities. PMID:8832346

Impact of Institution of a Stroke Program upon Referral Bias at a Rural Academic Medical Center

ERIC Educational Resources Information Center

Riggs, Jack E.; Libell, David P.; Brooks, Claudette E.; Hobbs, Gerald R.

2005-01-01

Context: Referral bias reflecting the preferential hospital transfer of patients with intracerebral hemorrhage (ICH) has been demonstrated as the major contributing factor for an observed high nonrisk-adjusted in-hospital crude acute stroke mortality rate at a rural academic medical center. Purpose: This study was done to assess the impact of a…

Impact of Institution of a Stroke Program Upon Referral Bias at a Rural Academic Medical Center

ERIC Educational Resources Information Center

Riggs, Jack E.; Libell, David P.; Brooks, Claudette E.; Hobbs, Gerald R.

2005-01-01

Context: Referral bias reflecting the preferential hospital transfer of patients with intracerebral hemorrhage (ICH) has been demonstrated as the major contributing factor for an observed high nonrisk-adjusted in-hospital crude acute stroke mortality rate at a rural academic medical center. Purpose: This study was done to assess the impact of a…

A Financial Ratio Analysis of For-Profit and Non-Profit Rural Referral Centers

ERIC Educational Resources Information Center

McCue, Michael J.; Nayar, Preethy

2009-01-01

Context: National financial data show that rural referral center (RRC) hospitals have performed well financially. RRC hospitals' median cash flow margin ratio was 10.04% in 2002 and grew to 11.04% in 2004. Purpose: The aim of this study is to compare the ratio analysis of key operational and financial performance measures of for-profit RRCs to…

[The specialty clinical centers within the structure of the regional multi-specialty hospital].

PubMed

Fadeev, M G

2008-01-01

The analysis of the functioning of the regional referral clinical center of hand surgery, the eye injury center, the pediatric burns center and the neurosurgical center situated on the basis of large multi-field hospitals of the City of Ekaterinburg is presented. Such common conditions of their activity as experienced manpower availability and medical Academy chairs maintenance are revealed. The special referral clinical centers organized prior to the perstroyka and reformation, continue to function successfully providing high-tech medical care to the patients of the megapolis and to the inhabitants of the Sverdlovskaya Oblast. The effectiveness and perspectiveness of further functioning of the special referral clinical centers embedded into the structure of the municipal multi-field hospitals in the conditions of health reforms is demonstrated.

An agenda for change in referral--consensus from general practice.

PubMed Central

McColl, E; Newton, J; Hutchinson, A

1994-01-01

BACKGROUND. Wide variations in rates of referral from primary to secondary care have been a matter of concern for many years. Effective strategies for optimizing referral depend on doctors being able to understand what the influences on their referral behaviour are, as well as having the ability to identify priority areas for action and to develop strategies for pushing through effective measures. AIM. This study set out to ascertain general practitioners' priorities for change with respect to the referral process, and to set an agenda for change to be tackled by general practitioners, providers, policy makers and educationalists. METHOD. Through the use of the Delphi technique and focused interviews, general practitioners throughout Northumberland contributed to the consensus view. RESULTS. The main themes to emerge related to hospital waiting lists, open access, flow of information between secondary and primary care and general practitioners' knowledge and training. Ideas for implementing change included the production of directories of hospital services and the development of guidelines for the use of the term 'urgent' in referral letters. CONCLUSION. All of the proposed changes are manageable and share the burden between general practice and other professionals with an interest in the referral process. PMID:8185989

Achieving a competitive advantage through referral management.

PubMed

D'Amaro, R; Thomas, C S

1989-01-01

The physician remains the primary referral source in medical service. Referral patterns, in turn, reflect interactions between referring physicians and consultants which relate to quality of care, costs, and personal factors such as age and common training. Referrals initiated by patients relate to the desire to seek a second opinion and are heavily influenced by other family members. Alterations in the referral process are emerging due to cost escalation, the emergence of large payor groupings and aggregation of physicians into larger group settings. Strategies to manage the referral process include enhanced communications using new telecommunication technology and joint ventures with hospitals.

Audit of Childbirth Emergency Referrals by Trained Traditional Birth Attendants in Enugu, Southeast, Nigeria.

PubMed

Okafor, I I; Arinze-Onyia, S U; Ohayi, Sar; Onyekpa, J I; Ugwu, E O

2015-01-01

The essence of training traditional birth attendants (TBAs) is to attend to women in uncomplicated labor and to refer them immediately to hospitals when complications develop. The aim was to audit childbirth emergency referrals by trained TBAs to a specialist hospital in Enugu, Nigeria. A retrospective study of 205 childbirth emergencies referred to Semino Hospital and Maternity (SHM), Enugu by trained TBAs from August 1, 2011 to January 31, 2014. Data analysis was descriptive and inferential at 95% confidence level. Most of the patients (185/205, 90.2%) were married and (100/205, 48.8%) had earlier booked for antenatal care in formal health facilities. There were obstetric danger signs or previous bad obstetric histories (pregnancies with unfavorable outcome) in 110 (110/205, 53.7%) women on admission at SHM. One hundred and fifteen (115/205, 56.1%) women walked into the hospital by themselves while 50 (50/205, 24.39%) could not walk. The fetal heart sounds were normal in 94 (94/205, 45.6%), abnormal in 65 (65/205, 31.8%) and absent in 42 (42/205, 20.4%) of the women on admission. Five healthy babies were delivered by the TBAs before referring their mothers. Delays of more than 12 h had occurred in 155 (155/205, 76.6%) of the women before referrals. Prolonged labor (100/205, 48.8%), obstructed labor (40/205, 19.5%), attempted vaginal birth after previous cesarean delivery (40/205, 19.5%) and malpresentation (30/205, 14.6%) were the common indications for referrals. The maternal mortality and perinatal mortality ratios were 610/100,000 live births and 228/1000 total births respectively. Delays at TBA centers are common before referral and most patients are referred in poor clinical state. Further training and re-training of the TBAs with more emphasis on recognition of obstetric danger signs and bad obstetric histories may help in screening high-risk patients for prompt referral to hospitals before complications develop.

The impact of early specialist management on outcomes of patients with in-hospital stroke.

PubMed

Manawadu, Dulka; Choyi, Jithesh; Kalra, Lalit

2014-01-01

Delays in treatment of in-hospital stroke (IHS) adversely affect patient outcomes. We hypothesised that early referral and specialist management of IHS patients will improve outcomes at 90 days. Baseline characteristics, assessment delays, thrombolysis eligibility, 90-day functional outcomes and all-cause mortality were compared between IHS patients referred for specialist stroke management within 3 hours of symptom onset (early referrals) and later referrals. Patients were identified from a prospective stroke registry between January 2009 and December 2010. Inclusion criteria were primary admission with a non-stroke diagnosis, onset of new neurological deficits after admission and early ischaemic changes on CT or MR imaging. Eighty four (4.6%) of 1836 stroke patients had IHS (mean age 74 year; 51% male, median NIHSS score 10). There were no significant differences in baseline characteristics between 53 (63%) early and 31 (37%) late referrals. Thrombolysis was performed in 29 (76%) of the 37/78 (47%) potentially eligible patients; 7 patients were excluded because specialist referral was delayed beyond 4.5 hours despite symptom recognition within 3 hours of onset. Early referral improved functional outcomes (modified Rankin Scale 0-2 at 90 days 40% v 7%, p = 0.001) and was an independent predictor of mRS 0-2 at 90 days after adjusting for age, pre-morbid function, primary cause for hospital admission and stroke severity [OR 1.13 (95% C.I.  = 1.10-1.27), p = 0.002]. Early referral and specialist management of IHS patients that includes thrombolysis is associated with better functional outcomes at 90 days.

Reliability of abstracting performance measures: results of the cardiac rehabilitation referral and reliability (CR3) project.

PubMed

Thomas, Randal J; Chiu, Jensen S; Goff, David C; King, Marjorie; Lahr, Brian; Lichtman, Steven W; Lui, Karen; Pack, Quinn R; Shahriary, Melanie

2014-01-01

Assessment of the reliability of performance measure (PM) abstraction is an important step in PM validation. Reliability has not been previously assessed for abstracting PMs for the referral of patients to cardiac rehabilitation (CR) and secondary prevention (SP) programs. To help validate these PMs, we carried out a multicenter assessment of their reliability. Hospitals and clinical practices from around the United States were invited to participate in the Cardiac Rehabilitation Referral Reliability (CR3) Project. Twenty-nine hospitals and 23 outpatient centers expressed interest in participating. Seven hospitals and 6 outpatient centers met participation criteria and submitted completed data. Site coordinators identified 35 patients whose charts were reviewed by 2 site abstractors twice, 1 week apart. Percent agreement and the Cohen κ statistic were used to describe intra- and interabstractor reliability for patient eligibility for CR/SP, patient exceptions for CR/SP referral, and documented referral to CR/SP. Results were obtained from within-site data, as well as from pooled data of all inpatient and all outpatient sites. We found that intra-abstractor reliability reflected excellent repeatability (≥ 90% agreement; κ ≥ 0.75) for ratings of CR/SP eligibility, exceptions, and referral, both from pooled and site-specific analyses of inpatient and outpatient data. Similarly, the interabstractor agreement from pooled analysis ranged from good to excellent for the 3 items, although with slightly lower measures of reliability. Abstraction of PMs for CR/SP referral has high reliability, supporting the use of these PMs in quality improvement initiatives aimed at increasing CR/SP delivery to patients with cardiovascular disease.

Interpretations of referral appropriateness by senior health managers in five PCT areas in England: a qualitative investigation.

PubMed

Blundell, N; Clarke, Aileen; Mays, N

2010-06-01

To explore interpretations of "appropriate" and "inappropriate" elective referral from primary to secondary surgical care among senior clinical and non-clinical managers in five purposively sampled primary care trusts (PCTs) and their main associated acute hospitals in the English National Health Service (NHS). Semi-structured face-to-face interviews were undertaken with senior managerial staff from clinical and non-clinical backgrounds. Interviews were tape-recorded, transcribed and analysed according to the Framework approach developed at the National Centre for Social Research using N6 (NUD*IST6) qualitative data analysis software. Twenty-two people of 23 approached were interviewed (between three and five respondents per PCT and associated acute hospital). Three attributes relating to appropriateness of referral were identified: necessity: whether a patient with given characteristics was believed suitable for referral; destination or level: where or to whom a patient should be referred; and quality (or process): how a referral was carried out, including (eg, investigations undertaken before referral, information contained in the referral and extent of patient involvement in the referral decision. Attributes were hierarchical. "Necessity" was viewed as the most fundamental attribute, followed by "destination" and, finally, "quality". In general, but not always, all three attributes were perceived as necessary for a referral to be defined as appropriate. For senior clinical and non-clinical managers at the local level in the English NHS, three hierarchical attributes (necessity, appropriateness of destination and quality of referral process) contributed to the overall concept of appropriateness of referral from primary to secondary surgical care.

Fundholders' referral patterns and perceptions of service quality in hospital provision of elective general surgery.

PubMed Central

Whynes, D K; Reed, G

1994-01-01

BACKGROUND. The introduction of fundholding established an internal market in public sector health care, involving purchasers and providers contracting for the supply of health care. AIM. This study set out to examine fundholders' hospital referral patterns, and to evaluate the quality of the service provided to patients undergoing elective general surgery, as perceived by fundholding general practitioners. METHOD. A questionnaire was posted to the senior partners of all fundholding practices in the Trent Regional Health Authority area. This questionnaire requested assessments of the importance of 13 specified aspects of service quality and the quality of provision by general practitioners' most frequently-used hospitals. Five-point scales were employed in each case. Respondents were asked to provide additional details about their practice. RESULTS. A 67% response rate was achieved. Confidence in the consultant's ability, short waiting times and informative feedback from the providers emerged as the most important elements in referral decisions, while the cost of treatment and patient convenience received lower importance ratings. In terms of how well their providers were seen to perform, fundholders ranked confidence in the consultant and patient convenience highest, and style of hospital management lowest. The majority of referrals seemed to be local. CONCLUSION. Judged in terms of fundholders' perceptions, sizeable variations in service quality between hospital providers of general surgery are evident. PMID:7748666

Shifting hospital care to primary care: An evaluation of cardiology care in a primary care setting in the Netherlands.

PubMed

Quanjel, Tessa C C; Struijs, Jeroen N; Spreeuwenberg, Marieke D; Baan, Caroline A; Ruwaard, Dirk

2018-05-09

In an attempt to deal with the pressures on the healthcare system and to guarantee sustainability, changes are needed. This study is focused on a cardiology Primary Care Plus intervention in which cardiologists provide consultations with patients in a primary care setting in order to prevent unnecessary referrals to the hospital. This study explores which patients with non-acute and low-complexity cardiology-related health complaints should be excluded from Primary Care Plus and referred directly to specialist care in the hospital. This is a retrospective observational study based on quantitative data. Data collected between January 1 and December 31, 2015 were extracted from the electronic medical record system. Logistic regression analyses were used to select patient groups that should be excluded from referral to Primary Care Plus. In total, 1525 patients were included in the analyses. Results showed that male patients, older patients, those with the referral indication 'Stable Angina Pectoris' or 'Dyspnoea' and patients whose reason for referral was 'To confirm disease' or 'Screening of unclear pathology' had a significantly higher probability of being referred to hospital care after Primary Care Plus. To achieve efficiency one should exclude patient groups with a significantly higher probability of being referred to hospital care after Primary Care Plus. NTR6629 (Data registered: 25-08-2017) (registered retrospectively).

Medicare managed care plan performance: a comparison across hospitalization types.

PubMed

Basu, Jayasree; Mobley, Lee Rivers

2012-01-01

The study evaluates the performance of Medicare managed care (Medicare Advantage [MA]) Plans in comparison to Medicare fee-for-service (FFS) Plans in three states with historically high Medicare managed care penetration (New York, California, Florida), in terms of lowering the risks of preventable or ambulatory care sensitive conditions (ACSC) hospital admissions and providing increased referrals for admissions for specialty procedures. Using 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP-SID) of the Agency for Healthcare Research and Quality, ACSC admissions are compared with 'marker' admissions and 'referral-sensitive' admissions, using a multinomial logistic regression approach. The year 2004 represents a strategic time to test the impact of MA on preventable hospitalizations, because the HMOs dominated the market composition in that time period. MA enrollees in California experienced 22% lower relative risk (RRR= 0.78, p<0.01), those in Florida experienced 16% lower relative risk (RRR= 0.84, p<0.01), while those in New York experienced 9% lower relative risk (RRR=0.91, p<0.01) of preventable (versus marker) admissions compared to their FFS counterparts. MA enrollees in New York experienced 37% higher relative risk (RRR=1.37, p<0.01) and those in Florida had 41% higher relative risk (RRR=1.41, p<0.01)-while MA enrollees in California had 13% lower relative risk (RRR=0.87, p<0.01)-of referral-sensitive (versus marker) admissions compared to their FFS counterparts. While MA plans were associated with reductions in preventable hospitalizations in all three states, the effects on referral-sensitive admissions varied, with California experiencing lower relative risk of referral-sensitive admissions for MA plan enrollees. The lower relative risk of preventable admissions for MA plan enrollees in New York and Florida became more pronounced after accounting for selection bias.

Dysphagia referrals to a district general hospital gastroenterology unit: hard to swallow.

PubMed

Melleney, Elizabeth Mary-Ann; Subhani, Javaid Mohammed; Willoughby, Charles Peter

2004-01-01

The aim of our study was to audit dysphagia referrals received by a specialist gastroenterology unit during an entire year. We used a prospective audit carried out over a 12-month period at the District General Hospital gastroenterology unit. The audit included 396 consecutive patients who were referred with swallowing difficulties. We found that 60 referrals (15.2%) were inaccurate and the patients had no swallowing problem. Of the 336 patients with genuine dysphagia, only 29 (8.6%) were new cancer cases. The large majority of subjects had benign disease mostly related to acid reflux. Weight loss was significantly associated with malignancy but also occurred in one third of patients with reflux alone. The temporal pattern of dysphagia was not significantly predictive of cancer. All the cancer patients were above the age of 50 years. Although patients were in general assessed rapidly after hospital referral, the productivity, in terms of early tumor diagnosis, was extremely low. We conclude that there is a substantial rate of inaccurate referrals of dysphagia patients. Most true cases of swallowing difficulty relate to benign disease. Even the devotion of considerable resources to the early diagnosis of esophago gastric malignancy in an attempt to conform with best practice guidelines results in a very low success rate in terms of the detection of potentially curable tumors.

General practitioners' referrals to specialist outpatient clinics. II. Locations of specialist outpatient clinics to which general practitioners refer patients.

PubMed Central

Coulter, A.; Noone, A.; Goldacre, M.

1989-01-01

Although linkage by computer of hospital administration systems across all clinics in a health district is becoming a practical possibility, complete records of general practitioners' referrals to outpatient clinics will be difficult to achieve. Data from a large study of general practitioners' referrals to such clinics were used to calculate the proportion of referrals that crossed district boundaries, the proportion that were made to the private sector; and the number of locations that each practice referred patients to. Of the 17,601 referrals from practices in Oxford Regional Health Authority, 13,857 (78.7%) were made to NHS outpatient clinics within practices' own districts, 1524 (8.7%) to clinics in other districts in the same region, 420 (2.4%) to NHS clinics in other regions, and 1800 (10.2%) to the private sector; but these proportions varied considerably among the practices. The mean number of different NHS hospitals or clinics that each practice referred patients to was 15.8 (range 4-42). PMID:2504414

Selection of a cardiac surgery provider in the managed care era.

PubMed

Shahian, D M; Yip, W; Westcott, G; Jacobson, J

2000-11-01

Many health planners promote the use of competition to contain cost and improve quality of care. Using a standard econometric model, we examined the evidence for "value-based" cardiac surgery provider selection in eastern Massachusetts, where there is significant competition and managed care penetration. McFadden's conditional logit model was used to study cardiac surgery provider selection among 6952 patients and eight metropolitan Boston hospitals in 1997. Hospital predictor variables included beds, cardiac surgery case volume, objective clinical and financial performance, reputation (percent out-of-state referrals, cardiac residency program), distance from patient's home to hospital, and historical referral patterns. Subgroup analyses were performed for each major payer category. Distance from patient's home to hospital (odds ratio 0.90; P =.000) and the historical referral pattern from each patient's hometown (z = 45.305; P =.000) were important predictors in all models. A cardiac surgery residency enhanced the probability of selection (odds ratio 5.25; P =.000), as did percent out-of-state referrals (odds ratio 1.10; P =.001). Higher mortality rates were associated with decreased probability of selection (odds ratio 0.51; P =.027), but higher length of stay was paradoxically associated with greater probability (odds ratio 1.72; P =.000). Total hospital costs were irrelevant (odds ratio 1.00; P =.179). When analyzed by payer subgroup, Medicare patients appeared to select hospitals with both low mortality (odds ratio 0.43; P =.176) and short length of stay (odds ratio 0.76; P =.213), although the results did not achieve statistical significance. The commercial managed care subgroup exhibited the least "value-based" behavior. The odds ratio for length of stay was the highest of any group (odds ratio = 2.589; P =.000) and there was a subset of hospitals for which higher mortality was actually associated with greater likelihood of selection. The observable determinants of cardiac surgery provider selection are related to hospital reputation, historical referral patterns, and patient proximity, not objective clinical or cost performance. The paradoxic behavior of commercial managed care probably results from unobserved choice factors that are not primarily based on objective provider performance.

[Correct and timely referral of patients to centers of reference].

PubMed

Costa, Joana; Valença-Filipe, Rita; Rodrigues, Jorge

2013-01-01

The correct and timely referral of patients, from peripheral hospitals, without specialized surgical care, namely in hand surgery, like Plastic Surgery or Orthopedics is of crucial importance. The authors report the case of a patient that presents in the Plastic Surgery Department with a chronic infection of the hypothenar eminence of the right hand. The clinical history suggests the persistence of a foreign body, despite two previous surgical procedures for removal, performed in the residence hospital. Surgical exploration was performed and the foreign body was removed without complications. The intent of this presentation is to alert for the importance of the timely referral of patients that can benefit of specialized care, namely of plastic surgery, when this is no possible in the residence hospital, in view of better health care and better patient treatment.

Can National Healthcare-Associated Infections (HAIs) Data Differentiate Hospitals in the United States?

PubMed

Masnick, Max; Morgan, Daniel J; Sorkin, John D; Macek, Mark D; Brown, Jessica P; Rheingans, Penny; Harris, Anthony D

2017-10-01

OBJECTIVE To determine whether patients using the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website (http://medicare.gov/hospitalcompare) can use nationally reported healthcare-associated infection (HAI) data to differentiate hospitals. DESIGN Secondary analysis of publicly available HAI data for calendar year 2013. METHODS We assessed the availability of HAI data for geographically proximate hospitals (ie, hospitals within the same referral region) and then analyzed these data to determine whether they are useful to differentiate hospitals. We assessed data for the 6 HAIs reported by hospitals to the Centers for Disease Control and Prevention (CDC). RESULTS Data were analyzed for 4,561 hospitals representing 88% of registered community and federal government hospitals in the United States. Healthcare-associated infection data are only useful for comparing hospitals if they are available for multiple hospitals within a geographic region. We found that data availability differed by HAI. Clostridium difficile infections (CDI) data were most available, with 82% of geographic regions (ie, hospital referral regions) having >50% of hospitals reporting them. In contrast, 4% of geographic regions had >50% of member hospitals reporting surgical site infections (SSI) for hysterectomies, which had the lowest availability. The ability of HAI data to differentiate hospitals differed by HAI: 72% of hospital referral regions had at least 1 pair of hospitals with statistically different risk-adjusted CDI rates (SIRs), compared to 9% for SSI (hysterectomy). CONCLUSIONS HAI data generally are reported by enough hospitals to meet minimal criteria for useful comparisons in many geographic locations, though this varies by type of HAI. CDI and catheter-associated urinary tract infection (CAUTI) are more likely to differentiate hospitals than the other publicly reported HAIs. Infect Control Hosp Epidemiol 2017;38:1167-1171.

Cambridge community Optometry Glaucoma Scheme.

PubMed

Keenan, Jonathan; Shahid, Humma; Bourne, Rupert R; White, Andrew J; Martin, Keith R

2015-04-01

With a higher life expectancy, there is an increased demand for hospital glaucoma services in the United Kingdom. The Cambridge community Optometry Glaucoma Scheme (COGS) was initiated in 2010, where new referrals for suspected glaucoma are evaluated by community optometrists with a special interest in glaucoma, with virtual electronic review and validation by a consultant ophthalmologist with special interest in glaucoma. 1733 patients were evaluated by this scheme between 2010 and 2013. Clinical assessment is performed by the optometrist at a remote site. Goldmann applanation tonometry, pachymetry, monoscopic colour optic disc photographs and automated Humphrey visual field testing are performed. A clinical decision is made as to whether a patient has glaucoma or is a suspect, and referred on or discharged as a false positive referral. The clinical findings, optic disc photographs and visual field test results are transmitted electronically for virtual review by a consultant ophthalmologist. The number of false positive referrals from initial referral into the scheme. Of the patients, 46.6% were discharged at assessment and a further 5.7% were discharged following virtual review. Of the patients initially discharged, 2.8% were recalled following virtual review. Following assessment at the hospital, a further 10.5% were discharged after a single visit. The COGS community-based glaucoma screening programme is a safe and effective way of evaluating glaucoma referrals in the community and reducing false-positive referrals for glaucoma into the hospital system. © 2014 Royal Australian and New Zealand College of Ophthalmologists.

Interim Results of a National Test of the Rapid Assessment of Hospital Procurement Barriers in Donation (RAPiD)

PubMed Central

Traino, H. M.; Alolod, G. P.; Shafer, T.; Siminoff, L. A.

2012-01-01

Organ donation remains a major public health challenge with over 114 000 people on the waitlist in the United States. Among other factors, extant research highlights the need to improve the identification and timely referral of potential donors by hospital health-care providers (HCPs) to organ procurement organizations (OPOs). We implemented a national test of the Rapid Assessment of hospital Procurement barriers in Donation (RAPiD) to identify assets and barriers to the organ donation and patient referral processes; assess hospital–OPO relationships and offer tailored recommendations for improving these processes. Having partnered with seven OPOs, data were collected at 70 hospitals with high donor potential in the form of direct observations and interviews with 2358 HCPs. We found that donation attitudes and knowledge among HCPs were high, but use of standard referral criteria was lacking. Significant differences were found in the donation-related attitudes, knowledge and behaviors of physicians and emergency department staff as compared to other staff in intensive care units with high organ donor potential. Also, while OPO staff were generally viewed positively, they were often perceived as outsiders rather than members of healthcare teams. Recommendations for improving the referral and donation processes are discussed. PMID:22900761

Brief surgical procedure code lists for outcomes measurement and quality improvement in resource-limited settings.

PubMed

Liu, Charles; Kayima, Peter; Riesel, Johanna; Situma, Martin; Chang, David; Firth, Paul

2017-11-01

The lack of a classification system for surgical procedures in resource-limited settings hinders outcomes measurement and reporting. Existing procedure coding systems are prohibitively large and expensive to implement. We describe the creation and prospective validation of 3 brief procedure code lists applicable in low-resource settings, based on analysis of surgical procedures performed at Mbarara Regional Referral Hospital, Uganda's second largest public hospital. We reviewed operating room logbooks to identify all surgical operations performed at Mbarara Regional Referral Hospital during 2014. Based on the documented indication for surgery and procedure(s) performed, we assigned each operation up to 4 procedure codes from the International Classification of Diseases, 9th Revision, Clinical Modification. Coding of procedures was performed by 2 investigators, and a random 20% of procedures were coded by both investigators. These codes were aggregated to generate procedure code lists. During 2014, 6,464 surgical procedures were performed at Mbarara Regional Referral Hospital, to which we assigned 435 unique procedure codes. Substantial inter-rater reliability was achieved (κ = 0.7037). The 111 most common procedure codes accounted for 90% of all codes assigned, 180 accounted for 95%, and 278 accounted for 98%. We considered these sets of codes as 3 procedure code lists. In a prospective validation, we found that these lists described 83.2%, 89.2%, and 92.6% of surgical procedures performed at Mbarara Regional Referral Hospital during August to September of 2015, respectively. Empirically generated brief procedure code lists based on International Classification of Diseases, 9th Revision, Clinical Modification can be used to classify almost all surgical procedures performed at a Ugandan referral hospital. Such a standardized procedure coding system may enable better surgical data collection for administration, research, and quality improvement in resource-limited settings. Copyright © 2017 Elsevier Inc. All rights reserved.

Physician self-referral and physician-owned specialty facilities.

PubMed

Casalino, Lawrence P

2008-06-01

Physician self-referral ranges from suggesting a follow-up appointment, to sending a patient to a facility in which the doctor has an ownership interest or financial relationship. Physician referral to facilities in which the physicians have an ownership interest is becoming increasingly common and not always medically appropriate. This Synthesis reviews the evidence on physician self-referral arrangements, their effect on costs and utilization, and their effect on general hospitals. Key findings include: the rise in self-referral is sparked by financial, regulatory and clinical incentives, including patient convenience and doctors trying to preserve their income in the changing health care landscape. Strong evidence suggests self-referral leads to increased usage of health care services; but there is insufficient evidence to determine whether this increased usage reflects doctors meeting an unmet need or ordering clinically inappropriate care. The more significant a physician's financial interest in a facility, the more likely the doctor is to refer patients there. Arrangements through which doctors receive fees for patient referrals to third-party centers, such as "pay-per-click," time-share, and leasing arrangements, do not seem to offer benefits beyond increasing physician income. So far, the profit margins of general hospitals have not been harmed by the rise in doctor-owned facilities.

Safe transport from a specialist paediatric intensive care unit to a referral hospital.

PubMed

Solomon, Jennifer; Clarke, Dave

2009-12-01

There are 23 paediatric intensive care units (PICU) in the UK and 19 of these have a retrieval team responsible for the safe and uneventful transfer of critically ill children from referring hospitals. There are two established PICUs in University Hospitals of Leicester (UHL) NHS Trust that work as a team. In 2001, a transfer service was introduced to support the UHL PICU retrieval service and the referring district general hospitals. At the time of writing this article there was no other PICU in the UK providing a dedicated paediatric clinical transport nurse service, whose main responsibility is the safe transfer of infants and children back to their local hospitals. This article will discuss the development of this service and the benefits to PICU and referral hospitals.

Performance of CT examinations in children with suspected acute appendicitis in the community setting: a need for more education.

PubMed

Kim, Michael E; Orth, Robert C; Fallon, Sara C; Lopez, Monica E; Brandt, Mary L; Zhang, Wei; Bisset, George S

2015-04-01

Despite a recent focus on the preferential use of ultrasound over CT for pediatric appendicitis, most children transferred from community hospitals still undergo diagnostic CT scans. The purpose of this study was to evaluate CT techniques performed for children with acute appendicitis at nonpediatric treatment centers. All patients treated for acute appendicitis at our tertiary-care pediatric hospital from July 1, 2011, through June 30, 2012, were identified. Patient demographics, imaging modality used to diagnoses appendicitis (CT or ultrasound), location (home or referral institution), and CT technique parameters were collected. The estimated mean organ radiation dose, number of imaging phases, and use of contrast media were evaluated at home and referral institutions. During the study period, 1215 patients underwent appendectomies after imaging, with 442 (36.4%) imaged at referral facilities. Most referral patients received a diagnosis by CT (n=384, 87%), compared with 73 of 773 (9.4%) who received a diagnosis by CT at the home institution. The estimated mean (±SD) organ radiation dose was not statistically significantly different between home and referral institutions (13.5±7.3 vs 12.9±6.4 mGy; p=0.58) for single-phase examinations. Of 384 referral patients, 344 had images available for review. In total, 40% (138/344) of patients from referral centers were imaged with suboptimal CT techniques: 50 delayed phase only, 52 dual phase (eight of which were imaged twice in delayed phase), eight triple phase, and 36 without IV contrast agent. CT parameters and radiation doses from single-phase examinations in children with appendicitis were similar at nonpediatric treatment centers and a tertiary care children's hospital. Future educational outreach should focus on optimizing other technical parameters.

Rationing of hip and knee referrals in the public hospital: the true unmet need.

PubMed

Inglis, Tom; Armour, Paul; Inglis, Grahame; Hooper, Gary

2017-03-24

The aim of this paper is to outline the development of a triage system for elective hip and knee referrals to the Orthopaedic Department of the Canterbury District Health Board (CDHB), and to determine the unmet need within this population for accessing first specialist assessment (FSA). Between 1 August 2015 and 31 March 2016 data was collected from all elective hip and knee referrals that underwent triage for a FSA. The number of outpatient appointments available according to the government four-month waiting time is set by the CDHB. Patients were triaged by two consultant surgeons on the basis of their referral letter and radiological imaging into one of five categories: accepted for FSA, insufficient information, no capacity, low priority or direct entry to waiting list (if already seen by a specialist). Those not accepted for an FSA were returned to general practitioner (GP) care. During the study period there were 1,733 referrals (838 hip related referrals and 895 knee related referrals) to the orthopaedic department with a request for FSA. All patients had failed conservative management. Of these referrals 43% of hip and 54% of knee related referrals could not be offered an FSA and were returned, following triage, to general practitioner care unseen. Only 8% and 9% respectively were declined for insufficient information in the referral letter or lack of need. This study details the implementation of a triage system for elective hip and knee referrals to the CDHB and with accurate data we have been able to determine the large number of patients unable to access a specialist opinion. These patients represent the unmet need within our community and highlights the degree of rationing taking place within the public hospital.

Time-series analysis of the barriers for admission into a spinal rehabilitation unit.

PubMed

New, P W; Akram, M

2016-02-01

This is a prospective open-cohort case series. The objective of this study was to assess changes over time in the duration of key acute hospital process barriers for patients with spinal cord damage (SCD) from admission until transfer into spinal rehabilitation unit (SRU) or other destinations. The study was conducted in Acute hospitals, Victoria, Australia (2006-2013). Duration of the following discrete sequential processes was measured: acute hospital admission until referral to SRU, referral until SRU assessment, SRU assessment until ready for SRU transfer and ready for transfer until SRU admission. Time-series analysis was performed using a generalised additive model (GAM). Seasonality of non-traumatic spinal cord dysfunction (SCDys) was examined. GAM analysis shows that the waiting time for admission into SRU was significantly (P<0.001) longer for patients who were female, who had tetraplegia, who were motor complete, had a pelvic pressure ulcer and who were referred from another health network. Age had a non-linear effect on the duration of waiting for transfer from acute hospital to SRU and both the acute hospital and SRU length of stay (LOS). The duration patients spent waiting for SRU admission increased over the study period. There was an increase in the number of referrals over the study period and an increase in the number of patients accepted but not admitted into the SRU. There was no notable seasonal influence on the referral of patients with SCDys. Time-series analysis provides additional insights into changes in the waiting times for SRU admission and the LOS in hospital for patients with SCD.

The “jaundice hotline” for the rapid assessment of patients with jaundice

PubMed Central

Mitchell, Jonathan; Hussaini, Hyder; McGovern, Dermot; Farrow, Richard; Maskell, Giles; Dalton, Harry

2002-01-01

Problem Patients with jaundice require rapid diagnosis and treatment, yet such patients are often subject to delay. Design An open referral, rapid access jaundice clinic was established by reorganisation of existing services and without the need for significant extra resources. Background and setting A large general hospital in a largely rural and geographically isolated area. Key measures for improvement Waiting times for referral, consultation, diagnosis, and treatment, length of stay in hospital, and general practitioners' and patients' satisfaction with the service. Strategies for change Referrals were made through a 24 hour telephone answering machine and fax line. Initial assessment of patients was carried out by junior staff as part of their working week. Dedicated ultrasonography appointments were made available. Effects of change Of 107 patients seen in the first year of the service, 62 had biliary obstruction. The mean time between referral and consultation was 2.5 days. Patients who went on to endoscopic retrograde cholangiopancreatography waited 5.7 days on average. The mean length of stay in hospital in the 69 patients who were admitted was 6.1 days, compared with 11.5 days in 1996, as shown by audit data. Nearly all the 36 general practices (95%) and the 30 consecutive patients (97%) that were surveyed rated the service as above average or excellent. Lessons learnt An open referral, rapid access service for patients with jaundice can shorten time to diagnosis and treatment and length of stay in hospital. These improvements can occur through the reorganisation of existing services and with minimal extra cost. PMID:12142314

Comparing policies for children of parents attending hospital emergency departments after intimate partner violence, substance abuse or suicide attempt.

PubMed

Hoytema van Konijnenburg, Eva M M; Diderich, Hester M; Teeuw, Arianne H; Klein Velderman, Mariska; Oudesluys-Murphy, Anne Marie; van der Lee, Johanna H

2016-03-01

To improve identification of child maltreatment, a new policy ('Hague protocol') was implemented in hospitals in The Netherlands, stating that adults attending the hospital emergency department after intimate partner violence, substance abuse or a suicide attempt should be asked whether they care for children. If so, these children are referred to the Reporting Center for Child Abuse and Neglect (RCCAN), for assessment and referrals to support services. An adapted, hospital-based version of this protocol ('Amsterdam protocol') was implemented in another region. Children are identified in the same manner, but, instead of a RCCAN referral, they are referred to the pediatric outpatient department for an assessment, including a physical examination, and referrals to services. We compared results of both protocols to assess how differences between the protocols affect the outcomes on implementation, detection of child maltreatment and referrals to services. Furthermore, we assessed social validity and results of a screening physical examination. We included 212 families from the Amsterdam protocol (cohort study with reports by pediatric staff and parents) and 565 families from the Hague protocol (study of RCCAN records and telephone interviews with parents). We found that the RCCAN identified more maltreatment than pediatric staff (98% versus at least 51%), but referrals to services were similar (82% versus 80% of the total sample) and parents were positive about both interventions. Physical examination revealed signs of maltreatment in 5%. We conclude that, despite the differences, both procedures can serve as suitable methods to identify and refer children at risk for maltreatment. Copyright © 2015 Elsevier Ltd. All rights reserved.

Unravelling referral paths relating to the dental care of children: a study in Liverpool.

PubMed

Harris, Rebecca V; Pender, Susan M; Merry, Alison; Leo, Anthony

2008-04-01

To describe primary care referral networks relating to children's dental care and the main influences on referral decisions taken by dentists working in a primary care setting. A postal questionnaire to all 130 general dental practitioners (GDPs) in contract with Primary Care Trusts (PCTs), and 24 Community Dental Service (CDS) dentists in Liverpool. Characteristics of patient groups and factors influencing the choice of referral pathway of children referred from primary dental care. There were good responses rates (110 [85%] GDPs and 22 [92%] CDS dentists). The two main reasons why GDPs referred children to hospitals were (a) for treatment under general anaesthetic (GA) or relative analgesia (RA) and (b) for restorative care of dentally anxious children. GDPs also referred anxious children requiring simple restorative care and/or RA to the CDS. Only eight GDPs (7%) cited a lack of experience as a reason for referral of dentally anxious children for simple restorative care, compared to 53 (48%) who cited a lack of RA facilities, and 25 (23%) who cited financial considerations. GDPs refer children to both hospital services and the CDS, and identify a lack of RA facilities and economic pressures as key reasons for referral.

Data collection as the first step in program development: the experience of a chronic care palliative unit.

PubMed

Munn, B; Worobec, F

1997-01-01

This retrospective descriptive study of 73 patients who died in St. Peter's Hospital examines and contrasts the patients profile and referral sources of a palliative care unit in a chronic care hospital over two six-month periods during 1994 and 1995. Shortened length of stay (83.8 and 43.2 days respectively), documentation issues, CPR practices (CPR was desired by seven patients up to the time of death), and lack of referrals from long-term care facilities have led St. Peter's Hospital to ask further questions of its palliative care program, e.g. given the lack of referrals from long-term care facilities, how is palliative care being managed in this sector? In Ontario, palliative care has been placed under the domain of chronic care and program development depends in part on the knowledge of the population it serves. This study is a first step.

Contracting between public agencies and private psychiatric inpatient facilities.

PubMed

Fisher, W H; Dorwart, R A; Schlesinger, M; Davidson, H

1991-08-01

Purchasing human services through contracts with private providers has become an increasingly common practice over the past 20 years. Using data from a national survey of psychiatric inpatient facilities, this paper examines the extent to which psychiatric units in privately controlled general hospitals and private psychiatric specialty hospitals (N = 611) participate in contractual arrangements to provide services to governmental bodies. It also examines how the likelihood of such a practice is affected by hospital characteristics (general or specialty, for profit or nonprofit) and features of hospitals' environments, including the competitiveness of the market for psychiatric inpatient care and the population's need for services in the hospital's county. The findings indicate that nonprofit psychiatric specialty hospitals were more likely than other types of hospitals to enter into such contracts, and that forces such as local competition and need for services were not predictors of such involvement. Contracting was shown to have a significant impact on the level of referrals a hospital accepted, but these levels were also affected by competition and need. Among hospitals with public contracts, referral acceptance from public agencies was unaffected by these factors, but they did have a significant effect on referral acceptance by hospitals without public contracts. These data suggest that public agencies contracting for services with private hospitals may represent a means by which "public sector" patients may gain access to private providers. Further, this mechanism may impose sufficient structure and regulation on the acceptance of such patients that many concerns of hospital administrators regarding patients who are costly and difficult to treat and discharge can be allayed.

Organizing uninsured safety-net access to specialist physician services.

PubMed

Hall, Mark A

2013-05-01

Arranging referrals for specialist services is often the greatest difficulty that safety-net access programs face in attempting to provide fairly comprehensive services for the uninsured. When office-based community specialists are asked to care for uninsured patients, they cite the following barriers: difficulty determining which patients merit charity care, having to arrange for services patients need from other providers, and concerns about liability for providing inadequate care. Solutions to these barriers to specialist access can be found in the same institutional arrangements that support primary care and hospital services for the uninsured. These safety-net organization structures can be extended to include specialist physician care by funding community health centers to contract for specialist referrals, using free-standing referral programs to subsidize community specialists who accept uninsured patients at discounted rates, and encouraging hospitals through tax exemption or disproportionate share funding to require specialists on their medical staffs to accept an allocation of uninsured office-based referrals.

Smart phones make smart referrals: The use of mobile phone technology in burn care - A retrospective case series.

PubMed

den Hollander, Daan; Mars, Maurice

2017-02-01

Telemedicine using cellular phones allows for real-time consultation of burn patients seen at distant hospitals. Telephonic consultations to our unit have required completion of a proforma, to ensure collection of the following information: demographics, mechanism of injury, vital signs, relevant laboratory data, management at the referring hospital and advice given by the burn team. Since December 2014 we have required referring doctors to send photographs of the burn wounds to the burns specialist before making a decision on acceptance of the referral or providing management advice. The photographs are taken and sent by smartphone using MMS or WhatsApp. The cases, with photographs, are entered into a database of telemedicine consultations which we have retrospectively reviewed. During the study period (December 2014-July 2015) we were consulted about 119 patients, in 100 of whom the telemedicine consultation was completed. Inappropriate transfer to the burns centre was avoided in 38% of cases, and in 28% a period of treatment in the referral hospital was advised before transfer. For a total of 66% of patients the telemedicine consultation changed, and either avoided an inappropriate admission, or delayed admission in late referrals until the patient was ready for definitive treatment. We conclude that telemedicine consultations using a cellular phone significantly change referral pathways in burns. Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.

Audit of Childbirth Emergency Referrals by Trained Traditional Birth Attendants in Enugu, Southeast, Nigeria

PubMed Central

Okafor, II; Arinze-Onyia, SU; Ohayi, SAR; Onyekpa, JI; Ugwu, EO

2015-01-01

Background: The essence of training traditional birth attendants (TBAs) is to attend to women in uncomplicated labor and to refer them immediately to hospitals when complications develop. Aim: The aim was to audit childbirth emergency referrals by trained TBAs to a specialist hospital in Enugu, Nigeria. Subjects and Methods: A retrospective study of 205 childbirth emergencies referred to Semino Hospital and Maternity (SHM), Enugu by trained TBAs from August 1, 2011 to January 31, 2014. Data analysis was descriptive and inferential at 95% confidence level. Results: Most of the patients (185/205, 90.2%) were married and (100/205, 48.8%) had earlier booked for antenatal care in formal health facilities. There were obstetric danger signs or previous bad obstetric histories (pregnancies with unfavorable outcome) in 110 (110/205, 53.7%) women on admission at SHM. One hundred and fifteen (115/205, 56.1%) women walked into the hospital by themselves while 50 (50/205, 24.39%) could not walk. The fetal heart sounds were normal in 94 (94/205, 45.6%), abnormal in 65 (65/205, 31.8%) and absent in 42 (42/205, 20.4%) of the women on admission. Five healthy babies were delivered by the TBAs before referring their mothers. Delays of more than 12 h had occurred in 155 (155/205, 76.6%) of the women before referrals. Prolonged labor (100/205, 48.8%), obstructed labor (40/205, 19.5%), attempted vaginal birth after previous cesarean delivery (40/205, 19.5%) and malpresentation (30/205, 14.6%) were the common indications for referrals. The maternal mortality and perinatal mortality ratios were 610/100,000 live births and 228/1000 total births respectively. Conclusion: Delays at TBA centers are common before referral and most patients are referred in poor clinical state. Further training and re-training of the TBAs with more emphasis on recognition of obstetric danger signs and bad obstetric histories may help in screening high-risk patients for prompt referral to hospitals before complications develop. PMID:26229721

The false negative rate and the role for virtual review in a nationally evaluated glaucoma referral refinement scheme.

PubMed

Ratnarajan, Gokulan; Kean, Jane; French, Karen; Parker, Mike; Bourne, Rupert

2015-09-01

To establish the safety of the CHANGES glaucoma referral refinement scheme (GRRS). The CHANGES scheme risk stratifies glaucoma referrals, with low risk referrals seen by a community based specialist optometrist (OSI) while high risk referrals are referred directly to the hospital. In this study, those patients discharged by the OSI were reviewed by the consultant ophthalmologist to establish a 'false negative' rate (Study 1). Virtual review of optic disc photographs was carried out both by a hospital-based specialist optometrist as well as the consultant ophthalmologist (Study 2). None of these 34 discharged patients seen by the consultant were found to have glaucoma or started on treatment to lower the intra-ocular pressure. Five of the 34 (15%) were classified as 'glaucoma suspect' based on the appearance of the optic disc and offered a follow-up appointment. Virtual review by both the consultant and optometrist had a sensitivity of 80%, whilst the false positive rate for the optometrist was 3.4%, and 32% for the consultant (p < 0.05). The false negative rate of the OSIs in the CHANGES scheme was 15%, however there were no patients where glaucoma was missed. Virtual review in experienced hands can be as effective as clinical review by a consultant, and is a valid method to ensure glaucoma is not missed in GRRS. The CHANGES scheme, which includes virtual review, is effective at reducing referrals to the hospital whilst not compromising patient safety. © 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists.

Referral Regions for Time-Sensitive Acute Care Conditions in the United States.

PubMed

Wallace, David J; Mohan, Deepika; Angus, Derek C; Driessen, Julia R; Seymour, Christopher M; Yealy, Donald M; Roberts, Mark M; Kurland, Kristen S; Kahn, Jeremy M

2018-03-24

Regional, coordinated care for time-sensitive and high-risk medical conditions is a priority in the United States. A necessary precursor to coordinated regional care is regions that are actionable from clinical and policy standpoints. The Dartmouth Atlas of Health Care, the major health care referral construct in the United States, uses regions that cross state and county boundaries, limiting fiscal or political ownership by key governmental stakeholders in positions to create incentive and regulate regional care coordination. Our objective is to develop and evaluate referral regions that define care patterns for patients with acute myocardial infraction, acute stroke, or trauma, yet also preserve essential political boundaries. We developed a novel set of acute care referral regions using Medicare data in the United States from 2011. For acute myocardial infraction, acute stroke, or trauma, we iteratively aggregated counties according to patient home location and treating hospital address, using a spatial algorithm. We evaluated referral political boundary preservation and spatial accuracy for each set of referral regions. The new set of referral regions, the Pittsburgh Atlas, had 326 distinct regions. These referral regions did not cross any county or state borders, whereas 43.1% and 98.1% of all Dartmouth Atlas hospital referral regions crossed county and state borders. The Pittsburgh Atlas was comparable to the Dartmouth Atlas in measures of spatial accuracy and identified larger at-risk populations for all 3 conditions. A novel and straightforward spatial algorithm generated referral regions that were politically actionable and accountable for time-sensitive medical emergencies. Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

The impact of glaucoma referral refinement criteria on referral to, and first-visit discharge rates from, the hospital eye service: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways project.

PubMed

Ratnarajan, Gokulan; Newsom, Wendy; French, Karen; Kean, Jane; Chang, Lydia; Parker, Mike; Garway-Heath, David F; Bourne, Rupert R A

2013-03-01

To assess the impact of referral refinement criteria on the number of patients referred to, and first-visit discharges from, the Hospital Eye Service (HES) in relation to the National Institute for Health & Clinical Excellence (NICE) Glaucoma Guidelines, Joint College Group Guidance (JCG) and the NICE commissioning guidance. All low-risk (one risk factor: suspicious optic disc, abnormal visual field (VF), raised intra-ocular pressure (IOP) (22-28 mmHg) or IOP asymmetry (>5 mmHg) and high-risk (more than one risk factor, shallow anterior chamber or IOP >28 mmHg) referrals to the HES from 2006 to 2011 were analysed. Low-risk referrals were seen by Optometrists with a specialist interest in glaucoma and high-risk referrals were referred directly to the HES. Two thousand nine hundred and twelve patient records were analysed. The highest Consultant first-visit discharge rates were for referrals based on IOP alone (45% for IOP 22-28 mmHg) and IOP asymmetry (53%), VF defect alone (46%) and for abnormal IOP and VF (54%). The lowest first-visit discharge rates were for referrals for suspicious optic disc (19%) and IOP >28 mmHg (22%). 73% of patients aged 65-80 and 60% of patients aged >80 who were referred by the OSI due to an IOP between 22-28 mmHg would have satisfied the JCG criteria for non-referral. For patients referred with an IOP >28 mmHg and an otherwise normal examination, adherence to the NICE commissioning guidance would have resulted in 6% fewer referrals. In 2010 this scheme reduced the number of patients attending the HES by 15%, which resulted in a saving of £16 258 (13%). The results support that referrals for a raised IOP alone or in combination with an abnormal VF be classified as low-risk and undergo referral refinement. Adherence to the JCG and the NICE commissioning guidance as onward referral criteria for specialist optometrists in this referral refinement scheme would result in fewer referrals. Ophthalmic & Physiological Optics © 2013 The College of Optometrists.

Referrals. Electric avenue.

PubMed

Solly, J

2001-11-22

A pilot electronic booking project for outpatient appointments at King's College Hospital, London, has been well received by consultants. But only a minority of practices are taking part--only 24 of the 160 local practices are participating. A considerable culture change is needed to persuade practices to become involved. GPs accustomed to traditional referral letters find electronic referrals a big step. More day-to-day support might encourage GP involvement.

An Epidemiologic Study on Ageing and Dysphagia in the Acute Care Geriatric-Hospitalized Population: A Replication and Continuation Study.

PubMed

Leder, Steven B; Suiter, Debra M; Agogo, George O; Cooney, Leo M

2016-10-01

United States census data project dramatic increases in the geriatric population ageing demographics by 2060 with concomitant health-care consequences. The purpose of this replication and continuation study was to collect new 2014 demographic data relative to ageing, swallow evaluation referral rates, and oral feeding status in geriatric-hospitalized patients for comparison with published data from 2000 to 2007. This was a planned data acquisition study of consecutive hospitalized patients referred for swallow assessments. Swallow evaluation referral rates for 2014 were described according to inpatient discharges, age range 60-105 years grouped by decade, gender, admitting diagnostic category, results of swallow evaluations, and oral feeding status. Determination of aspiration risk status was made with the Yale Swallow Protocol and diagnosis of dysphagia made with fiberoptic endoscopic evaluation of swallowing (FEES). There were 1348 referrals and 961 patients ≥60 years of age participated. Overall swallow evaluation referral rates increased an average of 63 % between the comparison years 2007 and 2014 with consistent increases corresponding to the decades, i.e., 60-69 (46 %), 70-79 (68 %), 80-89 (53 %), and 90+ (222 %). A total of 75 % of participants resumed oral alimentation and oral medications. Swallow evaluation referral rates increased by 63 % for 60-90+ year-old acute care geriatric-hospitalized participants despite only a 23 % increase in inpatient discharges for the years 2007 versus 2014. This corroborated previously reported increases for individual years from 2000 to 2007. For timely, safe, and successful initiation of oral alimentation, it is important to perform a reliable swallow screen for aspiration risk assessment with the Yale Swallow Protocol and, if failed, instrumental testing with FEES. More dysphagia specialists are needed through 2060 and beyond due to projections of continued population ageing resulting in ever increasing referral rates for swallow assessments.

Integration of Palliative Care Into Comprehensive Cancer Treatment at Moi Teaching and Referral Hospital in Western Kenya

PubMed Central

Kipsang, Susan; Gramelspacher, Gregory; Choi, Eunyoung; Brown, Colleen; Hill, Adam B.; Loehrer, Patrick J.; Busakhala, Naftali; Chite Asirwa, F.

2015-01-01

Purpose The prognosis for the majority of patients with cancer in Kenya is poor, with most patients presenting with advanced disease. In addition, many patients are unable to afford the optimal therapies required. Therefore, palliative care is an essential part of comprehensive cancer care. This study reviews the implementation of a palliative care service based at the Moi Teaching and Referral Hospital in Eldoret, Kenya, and describes the current scope and challenges of providing palliative care services in an East African tertiary public referral hospital. Methods This is a review of the palliative care clinical services at the only tertiary public referral hospital in western Kenya from January 2012 through September 2014. Palliative care team members documented each patient's encounter on standardized palliative care assessment forms; data were then entered into the Academic Model Providing Access to Health Care (AMPATH)-Oncology database. Interviews were also conducted to identify current challenges and opportunities for program improvement. Results This study documents the implementation of a palliative care service line in Eldoret, Kenya. Barriers to providing optimal palliative cancer care include distance to pharmacies that stock opioids, limited selection of opioid preparations, education of health care workers in palliative care, access to palliative chemoradiation, and limited availability of outpatient and inpatient hospice services. Conclusion Palliative care services in Eldoret, Kenya, have become a key component of its comprehensive cancer treatment program. PMID:28804768

Integration of Palliative Care Into Comprehensive Cancer Treatment at Moi Teaching and Referral Hospital in Western Kenya.

PubMed

Cornetta, Kenneth; Kipsang, Susan; Gramelspacher, Gregory; Choi, Eunyoung; Brown, Colleen; Hill, Adam B; Loehrer, Patrick J; Busakhala, Naftali; Chite Asirwa, F

2015-10-01

The prognosis for the majority of patients with cancer in Kenya is poor, with most patients presenting with advanced disease. In addition, many patients are unable to afford the optimal therapies required. Therefore, palliative care is an essential part of comprehensive cancer care. This study reviews the implementation of a palliative care service based at the Moi Teaching and Referral Hospital in Eldoret, Kenya, and describes the current scope and challenges of providing palliative care services in an East African tertiary public referral hospital. This is a review of the palliative care clinical services at the only tertiary public referral hospital in western Kenya from January 2012 through September 2014. Palliative care team members documented each patient's encounter on standardized palliative care assessment forms; data were then entered into the Academic Model Providing Access to Health Care (AMPATH)-Oncology database. Interviews were also conducted to identify current challenges and opportunities for program improvement. This study documents the implementation of a palliative care service line in Eldoret, Kenya. Barriers to providing optimal palliative cancer care include distance to pharmacies that stock opioids, limited selection of opioid preparations, education of health care workers in palliative care, access to palliative chemoradiation, and limited availability of outpatient and inpatient hospice services. Palliative care services in Eldoret, Kenya, have become a key component of its comprehensive cancer treatment program.

Estimating the cost of healthcare delivery in three hospitals in southern ghana.

PubMed

Aboagye, A Q Q; Degboe, A N K; Obuobi, A A D

2010-09-01

The cost burden (called full cost) of providing health services at a referral, a district and a mission hospital in Ghana were determined. Standard cost-finding and cost analysis tools recommended by World Health Organization are used to analyse 2002 and 2003 hospital data. Full cost centre costs were computed by taking into account cash and non-cash expenses and allocating overhead costs to intermediate and final patient care centres. The full costs of running the mission hospital in 2002 and 2003 were US$600,295 and US$758,647 respectively; for the district hospital, the respective costs were US$496,240 and US$487,537; and for the referral hospital, the respective costs were US$1,160,535 and US$1,394,321. Of these, overhead costs ranged between 20% and 42%, while salaries made up between 45% and 60%. Based on healthcare utilization data, in 2003 the estimated cost per outpatient attendance was US$ 2.25 at the mission hospital, US$ 4.51 at the district hospital and US$8.5 at the referral hospital; inpatient day costs were US$ 6.05, US$ 9.95 and US$18.8 at the respective hospitals. User fees charged at service delivery points were generally below cost. However, some service delivery points have the potential to recover their costs. Salaries are the major cost component of the three hospitals. Overhead costs constitute an important part of hospital costs and must be noted in efforts to recover costs. Cost structures are different at different types of hospitals. Unit costs at service delivery points can be estimated and projected into the future.

Gender and socioeconomic status as determinants of waiting time for inpatient surgery in a system with implicit queue management.

PubMed

Arnesen, Kjell E; Erikssen, Jan; Stavem, Knut

2002-12-01

In a system with implicit queue management, to examine gender and socioeconomic status as determinants of waiting time for inpatient surgery, after adjusting for other potential predictors. A cohort of 452 subjects was examined in outpatient clinics of a general hospital and referred to inpatient surgery. They were followed until scheduled hospital admission (n=396) or until the requested procedure no longer was relevant (n=56). We compared waiting time between groups from referral date until hospital admission, using Kaplan-Meier estimates of waiting times and log rank test. A Cox proportional hazards model was used for assessing the risk ratio (RR) of hospital admission for scheduled surgery. Gender and socioeconomic status could not explain variations in waiting time. However, patients with suspected/verified neoplastic disease or a risk of serious deterioration without treatment had markedly shorter waiting times than the reference groups, with adjusted RR (95% confidence intervals (95%CI)) of time to receiving in-patient surgery of 2.3 (1.7-3.0) and 2.0 (1.3-3.0), respectively. Being on sick leave was associated with shorter waiting time, adjusted RR of 1.7 (1.2-2.5). Referrals from within the hospital or other hospitals had also shorter waiting times than referrals from primary health care physicians, adjusted RR=1.4 (1.1-1.8). There was no evidence of bias against women or people in lower socioeconomic classes in this implicit queue management system. However, patients' access to inpatient surgery was associated with malignancy, prognosis, sick leave status, physician experience, referral pattern and the major diagnosis category.

Complex care systems in developing countries: breast cancer patient navigation in Ethiopia.

PubMed

Dye, Timothy D; Bogale, Solomon; Hobden, Claire; Tilahun, Yared; Hechter, Vanessa; Deressa, Teshome; Bizé, Marion; Reeler, Anne

2010-02-01

As the global visibility and importance of breast cancer increases, especially in developing countries, ensuring that countries strengthen and develop health systems that support prevention, diagnosis, and treatment of a complex chronic disease is a priority. Understanding how breast cancer patients navigate health systems to reach appropriate levels of care is critical in assessing and improving the health system response in countries to an increasing breast cancer burden in their populations. Ethiopia has accelerated attention to breast cancer, expanding clinical and public health efforts at diagnosing and treating breast cancer earlier and more efficiently. This project used a mixed-method approach to assessing patient navigation of the healthcare system that resulted in care at the cancer referral hospital for Ethiopia (Tikur Anbessa Hospital [TAH]). In total, 69 patients representative of the entire breast cancer clinical population at TAH were interviewed. Navigation chains are widely divergent and typically involve 3 or more care nodes until they reach the referral hospital. Patients who consult traditional healers have significantly more care nodes to reach the referral hospital than others, and patients who have direct access to local and regional hospitals have the smallest number of care nodes. Patients report moving laterally from 1 health institution to another or regressing to lower levels of care, sometimes complicated by reinvolving traditional healers. The care system can be streamlined for breast cancer patients in Ethiopia to facilitate patient access to available and clinically effective diagnostic and treatment services in the country, largely through improving local primary care and hospital capacity to provide basic breast cancer services and improve detection and referral. Copyright 2009 American Cancer Society.

Casualty and surgical services in Perthshire general practitioner hospitals 1954-84

PubMed Central

Blair, J.S.G.; Grant, J.; McBride, H.; Martin, A.; Ross, R.T.A.

1986-01-01

The results are reported of a study of casualty and surgical services in five general practitioner hospitals in Perthshire — Aberfeldy, Auchterarder, Blairgowrie, Crieff and Pitlochry. Details of the total workload, the nature of the conditions treated and the referral rate to major hospitals are given. Figures for the Royal Infirmary, Perth, the main referral hospital for the county, are also given for comparison. The surgical service at one of the rural hospitals is described. Experience has demonstrated the usefulness of these hospitals in providing casualty and surgical services to both the local population and to visitors, and their superiority in providing these services over health centres because staff and beds are available 24 hours a day. Rural general practitioner hospitals merit a continuing share of resources and bed allocation as they spare major hospitals surgical and medical work. The general practitioners serving the hospitals studied here undertook almost 40% of the total accident and emergency workload in the Perth and Kinross area of Scotland. PMID:3735224

Integrated musculoskeletal service design by GP consortia

PubMed Central

2011-01-01

Background Musculoskeletal conditions are common in primary care and are associated with significant co-morbidity and impairment of quality of life. Traditional care pathways combined community-based physiotherapy with GP referral to hospital for a consultant opinion. Locally, this model led to only 30% of hospital consultant orthopaedic referrals being listed for surgery, with the majority being referred for physiotherapy. The NHS musculoskeletal framework proposed the use of interface services to provide expertise in diagnosis, triage and management of musculoskeletal problems not requiring surgery. The White Paper Equity and Excellence: Liberating the NHS has replaced PCT commissioning with GP consortia, who will lead future service development. Setting Primary and community care, integrated with secondary care, in the NHS in England. Question How can GP consortia lead the development of integrated musculoskeletal services? Review: The Ealing experience We explore here how Ealing implemented a ‘See and Treat’ interface clinic model to improve surgical conversion rates, reduce unnecessary hospital referrals and provide community treatment more efficiently than a triage model. A high-profile GP education programme enabled GPs to triage in their practices and manage patients without referral. Conclusion In Ealing, we demonstrated that most patients with musculoskeletal conditions can be managed in primary care and community settings. The integrated musculoskeletal service provides clear and fast routes to secondary care. This is both clinically effective and cost-effective, reserving hospital referral for patients most likely to need surgery. GP consortia, in conjunction with strong clinical leadership, inbuilt organisational and professional learning, and a GP champion, are well placed to deliver service redesign by co-ordinating primary care development, local commissioning of community services and the acute commissioning vehicles responsible for secondary care. The immediate priority for GP consortia is to develop a truly integrated service by facilitating consultant opinions within a community setting. PMID:25949643

Pediatric primary care providers' perspectives regarding hospital discharge communication: a mixed methods analysis.

PubMed

Leyenaar, JoAnna K; Bergert, Lora; Mallory, Leah A; Engel, Richard; Rassbach, Caroline; Shen, Mark; Woehrlen, Tess; Cooperberg, David; Coghlin, Daniel

2015-01-01

Effective communication between inpatient and outpatient providers may mitigate risks of adverse events associated with hospital discharge. However, there is an absence of pediatric literature defining effective discharge communication strategies at both freestanding children's hospitals and general hospitals. The objectives of this study were to assess associations between pediatric primary care providers' (PCPs) reported receipt of discharge communication and referral hospital type, and to describe PCPs' perspectives regarding effective discharge communication and areas for improvement. We administered a questionnaire to PCPs referring to 16 pediatric hospital medicine programs nationally. Multivariable models were developed to assess associations between referral hospital type and receipt and completeness of discharge communication. Open-ended questions asked respondents to describe effective strategies and areas requiring improvement regarding discharge communication. Conventional qualitative content analysis was performed to identify emergent themes. Responses were received from 201 PCPs, for a response rate of 63%. Although there were no differences between referral hospital type and PCP-reported receipt of discharge communication (relative risk 1.61, 95% confidence interval 0.97-2.67), PCPs referring to general hospitals more frequently reported completeness of discharge communication relative to those referring to freestanding children's hospitals (relative risk 1.78, 95% confidence interval 1.26-2.51). Analysis of free text responses yielded 4 major themes: 1) structured discharge communication, 2) direct personal communication, 3) reliability and timeliness of communication, and 4) communication for effective postdischarge care. This study highlights potential differences in the experiences of PCPs referring to general hospitals and freestanding children's hospitals, and presents valuable contextual data for future quality improvement initiatives. Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Women's perceptions of the quality of emergency obstetric care in a referral hospital in rural Tanzania.

PubMed

Stal, Karen Berit; Pallangyo, Pedro; van Elteren, Marianne; van den Akker, Thomas; van Roosmalen, Jos; Nyamtema, Angelo

2015-07-01

To assess perceptions of the quality of obstetric care of women who delivered in a rural Tanzanian referral hospital. A descriptive-exploratory qualitative study, using semistructured in-depth interviews and participatory observation. Nineteen recently delivered women and 3 health workers were interviewed. Although most women held positive views about the care they received in hospital, several participants expressed major concerns about negative attitudes of healthcare workers. Lack of medical communication given by care providers constituted a major complaint. A more positive attitude by health workers and the provision of adequate medical information may promote a more positive hospital experience of women in need of obstetric care and enhance attendance. © 2015 John Wiley & Sons Ltd.

Improving patient access to prevent sight loss: ophthalmic electronic referrals and communication (Scotland).

PubMed

Khan, A A; Mustafa, M Z; Sanders, R

2015-02-01

With the number of people with sight loss predicted to double to four million people in the UK by the year 2050, preventable visual loss is a significant public health issue. Sight loss is associated with an increased risk of falls, accidents and depression and evidence suggests that 50% of sight loss can be avoided. Timely diagnosis is central to the prevention of sight loss. Access to care can be a limiting factor in preventable cases. By improving referrals and access to hospital eye services it is possible to treat and minimise the number of patients with preventable sight loss and the impact this has on wider society. In 2005, NHS Fife took part in a flagship pilot funded by the Scottish government e-health department to evaluate the feasibility, safety, clinical effectiveness, and cost of electronic referral with images of patients directly from community optometrists to Hospital Eye Service (HES). The pilot study showed that electronic referral was feasible, fast, safe, and obviated the need for outpatient appointments in 128 (37%) patients with a high patient satisfaction. The results of the pilot study were presented and in May 2007, the electronic referral system was rolled out regionally in southeast Scotland. Referrals were accepted at a single site with vetting by a trained team and appointments were allocated within 48 hours. Following the implementation of electronic referral, waiting times were reduced from a median of 14 to 4 weeks. Significantly fewer new patients were seen (7462 vs 8714 [p < 0.001]). There were also fewer casualties (1984 vs 2671 [p < 0.001]) and 'did not arrive' (DNA) new patients (503 vs 635 [p < 0.001]). In 2010 the Scottish Government Health Department committed £ 6.6 million to community and hospital ophthalmic services forming the Eyecare Integration Project in 2011. The main aim of this project was to create electronic communication between community optometry practices and hospital eye departments. Five electronic forms were specifically designed for cataract, glaucoma, macula, paediatric and general ophthalmic disease. A Virtual Private Network was created which enabled optometrists to connect to the Scottish clinical information gateway system and send referrals to hospital and receive referral status feedback. Numerous hurdles have been encountered and overcome in order to deliver this project. An efficient unique system has been described within the NHS whereby the provision of eye care has been modernised by creating a user-friendly electronic interface between the community and HES. This system ensures patients are vetted into the correct specialist clinic and thus will be less likely to go blind from treatable conditions. Urgent conditions will continue to be prioritised and savings made with efficiencies gained can be re-invested towards better overall patient care. Copyright © 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Do referral-management schemes reduce hospital outpatient attendances? Time-series evaluation of primary care referral management.

PubMed

Cox, Jonathan Ms; Steel, Nicholas; Clark, Allan B; Kumaravel, Bharathy; Bachmann, Max O

2013-06-01

Ninety-one per cent of primary care trusts were using some form of referral management in 2009, although evidence for its effectiveness is limited. To assess the impact of three referral-management centres (RMCs) and two internal peer-review approaches to referral management on hospital outpatient attendance rates. A retrospective time-series analysis of 376 000 outpatient attendances over 3 years from 85 practices divided into five groups, with 714 000 registered patients in one English primary care trust. The age-standardised GP-referred first outpatient monthly attendance rate was calculated for each group from April 2009 to March 2012. This was divided by the equivalent monthly England rate, to derive a rate ratio. Linear regression tested for association between the introduction of referral management and change in the outpatient attendance rate and rate ratio. Annual group budgets for referral management were obtained. Referral management was not associated with a reduction in the outpatient attendance rate in any group. There was a statistically significant increase in attendance rate in one group (a RMC), which had an increase of 1.05 attendances per 1000 persons per month (95% confidence interval = 0.46 to 1.64; attendance rate ratio increase of 0.07) after adjustment for autocorrelation. Mean annual budgets ranged from £0.55 to £6.23 per registered patient in 2011/2012. RMCs were more expensive (mean annual budget £5.18 per registered patient) than internal peer-review approaches (mean annual budget £0.97 per registered patient). Referral-management schemes did not reduce outpatient attendance rates. RMCs were more expensive than internal peer review.

A comparative study of the quality of care and glycemic control among ambulatory type 2 diabetes mellitus clients, at a Tertiary Referral Hospital and a Regional Hospital in Central Kenya.

PubMed

Mwavua, Shillah Mwaniga; Ndungu, Edward Kiogora; Mutai, Kenneth K; Joshi, Mark David

2016-01-05

Peripheral public health facilities remain the most frequented by the majority of the population in Kenya; yet remain sub-optimally equipped and not optimized for non-communicable diseases care. We undertook a descriptive, cross sectional study among ambulatory type 2 diabetes mellitus clients, attending Kenyatta National Referral Hospital (KNH), and Thika District Hospital (TDH) in Central Kenya. Systematic random sampling was used. HbA1c was assessed for glycemic control and the following, as markers of quality of care: direct client costs, clinic appointment interval and frequency of self monitoring test, affordability and satisfaction with care. We enrolled 200 clients, (Kenyatta National Hospital 120; Thika District Hospital 80); Majority of the patients 66.5% were females, the mean age was 57.8 years; and 58% of the patients had basic primary education. 67.5% had diabetes for less than 10 years and 40% were on insulin therapy. The proportion (95% CI) with good glycemic was 17% (12.0-22.5 respectively) in the two facilities [Kenyatta National Hospital 18.3% (11.5-25.6); Thika District Hospital 15% (CI 7.4-23.7); P = 0.539]. However, in Thika District Hospital clients were more likely to have a clinic driven routine urinalysis and weight, they were also accorded shorter clinic appointment intervals; incurred half to three quarter lower direct costs, and reported greater affordability and satisfactions with care. In conclusion, we demonstrate that in Thika district hospital, glycemic control and diabetic care is suboptimal; but comparable to that of Kenyatta National Referral hospital. Opportunities for improvement of care abound at peripheral health facilities.

Shared Care: A Quality Improvement Initiative to Optimize Primary Care Management of Constipation

PubMed Central

Vernacchio, Louis; Trudell, Emily; Antonelli, Richard; Nurko, Samuel; Leichtner, Alan M.; Lightdale, Jenifer R.

2015-01-01

BACKGROUND: Pediatric constipation is commonly managed in the primary care setting, where there is much variability in management and specialty referral use. Shared Care is a collaborative quality improvement initiative between Boston Children’s Hospital and the Pediatric Physician’s Organization at Children’s (PPOC), through which subspecialists provide primary care providers with education, decision-support tools, pre-referral management recommendations, and access to advice. We investigated whether Shared Care reduces referrals and improves adherence to established clinical guidelines. METHODS: We reviewed the primary care management of patients 1 to 18 years old seen by a Boston Children’s Hospital gastroenterologist and diagnosed with constipation who were referred from PPOC practices in the 6 months before and after implementation of Shared Care. Charts were assessed for patient factors and key components of management. We also tracked referral rates for all PPOC patients for 29 months before implementation and 19 months after implementation. RESULTS: Fewer active patients in the sample were referred after implementation (61/27 365 [0.22%] vs 90/27 792 [0.36%], P = .003). The duration of pre-referral management increased, and the rate of fecal impaction decreased after implementation. No differences were observed in documentation of key management recommendations. Analysis of medical claims showed no statistically significant change in referrals. CONCLUSIONS: A multifaceted initiative to support primary care management of constipation can alter clinical care, but changes in referral behavior and pre-referral management may be difficult to detect and sustain. Future efforts may benefit from novel approaches to provider engagement and systems integration. PMID:25896837

Comparison of referral and non-referral hypertensive disorders during pregnancy: an analysis of 271 consecutive cases at a tertiary hospital.

PubMed

Liu, Ching-Ming; Chang, Shuenn-Dyh; Cheng, Po-Jen

2005-05-01

This retrospective cohort study analyzed the clinical manifestations in patients with preeclampsia and eclampsia, assessed the risk factors compared to the severity of hypertensive disorders on maternal and perinatal morbidity, and mortality between the referral and non-referral patients. 271 pregnant women with preeclampsia and eclampsia were assessed (1993 to 1997). Chi-square analysis was used for the comparison of categorical variables, and the comparison of the two independent variables of proportions in estimation of confidence intervals and calculated odds ratio of the referral and non-referral groups. Multivariate logistic regression was used for adjusting potential confounding risk factors. Of the 271 patients included in this study, 71 (26.2%) patients were referrals from other hospitals. Most of the 62 (87.3%) referral patients were transferred during the period 21 and 37 weeks of gestation. Univariate analysis revealed that referral patients with hypertensive disorder were significantly associated with SBP > or =180, DBP > or =105, severe preclampsia, haemolysis, elevated liver enzymes, low platelets (HELLP), emergency C/S, maternal complications, and low birth weight babies, as well as poor Apgar score. Multivariate logistic regression analyses revealed that the risk factors identified to be significantly associated with increased risk of referral patients included: diastolic blood pressure above 105 mmHg (adjusted odds ratio, 2.09; 95 percent confidence interval, 1.06 to 4.13; P = 0.034), severe preeclampsia (adjusted odds ratio, 3.46; 95 percent confidence interval, 1.76 to 6.81; P < 0.001), eclampsia (adjusted odds ratio, 2.77; 95 percent confidence interval, 0.92 to 8.35; P = 0.071), HELLP syndrome (adjusted odds ratio, 18.81; 95 percent confidence interval, 2.14 to 164.99; P = 0.008). The significant factors associated with the referral patients with hypertensive disorders were severe preeclampsia, HELLP, and eclampsia. Lack of prenatal care was the major avoidable factor found in referral and high risk patients. Time constraints relating to referral patients and the appropriateness of patient-centered care for patient safety and better quality of health care need further investigation on national and multi-center clinical trials.

Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures.

PubMed

Stewart, Barclay T; Tansley, Gavin; Gyedu, Adam; Ofosu, Anthony; Donkor, Peter; Appiah-Denkyira, Ebenezer; Quansah, Robert; Clarke, Damian L; Volmink, Jimmy; Mock, Charles

2016-08-17

Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known. To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana. Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014. All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis. Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure-capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440-1418 vs 360; interquartile range, 0-896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%-83.4%) and 71.4% (UI, 64.4%-75.0%), respectively. Five hospitals were identified for targeted capability improvement. Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery.

Specialisation of spinal services: consequences for cervical trauma management in the district hospital

PubMed Central

Rethnam, Ulfin; Cordell-Smith, James; Sinha, Amit

2007-01-01

Background Specialisation in spinal services has lead to a low threshold for referral of cervical spine injuries from district general hospitals. We aim to assess the capability of a district general hospital in providing the halo vest device and the expertise available in applying the device for unstable cervical spine injuries prior to transfer to a referral centre. Methods The study was a postal questionnaire survey of trauma consultants at district general hospitals without on-site spinal units in the United Kingdom. Seventy institutions were selected randomly from an electronic NHS directory. We posed seven questions on the local availability, expertise and training with halo vest application, and transferral policies in patients with spinal trauma. Results The response rate was 51/70 (73%). Nineteen of the hospitals (37%) did not stock the halo vest device. Also, one third of the participants (18/51, 35%, 95% confidence interval 22 – 50%) were not confident in application of the halo vest device and resorted to transfer of patients to referral centres without halo immobilization. Conclusion The lack of equipment and expertise to apply the halo vest device for unstable cervical spine injuries is highlighted in this study. Training of all trauma surgeons in the application of the halo device would overcome this deficiency. PMID:18271985

Glaucoma-service provision in Scotland: introduction and need for Scottish Intercollegiate Guidelines Network guidelines.

PubMed

Syrogiannis, Andreas; Rotchford, Alan P; Agarwal, Pankaj Kumar; Kumarasamy, Manjula; Montgomery, Donald; Burr, Jennifer; Sanders, Roshini

2015-01-01

To describe the pattern of glaucoma-service delivery in Scotland and identify areas for improvement, taking into account Scottish General Ophthalmic Services (GOS) arrangements and the Eye Care Integration project, and to design Scottish Intercollegiate Guidelines Network (SIGN) guidelines to refine the primary and secondary interface of glaucoma care. A glaucoma-survey questionnaire was sent to all consultant glaucomatologists in Scotland. The design of SIGN guidelines was based on the results of the questionnaire using SIGN methodology. Over 90% of Scottish glaucoma care is triaged and delivered within hospital services. Despite GOS referral, information is variable. There are no consistent discharge practices to the community. These results led to defined research questions that were answered, thus formulating the content of the SIGN guidelines. The guideline covers the assessment of patients in primary care, referral criteria to hospital, discharge criteria from hospital to community, and monitoring of patients at risk of glaucoma. With increasing age and limitations to hospital resources, refining glaucoma pathways between primary and secondary care has become a necessity. Scotland has unique eye care arrangements with both the GOS and Eye Care Integration project. It is hoped that implementation of SIGN guidelines will identify glaucoma at the earliest opportunity and reduce the rate of false-positive referrals to hospital.

[Patients with ICD-10 disorders F3 and F4 in psychiatric and psychosomatic in-patient units - who is treated where? : Allocation features from the PfAD study].

PubMed

Bichescu-Burian, D; Cerisier, C; Czekaj, A; Grempler, J; Hund, S; Jaeger, S; Schmid, P; Weithmann, G; Steinert, T

2017-01-01

In Germany, in-patient treatment of patients with depressive, neurotic, anxiety, and somatoform disorders (ICD-10 F3, F4) is carried out in different settings in psychiatry and psychosomatics. Which patient characteristics determine referral to one or the other specialty is a crucial question in mental health policy and is a matter of ongoing controversy. However, comparative data on patient populations are widely lacking. In the study of Treatment Pathways of Patients with Anxiety and Depression (PfAD study), a total of 320 patients with ICD-10 F3/F4 clinical diagnoses were consecutively recruited from four treatment settings (psychiatric depression ward, psychiatric crisis intervention ward, psychiatric day hospitals, or psychosomatic hospital units; 80 participants per setting) and investigated. In all treatment settings, patients with considerable severity of illness and chronicity were treated. Female gender, higher education, and higher income predicted referral to psychosomatic units; male gender, transfer from another hospital or emergency hospitalization, co-morbidity with a personality disorder, higher general psychiatric co-morbidity, and danger to self at admission predicted referral to psychiatric unit. Patients in psychosomatic units had neither more psychosomatic disorders nor more somatic problems. There is considerable overlap between the clientele of psychiatric and psychosomatic units. Referral and allocation appears to be determined by aspects of severity and social status.

Understanding health care provider barriers to hospital affiliated medical fitness center facility referral: a questionnaire survey and semi structured interviews.

PubMed

Smock, Carissa; Alemagno, Sonia

2017-08-03

The purpose of this study is to understand health care provider barriers to referring patients to Medical Fitness Center Facilities within an affiliated teaching hospital system using referral of diabetic services as an example. The aims of this study include: (1) to assess health care providers' awareness and use of facilities, (2) to determine barriers to referring patients to facilities, (3) identify current and needed resources and/or changes to increase referral to facilities. A 20-item electronic survey and requests for semi-structured interviews were administered to hospital system directors and managers (n = 51). Directors and managers instructed physicians and staff to complete the survey and interviews as applicable. Perceived barriers, knowledge, utilization, and referral of patients to Medical Fitness Center Facilities were collected and examined. Descriptive statistics were generated regarding practice characteristics, provider characteristics, and referral. Of the health care providers surveyed and interviewed (n = 25) 40% indicated verbally suggesting use of facilities, 24% provided a flyer about the facilities. No respondents indicated that they directly referred patients to the facilities. However, 16% referred patients to other locations for physical activity - including their own department's management and prevention services. 20% do not refer to Medical Fitness Center Facilities or any other lifestyle programs/locations. Lack of time (92%) and lack of standard guidelines and operating procedures (88%) are barriers to referral. All respondents indicated a strong ability to refer patients to Medical Fitness Center Facilities if given education about referral programs available as well as standard clinical guidelines and protocol for delivery. The results of this study indicate that, although few healthcare providers are currently referring patients to Medical Fitness Center Facilities, health care providers with an affiliated Medical Fitness Center Facility not only want clinical standard guidelines, protocol, and training to refer patients to Medical Fitness Center Facilities, but believe they have the ability to increase referral if given these tools. The Medical Fitness Association has a unique opportunity to bridge health care providers to Medical Fitness Center Facilities by developing clinical practice guidelines in cooperation with the American Diabetes Association.

[Nosocomial urinary tract and surgical site infection rates in the Maternity Ward at the General Referral Hospital in Katuba, Lubumbashi, Democratic Republic of the Congo].

PubMed

Lukuke, Hendrick Mbutshu; Kasamba, Eric; Mahuridi, Abdulu; Nlandu, Roger Ngatu; Narufumi, Suganuma; Mukengeshayi, Abel Ntambue; Malou, Vicky; Makoutode, Michel; Kaj, Françoise Malonga

2017-01-01

In Intertropical Africa hospitalized patients are exposed to a risk of nosocomial infections. The dearth of published data on this subject limits the descriptive analysis of the situation. This study aimed to determine the incidence, the germs responsible for these infections and the risk factors of nosocomial infections in the Maternity Ward at the General Referral Hospital in Katuba, Lubumbashi, Democratic Republic of the Congo. We conducted a descriptive, longitudinal study from 1 October 2014 to 1 January 2015. Our study population consisted of 207 women who had been hospitalized in the Maternity Ward at the General Referral Hospital in Katuba. We carried out a comprehensive data collection. Nosocomial infection rate accounted for 15.5%. Parturient women who had been hospitalized for more than three days were three times more likely to develop a nosocomial infection (p=0.003), while those who had had a complicated delivery were four times more likely to be at risk of developing nosocomial infection (p = 0.000). Escherichia coli was the most isolated causative agent (38.1%), followed by Citrobacter freundi (23.8%), Acinobacter baumani (.18, 2%), Staphylococcus aureus (18.2%), Enterococcus aureus (14.3%) and Pseudomonas aeroginosa (9.1%). Ampicillin was the most prescribed antibiotic, to which isolated microbes were resistant. It is necessary to improve hospital hygiene and to conduct further study to examine the similarity between germs strains in the environment and those in biological fluids.

Prevalence of cannabis residues in psychiatric patients: a case study of two mental health referral hospitals in Uganda.

PubMed

Awuzu, Epaenetus A; Kaye, Emmanuel; Vudriko, Patrick

2014-01-08

Various studies have reported that abuse of cannabis is a risk factor for psychosis. The aims of this study were to determine the prevalence of delta 9-tetrahydrocanabinol (Δ(9)-THC), a major metabolite of cannabis, in psychiatric patients in Uganda, and to assess the diagnostic capacity of two referral mental health hospitals to screen patients for exposure to cannabis in Uganda. Socio-demographic characteristics of the patients were collected through questionnaires and review of medical records. Urine samples were collected from 100 patients and analyzed using Δ(9)-THC immunochromatographic kit (Standard Diagnostics(®), South Korea). Seventeen percent of the patients tested positive for Δ(9)-THC residues in their urine. There was strong association (P < 0.05) between history of previous abuse of cannabis and presence of Δ(9)-THC residues in the urine. Alcohol, cocaine, heroin, pethidine, tobacco, khat and kuber were the other substances abused in various combinations. Both referral hospitals lacked laboratory diagnostic kits for detection of cannabis in psychiatric patients. In conclusion, previous abuse of cannabis is associated with occurrence of the residues in psychiatric patients, yet referral mental health facilities in Uganda do not have the appropriate diagnostic kits for detection of cannabis residues as a basis for evidence-based psychotherapy.

Relationships between heart rate and age, bodyweight and breed in 10,849 dogs.

PubMed

Hezzell, M J; Dennis, S G; Humm, K; Agee, L; Boswood, A

2013-06-01

To evaluate relationships between heart rate and clinical variables in healthy dogs and dogs examined at a referral hospital. Clinical data were extracted from the electronic patient records of a first opinion group (5000 healthy dogs) and a referral hospital (5849 dogs). Univariable and multi-variable general linear models were used to assess associations between heart rate and clinical characteristics. Separate multi-variable models were constructed for first opinion and referral populations. In healthy dogs, heart rate was negatively associated with bodyweight (P<0.001) but was higher in Chihuahuas. The mean difference in heart rate between a 5 and 55 kg dog was 10.5 beats per minute. In dogs presenting to a referral hospital, heart rate was negatively associated with bodyweight (P<0.001) and the following breeds; border collie, golden retriever, Labrador retriever, springer spaniel and West Highland white terrier and positively associated with age, admitting service (emergency and critical care, emergency first opinion and cardiology) and the following breeds; Cavalier King Charles spaniel, Staffordshire bull terrier and Yorkshire terrier. Bodyweight, age, breed and disease status all influence heart rate in dogs, although these factors account for a relatively small proportion of the overall variability in heart rate. © 2013 British Small Animal Veterinary Association.

Bayesian exponential random graph modelling of interhospital patient referral networks.

PubMed

Caimo, Alberto; Pallotti, Francesca; Lomi, Alessandro

2017-08-15

Using original data that we have collected on referral relations between 110 hospitals serving a large regional community, we show how recently derived Bayesian exponential random graph models may be adopted to illuminate core empirical issues in research on relational coordination among healthcare organisations. We show how a rigorous Bayesian computation approach supports a fully probabilistic analytical framework that alleviates well-known problems in the estimation of model parameters of exponential random graph models. We also show how the main structural features of interhospital patient referral networks that prior studies have described can be reproduced with accuracy by specifying the system of local dependencies that produce - but at the same time are induced by - decentralised collaborative arrangements between hospitals. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

42 CFR 412.96 - Special treatment: Referral centers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Special Treatment of Certain Facilities Under the Prospective Payment System for Inpatient Operating Costs § 412.96 Special treatment... 42 Public Health 2 2010-10-01 2010-10-01 false Special treatment: Referral centers. 412.96 Section...

The challenge of managing extensively drug-resistant tuberculosis at a referral hospital in the state of São Paulo, Brazil: a report of three cases

PubMed Central

Arbex, Marcos Abdo; de Siqueira, Hélio Ribeiro; D'Ambrosio, Lia; Migliori, Giovanni Battista

2015-01-01

ABSTRACT Here, we report the cases of three patients diagnosed with extensively drug-resistant tuberculosis and admitted to a referral hospital in the state of São Paulo, Brazil, showing the clinical and radiological evolution, as well as laboratory test results, over a one-year period. Treatment was based on the World Health Organization guidelines, with the inclusion of a new proposal for the use of a combination of antituberculosis drugs (imipenem and linezolid). In the cases studied, we show the challenge of creating an acceptable, effective treatment regimen including drugs that are more toxic, are more expensive, and are administered for longer periods. We also show that treatment costs are significantly higher for such patients, which could have an impact on health care systems, even after hospital discharge. We highlight the fact that in extreme cases, such as those reported here, hospitalization at a referral center seems to be the most effective strategy for providing appropriate treatment and increasing the chance of cure. In conclusion, health professionals and governments must make every effort to prevent cases of multidrug-resistant and extensively drug-resistant tuberculosis. PMID:26785966

Implementing shared decision-making in routine practice: barriers and opportunities.

PubMed

Holmes-Rovner, Margaret; Valade, Diane; Orlowski, Catherine; Draus, Catherine; Nabozny-Valerio, Barbara; Keiser, Susan

2000-09-01

OBJECTIVE: Determine feasibility of shared decision-making programmes in fee-for-service hospital systems including physicians' offices and in-patient facilities. DESIGN: Survey and participant observation. Data obtained during Phase 1 of a patient outcome study. SETTINGS AND PARTICIPANTS: Three hospitals in Michigan: one 299-bed rural regional hospital, one 650-bed urban community hospital, one 459-bed urban and suburban teaching hospital. All nurses and physicians who agreed to use the programmes participated in the evaluation (n = 34). INTERVENTION: Two shared decision-making(R) (SDP) multimedia programmes: surgical treatment choice for breast cancer and ischaemic heart disease treatment choice. MAIN OUTCOME MEASURES: (1) clinicians' evaluations of programme quality; (2) challenges in hospital settings; and (3) patient referral rates. RESULTS: SDP programmes were judged to be clear, accurate and about the right length and amount of information. Programmes were judged to be informative and appropriate for patients to see before making a decision. Clinicians were neutral about patients' desire to participate in treatment decision-making. Referral volume to SDPs was lower than expected: 24 patients in 7 months across three hospitals. Implementation challenges centred on time pressures in patient care. CONCLUSIONS: Productivity and time pressure in US health care severely constrain shared decision-making programme implementation. Physician referral may not be a reliable mechanism for patient access. Possible innovations include: (1) incorporation into the informed consent process; (2) provider or payer negotiated requirement in the routine hospital procedure to use the SDP as a quality indicator; and (3) payer reimbursement to professional providers who make SDP programmes available to patients.

Tinnitus referral pathways within the National Health Service in England: a survey of their perceived effectiveness among audiology staff

PubMed Central

2011-01-01

Background In the UK, audiology services deliver the majority of tinnitus patient care, but not all patients experience the same level of service. In 2009, the Department of Health released a Good Practice Guide to inform commissioners about key aspects of a quality tinnitus service in order to promote equity of tinnitus patient care in UK primary care, audiology, and in specialist multi-disciplinary centres. The purpose of the present research was to evaluate utilisation and opinions on pathways for the referral of tinnitus patients to and from English Audiology Departments. Methods We surveyed all audiology staff engaged in providing tinnitus services across England. A 36-item questionnaire was mailed to 351 clinicians in all 163 National Health Service (NHS) Trusts identified as having a tinnitus service. 138 clinicians responded. The results presented here describe experiences and opinions of the current patient pathways to and from the audiology tinnitus service. Results The most common referral pathway was from general practice to a hospital-based Ear, Nose & Throat department and from there to a hospital-based audiology department (64%). Respondents considered the NHS tinnitus referral process to be generally effective (67%), but expressed needs for improving GP referral and patients' access to services. 'Open access' to the audiology clinic was rarely an option for patients (9%), nor was the opportunity to access specialist counselling provided by clinical psychology (35%). To decrease the number of inappropriate referrals, 40% of respondents called for greater awareness by referrers about the audiology tinnitus service. Conclusions Respondents in the present survey were generally satisfied with the tinnitus referral system. However, they highlighted some potential targets for service improvement including 1] faster and more appropriate referral from GPs, to be achieved through education on tinnitus referral criteria, 2] improved access to psychological services through audiologist training, and 3] ongoing support from tinnitus support groups, national charities, or open access to the tinnitus clinic for existing patients. PMID:21733188

Tinnitus referral pathways within the National Health Service in England: a survey of their perceived effectiveness among audiology staff.

PubMed

Gander, Phillip E; Hoare, Derek J; Collins, Luke; Smith, Sandra; Hall, Deborah A

2011-07-06

In the UK, audiology services deliver the majority of tinnitus patient care, but not all patients experience the same level of service. In 2009, the Department of Health released a Good Practice Guide to inform commissioners about key aspects of a quality tinnitus service in order to promote equity of tinnitus patient care in UK primary care, audiology, and in specialist multi-disciplinary centres. The purpose of the present research was to evaluate utilisation and opinions on pathways for the referral of tinnitus patients to and from English Audiology Departments. We surveyed all audiology staff engaged in providing tinnitus services across England. A 36-item questionnaire was mailed to 351 clinicians in all 163 National Health Service (NHS) Trusts identified as having a tinnitus service. 138 clinicians responded. The results presented here describe experiences and opinions of the current patient pathways to and from the audiology tinnitus service. The most common referral pathway was from general practice to a hospital-based Ear, Nose & Throat department and from there to a hospital-based audiology department (64%). Respondents considered the NHS tinnitus referral process to be generally effective (67%), but expressed needs for improving GP referral and patients' access to services. 'Open access' to the audiology clinic was rarely an option for patients (9%), nor was the opportunity to access specialist counselling provided by clinical psychology (35%). To decrease the number of inappropriate referrals, 40% of respondents called for greater awareness by referrers about the audiology tinnitus service. Respondents in the present survey were generally satisfied with the tinnitus referral system. However, they highlighted some potential targets for service improvement including 1] faster and more appropriate referral from GPs, to be achieved through education on tinnitus referral criteria, 2] improved access to psychological services through audiologist training, and 3] ongoing support from tinnitus support groups, national charities, or open access to the tinnitus clinic for existing patients.

Preschool children's vision screening in New Zealand: a retrospective evaluation of referral accuracy

PubMed Central

Langeslag-Smith, Miriam A; Vandal, Alain C; Briane, Vincent; Thompson, Benjamin; Anstice, Nicola S

2015-01-01

Objectives To assess the accuracy of preschool vision screening in a large, ethnically diverse, urban population in South Auckland, New Zealand. Design Retrospective longitudinal study. Methods B4 School Check vision screening records (n=5572) were compared with hospital eye department data for children referred from screening due to impaired acuity in one or both eyes who attended a referral appointment (n=556). False positive screens were identified by comparing screening data from the eyes that failed screening with hospital data. Estimation of false negative screening rates relied on data from eyes that passed screening. Data were analysed using logistic regression modelling accounting for the high correlation between results for the two eyes of each child. Primary outcome measure Positive predictive value of the preschool vision screening programme. Results Screening produced high numbers of false positive referrals, resulting in poor positive predictive value (PPV=31%, 95% CI 26% to 38%). High estimated negative predictive value (NPV=92%, 95% CI 88% to 95%) suggested most children with a vision disorder were identified at screening. Relaxing the referral criteria for acuity from worse than 6/9 to worse than 6/12 improved PPV without adversely affecting NPV. Conclusions The B4 School Check generated numerous false positive referrals and consequently had a low PPV. There is scope for reducing costs by altering the visual acuity criterion for referral. PMID:26614622

[Body packer: review and experience in a referral hospital].

PubMed

Madrazo, Zoilo; Silvio-Estaba, Leonardo; Secanella, Luis; García-Barrasa, Arantxa; Aranda, Humberto; Golda, Thomas; Biondo, Sebastiano; Rafecas, Antoni

2007-09-01

Smuggling of illicit drugs by concealing them within the human body (body packer) is a medical-legal issue that has increased in the last few decades. Physicians, especially those working in the emergency department, should be familiar with the diagnostic and therapeutic management -usually conservative management- of this type of patient and their possible complications. The present article reviews the general concepts and physiopathology associated with transport of packages in the digestive tract and describes the experience of a referral hospital with a protocol specifically designed for these patients.

Referral pathways for patients with TIA avoiding hospital admission: a scoping review

PubMed Central

Evans, Bridie Angela; Ali, Khalid; Bulger, Jenna; Ford, Gary A; Jones, Matthew; Moore, Chris; Porter, Alison; Pryce, Alan David; Quinn, Tom; Seagrove, Anne C; Whitman, Shirley; Rees, Nigel

2017-01-01

Objective To identify the features and effects of a pathway for emergency assessment and referral of patients with suspected transient ischaemic attack (TIA) in order to avoid admission to hospital. Design Scoping review. Data sources PubMed, CINAHL Web of Science, Scopus. Study selection Reports of primary research on referral of patients with suspected TIA directly to specialist outpatient services. Data extraction We screened studies for eligibility and extracted data from relevant studies. Data were analysed to describe setting, assessment and referral processes, treatment, implementation and outcomes. Results 8 international studies were identified, mostly cohort designs. 4 pathways were used by family doctors and 3 pathways by emergency department physicians. No pathways used by paramedics were found. Referrals were made to specialist clinic either directly or via a 24-hour helpline. Practitioners identified TIA symptoms and risk of further events using a checklist including the ABCD2 tool or clinical assessment. Antiplatelet medication was often given, usually aspirin unless contraindicated. Some patients underwent tests before referral and discharge. 5 studies reported reduced incident of stroke at 90 days, from 6–10% predicted rate to 1.3–2.1% actual rate. Between 44% and 83% of suspected TIA cases in these studies were referred through the pathways. Conclusions Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalisation of patients with TIA. No pathways for paramedical use were reported. We will use results of this scoping review to inform development of a paramedical referral pathway to be tested in a feasibility trial. Trial registration number ISRCTN85516498. Stage: pre-results. PMID:28196949

Referral pathways for patients with TIA avoiding hospital admission: a scoping review.

PubMed

Evans, Bridie Angela; Ali, Khalid; Bulger, Jenna; Ford, Gary A; Jones, Matthew; Moore, Chris; Porter, Alison; Pryce, Alan David; Quinn, Tom; Seagrove, Anne C; Snooks, Helen; Whitman, Shirley; Rees, Nigel

2017-02-14

To identify the features and effects of a pathway for emergency assessment and referral of patients with suspected transient ischaemic attack (TIA) in order to avoid admission to hospital. Scoping review. PubMed, CINAHL Web of Science, Scopus. Reports of primary research on referral of patients with suspected TIA directly to specialist outpatient services. We screened studies for eligibility and extracted data from relevant studies. Data were analysed to describe setting, assessment and referral processes, treatment, implementation and outcomes. 8 international studies were identified, mostly cohort designs. 4 pathways were used by family doctors and 3 pathways by emergency department physicians. No pathways used by paramedics were found. Referrals were made to specialist clinic either directly or via a 24-hour helpline. Practitioners identified TIA symptoms and risk of further events using a checklist including the ABCD2 tool or clinical assessment. Antiplatelet medication was often given, usually aspirin unless contraindicated. Some patients underwent tests before referral and discharge. 5 studies reported reduced incident of stroke at 90 days, from 6-10% predicted rate to 1.3-2.1% actual rate. Between 44% and 83% of suspected TIA cases in these studies were referred through the pathways. Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalisation of patients with TIA. No pathways for paramedical use were reported. We will use results of this scoping review to inform development of a paramedical referral pathway to be tested in a feasibility trial. ISRCTN85516498. Stage: pre-results. 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/.

Referral hospitals in the Democratic Republic of Congo as complex adaptive systems: similar program, different dynamics.

PubMed

Karemere, Hermès; Ribesse, Nathalie; Kahindo, Jean-Bosco; Macq, Jean

2015-01-01

In many African countries, first referral hospitals received little attention from development agencies until recently. We report the evolution of two of them in an unstable region like Eastern Democratic Republic of Congo when receiving the support from development aid program. Specifically, we aimed at studying how actors' network and institutional framework evolved over time and what could matter the most when looking at their performance in such an environment. We performed two cases studies between 2006 and 2010. We used multiple sources of data: reports to document events; health information system for hospital services production, and "key-informants" interviews to interpret the relation between interventions and services production. Our analysis was inspired from complex adaptive system theory. It started from the analysis of events implementation, to explore interaction process between the main agents in each hospital, and the consequence it could have on hospital health services production. This led to the development of new theoretical propositions. Two events implemented in the frame of the development aid program were identified by most of the key-informants interviewed as having the greatest impact on hospital performance: the development of a hospital plan and the performance based financing. They resulted in contrasting interaction process between the main agents between the two hospitals. Two groups of services production were reviewed: consultation at outpatient department and admissions, and surgery. The evolution of both groups of services production were different between both hospitals. By studying two first referral hospitals through the lens of a Complex Adaptive System, their performance in a context of development aid takes a different meaning. Success is not only measured through increased hospital production but through meaningful process of hospital agents'" network adaptation. Expected process is not necessarily a change; strengthened equilibrium and existing institutional arrangement may be a preferable result. Much more attention should be given in future international aid to the proper understanding of the hospital adaptation capacities.

Healthcare Resource Availability, Quality of Care, and Acute Ischemic Stroke Outcomes.

PubMed

O'Brien, Emily C; Wu, Jingjing; Zhao, Xin; Schulte, Phillip J; Fonarow, Gregg C; Hernandez, Adrian F; Schwamm, Lee H; Peterson, Eric D; Bhatt, Deepak L; Smith, Eric E

2017-02-03

Healthcare resources vary geographically, but associations between hospital-based resources and acute stroke quality and outcomes remain unclear. Using Get With The Guidelines-Stroke and Dartmouth Atlas of Health Care data, we examined associations between healthcare resource availability, stroke care, and outcomes. We categorized hospital referral regions with high-, medium-, or low-resource levels based on the 2006 national per-capita availability median of 6 relevant acute stroke care resources. Using multivariable logistic regression, we examined healthcare resource level and in-hospital quality and outcomes. Of 1 480 308 admitted ischemic stroke patients (2006-2013), 28.8% were hospitalized in low-, 44.4% in medium-, and 26.9% in high-resource hospital referral regions. Quality-of-care/timeliness metrics, adjusted length of stay, and in-hospital mortality were similar across all resource levels. Significant variation exists in regional availability of healthcare resources for acute ischemic stroke treatment, yet among Get With the Guidelines-Stroke hospitals, quality of care and in-hospital outcomes did not differ by regional resource availability. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

A study of the provision of hospital based dental General Anaesthetic services for children in the North West of England: Part 2--the views and experience of families and dentists regarding service needs, treatment and prevention.

PubMed

Goodwin, Michaela; Pretty, Iain A; Sanders, Caroline

2015-04-09

Patterns of service delivery and the organisation of Dental General Anaesthesia (DGA) have been found to differ across hospitals. This paper reports on qualitative research aimed to understand the impact of such variation by exploring views and experiences of families receiving care in different hospital sites, as well as dentists involved in referral and delivery of care. Qualitative semi-structured interviews were conducted with 26 people comprising parents (n = 15), dentists working in primary care (n = 6) and operating dentists (n = 5) in relation to DGA. Participants were recruited from areas across the North West of England to ensure a variety referral and treatment experiences were captured. Field notes were made during visits to all settings included in the study and explored alongside interview transcripts to elicit key themes. A variety of positive and negative impacts on children and parents throughout the referral process and operation day were apparent. Key themes established were clustered around three key topics: 1. Organisational and professional concerns regarding referrals, delivery of treatment and prevention. 2. The role of hospital environment and routine on the emotional experiences of children. 3. The influence of the wider social context on dental health. These findings suggest the need and perceived value of: tailored services for children (such as play specialists) and improved information, such as clear guidance regarding wait times and what is to be expected on the day of the procedure. These features were viewed to be helpful in alleviating the stress and anxiety often associated with DGA. While some elements will always be restricted in part to the hospital setting in which they occur, there are several aspects where best practice could be shared amongst hospitals and, where issues such as wait times have been acknowledged, alternative pathways can be explored in order to address areas which can impact negatively on children.

Changes in referral protocols for cardiac surgery: do financial considerations come at a cost?

PubMed

Amado, José; Bento, Dina; Silva, Daniela; Chin, Joana; Marques, Nuno; Gago, Paula; Mimoso, Jorge; de Jesus, Ilídio

2015-10-01

The aim of this study was to determine whether changes to referral protocols for cardiac surgery have had an impact on waiting times, hospitalizations and mortality during the waiting period and during the first year of follow-up after surgery. In this retrospective study of patients referred for cardiac surgery between January 1, 2008 and September 30, 2014, the study population was divided into two groups: those referred before (group A, January 1, 2008 to August 31, 2011) and after (group B, September 1, 2011 to September 30, 2014) the change in referral protocols. A telephone follow-up was conducted. There were 864 patients referred for cardiac surgery, 557 in group A and 307 in group B. Patient characteristics were similar between groups. The mean waiting time for surgery was 10.6±18.5 days and 55.7±79.9 days in groups A and B, respectively (p=0.00). During the waiting period two patients (0.4%) were hospitalized in group A and 28 (9.1%) in group B (p=0:00); mortality was, respectively, 0% and 2.3% (p=0.00). During one-year follow-up 12.8% of group A patients and 16% of group B patients were hospitalized. Cardiovascular mortality in this period was around 5% in both groups (p>0.05). Changes to referral protocols for cardiac surgery had an impact on waiting times, on the number of hospitalizations and on mortality in this period. Copyright © 2014 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

Impact of discharge planning decision support on time to readmission among older adult medical patients.

PubMed

Bowles, Kathryn H; Hanlon, Alexandra; Holland, Diane; Potashnik, Sheryl L; Topaz, Maxim

2014-01-01

Hospital clinicians are overwhelmed with the volume of patients churning through the health care systems. The study purpose was to determine whether alerting case managers about high-risk patients by supplying decision support results in better discharge plans as evidenced by time to first hospital readmission. Four medical units at one urban, university medical center. A quasi-experimental study including a usual care and experimental phase with hospitalized English-speaking patients aged 55 years and older. The intervention included using an evidence-based screening tool, the Discharge Decision Support System (D2S2), that supports clinicians' discharge referral decision making by identifying high-risk patients upon admission who need a referral for post-acute care. The usual care phase included collection of the D2S2 information, but not sharing the information with case managers. The experimental phase included data collection and then sharing the results with the case managers. The study compared time to readmission between index discharge date and 30 and 60 days in patients in both groups (usual care vs. experimental). After sharing the D2S2 results, the percentage of referral or high-risk patients readmitted by 30 and 60 days decreased by 6% and 9%, respectively, representing a 26% relative reduction in readmissions for both periods. Supplying decision support to identify high-risk patients recommended for postacute referral is associated with better discharge plans as evidenced by an increase in time to first hospital readmission. The tool supplies standardized information upon admission allowing more time to work with high-risk admissions.

Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures

PubMed Central

Stewart, Barclay T.; Tansley, Gavin; Gyedu, Adam; Ofosu, Anthony; Donkor, Peter; Appiah-Denkyira, Ebenezer; Quansah, Robert; Clarke, Damian L.; Volmink, Jimmy; Mock, Charles

2017-01-01

IMPORTANCE Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known. OBJECTIVES To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana. DESIGN, SETTING, AND PARTICIPANTS Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014. MAIN OUTCOMES AND MEASURES All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis. RESULTS Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure–capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440–1418 vs 360; interquartile range, 0–896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%–83.4%) and 71.4% (UI, 64.4%–75.0%), respectively. Five hospitals were identified for targeted capability improvement. CONCLUSIONS AND RELEVANCE Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery. PMID:27331865

Diagnosis and outcome of psychiatric referrals to the Field Mental Health Team, 202 Field Hospital, Op Telic I.

PubMed

Scott, J N

2005-06-01

To assess referrals to a Field Hospital Mental Health Team (FMHT), assign a diagnosis, provide appropriate treatment, and decide whether suitable for safe return to unit in theatre (RTU), or evacuation home on psychiatric grounds (evac). All documented referrals to the FMHT of 202 Field Hospital during the Op Telic 1 study period of 17 March (day 1) to 23 July 2003 (day 129) were included. Data were collected on rank, gender, diagnosis, outcome (whether RTU or evac), and whether TA before mobilisation. Diagnosis was assigned by ICD-10 criteria. The FMHT documented 170 cases, 12 of whom were seen twice and one on three occasions, resulting in 184 referrals, all of whom were British. The commonest diagnosis was adjustment reaction (F43), accounting for 68% of all cases (n = 116). These were divided between chiefly theatre-related (n = 77) or chiefly home-related (n = 39) reactions. The majority (94%) of these cases were RTU. Referrals where the diagnosis was a Depressive disorder (F32, n = 23) or Intentional self-harm (by sharp object, X78, n = 7) were evacuated. Outcome was similar for Regular and TA personnel, with on average 72% of cases RTU. The majority of cases seen were ORs, reflecting their numbers in theatre. Only 14 NCOs and 14 officers were referred. Thirteen of the latter were TA before mobilisation. Gender was not associated with outcome, or TA status, but was associated with rank, in that significantly more female officers were referred. The FMHT role tasks emerged as (a) psychiatric triage and treatment, (b) psychological support of hospital staff, and (c) welfare and pastoral care liaison. The utility of the psychiatric management model employed, built upon previous military medical doctrines, was tested in a modern theatre of conflict, and seemed to prove its worth.

Interdisciplinary Rehabilitation Referrals in a Concussion Clinic Cohort: An Exploratory Analysis.

PubMed

Vargo, Mary M; Vargo, Kevin G; Gunzler, Douglas; Fox, Kermit W

2016-03-01

To assess the frequency and spectrum of referrals to rehabilitation disciplines in a concussion clinic population and factors associated with need for referral. Retrospective study. Concussion clinic within the Physical Medicine and Rehabilitation Department of an academic medical center. Patients receiving physiatric management for concussion care. Referral to physical therapy (PT), occupational therapy, speech therapy (ST), neuropsychology, or any referral (Any), and reasons for referral. Demographic and clinical variables were analyzed for possible association with referral to rehabilitation disciplines. These independent variables included mechanism of injury, referral source, age, gender, provider, days since injury, presenting Sports Concussion Assessment Tool 2 (SCAT2) symptom score, insurance type, clinical risk factors, whether the injury was work related and whether the patient had been hospitalized. Among 262 patients meeting inclusion criteria, the most commonly prescribed individual therapy was physical therapy (74 patients; 28%), followed by speech therapy (60 patients, 23%), neuropsychology (27 patients, 10.3%), and occupational therapy (19 patients, 7.2%). In all, 121 (46%) of patients were referred to one or more disciplines. The most common reasons for referral were cognitive strategies (54 patients, 21%), balance/vestibular therapy (50 patients,19%), and neck pain (32 patients, 12%). Per multivariate logistic regression analysis, covariates associated with PT: age, SCAT2 symptom score, gender, provider, and (inversely) cognitive/learning disorder; ST: time elapsed since injury, gender, and referral source of internal clinic; Any: SCAT2 symptom score. Referrals did not significantly vary by mechanism of injury (sports, fall, vehicular, etc), whether work-related, or whether the patient had been hospitalized. Insurance factors were significant for PT and Any on the univariate analysis but not logistic regression. Relatively little has been described about the typical rehabilitation requirements of individuals recovering from concussion. Although rest and guided return to usual activities have been emphasized as mainstays of management, a large number of patients in this concussion cohort were determined to require additional rehabilitation services to assist in recovery. Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

Design and development of a computer-based clinical referral system for use within a physician hospital organization.

PubMed

Sittig, D F; Franklin, M; Turetsky, M; Sussman, A J; Bates, D W; Komaroff, A L; Teich, J M

1998-01-01

The process of creating a clinical referral for a patient and the transfer of information from the primary care physician to the specialist and back again is a key component in the struggle to deliver less costly and more effective clinical care. We have created a computer-based clinical referral application which facilitates 1) identifying an appropriate specialist; 2) collecting the clinical, demographic, and financial data required to generate a referral; and 3) transferring the information between the specialist and the primary care physician. Preliminary results indicate that the new computer-based process is faster.

The Effect of 5S-Continuous Quality Improvement-Total Quality Management Approach on Staff Motivation, Patients’ Waiting Time and Patient Satisfaction with Services at Hospitals in Uganda

PubMed Central

Take, Naoki; Byakika, Sarah; Tasei, Hiroshi; Yoshikawa, Toru

2015-01-01

This study aimed at analyzing the effect of 5S practice on staff motivation, patients’ waiting time and patient satisfaction with health services at hospitals in Uganda. Double-difference estimates were measured for 13 Regional Referral Hospitals and eight General Hospitals implementing 5S practice separately. The study for Regional Referral Hospitals revealed 5S practice had the effect on staff motivation in terms of commitment to work in the current hospital and waiting time in the dispensary in 10 hospitals implementing 5S, but significant difference was not identified on patient satisfaction. The study for General Hospitals indicated the effect of 5S practice on patient satisfaction as well as waiting time, but staff motivation in two hospitals did not improve. 5S practice enables the hospitals to improve the quality of services in terms of staff motivation, waiting time and patient satisfaction and it takes as least four years in Uganda. The fourth year since the commencement of 5S can be a threshold to move forward to the next step, Continuous Quality Improvement. PMID:28299136

The Effect of 5S-Continuous Quality Improvement-Total Quality Management Approach on Staff Motivation, Patients' Waiting Time and Patient Satisfaction with Services at Hospitals in Uganda.

PubMed

Take, Naoki; Byakika, Sarah; Tasei, Hiroshi; Yoshikawa, Toru

2015-03-31

This study aimed at analyzing the effect of 5S practice on staff motivation, patients' waiting time and patient satisfaction with health services at hospitals in Uganda. Double-difference estimates were measured for 13 Regional Referral Hospitals and eight General Hospitals implementing 5S practice separately. The study for Regional Referral Hospitals revealed 5S practice had the effect on staff motivation in terms of commitment to work in the current hospital and waiting time in the dispensary in 10 hospitals implementing 5S, but significant difference was not identified on patient satisfaction. The study for General Hospitals indicated the effect of 5S practice on patient satisfaction as well as waiting time, but staff motivation in two hospitals did not improve. 5S practice enables the hospitals to improve the quality of services in terms of staff motivation, waiting time and patient satisfaction and it takes as least four years in Uganda. The fourth year since the commencement of 5S can be a threshold to move forward to the next step, Continuous Quality Improvement.

Inter-Facility Transfer of Pediatric Burn Patients from U.S. Emergency Departments

PubMed Central

Johnson, Sarah A.; Shi, Junxin; Groner, Jonathan I.; Thakkar, Rajan K.; Fabia, Renata; Besner, Gail E.; Xiang, Huiyun; Wheeler, Krista K.

2016-01-01

Purpose To describe the epidemiology of pediatric burn patients seen in U.S. emergency departments (EDs) and to determine factors associated with inter-facility transfer. Methods We analyzed data from the 2012 Nationwide Emergency Department Sample. Current American Burn Association (ABA) Guidelines were used to identify children <18 who met criteria for referral to burn centers. Burn patient admission volume was used as a proxy for burn expertise. Logistic models were fitted to examine the odds of transfer from low volume hospitals. Results In 2012, there were an estimated 126,742 (95% CI: 116,104–137,380) pediatric burn ED visits in the U.S. Of the 69,003 (54.4%) meeting referral criteria, 83.2% were in low volume hospitals. Only 8.2% of patients meeting criteria were transferred from low volume hospitals. Of the 52,604 (95% CI: 48,433 – 56,775) not transferred, 98.3% were treated and released and 1.7% were admitted without transfer; 54.7% of burns involved hands. Conclusions Over 90% of pediatric burn ED patients meet ABA burn referral criteria but are not transferred from low volume hospitals. Perhaps a portion of the 92% of patients currently receiving definitive care in low volume hospitals are under-referred and would have improved clinical outcomes if transferred at the time of presentation. PMID:27554628

Plastic surgery outpatient audit: principles and practice of "consultant only" clinics.

PubMed

Griffiths, R W

1990-11-01

The effect of instituting "consultant only" clinics on plastic surgery outpatient activity was to produce a 19% reduction in both clinic sessions and new patient bookings, but a 50% reduction in booked follow-up patients; non-attender rates reduced from 20% to 11% (Northern General Hospital, April 1986-March 1989). Mean clinic attendances reduced from 35 to 26 (Northern General Hospital) and from 33 to 27 (Barnsley District Hospital)--26% and 18%, respectively. Analysis of new referrals to such clinics in the 6 months January-June 1989 showed 41% of patients came from general practitioners, although 80% of "aesthetic" conditions came from this source. 31% of referrals were for malignancy, 51/72 (70%) being basal cell carcinomas. Malignancies waited on average 4 weeks, benign conditions 15 weeks, and "aesthetic" conditions 28 weeks from referral to consultation. Such clinic management has dramatically reduced follow-up episodes, but regulation of new patient attendances is associated with appreciable waiting times for non-malignant conditions. To reduce such waiting times and pursue a "consultant only" clinic policy nationally requires many more consultants.

Health issues of refugees attending an infectious disease refugee health clinic in a regional Australian hospital

PubMed

J Masters, Peta; J Lanfranco, Penelope; Sneath, Emmy; J Wade, Amanda; Huffam, Sarah; Pollard, James; Standish, James; McCloskey, Kate; Athan, Eugene; P O'Brien, Daniel; Friedman, N Deborah

2018-05-01

Refugees in Australia present with conditions different to those of the general population. The aim of this study was to review the reasons for referral, prevalence of conditions and treatment outcomes for refugee patients attending a specialist referral clinic in regional Victoria. A retrospective review was undertaken of patients attending the refugee health clinic at University Hospital Geelong from January 2007 to December 2012. Two hundred and ninety-one refugee patients attended the clinic over the six-year period. Latent tuberculosis infection (LTBI) (54.6%), vitamin deficiencies (15.8%), hepatitis B (11%) and schistosomiasis (11%) were the most common diagnoses. Less than two-thirds of the patients completed LTBI treatment; 35.4% of patients attended all scheduled clinic appointments. LTBI, vitamin deficiencies, parasitic infections and hepatitis B were the most common diagnoses among refugees referred to the University Hospital Geelong (UHG) Refugee Health Clinic from January 2007 to December 2012. General practitioners play an important role in the care of refugees, guiding referral to specialist services when necessary and recognising the potential implications of suboptimal clinic attendance and treatment completion.

Reactions to Psychiatry Referral in Patients Presenting with Physical Complaints to Medical and Surgical Outpatient Services.

PubMed

Singh, Shubh Mohan; Subodh, B N; Mehra, Aseem; Mehdi, Abbas

2017-01-01

While it is well known that patients with psychiatric illness feel stigmatized, little is known about the reactions to a psychiatric referral among those who visit general hospital medical and surgical services for their complaints. This study assessed the sociodemographic details, psychiatric diagnosis, somatic symptom severity, and interview-based reactions to referral among patients referred to psychiatry services from other departments in a general tertiary hospital in North India. Fifty-nine males and 101 females were assessed over 6 months for this purpose. A majority of patients were diagnosed with a psychiatric disorder and had significant somatic symptom severity. The themes explored were the decision to accept the referral, possibility of the presence of mental illness as signified by a psychiatric diagnosis and factors that enabled or impeded psychiatric treatment seeking. Results indicate that patients did not empower in decision-making, a reluctance to accept the possibility of a psychiatric diagnosis and accept medication and had poor knowledge about psychiatry. Referring clinicians and psychiatrists should be sensitive to patient perceptions so that better care is possible.

Quality of psychiatric care in the general hospital: referrer perceptions of an inpatient liaison psychiatry service.

PubMed

Solomons, Luke C; Thachil, Ajoy; Burgess, Caroline; Hopper, Adrian; Glen-Day, Vicky; Ranjith, Gopinath; Hodgkiss, Andrew

2011-01-01

To explore the experience of senior staff on acute medical wards using an established inpatient liaison psychiatry service and obtain their views on clinically relevant performance measures. Semistructured face-to-face interviews with consultants and senior nurses were taped, transcribed and analyzed manually using the framework method of analysis. Twenty-five referrers were interviewed. Four key themes were identified - benefits of the liaison service, potential areas of improvement, indices of service performance such as speed and quality of response and expanded substance misuse service. Respondents felt the liaison service benefited patients, staff and service delivery in the general hospital. Medical consultants wanted stepped management plans devised by consultant liaison psychiatrists. Senior nurses, who perceived themselves as frontline crisis managers, valued on-the-spot input on patient management. Consultants and senior nurses differed in their expectations of liaison psychiatry. Referrers valued speed of response and regarded time from referral to definitive management plan as a key performance indicator for benchmarking services. Copyright © 2011 Elsevier Inc. All rights reserved.

Using web technology and Java mobile software agents to manage outside referrals.

PubMed Central

Murphy, S. N.; Ng, T.; Sittig, D. F.; Barnett, G. O.

1998-01-01

A prototype, web-based referral application was created with the objective of providing outside primary care providers (PCP's) the means to refer patients to the Massachusetts General Hospital and the Brigham and Women's Hospital. The application was designed to achieve the two primary objectives of providing the consultant with enough data to make decisions even at the initial visit, and providing the PCP with a prompt response from the consultant. The system uses a web browser/server to initiate the referral and Java mobile software agents to support the workflow of the referral. This combination provides a light client implementation that can run on a wide variety of hardware and software platforms found in the office of the PCP. The implementation can guarantee a high degree of security for the computer of the PCP. Agents can be adapted to support the wide variety of data types that may be used in referral transactions, including reports with complex presentation needs and scanned (faxed) images Agents can be delivered to the PCP as running applications that can perform ongoing queries and alerts at the office of the PCP. Finally, the agent architecture is designed to scale in a natural and seamless manner for unforeseen future needs. PMID:9929190

Implementation of medical retina virtual clinics in a tertiary eye care referral centre.

PubMed

Kortuem, Karsten; Fasler, Katrin; Charnley, Amanda; Khambati, Hussain; Fasolo, Sandro; Katz, Menachem; Balaskas, Konstantinos; Rajendram, Ranjan; Hamilton, Robin; Keane, Pearse A; Sim, Dawn A

2018-01-06

The increasing incidence of medical retinal diseases has created capacity issues across UK. In this study, we describe the implementation and outcomes of virtual medical retina clinics (VMRCs) at Moorfields Eye Hospital, South Division, London. It represents a promising solution to ensure that patients are seen and treated in a timely fashion METHODS: First attendances in the VMRC (September 2016-May 2017) were included. It was open to non-urgent external referrals and to existing patients in a face-to-face clinic (F2FC). All patients received visual acuity testing, dilated fundus photography and optical coherence tomography scans. Grading was performed by consultants, fellows and allied healthcare professionals. Outcomes of these virtual consultations and reasons for F2FC referrals were assessed. A total number of 1729 patients were included (1543 were internal and 186 external referrals). The majority were diagnosed with diabetic retinopathy (75.1% of internal and 46.8% of external referrals). Of the internal referrals, 14.6% were discharged, 54.5% continued in VMRC and 30.9% were brought to a F2FC. Of the external referrals, 45.5% were discharged, 37.1% continued in VMRC and 17.4% were brought to a F2FC. The main reason for F2FC referrals was image quality (34.7%), followed by detection of potentially treatable disease (20.2%). VMRC can be implemented successfully using existing resources within a hospital eye service. It may also serve as a first-line rapid-access clinic for low-risk referrals. This would enable medical retinal services to cope with increasing demand and efficiently allocate resources to those who require treatment. © 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.

Characterization and referral patterns of ST-elevation myocardial infarction patients admitted to chest pain units rather than directly to catherization laboratories. Data from the German Chest Pain Unit Registry.

PubMed

Schmidt, Frank P; Perne, Andrea; Hochadel, Matthias; Giannitsis, Evangelos; Darius, Harald; Maier, Lars S; Schmitt, Claus; Heusch, Gerd; Voigtländer, Thomas; Mudra, Harald; Gori, Tommaso; Senges, Jochen; Münzel, Thomas

2017-03-15

Direct transfer to the catheterization laboratory for primary percutaneous coronary intervention (PCI) is standard of care for patients with ST-segment elevation myocardial infarction (STEMI). Nevertheless, a significant number of STEMI-patients are initially treated in chest pain units (CPUs) of admitting hospitals. Thus, it is important to characterize these patients and to define why an important deviation from recommended clinical pathways occurs and in particular to quantify the impact of deviation on critical time intervals. 1679 STEMI patients admitted to a CPU in the period from 2010 to 2015 were enrolled in the German CPU registry (8.5% of 19,666). 55.9% of the patients were delivered by an emergency medical system (EMS), 16.1% transferred from other hospitals and 15.2% referred by a general practitioner (GP). 12.7% were self-referrals. 55% did not get a pre-hospital ECG. Compared to the EMS, referral by GPs markedly delayed critical time intervals while a pre-hospital ECG demonstrating ST-segment elevation reduced door-to-balloon time. When compared to STEMI patients (n=21,674) enrolled in the ALKK-registry, CPU-STEMI patients had a lower risk profile, their treatment in the CPU was guideline-conform and in-hospital mortality was low (1.5%). CPU-STEMI patients represent a numerically significant group because a pre-hospital ECG was not documented. Treatment in the CPU is guideline-conform and the intra-hospital mortality is low. The lack of a pre-hospital ECG and admission via the GP substantially delay critical time intervals suggesting that in patients with symptoms suggestive an ACS, the EMS should be contacted and not the GP. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Associations between presence of relevant information in referrals to radiology and prevalence rates in patients with suspected pulmonary embolism.

PubMed

Hedner, Charlotta; Sundgren, Pia C; Kelly, Aine Marie

2013-09-01

The purpose of this study was to assess if the presence of information including the pretest probability (Wells score), other known risk factors, and symptoms given on referrals for computed tomography (CT) pulmonary angiography correlated with prevalence rates for pulmonary embolism (PE). Also, to evaluate for differences between a university and a regional hospital setting regarding patient characteristics, amount of relevant information provided on referrals, and prevalence rates for pulmonary embolism. Retrospective review of all consecutive referrals (emergency room, inpatient, and outpatient) for CT performed on children and adults for suspected PE from two sites: a tertiary (university) hospital (site 1) and a secondary (regional) hospital (site 2) over a 5-year period. The overall prevalence rate was 510/3641 or 14% of all referrals. Significantly higher number of males had a positive CT compared to women (18% versus 12%, P < .001). Although no statistically significant relationship between a greater amount of relevant information on the referral and the probability for positive finding existed, a slight trend was noted (P = .09). In two categories, "hypoxia" and "signs of deep vein thrombosis," the presence of this information conferred a higher probability for pulmonary embolism, P < .001. In the categories, "chest pain," "malaise," and "smoker/chronic obstructive pulmonary disease", the absence of information conferred a higher probability for pulmonary embolism. The amount of relevant clinical information on the request did not correlate with prevalence rates, which may reflect a lack of documentation on the part of emergency physicians who may use a "gestalt" approach. Request forms likely did not capture all relevant patient risks and many factors may interact with each other, both positively and negatively. Pretest probability estimations were rarely performed, despite their inclusion in major society guidelines. Copyright © 2013 AUR. Published by Elsevier Inc. All rights reserved.

Health and economic effects from linking bedside and outpatient tobacco cessation services for hospitalized smokers in two large hospitals: study protocol for a randomized controlled trial.

PubMed

Fellows, Jeffrey L; Mularski, Richard; Waiwaiole, Lisa; Funkhouser, Kim; Mitchell, Julie; Arnold, Kathleen; Luke, Sabrina

2012-08-01

Extended smoking cessation follow-up after hospital discharge significantly increases abstinence. Hospital smoke-free policies create a period of 'forced abstinence' for smokers, thus providing an opportunity to integrate tobacco dependence treatment, and to support post-discharge maintenance of hospital-acquired abstinence. This study is funded by the National Heart, Lung, and Blood Institute (1U01HL1053231). The Inpatient Technology-Supported Assisted Referral study is a multi-center, randomized clinical effectiveness trial being conducted at Kaiser Permanente Northwest (KPNW) and at Oregon Health & Science University (OHSU) hospitals in Portland, Oregon. The study assesses the effectiveness and cost-effectiveness of linking a practical inpatient assisted referral to outpatient cessation services plus interactive voice recognition (AR + IVR) follow-up calls, compared to usual care inpatient counseling (UC). In November 2011, we began recruiting 900 hospital patients age ≥18 years who smoked ≥1 cigarettes in the past 30 days, willing to remain abstinent postdischarge, have a working phone, live within 50 miles of the hospital, speak English, and have no health-related barriers to participation. Each site will randomize 450 patients to AR + IVR or UC using a 2:1 assignment strategy. Participants in the AR + IVR arm will receive a brief inpatient cessation consult plus a referral to available outpatient cessation programs and medications, and four IVR follow-up calls over seven weeks postdischarge. Participants do not have to accept the referral. At KPNW, UC participants will receive brief inpatient counseling and encouragement to self-enroll in available outpatient services. The primary outcome is self-reported thirty-day smoking abstinence at six months postrandomization for AR + IVR participants compared to usual care. Additional outcomes include self-reported and biochemically confirmed seven-day abstinence at six months, self-reported seven-day, thirty-day, and continuous abstinence at twelve months, intervention dose response at six and twelve months for AR + IVR recipients, incremental cost-effectiveness of AR + IVR intervention compared to usual care at six and twelve months, and health-care utilization and expenditures at twelve months for AR + IVR recipients compared to UC. This study will provide important evidence for the effectiveness and cost-effectiveness of linking hospital-based tobacco treatment specialists' services with discharge follow-up care. ClinicalTrials.gov: NCT01236079.

District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries

PubMed Central

Stewart, Barclay T; Gyedu, Adam; Quansah, Robert; Addo, Wilfred Larbi; Afoko, Akis; Agbenorku, Pius; Amponsah-Manu, Forster; Ankomah, James; Appiah-Denkyira, Ebenezer; Baffoe, Peter; Debrah, Sam; Donkor, Peter; Dorvlo, Theodor; Japiong, Kennedy; Kushner, Adam L; Morna, Martin; Ofosu, Anthony; Oppong-Nketia, Victor; Tabiri, Stephen; Mock, Charles

2015-01-01

Introduction Prospective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly. Methods Consensus on trauma care audit filters was built between twenty panelists using a Delphi technique with four anonymous, iterative surveys designed to elicit: i) trauma care processes to be measured; ii) important features of audit filters for the district-level hospital setting; and iii) potentially useful filters. Filters were ranked on a scale from 0 – 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8. Results Panelists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1 - 0.58; Round 2 - 0.66; Round 3 - 0.76; and Round 4 - 0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage - vital signs are recorded within 15 minutes of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation - a large bore IV was placed within 15 minutes of patient arrival; referral - if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer. Conclusion This study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step toward improving care for the injured at district-level hospitals in LMICs. PMID:26492882

Preschool children's vision screening in New Zealand: a retrospective evaluation of referral accuracy.

PubMed

Langeslag-Smith, Miriam A; Vandal, Alain C; Briane, Vincent; Thompson, Benjamin; Anstice, Nicola S

2015-11-27

To assess the accuracy of preschool vision screening in a large, ethnically diverse, urban population in South Auckland, New Zealand. Retrospective longitudinal study. B4 School Check vision screening records (n=5572) were compared with hospital eye department data for children referred from screening due to impaired acuity in one or both eyes who attended a referral appointment (n=556). False positive screens were identified by comparing screening data from the eyes that failed screening with hospital data. Estimation of false negative screening rates relied on data from eyes that passed screening. Data were analysed using logistic regression modelling accounting for the high correlation between results for the two eyes of each child. Positive predictive value of the preschool vision screening programme. Screening produced high numbers of false positive referrals, resulting in poor positive predictive value (PPV=31%, 95% CI 26% to 38%). High estimated negative predictive value (NPV=92%, 95% CI 88% to 95%) suggested most children with a vision disorder were identified at screening. Relaxing the referral criteria for acuity from worse than 6/9 to worse than 6/12 improved PPV without adversely affecting NPV. The B4 School Check generated numerous false positive referrals and consequently had a low PPV. There is scope for reducing costs by altering the visual acuity criterion for referral. 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/

Development and evaluation of training in culturally specific screening and brief intervention for hospital patients with alcohol-related injuries.

PubMed

Whitty, Megan; Nagel, Tricia; Jayaraj, Rama; Kavanagh, David

2016-02-01

To evaluate health practitioners' confidence and knowledge of alcohol screening, brief intervention and referral after training in a culturally adapted intervention on alcohol misuse and well-being issues for trauma patients. Mixed methods, involving semi-structured interviews at baseline and a post-workshop questionnaire. Targeted acute care within a remote area major tertiary referral hospital. Ten key informants and 69 questionnaire respondents from relevant community services and hospital-based health care professionals. Screening and brief intervention training workshops and resources for 59 hospital staff. Self-reported staff knowledge of alcohol screening, brief intervention and referral, and satisfaction with workshop content and format. After training, 44% of participants reported being motivated to implement alcohol screening and intervention. Satisfaction with training was high, and most participants reported that their knowledge of screening and brief intervention was improved. Targeted educational interventions can improve the knowledge and confidence of inpatient staff who manage patients at high risk of alcohol use disorder. Further research is needed to determine the duration of the effect and influence on practice behaviour. Ongoing integrated training, linked with systemic support and established quality improvement processes, is required to facilitate sustained change and widespread dissemination. © 2015 National Rural Health Alliance Inc.

Barriers to knowledge sharing in Chinese healthcare referral services: an emergent theoretical model.

PubMed

Zhou, Lihong; Nunes, Miguel Baptista

2016-01-01

This paper reports on a research study that aims to identify and explain barriers to knowledge sharing (KS) in the provision of healthcare referral services in Chinese healthcare organisations. An inductive case study approach was employed, in which 24 healthcare professionals and workers from four healthcare organisations in the province of Hubei, Central China, were interviewed using semi-structured scripts. Through data analysis, 14 KS barriers emerged in four main themes: interpersonal trust barriers, communication barriers, management and leadership barriers, and inter-institutional barriers. A cause-consequence analysis of the identified barriers revealed that three of them are at the core of the majority of problems, namely, the absence of national and local policies for inter-hospital KS, lack of a specific hospital KS requirement, and lack of mutual acquaintance. To resolve KS problems, it is of great importance that healthcare governance agencies, both at the national and regional levels, take leadership in the process of KS implementation by establishing specific and strong policies for inter-institutional KS in the referral process. This paper raises important issues that exceed academic interests and are important to healthcare professionals, hospital managers, and Information communication technology (ICT) managers in hospitals, as well as healthcare politicians and policy makers.

Adult and paediatric mortality patterns in a referral hospital in Liberia 1 year after the end of the war.

PubMed

Huerga, Helena; Vasset, Brigitte; Prados, Elisa

2009-05-01

The aim of this study was to describe and analyse hospital mortality patterns after the Liberian war. Data were collected retrospectively from January to July 2005 in a referral hospital in Monrovia, Liberia. The overall fatality rate was 17.2% (438/2543) of medical admissions. One-third of deaths occurred in the first 24h. The adult fatality rate was 23.3% (241/1034). Non-infectious diseases accounted for 56% of the adult deaths. The main causes of death were meningitis (16%), stroke (14%) and heart failure (10%). Associated fatality rates were 48%, 54% and 31% respectively. The paediatric fatality rate was 13.1% (197/1509). Infectious diseases caused 66% of paediatric deaths. In infants <1 month old, the fatality rate was 18% and main causes of death were neonatal sepsis (47%), respiratory distress (24%) and prematurity (18%). The main causes of death in infants > or =1 month old were respiratory infections (27%), malaria (23%) and severe malnutrition (16%). Associated fatality rates were 12%, 10% and 19%. Fatality rates were similar to those found in other sub-Saharan countries without a previous conflict. Early deaths could decrease through recognition and early referral of severe cases from health centres to the hospital and through assessment and priority treatment of these patients at arrival.

Barriers to knowledge sharing in Chinese healthcare referral services: an emergent theoretical model

PubMed Central

Nunes, Miguel Baptista

2016-01-01

Background This paper reports on a research study that aims to identify and explain barriers to knowledge sharing (KS) in the provision of healthcare referral services in Chinese healthcare organisations. Design An inductive case study approach was employed, in which 24 healthcare professionals and workers from four healthcare organisations in the province of Hubei, Central China, were interviewed using semi-structured scripts. Results Through data analysis, 14 KS barriers emerged in four main themes: interpersonal trust barriers, communication barriers, management and leadership barriers, and inter-institutional barriers. A cause–consequence analysis of the identified barriers revealed that three of them are at the core of the majority of problems, namely, the absence of national and local policies for inter-hospital KS, lack of a specific hospital KS requirement, and lack of mutual acquaintance. Conclusions To resolve KS problems, it is of great importance that healthcare governance agencies, both at the national and regional levels, take leadership in the process of KS implementation by establishing specific and strong policies for inter-institutional KS in the referral process. This paper raises important issues that exceed academic interests and are important to healthcare professionals, hospital managers, and Information communication technology (ICT) managers in hospitals, as well as healthcare politicians and policy makers. PMID:26895146

Creating a Shared Formulary in 7 Critical Access Hospitals

ERIC Educational Resources Information Center

Wakefield, Douglas S.; Ward, Marcia M.; Loes, Jean L.; O'Brien, John; Abbas, Nancy

2010-01-01

Purpose: This paper reports a case study of 7 Critical Access Hospitals' (CAH) and 1 rural referral hospital's successful collaboration to develop a shared formulary. Methods: Study methods included document reviews, interviews with key informants, and use of descriptive statistics. Findings: Through a systematic review and decision process, CAH…

Referrals to the Glasgow sheriff court liaison scheme since the introduction of referral criteria.

PubMed

Orr, Eilidh M; Baker, Melanie; Ramsay, Louise

2007-10-01

This study is an audit of a court liaison scheme operating in Glasgow sheriff court. It represents a follow-on of previous work after the introduction of referral criteria to delineate more closely the appropriate population to be seen. Results were compared with the previous audit. The total number of referrals decreased by 66%, however, the proportion with a psychotic illness increased to 33%. A high referral rate of prisoners with addictions continued, although the service was not primarily designed for them. Fewer patients with no psychiatric diagnosis were referred to the scheme. Outcomes were, however, similar with approximately the same admission rate to hospital. The introduction of criteria appears to have reduced the numbers of inappropriate referrals without excluding the population with serious mental disorder. The introduction of referral criteria seems to have been beneficial to the scheme. The scheme has since changed again and so there may be benefit for a further audit to monitor the continuing appropriateness of referrals. The provision of specific interventions targeting prisoners with addictions is also supported by this audit.

Audit of referral of obstetric emergencies in Angola: a tool for assessing quality of care.

PubMed

Strand, R T; de Campos, P A; Paulsson, G; de Oliveira, J; Bergström, S

2009-06-01

By auditing various aspects of referrals of obstetric emergencies, we wanted to study the effectiveness over time of a recently established network of peripheral birth units and two central hospitals in Luanda. 157 women referred for obstetric emergencies were studied regarding clinical outcome and process indicators like waiting time, partogramme quality and Caesarean section rate (CSR). After a change in routines at hospital admission and further partogramme education 92 referred women were compared with the former. Maternal mortality decreased from 17.8% to nil in the second. Total mean waiting time was reduced from 13.7 hours to 1.2 hours. Partogramme quality was significantly improved. CSR increased from 13 to 30%. Prolonged labour was the most common diagnosis.This study demonstrates the importance of clinic-based audit to enhance quality of care regarding referrals of patients with obstetric emergencies.

An analysis of OSHA inspections assessing contaminant exposures in general medical and surgical hospitals.

PubMed

Knight, Jordan L; Sleeth, Darrah K; Larson, Rodney R; Pahler, Leon F

2013-04-01

This study analyzed data from the Occupational Safety and Health Administration's (OSHA) Chemical Exposure Health Database to assess contaminant exposures in general medical and surgical hospitals. Seventy-five inspections conducted in these hospitals from 2005 through 2009 were identified. Five categories of inspections were conducted, the three most common being complaint-based, planned, and referral-based inspections. Complaint-based inspections comprised the majority of inspections-55 (73%) of the 75 conducted. The overall violation rate for all inspection types was 68%. This finding was compared to the violation rates of planned inspections (100%), referral-based inspections (83%), and complaint-based inspections (62%). Asbestos was the hazardous substance most commonly sampled and cited by OSHA in hospitals, with 127 samples collected during 24 inspections; 31% of the total 75 inspections resulting in one or more violations were due to asbestos. Copyright 2013, SLACK Incorporated.

Financial Analysis of Treating Periprosthetic Joint Infections at a Tertiary Referral Center.

PubMed

Waddell, Bradford S; Briski, David C; Meyer, Mark S; Ochsner, John L; Chimento, George F

2016-05-01

Periprosthetic joint infection (PJI) is a significant challenge to the orthopedic surgeon, patient, hospital, and insurance provider. Our study compares the financial information of self-originating and referral 2-stage revision hip and knee surgeries at our tertiary referral center for hip or knee PJI over the last 4 years. We performed an in-house retrospective financial review of all patients who underwent 2-stage revision hip or knee arthroplasty for infection between January 2008 and August 2013, comparing self-originating and referral cases. We found an increasing number of referrals over the study period. There was an increased cost of treating hips over knees. All scenarios generated a positive net income; however, referral hip PJIs offered lower reimbursement and net income per case (although not statistically significant), whereas knee PJIs offered higher reimbursement and net income per case (although not statistically significant). With referral centers treating increased numbers of infected joints performed elsewhere, we show continued financial incentive in accepting referrals, although with less financial gain than when treating one's own hip PJI and an increased financial gain when treating referral knee PJIs. Copyright © 2016 Elsevier Inc. All rights reserved.

Innovation in managing the referral process at a Canadian pediatric hospital.

PubMed

MacGregor, Daune; Parker, Sandra; MacMillan, Sharon; Blais, Irene; Wong, Eugene; Robertson, Chris J; Bruce-Barrett, Cindy

2009-01-01

The provision of timely and optimal patient care is a priority in pediatric academic health science centres. Timely access to care is optimized when there is an efficient and consistent referral system in place. In order to improve the patient referral process and, therefore, access to care, an innovative web-based system was developed and implemented. The Ambulatory Referral Management System enables the electronic routing for submission, review, triage and management of all outpatient referrals. The implementation of this system has provided significant metrics that have informed how processes can be improved to increase access to care. Use of the system has improved efficiency in the referral process and has reduced the work associated with the previous paper-based referral system. It has also enhanced communication between the healthcare provider and the patient and family and has improved the security and confidentiality of patient information management. Referral guidelines embedded within the system have helped to ensure that referrals are more complete and that the patient being referred meets the criteria for assessment and treatment in an ambulatory setting. The system calculates and reports on wait times, as well as other measures.

Evaluation of specialist referrals at a rural health care clinic.

PubMed

Biggerstaff, Mary Ellen; Short, Nancy

2017-07-01

Transition to a value-based care system involves reducing costs improving population health and enhancing the patient experience. Many rural hospitals must rely on specialist referrals because of a lack of an internal system of specialists on staff. This evaluation of the existing specialist referrals from primary care was conducted to better understand and improve the referral process and address costs, population health, and the patient experience. A 6-month retrospective chart review was conducted to evaluate quality and outcomes of specialty referrals submitted by 10 primary care providers. During a 6-month period in 2015, there was a total of 13,601 primary care patient visits and 3814 referrals, a referral rate of approximately 27%. The most striking result of this review was that nearly 50% of referred patients were not making the prescribed specialist appointment. Rather than finding a large number of unnecessary referrals, we found overall referral rates higher than expected, and a large percentage of our patients were not completing their referrals. The data and patterns emerging from this investigation would guide the development of referral protocols for a newly formed accountable care organization and lead to further quality improvement projects: a LEAN effort, dissemination of results to clinical and executive staff, protocols for orthopedic and neurosurgical referrals, and recommendations for future process improvements. ©2017 American Association of Nurse Practitioners.

Reasons for low uptake of referrals to ear and hearing services for children in Malawi.

PubMed

Bright, Tess; Mulwafu, Wakisa; Thindwa, Richard; Zuurmond, Maria; Polack, Sarah

2017-01-01

Early detection and appropriate intervention for children with hearing impairment is important for maximizing functioning and quality of life. The lack of ear and hearing services in low income countries is a significant challenge, however, evidence suggests that even where such services are available, and children are referred to them, uptake is low. The aim of this study was to assess uptake of and barriers to referrals to ear and hearing services for children in Thyolo District, Malawi. This was a mixed methods study. A survey was conducted with 170 caregivers of children who were referred for ear and hearing services during community-based screening camps to assess whether they had attended their referral and reasons for non-attendance. Semi-structured interviews were conducted with 23 caregivers of children who did not take up their referral to explore in-depth the reasons for non-uptake. In addition, 15 stakeholders were interviewed. Thematic analysis of the interview data was conducted and emerging trends were analysed. Referral uptake was very low with only 5 out of 150 (3%) children attending. Seven main interacting themes for non-uptake of referral were identified in the semi-structured interviews: location of the hospital, lack of transport, other indirect costs of seeking care, fear and uncertainty about the referral hospital, procedural problems within the camps, awareness and understanding of hearing loss, and lack of visibility and availability of services. This study has highlighted a range of interacting challenges faced by families in accessing ear and hearing services in this setting. Understanding these context specific barriers to non-uptake of ear and hearing services is important for designing appropriate interventions to increase uptake.

What kinds of cases do paediatricians refer to clinical ethics? Insights from 184 case referrals at an Australian paediatric hospital.

PubMed

McDougall, Rosalind J; Notini, Lauren

2016-09-01

Clinical ethics has been developing in paediatric healthcare for several decades. However, information about how paediatricians use clinical ethics case consultation services is extremely limited. In this project, we analysed a large set of case records from the clinical ethics service of one paediatric hospital in Australia. We applied a paediatric-specific typology to the case referrals, based on the triadic doctor-patient-parent relationship. We reviewed the 184 cases referred to the service in the period 2005-2014, noting features including the type of case, the referring department(s) and the patient's age at referral. The two most common types of referral involved clinician uncertainty about the appropriate care pathway for the child (26% of total referrals) and situations where the child's parents disagreed with the doctors' recommendations for the child's care (22% of total referrals). Referrals came from 28 different departments. Cancer, cardiology/cardiac surgery and general medicine referred the highest numbers of cases. The most common patient age groups were children under 1, and 14-15 years old. For three controversial areas of paediatric healthcare, clinicians had initiated processes of routine review of cases by the clinical ethics service. These insights into the way in which one very active paediatric clinical ethics service is used further our understanding of the work of paediatric clinical ethics, particularly the kinds of ethically challenging cases that paediatricians view as appropriate to refer for clinical ethics support. 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/

Reasons for low uptake of referrals to ear and hearing services for children in Malawi

PubMed Central

Mulwafu, Wakisa; Thindwa, Richard; Zuurmond, Maria; Polack, Sarah

2017-01-01

Background Early detection and appropriate intervention for children with hearing impairment is important for maximizing functioning and quality of life. The lack of ear and hearing services in low income countries is a significant challenge, however, evidence suggests that even where such services are available, and children are referred to them, uptake is low. The aim of this study was to assess uptake of and barriers to referrals to ear and hearing services for children in Thyolo District, Malawi. Methods This was a mixed methods study. A survey was conducted with 170 caregivers of children who were referred for ear and hearing services during community-based screening camps to assess whether they had attended their referral and reasons for non-attendance. Semi-structured interviews were conducted with 23 caregivers of children who did not take up their referral to explore in-depth the reasons for non-uptake. In addition, 15 stakeholders were interviewed. Thematic analysis of the interview data was conducted and emerging trends were analysed. Results Referral uptake was very low with only 5 out of 150 (3%) children attending. Seven main interacting themes for non-uptake of referral were identified in the semi-structured interviews: location of the hospital, lack of transport, other indirect costs of seeking care, fear and uncertainty about the referral hospital, procedural problems within the camps, awareness and understanding of hearing loss, and lack of visibility and availability of services. Conclusion This study has highlighted a range of interacting challenges faced by families in accessing ear and hearing services in this setting. Understanding these context specific barriers to non-uptake of ear and hearing services is important for designing appropriate interventions to increase uptake. PMID:29261683

Compliance with referral of sick children: a survey in five districts of Afghanistan.

PubMed

Newbrander, William; Ickx, Paul; Werner, Robert; Mujadidi, Farooq

2012-04-27

Recognition and referral of sick children to a facility where they can obtain appropriate treatment is critical for helping reduce child mortality. A well-functioning referral system and compliance by caretakers with referrals are essential. This paper examines referral patterns for sick children, and factors that influence caretakers' compliance with referral of sick children to higher-level health facilities in Afghanistan. The study was conducted in 5 rural districts of 5 Afghan provinces using interviews with parents or caretakers in 492 randomly selected households with a child from 0 to 2 years old who had been sick within the previous 2 weeks with diarrhea, acute respiratory infection (ARI), or fever. Data collectors from local nongovernmental organizations used a questionnaire to assess compliance with a referral recommendation and identify barriers to compliance. The number of referrals, 99 out of 492 cases, was reasonable. We found a high number of referrals by community health workers (CHWs), especially for ARI. Caretakers were more likely to comply with referral recommendations from community members (relative, friend, CHW, traditional healer) than with recommendations from health workers (at public clinics and hospitals or private clinics and pharmacies). Distance and transportation costs did not create barriers for most families of referred sick children. Although the average cost of transportation in a subsample of 75 cases was relatively high (US$11.28), most families (63%) who went to the referral site walked and hence paid nothing. Most caretakers (75%) complied with referral advice. Use of referral slips by health care providers was higher for urgent referrals, and receiving a referral slip significantly increased caretakers' compliance with referral. Use of referral slips is important to increase compliance with referral recommendations in rural Afghanistan.

Compliance with referral of sick children: a survey in five districts of Afghanistan

PubMed Central

2012-01-01

Background Recognition and referral of sick children to a facility where they can obtain appropriate treatment is critical for helping reduce child mortality. A well-functioning referral system and compliance by caretakers with referrals are essential. This paper examines referral patterns for sick children, and factors that influence caretakers’ compliance with referral of sick children to higher-level health facilities in Afghanistan. Methods The study was conducted in 5 rural districts of 5 Afghan provinces using interviews with parents or caretakers in 492 randomly selected households with a child from 0 to 2 years old who had been sick within the previous 2 weeks with diarrhea, acute respiratory infection (ARI), or fever. Data collectors from local nongovernmental organizations used a questionnaire to assess compliance with a referral recommendation and identify barriers to compliance. Results The number of referrals, 99 out of 492 cases, was reasonable. We found a high number of referrals by community health workers (CHWs), especially for ARI. Caretakers were more likely to comply with referral recommendations from community members (relative, friend, CHW, traditional healer) than with recommendations from health workers (at public clinics and hospitals or private clinics and pharmacies). Distance and transportation costs did not create barriers for most families of referred sick children. Although the average cost of transportation in a subsample of 75 cases was relatively high (US$11.28), most families (63%) who went to the referral site walked and hence paid nothing. Most caretakers (75%) complied with referral advice. Use of referral slips by health care providers was higher for urgent referrals, and receiving a referral slip significantly increased caretakers’ compliance with referral. Conclusions Use of referral slips is important to increase compliance with referral recommendations in rural Afghanistan. PMID:22540424

Identifying barriers from home to the appropriate hospital through near-miss audits in developing countries.

PubMed

Filippi, Véronique; Richard, Fabienne; Lange, Isabelle; Ouattara, Fatoumata

2009-06-01

Near-miss cases often arrive in critical condition in referral hospitals in developing countries. Understanding the reasons why women arrive at these hospitals in a moribund state is crucial to the reduction of the incidence and case fatality of severe obstetric complications. This paper discusses how near-miss audits can empower the hospital teams to document and help reduce barriers to obstetric care in the most useful way and makes practical suggestions on interviews, analytical framework, ethical issues and staff motivation. Review of the evidence shows that case reviews and confidential enquiries appear particularly suitable to the understanding of delays. Criterion-based audits can also achieve this by establishing criteria for referral. However, hospital staff have limited intervention tools at their disposal to address barriers to emergency care at the community level. It is therefore important to involve the district management team and representatives of the community in auditing the health care seeking and treatment of women with near-miss complications.

Referral pathways of patients with gallstones: a potential source of financial waste in the U.K. National Health Service?

PubMed

Borowski, David; Knox, Margaret; Kanakala, Venkat; Richardson, Stuart; Seymour, Keith; Attwood, Stephen; Slater, Bary

2010-01-01

Gallstone-related illnesses are one of the most common reasons for emergency hospital admissions, often with serious complications. Standard treatment of uncomplicated gallstone-disease is by laparoscopic cholecystectomy, which can be safely and cost-effectively performed during a short hospital stay or as day-case. This paper aims to evaluate the referral pattern of patients with gallstones, which treatment is given and whether patients admitted as emergency could have benefited from earlier elective referral. The management of these patients is examined in the context of payment by results to determine cost and potential savings. The approach takens was prospective clinical audit and patient questionnaire in a district general hospital. Cost comparisons were made using secondary care income (NHS tariff) and estimated cost of hospitalisation, investigations and treatment. Between May and July 2007, 114 patients were admitted with symptomatic gallstones, 62 (54.4 per cent) were emergencies. Cholecystectomy was performed in all 52 elective patients and performed or planned for 59/62 (95.2 per cent) emergencies. A total 17/62 emergencies (27.4 per cent) presented with complications of gallstones. 38/62 (61.3 per cent) had similar symptoms before, with 21/38 (55.3 per cent) diagnosed in primary care or by another hospital department. 11 (52.4 per cent) of these had not been referred for a surgical opinion; taking account of age, co-morbidity and data acquired for elective admissions, the cost of their treatment could have been reduced by at least pounds 16,194. A large proportion of patients admitted with symptomatic biliary disease could have been referred earlier and electively. Such referral practice could improve the quality of care and reduce cost for the NHS both in primary and secondary care.

Predicting the decisions of hospital based child protection teams to report to child protective services, police and community welfare services.

PubMed

Benbenishty, Rami; Jedwab, Merav; Chen, Wendy; Glasser, Saralee; Slutzky, Hanna; Siegal, Gil; Lavi-Sahar, Zohar; Lerner-Geva, Liat

2014-01-01

This study examines judgments made by hospital-based child protection teams (CPTs) when determining if there is reasonable suspicion that a child has been maltreated, and whether to report the case to a community welfare agency, to child protective services (CPS) and/or to the police. A prospective multi-center study of all 968 consecutive cases referred to CPTs during 2010-2011 in six medical centers in Israel. Centers were purposefully selected to represent the heterogeneity of medical centers in Israel in terms of size, geographical location and population characteristics. A structured questionnaire was designed to capture relevant information and judgments on each child referred to the team. Bivariate associations and multivariate multinomial logistic regressions were conducted to predict whether the decisions would be (a) to close the case, (b) to refer the case to community welfare services, or (c) to report it to CPS and/or the police. Bivariate and multivariate analyses identified a large number of case characteristics associated with higher probability of reporting to CPS/police or of referral to community welfare services. Case characteristics associated with the decisions include socio-demographic (e.g., ethnicity and financial status), parental functioning (e.g., mental health), previous contacts with authorities and hospital, current referral characteristics (e.g., parental referral vs. child referral), physical findings, and suspicious behaviors of child and parent. Most of the findings suggest that decisions of CPTs are based on indices that have strong support in the professional literature. Existing heterogeneity between cases, practitioners and medical centers had an impact on the overall predictability of the decision to report. Attending to collaboration between hospitals and community agencies is suggested to support learning and quality improvement. Copyright © 2013 Elsevier Ltd. All rights reserved.

Impact of Introducing Full-time In-house Coordinators on Referral and Organ Donation Rates in Rio de Janeiro Public Hospitals: A Health Care Innovation Practice.

PubMed

Sarlo, R; Pereira, G; Surica, M; Almeida, D; Araújo, C; Figueiredo, O; Rocha, E; Vargas, E

2016-09-01

Establishing an organization to promote organ donation and a good organ procurement team assure quality and improve performance on organ donation rates. Brazil's organ procurement structure is based on 2 models disseminated worldwide: the "Spanish model," based on in-house coordinators, and the "American organ procurement organization (OPO) model," with extra-hospital coordinators. In 2006, Brazil's Federal Government had formally introduced the in-house coordination model for every hospital equipped with a mechanical ventilator bed. In January 2012, the Rio de Janeiro State OPO, Programa Estadual de Transplantes, introduced an innovation in the organization of the in-house coordination model in 4 selected public hospitals with high organ donation potential. It consisted in launching full-time in-house coordination teams, with ≥1 physician and 2 nurses per hospital fully dedicated to organ procurement. The objectives were to observe the impact of this innovation in referral and organ donor conversion rates and to analyze the importance of middle managers in health care innovation implementation. Comparing the year before implementation (2011) and the year of 2014 showed that this innovation led to an overall increase in referrals-from 131 to 305 per year (+132%) and conversion rates-from 20% to 42% per year-resulting in an increase in number of donors from 26 to 128 per year (+390%). Despite wide variations among hospitals in the outcomes, our results seem very encouraging and express a positive impact of this model, suggesting that dissemination to other hospitals may increase the number of donors and transplants in our region. Copyright © 2016 Elsevier Inc. All rights reserved.

Electronic referrals: what matters to the users.

PubMed

Warren, Jim; Gu, Yulong; Day, Karen; White, Sue; Pollock, Malcolm

2012-01-01

Between September 2010 and May 2011 we evaluated three implementations of electronic referral (eReferral) systems at Hutt Valley, Northland and Canterbury District Health Boards in New Zealand. Qualitative and quantitative data were gathered through project documentation, database records and stakeholder interviews. This paper reports on the user perspectives based on interviews with 78 clinical, management and operational stakeholders in the three regions. Themes that emerge across the regions are compared and synthesised. Interviews focused on pre-planned domains including quality of referral, ease of use and patient safety, but agendas were adapted progressively to elaborate and triangulate on themes emerging from earlier interviews and to clarify indications from analysis of database records. The eReferral users, including general practitioners, specialists and administrative staff, report benefits in the areas of: (1) availability and transparency of referral-related data; (2) work transformation; (3) improved data quality and (4) the convenience of auto-population from the practice management system into the referral forms. eReferral provides enhanced visibility of referral data and status within the limits of the implementation (which only goes to the hospital door in some cases). Users in all projects indicated the desire to further exploit IT to enhance two-way communication between community and hospital. Reduced administrative handling is a clear work transformation benefit with mixed feedback regarding clinical workload impact. Innovations such as GP eReferral triaging teams illustrate the further potential for workflow transformation. Consistent structure in eReferrals, as well as simple legibility, enhances data quality. Efficiency and completeness is provided by auto-population of forms from system data, but opens issues around data accuracy. All three projects highlight the importance of user involvement in design, implementation and refinement. In keeping with this, Canterbury utilises a systematic pathway definition process that brings together GPs and specialist to debate and agree on the local management of a condition. User feedback exposes many opportunities for improving usability. The findings are based on individual experiences accounted by participating stakeholders; the risk of bias is mitigated, however, by triangulation across three distinct implementations of eReferrals. Quantitative follow-up on key outstanding issues, notably impact of structured eReferral forms on GP time to write a referral, is warranted. Key eReferral users include clinicians on both ends of the referral process as well as the administrative staff. User experience in three eReferral projects has shown that they particularly appreciate improvement of referral visibility, as well as information quality; promising workflow transformations have been achieved in some places. Auto-population of forms leads to opportunities, and issues, that are prompting further attention to data quality. While the importance of user feedback should be obvious, it is not universal to seek it or to provide resources to effectively follow up with improvements driven by such feedback. To maximise benefits, innovative health IT projects must take an iterative approach guided by ongoing user experience.

Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System

PubMed Central

Barker, Lisa A.; Gout, Belinda S.; Crowe, Timothy C.

2011-01-01

Malnutrition is a debilitating and highly prevalent condition in the acute hospital setting, with Australian and international studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay, higher treatment costs and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals. In Australia, nutrition screening upon hospital admission is not mandatory, which is of concern knowing that malnutrition remains under-reported and often poorly documented. Unidentified malnutrition not only heightens the risk of adverse complications for patients, but can potentially result in foregone reimbursements to the hospital through casemix-based funding schemes. It is strongly recommended that mandatory nutrition screening be widely adopted in line with published best-practice guidelines to effectively target and reduce the incidence of hospital malnutrition. PMID:21556200

[Governance of tertiary referral hospitals in the Democratic Republic of the Congo: a critical interpretive synthesis of the literature].

PubMed

Karemere, H; Kahindo, J B; Ribesse, N; Macq, J

2013-01-01

Because hospitals are complex enterprises requiring adaptive systems, it is appropriate to apply the theory and terminology of governance or even better adaptive governance to the interpretation of their management. This study focused on understanding hospital governance in Logo, Bunia, and Katana, three hospitals in two regions of the eastern DRC, which has been characterized by intermittent armed conflict since 1996. In such a context of war and continuous insecurity, how can governance be interpreted for hospitals required to adapt to a constantly changing environment to be able to continue to provide health care? A critical interpretive synthesis of the literature, identified by searching for keywords related to governance. The concepts of governance, adaptive governance, performance, leadership, and complex adaptive system concepts are defined. The interpretation of the concepts helps us to better understand (1) the hospital as a complex adaptive system, (2) the governance of tertiary referral hospitals, (3) analysis of hospital performance, and (4) leadership for good governance of these hospitals. The interpretation of these concepts raises several questions about their application to the eastern DRC. Conclusion. This critical interpretive synthesis opens the door to a new way of exploring tertiary hospitals and their governance in the eastern DRC.

Improving donation outcomes: hospital development and the Rapid Assessment of Hospital Procurement Barriers in Donation.

PubMed

Siminoff, Laura A; Traino, Heather M

2009-06-01

Deficiencies in the donation process continue to contribute to the shortage of organs available for transplant. Continuous quality improvement of hospitals' donation processes is needed to identify and correct the problems. To test the Rapid Assessment of Hospital Procurement Barriers in Donation (RAPiD), a direct observation technique with a focused ethnographic strategy, for assessing hospitals' donation processes and identifying areas in need of continuous quality improvement interventions. A pre-post assessment of hospitals' barriers to patient identification and referral, and family consent to donation. Seventeen hospitals within the catchment area of a Northeastern organ procurement organization were assessed by using the RAPiD method. Hospital administrators, health care providers, and staff (N = 537) were interviewed as part of the assessments. Interventions, including on-site training and education, and the use of in-house coordinators, were specifically tailored to each hospital's unique set of barriers to donation. The interventions were delivered to the hospitals in the form of recommendations. The participating organ procurement organization was responsible for implementation of the interventions. The RAPiD hospital evaluations revealed gaps in respondents' knowledge of organ donation, brain death, and referral criteria; a reluctance to declare brain death; and a rocky relationship between the hospitals and the organ procurement organization. As a result of the interventions, 9 hospitals' environments for organ donation improved, 7 showed no change, and 1 was worse.

Patient compliance with managed care emergency department referral: an orthopaedic view.

PubMed

Saroff, Don; Dell, Rick; Brown, E Richard

2002-04-01

Patient compliance with emergency department (ED)-generated referral is an important part of the delivery of quality health care. Although many studies from non-managed care health centers have reported on ED patient compliance, no studies have reported on this in a managed care setting. The objective of this study is to examine patient compliance with ED-generated referral and to produce a benchmark of follow-up rates possible in a capitated managed care system. That is to say, in a health care system whose members pay a uniform per capita payment or fee, one that has salaried physicians, owns its own hospitals, and has a mechanism of transition from ED to outpatient clinic that ensures referral accessibility. Retrospective review of consecutive ED patient compliance with ED-generated referral. All consecutive patients who presented to a managed care hospital's ED with an acute fracture and who were given an outpatient referral during the period from 23rd December 1998 to 23rd January, 1999. Of 8000 consecutive ED patients, 234 were included in the study. Compliance with ED-generated referral was determined from outpatient clinic records. Of the 234 patients treated in the ED and referred, 222 (94.9%) complied with follow-up appointments. We have demonstrated that an ED patient follow-up compliance rate of 94.9% can be obtained. It is probable that the high compliance rate is due to the features of the system studied. The high rate may also be related to the specific diagnosis studied, although previous literature reports poor ED patient compliance for the same diagnosis in a different ED setting. Additional research is needed to determine whether the high compliance rate reported in this study can be obtained in ED settings that are not part of a similar managed care system and to determine the role of referral accessibility (or inaccessibility) in current ED settings.

The Portsmouth-based glaucoma refinement scheme: a role for virtual clinics in the future?

PubMed

Trikha, S; Macgregor, C; Jeffery, M; Kirwan, J

2012-10-01

Glaucoma referrals continue to impart a significant burden on Hospital Eye Services (HES), with a large proportion of these false positives. To evaluate the Portsmouth glaucoma scheme, utilising virtual clinics, digital technology, and community optometrists to streamline glaucoma referrals. The stages of the patient trail were mapped and, at each step of the process, 100 consecutive patient decisions were identified. The diagnostic outcomes of 50 consecutive patients referred from the refinement scheme to the HES were identified. A total of 76% of 'glaucoma' referrals were suitable for the refinement scheme. Overall, 94% of disc images were gradeable in the virtual clinic. In all, 11% of patients 'attending' the virtual clinic were accepted into HES, with 89% being discharged for community follow-up. Of referrals accepted into HES, the positive predictive value (glaucoma/ocular hypertension/suspect) was 0.78 vs 0.37 in the predating 'unrefined' scheme (95% CI 0.65-0.87). The scheme has released 1400 clinic slots/year for HES, and has produced a £244 200/year cost saving for Portsmouth Hospitals' Trust. The refinement scheme is streamlining referrals and increasing the positive predictive rate in the diagnosis of glaucoma, glaucoma suspect or ocular hypertension. This consultant-led practice-based commissioning scheme, if adopted widely, is likely to incur a significant cost saving while maintaining high quality of care within the NHS.

Electronic Referrals and Digital Imaging Systems in Ophthalmology: A Global Perspective.

PubMed

Jeganathan, V Swetha E; Hall, H Nikki; Sanders, Roshini

2017-01-01

Ophthalmology departments face intensifying pressure to expedite sight-saving treatments and reduce the global burden of disease. The use of electronic communication systems, digital imaging, and redesigned service care models is imperative for addressing such demands. The recently developed Scottish Eyecare Integration Project involves an electronic referral system from community optometry to the hospital ophthalmology department using National Health Service (NHS) email with digital ophthalmic images attached, via a virtual private network connection. The benefits over the previous system include reduced waiting times, improved triage, e-diagnosis in 20% without the need for hospital attendance, and rapid electronic feedback to referrers. We draw on the experience of the Scottish Eyecare Integration Project and discuss the global applications of this and other advances in teleophthalmology. We focus particularly on the implications for management and screening of chronic disease, such as glaucoma and diabetic eye disease, and ophthalmic disease, such as retinopathy of prematurity where diagnosis is almost entirely and critically dependent on fundus appearance. Currently in Scotland, approximately 75% of all referrals are electronic from community to hospital. The Scottish Eyecare Integration Project is globally the first of its kind and unique in a national health service. Such speedy, safe, and efficient models of communication are geographically sensitive to service provision, especially in remote and rural regions. Along with advances in teleophthalmology, such systems promote the earlier detection of sight-threatening disease and safe follow-up of non-sight-threatening disease in the community. Copyright© 2017 Asia-Pacific Academy of Ophthalmology.

Offering general pediatric care during the hard times of the 2014 Ebola outbreak: looking back at how many came and how well they fared at a Médecins Sans Frontières referral hospital in rural Sierra Leone.

PubMed

Hermans, Veerle; Zachariah, Rony; Woldeyohannes, Desalegn; Saffa, Gbessay; Kamara, Dauda; Ortuno-Gutierrez, Nimer; Kizito, Walter; Manzi, Marcel; Alders, Petra; Maikere, Jacob

2017-01-25

In Bo district, rural Sierra Leone, we assessed the burden of the 2014 Ebola outbreak on under-five consultations at a primary health center and the quality of care for under-15 children at a Médecins Sans Frontières (MSF) referral hospital. Retrospective cohort study, comparing a period before (May-October 2013) and during the same period of the Ebola outbreak (2014). Health worker infections occurred at the outbreak peak (October 2014), resulting in hospital closure due to fear of occupational-risk of contracting Ebola. Standardized hospital exit outcomes and case fatality were used to assess quality of care until closure. A total of 13,658 children under-five, were seen at the primary health center during 2013 compared to 8761 in 2014; a consultation decline of 36%. Of 6497 children seen in the hospital emergency room, during the outbreak, patients coming from within hospital catchment area declined with 38% and there were significantly more self-referrals (80% vs. 61%, P < 0.001). During Ebola, 23 children were dead on arrival and the proportion of children in severe clinical status (requiring urgent attention) was higher (74% during Ebola vs. 65% before, P < 0.001). Of 5,223 children with available hospital outcomes, unfavorable outcomes (combination of deaths and abandoned) were less than 15% during both periods, which is within the maximum acceptable in-house threshold set by MSF. Case fatality for severe malaria and lower respiratory tract infections (n = 3752) were similar (≤15%). Valuable and good quality pediatric care was being provided in the pediatric hospital during the 2014 Ebola outbreak, but could not be sustained because of hospital closure. Health facility and health worker safety should be tackled as a universal requirement to try to avoid a déjà-vu.

Neurobehavioral Factors Associated with Referral for Learning Problems in a Community Sample: Evidence for an Adaptational Model for Learning Disorders.

ERIC Educational Resources Information Center

Waber, Deborah P.; Weiler, Michael D.; Forbes, Peter W.; Bernstein, Jane H.; Bellinger, David C.; Rappaport, Leonard

2003-01-01

Comparison of community children referred for learning disability evaluation (CR, n=17) with children not-referred in community general education (CGE, n=161), community special education (CSE, n=30), or from outpatient hospital referrals (HR). CR group performance was equivalent to that of CSE and HR groups. Results suggest conceptualizing…

Non-Accidental Head Injury in New Zealand: The Outcome of Referral to Statutory Authorities

ERIC Educational Resources Information Center

Kelly, Patrick; MacCormick, Judith; Strange, Rebecca

2009-01-01

Objectives: To describe the outcome of referral to the statutory authorities for infants under 2 years with non-accidental head injury (NAHI), and to establish whether the authorities held sufficient information to develop a risk profile for these cases. Methods: Retrospective review of cases admitted to hospital in Auckland, New Zealand from 1988…

Low-acuity presentations to regional emergency departments: What is the issue?

PubMed

Cheek, Colleen; Allen, Penny; Shires, Lizzi; Parry, Denise; Ruigrok, Marielle

2016-04-01

To explore GP-referrals and self-referrals to EDs and factors associated with patients seeking low-acuity care at ED. Retrospective analysis of all ED presentations to Mersey Community Hospital and North West Regional Hospital (Tasmania) between 1 January 2009 and 31 December 2013. Cross-sectional survey of patients presenting to the EDs for care triaged as low-acuity. There were 255,365 ED presentations in the retrospective data: 11,252 (4.4%) GP-referrals and 218,205 (85.4%) self-referrals. At ED 49% of GP-referrals were triaged ATS 4 or 5 and 35% of self-referrals were triaged ATS 1-3. There were 138 (84.2%) low-acuity patients who completed the survey; predominantly, all attended for acute injury or illness. Single point-of-care convenience was most commonly selected (71%) as a reason for attending ED. Over 85% of patients who seek emergency care in this region self-refer, so understanding health-seeking behaviour is important. Most low-acuity patients are acutely injured or unwell, and the decision to go to ED is based on their perception of accessibility of expertise aligned with their need. The term 'GP-type' is misleading in this context and should not be used. Providing low-acuity care in parallel with providing a specialised emergency service meets the needs of the local community and is likely to be the lowest cost model in a regional and rural area. Funding models must reflect the actual cost of delivering this important service rather than presentation types. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

A qualitative study of conceptions and attitudes regarding maternal mortality among traditional birth attendants in rural Guatemala.

PubMed

Rööst, Mattias; Johnsdotter, Sara; Liljestrand, Jerker; Essén, Birgitta

2004-12-01

To explore conceptions of obstetric emergency care among traditional birth attendants in rural Guatemala, elucidating social and cultural factors. design Qualitative in-depth interview study. Rural Guatemala. Thirteen traditional birth attendants from 11 villages around San Miguel Ixtahuacán, Guatemala. Interviews with semi-structured, thematic, open-ended questions. Interview topics were: traditional birth attendants' experiences and conceptions as to the causes of complications, attitudes towards hospital care and referral of obstetric complications. Conceptions of obstetric complications, hospital referrals and maternal mortality among traditional birth attendants. Pregnant women rather than traditional birth attendants appear to make the decision on how to handle a complication, based on moralistically and fatalistically influenced thoughts about the nature of complications, in combination with a fear of caesarean section, maltreatment and discrimination at a hospital level. There is a discrepancy between what traditional birth attendants consider appropriate in cases of complications, and the actions they implement to handle them. Parameters in the referral system, such as logistics and socio-economic factors, are sometimes subordinated to cultural values by the target group. To have an impact on maternal mortality, bilateral culture-sensitive education should be included in maternal health programs.

Management and organization reforms at the Muhimbili National Hospital: challenges and prospects.

PubMed

Mwangu, M A; Mbembati, N A A; Muhondwa, E P Y; Leshabari, M T

2008-08-01

To establish the state of organization structures and management situation existing at the Muhimbili National Hospital (MNH) and Muhimbili University College of Health Sciences (MUCHS) prior to the start of the MNH reforms and physical infrastructure rehabilitations. A checklist of key information items was used to get facts and figures about the organization of the MNH and management situation. Interviews with MNH and MUCHS leaders, and documentation of existing hospital data were done to gather the necessary information. The survey reveals that there are a number of organizational, managerial and human resource deficiencies that are impinging on the smooth running of the hospital as a national referral entity. The survey also revealed a complex relationship existing between the hospital and the college (MUCHS) that has a bearing on the functioning of both entities. In order for the hospital to function effectively as a referral hospital with a training component inbuilt, four basic things need to be put in place among others: a sound organization structure; adequate staffing levels especially of specialist cadre; a functional information system especially for inpatient services and a good working relationship with the college.

The added value of a mobile application of Community Case Management on referral, re-consultation and hospitalization rates of children aged under 5 years in two districts in Northern Malawi: study protocol for a pragmatic, stepped-wedge cluster-randomized controlled trial.

PubMed

Hardy, Victoria; O'Connor, Yvonne; Heavin, Ciara; Mastellos, Nikolaos; Tran, Tammy; O'Donoghue, John; Fitzpatrick, Annette L; Ide, Nicole; Wu, Tsung-Shu Joseph; Chirambo, Griphin Baxter; Muula, Adamson S; Nyirenda, Moffat; Carlsson, Sven; Andersson, Bo; Thompson, Matthew

2017-10-11

There is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary re-consultations and hospital admissions. This trial aims to evaluate the added value of the Supporting LIFE electronic Community Case Management Application (SL eCCM App) compared to paper-based CCM on urgent referral, re-consultation and hospitalization rates, in two districts in Northern Malawi. This is a pragmatic, stepped-wedge cluster-randomized trial assessing the added value of the SL eCCM App on urgent referral, re-consultation and hospitalization rates of children aged 2 months and older to up to 5 years, within 7 days of the index visit. One hundred and two health surveillance assistants (HSAs) were stratified into six clusters based on geographical location, and clusters randomized to the timing of crossover to the intervention using simple, computer-generated randomization. Training workshops were conducted prior to the control (paper-CCM) and intervention (paper-CCM + SL eCCM App) in assigned clusters. Neither participants nor study personnel were blinded to allocation. Outcome measures were determined by abstraction of clinical data from patient records 2 weeks after recruitment. A nested qualitative study explored perceptions of adherence to urgent referral recommendations and a cost evaluation determined the financial and time-related costs to caregivers of subsequent health care utilization. The trial was conducted between July 2016 and February 2017. This is the first large-scale trial evaluating the value of adding a mobile application of CCM to the assessment of children aged under 5 years. The trial will generate evidence on the potential use of mobile health for CCM in Malawi, and more widely in other low- and middle-income countries. ClinicalTrials.gov, ID: NCT02763345 . Registered on 3 May 2016.

Association between payments from manufacturers of pharmaceuticals to physicians and regional prescribing: cross sectional ecological study.

PubMed

Fleischman, William; Agrawal, Shantanu; King, Marissa; Venkatesh, Arjun K; Krumholz, Harlan M; McKee, Douglas; Brown, Douglas; Ross, Joseph S

2016-08-18

 To examine the association between payments made by the manufacturers of pharmaceuticals to physicians and prescribing by physicians within hospital referral regions.  Cross sectional analysis of 2013 and 2014 Open Payments and Medicare Part D prescribing data for two classes of commonly prescribed, commonly marketed drugs: oral anticoagulants and non-insulin diabetes drugs, overall and stratified by physician and payment type.  306 hospital referral regions, United States.  45 949 454 Medicare Part D prescriptions written by 623 886 physicians to 10 513 173 patients for two drug classes: oral anticoagulants and non-insulin diabetes drugs.  Proportion, or market share, of marketed oral anticoagulants and non-insulin diabetes drugs prescribed by physicians among all drugs in each class and within hospital referral regions.  Among 306 hospital referral regions, there were 977 407 payments to physicians totaling $61 026 140 (£46 174 600; €54 632 500) related to oral anticoagulants, and 1 787 884 payments totaling $108 417 616 related to non-insulin diabetes drugs. The median market share of the hospital referral regions was 21.6% for marketed oral anticoagulants and 12.6% for marketed non-insulin diabetes drugs. Among hospital referral regions, one additional payment (median value $13, interquartile range, $10-$18) was associated with 94 (95% confidence interval 76 to 112) additional days filled of marketed oral anticoagulants and 107 (89 to 125) additional days filled of marketed non-insulin diabetes drugs (P<0.001). Payments to specialists were associated with greater prescribing of marketed drugs than payments to non-specialists (212 v 100 additional days filled per payment of marketed oral anticoagulants, 331 v 114 for marketed non-insulin diabetes drugs, P<0.001). Payments for speaker and consulting fees for non-insulin diabetes drugs were associated with greater prescribing of marketed drugs than payments for food and beverages or educational materials (484 v 110, P<0.001).  Payments by the manufacturers of pharmaceuticals to physicians were associated with greater regional prescribing of marketed drugs among Medicare Part D beneficiaries. Payments to specialists and payments for speaker and consulting fees were predominantly associated with greater regional prescribing of marketed drugs than payments to non-specialists or payments for food and beverages, gifts, or educational materials. As a cross sectional, ecological study, we cannot prove causation between payments to physicians and increased prescribing. Furthermore, our findings should be interpreted only at the regional level. Our study is limited to prescribing by physicians and the two drug classes studied. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Branding. Presbyterian Hospital of Dallas, TX.

PubMed

2006-01-01

To help position Presbyterian Hospital of Dallas as a referral center rather than a large community hospital, the facility launched an aggressive multiphase campaign, with Phase I already underway as of April. By using real-life patient testimonials to highlight procedures, technologies, and services not offered by competitors, the effort hopes to increase brand recognition in the Dallas area.

USING POSITIVE CLINICAL LEADERSHIP TO SUPPORT A CULTURE OF PRESSURE INJURY PREVENTION.

PubMed

Sage, Sarah; Tudor, Hannah

2017-03-01

The Royal Melbourne Hospital (RMH) is an 800 bed tertiary referral service within metropolitan Melbourne. While the hospital acquired pressure injury (HAPI) incidence rate is low (2.5%), there is still work to be done in this area.

Referral patterns of special needs patients at the Royal Dental Hospital of Melbourne, Victoria, Australia.

PubMed

Mohamed Rohani, M; Calache, H; Borromeo, G L

2017-06-01

Special Needs Dentistry (SND) has been recognized as a dental specialty in Australia since 2003 but there have been no studies addressing the profile of patients for specialist care. The purpose of this study is to identify, via referrals received, the profile of patients and quality of referrals at the largest public SND unit in Victoria, Australia. All referrals received over a 6-month period (1 January-30 June 2013) by the integrated SND unit (ISNU) were reviewed prior to allocation to the outpatient clinic (OP), domiciliary (DOM) or general anaesthetic (GA) services. Six-hundred and eighty-eight referrals were received with the majority for the OP clinic (68.3%), followed by DOM (22.4%) and GA services (9.3%) (χ 2  = 360.2, P < 0.001). A referral may have specified more than one special needs condition with the most common category being those who were medically compromised (81.7%). The reasons for referral included lack of compliance (27.2%), further management due to multiple medical conditions or GA services required (9.9%), or for multiple other reasons (62.9%). A diverse pattern of SND patients was referred to the ISNU with a majority of referrals having no specific referral reason cited, suggesting poor quality of referrals. © 2016 Australian Dental Association.

Colonization of patients, healthcare workers, and the environment with healthcare-associated Staphylococcus epidermidis genotypes in an intensive care unit: a prospective observational cohort study.

PubMed

Widerström, Micael; Wiström, Johan; Edebro, Helén; Marklund, Elisabeth; Backman, Mattias; Lindqvist, Per; Monsen, Tor

2016-12-09

During the last decades, healthcare-associated genotypes of methicillin-resistant Staphylococcus epidermidis (HA-MRSE) have been established as important opportunistic pathogens. However, data on potential reservoirs on HA-MRSE is limited. The aim of the present study was to investigate the dynamics and to which extent HA-MRSE genotypes colonize patients, healthcare workers (HCWs) and the environment in an intensive care unit (ICU). Over 12 months in 2006-2007, swab samples were obtained from patients admitted directly from the community to the ICU and patients transferred from a referral hospital, as well as from HCWs, and the ICU environment. Patients were sampled every third day during hospitalization. Antibiotic susceptibility testing was performed according to EUCAST guidelines. Pulsed-field gel electrophoresis and multilocus sequence typing were used to determine the genetic relatedness of a subset of MRSE isolates. We identified 620 MRSE isolates from 570 cultures obtained from 37 HCWs, 14 patients, and 14 environmental surfaces in the ICU. HA-MRSE genotypes were identified at admission in only one of the nine patients admitted directly from the community, of which the majority subsequently were colonized by HA-MRSE genotypes within 3 days during hospitalization. Almost all (89%) of HCWs were nasal carriers of HA-MRSE genotypes. Similarly, a significant proportion of patients transferred from the referral hospital and fomites in the ICU were widely colonized with HA-MRSE genotypes. Patients transferred from a referral hospital, HCWs, and the hospital environment serve as important reservoirs for HA-MRSE. These observations highlight the need for implementation of effective infection prevention and control measures aiming at reducing HA-MRSE transmission in the healthcare setting.

District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries.

PubMed

Stewart, Barclay T; Gyedu, Adam; Quansah, Robert; Addo, Wilfred Larbi; Afoko, Akis; Agbenorku, Pius; Amponsah-Manu, Forster; Ankomah, James; Appiah-Denkyira, Ebenezer; Baffoe, Peter; Debrah, Sam; Donkor, Peter; Dorvlo, Theodor; Japiong, Kennedy; Kushner, Adam L; Morna, Martin; Ofosu, Anthony; Oppong-Nketia, Victor; Tabiri, Stephen; Mock, Charles

2016-01-01

Prospective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly. Consensus on trauma care audit filters was built between twenty panellists using a Delphi technique with four anonymous, iterative surveys designed to elicit: (i) trauma care processes to be measured; (ii) important features of audit filters for the district-level hospital setting; and (iii) potentially useful filters. Filters were ranked on a scale from 0 to 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8. Panellists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1--0.58; Round 2--0.66; Round 3--0.76; and Round 4--0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage--vital signs are recorded within 15 min of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation--a large bore IV was placed within 15 min of patient arrival; referral--if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer. This study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step towards improving care for the injured at district-level hospitals in LMICs. Copyright © 2015 Elsevier Ltd. All rights reserved.

Hospital referral patterns: how emergency medical care is accessed in a disaster.

PubMed

Reilly, Michael J; Markenson, David

2010-10-01

A prevalent assumption in hospital emergency preparedness planning is that patient arrival from a disaster scene will occur through a coordinated system of patient distribution based on the number of victims, capabilities of the receiving hospitals, and the nature and severity of illness or injury. In spite of the strength of the emergency medical services system, case reports in the literature and major incident after-action reports have shown that most patients who present at a health care facility after a disaster or other major emergency do not necessarily arrive via ambulance. If these reports of arrival of patients outside an organized emergency medical services system are accurate, then hospitals should be planning differently for the impact of an unorganized influx of patients on the health care system. Hospitals need to consider alternative patterns of patient referral, including the mass convergence of self-referred patients, when performing major incident planning. We conducted a retrospective review of published studies from the past 25 years to identify reports of patient care during disasters or major emergency incidents that described the patients' method of arrival at the hospital. Using a structured mechanism, we aggregated and analyzed the data. Detailed data on 8303 patients from more than 25 years of literature were collected. Many reports suggest that only a fraction of the patients who are treated in emergency departments following disasters arrive via ambulance, particularly in the early postincident stages of an event. Our 25 years of aggregate data suggest that only 36% of disaster victims are transported to hospitals via ambulance, whereas 63% use alternate means to seek emergency medical care. Hospitals should evaluate their emergency plans to consider the implications of alternate referral patterns of patients during a disaster. Additional consideration should be given to mass triage, site security, and the potential need for decontamination after a major incident.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Alcohol and Other Drug Use among Adolescents: Evaluation of a Pediatric Residency Curriculum

ERIC Educational Resources Information Center

Ryan, Sheryl A.; Martel, Shara; Pantalon, Michael; Martino, Steve; Tetrault, Jeanette; Thung, Stephen F.; Bernstein, Steven L.; Auinger, Peggy; Green, Michael L.; Fiellin, David A.; O'Connor, Patrick G.; D'Onofrio, Gail

2012-01-01

The objective of this study was to evaluate the integration of a screening, brief intervention, and referral to treatment (SBIRT) curriculum for alcohol and other drug use into a pediatric residency program. Pediatric and medicine/pediatric residents in an adolescent medicine rotation located in an urban teaching hospital participated in the…

A web-based referral system for neurosurgery--a solution to our problems?

PubMed

Choo, Melissa C; Thennakon, Shyamica; Shapey, Jonathan; Tolias, Christos M

2011-06-01

Accurate handover is very important in the running of all modern neurosurgical units. Referrals are notoriously difficult to track and review due to poor quality of written paper-based recorded information for handover (illegibility, incomplete paper trail, repetition of information and loss of patients). We have recently introduced a web-based referral system to three of our referring hospitals. To review the experience of a tertiary neurosurgical unit in using the UK's first real time online referral system and to discuss its strengths and weaknesses in comparison to the currently used written paper-based referral system. A retrospective analysis of all paper-based referrals made to our unit in March 2009, compared to 14 months' referrals through the web system. Patterns of information recorded in both systems were investigated and advantages and disadvantages of each identified. One hundred ninety-six patients were referred using the online system, 483 using the traditional method. Significant problems of illegibility and missing information were identified with the paper-based referrals. In comparison, 100% documentation was achieved with the online referral system. Only 63% penetrance in the best performing trust was found using the online system, with significant delays in responding to referrals. Traditional written paper-based referrals do not provide an acceptable level of documentation. We present our experience and difficulties implementing a web-based system to address this. Although our data are unable to show improved patient care, we believe the potential benefits of a fully integrated system may offer a solution.

Assessing the success of the WomanKind program: an integrated model of 24-hour health care response to domestic violence.

PubMed

Short, Lynn M; Hadley, Susan M; Bates, Bonnie

2002-01-01

The WomanKind program, a non-profit health care based program for for victims of domestic/intimate partner violence (IPV), seeks to enable and motivate health care providers to identify victims of such violence and refer them to WomanKind's in-house services. An evaluation designed to assess client referral to WomanKind services and the impact of health care provider training was carried out. Data were collected at three intervals over a 2-year period at 3 intervention and 2 comparison hospitals located in Minneapolis, MN. The focus of data collection efforts was to assess the providers' knowledge, attitudes, beliefs, and behaviors (KABB) concerning identification and referral of victims of IPV. Hospital staff and volunteer advocate training programs also were evaluated. Chart reviews were conducted and client referrals assessed. Providers at WomanKind hospitals demonstrated significantly higher knowledge, attitudes, beliefs and behaviors than those at comparison hospitals throughout the study. During the data collection period, 1719 IPV victims were identified and referred to the WomanKind program, while only 27 IPV victims were referred to trained social workers at the comparison hospitals. Chart reviews indicated that emergency staff at the intervention sites provide documentation of IPV in patient records twice as frequently as emergency staff at the comparison sites. This research underscores the efficacy of a well-structured, multidisciplinary effort to deliver services to IPV victims. The results demonstrate that specialized training and on-site client services create a significant positive impact on the KABB of health care providers.

Addressing the third delay: implementing a novel obstetric triage system in Ghana.

PubMed

Goodman, David M; Srofenyoh, Emmanuel K; Ramaswamy, Rohit; Bryce, Fiona; Floyd, Liz; Olufolabi, Adeyemi; Tetteh, Cecilia; Owen, Medge D

2018-01-01

Institutional delivery has been proposed as a method for reducing maternal morbidity and mortality, but little is known about how referral hospitals in low-resource settings can best manage the expected influx of patients. In this study, we assess the impact of an obstetric triage improvement programme on reducing hospital-based delay in a referral hospital in Accra, Ghana. An Active Implementation Framework is used to describe a 5-year intervention to introduce and monitor obstetric triage capabilities. Baseline data, collected from September to November 2012, revealed significant delays in patient assessment on arrival. A triage training course and monitoring of quality improvement tools occurred in 2013 and 2014. Implementation barriers led to the construction of a free-standing obstetric triage pavilion, opened January 2015, with dedicated midwives. Data were collected at three time intervals following the triage pavilion opening and compared with baseline including: referral indications, patient and labour characteristics, waiting time from arrival to assessment and the documentation of a care plan. An obstetric triage improvement programme reduced the median (IQR) patient waiting time from facility arrival to first assessment by a midwife from 40 min (15-100) to 5 min (2-6) (p<0.001) over the 5-year intervention. The triage pavilion enhanced performance resulting in the elimination of previous delays associated with the time of admission and disease acuity. Care plan documentation increased from 51% to 96%. Obstetric triage, when properly implemented, reduced delay in a busy, low-resource hospital. The implementation process was sustained under local leadership during transition to a new hospital.

Burden, etiology and predictors of visual impairment among children attending Mulago National Referral Hospital eye clinic, Uganda.

PubMed

Kinengyere, Patience; Kizito, Samuel; Kiggundu, John Baptist; Ampaire, Anne; Wabulembo, Geoffrey

2017-09-01

Childhood visual impairment (CVI) has not been given due attention. Knowledge of CVI is important in planning preventive measures. The aim of this study was determine the prevalence, etiology and the factors associated with childhood visual impairment among the children attending the eye clinic in Mulago National Referral Hospital. This was a cross sectional hospital based study among 318 children attending the Mulago Hospital eye clinic between January 2015 to March 2015. Ocular and general history was taken and patient examination done. The data generated was entered by Epidata and analyzed by STATA 12. The prevalence of CVI was 42.14%, 134 patients with 49 patients (15.41%) having moderate visual impairment, 45 patients (14.15%) having severe visual impairment and 40 patients (12.58%) presenting with blindness. Significant predictors included; increasing age, delayed developmental milestones and having abnormal corneal, refractive and fundus findings. There is a high burden of visual impairment among children in Uganda. It is vital to screen all the children presenting to hospital for visual impairment. Majority of the causes of the visual impairment are preventable.

Timely access to specialist medical oncology services closer to home for rural patients: experience from the Townsville Teleoncology Model.

PubMed

Sabesan, Sabe; Roberts, Lynden J; Aiken, Peter; Joshi, Abhishek; Larkins, Sarah

2014-08-01

Prior to 2009, the teleoncology model of the Townsville Cancer Centre (TCC) did not achieve its aims of equal waiting times for rural and urban patients and the provision of reliable, local acute cancer care. From 2007-2009, 60 new patients from Mt Isa travelled to TCC for their first consultation and their first dose of chemotherapy. Six of these patients required inter-hospital transfers and eight required urgent flights to attend outpatient clinics. Only 50% these rural patients (n = 30) were reviewed within one week of their referral, compared with 90% of Townsville patients. A descriptive study. TCC provides teleoncology services to 21 rural towns; the largest is Mt Isa, Qld. Specialist review of 90% of urgent cases within 24 hours, and 90% of non-urgent cases within one week of referral via videoconferencing. A 50% reduction in inpatient inter-hospital transfers from Mt Isa to Townsville. Employment of a half-time medical officer and a half-time cancer care coordinator, and implementation of new policies. Between 2009 and 2011, TCC provided cancer care to 70 new patients from Mt Isa. Of these new patients, 93% (65/70) were seen within one week of referral. All 17 patients requiring urgent reviews were seen within 24 hours of referral and managed locally thus eliminating the need for inpatient inter-hospital transfers. Provision of timely acute cancer care closer to home requires an increase in the rural case complexity and human resources. © 2014 National Rural Health Alliance Inc.

Regional process redesign of lung cancer care: a learning health system pilot project.

PubMed

Fung-Kee-Fung, M; Maziak, D E; Pantarotto, J R; Smylie, J; Taylor, L; Timlin, T; Cacciotti, T; Villeneuve, P J; Dennie, C; Bornais, C; Madore, S; Aquino, J; Wheatley-Price, P; Ozer, R S; Stewart, D J

2018-02-01

The Ottawa Hospital (toh) defined delay to timely lung cancer care as a system design problem. Recognizing the patient need for an integrated journey and the need for dynamic alignment of providers, toh used a learning health system (lhs) vision to redesign regional diagnostic processes. A lhs is driven by feedback utilizing operational and clinical information to drive system optimization and innovation. An essential component of a lhs is a collaborative platform that provides connectivity across silos, organizations, and professions. To operationalize a lhs, we developed the Ottawa Health Transformation Model (ohtm) as a consensus approach that addresses process barriers, resistance to change, and conflicting priorities. A regional Community of Practice (cop) was established to engage stakeholders, and a dedicated transformation team supported process improvements and implementation. The project operationalized the lung cancer diagnostic pathway and optimized patient flow from referral to initiation of treatment. Twelve major processes in referral, review, diagnostics, assessment, triage, and consult were redesigned. The Ottawa Hospital now provides a diagnosis to 80% of referrals within the provincial target of 28 days. The median patient journey from referral to initial treatment decreased by 48% from 92 to 47 days. The initiative optimized regional integration from referral to initial treatment. Use of a lhs lens enabled the creation of a system that is standardized to best practice and open to ongoing innovation. Continued transformation initiatives across the continuum of care are needed to incorporate best practice and optimize delivery systems for regional populations.

The Portsmouth-based glaucoma refinement scheme: a role for virtual clinics in the future?

PubMed Central

Trikha, S; Macgregor, C; Jeffery, M; Kirwan, J

2012-01-01

Background Glaucoma referrals continue to impart a significant burden on Hospital Eye Services (HES), with a large proportion of these false positives. Aims To evaluate the Portsmouth glaucoma scheme, utilising virtual clinics, digital technology, and community optometrists to streamline glaucoma referrals. Method The stages of the patient trail were mapped and, at each step of the process, 100 consecutive patient decisions were identified. The diagnostic outcomes of 50 consecutive patients referred from the refinement scheme to the HES were identified. Results A total of 76% of ‘glaucoma' referrals were suitable for the refinement scheme. Overall, 94% of disc images were gradeable in the virtual clinic. In all, 11% of patients ‘attending' the virtual clinic were accepted into HES, with 89% being discharged for community follow-up. Of referrals accepted into HES, the positive predictive value (glaucoma/ocular hypertension/suspect) was 0.78 vs 0.37 in the predating ‘unrefined' scheme (95% CI 0.65–0.87). The scheme has released 1400 clinic slots/year for HES, and has produced a £244 200/year cost saving for Portsmouth Hospitals' Trust. Conclusion The refinement scheme is streamlining referrals and increasing the positive predictive rate in the diagnosis of glaucoma, glaucoma suspect or ocular hypertension. This consultant-led practice-based commissioning scheme, if adopted widely, is likely to incur a significant cost saving while maintaining high quality of care within the NHS. PMID:22766539

Increased Screening for Child Physical Abuse in Emergency Departments in a Regional Trauma System: Response to a Sentinel Event.

PubMed

Wilkins, Ginger G; Ball, Jane; Mann, N Clay; Nadkarni, Milan; Meredith, J Wayne

2016-01-01

A pediatric patient was assaulted while being treated at a Level 1 pediatric trauma center, prompting a Centers for Medicare & Medicaid Services site visit. The process of screening for physical abuse and protection of patients was reevaluated and revised, and a new guideline was implemented and shared with referral hospitals. During this same time period, 13 referral hospitals participated in an unrelated federally funded study determining the impact of recognition and care of injured children in states with and without a pediatric emergency care facility recognition program. A pre-post study analysis revealed that screening for abuse doubled during this time period.

An analysis of whether a working-age ward-based liaison psychiatry service requires the input of a liaison psychiatrist.

PubMed

Guthrie, Elspeth A; McMeekin, Aaron T; Khan, Sylvia; Makin, Sally; Shaw, Ben; Longson, Damien

2017-06-01

Aims and method This article presents a 12-month case series to determine the fraction of ward referrals of adults of working age who needed a liaison psychiatrist in a busy tertiary referral teaching hospital. Results The service received 344 referrals resulting in 1259 face-to-face contacts. Depression accounted for the most face-to-face contacts. We deemed the involvement of a liaison psychiatrist necessary in 241 (70.1%) referrals, with medication management as the most common reason. Clinical implications A substantial amount of liaison ward work involves the treatment and management of severe and complex mental health problems. Our analysis suggests that in the majority of cases the input of a liaison psychiatrist is required.

Implementing a working together model for Aboriginal patients with acute coronary syndrome: an Aboriginal Hospital Liaison Officer and a specialist cardiac nurse working together to improve hospital care.

PubMed

Daws, Karen; Punch, Amanda; Winters, Michelle; Posenelli, Sonia; Willis, John; MacIsaac, Andrew; Rahman, Muhammad Aziz; Worrall-Carter, Linda

2014-11-01

Acute coronary syndrome (ACS) contributes to the disparity in life expectancy between Aboriginal and non-Aboriginal Australians. Improving hospital care for Aboriginal patients has been identified as a means of addressing this disparity. This project developed and implemented a working together model of care, comprising an Aboriginal Hospital Liaison Officer and a specialist cardiac nurse, providing care coordination specifically directed at improving attendance at cardiac rehabilitation services for Aboriginal Australians in a large metropolitan hospital in Melbourne. A quality improvement framework using a retrospective case notes audit evaluated Aboriginal patients' admissions to hospital and identified low attendance rates at cardiac rehabilitation services. A working together model of care coordination by an Aboriginal Hospital Liaison Officer and a specialist cardiac nurse was implemented to improve cardiac rehabilitation attendance in Aboriginal patients admitted with ACS to the cardiac wards of the hospital. A retrospective medical records audit showed that there were 68 Aboriginal patients admitted to the cardiac wards with ACS from 1 July 2008 to 30 June 2011. A referral to cardiac rehabilitation was recorded for 42% of these. During the implementation of the model of care, 13 of 15 patients (86%) received a referral to cardiac rehabilitation and eight of the 13 (62%) attended. Implementation of the working together model demonstrated improved referral to and attendance at cardiac rehabilitation services, thereby, has potential to prevent complications and mortality. WHAT IS KNOWN ABOUT THE TOPIC?: Aboriginal Australians experience disparities in access to recommended care for acute coronary syndrome. This may contribute to the life expectancy gap between Aboriginal and non-Aboriginal Australians. WHAT DOES THIS PAPER ADD?: This paper describes a model of care involving an Aboriginal Hospital Liaisons Officer and a specialist cardiac nurse working together to improve hospital care and attendance at cardiac rehabilitation services for Aboriginal Australians with acute coronary syndrome. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: The working together model of care could be implemented across mainstream health services where Aboriginal people attend for specialist care.

Estimating the costs for the treatment of abortion complications in two public referral hospitals: a cross-sectional study in Ouagadougou, Burkina Faso.

PubMed

Ilboudo, Patrick G C; Greco, Giulia; Sundby, Johanne; Torsvik, Gaute

2016-10-07

Treatment costs of induced abortion complications can consume a substantial amount of hospital resources. This use of hospitals scarce resources to treat induced abortion complications may affect hospitals' capacities to deliver other health care services. In spite of the importance of studying the burden of the treatment of induced abortion complications, few studies have been conducted to document the costs of treating abortion complications in Burkina Faso. Our objective was to estimate the costs of six abortion complications including incomplete abortion, hemorrhage, shock, infection/sepsis, cervix or vagina laceration, and uterus perforation treated in two public referral hospital facilities in Ouagadougou and the cost saving of providing safe abortion care services. The distribution of abortion-related complications was assessed through a review of postabortion care-registers combined with interviews with key informants in maternity wards and in hospital facilities. Two structured questionnaires were used for data collection following the perspective of the hospital. The first questionnaire collected information on the units and the unit costs of drugs and medical supplies used in the treatment of each complication. The second questionnaire gathered information on salaries and overhead expenses. All data were entered in a spreadsheet designed for studying abortion, and analyses were performed on Excel 2007. Across six types of abortion complications, the mean cost per patient was USD45.86. The total cost to these two public referral hospital facilities for treating the complications of abortion was USD22,472.53 in 2010 equivalent to USD24,466.21 in 2015. Provision of safe abortion care services to women who suffered from complications of unsafe induced abortion and who received care in these public hospitals would only have cost USD2,694, giving potential savings of more than USD19,778.53 in that year. The treatment of the complications of abortion consumes a significant proportion (up to USD22,472.53) of the two public hospitals resources in Burkina Faso. Safe abortion care services may represent a cost beneficial alternative, as it may have saved USD19,778.53 in 2010.

Hospital Workers Disaster Management and Hospital Nonstructural: A Study in Bandar Abbas, Iran

PubMed Central

Lakbala, Parvin

2016-01-01

Introduction: A devastating earthquake is inevitable in the long term and likely in the near future in Iran. The objective of the study was to assess the knowledge of hospital staff to disaster management system in hospital and to determine nonstructural safety assessment in Shahid Mohammadi hospital in Bandar Abbas city of Iran. This hospital is the main referral hospital in Hormozgan province with a capacity of about 450 beds and the highest patient admissions. Methods: The cross-sectional study was conducted in 2013 on 200 healthcare workers at Shahid Mohammadi hospital, in the city of Bandar Abbas, Iran. This hospital is the main referral hospital in Hormozgan province and has a capacity of about 450 beds with highest numbers of patient admissions. Questionnaire and checklist used for assessing health workers knowledge and awareness towards disaster management and nonstructural safety this hospital. Results: This study found that knowledge, awareness, and disaster preparedness of hospital staff need continual reinforcement to improve self efficacy for disaster management. Equipping health care facilities at the time of natural disasters, especially earthquakes are of great importance all over the world, especially in Iran. This requires the national strategies and planning for all health facilities. Conclusion: It seems due to limitations of hospital beds, insufficient of personnel, and medical equipment, health care providers paid greater attention to this issue. Since this hospital is the only educational public hospital in the province, it is essential to pay much attention to the risk management not only to this hospital but at the national level to health facilities. PMID:26573039

Multi-stakeholder perspectives of locally commissioned enhanced optometric services

PubMed Central

Baker, H; Harper, R A; Edgar, D F; Lawrenson, J G

2016-01-01

Objectives To explore views of all stakeholders (patients, optometrists, general practitioners (GPs), commissioners and ophthalmologists) regarding the operation of community-based enhanced optometric services. Design Qualitative study using mixed methods (patient satisfaction surveys, semi-structured telephone interviews and optometrist focus groups). Setting A minor eye conditions scheme (MECS) and glaucoma referral refinement scheme (GRRS) provided by accredited community optometrists. Participants 189 patients, 25 community optometrists, 4 glaucoma specialist hospital optometrists (GRRS), 5 ophthalmologists, 6 GPs (MECS), 4 commissioners. Results Overall, 99% (GRRS) and 100% (MECS) patients were satisfied with their optometrists’ examination. The vast majority rated the following as ‘very good’; examination duration, optometrists’ listening skills, explanations of tests and management, patient involvement in decision-making, treating the patient with care and concern. 99% of MECS patients would recommend the service. Manchester optometrists were enthusiastic about GRRS, feeling fortunate to practise in a ‘pro-optometry’ area. No major negatives were reported, although both schemes were limited to patients resident within certain postcode areas, and some inappropriate GP referrals occurred (MECS). Communication with hospitals was praised in GRRS but was variable, depending on hospital (MECS). Training for both schemes was valuable and appropriate but should be ongoing. MECS GPs were very supportive, reporting the scheme would reduce secondary care referral numbers, although some MECS patients were referred back to GPs for medication. Ophthalmologists (MECS and GRRS) expressed very positive views and widely acknowledged that these new care pathways would reduce unnecessary referrals and shorten patient waiting times. Commissioners felt both schemes met or exceeded expectations in terms of quality of care, allowing patients to be seen quicker and more efficiently. Conclusions Locally commissioned schemes can be a positive experience for all involved. With appropriate training, clear referral pathways and good communication, community optometrists can offer high-quality services that are highly acceptable to patients, health professionals and commissioners. PMID:27798000

Tertiary-care facility's seniors association attracts its highest number of referrals through word-of-mouth. University Hospital, Denver, CO.

PubMed

Lewicki, G

1999-01-01

University Hospital, Denver, has started its University Seniors Assn. to promote health and wellness to people 50 and older. Within four months the organization had 500 members. Now the association is 3,500 members strong.

The identification of agreed criteria for referral following the dental inspection of children in the school setting.

PubMed

Milsom, K; Tickle, M; Jenner, A; Moulding, G

1999-01-09

To clarify the function of the school based dental inspection. For representatives of the Community Dental Service, General Dental Service and Hospital Dental Service to identify an agreed set of criteria for the referral of children following school dental inspection. Qualitative research methodology used to establish a consensus for the inclusion of referral criteria following dental screening. Ellesmere Port, Cheshire, England. A Delphi technique was used to establish a consensus amongst the study participants on the inclusion of nine possible criteria for referral following dental screening. All participants scored each criterion in the range 1-9, with a score of 1 indicating that referral of individuals with the condition should definitely not take place, and a score of 9 indicating referral should definitely take place. Referral criteria were accepted only if they achieved a group median score of 7 or more, with an interquartile range of three scale points, with the lower value being no less than 7. Four of the nine possible criteria met the agreed group standard for inclusion: 'Sepsis', 'Caries in the secondary dentition', 'Overjet > 10 mm', and 'Registered & caries in the permanent dentition'. It is possible to agree clear criteria for the referral of children following the school dental inspection.

A prospective survey of secondary care tooth wear referrals: demographics, reasons for concern and referral outcomes.

PubMed

Ahmed, K E; Murray, C A; Whitters, C J

2014-03-01

To provide a descriptive investigation of general dental practitioners' (GDPs) referrals to Glasgow Dental Hospital and School for management of tooth wear. One hundred and twenty-four patient-referrals were reviewed over a 12 month period. A questionnaire was also completed by patients and three reviewing consultants to identify patient demographics, patient perception, consultant's diagnosis and referral outcome. Overall survey return-rate was 67% of 124 included referrals. Males represented 72% of referrals compared to 28% for females (p = 0.001). A significant percentage of patients inhabited the most-deprived areas (59%, p = 0.002). Sixty-one percent of patients were aware of their tooth wear within the past five years. Aesthetics was the primary concern for 54% of patients (p = 0.001). Attrition was the main aetiology of tooth wear in 51% of referrals (p = 0.001). Ninety-two percent of patients (n = 76/83) did not require specialist treatment and were consequently returned to their GDP, referred for hypnotherapy or reviewed later. There was a significant association between social deprivation and tooth wear in GDP referrals to a secondary care dental facility. Males aware of their tooth wear for the preceding five years, presenting with appearance as their main complaint and displaying evidence of attrition were more likely to be referred by GDPs for specialist management or advice.

The assessment and management of chest pain in primary care: A focus on acute coronary syndrome

PubMed

Thomsett, Richard; Cullen, Louise

2018-05-01

Chest pain is a common presentation and diagnosis can be challenging. There are many causes for chest pain, including life-threatening conditions such as acute coronary syndrome (ACS), which can prove difficult to diagnose. This article focuses on diagnosis and early management of patients with possible ACS. Key differentials and essential primary care investigations and management are outlined. Hospital-based risk stratification and management are described, providing an outline of what patients can expect if referred to hospital. In primary care, an electrocardiogram (ECG) is the only investigation required for most patients while referral is made to hospital. Troponin testing should rarely be requested to investigate patients with suspected ACS in the primary care setting. Initial treatment may include aspirin, glyceryl trinitrate and oxygen if required. If ACS is suspected as the cause of the symptoms, urgent referral for definitive risk stratification is required.

Use of an appendicitis medical information sheet in the pediatric primary care system.

PubMed

Oyachi, Noboru; Yagasaki, Hideaki; Suzuki, Takeyuki; Higashida, Kosuke; Komai, Takayuki; Hasuda, Norio; Takano, Kunio; Obana, Kazuko

2016-10-01

Accurate and prompt diagnosis is required for the primary evaluation of pediatric appendicitis. Among pediatricians and surgeons working in Yamanashi Prefecture, the pediatric appendicitis medical information (PAMI) sheet was edited in April 2011 to reflect the diagnostic results of the pediatric primary and emergency medical service and used as a referral document for surgical consultation to secondary hospitals. The PAMI sheet consisted of sections for history taking, symptoms, physical signs and laboratory findings without a scoring system. For 32 consecutive months starting in April 2011, 59 patients hospitalized for suspected appendicitis were retrospectively reviewed. In particular, a total of 17 referral patients evaluated with the PAMI sheet were assessed in order to evaluate the utility of the form. The pediatric surgeons were able to easily determine patient condition from the PAMI sheet. In total, 13 of 17 patients had appendicitis. According to the physical findings of the 17 studied patients, the judgment of right lower quadrant tenderness (κ = 0.63) and guarding (κ = 1.00) was consistent between the pediatric surgeons and primary attending pediatricians. The PAMI sheet aids in the collection of detailed history and objective data with a high level of accuracy, and provides useful referral diagnostic information to the secondary-level hospitals. © 2016 Japan Pediatric Society.

The Impact of Hospital Closures and Hospital and Population Characteristics on Increasing Emergency Department Volume: A Geographic Analysis.

PubMed

Lee, David C; Carr, Brendan G; Smith, Tony E; Tran, Van C; Polsky, Daniel; Branas, Charles C

2015-12-01

Emergency visits are rising nationally, whereas the number of emergency departments is shrinking. However, volume has not increased uniformly at all emergency departments. It is unclear what factors account for this variability in emergency volume growth rates. The objective of this study was to test the association of hospital and population characteristics and the effect of hospital closures with increases in emergency department volume. The study team analyzed emergency department volume at New York State hospitals from 2004 to 2010 using data from cost reports and administrative databases. Multivariate regression was used to evaluate characteristics associated with emergency volume growth. Spatial analytics and distances between hospitals were used in calculating the predicted impact of hospital closures on emergency department use. Among the 192 New York hospitals open from 2004 to 2010, the mean annual increase in emergency department visits was 2.7%, but the range was wide (-5.5% to 11.3%). Emergency volume increased nearly twice as fast at tertiary referral centers (4.8%) and nonurban hospitals (3.7% versus urban at 2.1%) after adjusting for other characteristics. The effect of hospital closures also strongly predicted variation in growth. Emergency volume is increasing faster at specific hospitals: tertiary referral centers, nonurban hospitals, and those near hospital closures. This study provides an understanding of how emergency volume varies among hospitals and predicts the effect of hospital closures in a statewide region. Understanding the impact of these factors on emergency department use is essential to ensure that these populations have access to critical emergency services.

Home treatment for acute psychiatric illness.

PubMed

Dean, C; Gadd, E M

1990-11-03

To determine the factors influencing the successful outcome of community treatment for severe acute psychiatric illnesses that are traditionally treated in hospital. All patients from a single electoral ward who were either admitted to hospital or treated at home over a two year period (1 October 1987 to 30 September 1989) were included in the study and their case notes audited. The second year of the study is reported. Electoral ward of Sparkbrook, Birmingham. 99 Patients aged 16-65 with severe acute psychiatric illness. 65 Patients were managed by home treatment alone; 34 required admission to hospital. The location of treatment was significantly (all p less than 0.05) influenced by social characteristics of the patients (marital state, age (in men), ethnicity, and living alone) and by characteristics of the referral (occurring out of hours; assessment taking place at hospital or police station). DSM-III-R diagnosis was more weakly associated with outcome. Violence during the episode was significantly related to admission, although deliberate self harm was not. Home treatment is feasible for most patients with acute psychiatric illness. A 24 hour on call assessment service increases the likelihood of success because admission is determined more strongly by social characteristics of the patient and the referral than by illness factors. Admission will still be required for some patients. A locally based mental health resource centre, a 24 hour on call service, an open referral system, and an active follow up policy increase the effectiveness of a home treatment service.

Home treatment for acute psychiatric illness.

PubMed Central

Dean, C; Gadd, E M

1990-01-01

OBJECTIVE--To determine the factors influencing the successful outcome of community treatment for severe acute psychiatric illnesses that are traditionally treated in hospital. DESIGN--All patients from a single electoral ward who were either admitted to hospital or treated at home over a two year period (1 October 1987 to 30 September 1989) were included in the study and their case notes audited. The second year of the study is reported. SETTING--Electoral ward of Sparkbrook, Birmingham. SUBJECTS--99 Patients aged 16-65 with severe acute psychiatric illness. RESULTS--65 Patients were managed by home treatment alone; 34 required admission to hospital. The location of treatment was significantly (all p less than 0.05) influenced by social characteristics of the patients (marital state, age (in men), ethnicity, and living alone) and by characteristics of the referral (occurring out of hours; assessment taking place at hospital or police station). DSM-III-R diagnosis was more weakly associated with outcome. Violence during the episode was significantly related to admission, although deliberate self harm was not. CONCLUSIONS--Home treatment is feasible for most patients with acute psychiatric illness. A 24 hour on call assessment service increases the likelihood of success because admission is determined more strongly by social characteristics of the patient and the referral than by illness factors. Admission will still be required for some patients. A locally based mental health resource centre, a 24 hour on call service, an open referral system, and an active follow up policy increase the effectiveness of a home treatment service. PMID:2249049

[Effectiveness of a new model of telephone derivation shared between primary care and hospital care].

PubMed

Azogil-López, Luis Miguel; Pérez-Lázaro, Juan José; Ávila-Pecci, Patricia; Medrano-Sánchez, Esther María; Coronado-Vázquez, María Valle

2018-04-23

The purpose of this study is to find out whether telephone referral from Primary Health Care to Internal Medicine Consult manages to reduce waiting days as compared to traditional referral. This study also aims to know how acceptable is the telephone referral to general practitioners and their patients. No blind randomized controlled clinical trial. Northern Huelva Health District. 154 patients. Patients referrals from intervention clinicians were sent via telephone consultation, whereas patients referrals from control clinicians were sent by traditional via. Number of days from referral request to Internal Medicine Consult. Number of telephone and traditional referrals. Number of doctors and patients denied. Denial reasons. A statistically significant difference was found between groups, with an average of 27 (21-34) days. Among General Practitioners, 8 of the first 58 total doctors after randomization and, subsequently, 6 of the 20 doctors of the test group refused to engage in the trial because they considered "excessive time and effort consuming". 50% of patients referred by the 14 General Practitioners finally randomized to the intervention group were denied referral by telephone due to patient's complexity. Telephone referral significantly reduces waiting days for Internal Medicine consult. This type of referral did not mean an "excessive time and effort consuming" to General Practitioners and was not all that beneficial to complex patients. Copyright © 2018 The Authors. Publicado por Elsevier España, S.L.U. All rights reserved.

Weight management services for adults--highlighting the role of primary care.

PubMed

Hassan, S J; O'Shea, D

2012-01-01

Ireland has the fourth highest prevalence of overweight and obese men in the European Union and the seventh highest prevalence among women. This study focuses on 777 referrals on the waiting list for Ireland's only fully funded hospital-based adult weight management service with special emphasis on the role of primary care in the referral process. Since our last review two years ago, we found that patients are now being referred at a younger age (mean 43 years). The mean BMI at referral has increased from 44 to 46. Five hundred and forty eight (70%) referrals were from primary care with males accounting for 163 (30%) of these, despite male obesity being more prevalent. Interestingly, as the distance from Dublin increased, the number of referrals decreased. Overall this is a concerning trend showing the increasing burden of obesity on a younger population and a health system inadequately equipped to deal with the problem. It also highlights the central role of the primary care physician in the timely and appropriate referral to optimise use of our available resources.

Factors affecting subspecialty referrals by pediatric primary care providers for children with obesity-related comorbidities.

PubMed

Walsh, Carolyn O; Milliren, Carly E; Feldman, Henry A; Taveras, Elsie M

2013-08-01

To determine referral patterns from pediatric primary care to subspecialists for overweight/obesity and related comorbidities. We used the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to identify overweight/obesity and 5 related comorbidities in primary care visits between 2005 and 2009 by children 6 to 18 years. The primary outcome was whether the visit ended in referral. We used multivariable analysis to examine factors associated with referral. We identified 34,225 database visits. A total of 17.1% were with overweight (body mass index=85th to 94th percentile) or obese (body mass index≥95th percentile) patients. A total of 7.1% of primary care visits with overweight/obese children ended in referral. Referral was more likely when obesity was the reason for visit (odds ratio=2.83; 95% confidence interval=1.61-4.97) but was not associated with presence of a comorbidity (odds ratio=1.35; 95% confidence interval=0.75-2.44). Most overweight or obese children are not referred, regardless of comorbidity status. One reason may be low levels of appropriate diagnosis.

Is there an increased clinical severity of patients with eating disorders under managed care?

PubMed

Bravender, T; Robertson, L; Woods, E R; Gordon, C M; Forman, S

1999-06-01

We sought to examine possible differences in medical status at presentation in 1996, compared to 1991, of adolescents with eating disorders (EDs) at a hospital-based multidisciplinary care program to reflect the increasing market penetration of managed care. Charts were reviewed for all new patients scheduled in a hospital-based outpatient ED program in 1996 and 1991. The 92-item standardized data extraction form included information on demographics, indicators of illness severity at the first visit, and subsequent hospitalization. The need for primary care referral was verified using billing records. Data were analyzed with Student's t-test, Chi-square, Fisher's exact, and Mann-Whitney U tests using SPSS 7.5. Of the 153 total patients, 133 kept their intake appointment and 130 (98%) of these had charts available for review. The age, racial/ethnic characteristics, and average length of disordered eating behaviors were not significantly different over the 5-year period. Referral from a primary care clinician was more commonly required in 1996 than 1991 (59% vs. 11%; p < .0001). Eighteen percent of the patients seen in 1996 were admitted from the initial appointment for medical stabilization, compared to 1.5% in 1991 (p = .002). Comparing 1996 to 1991, a similar number of patients had symptoms consistent with anorexia nervosa, whereas fewer patients in 1996 gave a history of bingeing and purging (22% vs. 40%; p = .027). There were no significant differences in indicators of illness severity, treatment by primary care clinician prior to referral, or hospitalization rates for those patients with and without managed care. Patients in 1996 were more likely to require referrals, were less likely to have symptoms consistent with bulimia nervosa, and were more likely to be admitted for medical stabilization. There were no differences in patient presentation characteristics or initial hospitalization rates based on their managed care status. Further research is needed to investigate the changes in illness severity at presentation and to assess the role that managed care plays in the treatment of patients with eating disorders.

Exceptions to the Stark law: practical considerations for surgeons.

PubMed

Satiani, Bhagwan

2006-03-01

The purpose of this study was to provide an understanding of the applicable legislative exceptions to prohibitions under the Stark law, which governs common legitimate business relationships in surgical practice. Stark I and II prohibits all referrals (and claims) for the provision of designated health services for federal reimbursement if a physician or immediate family member has any financial relationship with the entity. Regardless of intent (unlike the antikickback statute), any financial relationship is illegal unless specifically excepted by statute. These exceptions are relevant to ownership, compensation arrangements, or both. The most important ones relevant to surgeons are as follows: physician service exception (services rendered in an intragroup referral); in-office ancillary services exception (office-based vascular laboratory); the whole hospital exception (ownership interest in a hospital or department); lease exception (conditions that must be met for a lease not to be considered illegal); bona fide employment exception (important to academic medical centers); personal services arrangement exception (vascular laboratory medical directorship); physician incentive plans exception (if volume or value of referrals are an issue); hospital-affiliated group practice exception (physician services billed by a hospital); recruitment arrangement exception (inducements by hospitals to relocate); items/services exception (transcription services purchased from a hospital); fair market value exception (covers services provided to health care entities); indirect compensation arrangements (dealings between a hospital and entity owned by physicians); and academic medical centers exception (new phase II rules broaden the definition of academic medical centers and ease the requirement that practice plans be tax-exempt organizations, among other changes. Although expert legal advice is required for navigation through the maze of Stark laws, it is incumbent on surgeons in private practice and at academic centers to have basic knowledge of exceptions under this burdensome statute. Antikickback "safe harbors" provide some protection against possible Stark violations. Penalties for violating Stark laws are severe, including fines of up to $15,000 per service and the economic threat of exclusion from participation in federal health care programs.

Patient trends in orthopedic traumas and related disorders after tsunami caused by the Great East Japan Earthquake: An experience in the primary referral medical center.

PubMed

Matsuzawa, Gaku; Sano, Hirotaka; Ohnuma, Hideji; Tomiya, Akihito; Kuwahara, Yoshiyuki; Hashimoto, Chihiro; Imamura, Itaru; Ishibashi, Satoru; Kobayashi, Michio; Kobayashi, Masakazu; Ishii, Tadashi; Kaneda, Iwao; Itoi, Eiji

2016-07-01

In the Great East Japan Earthquake, the Japanese Red Cross Ishinomaki Hospital played an important role as a principal referral center within the Ishinomaki region, one of the most severely affected areas in eastern Japan. The present study describes the patient population, clinical characteristics, and time courses of the medical problems observed at this hospital. A retrospective survey of medical logs and records was conducted on the first 2 weeks after the earthquake to characterize orthopedic traumas and related disorders treated during this catastrophe. Patient number, severity of injuries, number of patients secondarily transported to the referral medical centers in the inland area, and the number of surgeries performed during the study period were investigated. Totally, 7686 patients visited the hospital. Of which, 1807 patients suffered from exogenous diseases, such as trauma, burns, crush syndrome, deep venous thrombosis, and infectious diseases. Patients who suffered from hypothermia were the most frequently seen within the first 2 weeks after the earthquake. Interestingly, most patients' conditions were not severe and required only simple treatments. Four patients (0.2% of patients with exogenous diseases) were secondarily transported to the referral medical centers in the inland area and only four patients were surgically treated because of a lack of available implants, surgical devices, and electric power supply. The Great East Japan Earthquake and subsequent tsunami, which occurred during an early spring afternoon, resulted in a unique orthopedic patient population, which included few severely injured patients compared with numerous deaths. We believe that each coastal region hospital should develop its own emergency medical care system to address future tsunami events while considering their surrounding environment. The information described in the present study should be important for preparation toward future events involving massive earthquakes followed by tsunami disasters. Copyright © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

Pediatric Neurosurgical Outcomes Following a Neurosurgery Health System Intervention at Mulago National Referral Hospital in Uganda.

PubMed

Fuller, Anthony T; Haglund, Michael M; Lim, Stephanie; Mukasa, John; Muhumuza, Michael; Kiryabwire, Joel; Ssenyonjo, Hussein; Smith, Emily R

2016-11-01

Pediatric neurosurgical cases have been identified as an important target for impacting health disparities in Uganda, with over 50% of the population being less than 15 years of age. The objective of the present study was to evaluate the effects of the Duke-Mulago collaboration on pediatric neurosurgical outcomes in Mulago National Referral Hospital. We performed retrospective analysis of all pediatric neurosurgical cases who presented at Mulago National Referral Hospital in Kampala, Uganda, to examine overall, preprogram (2005-2007), and postprogram (2008-2013) outcomes. We analyzed mortality, presurgical infections, postsurgical infections, length of stay, types of procedures, and significant predictors of mortality. Data on neurosurgical cases was collected from surgical logbooks, patient charts, and Mulago National Referral Hospital's yearly death registry. Of 820 pediatric neurosurgical cases, outcome data were complete for 374 children. Among children who died within 30 days of a surgical procedure, the largest group was less than a year old (45%). Postinitiation of the Duke-Mulago collaboration, we identified an overall increase in procedures, with the greatest increase in cases with complex diagnoses. Although children ages 6-18 years of age were 6.66 times more likely to die than their younger counterparts preprogram, age was no longer a predictive variable postprogram. When comparing pre- and postprogram outcomes, mortality among pediatric patients within 30 days after a neurosurgical procedure increased from 4.3% to 10.0%, mortality after 30 days increased slightly from 4.9% to 5.0%, presurgical infections decreased by 4.6%, and postsurgery infections decreased slightly by 0.7%. Our data show the provision of more complex neurological procedures does not necessitate improved outcomes. Rather, combining these higher-level procedures with essential pre- and postoperative care and continued efforts in health system strengthening for pediatric neurosurgical care throughout Uganda will help to address and decrease the burden throughout the country. Copyright © 2016 Elsevier Inc. All rights reserved.

A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization.

PubMed

Raven, Maria C; Steiner, Faye

2018-06-01

Many policymakers believe that expanding access to outpatient care will reduce emergency department (ED) use. However, outpatient health care providers often refer their patients to EDs for evaluation and management. We examine the factors underlying outpatient provider referral, its effect on ED visit volume, and whether referred ED visits are more likely to result in hospitalization than self-referred visits. We conducted a cross-sectional study of 19,342 adult (>18 years) respondents to the 2012 to 2014 National Health Interview Survey who reported they had visited an ED at least once in the past 12 months, representing an estimated 44,152,870 US adults. We categorized individuals as having been referred to the ED by an outside health care provider if they responded affirmatively to "your health care provider advised you to go" as a reason for their most recent ED visit. We performed descriptive analyses and logistic regressions to examine factors associated with outpatient health care provider referral to the ED. Respondents could choose multiple other reasons for their most recent ED visit, and we used existing Centers for Disease Control and Prevention guidelines to group these reasons into 2 categories: seriousness of the medical condition and lack of access to other providers. Our 2 main outcomes were whether an outpatient health care provider referred an individual to the ED and whether that ED visit resulted in hospitalization. Of the 44,152,870 US adults (18.58%; 95% confidence interval [CI] 18.21% to 18.95%) with one or more ED visits in the previous 12 months, 10,913,271 (24.72%; 95% CI 23.80% to 25.64%) were referred to the ED by an outpatient provider. Respondents who reported their ED visit was due to the seriousness of their medical condition were more likely to be referred to the ED (odds ratio [OR] 2.18; 95% CI 1.91 to 2.49), whereas those reporting a lack of access to other providers were less likely to be referred (OR 0.58; 95% CI 0.52 to 0.64). Visits referred to the ED were more likely to result in hospitalization than self-referrals (OR 2.07; 95% CI 1.87 to 2.31). Almost one quarter of individuals' most recent ED visits were driven by referrals from outpatient health care providers. Being referred to the ED by an outpatient provider is strongly associated with the seriousness of one's medical condition, which also increases the odds of hospitalization compared with ED discharge. After controlling for seriousness of medical condition, ED referral by an outpatient provider continues to have an independent association with hospitalization. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Evaluating the feasibility of the KDIGO CKD referral recommendations.

PubMed

Singh, Karandeep; Waikar, Sushrut S; Samal, Lipika

2017-07-07

In 2012, the international nephrology organization Kidney Disease Improving Global Outcomes (KDIGO) released recommendations for nephrology referral for chronic kidney disease (CKD) patients. The feasibility of adhering to these recommendations is unknown. We conducted a retrospective analysis of the primary care population at Brigham and Women's Hospital (BWH). We translated referral recommendations based upon serum creatinine, estimated glomerular filtration rate (eGFR), and albuminuria into a set of computable criteria in order to project referral volume if the KDIGO referral recommendations were to be implemented. Using electronic health record data, we evaluated each patient using the computable criteria at the times that the patient made clinic visits in 2013. We then compared the projected referral volume with baseline nephrology clinic volume. Out of 56,461 primary care patients at BWH, we identified 5593 (9.9%) who had CKD based on albuminuria or estimated GFR. Referring patients identified by the computable criteria would have resulted in 2240 additional referrals to nephrology. In 2013, this would represent a 38.0% (2240/5892) increase in total nephrology patient volume and 67.3% (2240/3326) increase in new referral volume. This is the first study to examine the projected impact of implementing the 2012 KDIGO referral recommendations. Given the large increase in the number of referrals, this study is suggestive that implementing the KDIGO referral guidelines may not be feasible under current practice models due to a supply-demand mismatch. We need to consider new strategies on how to deliver optimal care to CKD patients using the available workforce in the U.S. health care system.

Auditing surgical service provision at a South African tertiary institution: Implications for the development of district services.

PubMed

Laing, G L; Skinner, D L; Bruce, J L; Aldous, C; Govindasamy, V; Thomson, S R; Clarke, D L

2017-11-01

The optimal management of resources within South African state hospitals has been hampered by a paucity of data due to a lack of robust auditing information systems. This study reviews the use of a Hybrid Electronic Medical Record (HEMR) system to capture and aggregate data pertaining to the inpatient service demands on a South African tertiary surgical service. This dataset was used to analyse the appropriateness of tertiary surgical resource utilisation. The HEMR system was implemented at Greys Hospital, in the city of Pietermaritzburg, Kwa-Zulu Natal, South Africa on 1 January 2013. Inpatient data pertaining to surgical admissions and operative interventions were captured prospectively. Following an 18-month study period, the data were extracted, aggregated and analysed. The district referral hospitals were mapped, and district surgical procedures performed within the tertiary center were identified and quantified. Results: 7314 patients were admitted and managed by the tertiary surgical service during the study period. The median patient age was 33 years (IQR 6.5-42.4 years). 59.7% were male and 40.3% were female. General, trauma and paediatric surgical admissions constituted 54.8%, 28.6% and 16.6% respectively. Emergency admissions constituted 62.4% and elective admissions 37.6%. Referral sources were captured for 6653 (91%) of the cohort. 4338 (65.2%) patients were referred from district hospitals. The district hospital (Northdale) closest to Greys Hospital was responsible for 1675 (25.2%) of surgical referrals. 4174 operative procedures were performed during the study period, 54.7% performed as an emergency, 34.1% electively and 11.2% semi-electively. The median waiting time for emergency operative intervention was 535 minutes (IQR 130-663). A total of 1272 (30.5%) operative procedures performed were assessed as district-level operations. The time intervals of 07:00-07:59 and 17:00-17:59 were identified as the time periods during which the least number of emergency procedures were performed in the operating theatres. The HEMR system enabled the Pietermaritzburg Metropolitan Department of Surgery to quantify the burden of surgical disease and map district referral patterns. Thirty percent of operative procedures performed were assessed as district-level operations. Potentially correctable deficits identified within the tertiary center were lengthy delays to emergency surgery and non-optimal theatre utilisation periods.

[Self-referrals at Emergency Care Access Points and triage by General Practitioner Cooperatives].

PubMed

Smits, M; Rutten, M; Schepers, L; Giesen, P

2017-01-01

There is a trend for General Practitioner Cooperatives (GPCs) to co-locate with emergency departments (EDs) of hospitals at Emergency Care Access Points (ECAPs), where the GPCs generally conduct triage and treat a large part of self-referrals who would have gone to the ED by themselves in the past. We have examined patient and care characteristics of self-referrals at ECAPs where triage was conducted by GPCs, also to determine the percentage of self-referrals being referred to the ED. Retrospective cross-sectional observational study. Descriptive analyses of routine registration data from self-referrals of five ECAPs (n = 20.451). Patient age, gender, arrival time, urgency, diagnosis and referral were analysed. Of the self-referrals, 57.9% was male and the mean age was 32.7 years. The number of self-referrals per hour was highest during weekends, particularly between 11 a.m. and 5 p.m. On weekdays, there was a peak between 5 and 9 p.m. Self-referrals were mostly assigned a low-urgency grade (35.7% - U4 or U5) or a mid-urgency grade (49% - U3). Almost half of the self-referrals had trauma of the locomotor system (28%) or the skin (27.3%). In total, 23% of the patients was referred to the ED. Self-referred patients at GPCs are typically young, male and have low- to mid-urgency trauma-related problems. Many self-referrals present themselves on weekend days or early weekday evenings. Over three quarters of these patients can be treated by the GPCs, without referral to the ED. This reduces the workload at the ED.

The development of the modified blaylock tool for occupational therapy referral (MBTOTR): a preliminary evaluation of its utility in acute care.

PubMed

Tan, Emma Su Zan; Mackenzie, Lynette; Travasssaros, Katrina; Yeo, Megan

2016-08-01

Acute hospitals are facing more complex admissions with older people at increased risk of functional decline. This study aimed to create and trial the feasibility of a new screening tool designed to identify patients at risk of functional decline who need an occupational therapy referral within acute care. Ten screening tools were reviewed and the Modified Blaylock Tool for Occupational Therapy Referral (MBTOTR) was developed. The MBTOTR was applied in a retrospective chart review of 50 patients over the age of 65 years who were admitted to five acute wards. Data on patients identified at risk of functional decline were compared to patients who were referred to occupational therapy. Occupational therapy referrals were made by ward staff for 14 out of the 50 patients reviewed (32.5%). Only 14% (n = 7) of patients did not require a referral. The MBTOTR identified no irrelevant occupational therapy referrals. However, 66.5% of patients identified as needing an occupational therapy referral did not get one. The MBTOTR identified high risk acute patients requiring an occupational therapy referral who were not referred to occupational therapy. Use of the MBTOTR would facilitate early occupational therapy referrals for complex patients, and potentially better discharge outcomes. Implications for rehabilitation The MBTOTR can be used in acute care settings to facilitate relevant occupational therapy referrals. Without a screening tool, many older people who should have an occupational therapy assessment may not receive a referral for occupational therapy. Nursing and medical staff need to use this tool to identify older people in their care who may benefit from occupational therapy assessment and intervention. If occupational therapy referrals can be made early, this may contribute to reducing delays to discharge plans for complex patients.

National HIV Testing Day at CDC-funded HIV counseling, testing, and referral sites--United States, 1994-1998.

PubMed

2000-06-23

CDC-funded human immunodeficiency virus (HIV) counseling, testing, and referral sites are an integral part of national HIV prevention efforts (1). Voluntary counseling, testing, and referral opportunities are offered to persons at risk for HIV infection at approximately 11,000 sites, including dedicated HIV counseling and testing sites, sexually transmitted disease (STD) clinics, drug-treatment centers, hospitals, and prisons. Services also are offered to women in family planning and prenatal/obstetric clinics to increase HIV prevention efforts among women and decrease the risk for perinatal HIV transmission. To increase use of HIV counseling, testing, and referral services by those at risk for HIV infection, in 1995, the National Association of People with AIDS designated June 27 each year as National HIV Testing Day. This report compares use of CDC-funded counseling, testing, and referral services the week before and the week of June 27 from 1994 through 1998 and documents the importance of a national public health campaign designed to increase knowledge of HIV serostatus.

Use of a "secure room" and a security guard in the management of the violent, aggressive or suicidal patient in a rural hospital: a 3-year audit.

PubMed

Brock, Gordon; Gurekas, Vydas; Gelinas, Anne-Fredrique; Rollin, Karina

2009-01-01

Little has been published on the management of psychiatric crises in rural areas, and little is known of the security needs or use of "secure rooms" in rural hospitals. We conducted a 3-year retrospective chart audit on the use of our secure room/security guard system at a rural hospital in a town of 3500, located 220 km from our psychiatric referral centre. Use of our secure room/security guard system occurred at the rate of 1.1 uses/1000 emergency department visits, with the most common indication being physician perception of risk of patient suicide or self-harm. Concern for staff safety was a factor in 10% of uses. Eighty percent of patients were treated locally, with most being released from the secure room after 2 days or less. Fourteen percent of patients required ultimate transfer to our psychiatric referral centre and 6% to a detoxification centre. The average annual cost of security was $16 259.61. A secure room can provide the opportunity for close observation of a potentially self-harming patient, additional security for staff and early warning if a patient flees the hospital. Most admissions were handled locally, obviating the need for transfer to distant psychiatric referral centres. Most patients who were admitted were already known as having a psychiatric illness and 80% of the patients required the use of the secure room/security guard system for less than a 2-night stay, suggesting that most rural mental health crises pass quickly. Most patients admitted to a rural hospital with a mental health crisis can be managed locally if an adequate secure room/security guard system is available.

The choice of alternatives to acute hospitalization: a descriptive study from Hallingdal, Norway

PubMed Central

2013-01-01

Background Hallingdal is a rural region in southern Norway. General practitioners (GPs) refer acutely somatically ill patients to any of three levels of care: municipal nursing homes, the regional community hospital or the local general hospital. The objective of this paper is to describe the patterns of referrals to the three different somatic emergency service levels in Hallingdal and to elucidate possible explanations for the differences in referrals. Methods Quantitative methods were used to analyse local patient statistics and qualitative methods including focus group interviews were used to explore differences in referral rates between GPs. The acute somatic admissions from the six municipalities of Hallingdal were analysed for the two-year period 2010–11 (n = 1777). A focus group interview was held with the chief municipal medical officers of the six municipalities. The main outcome measure was the numbers of admissions to the three different levels of acute care in 2010–11. Reflections of the focus group members about the differences in admission patterns were also analysed. Results Acute admissions at a level lower than the local general hospital ranged from 9% to 29% between the municipalities. Foremost among the local factors affecting the individual doctor’s admission practice were the geographical distance to the different places of care and the GP’s working experience in the local community. Conclusion The experience from Hallingdal demonstrates that GPs use available alternatives to hospitalization but to varying degrees. This can be explained by socio-demographic factors and factors related to the medical reasons for admission. However, there are also important local factors related to the individual GP and the structural preparedness for alternatives in the community. PMID:23800090

Characteristics and outcomes of pediatric patients presenting at Cambodian referral hospitals without appointments: an observational study.

PubMed

Yore, Mackensie A; Strehlow, Matthew C; Yan, Lily D; Pirrotta, Elizabeth A; Woods, Joan L; Somontha, Koy; Sovannra, Yim; Auerbach, Lauren; Backer, Rebecca; Grundmann, Christophe; Mahadevan, Swaminatha V

2018-03-13

Emergency medicine is a young specialty in many low- and middle-income countries (LMICs). Although many patients seeking emergency or acute care are children, little information is available about the needs and current treatment of this group in LMICs. In this observational study, we sought to describe characteristics, chief complaints, management, and outcomes of children presenting for unscheduled visits to two Cambodian public hospitals. Children enrolled in the study presented without appointment for treatment at one of two Cambodian public referral hospitals during a 4-week period in 2012. Researchers used standardized questionnaires and hospital records to collect demographic and clinical data. Patients were followed up at 48 h and 14 days after initial presentation. Multivariate logistic regression identified factors associated with hospital admission. This study included 867 unscheduled visits. Mean patient age was 5.7 years (standard deviation 4.8 years). Of the 35 different presenting complaints, fever (63%), respiratory problems (25%), and skin complaints (24%) were most common. The majority of patients were admitted (51%), while 1% were transferred to another facility. Seven patients (1%) died within 14 days. Follow-up rates were 83% at 48 h and 75% at 14 days. Predictors of admission included transfer or referral from another health provider, seeking prior care for the presenting problem, low socioeconomic status, onset of symptoms within 24 h of seeking care, abnormal vital signs or temperature, and chief complaint of abdominal pain or fever. While the admission rate in this study was high, mortality was low. More effective identification and management of children who can be treated and released may free up scarce inpatient resources for children who warrant admission.

Utilization of Parenteral Morphine by Application of ATC/DDD Methodology: Retrospective Study in the Referral Teaching Hospital.

PubMed

Dragojevic-Simic, Viktorija; Rancic, Nemanja; Stamenkovic, Dusica; Simic, Radoje

2017-01-01

Few studies analyzed the pattern of opioid analgesic utilization in hospital settings. The aim of this study was to determine the consumption pattern of parenteral morphine in patients hospitalized in the Serbian referral teaching hospital and to correlate it with utilization at the national and international level. In retrospective study, the required data were extracted from medical records of surgical patients who received parenteral morphine in the 5-year period, from 2011 to 2015. We used the Anatomical Therapeutic Chemical Classification/Defined Daily Doses (DDD) international system for consumption evaluation. While the number of performed surgical procedures in our hospital steadily increased from 2011 to 2015, the number of inpatient bed-days decreased from 2012. However, the consumption of parenteral morphine varied and was not more than 0.867 DDD/100 bed-days in the observed period. Based on the available data, parenteral morphine consumption in our hospital was lower compared with international data. The low level of morphine use in the hospital was in accordance with national data, and compared with other countries, morphine consumption applied for medical indications in Serbia was low. Adequate legal provision to ensure the availability of opioids, better education and training of medical personnel, as well as multidisciplinary approach should enable more rational and individual pain management in the future, not only within the hospitals.

Do financial incentives linked to ownership of specialty hospitals affect physicians' practice patterns?

PubMed

Mitchell, Jean M

2008-07-01

Although physician-owned specialty hospitals have become increasingly prevalent in recent years, little research has examined whether the financial incentives linked to ownership influence physicians' referral rates for services performed at the specialty hospital. We compared the practice patterns of physician owners of specialty hospitals in Oklahoma, before and after ownership, to the practice patterns of physician nonowners who treated similar cases over the same time period in Oklahoma markets without physician-owned specialty hospitals. We constructed episodes of care for injured workers with a primary diagnosis of back/spine disorders. We used pre-post comparisons and difference-in-differences analysis to evaluate changes in practice patterns for physician owners and nonowners over the time period spanned by the entry of the specialty hospital. Findings suggest the introduction of financial incentives linked to ownership coincided with a significant change in the practice patterns of physician owners, whereas such changes were not evident among physician nonowners. After physicians established ownership interests in a specialty hospital, the frequency of use of surgery, diagnostic, and ancillary services used in the treatment of injured workers with back/spine disorders increased significantly. Physician ownership of specialty hospitals altered the frequency of use for an array of procedures rendered to patients treated at these hospitals. Given the growth in physician-owned specialty hospitals, these findings suggest that health care expenditures will be substantially greater for patients treated at these institutions relative to persons who obtain care from nonself-referral providers.

Awareness of Stroke Risk after TIA in Swiss General Practitioners and Hospital Physicians.

PubMed

Streit, Sven; Baumann, Philippe; Barth, Jürgen; Mattle, Heinrich P; Arnold, Marcel; Bassetti, Claudio L; Meli, Damian N; Fischer, Urs

2015-01-01

Transient ischemic attacks (TIA) are stroke warning signs and emergency situations, and, if immediately investigated, doctors can intervene to prevent strokes. Nevertheless, many patients delay going to the doctor, and doctors might delay urgently needed investigations and preventative treatments. We set out to determine how much general practitioners (GPs) and hospital physicians (HPs) knew about stroke risk after TIA, and to measure their referral rates. We used a structured questionnaire to ask GPs and HPs in the catchment area of the University Hospital of Bern to estimate a patient's risk of stroke after TIA. We also assessed their referral behavior. We then statistically analysed their reasons for deciding not to immediately refer patients. Of the 1545 physicians, 40% (614) returned the survey. Of these, 75% (457) overestimated stroke risk within 24 hours, and 40% (245) overestimated risk within 3 months after TIA. Only 9% (53) underestimated stroke risk within 24 hours and 26% (158) underestimated risk within 3 months; 78% (473) of physicians overestimated the amount that carotid endarterectomy reduces stroke risk; 93% (543) would rigorously investigate the cause of a TIA, but only 38% (229) would refer TIA patients for urgent investigations "very often". Physicians most commonly gave these reasons for not making emergency referrals: patient's advanced age; patient's preference; patient was multimorbid; and, patient needed long-term care. Although physicians overestimate stroke risk after TIA, their rate of emergency referral is modest, mainly because they tend not to refer multimorbid and elderly patients at the appropriate rate. Since old and frail patients benefit from urgent investigations and treatment after TIA as much as younger patients, future educational campaigns should focus on the importance of emergency evaluations for all TIA patients.

Mental Capacity Assessments Among Inpatients Referred to the Consultation-Liaison Psychiatry Unit at a University Hospital in Bangkok, Thailand.

PubMed

Pariwatcharakul, Pornjira; Singhakant, Supachoke

2017-03-01

Clinicians routinely assess patients' mental capacity on a daily basis, but a more thorough assessment may be needed in complex cases. We aimed to identify the characteristics of inpatients in a general hospital, who were referred to a liaison psychiatry service for mental capacity assessment, reasons for the referrals, and the factors associated with their mental capacity. A 6-year retrospective study (2008-2013) was conducted using data collected routinely (e.g., age, gender, diagnosis, Thai Mental State Examination score, reasons for the referral, and the outcome of capacity assessment) on referrals for mental capacity assessment to a Consultation-liaison Psychiatry Unit at a university hospital in Thailand. Among 6194 consecutive referrals to the liaison-psychiatry services, only 0.6 % [n = 37, mean age (SD), 59.83 (20.42)] were referred for capacity assessment, 43.24 % of which lacked mental capacity. The most common requests from referring physicians were for assessment of testamentary capacity (15 assessed, 53.33 % lacking capacity), financial management capacity (14 assessed, 50 % lacking capacity), and capacity to consent to treatment (9 assessed, 22.22 % lacking capacity). Delirium, rather than dementia or other mental disorders, was associated with mental incapacity (p < 0.001) and being more dependent during the admission (p = 0.048). There were no significant differences for mean age (p = 0.257) or Thai Mental State Examination score (p = 0.206). The main request from referring clinicians was to assess testamentary capacity. Delirium and being more dependent during the admission were associated with lack of mental capacity, whereas age and dementia were not.

A critical appraisal of guidelines used for management of severe acute malnutrition in South Africa's referral system.

PubMed

Mambulu-Chikankheni, Faith Nankasa; Eyles, John; Eboreime, Ejemai Amaize; Ditlopo, Prudence

2017-10-18

Focusing on healthcare referral processes for children with severe acute malnutrition (SAM) in South Africa, this paper discusses the comprehensiveness of documents (global and national) that guide the country's SAM healthcare. This research is relevant because South African studies on SAM mostly examine the implementation of WHO guidelines in hospitals, making their technical relevance to the country's lower level and referral healthcare system under-explored. To add to both literature and methods for studying SAM healthcare, we critically appraised four child healthcare guidelines (global and national) and conducted complementary expert interviews (n = 5). Combining both methods enabled us to examine the comprehensiveness of the documents as related to guiding SAM healthcare within the country's referral system as well as the credibility (rigour and stakeholder representation) of the guideline documents' development process. None of the guidelines appraised covered all steps of SAM referrals; however, each addressed certain steps thoroughly, apart from transit care. Our study also revealed that national documents were mostly modelled after WHO guidelines but were not explicitly adapted to local context. Furthermore, we found most guidelines' formulation processes to be unclear and stakeholder involvement in the process to be minimal. In adapting guidelines for management of SAM in South Africa, it is important that local context applicability is taken into consideration. In doing this, wider stakeholder involvement is essential; this is important because factors that affect SAM management go beyond in-hospital care. Community, civil society, medical and administrative involvement during guideline formulation processes will enhance acceptability and adherence to the guidelines.

Increasing podiatry referrals for patients with inflammatory arthritis at a tertiary hospital in Singapore: A quality improvement project.

PubMed

Carter, K; Cheung, P P; Rome, K; Santosa, A; Lahiri, M

2017-06-01

Foot disease is highly prevalent in people with inflammatory arthritis and is often under-recognized. Podiatry intervention can significantly reduce foot pain and disability, with timely access being the key factor. The aim of this study was to plan and implement a quality improvement project to identify the barriers to, and improve, uptake of podiatry services among patients with inflammatory arthritis-related foot problems seen at a tertiary hospital in Singapore. A 6-month quality improvement program was conducted by a team of key stakeholders using quality improvement tools to identify, implement and test several interventions designed to improve uptake of podiatry services. The number of patients referred for podiatry assessment was recorded on a weekly basis by an experienced podiatrist. The criterion for appropriate referral to podiatry was those patients with current or previous foot problems such as foot pain, swelling and deformity. Interventions included education initiatives, revised workflow, development of national guidelines for inflammatory arthritis, local podiatry guidelines for the management of foot and ankle problems, routine use of outcome measures, and introduction of a fully integrated rheumatology-podiatry service with reduced cost package. Referral rates increased from 8% to 11%, and were sustained beyond the study period. Complete incorporation of podiatry into the rheumatology consultation as part of the multidisciplinary team package further increased referrals to achieve the target of full uptake of the podiatry service. Through a structured quality improvement program, referrals to podiatry increased and improved the uptake and acceptance of rheumatology-podiatry services. Copyright © 2016 Elsevier Ltd. All rights reserved.

How many referrals to a pediatric orthopaedic hospital specialty clinic are primary care problems?

PubMed

Hsu, Eric Y; Schwend, Richard M; Julia, Leamon

2012-01-01

Many primary care physicians believe that there are too few pediatric orthopaedic specialists available to meet their patients' needs. However, a recent survey by the Practice Management Committee of the Pediatric Orthopaedic Society of North America found that new referrals were often for cases that could have been managed by primary care practitioners. We wished to determine how many new referral cases seen by pediatric orthopaedic surgeons are in fact conditions that can be readily managed by a primary care physician should he/she chose to do so. We prospectively studied all new referrals to our hospital-based orthopaedic clinic during August 2010. Each new referral was evaluated for whether it met the American Board of Pediatrics criteria for being a condition that could be managed by a primary care pediatrician. Each referral was also evaluated for whether it met the American Academy of Pediatrics Surgery Advisory Panel guidelines recommending referral to an orthopaedic specialist, regardless of whether it is for general orthopaedics or pediatric orthopaedics. On the basis of these criteria, we classified conditions as either a condition manageable by primary care physicians or a condition that should be referred to an orthopaedic surgeon or a pediatric orthopaedic surgeon. We used these guidelines not to identify diagnosis that primary care physicians should treat but, rather, to compare the guideline-delineated referrals with the actual referrals our specialty pediatric orthopaedic clinic received over a period of 1 month. A total of 529 new patient referrals were seen during August 2010. A total of 246 (47%) were considered primary care conditions and 283 (53%) orthopaedic specialty conditions. The most common primary care condition was a nondisplaced phalanx fracture (25/246, 10.1%) and the most common specialty condition was a displaced single-bone upper extremity fracture needing reduction (36/283, 13%). Only 77 (14.6%) of the total cases met the strict American Academy of Pediatrics Surgery Advisory Panel guidelines recommending referral to pediatric orthopaedics, with scoliosis being the most frequent condition. For 38 (7.2%) cases, surgical treatment was required or recommended. Patient age, referral source, or type of insurance did not influence whether the condition was a primary care or a specialty care case. A total of 134 (25%) cases were referred without having an initial diagnosis made by the referring clinician. These patients were more likely to have been referred from a primary care practitioner than from a tertiary care practitioner whether the diagnosis eventually made was considered to be a primary care condition (P=0.03; relative risk, 1.9; 95% confidence interval, 96-3.86). Almost half of all new referrals to a tertiary pediatric orthopaedic clinic were for conditions considered to be manageable by primary care physicians should they chose to do so. This has implications for pediatric orthopaedic workforce availability, reimbursement under the Affordable Care Act, and pediatric musculoskeletal training needs for providers of primary care.

Adaptation of a hospital electronic referral system for antimicrobial stewardship prospective audit and feedback rounds.

PubMed

Rawlins, Matthew D M; Raby, Edward; Sanfilippo, Frank M; Douglass, Rae; Chambers, Jonathan; McLellan, Duncan; Dyer, John R

2018-05-04

To evaluate the impact of the adaptation of an existing electronic referral application for use in antimicrobial stewardship prospective audit and feedback rounds (antimicrobial rounds). Retrospective, single-centre observational study between March 2015 and February 2016. A new quaternary referral centre. Adults referred for antimicrobial rounds outside of the intensive care and haematology units. Adaptation of an electronic referral application used by medical and allied health staff. A questionnaire-style referral form was designed to capture patient clinical details using a combination of free text and dropdown menus. Clinical pharmacists were educated and granted access to the system. The proportion of completed electronic referrals of total round reviews by month for the 12 months after implementation. The time from request to completion of reviews. The impact on adherence to advice provided on rounds. The impact on the institutional usage of broad-spectrum antibiotics: glycopeptides, carbapenems, third and fourth generation cephalosporins, fluoroquinolones and piperacillin/tazobactam. Over the study period, the proportion of electronic referrals of completed antimicrobial round reviews increased from 59% to 88% (P < 0.001); 75.7% of accepted electronic referrals were seen within 48 h of request. The proportion of advice ignored fell from 18% to 8.5% (P < 0.001). Piperacillin/tazobactam, fluoroquinolone and glycopeptide usage decreased. The adaptation of an electronic referral application for antimicrobial rounds was associated with increased adherence to advice and reduction in use in target antibiotics. Our model is now used at other institutions.

First quality score for referral letters in gastroenterology—a validation study

PubMed Central

Eskeland, Sigrun Losada; Brunborg, Cathrine; Seip, Birgitte; Wiencke, Kristine; Hovde, Øistein; Owen, Tanja; Skogestad, Erik; Huppertz-Hauss, Gert; Halvorsen, Fred-Arne; Garborg, Kjetil; Aabakken, Lars; de Lange, Thomas

2016-01-01

Objective To create and validate an objective and reliable score to assess referral quality in gastroenterology. Design An observational multicentre study. Setting and participants 25 gastroenterologists participated in selecting variables for a Thirty Point Score (TPS) for quality assessment of referrals to gastroenterology specialist healthcare for 9 common indications. From May to September 2014, 7 hospitals from the South-Eastern Norway Regional Health Authority participated in collecting and scoring 327 referrals to a gastroenterologist. Main outcome measure Correlation between the TPS and a visual analogue scale (VAS) for referral quality. Results The 327 referrals had an average TPS of 13.2 (range 1–25) and an average VAS of 4.7 (range 0.2–9.5). The reliability of the score was excellent, with an intra-rater intraclass correlation coefficient (ICC) of 0.87 and inter-rater ICC of 0.91. The overall correlation between the TPS and the VAS was moderate (r=0.42), and ranged from fair to substantial for the various indications. Mean agreement was good (ICC=0.47, 95% CI (0.34 to 0.57)), ranging from poor to good. Conclusions The TPS is reliable, objective and shows good agreement with the subjective VAS. The score may be a useful tool for assessing referral quality in gastroenterology, particularly important when evaluating the effect of interventions to improve referral quality. PMID:27855107

Rapid operation assessment of voluntary HIV counselling and testing services in three cities in China, 2009.

PubMed

Ma, W; Ye, S; Xiao, Y; Jin, C; Li, Y; Zhao, L; Cai, Y; Liu, B; Detels, R

2013-12-01

To assess the operation of voluntary counselling and testing (VCT) services forhuman immunodeficiency virus (HIV) in three cities in China. A cross-sectional study using mixed methods, including focus group discussions,in-depth interviews, field assessment, archive checking and structured questionnaire interviews, was conducted to assess different aspects of VCT services. Surveys were undertaken in six counties of three China Global Fund AIDS Program (Round Five) cities, including 11 VCT clinics, 38 counsellors, 83 clients and 332 individuals at risk for HIV infection. All counsellors were trained and approved for providing counselling. As there were adequate numbers of clinics and counsellors, VCT services ran smoothly. Clients were generally satisfied with VCT services and considered service operation to be adequate. Problems with the VCT programme included fewer VCT services in general hospitals, lack of a referral mechanism, and long delays between testing and receipt of results. The operation of VCT services in the three cities was generally adequate, but referral services were poor. More attention needs to be paid to HIV testing and counselling in general hospitals, and referral networks need to be strengthened.

Confirmatory Factor Analysis of the WISC-IV in a Hospital Referral Sample

ERIC Educational Resources Information Center

Devena, Sarah E.; Gay, Catherine E.; Watkins, Marley W.

2013-01-01

Confirmatory factor analysis was used to determine the factor structure of the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) scores of 297 children referred to a children's hospital in the Southwestern United States. Results support previous findings that indicate the WISC-IV is best represented by a direct hierarchical…

Mental Health Services in a Rural Area: The Integrated Relationship between State Hospital and Community Mental Health Centers. Notes from the Field.

ERIC Educational Resources Information Center

Bittle, Ronald G.

1988-01-01

Describes "linkage agreement" system between Illinois community mental health centers and Anna Mental Health and Developmental Center serving 28 rural counties. Agreements specify responsibilities of community centers and hospital staff regarding referrals, client treatment, and discharge. Describes improvements over previous…

Mortality in newborns referred to tertiary hospital: An introspection

PubMed Central

Aggarwal, Kailash Chandra; Gupta, Ratan; Sharma, Shobha; Sehgal, Rachna; Roy, Manas Pratim

2015-01-01

Background: India is one of the largest contributors in the pool of neonatal death in the world. However, there are inadequate data on newborns referred to tertiary care centers. The present study aimed to find out predictors of mortality among newborns delivered elsewhere and admitted in a tertiary hospital in New Delhi between February and September 2014. Materials and Methods: Hospital data for were retrieved and analyzed for determining predictors for mortality of the newborns. Time of admission, referral and presenting clinical features were considered. Results: Out of 1496 newborns included in the study, there were 300 deaths. About 43% deaths took place in first 24 hours of life. Asphyxia and low birth weight were the main causes of death in early neonatal period, whereas sepsis had maximum contribution in deaths during late neonatal period. Severe hypothermia, severe respiratory distress, admission within first 24 hours of life, absence of health personnel during transport and referral from any hospital had significant correlation with mortality. Conclusions: There is need for ensure thermoregulation, respiratory sufficiency and presence of health personnel during transport. PMID:26288788

Sauti Za Wananchi "voice of the people": patient satisfaction on the medical wards at a Kenyan Referral Hospital.

PubMed

Stone, Geren Starr; Jerotich, Tecla Sum; Cheriro, Betsy Rono; Kiptoo, Robert Sitienei; Crowe, Susie Joanne; Koros, Elijah Kipkorir; Muthoni, Doreen Mutegi; Onalo, Paul Theodore

2014-01-01

Patient satisfaction is one indicator of healthcare quality. Few studies have examined the inpatient experiences in resource-scarce environments in sub-Saharan Africa. To examine patient satisfaction on the public medical wards at a Kenyan referral hospital, we performed a cross-sectional survey focused on patients' satisfaction with medical information and their relationship with staffing and hospital routine. Ratings of communication with providers, efforts to protect privacy, information about costs, food, and hospital environment were also elicited. Overall, the average patient satisfaction rating was 64.7, nearly midway between "average" and "good" Higher rated satisfaction was associated with higher self-rated general health scores and self-rated health gains during the hospitalization (p=0.023 and p=0.001). Women who shared a hospital bed found privacy to be "below average" to "poor" Most men (72.7%) felt information about costs was insufficient. Patients rated food and environmental quality favorably while also frequently suggesting these areas could be improved. Overall, patients expressed satisfaction with the care provided. These ratings may reflect modest patients' expectations as well as acceptable circumstances and performance. Women expressed concern about privacy while men expressed a desire for more information on costs. Inconsistencies were noted between patient ratings and free response answers.

A technician-delivered 'virtual clinic' for triaging low-risk glaucoma referrals.

PubMed

Kotecha, A; Brookes, J; Foster, P J

2017-06-01

PurposeThe purpose of this study is to describe the outcomes of a technician-delivered glaucoma referral triaging service with 'virtual review' of resultant data by a consultant ophthalmologist.Patients and methodsThe Glaucoma Screening Clinic reviewed new optometrist or GP-initiated glaucoma suspect referrals into a specialist ophthalmic hospital. Patients underwent testing by three ophthalmic technicians in a dedicated clinical facility. Data were reviewed at a different time and date by a consultant glaucoma ophthalmologist. Approximately 10% of discharged patients were reviewed in a face-to-face consultant-led clinic to examine the false-negative rate of the service.ResultsBetween 1 March 2014 and 31 March 2016, 1380 patients were seen in the clinic. The number of patients discharged following consultant virtual review was 855 (62%). The positive predictive value of onward referrals was 84%. Three of the 82 patients brought back for face-to-face review were deemed to require treatment, equating to negative predictive value of 96%.ConclusionsOur technician-delivered glaucoma referral triaging clinic incorporates consultant 'virtual review' to provide a service model that significantly reduces the number of onward referrals into the glaucoma outpatient department. This model may be an alternative to departments where there are difficulties in implementing optometrist-led community-based referral refinement schemes.

The Accuracy of Measurements of Nonmelanoma Skin Cancer Sizes Referred to the Mohs Surgery Clinic.

PubMed

To, Derek; Macdonald, Jillian

Tumour size is a crucial factor used to plan Mohs procedures. Larger tumours require more time and stages of excision, and they need to be triaged as a higher priority. Therefore, the accuracy in measurement of tumour size is critical. To investigate if there is a significant difference in accuracy of tumour measurements in referrals between dermatologists and nondermatologists. Performed a retrospective study of 180 referrals from dermatologists and 47 referrals from nondermatologists to The Ottawa Hospital Riverside Mohs Surgery Clinic. We compared the mean size difference of tumours between the preoperative size and the size reported on referral. Average reported size upon referral of nonmelanoma skin cancer (NMSC) was 1.39 cm 2 and 1.35 cm 2 from dermatologists and nondermatologists, respectively ( P = .881). During the preoperative assessment, tumour sizes were 0.65 cm 2 and 1.45 cm 2 larger than that reported from dermatologists and nondermatologists, respectively ( P < .05). The duration between referral and preoperative assessment was 3 to 4 months for both groups ( P = .26). The accuracy of tumour measurements between dermatologists and nondermatologists differed significantly, as nondermatologists underestimated the size of NMSCs. This directly affects triaging patients and operative management in Mohs surgery. To compensate for size underestimation, early and prompt referrals of NMSCs from nondermatologists are warranted.

Malaria and HIV among pediatric inpatients in two Tanzanian referral hospitals: A prospective study.

PubMed

Smart, Luke R; Orgenes, Neema; Mazigo, Humphrey D; Minde, Mercy; Hokororo, Adolfine; Shakir, Muhammad; Verweij, Jaco J; Downs, Jennifer A; Peck, Robert N

2016-07-01

Malaria remains common in sub-Saharan Africa, but it is frequently over-diagnosed and over-treated in hospitalized children. HIV is prevalent in many malaria endemic areas and may delay parasite clearance and increase mortality among children with malaria. This prospective cohort study enrolled children with suspected malaria between 3 months and 12 years of age hospitalized at two referral hospitals in Tanzania. Both a thick blood smear (BS) and a malaria rapid diagnostic test (mRDT) were performed. If discordant results were obtained, PCR was performed for Plasmodium falciparum. Malaria was confirmed if two out of three tests were positive. Malaria parasite densities were determined for two consecutive days after diagnosis and treatment of malaria. All participants were tested for HIV. Among 1492 hospitalized children, 400 (26.8%) were enrolled with suspected malaria infection. There were 196/400 (49.0%) males, and the median age was 18 [9-36] months. BS was positive in 95/400 (23.8%), and mRDT was positive in 70/400 (17.5%), with moderate agreement (Kappa=0.598). Concordant results excluded malaria in 291/400 (72.8%) and confirmed malaria in 56/400 (14.0%). PCR performed on 53 discordant results confirmed malaria in 1/39 of the BS-positive/mRDT-negative cases, and 6/14 of the BS-negative/mRDT-positive cases. The prevalence of confirmed malaria was 63/400 (15.8%). In multivariable logistic regression, malaria was associated with HIV (OR 3.45 [1.65-7.20], p=0.001). Current breastfeeding (OR 0.25 [0.11-0.56], p=0.001) and higher hemoglobin (OR 0.70 [0.60-0.81], p<0.001 per 1g/dL) were associated with decreased odds of malaria. Malaria parasite clearance was delayed in HIV-infected participants (p<0.001). Malaria is over-diagnosed even at referral centers in high transmission areas. Hospitalized HIV-infected children are more likely to have malaria and exhibit delayed clearance of parasites. Hospitals should consider using mRDTs as a first step for malaria testing among hospitalized children in sub-Saharan Africa. Copyright © 2016 Elsevier B.V. All rights reserved.

Malaria and HIV among pediatric inpatients in two Tanzanian referral hospitals: a prospective study

PubMed Central

Smart, Luke R.; Orgenes, Neema; Mazigo, Humphrey D.; Minde, Mercy; Hokororo, Adolfine; Shakir, Muhammad; Verweij, Jaco J.; Downs, Jennifer A.; Peck, Robert N.

2016-01-01

Malaria remains common in sub-Saharan Africa, but it is frequently over-diagnosed and over-treated in hospitalized children. HIV is prevalent in many malaria endemic areas and may delay parasite clearance and increase mortality among children with malaria. This prospective cohort study enrolled children with suspected malaria between 3 months and 12 years of age hospitalized at two referral hospitals in Tanzania. Both a thick blood smear (BS) and a malaria rapid diagnostic test (mRDT) were performed. If discordant results were obtained, PCR was performed for P. falciparum. Malaria was confirmed if two out of three tests were positive. Malaria parasite densities were determined for two consecutive days after diagnosis and treatment of malaria. All participants were tested for HIV. Among 1492 hospitalized children, 400 (26.8%) were enrolled with suspected malaria infection. There were 196/400 (49.0%) males, and the median age was 18 [9–36] months. BS was positive in 95/400 (23.8%), and mRDT was positive in 70/400 (17.5%), with moderate agreement (Kappa = 0.598). Concordant results excluded malaria in 291/400 (72.8%) and confirmed malaria in 56/400 (14.0%). PCR performed on 53 discordant results confirmed malaria in 1/39 of the BS-positive/mRDT-negative cases, and 6/14 of the BS-negative/mRDT-positive cases. The prevalence of confirmed malaria was 63/400 (15.8%). In multivariable logistic regression, malaria was associated with HIV (OR 3.45 [1.65–7.20], p=0.001). Current breastfeeding (OR 0.25 [0.11–0.56], p=0.001) and higher hemoglobin (OR 0.70 [0.60–0.81], p<0.001 per 1g/dL) were associated with decreased odds of malaria. Malaria parasite clearance was delayed in HIV-infected participants (p<0.001). Malaria is over-diagnosed even at referral centers in high transmission areas. Hospitalized HIV-infected children are more likely to have malaria and exhibit delayed clearance of parasites. Hospitals should consider using mRDTs as a first step for malaria testing among hospitalized children in sub-Saharan Africa. PMID:27001145

Obstetrical referrals by traditional birth attendants.

PubMed

Mustafa, Rozina; Hashmi, Haleema; Mustafa, Rubina

2012-01-01

In Pakistan 90% of births are conducted by TBA's. In most cases, TBA's are unable to diagnose the complications and are often unable to take decisions on timely referral. The objective of this study was to determine the prevalence, nature and outcome of life threatening obstetrical conditions in referrals by Traditional Birth Attendants (TBAs). This Observational, Descriptive study was conducted from January to December 2007, in the obstetrical unit of Fatima Hospital, Baqai Medical University, a tertiary care community based hospital. The study included patients referred by TBA's who developed life threatening obstetric conditions (LTOCs). Total 64 patients were referred by TBA's. The prevalence was 7.8%. Out of them, 53 (82.8%) patients admitted with life threatening obstetric conditions. The near-miss morbidities and mortalities were 45 (84.9%) and 8 (15%) respectively. Maternal mortality to Near-miss morbidity ratio was 1:6. Obstructed labour caused near-miss morbidity in 32 (60.3%) patients with no mortality. Postpartum haemorrhage as life threatening condition developed in 16 (30.1%) patients with 10 (18.8%) near-miss morbidities and 6 (11.3%) mortalities. Puerperal sepsis accounted for 1 (1.88%) near-miss morbidity and 2 (3.76%) mortalities. The mortality index for puerperal sepsis is (66.6%) almost double of postpartum haemorrhage (37.5%). Mortality to near miss morbidity ratio is high. Misidentification and late referrals of complicated cases by TBA's were responsible for near-miss morbidities and mortalities.

Written advice can provide a safe and acceptable alternative to new patient assessment for selected referrals to haematologists.

PubMed

Ganly, Peter S; Keeman, Helen; Spearing, Ruth L; Smith, Mark P; Patton, Nigel; Merriman, Eileen G; Gibbons, Steve S

2008-01-07

To measure the safety and acceptability of providing written advice (WA) for selected patients referred to a haematology service, as an alternative to inpatient or outpatient assessment. Review of the initial management and subsequent course of patients newly referred to a tertiary referral hospital in Christchurch, New Zealand, between 16 October 2003 and 8 June 2006. Structured questionnaires were sent to all referring doctors and patients recently managed with WA. Numbers and diagnoses of patients managed with WA, early assessment or delayed assessment; re-referral and treatment details; characteristics of WA letters; and opinions of referring doctors and their patients on the WA process. 26% of new referrals (714/2785) were managed with prompt WA, while 16% (455/2785) received the alternative of delayed assessment. After a median follow-up of 23 months (range, 8-40 months), 13% of those managed with WA (91/714) were re-referred back to the same haematologists; 7% (52/714) were assessed in hospital and 2% (15/714) eventually required treatment. There were no deaths due to haematological causes. Over 90% of responding referring doctors said the WA process was rapid and effective, and 77% of recently managed patients were pleased to be treated by their own doctors. Using WA to manage a substantial minority of patients referred to haematologists can be rapid and safe. It is widely accepted by referring doctors.

'Heads you win, tails I lose': a critical incident study of GPs' decisions about emergency admission referrals.

PubMed

Dempsey, Owen P; Bekker, Hilary L

2002-12-01

Acute hospital Trusts' inability to cope with the numbers of emergency admissions has led to the production of guidelines by the Department of Health aimed at reducing inappropriate admissions by GPs. There is a paucity of research describing GPs' decisions to (not) admit patients and it is unclear how effective these guidelines are in changing these practices. To describe GPs' decision-making about referrals for emergency hospital admissions. Observational design using the critical incident technique to elicit data. Eight GPs in West Yorkshire recorded details of memorable emergency admission decisions, both prospective and retrospective consultations. The transcript data were classified by theme using NUD*IST. Forty prospective and 8 retrospective consultations were analysed. Factors affecting GPs' decisions were:Identification of all consequences for all stakeholders in the decision. Emotional impact on the GP of managing these conflicting needs. 'Peer review' of the GP's professionalism about the decision. Contextual pressures limiting effectiveness of GPs' decision-making. Referral decisions require the evaluation of several conflicting consequences for many stakeholders in time-pressured and peer-reviewed situations. These factors encourage the use of heuristics, i.e. GPs' judgements will be influenced more by the social context of the choice than information about the patient's condition. Emergency referral guidelines provide more information to evaluate from another stakeholder; introducing guidelines is likely to increase GPs' use of heuristics and the making of less optimal decisions.

Referral bias in hospital register studies of geographical and industrial differences in health.

PubMed

Soll-Johanning, Helle; Hannerz, Harald; Tüchsen, Finn

2004-05-01

The Danish National Hospital Register contains four patient types: full-time inpatients, part-time inpatients, outpatients and emergency ward patients. The aim of the present study was to investigate whether results from comparative hospital register studies depend on which patient types we choose to include in the analysis. The hospital register was linked to the centralised civil register and the employment classification module. All economically active persons in Denmark aged 20-59 years 1st January 1995 (N = 2,281,480) were followed for six years. We calculated SIRs, first by county then by industry and finally by industry adjusted for county, for a variety of diagnostic groups and for each of the following types of cases: A) full-time inpatients, B) all inpatients, C) all inpatients and outpatients, D) all patients. The ratio between the maximum and the minimum of the four types of SIRs was calculated for each combination of the examined population groups and diseases. A max/min ratio was regarded as a sign of referral bias if it was above 1.2 and statistically significant. When calculating SIRs by county 46.7 percent of the max/min ratios signified referral bias. The percentage was 5.5 when calculating SIRs by industry and only 1.7 when they were calculated by industry adjusted for county. Estimates of geographical health differences are often distorted by differences in the health care organisation. Estimates of industrial health differences tend to be robust with a few identifiable exceptions. Standardisation for county will eliminate bias.

The effect of referral and transfer patients on hospital funding in a capitated health care delivery system.

PubMed

Pietz, Kenneth; Byrne, Margaret M; Daw, Christina; Petersen, Laura A

2007-10-01

(1) To investigate whether inpatients referred or transferred between facilities result in increased financial loss compared with those admitted directly, in a health care delivery system funded by capitation methods. (2) To determine whether the higher cost of those patients transferred or referred is fairly compensated by a diagnosis-based risk adjustment system, and whether tertiary care facilities bear an unfair financial burden for such patients in a capitated financing environment. The study cohort included all Veterans Affairs (VA) beneficiaries who received inpatient care during fiscal year (FY) 2004. Referral was defined as an outpatient visit to 1 facility followed by an admission to another facility. Transfers were consecutive inpatient stays at different hospitals. We defined loss as cost minus the share of budget determined by a Diagnostic Cost Group-based allocation. Both t tests and linear regression were used to compare the effect on cost and loss for patients transferred or not and referred or not. Mean loss to a facility for patients transferred in was 1231 dollars more than for those not transferred. Mean loss for referred patients was 3341 dollars more than for those not referred, controlling for disease burden. For tertiary hospitals, the difference in losses for transfer patients was less than for other hospitals but greater for referral patients. Patients referred or transferred from other facilities are more costly than those who are not. The difference may not be compensated by a diagnosis-based allocation system. A capitated health care system may consider additional funding to cover the cost of such patients.

The Direct Referral to Endovascular Center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network.

PubMed

Rodríguez-Pardo, J; Fuentes, B; Alonso de Leciñana, M; Ximénez-Carrillo, Á; Zapata-Wainberg, G; Álvarez-Fraga, J; Barriga, F J; Castillo, L; Carneado-Ruiz, J; Díaz-Guzman, J; Egido-Herrero, J; de Felipe, A; Fernández-Ferro, J; Frade-Pardo, L; García-Gallardo, Á; García-Pastor, A; Gil-Núñez, A; Gómez-Escalonilla, C; Guillán, M; Herrero-Infante, Y; Masjuan-Vallejo, J; Ortega-Casarrubios, M Á; Vivancos-Mora, J; Díez-Tejedor, E

2017-03-01

For patients with acute ischaemic stroke due to large-vessel occlusion, it has recently been shown that mechanical thrombectomy (MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT-providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation (RACE) have been developed to predict large-vessel occlusion at a pre-hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy. The Direct Referral to Endovascular Center criteria were defined based on a retrospective cohort of 317 patients admitted to a stroke center. The association of age, sex, RACE scale score and blood pressure with the likelihood of receiving MT were analyzed. Cut-off points with the highest association were thereafter evaluated in a prospective cohort of 153 patients from nine stroke units comprising the Madrid Stroke Network. Patients with a RACE scale score ≥ 5, systolic blood pressure <190 mmHg and age <81 years showed a significantly higher probability of undergoing MT (odds ratio, 33.38; 95% confidence interval, 12-92.9). This outcome was confirmed in the prospective cohort, with 68% sensitivity, 84% specificity, 42% positive and 94% negative predictive values for MT, ruling out 83% of hemorrhagic strokes. The Direct Referral to Endovascular Center criteria could be useful for identifying patients suitable for MT. © 2017 EAN.

[The Referral Field Hospital of the Emergency Response Unit (ERU) of the German Red Cross].

PubMed

Schnabel, M; Munz, R; Bohe, M

2000-07-14

Emergency Response units (ERUs) have been developed as a part of the International Federation of Red Cross and Red Crescent Societies strategy to provide fast and effective medical and technical help to victims of disasters of any kind. ERUs provide timely, professional and organised response in a standardised and streamlined way by a balanced composition of professional staff and predesigned equipment. The German Red Cross ERUs "Referral Hospital" and "Specialised Water" took part in the world wide humanitarian help for refugees during the Kosovo war and actually for earthquake victims in Turkey. During the Kosovo-operation the ERU "Referral Hospital" and "Specialised Water" were situated in Macedonia close to the kosovarian boarder at refugee camp Stenkovec I. The Field-Hospital was responsible for all kind of medical emergencies, for a total number of more than 50,000 refugees. During the mission 6225 patients were treated in our Out Patient Department; 541 were hospitalised. Among those 102 medium and major surgical procedures and 105 deliveries were performed. Surprisingly there was no increased rate of infections or perinatal deaths. During the Kosovo war and actually in Turkey the ERU concept prove itself to be a powerful strategy to provide fast needed medical help to victims of different kind of disasters. Humanitarian work in situations of war, internal disorder and various states of emergency in foreign countries and cultures demand flexibility and the ability to improvise while working under such conditions. The confrontation with non-combatants injured by buried landmines is underlining the growing world-wide demand for a total ban on these vile weapons.

Previous radiographic experience of children referred for dental extractions under general anaesthesia in the U.K.

PubMed

Young, N L; Rodd, H D; Craig, S A

2009-03-01

To determine what proportion of children undergo radiographic assessment prior to referral to a dental hospital for extractions under general anaesthesia. This prospective survey was conducted over a 6-month period. A data sheet was used to record the following information: patient's age; referrer's name and place of work (general dental practice or community dental service); teeth to be extracted (primary dentition and/or permanent dentition) and reported previous radiographic examination. Patients were excluded from the study if, following a clinical examination, radiographs were not actually deemed necessary for diagnosis and treatment planning purposes. Clinical setting A paediatric dentistry clinic within a dental hospital in the North of England. Participants 161 patients with a mean age of six years (SD = 2.2, range = 3-14 years) who were referred to the dental hospital for extractions under general anaesthesia. Overall, 12.4% of children had reportedly undergone a previous radiographic assessment prior to hospital referral. A significantly greater proportion of children referred for permanent tooth extractions had been subject to radiographic examination compared to children referred for primary tooth extractions (46.2% as compared to 6.3%; P = 0.001 chi-squared test). Furthermore, patients referred from the community dental service were significantly more likely to have had previous dental radiographs than children referred from general dental practice (36.9% compared to 9.3%; P = 0.003 chi-squared test). Radiographs do not appear to be routinely employed for caries diagnosis and treatment planning in young children within general dental practice in the U.K.

Low hospital referral rates of school scoliosis screening positives in an urban district of mainland China.

PubMed

Guo, Yawen; Jiang, Qingwu; Tanimoto, Tetsuya; Kami, Masahiro; Luo, Chunyan; Leppold, Claire; Nishimura, Koichi; He, Yongpin; Kato, Shigeaki; Ding, Xiaocang

2017-04-01

Significant prevalence rates of adolescent scoliosis in China were suggested in previous studies. However, school screenings for adolescent scoliosis have been suspended due to low rates of positive detection under the past screening system in China. The present study was undertaken to screen for adolescent scoliosis in middle school students under a modern assessment system in a district of Shanghai. We performed a population-based, cross-sectional study of a middle school scoliosis screening program in the Jingan district. In 2015, schoolchildren were initially screened by visual inspection of clinical signs and the forward-bending test. Suspected cases were referred for radiography in hospital for scoliosis diagnosis. A total of 5327 middle school students (grades 6-8) were screened with 520 (9.76%) positives (the positive rates of girls and boys at 15.28% and 4.59%, respectively) and no statistically significant difference among grades. Only 301 positives (57.9%) followed the referral for hospital radiography. There were 102 cases (33.9%) that were diagnosed with scoliosis by radiography criteria (Cobb angle ≥10°) including mild scoliosis (Cobb 10-25) for 94 cases and moderate scoliosis (Cobb 25-40) for 8 cases, and false-positives (Cobb 0) for 39 cases. The putative prevalence rate was estimated as 1.9% from the referred students. Under an accurate and modern assessment system, school screenings can detect scoliosis at a significant rate, but awareness of scoliosis risks is needed for residents in China to take up referrals for hospital diagnosis after school screenings.

Population genetic structuring of methicillin-resistant Staphylococcus aureus clone EMRSA-15 within UK reflects patient referral patterns

PubMed Central

Reuter, Sandra; Scriberras, James; Reynolds, Rosy; Brown, Nicholas M.; Török, M. Estée; James, Richard; Network, East of England Microbiology Research; Aanensen, David M.; Bentley, Stephen D.; Holden, Matthew T. G.; Parkhill, Julian; Spratt, Brian G.; Peacock, Sharon J.

2017-01-01

Antibiotic resistance forms a serious threat to the health of hospitalised patients, rendering otherwise treatable bacterial infections potentially life-threatening. A thorough understanding of the mechanisms by which resistance spreads between patients in different hospitals is required in order to design effective control strategies. We measured the differences between bacterial populations of 52 hospitals in the United Kingdom and Ireland, using whole-genome sequences from 1085 MRSA clonal complex 22 isolates collected between 1998 and 2012. The genetic differences between bacterial populations were compared with the number of patients transferred between hospitals and their regional structure. The MRSA populations within single hospitals, regions and countries were genetically distinct from the rest of the bacterial population at each of these levels. Hospitals from the same patient referral regions showed more similar MRSA populations, as did hospitals sharing many patients. Furthermore, the bacterial populations from different time-periods within the same hospital were generally more similar to each other than contemporaneous bacterial populations from different hospitals. We conclude that, while a large part of the dispersal and expansion of MRSA takes place among patients seeking care in single hospitals, inter-hospital spread of resistant bacteria is by no means a rare occurrence. Hospitals are exposed to constant introductions of MRSA on a number of levels: (1) most MRSA is received from hospitals that directly transfer large numbers of patients, while (2) fewer introductions happen between regions or (3) across national borders, reflecting lower numbers of transferred patients. A joint coordinated control effort between hospitals, is therefore paramount for the national control of MRSA, antibiotic-resistant bacteria and other hospital-associated pathogens. PMID:29026654

Health-care waste incineration and related dangers to public health: case study of the two teaching and referral hospitals in Kenya.

PubMed

Njagi, Nkonge A; Oloo, Mayabi A; Kithinji, J; Kithinji, Magambo J

2012-12-01

There are practically no low cost, environmentally friendly options in practice whether incineration, autoclaving, chemical treatment or microwaving (World Health Organisation in Health-care waste management training at national level, [2006] for treatment of health-care waste. In Kenya, incineration is the most popular treatment option for hazardous health-care waste from health-care facilities. It is the choice practiced at both Kenyatta National Hospital, Nairobi and Moi Teaching and Referral Hospital, Eldoret. A study was done on the possible public health risks posed by incineration of the segregated hazardous health-care waste in one of the incinerators in each of the two hospitals. Gaseous emissions were sampled and analyzed for specific gases the equipment was designed and the incinerators Combustion efficiency (CE) established. Combustion temperatures were also recorded. A flue gas analyzer (Model-Testos-350 XL) was used to sample flue gases in an incinerator under study at Kenyatta National Hospital--Nairobi and Moi Teaching and Referral Hospital--Eldoret to assess their incineration efficiency. Flue emissions were sampled when the incinerators were fully operational. However the flue gases sampled in the study, by use of the integrated pump were, oxygen, carbon monoxide, nitrogen dioxide, nitrous oxide, sulphur dioxide and No(x). The incinerator at KNH operated at a mean stack temperature of 746 °C and achieved a CE of 48.1 %. The incinerator at MTRH operated at a mean stack temperature of 811 °C and attained a CE of 60.8 %. The two health-care waste incinerators achieved CE below the specified minimum National limit of 99 %. At the detected stack temperatures, there was a possibility that other than the emissions identified, it was possible that the two incinerators tested released dioxins, furans and antineoplastic (cytotoxic drugs) fumes should the drugs be subjected to incineration in the two units.

Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia.

PubMed

Cameron, Peter A; Mitra, Biswadev; Fitzgerald, Mark; Scheinkestel, Carlos D; Stripp, Andrew; Batey, Chris; Niggemeyer, Louise; Truesdale, Melinda; Holman, Paul; Mehra, Rishi; Wasiak, Jason; Cleland, Heather

2009-07-06

To examine the response of the Victorian State Trauma System to the February 2009 bushfires. A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state's adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires. There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity. Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system.

Terrorist attacks in Paris: Surgical trauma experience in a referral center.

PubMed

Gregory, Thomas M; Bihel, Thomas; Guigui, Pierre; Pierrart, Jérôme; Bouyer, Benjamin; Magrino, Baptiste; Delgrande, Damien; Lafosse, Thibault; Al Khaili, Jaber; Baldacci, Antoine; Lonjon, Guillaume; Moreau, Sébastien; Lantieri, Laurent; Alsac, Jean-Marc; Dufourcq, Jean-Baptiste; Mantz, Jean; Juvin, Philippe; Halimi, Philippe; Douard, Richard; Mir, Olivier; Masmejean, Emmanuel

2016-10-01

On November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou. This study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records. Forty-one patients were referred to our center, and 22 requiring surgery were hospitalized for>24h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up. Rapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45days after the initial event. Copyright © 2016 Elsevier Ltd. All rights reserved.

Improving efficiency and saving money in an otolaryngology urgent referral clinic.

PubMed

Ibrahim, Nader; Virk, Jagdeep; George, Jason; Elmiyeh, Behrad; Singh, Arvind

2015-06-16

A closed loop audit of the ear nose and throat (ENT) urgent referral clinic at a London hospital was conducted assessing the number of patients reviewed, referral source, appropriateness of referral, presenting complaint and assigned follow-up appointments. Data was sourced from clinic letters and the patient appointment system over a 3-mo period. The initial cycle analysed 490 patients and the subsequent cycle 396. The initial audit yielded clinically relevant and cost effective recommendations which were implemented, and the audit cycle was subsequently repeated. The re-audit demonstrated decreased clinic numbers from an average 9.8 to 7.2 patients per clinic, in keeping with ENT United Kingdom guidelines. A 21% decrease in patient follow-up and 13% decrease in inappropriate referrals was achieved. Direct bookings into outpatient clinics decreased by 8%, due to correct referral pathway utilisation. Comparisons of all data sets were found to show statistical significance P < 0.05. We reported a total financial saving of £32490 in a period of 3 mo (£590 per clinic). We demonstrated that simple guidelines, supervision and consultant-led education which are non-labour intensive can have a significant impact on service provision and cost.

Are photographic records reliable for orthodontic screening?

PubMed

Mandall, N A

2002-06-01

The aim of the study was to evaluate the reliability of a panel of orthodontists for accepting new patient referrals based on clinical photographs. Eight orthodontists from Greater Manchester, Lancashire, Chester, and Derbyshire observed clinical photographs of 40 consecutive new patients attending the orthodontic department, Hope Hospital, Salford. They recorded whether or not they would accept the patient, as a new patient referral, in their department. Each consultant was asked to take into account factors, such as oral hygiene, dental development, and severity of the malocclusion. Kappa statistic for multiple-rater agreement and kappa statistic for intra-observer reliability were calculated. Inter-observer panel agreement for accepting new patient referrals based on photographic information was low (multiple rater kappa score 0.37). Intra-examiner agreement was better (kappa range 0.34-0.90). Clinician agreement for screening and accepting orthodontic referrals based on clinical photographs is comparable to that previously reported for other clinical decision making.

VA staff perceptions of the role of the extended care referral process in home and community-based services versus nursing home use posthospital discharge.

PubMed

Miller, Edward Alan; Intrator, Orna; Gadbois, Emily; Gidmark, Stefanie; Rudolph, James L

2017-01-01

Little is known about how the extended care referral process-its structure and participants-influences Veterans' use of home and community-based services (HCBS) over nursing home care within the Veterans Health Administration (VHA). This study thus characterizes the extended care referral process within the VHA and its impact on HCBS versus nursing home use at hospital discharge. Data derive from 35 semistructured interviews at 12 Veterans Affairs Medical Centers (VAMCs). Findings indicate that the referral process is characterized by a commitment by care teams to consider HCBS if possible, varied practice depending on the clinician that most heavily influences care team recommendations, and care team emphasis on respecting Veteran/family preferences even when they are contrary to care team recommendations. Potential modifications include adopting systematic assessment practices; improving Veteran, family, and provider education; and promoting informed selection through shared decision making.

Profile of atrial fibrillation inpatients: Cardiovascular risk factors and cardiac rehabilitation programme delivery and referral patterns.

PubMed

Gallagher, Robyn; Zhang, Ling; Roach, Kellie; Sadler, Leonie; Belshaw, Julie; Kirkness, Ann; Proctor, Ross; Neubeck, Lis

2015-12-01

Atrial fibrillation (AF) is increasingly common; however, the cardiovascular risk factor profile and the patterns of delivery and referral to cardiac rehabilitation (CR) in this population are poorly described. We conducted an audit of medical records (n = 145) of patients admitted with AF in one local health district in Sydney, Australia. Patients were aged a mean 72 years, and 51% were male. Lack of risk factor documentation was common. Despite this, 65% had two or more modifiable cardiovascular risk factors, including hypertension (63%) and hypercholesterolaemia (52%). Referral to Phase II CR occurred for 25% and was decreased with permanent AF diagnosis and increased with more risk factors. AF patients admitted to hospital have multiple cardiovascular risk factors but limited risk factor screening and/or referral to outpatient CR programmes. © 2014 Wiley Publishing Asia Pty Ltd.

Racial/Ethnic Differences in Patients' Selection of Surgeons and Hospitals for Breast Cancer Surgery.

PubMed

Freedman, Rachel A; Kouri, Elena M; West, Dee W; Keating, Nancy L

2015-05-01

Racial differences in breast cancer treatment may result in part from differences in the surgeons and hospitals from whom patients receive their care. However, little is known about differences in patients' selection of surgeons and hospitals. To examine racial/ethnic differences in how women selected their surgeons and hospitals for breast cancer surgery. We surveyed 500 women (222 non-Hispanic white, 142 non-Hispanic black, 89 English-speaking Hispanic, and 47 Spanish-speaking Hispanic) from northern California cancer registries with stage 0 to III breast cancer diagnosed during 2010 through 2011. We used multivariable logistic regression to assess the reasons for surgeon and hospital selection by race/ethnicity, adjusting for other patient characteristics. We also assessed the association between reasons for physician selection and patients' ratings of their surgeon and hospital. Reasons for surgeon and hospital selection and ratings of surgeon and hospital. The 500 participants represented a response rate of 47.8% and a participation rate of 69%. The most frequently reported reason for surgeon selection was referral by another physician (78%); the most frequently reported reason for hospital selection was because it was a part of a patient's health plan (58%). After adjustment, 79% to 87% of black and Spanish-speaking Hispanic women reported selecting their surgeon based on a physician's referral vs 76% of white women (P = .007). Black and Hispanic patients were less likely than white patients to report selecting their surgeon based on reputation (adjusted rates, 18% and 22% of black and Hispanic women, respectively, vs 32% of white women; P = .02). Black and Hispanic women were also less likely than white women to select their hospital based on reputation (adjusted rates, 7% and 15% vs 23%, respectively; P = .003). Women who selected their surgeon based on reputation more often rated the care from their surgeon as excellent (adjusted odds ratio, 2.21; 95% CI, 1.24-3.93); those reporting their surgeon was one of the only surgeons available through the health plan less often reported excellent quality of surgical care (adjusted odds ratio, 0.56; 95% CI, 0.34-0.91). Compared with white patients with breast cancer, minority patients were less actively involved in physician and hospital selection, relying more on physician referral and health plans rather than on reputation. Interventions to promote involvement in surgeon and hospital selection may have potential for addressing disparities related to lower-quality care from surgeons and hospitals.

Scrub typhus in the northern provinces of Vietnam: an observational study of admissions to a national referral hospital.

PubMed

Nadjm, Behzad; Thuy, Pham T; Trang, Van D; Ha, Le Dang; Kinh, Nguyen V; Wertheim, Heiman F

2014-11-01

Scrub typhus is a common cause of fever in parts of South East and Southern Asia. Little is known about the disease burden in Vietnam. A 2-year observational study of scrub typhus at a tertiary referral hospital in northern Vietnam was carried out. Diagnosis was based on a single serological test in patients with suggestive clinical symptoms. Scrub typhus was diagnosed in 3.5% (251/7226) of admissions. Cases occurred throughout the year, with incidence highest in the summer. Although complications were common, mortality was low (1.2%; 3/251). These data suggest that scrub typhus is common, with a seasonal distribution in northern Vietnam. © The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.

Franchise. Quantum leap.

PubMed

Mooney, Helen

2008-05-15

The Royal Marsden's chemotherapy unit in Kingston will not only treat its own patients who live locally, but also accept referrals from local GPs. The move is part of a trend by well-known hospitals to open franchises, led by the Moorfields Eye Hospital which has 11 satellite units, including one in Dubai. Franchising by specialist hospitals can increase services, raise income and expand their brand. It also allows specialist staff to work in a range of settings.

Disease management of early childhood caries: results of a pilot quality improvement project.

PubMed

Ng, Man Wai; Torresyap, Gay; White, Alex; Melvin, Patrice; Graham, Dionne; Kane, Daniel; Scoville, Richard; Ohiomoba, Henry

2012-08-01

The purpose is to report findings of a quality improvement (QI) project implemented at two hospital-based dental clinics that care for children with early childhood caries (ECC). We tested a disease management (DM) approach in children younger than age 60 months with ECC. After 30 months, for the 403 and 234 DM patients at Children's Hospital Boston (CHB) and Saint Joseph Hospital (SJH) who returned for at least two visits, rates of new cavitation, pain, and referrals to the OR were 26.1, 13.4 and 10.9% for CHB and 41.0, 7.3 and 14.9% for SJH. Rates of new cavitation, pain, and referrals to the OR for historical controls were 75.2, 21.7, and 20.9% for CHB and 71.3, 31.3, and 25.0% for SJH. A risk-based DM approach utilizing QI strategies to address ECC can be implemented into practice and has the potential to improve care and health outcomes.

Optimizing adherence to advice from antimicrobial stewardship audit and feedback rounds.

PubMed

Rawlins, Matthew D M; Sanfilippo, Frank M; Ingram, Paul R; McLellan, Duncan G J; Crawford, Colin; D'Orsogna, Luca; Dyer, John

2018-02-01

We examined adherence to antimicrobial stewardship prospective audit and feedback rounds in a rehabilitation service compared with the remainder of the acute hospital, and explored the reasons for this. Between October 2014 and December 2015, we retrospectively assessed the rate of non-adherence to advice from antimicrobial stewardship prospective audit and feedback rounds between the rehabilitation service and the acute hospital, along with the source of the patient referral. Compared with the rehabilitation service, acute hospital medical staff were almost twice as likely to not adhere to advice provided on antimicrobial stewardship prospective audit and feedback rounds (13.8% vs. 7.6%, p < 0.0001, relative risk 1.8 [95% confidence interval 1.3, 2.5]). In the rehabilitation service, referrals were more likely to come from medical staff (61.9% vs. 16.3%, p < 0.0001). These findings may be explained by regular, direct engagement of the antimicrobial stewardship team with the rehabilitation service clinical team, a model potentially applicable to other settings.

Biomaterials use in Mulago National Referral Hospital in Kampala, Uganda: Access and affordability.

PubMed

Bakwatanisa, Bosco; Enywaku, Alfred; Kiwanuka, Martin; Lamunu, Claire; Mbowa, Nicholas; Mukiibi, Denis; Namayega, Catherine; Ngabirano, Beryl; Ntambi, Henry; Reichert, William

2016-01-01

Students in Biomaterials BBE3102 at Makerere University in Kampala, Uganda were assigned semester long group projects in the first semester of the 2014-15 academic year to determine the biomaterials type and usage in Mulago National Referral Hospital, which is emblematic of large public hospitals across East Africa. Information gathering was conducted through student interviews with Mulago physicians because there were no archival records. The students divided themselves into seven project groups covering biomaterials use in the areas of wound closure, dental and oral surgery, cardiology, burn care, bone repair, ophthalmology and total joint replacement. As in the developed world, the majority of biomaterials used in Mulago are basic wound closure materials, dental materials, and bone fixation materials, all of which are comparatively inexpensive, easy to store, and readily available from either the government or local suppliers; however, there were significant issues with the implant supply chain, affordability, and patient compliance and follow-up in cases where specialty expertise and expensive implants were employed. © 2015 Wiley Periodicals, Inc.

Variation in Surgical Quality Measure Adherence within Hospital Referral Regions: Do Publicly Reported Surgical Quality Measures Distinguish among Hospitals That Patients Are Likely to Compare?

PubMed Central

Safavi, Kyan C; Dai, Feng; Gilbertsen, Todd A; Schonberger, Robert B

2014-01-01

Objective To determine whether surgical quality measures that Medicare publicly reports provide a basis for patients to choose a hospital from within their geographic region. Data Source The Department of Health and Human Services' public reporting website, Medicare Claims Processing Manual Baltimore, MD CMS http://www.medicare.gov/hospitalcompare. Study Design We identified hospitals (n = 2,953) reporting adherence rates to the quality measures intended to reduce surgical site infections (Surgical Care Improvement Project, 1–3) in 2012. We defined regions within which patients were likely to compare hospitals using the hospital referral regions (HRRs) from the Dartmouth Atlas of Health Care Project. We described distributions of reported SCIP adherence within each HRR, including medians, interquartile ranges (IQRs), skewness, and outliers. Principal Findings Ninety-seven percent of HRRs had median SCIP-1 scores ≥95 percent. In 93 percent of HRRs, half of the hospitals in the HRR were within 5 percent of the median hospital's score. In 62 percent of HRRs, hospitals were skewed toward the higher rates (negative skewness). Seven percent of HRRs demonstrated positive skewness. Only 1 percent had a positive outlier. SCIP-2 and SCIP-3 demonstrated similar distributions. Conclusions Publicly reported quality measures for surgical site infection prevention do not distinguish the majority of hospitals that patients are likely to choose from when selecting a surgical provider. More studies are needed to improve public reporting's ability to positively impact patient decision making. PMID:24611578

COP - Pet Owners - What is Comparative Oncology | Center for Cancer Research

Cancer.gov

What is Comparative Oncology? Cancer, in the pet population, is a spontaneous disease. Pet owners, motivated by the desire to prolong their animals' quality of life, frequently seek out the specialized care and treatment of veterinary oncologists at private referral veterinary hospitals and veterinary teaching hospitals across the country. Therapeutic modalities for veterinary

Caring for Young Adolescent Sexual Abuse Victims in a Hospital-Based Children's Advocacy Center

ERIC Educational Resources Information Center

Edinburgh, Laurel; Saewyc, Elizabeth; Levitt, Carolyn

2008-01-01

Objectives: This study compared health care assessments, referrals, treatment, and outcomes for young adolescent sexual assault/sexual abuse victims seen at a hospital-based Child Advocacy Center (CAC), to that provided to similar victims evaluated by other community providers. A second purpose was to document how common DNA evidence is found…

Ripple Effects of PPS on Nursing Homes: Swimming or Drowning in the Funding Stream?

ERIC Educational Resources Information Center

Swan, James H.; And Others

1990-01-01

Of 189 nursing homes, 83 percent reported that Medicare's hospital Prospective Payment System (PPS) affected patient needs, 53 percent said it affected patients and services provided, and 25 percent said it affected referrals to hospitals. PPS effects depended on facility factors of size, Medicare certification, tax status, and on local market…

Appropriateness of the study of iron deficiency anemia prior to referral for small bowel evaluation at a tertiary center

PubMed Central

Rodrigues, Jaime Pereira; Pinho, Rolando; Silva, Joana; Ponte, Ana; Sousa, Mafalda; Silva, João Carlos; Carvalho, João

2017-01-01

AIM To evaluate the adequacy of the study of iron deficiency anemia (IDA) in real life practice prior to referral to a gastroenterology department for small bowel evaluation. METHODS All consecutive patients referred to a gastroenterology department for small bowel investigation due to iron deficiency anemia, between January 2013 and December 2015 were included. Both patients referred from general practitioners or directly from different hospital departments were selected. Relevant clinical information regarding prior anemia workup was retrospectively collected from medical records. An appropriate pre-referral study was considered the execution of esophagogastroduodenoscopy (EGD) with Helicobacter pylori (H. pylori) investigation, colonoscopy with quality standards (recent, total and with adequate preparation) and celiac disease (CD) screening (through serologic testing and/or histopathological investigation). RESULTS A total of 77 patients (58.4% female, mean age 67.1 ± 16.7 years) were included. Most (53.2%) patients were referred from general practitioners, 41.6% from other hospital specialties and 5.2% directly from the emergency department. The mean pre-referral hemoglobin concentration was 8.8 ± 2.0 g/dL and the majority of anemias had microcytic (71.4%) and hypochromic (72.7%) characteristics. 77.9% of patients presented with an incomplete pre-referral study: EGD in 97.4%, with H. pylori investigation in 58.3%, colonoscopy with quality criteria in 63.6%, and CD screening in 24.7%. Patients with an appropriate study at the time of referral were younger (48.7 ± 17.7 vs 72.3 ± 12.3 years, P < 0.001). Small bowel evaluation was ultimately undertaken in 72.7% of patients, with a more frequent evaluation in patients with a quality colonoscopy at referral (78.6% vs 23.8%); P < 0.001 (OR = 11.7, 95%CI: 3.6-38.6). The most common diagnosis regarded as the likely cause of IDA was small bowel angioectasia (18.2%) but additional causes were also found in the upper and lower gastrointestinal tracts of near 20% of patients. Small bowel studies detected previously unknown non-small bowel findings in 7.7% of patients. CONCLUSION The study of anemia prior to referral to gastroenterology department is unsatisfactory. Only approximately a quarter of patients presented with an appropriate study. PMID:28706428

Appropriateness of the study of iron deficiency anemia prior to referral for small bowel evaluation at a tertiary center.

PubMed

Rodrigues, Jaime Pereira; Pinho, Rolando; Silva, Joana; Ponte, Ana; Sousa, Mafalda; Silva, João Carlos; Carvalho, João

2017-06-28

To evaluate the adequacy of the study of iron deficiency anemia (IDA) in real life practice prior to referral to a gastroenterology department for small bowel evaluation. All consecutive patients referred to a gastroenterology department for small bowel investigation due to iron deficiency anemia, between January 2013 and December 2015 were included. Both patients referred from general practitioners or directly from different hospital departments were selected. Relevant clinical information regarding prior anemia workup was retrospectively collected from medical records. An appropriate pre-referral study was considered the execution of esophagogastroduodenoscopy (EGD) with Helicobacter pylori ( H. pylori ) investigation, colonoscopy with quality standards (recent, total and with adequate preparation) and celiac disease (CD) screening (through serologic testing and/or histopathological investigation). A total of 77 patients (58.4% female, mean age 67.1 ± 16.7 years) were included. Most (53.2%) patients were referred from general practitioners, 41.6% from other hospital specialties and 5.2% directly from the emergency department. The mean pre-referral hemoglobin concentration was 8.8 ± 2.0 g/dL and the majority of anemias had microcytic (71.4%) and hypochromic (72.7%) characteristics. 77.9% of patients presented with an incomplete pre-referral study: EGD in 97.4%, with H. pylori investigation in 58.3%, colonoscopy with quality criteria in 63.6%, and CD screening in 24.7%. Patients with an appropriate study at the time of referral were younger (48.7 ± 17.7 vs 72.3 ± 12.3 years, P < 0.001). Small bowel evaluation was ultimately undertaken in 72.7% of patients, with a more frequent evaluation in patients with a quality colonoscopy at referral (78.6% vs 23.8%); P < 0.001 (OR = 11.7, 95%CI: 3.6-38.6). The most common diagnosis regarded as the likely cause of IDA was small bowel angioectasia (18.2%) but additional causes were also found in the upper and lower gastrointestinal tracts of near 20% of patients. Small bowel studies detected previously unknown non-small bowel findings in 7.7% of patients. The study of anemia prior to referral to gastroenterology department is unsatisfactory. Only approximately a quarter of patients presented with an appropriate study.

Community Care Workers, Poor Referral Networks and Consumption of Personal Resources in Rural South Africa

PubMed Central

Sips, Ilona; Haeri Mazanderani, Ahmad; Schneider, Helen; Greeff, Minrie; Barten, Francoise; Moshabela, Mosa

2014-01-01

Although home-based care (HBC) programs are widely implemented throughout Africa, their success depends on the existence of an enabling environment, including a referral system and supply of essential commodities. The objective of this study was to explore the current state of client referral patterns and practices by community care workers (CCWs), in an evolving environment of one rural South African sub-district. Using a participant triangulation approach, in-depth qualitative interviews were conducted with 17 CCWs, 32 HBC clients and 32 primary caregivers (PCGs). An open-ended interview guide was used for data collection. Participants were selected from comprehensive lists of CCWs and their clients, using a diversified criterion-based sampling method. Three independent researchers coded three sets of data – CCWs, Clients and PCGs, for referral patterns and practices of CCWs. Referrals from clinics and hospitals to HBC occurred infrequently, as only eight (25%) of the 32 clients interviewed were formally referred. Community care workers showed high levels of commitment and personal investment in supporting their clients to use the formal health care system. They went to the extent of using their own personal resources. Seven CCWs used their own money to ensure client access to clinics, and eight gave their own food to ensure treatment adherence. Community care workers are essential in linking clients to clinics and hospitals and to promote the appropriate use of medical services, although this effort frequently necessitated consumption of their own personal resources. Therefore, risk protection strategies are urgently needed so as to ensure sustainability of the current work performed by HBC organizations and the CCW volunteers. PMID:24781696

Barriers to providing quality emergency obstetric care in Addis Ababa, Ethiopia: Healthcare providers' perspectives on training, referrals and supervision, a mixed methods study.

PubMed

Austin, Anne; Gulema, Hanna; Belizan, Maria; Colaci, Daniela S; Kendall, Tamil; Tebeka, Mahlet; Hailemariam, Mengistu; Bekele, Delayehu; Tadesse, Lia; Berhane, Yemane; Langer, Ana

2015-03-29

Increasing women's access to and use of facilities for childbirth is a critical national strategy to improve maternal health outcomes in Ethiopia; however coverage alone is not enough as the quality of emergency obstetric services affects maternal mortality and morbidity. Addis Ababa has a much higher proportion of facility-based births (82%) than the national average (11%), but timely provision of quality emergency obstetric care remains a significant challenge for reducing maternal mortality and improving maternal health. The purpose of this study was to assess barriers to the provision of emergency obstetric care in Addis Ababa from the perspective of healthcare providers by analyzing three factors: implementation of national referral guidelines, staff training, and staff supervision. A mixed methods approach was used to assess barriers to quality emergency obstetric care. Qualitative analyses included twenty-nine, semi-structured, key informant interviews with providers from an urban referral network consisting of a hospital and seven health centers. Quantitative survey data were collected from 111 providers, 80% (111/138) of those providing maternal health services in the same referral network. Respondents identified a lack of transportation and communication infrastructure, overcrowding at the referral hospital, insufficient pre-service and in-service training, and absence of supportive supervision as key barriers to provision of quality emergency obstetric care. Dedicated transportation and communication infrastructure, improvements in pre-service and in-service training, and supportive supervision are needed to maximize the effective use of existing human resources and infrastructure, thus increasing access to and the provision of timely, high quality emergency obstetric care in Addis Ababa, Ethiopia.

Evaluation of pneumococcal and influenza vaccination coverage in rheumatology patients receiving biological therapy in a regional referral hospital.

PubMed

Fernández-Prada, María; Brandy-García, Anahy María; Rodríguez-Fonseca, Omar Darío; Huerta-González, Ismael; Fernández-Noval, Federico; Martínez-Ortega, Carmen

2018-05-08

Vaccination coverage for seasonal influenza and pneumococcus in rheumatology patients receiving biological treatment. To identify variables that predict vaccination adherence. Descriptive cross-sectional study. The study involved rheumatology patients who initiated biological therapy between 01/01/2016 and 12/31/2016 in a regional referral hospital. Variables included sociodemographic information, diagnostic data, treating physician, referral to the vaccine unit and vaccination against pneumococcus with 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23), as well as seasonal influenza (2016/17). Univariate, bivariate (Chi-square) and multivariate analysis (logistic regression) were performed. The differences were considered significant (P<.05) and the PASW v.18 software package was used. In all, 222 patients were included. Vaccination coverage was: PCV13, 80.2%; PPSV23, 77.9%; influenza 2016/17, 78.8%; PCV13+PPSV23, 75.2%; PCV13+PPSV23+influenza 2016/17, 68.9%. Axial spondylitis had the highest coverage (>80%) for pneumococcal vaccination and combination of pneumococcal with influenza. Overall, 27% of the patients were not referred to the unit. The treating physician was associated with statistical significance in each vaccine alone or combined, but referral to the vaccine unit was independently associated with the highest vaccination coverage (P<.001) in all cases. Compared to the scientific literature, we consider that the coverage of our patients against pneumococcus and influenza is high. Referral of these patients to the vaccine unit is the key to guarantee a correct immunization and to minimize some of the possible infectious adverse effects of biological therapies. Copyright © 2018 Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. Publicado por Elsevier España, S.L.U. All rights reserved.

Trends in physician referrals in the United States, 1999-2009.

PubMed

Barnett, Michael L; Song, Zirui; Landon, Bruce E

2012-01-23

Physician referrals play a central role in ambulatory care in the United States; however, little is known about national trends in physician referrals over time. The objective of this study was to assess changes in the annual rate of referrals to other physicians from physician office visits in the United States from 1999 to 2009. We analyzed nationally representative cross-sections of ambulatory patient visits in the United States, using a sample of 845 243 visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1993 to 2009, focusing on the decade from 1999 to 2009. The main outcome measures were survey-weighted estimates of the total number and percentage of visits resulting in a referral to another physician across several patient and physician characteristics. From 1999 to 2009, the probability that an ambulatory visit to a physician resulted in a referral to another physician increased from 4.8% to 9.3% (P < .001), a 94% increase. The absolute number of visits resulting in a physician referral increased 159% nationally during this time, from 41 million to 105 million. This trend was consistent across all subgroups examined, except for slower growth among physicians with ownership stakes in their practice (P = .02) or those with the majority of income from managed care contracts (P = .007). Changes in referral rates varied according to the principal symptoms accounting for patients' visits, with significant increases noted for visits to primary care physicians from patients with cardiovascular, gastrointestinal, orthopedic, dermatologic, and ear/nose/throat symptoms. The percentage and absolute number of ambulatory visits resulting in a referral in the United States grew substantially from 1999 to 2009. More research is necessary to understand the contribution of rising referral rates to costs of care.

Audit of an inpatient liaison psychiatry consultation service.

PubMed

Lyne, John; Hill, Michelle; Burke, Patricia; Ryan, Martina

2009-01-01

The purpose of this paper is to examine an audit that was performed of all patients referred to a liaison psychiatry inpatient consultation service which sought to establish a baseline for demographics, type of referral, and management of referrals, with a view to introducing improved evidence-based treatments. It also aims to examine timeliness of response to referrals benchmarked against published standards. All inpatient referrals to a liaison psychiatry service were recorded over a six-month period, including demographics, diagnosis, management and timeliness of response to referrals. The data were retrospectively analysed and compared against international standards. A total of 172 referrals were received in the six months. Commonest referral reasons included assessments regarding depressive disorders (23.8 per cent), delirium/other cognitive disorders (19.2 per cent), alcohol-related disorders (18.6 per cent), anxiety disorders (14.5 per cent), and risk management (12.2 per cent). Evidence-based practices were not utilised effectively for a number of different types of presentations. A total of 40.1 per cent of referrals were seen on the same day, 75.4 per cent by the end of the next day, and 93.4 per cent by the end of the following day. Use of a hospital protocol for management of delirium may improve outcomes for these patients. Evidence-based techniques, such as brief intervention therapies, may be beneficial for referrals involving alcohol dependence. Referrals were seen reasonably quickly, but there is room for improvement when compared with published standards. This paper provides valuable information for those involved in management of liaison psychiatry consultation services, providing ideas for development and implementation of evidence based practices.

The role of systematic inpatient cardiac rehabilitation referral in increasing equitable access and utilization.

PubMed

Grace, Sherry L; Leung, Yvonne W; Reid, Robert; Oh, Paul; Wu, Gilbert; Alter, David A; CRCARE Investigators

2012-01-01

While systematic referral strategies have been shown to significantly increase cardiac rehabilitation (CR) enrollment to approximately 70%, whether utilization rates increase among patient groups who are traditionally underrepresented has yet to be established. This study compared CR utilization based on age, marital status, rurality, socioeconomic indicators, clinical risk, and comorbidities following systematic versus nonsystematic CR referral. Coronary artery disease inpatients (N = 2635) from 11 Ontario hospitals, utilizing either systematic (n = 8 wards) or nonsystematic referral strategies (n = 8 wards), completed a survey including sociodemographics and activity status. Clinical data were extracted from charts. At 1 year, 1680 participants completed a mailed survey that assessed CR utilization. The association of patient characteristics and referral strategy on CR utilization was tested using χ. When compared to nonsystematic referral, systematic strategies resulted in significantly greater CR referral and enrollment among obese (32 vs 27% referred, P = .044; 33 vs 26% enrolled, P = .047) patients of lower socioeconomic status (41 vs 34% referred, P = .026; 42 vs 32% enrolled, P = .005); and lower activity status (63 vs 54% referred, P = .005; 62 vs 51% enrolled, P = .002). There was significantly greater enrollment among those of lower education (P = .04) when systematically referred; however, no significant differences in degree of CR participation based on referral strategy. Up to 11% more socioeconomically disadvantaged patients and those with more risk factors utilized CR where systematic processes were in place. They participated in CR to the same high degree as their nonsystematically referred counterparts. These referral strategies should be implemented to promote equitable access.

Improving access in gastroenterology: The single point of entry model for referrals

PubMed Central

Novak, Kerri L; Van Zanten, Sander Veldhuyzen; Pendharkar, Sachin R

2013-01-01

In 2005, a group of academic gastroenterologists in Calgary (Alberta) adopted a centralized referral intake system known as central triage. This system provided a single point of entry model (SEM) for referrals rather than the traditional system of individual practitioners managing their own referrals and queues. The goal of central triage was to improve wait times and referral management. In 2008, a similar system was developed in Edmonton at the University of Alberta Hospital (Edmonton, Alberta). SEMs have subsequently been adopted by numerous subspecialties throughout Alberta. There are many benefits of SEMs including improved access and reduced wait times. Understanding and measuring complex patient flow systems is key to improving access, and centralized intake systems provide an opportunity to better understand total demand and system bottlenecks. This knowledge is particularly important for specialties such as gastroenterology (GI), in which demand exceeds supply. While it is anticipated that SEMs will reduce wait times for GI care in Canada, the lack of sufficient resources to meet the demand for GI care necessitates additional strategies. PMID:24040629

Improving access in gastroenterology: the single point of entry model for referrals.

PubMed

Novak, Kerri; Veldhuyzen Van Zanten, Sander; Pendharkar, Sachin R

2013-11-01

In 2005, a group of academic gastroenterologists in Calgary (Alberta) adopted a centralized referral intake system known as central triage. This system provided a single point of entry model (SEM) for referrals rather than the traditional system of individual practitioners managing their own referrals and queues. The goal of central triage was to improve wait times and referral management. In 2008, a similar system was developed in Edmonton at the University of Alberta Hospital (Edmonton, Alberta). SEMs have subsequently been adopted by numerous subspecialties throughout Alberta. There are many benefits of SEMs including improved access and reduced wait times. Understanding and measuring complex patient flow systems is key to improving access, and centralized intake systems provide an opportunity to better understand total demand and system bottlenecks. This knowledge is particularly important for specialties such as gastroenterology (GI), in which demand exceeds supply. While it is anticipated that SEMs will reduce wait times for GI care in Canada, the lack of sufficient resources to meet the demand for GI care necessitates additional strategies.

Late presentation of canine nasal tumours in a UK referral hospital and treatment outcomes.

PubMed

Mason, S L; Maddox, T W; Lillis, S M; Blackwood, L

2013-07-01

To determine the computed tomographic stage of dogs with nasal tumours in a UK referral population, and whether stage, time to referral and treatment correlates with outcome. Retrospective review of clinical records and computed tomography scans of dogs with nasal tumours. Dogs (n=78) presented to a referral practice in the UK with suspected nasal tumours are presented with more late stage tumours than dogs in the USA and Japan. Length of time from initial presentation to referral did not correlate with tumour stage at diagnosis. Median survival times for radiotherapy-treated dogs in this population are equivalent to those previously reported for late stage nasal tumours. Dogs with nasal tumours are presented late in the course of disease in the North West of England. Dogs with clinical signs consistent with a nasal tumour should have timely imaging and biopsy, in order to make prompt treatment decisions. Although survival times are comparable with previous reports and radiotherapy is a valid treatment option for dogs with late stage disease, better outcomes are likely to be achievable with earlier treatment. © 2013 British Small Animal Veterinary Association.

Profile of referrals for early childhood developmental delay to ambulatory subspecialty clinics.

PubMed

Shevell, M I; Majnemer, A; Rosenbaum, P; Abrahamowicz, M

2001-09-01

The objective of this study was to determine the profile and pattern of referral to subspecialty clinics of young children with suspected developmental delay together with the factors prompting their referral. All children under 5 years of age referred to either developmental pediatrics or pediatric neurology clinics at a single tertiary hospital over an 18-month period were prospectively identified. Standardized demographic and referral information were collected at intake, final developmental delay subtype diagnosed was identified, and referring physicians were surveyed regarding factors prompting referral. A total of 224 children met study criteria. There was a marked male preponderance (166/224), especially among those with either cognitive or language delay. Two delay subtypes, global developmental delay and developmental language disorder, accounted for two thirds of the diagnoses made. For slightly more than one third of the children (75/224), the delay subtype diagnosed following specialty evaluation was different from that initially suspected by the referring physician. A mean delay of 15.5 months was observed for the cohort as a whole between initial parental concern and specialty assessment. For referring physicians, the major factor prompting referral was the severity of the observed delay. The most important aspects of the specialty evaluation according to referral sources were the identification of a possible etiology and confirmation of delay. A profile of referrals and the rationale thereof for a cohort of children with suspected developmental delay is presented that, although locale specific, has implications for service provision and training.

Relationship between physicians' perceived stigma toward depression and physician referral to psycho-oncology services on an oncology/hematology ward.

PubMed

Kim, Won-Hyoung; Bae, Jae-Nam; Lim, Joohan; Lee, Moon-Hee; Hahm, Bong-Jin; Yi, Hyeon Gyu

2018-03-01

This study was performed to identify relationships between physicians' perceived stigma toward depression and psycho-oncology service utilization on an oncology/hematology ward. The study participants were 235 patients in an oncology/hematology ward and 14 physicians undergoing an internal medicine residency training program in Inha University Hospital (Incheon, South Korea). Patients completed the Patient Health Questionnaire-9 (PHQ-9), and residents completed the Perceived Devaluation-Discrimination scale that evaluates perceived stigma toward depression. A total PHQ-9 score of ≥5 was defined as clinically significant depression. Physicians decided on referral on the basis of their opinions and those of their patients. The correlates of physicians' recommendation for referral to psycho-oncology services and real referrals psycho-oncology services were examined. Of the 235 patients, 143 had PHQ-9 determined depression, and of these 143 patients, 61 received psycho-oncology services. Physicians recommended that 87 patients consult psycho-oncology services. Multivariate analyses showed that lower physicians' perceived stigma regarding depression was significantly associated with physicians' recommendation for referral, and that real referral to psycho-oncology services was significantly associated with presence of a hematologic malignancy and lower physicians' perceived stigma toward depression. Physicians' perceived stigma toward depression was found to be associated with real referral to psycho-oncology services and with physician recommendation for referral to psycho-oncology services. Further investigations will be needed to examine how to reduce physicians' perceived stigma toward depression. Copyright © 2017 John Wiley & Sons, Ltd.

First quality score for referral letters in gastroenterology-a validation study.

PubMed

Eskeland, Sigrun Losada; Brunborg, Cathrine; Seip, Birgitte; Wiencke, Kristine; Hovde, Øistein; Owen, Tanja; Skogestad, Erik; Huppertz-Hauss, Gert; Halvorsen, Fred-Arne; Garborg, Kjetil; Aabakken, Lars; de Lange, Thomas

2016-10-08

To create and validate an objective and reliable score to assess referral quality in gastroenterology. An observational multicentre study. 25 gastroenterologists participated in selecting variables for a Thirty Point Score (TPS) for quality assessment of referrals to gastroenterology specialist healthcare for 9 common indications. From May to September 2014, 7 hospitals from the South-Eastern Norway Regional Health Authority participated in collecting and scoring 327 referrals to a gastroenterologist. Correlation between the TPS and a visual analogue scale (VAS) for referral quality. The 327 referrals had an average TPS of 13.2 (range 1-25) and an average VAS of 4.7 (range 0.2-9.5). The reliability of the score was excellent, with an intra-rater intraclass correlation coefficient (ICC) of 0.87 and inter-rater ICC of 0.91. The overall correlation between the TPS and the VAS was moderate (r=0.42), and ranged from fair to substantial for the various indications. Mean agreement was good (ICC=0.47, 95% CI (0.34 to 0.57)), ranging from poor to good. The TPS is reliable, objective and shows good agreement with the subjective VAS. The score may be a useful tool for assessing referral quality in gastroenterology, particularly important when evaluating the effect of interventions to improve referral quality. 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/.

Outcomes of in-hospital, out of intensive care and operation theatre cardiac arrests in a tertiary referral hospital

PubMed Central

Chakravarthy, Murali; Mitra, Sona; Nonis, Latha

2012-01-01

Objective Cardiac arrest in the hospital wards may not receive as much attention as it does in the operation theatre and intensive care unit (ICU). The experience and the qualifications of personnel in the ward may not be comparable to those in the other vital areas of the hospital. The outcome of cardiac arrest from the ward areas is a reasonable surrogate of training of the ward nurses and technicians in cardiopulmonary resuscitation. We conducted an audit to assess the issues surrounding the resuscitation of cardiac arrest in areas other than operation theatre and ICU in a tertiary referral hospital. Aims of the audit To assess the outcomes of cardiac arrest in a tertiary referral hospital. Areas such as wards, dialysis room and emergency room were considered for the audit. Methods This is a retrospective observational audit of the case records of all the adult patients who were resuscitated from ‘code blue’. Data for 2 years from 2007 was analysed by a research fellow unconnected with the resuscitations. Results Twenty-two thousand three hundred and forty-four patients were admitted as in-patients to the hospital during the 2 years, starting May 2007 through May 2009. One hundred code blue calls were received during this time. Twenty-two of the total calls received were false. Among the 78 confirmed cardiac arrests 69 occurred in the wards, 2 in emergency room, 1 in cardiac catheterisation laboratory and 3 in dialysis room. Twenty-eight patients were declared dead after unsuccessful cardiopulmonary resuscitation. Among the 50 who were resuscitated with a return of spontaneous rhythm 26 died. Twenty-four patients were discharged (survival rate of 30%). The survival decreased significantly as the age progressed beyond 60. The resuscitation rates were better in day shifts in contrast to the night. Higher survival was noted in patients who received resuscitation in less than a minute. Conclusion A overall survival to discharge rate of 30% was noted in this audit. Higher survival rates might be attributable to high rate and degree of training at the time of their employment, which was repeated at yearly interval. PMID:22572417

Trends in referral to a single encopresis clinic over 20 years.

PubMed

Fishman, Laurie; Rappaport, Leonard; Schonwald, Alison; Nurko, Samuel

2003-05-01

To compare the characteristics of children with encopresis referred to a single encopresis clinic over the course of 20 years, including symptoms, previous diagnostic and therapeutic interventions, and parental attitudes. A retrospective study was conducted of an encopresis clinic at a tertiary care pediatric hospital. Questionnaires at initial evaluation elicited information about bowel habits, soiling, previous evaluations, previous treatments, and parental attitudes. In 503 children with encopresis, the average age of referral dropped from 115 months during the earliest 5 years to 77 months during the most recent 5 years. Children who had soiling for >3 years before referral decreased from 63% to 12%. The use of barium enema before referral decreased from 14% to 5%, as did psychological evaluation, from 25% to 14%. Previous therapy with enemas decreased from 45% to 27%. Mineral oil use remained at approximately 50%, and 20% of children had no previous treatment. Symptoms at referral and parental attitudes did not change across the years. Children are now referred at an earlier age to our tertiary encopresis clinic. The number of invasive and psychological evaluations has decreased before referral. However, treatment by many primary care providers before the referral has not changed. These data may suggest that pediatricians have increased awareness of encopresis and greater appreciation of its primarily physical rather than psychological nature. Additional studies will be needed to determine how these factors affect outcome.

Reasons for referral and diagnostic concordance between physicians/surgeons and the consultation-liaison psychiatry team: An exploratory study from a tertiary care hospital in India

PubMed Central

Grover, Sandeep; Sahoo, Swapnajeet; Aggarwal, Shivali; Dhiman, Shallu; Chakrabarti, Subho; Avasthi, Ajit

2017-01-01

Background: Very few studies have evaluated the reasons for referral to consultation-liaison (CL) psychiatry teams. Aim: This study aimed to evaluate the psychiatric morbidity pattern, reasons for referral and diagnostic concordance between physicians/surgeons and the CL psychiatry team. Materials and Methods: Two hundred and nineteen psychiatric referrals made to the CL psychiatry team were assessed for reason for referral and diagnostic concordance in terms of reason of referral and psychiatric diagnosis made by the CL psychiatry team. Results: In 57% of cases, a specific psychiatric diagnosis was mentioned by the physician/surgeon. The most common specific psychiatric diagnoses considered by the physician/surgeon included depression, substance abuse, and delirium. Most common psychiatric diagnosis made by the CL psychiatric services was delirium followed by depressive disorders. Diagnostic concordance between physician/surgeon and psychiatrist was low (κ < 0.3) for depressive disorders and delirium and better for the diagnosis of substance dependence (κ = 0.678) and suicidality (κ = 0.655). Conclusions: The present study suggests that delirium is the most common diagnosis in referrals made to CL psychiatry team, and there is poor concordance between the psychiatric diagnosis considered by the physician/surgeon and the psychiatrist for delirium and depression; however, the concordance rates for substance dependence and suicidal behavior are acceptable. PMID:28827863

The Guy’s and St Thomas’s NHS Foundation Trust @home service: an overview of a new service

PubMed Central

Lee, Geraldine A.; Titchener, Karen

2017-01-01

Hospital in the home is a relatively new concept within the UK healthcare system. The Guy’s and St Thomas’s NHS Foundation Trust (GSTT) @home service ‘Bringing hospital care to your home’ was commissioned by Lambeth and Southwark CCG in 2014 to provide acute care in the patients’ place of residence by facilitating rapid discharge from hospital. The service is designed for 260–280 referrals each month from local hospitals, London Ambulance Service, GPs, district nurses and palliative care services. The GSTT@home provides intensive care for a short episode through multidisciplinary team work with the aim of returning the patient to their prior health status following an acute episode of ill health. The main criteria for referrals are adults, living within Lambeth or Southwark with an acute onset of illness often with acute exacerbations of chronic conditions. Care is delivered using 25 clinical pathways using integrated care teams, including those for respiratory disease, heart failure and palliative care services. Recently, the service extended to include overnight palliative care. As care shifts from hospital to the community, it is envisaged that these types of programmes will become an essential component of care provision. This paper describes the service and presents initial service evaluation data. PMID:28356923

The Guy's and St Thomas's NHS Foundation Trust @home service: an overview of a new service.

PubMed

Lee, Geraldine A; Titchener, Karen

2017-03-01

Hospital in the home is a relatively new concept within the UK healthcare system. The Guy's and St Thomas's NHS Foundation Trust (GSTT) @home service 'Bringing hospital care to your home' was commissioned by Lambeth and Southwark CCG in 2014 to provide acute care in the patients' place of residence by facilitating rapid discharge from hospital. The service is designed for 260-280 referrals each month from local hospitals, London Ambulance Service, GPs, district nurses and palliative care services. The GSTT@home provides intensive care for a short episode through multidisciplinary team work with the aim of returning the patient to their prior health status following an acute episode of ill health. The main criteria for referrals are adults, living within Lambeth or Southwark with an acute onset of illness often with acute exacerbations of chronic conditions. Care is delivered using 25 clinical pathways using integrated care teams, including those for respiratory disease, heart failure and palliative care services. Recently, the service extended to include overnight palliative care. As care shifts from hospital to the community, it is envisaged that these types of programmes will become an essential component of care provision. This paper describes the service and presents initial service evaluation data.

Caring Mental Patients Sharing the Same Rooms with Somatic Patients in General and Referral Hospitals in Rwanda: Analysis of Disadvantages and Advantages

PubMed Central

Gitimbwa, Siméon Sebatukura

2017-01-01

Hospitalizing mental patients in the same rooms with somatic patients is one of the consequences of the decentralization of mental health units in all hospitals of Rwanda. There is a necessity to discover and to analyze advantages and disadvantages of this practice. Mental health staffs of 31 general and referral hospitals have been interviewed on questions about disadvantages and advantages to hospitalize mental patients together with somatic patients. Results show these disadvantages: a therapeutic environment not appropriate or a lack of harmony in the rooms (58.1% of respondents); a lack of bodily safety for somatic patients (51.6%); a lack of safety on the properties of somatic patients (45.2%); a lack of psychological wellbeing of somatic patients (29%); a lack of safety for mental patients (29%). About the main advantages, 100% of respondents pointed out the treatment of mental patients followed even during the week-end and the break time by the guard nurses doing the ward round visit or the guard; 72.2% said it prevents discrimination, because mental patient feel that he is a patient like others; 50% said it prevents stigmatization (to avoid for example, the expression “he is mad”); 16.7% said that mental patients receive help from somatic patients. PMID:28473969

Caring Mental Patients Sharing the Same Rooms with Somatic Patients in General and Referral Hospitals in Rwanda: Analysis of Disadvantages and Advantages.

PubMed

Gitimbwa, Siméon Sebatukura

2014-01-01

Hospitalizing mental patients in the same rooms with somatic patients is one of the consequences of the decentralization of mental health units in all hospitals of Rwanda. There is a necessity to discover and to analyze advantages and disadvantages of this practice. Mental health staffs of 31 general and referral hospitals have been interviewed on questions about disadvantages and advantages to hospitalize mental patients together with somatic patients. Results show these disadvantages: a therapeutic environment not appropriate or a lack of harmony in the rooms (58.1% of respondents); a lack of bodily safety for somatic patients (51.6%); a lack of safety on the properties of somatic patients (45.2%); a lack of psychological wellbeing of somatic patients (29%); a lack of safety for mental patients (29%). About the main advantages, 100% of respondents pointed out the treatment of mental patients followed even during the week-end and the break time by the guard nurses doing the ward round visit or the guard; 72.2% said it prevents discrimination, because mental patient feel that he is a patient like others; 50% said it prevents stigmatization (to avoid for example, the expression "he is mad"); 16.7% said that mental patients receive help from somatic patients.

The hospital resource utilization associated with osteoporotic hip fractures in Kermanshah, Iran.

PubMed

Saeb, Morteza; Beyranvand, Mandana; Basiri, Zahra; Haghparast-Bidgoli, Hassan

2014-01-01

Hip fracture is the most serious complication of osteoporosis and imposes a significant financial burden on countries' economy. This study aimed to assess the hospitalization costs and length of stay associated with osteoporosis hip fractures and identify the major cost components in a referral hospital in Kermanshah city, Iran. In a prospective study, from May 21 2007 to May 21 2008, all patients with osteoporotic hip fracture admitted to a referral hospital for operation were recruited as the study sample. For each patient, information such as age, gender, length of stay (LOS) in hospital and intensive care unit (ICU), medical and diagnostic procedures and cost of surgery and implant were collected both through interview with the patient or a family member and the patients' hospital records. A total of 103 patients (56 men and 47 women) were studied. The average hospital length of stay (LOS) for the patients was 9.7 days, ranging from 5 to 38 days. The average total hospitalization costs was 7,208,588 IRR (US$774). The main components of the costs were ward stay (16.3%), operative (54.6%), implant (26%) and medical and diagnostic procedures (3.1%). The results of this study demonstrate that the hospital resource burden associated with osteoporotic hip fractures in Iran is substantial and expected to rise with the projected increase of life expectancy and the number of elderly in Iran. Estimating the economic burden of osteoporotic hip fractures provide information that can be of importance in the planning and design of preventive strategies. © 2014 KUMS, All rights reserved.

Estimation of Surgery Capacity in Haiti: Nationwide Survey of Hospitals.

PubMed

Tran, Tu M; Saint-Fort, Mackenson; Jose, Marie-Djenane; Henrys, Jean Hugues; Pierre Pierre, Jacques B; Cherian, Meena N; Gosselin, Richard A

2015-09-01

Haiti's surgical capacity was significantly strained by the 2010 earthquake. As the government and its partners rebuild the health system, emergency and essential surgical care must be a priority. A validated, facility-based assessment tool developed by WHO was completed by 45 hospitals nationwide. The hospitals were assessed for (1) infrastructure, (2) human resources, (3) surgical interventions and emergency care, and (4) material resources for resuscitation. Fisher's exact test was used to compare hospitals by sectors: public compared to private and mixed (public-private partnerships). The 45 hospitals included first-referral level to the national referral hospital: 20 were public sector and 25 were private or mixed sector. Blood banks (33% availability) and oxygen concentrators (58%) were notable infrastructural deficits. For human resources, 69% and 33% of hospitals employed at least one full-time surgeon and anaesthesiologist, respectively. Ninety-eight percent of hospitals reported capacity to perform resuscitation. General and obstetrical surgical interventions were relatively more available, for example 93% provided hernia repairs and 98% provided cesarean sections. More specialized interventions were at a deficit: cataract surgery (27%), cleft repairs (31%), clubfoot (42%), and open treatment of fractures (51%). Deficiencies in infrastructure and material resources were widespread and should be urgently addressed. Physician providers were mal-distributed relative to non-physician providers. Formal task-sharing to midlevel and general physician providers should be considered. The parity between public and private or mixed sector hospitals in availability of Ob/Gyn surgical interventions is evidence of concerted efforts to reduce maternal mortality. This ought to provide a roadmap for strengthening of surgical care capacity.

An Essential Pathology Package for Low- and Middle-Income Countries.

PubMed

Fleming, Kenneth A; Naidoo, Mahendra; Wilson, Michael; Flanigan, John; Horton, Susan; Kuti, Modupe; Looi, Lai Meng; Price, Chris; Ru, Kun; Ghafur, Abdul; Wang, Jianxiang; Lago, Nestor

2017-01-01

We review the current status of pathology services in low- and middle-income countries and propose an “essential pathology package” along with estimated costs. The purpose is to provide guidance to policy makers as countries move toward universal health care systems. Five key themes were reviewed using existing literature (role of leadership; education, training, and continuing professional development; technology; accreditation, management, and quality standards; and reimbursement systems). A tiered system is described, building on existing proposals. The economic analysis draws on the very limited published studies, combined with expert opinion. Countries have underinvested in pathology services, with detrimental effects on health care. The equipment needs for a tier 1 laboratory in a primary health facility are modest ($2-$5,000), compared with $150,000 to $200,000 in a district hospital, and higher in a referral hospital (depending on tests undertaken). Access to a national (or regional) specialized laboratory undertaking disease surveillance and registry is important. Recurrent costs of appropriate laboratories in district and referral hospitals are around 6% of the hospital budget in midsized hospitals and likely decline in the largest hospitals. Primary health facilities rely largely on single-use tests. Pathology is an essential component of good universal health care. © American Society for Clinical Pathology, 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Best practices: Use of an administrative review committee at New Hampshire Hospital to mitigate risk with high-profile patients.

PubMed

de Nesnera, Alexander; Folks, David G

2010-07-01

An increasing number of patients manifesting violent and aggressive behaviors are treated at New Hampshire Hospital. Over the past ten years, the volume of referrals on an involuntary emergency petition has increased 70%. New Hampshire Hospital has successfully initiated its Administrative Review Committee, which confers a risk management process to mitigate potential liability for the hospital and treating clinicians for these high-risk patients. This best practice is viewed as helpful by clinicians and by the hospital's legal counsel. Hospitals treating similar high-risk patients may also benefit from developing a similar committee and risk management process.

Childhood extravasation injuries: improved outcome following the introduction of hospital-wide guidelines.

PubMed

Ghanem, Ali M; Mansour, Abdulrab; Exton, Rebecca; Powell, Jonathan; Mashhadi, Syed; Bulstrode, Neil; Smith, Gillian

2015-04-01

Extravasation is an iatrogenic injury that may produce soft tissue necrosis requiring surgical reconstruction (Rose et al., 2008) and (Goon et al., 2006). Previous review of extravasation injuries within our hospital showed that early referral to plastic surgeons and washout of high-risk cases lead to favourable outcome in 86% of patients (Gault, 1993). Hospital-wide guidelines were introduced in 2005. This paper closes the audit loop by evaluating extravasation injuries outcome following the introduction of these guidelines. All patients referred to the plastic surgery department for extravasation injuries between October 2008 and October 2009 were reviewed. A favourable outcome was defined as resolution without tissue loss requiring surgical reconstruction. Patients were excluded if they sustained the extravasation in other institution. A total of 82 extravasation injuries in 78 patients were reviewed during the audit period. Mean age was 3.2 years (Median 0.2 years, Minimum 0 day, and maximum 16.7 years). The injuries were more frequent on the left half of the body (52%) and involving the upper limbs (59%). Mean time to referral was 8 h, with 60% of patients referred within 6 h of the injury, 30% in 6-12 h, and 10% referred after more than 12 h 26% of the injuries required washout treatment - the rest was treated conservatively. Tissue necrosis occurred in 3 cases (4%) but required no surgical intervention due to the small area affected. Our audit showed an improved outcome of extravasation injury following introduction of hospital-wide guidelines of early referral to specialist team and washout of high-risk cases. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Severe Traumatic Brain Injury at a Tertiary Referral Center in Tanzania: Epidemiology and Adherence to Brain Trauma Foundation Guidelines.

PubMed

Smart, Luke R; Mangat, Halinder S; Issarow, Benson; McClelland, Paul; Mayaya, Gerald; Kanumba, Emmanuel; Gerber, Linda M; Wu, Xian; Peck, Robert N; Ngayomela, Isidore; Fakhar, Malik; Stieg, Philip E; Härtl, Roger

2017-09-01

Severe traumatic brain injury (TBI) is a major cause of death and disability worldwide. Prospective TBI data from sub-Saharan Africa are sparse. This study examines epidemiology and explores management of patients with severe TBI and adherence to Brain Trauma Foundation Guidelines at a tertiary care referral hospital in Tanzania. Patients with severe TBI hospitalized at Bugando Medical Centre were recorded in a prospective registry including epidemiologic, clinical, treatment, and outcome data. Between September 2013 and October 2015, 371 patients with TBI were admitted; 33% (115/371) had severe TBI. Mean age was 32.0 years ± 20.1, and most patients were male (80.0%). Vehicular injuries were the most common cause of injury (65.2%). Approximately half of the patients (47.8%) were hospitalized on the day of injury. Computed tomography of the brain was performed in 49.6% of patients, and 58.3% were admitted to the intensive care unit. Continuous arterial blood pressure monitoring and intracranial pressure monitoring were not performed in any patient. Of patients with severe TBI, 38.3% received hyperosmolar therapy, and 35.7% underwent craniotomy. The 2-week mortality was 34.8%. Mortality of patients with severe TBI at Bugando Medical Centre, Tanzania, is approximately twice that in high-income countries. Intensive care unit care, computed tomography imaging, and continuous arterial blood pressure and intracranial pressure monitoring are underused or unavailable in the tertiary referral hospital setting. Improving outcomes after severe TBI will require concerted investment in prehospital care and improvement in availability of intensive care unit resources, computed tomography, and expertise in multidisciplinary care. Copyright © 2017 Elsevier Inc. All rights reserved.

Cancer in the Solomon Islands.

PubMed

Martiniuk, Alexandra; Jagilli, Rooney; Natuzzi, Eileen; Ilopitu, John Wesley; Oipata, Meltus; Christie, Annie-Marie; Korini, Jefferey; Vujovich-Dunn, Cassandra; Yu, William

2017-10-01

The Solomon Islands, with a population of 550,000, has significant challenges in addressing non-communicable diseases, including cancer, in the face of significant economic, cultural, general awareness and health system challenges. To summarise the existing knowledge regarding cancer in the Solomon Islands, to gather new data and make recommendations. A literature review was undertaken and cancer data from the National Referral Hospital, Honiara were analysed and are presented. Key stakeholders were interviewed for their perspectives including areas to target for ongoing, incremental improvements. Last, a health services audit for cancer using the WHO SARA tool was undertaken. Breast and cervical cancer remain the first and second most commonly identified cancers in the Solomon Islands. The Solomons cancer registry is hospital based and suffers from incomplete data collection due to its passive nature, lack of resources for data entry and processing resulting in weak data which is rarely used for decision-making. The health system audit revealed system and individual reasons for delayed diagnosis or lack of cancer treatment or palliation in the Solomon Islands. Reasons included lack of patient knowledge regarding symptoms, late referrals to the National Referral Hospital and inability of health care workers to detect cancers either due to lack of skills to do so, or lack of diagnostic capabilities, and an overall lack of access to any health care, due to geographical barriers and overall national economic fragility. The Solomon Islands is challenged in preventing, diagnosing, treating and palliating cancer. Stakeholders recommend establishing specialty expertise (in the form of a cancer unit), improved registry processes and increased collaboration between the sole tertiary hospital nationwide and other Solomon health services as important targets for incremental improvement. Copyright © 2017. Published by Elsevier Ltd.

The ecology of medical care on an isolated island in Okinawa, Japan: a retrospective open cohort study.

PubMed

Kaneko, Makoto; Matsushima, Masato; Irving, Greg

2017-01-14

We aimed to describe the ecology of medical care on an isolated island with limited access to secondary care, and to evaluate the gatekeeping function of the island's primary care clinic through comparison with a previous nationwide survey. We conducted this retrospective, open cohort study on Iheya, an isolated island in Okinawa Prefecture that has one primary care clinic. We considered Iheya as unique location in which to examine the role of primary care in Japan. Participants were patients who visited the island's clinic between February 1, 2013 and January 31, 2014. We calculated the number of visits to the clinic and referrals to off-island medical facilities using electronic medical records. We also compared data for Iheya with a nationwide survey conducted in 2003. Iheya had 1314 inhabitants in 2013. Of the 5682 visits to the clinic in the 1-year study period, 290 people were referred to off-island medical institutions. There were 64 referrals to emergency departments; of these, 57 people were admitted to hospital. The rate of visits to the clinic per month per 1000 inhabitants was 360.4 visits (95% confidence interval: 351.0-369.7). Of these, 18.4 (16.3-20.5) were referred off-island, with 4.1 (3.1-5.1) referrals to emergency departments and 3.6 (2.6-4.6) hospitalizations. Despite the high incidence of visits to the primary care clinic, the rates of hospital-based outpatient clinic visits, emergency department visits, and hospitalizations were lower than rates reported in a previous Japanese study. This suggests that several dimensions of primary care, its gatekeeping function in particular, are likely to play important roles in this geographical setting.

Subjective parameters markedly limit the referral of transplantation candidates to liver transplant centres.

PubMed

Vidal-Trécan, Gwenaëlle; Kone, Victoria; Pilette, Christophe; Nousbaum, Jean-Baptiste; Doll, Jacques; Buffet, Catherine; Eugene, Claude; Podevin, Philippe; Boutet, Olivier; Puyeo, Jacques; Conti, Filomena; Calmus, Yvon

2016-04-01

Equality of access to organ transplantation is a mandatory public health requirement. Referral from a local to a university hospital and then registration on the national waiting list are the two key steps enabling access to liver transplantation (LT). Although the latter procedure is well defined using the Model for End-stage Liver Disease score that improves equality of access, the former is mostly reliant on the practices of referring physicians. The aim of this study was to clarify the factors determining this initial step. This observational study included consecutive inpatients with cirrhosis of whatever origin in a cohort constituted between 2003 and 2008, using medical records and structured questionnaires concerning patient characteristics and the opinions of hospital clinicians. Candidates for LT were defined in line with these opinions. Four hundred and thirty-three patients, mostly affected by alcoholic cirrhosis, were included, 21.0% of whom were considered to be candidates for LT. Factors independently associated with their candidature were: physician empathy [odds ratio (OR) = 10.8; 95% CI: 4.0-29.5], adherence to treatment (OR = 16.6; 95% CI: 3.7-75.2), geographical area (OR = 6.8; 95% CI: 2.2-21.3) and the patient's physiological age (OR = 2.3; 95% CI: 1.1-4.7). Several subjective markers restrict the referral of patients from local hospitals to liver transplant centres. Their advancement to this second step is thus markedly weakened by initial subjectivity. The development of objective guidelines for local hospital physicians to assist them with their initial decision-making on LT is now necessary. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

HIV screening among TB patients and level of antiretroviral therapy and co-trimoxazole preventive therapy for TB/HIV patients in Hawassa University Referral Hospital: a five year retrospective study.

PubMed

Simieneh, Asnake; Hailemariam, Mengistu; Amsalu, Anteneh

2017-01-01

Initiation of antiretroviral therapy (ART) and co-trimoxazole preventive therapy (CPT) is recommended for tuberculosis (TB)/human immunodeficiency virus (HIV) co-infected patients to prevent opportunistic infection. The aim of this study was to assess the prevalence of HIV among TB patients and initiation of ART and provision of CPT for TB/HIV co-infected patients in Hawassa university referral hospital. A five year document review was done on 1961 TB patients who are registered at TB clinic of Hawassa university referral hospital from September 2009 to august 2014. Data were collected using checklist. Data analysis was done by using SPSS version 20 software. Bivariate and multivariate logistic regression analysis was used to determine the predictors of TB/HIV co-infection. Among 1961 TB patients diagnosed in the hospital, 95% (1765) were screened for HIV. Of these, 13.9% (246) were HIV positive. Out of 246 TB/HIV co-infected patients 31.7% (78/246) and 37.4% (92/246) were enrolled to start ART and CPT respectively. Roughly the trends of TB/HIV co-infection decreased with increased linkage to CPT, while linkage to ART was not regular across the year. The rate of TB/HIV co-infection was significantly associated with type of TB. Although, trend of HIV among TB patients has decreased across the year, only a minority of co-infected patients was linked to start ART and CPT. Therefore, screening of all TB patients for HIV and linkage of co-infected patients to HIV care to start ART and CPT should be strengthened in-line with the national guidelines.

Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management.

PubMed

Chyka, Peter A; Erdman, Andrew R; Christianson, Gwenn; Wax, Paul M; Booze, Lisa L; Manoguerra, Anthony S; Caravati, E Martin; Nelson, Lewis S; Olson, Kent R; Cobaugh, Daniel J; Scharman, Elizabeth J; Woolf, Alan D; Troutman, William G

2007-01-01

A review of U.S. poison center data for 2004 showed over 40,000 exposures to salicylate-containing products. A guideline that determines the conditions for emergency department referral and pre-hospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce health care costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with a suspected exposure to salicylates by 1) describing the process by which a specialist in poison information should evaluate an exposure to salicylates, 2) identifying the key decision elements in managing cases of salicylate exposure, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses: 1) Patients with stated or suspected self-harm or who are the victims of a potentially malicious administration of a salicylate, should be referred to an emergency department immediately. This referral should be guided by local poison center procedures. In general, this should occur regardless of the dose reported (Grade D). 2) The presence of typical symptoms of salicylate toxicity such as hematemesis, tachypnea, hyperpnea, dyspnea, tinnitus, deafness, lethargy, seizures, unexplained lethargy, or confusion warrants referral to an emergency department for evaluation (Grade C). 3) Patients who exhibit typical symptoms of salicylate toxicity or nonspecific symptoms such as unexplained lethargy, confusion, or dyspnea, which could indicate the development of chronic salicylate toxicity, should be referred to an emergency department (Grade C). 4) Patients without evidence of self-harm should have further evaluation, including determination of the dose, time of ingestion, presence of symptoms, history of other medical conditions, and the presence of co-ingestants. The acute ingestion of more than 150 mg/kg or 6.5 g of aspirin equivalent, whichever is less, warrants referral to an emergency department. Ingestion of greater than a lick or taste of oil of wintergreen (98% methyl salicylate) by children under 6 years of age and more than 4 mL of oil of wintergreen by patients 6 years of age and older could cause systemic salicylate toxicity and warrants referral to an emergency department (Grade C). 5) Do not induce emesis for ingestions of salicylates (Grade D). 6) Consider the out-of-hospital administration of activated charcoal for acute ingestions of a toxic dose if it is immediately available, no contraindications are present, the patient is not vomiting, and local guidelines for its out-of-hospital use are observed. However, do not delay transportation in order to administer activated charcoal (Grade D). 7) Women in the last trimester of pregnancy who ingest below the dose for emergency department referral and do not have other referral conditions should be directed to their primary care physician, obstetrician, or a non-emergent health care facility for evaluation of maternal and fetal risk. Routine referral to an emergency department for immediate care is not required (Grade C). 8) For asymptomatic patients with dermal exposures to methyl salicylate or salicylic acid, the skin should be thoroughly washed with soap and water and the patient can be observed at home for development of symptoms (Grade C). 9) For patients with an ocular exposure of methyl salicylate or salicylic acid, the eye(s) should be irrigated with room-temperature tap water for 15 minutes. If after irrigation the patient is having pain, decreased visual acuity, or persistent irritation, referral for an ophthalmological examination is indicated (Grade D). 10) Poison centers should monitor the onset of symptoms whenever possible by conducting follow-up calls at periodic intervals for approximately 12 hours after ingestion of non-enteric-coated salicylate products, and for approximately 24 hours after the ingestion of enteric-coated aspirin (Grade C).

Increasing competency in the care of homeless patients.

PubMed

Drury, Lin J

2008-04-01

Nurses play a critical role in helping homeless patients make the transition from revolving door hospitalizations or emergency department visits to ongoing care through an outpatient clinic. This column focuses on increasing competency in the care of homeless patients. The next column will focus on a different type of transition-preparing hospitalized patients for discharge and referral to home health care.

Complementary surveillance strategies are needed to better characterise the epidemiology, care pathways and treatment outcomes of tuberculosis in children.

PubMed

du Preez, Karen; Schaaf, H Simon; Dunbar, Rory; Walters, Elisabetta; Swartz, Alvera; Solomons, Regan; Hesseling, Anneke C

2018-03-23

Tuberculosis (TB) in young and HIV-infected children is frequently diagnosed at hospital level. In settings where general hospitals do not function as TB reporting units, the burden and severity of childhood TB may not be accurately reflected in routine TB surveillance data. Given the paucibacillary nature of childhood TB, microbiological surveillance alone will miss the majority of hospital-managed children. The study objective was to combine complementary hospital-based surveillance strategies to accurately report the burden, spectrum and outcomes of childhood TB managed at referral hospital-level in a high TB burden setting. We conducted a prospective cohort study including all children (< 13 years) managed for TB at a large referral hospital in Cape Town, South Africa during 2012. Children were identified through newly implemented clinical surveillance in addition to existing laboratory surveillance. Data were collected from clinical patient records, the National Health Laboratory Service database, and provincial electronic TB registers. Descriptive statistics were used to report overall TB disease burden, spectrum, care pathways and treatment outcomes. Univariate analysis compared characteristics between children identified through the two hospital-based surveillance strategies to characterise the group of children missed by existing laboratory surveillance. During 2012, 395 children (180 [45.6%] < 2 years) were managed for TB. Clinical surveillance identified 237 (60%) children in addition to laboratory surveillance. Ninety (24.3%) children were HIV co-infected; 113 (29.5%) had weight-for-age z-scores <- 3. Extra-pulmonary TB (EPTB) was diagnosed in 188 (47.6%); 77 (19.5%) with disseminated TB. Favourable TB treatment outcomes were reported in 300/344 (87.2%) children with drug-susceptible and 50/51 (98.0%) children with drug-resistant TB. Older children (OR 1.7; 95% CI 1.0-2.8), children with EPTB (OR 2.3; 95% CI 1.5-3.6) and in-hospital deaths (OR 5.4; 95% CI 1.1-26.9) were more frequently detected by laboratory surveillance. TB/HIV co-infected children were less likely to be identified through laboratory surveillance (OR 0.3; 95% CI 0.2-0.5). The burden and spectrum of childhood TB disease managed at referral hospital level in high burden settings is substantial. Hospital-based surveillance in addition to routine TB surveillance is essential to provide a complete picture of the burden, spectrum and impact of childhood TB in settings where hospitals are not TB reporting units.

Infective endocarditis; report from a main referral teaching hospital in Iran

PubMed Central

Heydari, Behrooz; Karimzadeh, Iman; Khalili, Hossein; Shojaei, Esfandiar; Ebrahimi, Abdolrasool

2017-01-01

Background/Objective: The aim of the present preliminary study was to assess the demographic, clinical, paraclinical, microbiological, echocardiographic, and therapeutic profile as well as in-hospital outcome of patients with infective endocarditis at a referral center for various infectious diseases in Iran. Methods: Required demographic, clinical, plausible complications and paraclinical data were collected from patients’ medical charts. Echocardiographic findings were obtained by performing transthoracic and/or transesophageal echocardiography as clinically indicated. In addition, details of management modalities and in-hospital outcome of patients were recorded. Results: During a 3-year period, 55 patients with definite or possible diagnosis of Infective endocarditis were admitted to the ward. Twenty one (38.2%) patients were injection drug users. Staphylococcus aureus and S.epidermidis were the most commonly isolated microorganisms. Management modalities of Infective endocarditis included antimicrobial therapy alone (48 cases) and the combination of antimicrobial therapy and surgery (7 cases). Conclusion: The rate of negative blood culture in our cohort is high. S. aureus and S.epidermidis were the most commonly isolated microorganisms from positive blood cultures. Congestive heart failure was the most frequent infective endocarditis complication as well as indication for surgery. In-hospital mortality rate of patients was unexpectedly low. PMID:28496492

Prevalence and antimicrobial susceptibility patterns of extended spectrum beta-lactamase producing Entrobacteriaceae in the University of Gondar Referral Hospital environments, northwest Ethiopia.

PubMed

Engda, Tigist; Moges, Feleke; Gelaw, Aschalew; Eshete, Setegn; Mekonnen, Feleke

2018-05-22

This study aimed at assessing the magnitude, distribution, and the antimicrobial susceptibility of the extended spectrum beta-lactamase producing Entrobacteriaceae in the University of Gondar Referral Hospital environments. Out of a total of 384 samples, 14.8% were ESBL producing Entrobacteriaceae, where 42.10% Klebsiella pneumoniae, 35.09% Escherchia coli and 7.01% Proteus mirabilis were the predominant isolates. Most ESBL producing isolates, that is, 24.56, 22.8, and 22.8% were found from waste water, sinks and bedside tables respectively. All ESBL producing Entrobacteriaceae were found to be resistant to ceftriaxone, ceftazidime, cefpirome, cefpodoxime, and amoxicillin with Clavulanic acid. Resistance rate was also high for non-beta-lactam antimicrobials, like chloramphenicol (70.18%), cotrimoxazole (64.91%), norfloxacin (42.10%), ciprofloxacin (43.86%), and gentamicin (19.30%).

[Primary lymphoma of the central nervous system: 20 years' experience in a referral hospital].

PubMed

Calderón-Garcidueñas, A L; Pacheco-Calleros, J; Castelán-Maldonado, E; Nocedal-Rustrián, F C

Primary central nervous system lymphomas (PCNSL) are rare neoplasms. AIM. To study the clinical aspects and the immuno-phenotype of all cases of PCNSL in a 20 years lapse in a referral hospital in Northeastern Mexico. From January 1986 to December 2005 all PCNSL histologically confirmed were studied. The primary lymphomas were 1% of malignant central nervous system neoplasms. 21 cases were studied (ages from 9-70 years) with male predominance (2:1). 24% patients had immuno-suppression. The more frequent clinical data were: papilledema (71%), headache (62%), paresis (48%) and seizures (33%). 33% of patients died during the first six months after diagnosis. The T lymphomas were 19% of cases and corresponded to small cell type. PCNSL are still a diagnostic challenge. Multicenter studies are required in order to determine the best treatment protocol.

Incident chronic kidney disease: trends in management and outcomes.

PubMed

Perkins, Robert M; Chang, Alex R; Wood, Kenneth E; Coresh, Josef; Matsushita, Kunihiro; Grams, Morgan

2016-06-01

Management trends in early chronic kidney disease (CKD) and their associations with clinical outcomes have not previously been reported. We evaluated incident (Stage G3A) CKD patients from an integrated health care system in 2004-06, 2007-09 and 2010-12 to determine adjusted trends in screening (urinary protein quantification), treatment [prescription for angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), and statin] and nephrology referral. For the same time periods, adjusted rates for mortality, progression to Stage G4 CKD and hospitalization for myocardial infarction or heart failure were calculated and compared across time periods. There were 728, 788 and 956 patients with incident CKD in 2004-06, 2007-09 and 2010-12, respectively. Adjusted rates of proteinuria quantification (31, 39 and 51 screens/100 person-years), statin prescription (53, 63 and 64 prescriptions/100 person-years) and nephrology referral (2, 3 and 5 referrals/100 person-years) all increased over time (P for trend <0.001 in all cases). ACEI/ARB prescription rates did not change (88, 83 and 80 prescriptions/100 person-years, P = 0.68). Adjusted death rates (7, 5 and 6 deaths/100 person-years), CKD progression (9, 10 and 7 progressors/100 person-years) and cardiovascular hospitalization (10, 8 and 9 hospitalizations per 100/person-years) did not change (P for trend >0.4 in all cases). In this integrated health care system, management of incident CKD over the past decade has intensified.

Diabetes Mellitus in Outpatients in Debre Berhan Referral Hospital, Ethiopia

PubMed Central

Habtewold, Tesfa Dejenie; Tsega, Wendwesen Dibekulu; Wale, Bayu Yihun

2016-01-01

Introduction. Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Most people with diabetes live in low- and middle-income countries and these will experience the greatest increase in cases of diabetes over the next 22 years. Objective. To assess the prevalence and associated factors of diabetes mellitus among outpatients of Debre Berhan Referral Hospital. Methods and Materials. A cross-sectional study was conducted from April to June 2015 among 385 patients. Random quota sampling technique was used to get individual patients and risk factors assessment. Patients diabetes status was ascertained by World Health Organization Diabetes Mellitus Diagnostic Criteria. The collected data were entered, cleaned, and analyzed and Chi-square test was applied to test any association between dependent and independent variable. Result. Out of the total 385 study patients, 368 have participated in the study yielding a response rate of 95.3%. Concerning clinical presentation of diabetes mellitus, 13.3% of patients reported thirst, 14.4% of patients declared polyurea, and 14.9% of patients ascertained unexplained weight loss. The statistically significant associated factors of diabetes mellitus were hypertensive history, obesity, the number of parities, and smoking history. Conclusion. The prevalence of diabetes mellitus among outpatients in Debre Berhan Referral Hospital was 0.34% and several clinical and behavioral factors contribute to the occurrence of diabetes mellitus which impose initiation of preventive, promotive, and curative strategies. PMID:26881245

Safe and sustainable increases in day case emergency surgery.

PubMed

Hotchen, Andrew J; Coleman, Grant; O'Callaghan, John M; McWhinnie, Doug

2016-03-01

Selected patients referred to emergency general surgery departments are suitable for day case emergency surgery with no overnight hospital stay. There are no well-described sustainable pathways for these expedited operations and in many hospitals patients undergo unnecessary admissions and experience long waiting times. The authors proposed a new, sustainable, day case emergency surgery pathway which was implemented to streamline the assessment, treatment and discharge of acute surgical referrals. It requires rapid assessment of the patient by a senior clinician, and ready availability of diagnostic services and operating facilities. To assess this pathway, the authors conducted a prospective audit of general surgical referrals to a district general hospital in the UK. During the inclusion period 746 emergency referrals were assessed, 281 (37%) of these underwent an operation. Over a 5-month investigation period, the audit found that approximately 27% of all emergency general surgery patients requiring an operation could be managed with day case emergency surgery. This figure was maintained throughout the duration of the study. Operations included incision and drainage of abscesses, incarcerated hernia repairs and appendicectomies. The average length of stay of all surgical admissions decreased from 5 days to less than 3 days and the median time to senior review was 30 minutes. The authors have developed a pathway involving permanent members of the surgical assessment team that is sustainable over a 5-month period. The pathway has allowed rapid assessment of patients and reduced unnecessary inpatient stay in a sustainable and reproducible manner.

[Cost-effectiveness of the deep vein thrombosis diagnosis process in primary care].

PubMed

Fuentes Camps, Eva; Luis del Val García, José; Bellmunt Montoya, Sergi; Hmimina Hmimina, Sara; Gómez Jabalera, Efren; Muñoz Pérez, Miguel Ángel

2016-04-01

To analyse the cost effectiveness of the application of diagnostic algorithms in patients with a first episode of suspected deep vein thrombosis (DVT) in Primary Care compared with systematic referral to specialised centres. Observational, cross-sectional, analytical study. Patients from hospital emergency rooms referred from Primary Care to complete clinical evaluation and diagnosis. A total of 138 patients with symptoms of a first episode of DVT were recruited; 22 were excluded (no Primary Care report, symptoms for more than 30 days, anticoagulant treatment, and previous DVT). Of the 116 patients finally included, 61% women and the mean age was 71 years. Variables from the Wells and Oudega clinical probability scales, D-dimer (portable and hospital), Doppler ultrasound, and direct costs generated by the three algorithms analysed: all patients were referred systematically, referral according to Wells and Oudega scale. DVT was confirmed in 18.9%. The two clinical probability scales showed a sensitivity of 100% (95% CI: 85.1 to 100) and a specificity of about 40%. With the application of the scales, one third of all referrals to hospital emergency rooms could have been avoided (P<.001). The diagnostic cost could have been reduced by € 8,620 according to Oudega and € 9,741 according to Wells, per 100 patients visited. The application of diagnostic algorithms when a DVT is suspected could lead to better diagnostic management by physicians, and a more cost effective process. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

The relationship of weekend admission and mortality on the public medical wards at a Kenyan referral hospital.

PubMed

Stone, Geren S; Aruasa, Wilson; Tarus, Titus; Shikanga, Mainard; Biwott, Benson; Ngetich, Thomas; Andale, Thomas; Cheriro, Betsy

2015-11-01

Research has demonstrated disparities in the outcomes of patients admitted to hospital on weekends in high-income countries. No published research has evaluated if any similar discrepancy exists in low-resource settings. To determine if any difference in mortality exists between weekend and weekday admissions on the public medical wards at a Kenyan referral hospital, we performed a retrospective observational study of inpatients over a 3-month study period. During the study period, 261 (27.3%) of the 956 patients were admitted over the weekend. The mortality rates for patients admitted on weekends and weekdays did not differ with 156 (22.4%) of the 695 patients admitted on weekdays dying compared to 55 (21.1%) of the 261 patients admitted on weekends. After adjusting for age, insurance status, co-morbid illness, HIV status, employment, referral status and gender, still no association existed between weekend admission and mortality. Among adult patients on the medical wards, patients admitted on weekends had similar mortality rates to those admitted on weekdays. This similarity may reflect a stable level of care or a generalized shortage of resources and staffing that subsumes any impact of weekly variations. Future research examining optimal staffing and resource levels is needed in such settings. © The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

[Community coordination of dental care needs in a home medical care support ward and at home].

PubMed

Sumi, Yasunori; Ozawa, Nobuyoshi; Miura, Hiroko; Miura, Hisayuki; Toba, Kenji

2011-01-01

The purpose of this study was to ascertain the current statuses and problems of dental home care patients by surveying the oral care status and needs of patients in the home medical care support ward at the National Center for Geriatrics and Gerontology. Patients that required continuous oral management even after discharge from the hospital were referred to local dental clinics to receive home dental care. We investigated the suitability and problems associated with such care, and identified the dental care needs of home patients and the status of local care coordination, including those in hospitals. The subjects were 82 patients. We ascertained their general condition and oral status, and also investigated the problems associated with patients judged to need specialized oral care by a dentist during oral treatment. Patients who required continuous specialized oral care after discharge from hospital were referred to dental clinics that could provide regular care, and the problems at the time of referral were identified. Dry mouth was reported by many patients. A large number of patients also needed specialized dental treatment such as the removal of dental calculus or tooth extraction. Problems were seen in oral function, with 38 of the patients (46%) unable to gargle and 23 (28%) unable to hold their mouths open. About half of the patients also had dementia, and communication with these patients was difficult. Of the 43 patients who were judged to need continuing oral care after discharge from hospital, their referral to a dental clinic for regular care was successful for 22 (51%) patients and unsuccessful for 21 (49%) patients. The reasons for unsuccessful referrals included the fact that the family, patient, nurse, or caregiver did not understand the need for specialized oral care. The present results suggest the need for specialized oral treatment in home medical care. These findings also suggest that coordinating seamless dental care among primary physicians, intermediates, and transferring care after hospital discharge to regular dentists is difficult.

The Quality and Utility of Surgical and Anesthetic Data at a Ugandan Regional Referral Hospital.

PubMed

Tumusiime, G; Was, A; Preston, M A; Riesel, J N; Ttendo, S S; Firth, P G

2017-02-01

There are little primary data available on the delivery or quality of surgical treatment in rural sub-Saharan African hospitals. To initiate a quality improvement system, we characterized the existing data capture at a Ugandan Regional Referral Hospital. We examined the surgical ward admission (January 2008-December/2011) and operating theater logbooks (January 2010-July 2011) at Mbarara Regional Referral Hospital. There were 6346 admissions recorded over three years. The mean patient age was 31.4 ± 22.3 years; 29.8 % (n = 1888) of admissions were children. Leading causes of admission were general surgical problems (n = 3050, 48.1 %), trauma (n = 2041, 32.2 %), oncology (n = 718, 11.3 %) and congenital condition (n = 193, 3.0 %). Laparotomy (n = 468, 35.3 %), incision and drainage (n = 188, 14.2 %) and hernia repair (n = 90, 6.8 %) were the most common surgical procedures. Of 1325 operative patients, 994 (75 %) had an ASA I-II score. Of patients undergoing 810 procedures booked as non-elective, 583 (72 %) had an ASA "E" rating. Records of 41.3 % (n-403/975) of patients age 5 years or older undergoing non-obstetric operations were missing from the ward logbook. Missing patients were younger (25 [13,40] versus 30 [18,46] years, p = 0.002) and had higher ASA scores (ASA III-V 29.0 % versus 18.9 %, p < 0.001) than patients recorded in the logbbook; there was no diffence in gender (male 62.8 % versus 67.0 %, p = 0.20). The hospital records system measures surgical care, but improved data capture is needed to determine outcomes with sufficient accuracy to guide and record expansion of surgical capacity.

Forty years of referrals and outcomes to a UK Child Development Centre (CDC): Has demand plateaued?

PubMed

Williams, A N; Mold, B; Kilbey, L; Naganna, P

2018-05-01

To explore 40 years of Child Development Centre (CDC) activity and outcomes at Northampton General Hospital 1974-2014. The study comprises 3 data sets: a published report from 1974 to 1999, an internal audit from 2001 to 2004, and more recent data collected from 2005 to 2014. The medical notes of all children who were assessed by the CDC in 2014 were reviewed, along with referral data collected by the CDC manager from this year and the preceding 10 years. From January 1, 1974 to December 31, 2014, 3,786 children were assessed. The male to female ratio is 2.8:1 from 2005 to 2014. Referrals for behavioural difficulties increased from 10% (10/100 referrals) in 1999-2004 to 17.8% (18/101 referrals) in 2014. Similarly, referrals for social and communication problems, "interaction" increased two and a half fold from 10% (10/100 referrals) in 1999-2004 to 26.7% (27/101 referrals) in 2014. Between 2004 and 2014, numbers of referrals for "developmental delay" halved (22.2% to 12%). We are aware of no other comparable extant UK CDC database. Services should plan for a referral rate of 6.5 per 1,000 preschool children. Between 1974 and 2014, there has clearly been a change in recorded assessment outcomes. From the mid-1980s, this reflects the change to a preschool assessment role and a shift away from purely educational outcome to include medical conditions. Covering 1974-2014, we demonstrate a clear increase in the number of referrals together with an increasing demand for assessments for social interaction and behavioural difficulties. This reflects the increased awareness of these neurodevelopmental difficulties and the changing diagnostic criteria which will now more likely result in an Autistic Spectrum Disorder diagnosis than previously. Together, these two features are most likely to have considerable implications for service development within Child Development Centres (CDCs) and Child Development Teams (CDTs). © 2018 John Wiley & Sons Ltd.

Intra-hospital organ and tissue donation coordination project: cost-effectiveness and social benefits

PubMed Central

Silva, Vanessa Silva e; Moura, Luciana Carvalho; Leite, Renata Fabiana; de Oliveira, Priscilla Caroliny; Schirmer, Janine; Roza, Bartira De’ Aguiar

2015-01-01

OBJECTIVE To evaluate the viability of a professional specialist in intra-hospital committees of organ and tissue donation for transplantation. METHODS Epidemiological, retrospective and cross-sectional study (2003-2011 and 2008-2012), which was performed using organ donation for transplants data in the state of Sao Paulo, Southeastern Brazil. Nine hospitals were evaluated (hospitals 1 to 9). Logistic regression was used to evaluate the differences in the number of brain death referrals and actual donors (dependent variables) after the professional specialist started work (independent variable) at the intra-hospital committee of organ and tissue donation for transplantation. To evaluate the hospital invoicing, the hourly wage of the doctor and registered nurse, according to the legislation of the Consolidation of Labor Laws, were calculated, as were the investment return and the time elapsed to do so. RESULTS Following the nursing specialist commencement on the committee, brain death referrals and the number of actual donors increased at hospital 2 (4.17 and 1.52, respectively). At hospital 7, the number of actual donors also increased from 0.005 to 1.54. In addition, after the nurse started working, hospital revenues increased by 190.0% (ranging 40.0% to 1.955%). The monthly cost for the nurse working 20 hours was US$397.97 while the doctor would cost US$3,526.67. The return on investment was 275% over the short term (0.36 years). CONCLUSIONS This paper showed that including a professional specialist in intra-hospital committees for organ and tissue donation for transplantation proved to be cost-effective. Further economic research in the area could contribute to the efficient public policy implementation of this organ and tissue harvesting model. PMID:26487290

Quality improvement in emergency obstetric referrals: qualitative study of provider perspectives in Assin North district, Ghana

PubMed Central

Afari, Henrietta; Hirschhorn, Lisa R; Michaelis, Annie; Barker, Pierre; Sodzi-Tettey, Sodzi

2014-01-01

Objective To describe healthcare worker (HCW)-identified system-based bottlenecks and the value of local engagement in designing strategies to improve referral processes related to emergency obstetric care in rural Ghana. Design Qualitative study using semistructured interviews of participants to obtain provider narratives. Setting Referral systems in obstetrics in Assin North Municipal Assembly, a rural district in Ghana. This included one district hospital, six health centres and four local health posts. This work was embedded in an ongoing quality improvement project in the district addressing barriers to existing referral protocols to lessen delays. Participants 18 HCWs (8 midwives, 4 community health officers, 3 medical assistants, 2 emergency room nurses, 1 doctor) at different facility levels within the district. Results We identified important gaps in referral processes in Assin North, with the most commonly noted including recognising danger signs, alerting receiving units, accompanying critically ill patients, documenting referral cases and giving and obtaining feedback on referred cases. Main root causes identified by providers were in four domains: (1) transportation, (2) communication, (3) clinical skills and management and (4) standards of care and monitoring, and suggested interventions that target these barriers. Mapping these challenges allowed for better understanding of next steps for developing comprehensive, evidence-based solutions to identified referral gaps within the district. Conclusions Providers are an important source of information on local referral delays and in the development of approaches to improvement responsive to these gaps. Better engagement of HCWs can help to identify and evaluate high-impact holistic interventions to address faulty referral systems which result in poor maternal outcomes in resource-poor settings. These perspectives need to be integrated with patient and community perspectives. PMID:24833695

Peri-operative management of high-risk paediatric adenotonsillectomy patients: A survey of 35 UK tertiary referral centres.

PubMed

Cheong, Ryan Chin Taw; Bowles, Philippe; Moore, Andrew; Watts, Simon

2017-05-01

Peri-operative management of high-risk paediatric patients undergoing adenotonsillectomy for treatment of obstructive sleep apnoea varies between tertiary referral hospitals. 'Day of surgery cancellation' (DoSC) rates of up to 11% have been reported due to pre-booked critical care being unavailable on the day of surgery as a result of competing needs from other hospital departments. We report the results of a survey of peri-operative management in UK tertiary care centres of high-risk paediatric patients undergoing adenotonsillectomy for obstructive sleep apnoea (OSA). An 8-point questionnaire was developed using a cloud-based software platform (www.surveymonkey.com). A web-link to the survey was embedded in a customised e-mail which was sent via secure server to the Clinical Leads for Paediatric Otolaryngology at 35 United Kingdom (UK) Tertiary referral centres. The survey response rate was 60% (n = 21). Almost all (94.1%) of centres considered paediatric critical care facilities to be limited, with 70.6% (n = 12) stating that DoSC often occurred due to unavailable paediatric critical care capacity. There was variation between tertiary referral units in the practice applied for pre-booking critical care beds (our survey identifies 6 variations) (Table 1). The most frequent selection method reported (47.1%) was at the discretion of the booking clinician at the time of listing the patient for surgery. In the context of limited critical care resources, variation in practice and difficulty in accurately predicting which patients will require post-operative critical care beds, a review and consensus on best practice in the peri-operative management of high risk paediatric adenotonsillectomy patients may offer a safe means of reducing cancellations and improving patient care, resource allocation and hospital efficiency. Copyright © 2017 Elsevier B.V. All rights reserved.

Hospice Agencies’ Hospital Contract Status and Differing Levels of Hospice Care

PubMed Central

Chung, Kyusuk; Richards, Nicole; Burke, Sloane C.

2014-01-01

In response to a 2011 finding that approximately 27% of Medicare-certified hospices do not provide a single day of general inpatient (GIP) level of care, the authors explored the extent to which hospices have contracts with hospitals for GIP. Using the 2007 National Home and Hospice Care Survey (NHHCS), we estimated that 1,119 agencies (32%) had no contract with any hospitals in 2007 and half of those with no contract did not have a contract with a skilled nursing facility (SNF) either. As a result, these hospices were unable to provide GIP patient referrals for those in need of inpatient care for acute pain and symptom management. More importantly, not having a contract with a hospital was just one of the factors influencing GIP provision. In the multivariate logistic model, after controlling for contract status with a hospital and other hospice characteristics, agencies in the second quartile of hospice patient census (12 to 29 vs. 73 or more, Adjusted OR=14.10; 95% CI: 4.26–46.62) were independently related to providing only routine home care. These hospices are more likely to rely solely on scatter beds for GIP provision. Given that a significant portion of hospices do not have a contract with a hospital, policy makers need to understand barriers to contracts with a hospital/SNF for GIP and consider a hospice’s contract status as one of the standards for hospice certification. In addition, further research is necessary to understand why hospices that do have a contract with a hospital do not make GIP referral. PMID:24576832

Hospice agencies' hospital contract status and differing levels of hospice care.

PubMed

Chung, Kyusuk; Richards, Nicole; Burke, Sloane

2015-05-01

In response to a 2011 finding that approximately 27% of Medicare-certified hospices do not provide a single day of general inpatient care (GIP), the authors explored the extent to which hospices have contracts with hospitals for GIP. Using the 2007 National Home and Hospice Care Survey, we estimated that 1119 (32%) agencies had no contract with any hospitals in 2007 and half of those with no contract did not have a contract with a skilled nursing facility (SNF) either. As a result, these hospices were unable to provide GIP referrals for those in need of inpatient care for acute pain and symptom management. More importantly, not having a contract with a hospital was just one of the factors influencing GIP provision. In the multivariate logistic model, after controlling for contract status with a hospital and other hospice characteristics, agencies in the second quartile of hospice patient census (12-29 vs 73 or more, adjusted odds ratio = 14.10; 95% confidence interval 4.26-46.62) were independently related to providing only routine home care. These hospices are more likely to rely solely on scatter beds for GIP provision. Given that a significant portion of hospices do not have a contract with a hospital, policy makers need to understand barriers to contracts with a hospital/SNF for GIP and consider a hospice's contract status as one of the standards for hospice certification. In addition, further research is necessary to understand why hospices that do have a contract with a hospital do not make GIP referral. © The Author(s) 2014.

Comprehensive assessment of critical care needs in a community hospital*.

PubMed

Sarti, Aimee J; Sutherland, Stephanie; Landriault, Angèle; Fothergill-Bourbonnais, Frances; Bouali, Redouane; Willett, Timothy; Hamstra, Stanley J; Cardinal, Pierre

2014-04-01

To design and implement a needs assessment process that identifies gaps in caring for critically ill patients in a community hospital. This mixed-method study was conducted between June 2011 and February 2012. A conceptual framework, centered on the critically ill patient, guided the design and selection of the data collection instruments. Different perspectives sampled included regional leaders, healthcare professionals at the community hospital and its referral hospital, as well as family members of patients who had received care at the community ICU. Data sources included interviews (n = 22), walk-throughs (n = 5), focus groups (n = 31), database searches, context questionnaires (n = 8), family surveys (n = 16), and simulations (n = 13). None. Nine needs were identified. At the community hospital, needs identified included lack of access to human resources, gaps in expertise, poor patient flow and ICU bed use, communication, lack of educational opportunities, and gaps in end-of-life care and interprofessional teamwork. Needs were also identified in the interhospital interaction between the community and referral hospitals, which included an inadequate hospital network and gaps in transfer and repatriation of patients. The methodology uncovered the causes and widespread impact of each need and how they interacted with one another. Proposed solutions by the participants are presented including both organizational and educational/clinical solutions. This study captured needs in a complex, interprofessional, interhospital context, which can be targeted with tailored interventions to improve patient outcomes in a community hospital. Furthermore, this study provides a preliminary framework and rigorous methodology to performing a needs assessment in this setting.

Impact of an antimicrobial stewardship intervention on appropriateness of prescribing for community-acquired pneumonia in an Australian regional hospital.

PubMed

Bond, Stuart E; Boutlis, Craig S; Yeo, Wilfred W; Miyakis, Spiros

2017-05-01

Community-acquired pneumonia (CAP) is the second commonest indication for antibiotic use in Australian hospitals and is therefore a frequent target for antimicrobial stewardship. A single-centre prospective study was conducted in a regional referral hospital comparing management of adult patients with CAP before and after an educational intervention. We demonstrated a reduction in duration of therapy and reduced inappropriate use of ceftriaxone-based regimens for non-severe CAP. © 2017 Royal Australasian College of Physicians.

Impact of referral letters on scheduling of hospital appointments: a randomised control trial.

PubMed

Jiwa, Moyez; Meng, Xingqiong; O'Shea, Carolyn; Magin, Parker; Dadich, Ann; Pillai, Vinita

2014-07-01

Communication is essential for triage, but intervention trials to improve it are scarce. Referral Writer (RW), a referral letter software program, enables documentation of clinical data and extracts relevant patient details from clinical software. To evaluate whether specialists are more confident about scheduling appointments when they receive more information in referral letters. Single-blind, parallel-groups, controlled design with a 1:1 randomisation. Australian GPs watched video vignettes virtually. GPs wrote referral letters after watching vignettes of patients with cancer symptoms. Letter content was scored against a benchmark. The proportions of referral letters triagable by a specialist with confidence, and in which the specialist was confident the patient had potentially life-limiting pathology were determined. Categorical outcomes were tested with χ(2) and continuous outcomes with t-tests. A random-effects logistic model assessed the influence of group randomisation (RW versus control), GP demographics, clinical specialty, and specialist referral assessor on specialist confidence in the information provided. The intervention (RW) group referred more patients and scored significantly higher on information relayed (mean difference 21.6 [95% confidence intervals {CI} = 20.1 to 23.2]). There was no difference in the proportion of letters for which specialists were confident they had sufficient information for appointment scheduling (RW 77.7% versus control 80.6%, P = 0.16). In the logistic model, limited agreement among specialists contributed substantially to the observed differences in appointment scheduling (P = 35% [95% CI 16% to 59%]). In isolation, referral letter templates are unlikely to improve the scheduling of specialist appointments, even when more information is relayed. © British Journal of General Practice 2014.

Audit of the Forensic Psychiatry Liaison Service to Glasgow Sheriff Court 1994 to 1998.

PubMed

White, T; Ramsay, L; Morrison, R

2002-01-01

This study seeks to describe the demographic, offence, and diagnostic details of subjects referred by the Procurator Fiscal at Glasgow Sheriff Court to the Forensic Psychiatry Liaison between 1994 and 1997. The initial outcome of the assessment and an assessment of medical time involved is presented. This study is a retrospective review of audit forms completed between 1993 and 1994 and once more in 1997. The referral criteria, age structure and offence pattern was broadly similar to that reported in court diversion schemes in England. A primary diagnosis of alcohol and/or drug dependence was seen in one third of referrals during both years of the audit. A marked increase (250%) in referrals between 1994 and 1997 resulted in a marked reduction of those admitted to hospital, and an increase in the percentage who had 'no psychiatric diagnosis'. The need for ongoing liaison between the Procurators Fiscal and the Forensic Psychiatrists involved would appear important in modifying referral criteria.

Risk indicators for referral during labor from community midwife to gynecologist: a prospective cohort study.

PubMed

Schuit, Ewoud; Hukkelhoven, Chantal W P M; van der Goes, Birgit Y; Overbeeke, Ilanit; Moons, Karel G M; Mol, Ben W J; Groenwold, Rolf H H; Kwee, Anneke

2016-10-01

To identify risk indicators for referral during labor from community midwife to a gynecologist in a prospective cohort of women with a singleton term pregnancy, starting labor with a community midwife between 2000 and 2007, registered in the Dutch national perinatal registry. Referral from community midwife to a gynecologist during labor, because of fetal distress, failure to progress in second stage of labor, meconium stained amniotic fluid, failure to progress in first stage of labor, wish for pain relief, a combination of other less urgent reasons or no referral (reference). A total of 241 595 (32%) were referred from community midwife to a gynecologist during labor, because of fetal distress (FD;5%), failure to progress in second stage of labor (FTP2;14%), meconium stained amniotic fluid (MSAF;24%), failure to progress in first stage of labor (FTP1;17%), wish for pain relief (WFPR;7%) or a combination of other less urgent reasons, for example, malpresentation (e.g. breech) or other nonspecified problems (OTHER;33%). The strongest overall risk indicators were gestational age (lower risk of referral because of FD, FTP2, MSAF, FTP1 and WFPR and a higher risk of referral because of OTHER at a gestational age between 37(+0) and 37(+)(6) weeks, and higher risks of referral for all reasons at a gestational age ≥41(+)(0) when compared to a gestational age between 38 (+)(0) and 40 (+)(6) weeks and no referral), the intended place of delivery (higher risk of all types of referral compared to no referral when the intended place of delivery was either at a midwife-led birth center or a hospital instead of at home) and birth history (higher risk of all types of referral compared to no referral when women had a history of instrumental vaginal delivery or when they were nulliparous instead of being multiparous without a history of an instrument vaginal delivery). Risk indicators associated with specific reasons of referral were maternal age, ethnicity, degree of urbanization, social economic status, neonatal gender and birth weight. Among low-risk pregnant women, a referral during labor is associated with readily available risk indicators. These risk indicators may be used to increase referral risk awareness and to counsel women for the intended place to start labor.

Acute Care Referral Systems in Liberia: Transfer and Referral Capabilities in a Low-Income Country.

PubMed

Kim, Jimin; Barreix, Maria; Babcock, Christine; Bills, Corey B

2017-12-01

Introduction Following two decades of armed conflict in Liberia, over 95% of health care facilities were partially or completely destroyed. Although the Liberian health system has undergone significant rehabilitation, one particular weakness is the lack of organized systems for referral and prehospital care. Acute care referral systems are a critical component of effective health care delivery and have led to improved quality of care and patient outcomes. Problem This study aimed to characterize the referral and transfer systems in the largest county of Liberia. A cross-sectional, health referral survey of a representative sample of health facilities in Montserrado County, Liberia was performed. A systematic random sample of all primary health care (PHC) clinics, fraction proportional to district population size, and all secondary and tertiary health facilities were included in the study sample. Collected data included baseline information about the health facility, patient flow, and qualitative and quantitative data regarding referral practices. A total of 62 health facilities-41 PHC clinics, 11 health centers (HCs), and 10 referral hospitals (RHs)-were surveyed during the 6-week study period. In sum, three percent of patients were referred to a higher-level of care. Communication between health facilities was largely unsystematic, with lack of specific protocols (n=3; 5.0%) and standardized documentation (n=26; 44.0%) for referral. While most health facilities reported walking as the primary means by which patients presented to initial health facilities (n=50; 81.0%), private vehicles, including commercial taxis (n=37; 60.0%), were the primary transport mechanism for referral of patients between health facilities. This study identified several weaknesses in acute care referral systems in Liberia, including lack of systematic care protocols for transfer, documentation, communication, and transport. However, several informal, well-functioning mechanisms for referral exist and could serve as the basis for a more robust system. Well-integrated acute care referral systems in low-income countries, like Liberia, may help to mitigate future public health crises by augmenting a country's capacity for emergency preparedness. Kim J , Barreix M , Babcock C , Bills CB . Acute care referral systems in Liberia: transfer and referral capabilities in a low-income country. Prehosp Disaster Med. 2017;32(6):642-650.

An audit of urgent referrals by the Procurator Fiscal to the Tayside Forensic Psychiatric Service.

PubMed

White, T; Rutherford, H

2005-10-01

This study describes the demographic, offence and diagnostic characteristics of subjects referred by the Procurators Fiscal operating from three courts in Tayside, Scotland. A comparison is made of referrals made between 1988 to 1995 and 1997 to 1998. There was an increased rate of referral on an urgent basis over time, primarily involving patients already in contact with the psychiatric services, 37% of whom were detained and admitted to hospital. This urgent assessment ensured that mentally-disordered offenders were not remanded in custody simply for the preparation of a report, and it allowed an early assessment to be made regarding the suitability for diversion from prosecution. This outcome is compatible with guidelines issued by the Home Office in 1990 (Home Office, 1990).

Effect of a brief outreach educational intervention on the translation of acute poisoning treatment guidelines to practice in rural Sri Lankan hospitals: a cluster randomized controlled trial.

PubMed

Senarathna, Lalith; Buckley, Nick A; Dibley, Michael J; Kelly, Patrick J; Jayamanna, Shaluka F; Gawarammana, Indika B; Dawson, Andrew H

2013-01-01

In developing countries, including Sri Lanka, a high proportion of acute poisoning and other medical emergencies are initially treated in rural peripheral hospitals. Patients are then usually transferred to referral hospitals for further treatment. Guidelines are often used to promote better patient care in these emergencies. We conducted a cluster randomized controlled trial (ISRCTN73983810) which aimed to assess the effect of a brief educational outreach ('academic detailing') intervention to promote the utilization of treatment guidelines for acute poisoning. This cluster RCT was conducted in the North Central Province of Sri Lanka. All peripheral hospitals in the province were randomized to either intervention or control. All hospitals received a copy of the guidelines. The intervention hospitals received a brief out-reach academic detailing workshop which explained poisoning treatment guidelines and guideline promotional items designed to be used in daily care. Data were collected on all patients admitted due to poisoning for 12 months post-intervention in all study hospitals. Information collected included type of poison exposure, initial investigations, treatments and hospital outcome. Patients transferred from peripheral hospitals to referral hospitals had their clinical outcomes recorded. There were 23 intervention and 23 control hospitals. There were no significant differences in the patient characteristics, such as age, gender and the poisons ingested. The intervention hospitals showed a significant improvement in administration of activated charcoal [OR 2.95 (95% CI 1.28-6.80)]. There was no difference between hospitals in use of other decontamination methods. This study shows that an educational intervention consisting of brief out-reach academic detailing was effective in changing treatment behavior in rural Sri Lankan hospitals. The intervention was only effective for treatments with direct clinician involvement, such as administering activated charcoal. It was not successful for treatments usually administered by non-professional staff such as forced emesis for poisoning. Controlled-Trials.com ISRCTN73983810 ISRCTN73983810.

Patterns of Palliative Care Referral in Patients Admitted With Heart Failure Requiring Mechanical Ventilation.

PubMed

Wiskar, Katie J; Celi, Leo Anthony; McDermid, Robert C; Walley, Keith R; Russell, James A; Boyd, John H; Rush, Barret

2018-04-01

Palliative care is recommended for advanced heart failure (HF) by several major societies, though prior studies indicate that it is underutilized. To investigate patterns of palliative care referral for patients admitted with HF exacerbations, as well as to examine patient and hospital factors associated with different rates of palliative care referral. Retrospective nationwide cohort analysis utilizing the National Inpatient Sample from 2006 to 2012. Patients referred to palliative care were compared to those who were not. Patients ≥18 years of age with a primary diagnosis of HF requiring mechanical ventilation (MV) were included. A cohort of non-HF patients with metastatic cancer was created for temporal comparison. Between 2006 and 2012, 74 824 patients underwent MV for HF. A referral to palliative care was made in 2903 (3.9%) patients. The rate of referral for palliative care in HF increased from 0.8% in 2006 to 6.4% in 2012 ( P < .01). In comparison, rate of palliative care referral in patients with cancer increased from 2.9% in 2006 to 11.9% in 2012 ( P < .01). In a multivariate logistic regression model, higher socioeconomic status (SES) was associated with increased access to palliative care ( P < .01). Racial differences were also observed in rates of referral to palliative care. The use of palliative care for patients with advanced HF increased during the study period; however, palliative care remains underutilized in this setting. Patient factors such as race and SES affect access to palliative care.

Email triage is an effective, efficient and safe way of managing new referrals to a neurologist.

PubMed

Patterson, Victor; Humphreys, Jenny; Henderson, Mark; Crealey, Grainne

2010-10-01

Patients referred to secondary care in the UK often wait many months to be seen, and the UK government has announced various initiatives to address this issue. Since 2002, we have developed an email referral system which allows some neurological referrals to be managed by advice and investigations rather than by a conventional hospital clinic appointment. This system has previously been shown to reduce clinic attendances and to be acceptable to patients and their general practitioners (GPs). To analyse the effects of an email triage system on waiting times, cost of care and safety over 5 years. Referral numbers and waiting times for clinics using this system were analysed. Cost was determined by comparing detailed costs with those of conventional care. Safety was analysed by examining the GP records of all patients referred from a single practice who had been dealt with by advice or investigation, noting deaths, re-referrals and changes in diagnosis. Waiting times fell from 72 to 4 weeks, despite an increase in referrals. The cost per patient of email referral was about £100, compared with £152 for conventional care, a 35% reduction. Safety data on 120 individuals showed a minor change in diagnosis in three. This system is safe, effective (in reducing waiting times) and efficient. It enables neurologists to focus on patients with significant neurological disease and, if applied more widely, could reduce costs and waiting times for neurology services in the UK.

Telemedicine in acute plastic surgical trauma and burns.

PubMed Central

Jones, S. M.; Milroy, C.; Pickford, M. A.

2004-01-01

BACKGROUND: Telemedicine is a relatively new development within the UK, but is increasingly useful in many areas of medicine including plastic surgery. Plastic surgery centres often work on a hub-and-spoke basis with many district hospitals referring to one tertiary centre. The Queen Victoria Hospital is one such centre receiving calls from more than 28 hospitals in the Southeast of England resulting in approximately 20 referrals a day. OBJECTIVE: A telemedicine system was developed to improve trauma management. This study was designed to establish whether digital images were sufficiently accurate enough to aid decision-making. A store-and-forward telemedicine system was devised and the images of 150 trauma referrals evaluated in terms of injury severity and operative priority by each member of the plastic surgical team. RESULTS: Correlation scores for assessed images were high. Accuracy of "transmitted image" in comparison to injury on examination scored > 97%. Operative priority scores tended to be higher than injury severity. CONCLUSIONS: Telemedicine is an accurate method by which to transfer information on plastic surgical trauma including burns. PMID:15239862

Patient and hospital characteristics on the variance of perioperative outcomes for pancreatic resection in the United States: a plea for outcome-based and not volume-based referral guidelines.

PubMed

Teh, Swee H; Diggs, Brian S; Deveney, Clifford W; Sheppard, Brett C

2009-08-01

There is an effect of patient and hospital characteristics on perioperative outcomes for pancreatic resection in the United States. Retrospective cohort study. Academic research. Patient data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from January 1988 to January 2003. In-hospital mortality, perioperative complications, and mortality following a major complication. A total of 103 222 patients underwent major pancreatic surgery. The annual number of pancreatic resections increased 15.0% during the 16-year study period. Resection for benign pancreatic disease increased 26.8%. Overall in-hospital mortality, perioperative complications, and mortality following a major complication were 6.5%, 35.6%, and 15.6%, respectively. Multivariate analysis demonstrated that significant independent predictors for these 3 perioperative outcomes were advancing age, male sex, medical comorbidity, and hospital volume for each type of pancreatic resection. The in-hospital mortality for pancreatoduodenectomy increases with age and ranges from 1.7% to 13.8% (P < .001). After adjusting for other confounders, the odds of in-hospital mortality for pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy in those 65 years or older were 4.78-fold, 3.84-fold, and 2.60-fold, respectively, lower in the high-volume hospitals compared with those in the lower-volume hospitals. Perioperative complications derived from this population-based study were higher than those reported in many case series. A significant disparity was noted in perioperative outcomes among surgical centers across the United States. An outcome-based referral guideline may have an immediate effect on improving the quality of care in patients who undergo pancreatic resection for benign and malignant disease.

A population health approach to reducing observational intensity bias in health risk adjustment: cross sectional analysis of insurance claims.

PubMed

Wennberg, David E; Sharp, Sandra M; Bevan, Gwyn; Skinner, Jonathan S; Gottlieb, Daniel J; Wennberg, John E

2014-04-10

To compare the performance of two new approaches to risk adjustment that are free of the influence of observational intensity with methods that depend on diagnoses listed in administrative databases. Administrative data from the US Medicare program for services provided in 2007 among 306 US hospital referral regions. Cross sectional analysis. 20% sample of fee for service Medicare beneficiaries residing in one of 306 hospital referral regions in the United States in 2007 (n = 5,153,877). The effect of health risk adjustment on age, sex, and race adjusted mortality and spending rates among hospital referral regions using four indices: the standard Centers for Medicare and Medicaid Services--Hierarchical Condition Categories (HCC) index used by the US Medicare program (calculated from diagnoses listed in Medicare's administrative database); a visit corrected HCC index (to reduce the effects of observational intensity on frequency of diagnoses); a poverty index (based on US census); and a population health index (calculated using data on incidence of hip fractures and strokes, and responses from a population based annual survey of health from the Centers for Disease Control and Prevention). Estimated variation in age, sex, and race adjusted mortality rates across hospital referral regions was reduced using the indices based on population health, poverty, and visit corrected HCC, but increased using the standard HCC index. Most of the residual variation in age, sex, and race adjusted mortality was explained (in terms of weighted R2) by the population health index: R2=0.65. The other indices explained less: R2=0.20 for the visit corrected HCC index; 0.19 for the poverty index, and 0.02 for the standard HCC index. The residual variation in age, sex, race, and price adjusted spending per capita across the 306 hospital referral regions explained by the indices (in terms of weighted R2) were 0.50 for the standard HCC index, 0.21 for the population health index, 0.12 for the poverty index, and 0.07 for the visit corrected HCC index, implying that only a modest amount of the variation in spending can be explained by factors most closely related to mortality. Further, once the HCC index is visit corrected it accounts for almost none of the residual variation in age, sex, and race adjusted spending. Health risk adjustment using either the poverty index or the population health index performed substantially better in terms of explaining actual mortality than the indices that relied on diagnoses from administrative databases; the population health index explained the majority of residual variation in age, sex, and race adjusted mortality. Owing to the influence of observational intensity on diagnoses from administrative databases, the standard HCC index over-adjusts for regional differences in spending. Research to improve health risk adjustment methods should focus on developing measures of risk that do not depend on observation influenced diagnoses recorded in administrative databases.

[Orientation of patients referred by their general practionner to the public or private hospital sector in France: A prospective epidemiologic study].

PubMed

Reuter, P-G; Kernéis, S; Turbelin, C; Souty, C; Arena, C; Gavazzi, G; Sarazin, M; Blanchon, T; Hanslik, T

2012-12-01

In-patients characteristics generate cost differences between hospitals. In France, there are few data on the characteristics on the patients referred to hospitals by their general practitioners (GPs) and none on the predictors of referral to the public or for-profit hospitals. The aim of this study was to analyze those characteristics and the predictors of referral to the public or for-profit hospitals. We collected, prospectively, the request for hospitalizations made by the GPs of the Sentinelles network in France, from 2007 to 2009. Patients' characteristics and also the reasons for that request were analyzed. A logistic regression was used to compare the population between local hospitals. Ten thousand seven hundred and eighteen statements were collected. The median age was 73 years. Patients were women in 51% of the cases, and only 14% of the hospitalizations had been planned. Hospitalization in the public sector was preferred for young children and the elderly (P<0.001). When compared to the patients referred to the private sector, patients addressed to the public sector were more often seen for emergencies (OR: 2.3 [2.0-2.8]), by a doctor different from their referring GP (OR: 1.7 [1.4-2.1]) and out of the GP's office. The reasons for hospital admission were different depending on the sector of hospitalization (P<0.001), patients addressed to the public sector hospitals presented with greater comorbidity or more complex diagnosis (for example: feeling ill, fainting or syncope and fever) or a greater disability (for example: stroke, neurological and psychiatric diseases). This study suggests that GPs send their patients to the public or for-profit hospitals according to criteria of severity, comorbidity and disability. Copyright © 2012 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.

Optimizing the pre-referral workup for gastroenterology and hepatology specialty care: consensus using the Delphi method.

PubMed

Ho, Chanda K; Boscardin, Christy K; Gleason, Nathaniel; Collado, Don; Terdiman, Jonathan; Terrault, Norah A; Gonzales, Ralph

2016-02-01

Specialty care referrals have doubled in the last decade. Optimization of the pre-referral workup by a primary care doctor can lead to a more efficient first specialty visit with the patient. Guidance regarding pre-referral laboratory testing is a first step towards improving the specialty referral process. Our aim was to establish consensus regarding appropriate pre-referral workup for common gastrointestinal and liver conditions. The Delphi method was used to establish local consensus for recommending certain laboratory tests prior to specialty referral for 13 clinical conditions. Seven conditions from The University of Michigan outpatient referral guidelines were used as a baseline. An expert panel of three PCPs and nine gastroenterologists from three academic hospitals participated in three iterative rounds of electronic surveys. Each panellist ranked each test using a 5-point Likert scale (strongly disagree to strongly agree). Local panellists could recommend additional tests for the initial diagnoses, and also recommended additional diagnoses needing guidelines: iron deficiency anaemia, abdominal pain, irritable bowel syndrome, fatty liver disease, liver mass and cirrhosis. Consensus was defined as ≥70% of experts scoring ≥4 (agree or strongly agree). Applying Delphi methodology to extrapolate externally developed referral guidelines for local implementation resulted in considerable modifications. For some conditions, many tests from the external group were eliminated by the local group (abdominal bloating; iron deficiency anaemia; irritable bowel syndrome). In contrast, for chronic diarrhoea, abnormal liver enzymes and viral hepatitis, all/most original tests were retained with additional tests added. For liver mass, fatty liver disease and cirrhosis, there was high concordance among the panel with few tests added or eliminated. Consideration of externally developed referral guidelines using a consensus-building process leads to significant local tailoring and adaption. Our next steps include implementation and dissemination of these guidelines and evaluating their impact on care efficiency in clinical practice. © 2015 John Wiley & Sons, Ltd.

Unfavorable effects of history of volume overload and late referral to a nephrologist on mortality in patients initiating dialysis: a multicenter prospective cohort study in Japan.

PubMed

Okazaki, Masaki; Inaguma, Daijo; Imaizumi, Takahiro; Kada, Akiko; Yaomura, Takaaki; Tsuboi, Naotake; Maruyama, Shoichi

2018-03-14

Patients with late referral and positive history of volume overload may have a poor prognosis after initiating dialysis due to insufficient and/or inadequate management of complications of renal failure and the lack of better dialysis preparation. Little is known about the influence of the relationship between history of volume overload and late referral on prognosis. We analyzed 1475 patients who had initiated dialysis for the first time from October 2011 to September 2013. late referral was defined as referral to a nephrologist < 3 months before dialysis initiation. The major outcomes were all-cause death and deaths due to cardiovascular diseases (CVD). The impact of late referral and history of volume overload on all-cause mortality was assessed by Cox proportional hazards models. Among 1475 patients, the mean patient age was 67.5 years. During the median follow-up of 2.2 years, 260 deaths occurred; 99 were due to CVD. Cox proportional hazards models demonstrated that late referral (adjusted hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.00-1.82) and history of volume overload (adjusted HR, 1.39; 95% CI, 1.06-1.81) were risk factors for all-cause mortality. Furthermore, late referral coexisting was associated with a history of volume overload increased mortality (adjusted HR, 2.10; 95% CI, 1.39-3.16 versus absence of late referral without history of volume overload) after adjusting for age, sex, diabetes, atherosclerotic disease, and laboratory values. Both late referral and history of volume overload were associated with increased risks of all-cause mortality. University Hospital Medical Information Network (UMIN000007096). Registered 18 January 2012, retrospectively registered. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000008349 .

Providing safe surgery for neonates in sub-Saharan Africa.

PubMed

Ameh, Emmanuel A; Ameh, Nkeiruka

2003-07-01

Advances in neonatal intensive care, total parenteral nutrition and improvements in technology have led to a greatly improved outcome of neonatal surgery in developed countries. In many parts of sub-Saharan Africa, however, neonatal surgery continues to pose wide-ranging challenges. Delivery outside hospital, delayed referral, poor transportation, and lack of appropriate personnel and facilities continue to contribute to increased morbidity and mortality in neonates, particularly under emergency situations. Antenatal supervision and hospital delivery needs to be encouraged in our communities. Adequate attention needs to be paid to providing appropriate facilities for neonatal transport and support and training of appropriate staff for neonatal surgery. Neonates with surgical problems should be adequately resuscitated before referral where necessary but surgery should not be unduly delayed. Major neonatal surgery should as much as possible be performed by those trained to operate on neonates. Appropriate research and international collaboration is necessary to improve neonatal surgical care in the environment.

"Call 911" STEMI protocol to reduce delays in transfer of patients from non primary percutaneous coronary intervention referral Centers.

PubMed

Baruch, Terrence; Rock, Alisa; Koenig, William J; Rokos, Ivan; French, William J

2010-09-01

Primary percutaneous coronary intervention (PPCI) is the preferred method of reperfusion for ST-segment elevation myocardial infarction (STEMI), if it can be performed in a timely manner by an experienced interventional cardiologist at a high volume STEMI Receiving Center. However, an estimated 50% of STEMI patients present to STEMI Referral Centers without PPCI capability. Transfer of STEMI patients for PPCI has been shown to improve outcomes as compared with fibrinolysis given at the presenting hospital. Nonetheless, transfer of STEMI patients for PPCI has not been used extensively in the United States and is associated with markedly prolonged transfer times. This study demonstrates that rapid transfer of STEMI patients from community hospitals without PPCI capability to a STEMI Receiving Center is both safe and feasible using a standardized protocol with an integrated transfer system.

Pre-hospital identification and post-recovery challenges of intoxication with synthetic cannabinoid containing legal high products such as 'Exodus Damnation'.

PubMed

Fitzpatrick, David; O'Meara, Patrick; Cunningham, Andrew

2016-11-01

This short report describes the case of a young adult male who had smoked a synthetic cannabinoid legal high product called 'Exodus Damnation'. The patient's presentation was atypical from that described in the literature, with hypotension and hypoxaemia. Of note was the rapid recovery after pre-hospital intervention with high-flow oxygen therapy and intravenous fluids. The patient refused on-going care, despite repeated advice to attend the Emergency Department. The distinct lack of specialist support and referral to drug treatment for this patient population, with whom ambulance services are coming into contact with increasing frequency, is reported. For those patients with the capacity to refuse on-going care, ambulance services may be in an opportune position to actively promote referral to support services for these vulnerable individuals. © The Author(s) 2016.

Peritonitis in Rwanda: Epidemiology and risk factors for morbidity and mortality.

PubMed

Ndayizeye, Leonard; Ngarambe, Christian; Smart, Blair; Riviello, Robert; Majyambere, Jean Paul; Rickard, Jennifer

2016-12-01

Few studies discuss causes and outcomes of peritonitis in low-income settings. This study describes epidemiology of patients with peritonitis at a Rwandan referral hospital. Identification of risk factors associated with mortality and unplanned reoperation could improve management of peritonitis. Data were collected on demographics, clinical presentation, operative findings, and outcomes for all patients with peritonitis. Multivariate regression analysis identified factors associated with in-hospital mortality and unplanned reoperation. A total of 280 patients presented with peritonitis over a 6-month period. Causes of peritonitis were complications of intestinal obstruction (39%) and appendicitis (17%). Thirty-six (13%) patients required unplanned reoperation, and in-hospital mortality was 17%. Factors associated with increased odds of in-hospital mortality were unplanned reoperation (adjusted odds ratio 34.12), vasopressor use (adjusted odds ratio 24.91), abnormal white blood cell count (adjusted odds ratio 12.6), intensive care unit admission (adjusted odds ratio 9.06), and American Society of Anesthesiologist score ≥3 (adjusted odds ratio 7.80). Factors associated with increased odds of unplanned reoperation included typhoid perforation (adjusted odds ratio 5.92) and hypoxia on admission (adjusted odds ratio 3.82). Peritonitis in Rwanda presents with high morbidity and mortality. Minimizing delays in care is important, as many patients with intestinal obstruction present with features of peritonitis. A better understanding of patient care and management prior to arrival at the referral hospital is needed to identify areas for improvement at the health center and district hospital. Copyright © 2016 Elsevier Inc. All rights reserved.

Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study

PubMed Central

2012-01-01

Background Despite the evidence of benefit, cardiac rehabilitation (CR) remains highly underutilized. The present study examined the effect of two inpatient and one outpatient strategy on CR utilization: allied healthcare provider completion of referral (a policy that had been endorsed and approved by the cardiac program leadership in advance; PRE-APPROVED); CR intake appointment booked before hospital discharge (PRE-BOOKED); and early outpatient education provided at the CR program shortly after inpatient discharge (EARLY ED). In this prospective observational study, 2,635 stable cardiac inpatients from 11 Ontario hospitals completed a sociodemographic survey, and clinical data were extracted from charts. One year later, participants were a mailed survey that assessed CR use. Participating inpatient units and CR programs to which patients were referred were coded to reflect whether each of the strategies was used (yes/no). The effect of each strategy on participants’ CR referral and enrollment was examined using generalized estimating equations. Results A total of 1,809 participants completed the post-test survey. Adjusted analyses revealed that the implementation of one of the inpatient strategies was significantly related to greater referral and enrollment (PRE-APPROVED: OR = 1.96, 95%CI = 1.26 to 3.05, and OR = 2.91, 95%CI = 2.20 to 3.85, respectively). EARLY ED also resulted in significantly greater enrollment (OR = 4.85, 95%CI = 2.96 to 7.95). Conclusions These readily-implementable strategies could significantly increase access to and enrollment in CR for the cardiac population. The impact of these strategies on wait times warrants exploration. PMID:23234558

Lack of patients? A hypothesis for understanding discrepancies between hospital resources and productivity.

PubMed

Bratlid, Dag

2006-04-02

Despite a substantial increase in hospital resources, increased hospital admissions and out-patient visits, long waiting lists have been a significant problem in Norwegian health care. A detailed analysis of the development in resource allocation and productivity at St. Olavs University Hospital in central Norway was therefore undertaken. Resource allocation and patient volume was analysed during the period 1995 to 2001. Data were analysed both for emergency and elective admissions as well as outpatient visits specified into new referrals and follow-up consultations. Full time employee equivalents for doctors and nurses increased by 36.6% and 25.9%, respectively, and all employees by 28.1%. However, admitted patients, outpatient consultations and surgical procedures only increased by 10%, 15% and 8.3%, respectively. Thus, the productivity for each hospital employee, defined as operations pr. surgeon, outpatient consultations pr. doctor etc. was significantly reduced. A striking finding was that although the number of outpatient consultations increased, the number of new referrals actually went down and the whole increase in activity at the outpatient clinics could be explained by a substantial increase in follow-up consultations. This trend was more evident in the surgical departments, where some departments actually showed a reduction in total outpatient consultations. In view of the slow increase in hospital activity in spite of a significant increase in resources, it can be speculated that patient volume might be a limiting factor for hospital activity. The health market (patient population) might not be big enough in relation to the investments in increased production capacity (equipment and manpower).

Lack of patients? – a hypothesis for understanding discrepancies between hospital resources and productivity

PubMed Central

Bratlid, Dag

2006-01-01

Background Despite a substantial increase in hospital resources, increased hospital admissions and out-patient visits, long waiting lists have been a significant problem in Norwegian health care. A detailed analysis of the development in resource allocation and productivity at St. Olavs University Hospital in central Norway was therefore undertaken. Methods Resource allocation and patient volume was analysed during the period 1995 to 2001. Data were analysed both for emergency and elective admissions as well as outpatient visits specified into new referrals and follow-up consultations. Results Full time employee equivalents for doctors and nurses increased by 36.6% and 25.9%, respectively, and all employees by 28.1%. However, admitted patients, outpatient consultations and surgical procedures only increased by 10%, 15% and 8.3%, respectively. Thus, the productivity for each hospital employee, defined as operations pr. surgeon, outpatient consultations pr. doctor etc. was significantly reduced. A striking finding was that although the number of outpatient consultations increased, the number of new referrals actually went down and the whole increase in activity at the outpatient clinics could be explained by a substantial increase in follow-up consultations. This trend was more evident in the surgical departments, where some departments actually showed a reduction in total outpatient consultations. Conclusion In view of the slow increase in hospital activity in spite of a significant increase in resources, it can be speculated that patient volume might be a limiting factor for hospital activity. The health market (patient population) might not be big enough in relation to the investments in increased production capacity (equipment and manpower). PMID:16579861

Overcoming bias in estimating the volume-outcome relationship.

PubMed

Tsai, Alexander C; Votruba, Mark; Bridges, John F P; Cebul, Randall D

2006-02-01

To examine the effect of hospital volume on 30-day mortality for patients with congestive heart failure (CHF) using administrative and clinical data in conventional regression and instrumental variables (IV) estimation models. The primary data consisted of longitudinal information on comorbid conditions, vital signs, clinical status, and laboratory test results for 21,555 Medicare-insured patients aged 65 years and older hospitalized for CHF in northeast Ohio in 1991-1997. The patient was the primary unit of analysis. We fit a linear probability model to the data to assess the effects of hospital volume on patient mortality within 30 days of admission. Both administrative and clinical data elements were included for risk adjustment. Linear distances between patients and hospitals were used to construct the instrument, which was then used to assess the endogeneity of hospital volume. When only administrative data elements were included in the risk adjustment model, the estimated volume-outcome effect was statistically significant (p=.029) but small in magnitude. The estimate was markedly attenuated in magnitude and statistical significance when clinical data were added to the model as risk adjusters (p=.39). IV estimation shifted the estimate in a direction consistent with selective referral, but we were unable to reject the consistency of the linear probability estimates. Use of only administrative data for volume-outcomes research may generate spurious findings. The IV analysis further suggests that conventional estimates of the volume-outcome relationship may be contaminated by selective referral effects. Taken together, our results suggest that efforts to concentrate hospital-based CHF care in high-volume hospitals may not reduce mortality among elderly patients.

Antenatal Clinic and Stop Smoking Services Staff Views on “Opt-Out” Referrals for Smoking Cessation in Pregnancy: A Framework Analysis

PubMed Central

Campbell, Katarzyna Anna; Bowker, Katharine Anna; Naughton, Felix; Sloan, Melanie; Cooper, Sue; Coleman, Tim

2016-01-01

Introduction: UK guidance recommends routine exhaled carbon monoxide (CO) screening for pregnant women and “opt-out” referrals to stop smoking services (SSS) of those with CO ≥ 4 ppm. We explored staff views on this referral pathway when implemented in one UK hospital Trust. Methods: Seventeen semi-structured interviews with staff involved in the implementation of the new referral pathway: six antenatal clinic staff (before and after implementation); five SSS staff (after). Data were analyzed using framework analysis. Results: Two themes were identified: (1) views on implementation of the pathway and (2) impact of the pathway on the women. Generally, staff felt that following training, referrals were less arduous to implement and better received than expected. The majority believed this pathway helped engage women motivated to quit and offered a unique chance to impart smoking cessation knowledge to hard-to-reach women, who might not otherwise contact SSS. An unexpected issue arose during implementation—dealing with non-smokers with high CO readings. Conclusions: According to staff, the “opt-out” referral pathway is an acceptable addition to routine antenatal care. It can help engage hard-to-reach women and educate them about the dangers of smoking in pregnancy. Incorporating advice on dealing with non-smokers with high CO into routine staff training could help future implementations. PMID:27754352

New hospital-based policy for children whose parents present at the ER due to domestic violence, substance abuse and/or a suicide attempt.

PubMed

Hoytema van Konijnenburg, Eva M M; Sieswerda-Hoogendoorn, Tessa; Brilleslijper-Kater, Sonja N; van der Lee, Johanna H; Teeuw, Arianne H

2013-02-01

Child maltreatment is a major social problem with many adverse consequences, and a substantial number of maltreated children are not identified by health care professionals. In 2010, in order to improve the identification of maltreated children in hospitals, a new hospital-based policy was developed in Amsterdam, The Netherlands. This policy was adapted from another policy that was developed in The Hague, the Netherlands, in 2007. In the new Amsterdam policy, all adults presenting at the emergency department due to domestic violence, substance abuse, and/or a suicide attempt are asked whether they have any children in their care. If this is the case, parents are urged to visit the outpatient pediatric department together with all of their children. During this visit, problems are evaluated and voluntary referrals can be arranged to different care organizations. If parents refuse to cooperate, their children are reported to the Dutch Child Abuse Counseling and Reporting Centre. The two aims of this study are to describe (1) characteristics of the identified families and (2) the referrals made to different voluntary and involuntary care organizations during the first 2 years after implementation of the policy. Data were collected from medical records. One hundred and six children from 60 households were included, of which 68 children because their mother was a victim of domestic violence. Referrals to care organizations were arranged for 99 children, of which 67 on a voluntary basis. The Amsterdam policy seems successful in arranging voluntary support for the majority of identified children.

Nutrition care-related practices and factors affecting nutritional intakes in hospital patients at risk of pressure ulcers.

PubMed

Roberts, S; Chaboyer, W; Desbrow, B

2015-08-01

Malnutrition is common in hospitals and is a risk factor for pressure ulcers. Nutrition care practices relating to the identification and treatment of malnutrition have not been assessed in patients at risk of pressure ulcers. The present study describes nutrition care practices and factors affecting nutritional intakes in this patient group. The study was conducted in four wards at two hospitals in Queensland, Australia. Adult patients at risk of pressure ulcers as a result of restricted mobility were observed for 24 h to determine their daily oral intake and practices such as nutrition screening, documentation and intervention. Independent samples t-tests and chi-squared tests were used to analyse dietary intake and nutrition care-related data. Predictors of receiving a dietitian referral were identified using logistic regression analyses. Two hundred and forty-one patients participated in the present study. The observed nutritional screening rate was 59% (142 patients). Weight and height were documented in 71% and 34% of cases. Sixty-nine patients (29%) received a dietitian referral. Predictors of receiving a dietitian referral included lower body mass index and longer length of stay. On average, patients consumed 73% and 72% of the energy and protein provided, respectively. Between 22% and 38% of patients consumed <50% of food provided at main meals. Nutrition care practices including malnutrition risk screening and documentation of nutritional parameters appear to be inadequate in patients at risk of pressure ulcers. A significant proportion of these patients eat inadequately at main meals, further increasing their risk of malnutrition and pressure ulcers. © 2014 The British Dietetic Association Ltd.

Outcomes of in-hospital, out of intensive care and operation theatre cardiac arrests in a tertiary referral hospital.

PubMed

Chakravarthy, Murali; Mitra, Sona; Nonis, Latha

2012-01-01

Cardiac arrest in the hospital wards may not receive as much attention as it does in the operation theatre and intensive care unit (ICU). The experience and the qualifications of personnel in the ward may not be comparable to those in the other vital areas of the hospital. The outcome of cardiac arrest from the ward areas is a reasonable surrogate of training of the ward nurses and technicians in cardiopulmonary resuscitation. We conducted an audit to assess the issues surrounding the resuscitation of cardiac arrest in areas other than operation theatre and ICU in a tertiary referral hospital. AIMS OF THE AUDIT: To assess the outcomes of cardiac arrest in a tertiary referral hospital. Areas such as wards, dialysis room and emergency room were considered for the audit. This is a retrospective observational audit of the case records of all the adult patients who were resuscitated from 'code blue'. Data for 2 years from 2007 was analysed by a research fellow unconnected with the resuscitations. Twenty-two thousand three hundred and forty-four patients were admitted as in-patients to the hospital during the 2 years, starting May 2007 through May 2009. One hundred code blue calls were received during this time. Twenty-two of the total calls received were false. Among the 78 confirmed cardiac arrests 69 occurred in the wards, 2 in emergency room, 1 in cardiac catheterisation laboratory and 3 in dialysis room. Twenty-eight patients were declared dead after unsuccessful cardiopulmonary resuscitation. Among the 50 who were resuscitated with a return of spontaneous rhythm 26 died. Twenty-four patients were discharged (survival rate of 30%). The survival decreased significantly as the age progressed beyond 60. The resuscitation rates were better in day shifts in contrast to the night. Higher survival was noted in patients who received resuscitation in less than a minute. A overall survival to discharge rate of 30% was noted in this audit. Higher survival rates might be attributable to high rate and degree of training at the time of their employment, which was repeated at yearly interval. Copyright © 2012 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): study protocol for a randomized controlled trial.

PubMed

McWilliams, Andrew; Roberge, Jason; Moore, Charity G; Ashby, Avery; Rossman, Whitney; Murphy, Stephanie; McCall, Stephannie; Brown, Ryan; Carpenter, Shannon; Rissmiller, Scott; Furney, Scott

2016-12-19

Hospital readmissions remain highly prevalent despite being the target of policies and financial penalties. Evidence comparing the effectiveness and costs of interventions to reduce readmissions is lacking, leaving healthcare systems with little guidance on how to improve quality and avoid costly penalties. Effective interventions likely need to bridge inpatient and outpatient settings, incorporate information technology, and use dedicated providers. Such complex innovations will require rigorous evaluation. The framework of quality improvement research provides an approach that both improves care locally and contributes to closing the current knowledge gaps for readmissions. In this trial, we will study a comprehensive intervention that incorporates these recommendations into an integrated practice unit, called transition services, with an aim of reducing 30-day readmission rates. We describe a nonblinded, pragmatic, controlled trial with two parallel groups comprising an evaluation of the effect of referral to a provider-led integrated practice unit, inclusive of comprehensive multidisciplinary care, dedicated paramedicine providers, and virtual visits, on 30-day readmission rates for high-risk hospitalized patients. An automated risk-scoring system will randomly generate referrals to either transition services or usual care for 1520 hospitalized patients who score as high-risk for readmission. Transition services will then engage with patients in the hospital setting using a patient navigator and provide bridging outpatient services for the 30 days following discharge. All outcome data are retrieved electronically from administrative medical records. After reapplication of inclusion and exclusion criteria at the time of hospital discharge, analyses will follow the intention-to-treat principle such that patients will be analyzed on the basis of the referral group to which they were initially randomized. The hospital transition program under study is complex and integrates the latest recommendations for readmission reduction strategies. As healthcare systems innovate to address readmissions through such complex interventions, there is significant benefit for stakeholders to have a clear understanding of the potential reach, cost, and real-world effectiveness. The pragmatic methods described here provide a template for conducting quality improvement research that fits seamlessly into existing care delivery and improvement efforts, leading to better-informed strategic decisions and the investments necessary to transform care and value for patients. ClinicalTrials.gov, NCT02763202 . Registered 3 March 2016 (retrospectively registered).

Impact of referral letters on scheduling of hospital appointments: a randomised control trial

PubMed Central

Jiwa, Moyez; Meng, Xingqiong; O’Shea, Carolyn; Magin, Parker; Dadich, Ann; Pillai, Vinita

2014-01-01

Background Communication is essential for triage, but intervention trials to improve it are scarce. Referral Writer (RW), a referral letter software program, enables documentation of clinical data and extracts relevant patient details from clinical software. Aim To evaluate whether specialists are more confident about scheduling appointments when they receive more information in referral letters. Design and setting Single-blind, parallel-groups, controlled design with a 1:1 randomisation. Australian GPs watched video vignettes virtually. Method GPs wrote referral letters after watching vignettes of patients with cancer symptoms. Letter content was scored against a benchmark. The proportions of referral letters triagable by a specialist with confidence, and in which the specialist was confident the patient had potentially life-limiting pathology were determined. Categorical outcomes were tested with χ2 and continuous outcomes with t-tests. A random-effects logistic model assessed the influence of group randomisation (RW versus control), GP demographics, clinical specialty, and specialist referral assessor on specialist confidence in the information provided. Results The intervention (RW) group referred more patients and scored significantly higher on information relayed (mean difference 21.6 [95% confidence intervals {CI} = 20.1 to 23.2]). There was no difference in the proportion of letters for which specialists were confident they had sufficient information for appointment scheduling (RW 77.7% versus control 80.6%, P = 0.16). In the logistic model, limited agreement among specialists contributed substantially to the observed differences in appointment scheduling (P = 35% [95% CI 16% to 59%]). Conclusion In isolation, referral letter templates are unlikely to improve the scheduling of specialist appointments, even when more information is relayed. PMID:24982494

COP - Pet Owners - What is Comparative Oncology | Center for Cancer Research

Cancer.gov

What is Comparative Oncology? Cancer, in the pet population, is a spontaneous disease. Pet owners, motivated by the desire to prolong their animals' quality of life, frequently seek out the specialized care and treatment of veterinary oncologists at private referral veterinary hospitals and veterinary teaching hospitals across the country. Therapeutic modalities for veterinary cancer patients are similar to those for humans, including surgery, chemotherapy, radiation therapy, and biotherapy.

Telemedicine in Majuro Hospital, Marshall Islands.

PubMed

Gunawardane, K J

2000-09-01

Since March 1998 up to June 2000, telemedicine activities in Marshall Islands have mainly been for Referrals to Tripler Army Medical Center (TAMC) in Hawaii. The activities are based on a computer which has the Internet connection and accessories including a digital camera, flatbed scanner with a transparency adapter, color printer, a video printer, ophthalmoscope, otoscope and a video Lens, all of which were donated by Project Akamai in Hawaii. Two sessions of training were conducted by representatives from Akamai Project and from PBMA at the very beginning of the establishment of the unit, to all levels of Health Care Providers in Ministry of Health in Majuro. The computer and Internet facility is available 24 hours. Since March 1998 to June 2000, there had been 144 telemedicine consultations to TAMC. Out of a total of 326 off-island referrals for the same period, approximately 80 patients have been sent to TAMC using the PIHCP/Telemedicine program. This accounts for approximately 25% of total off-island referrals. This represents a significant reduction in cost. In addition to cost reduction the telemedicine unit most important impact is on the health providers, especially the physicians working at Majuro Hospital. Availability of medical information through internet has helped them to feel less isolated from the constantly changing field of medical science.

Development of a cardiac technician led paediatric echocardiographic service--experience from a district general hospital in the United Kingdom.

PubMed

Allen, Jane; Dickinson, David F; Ramachandran, Arun; Thomson, John D R

2005-06-01

To report our experience in providing cardiac technician led paediatric echocardiography services in a district general hospital in the United Kingdom. We have collected prospectively the numbers of referrals, and the proportion of abnormal echocardiograms, since inception of the service in 2000. In additional, for a period of 12 months, we have audited in detail the patterns of referral to the service, and outcomes, assessing the effect of the service on the outreach clinic run by a visiting paediatric cardiologist. Use of the system resulted in detection of a wide range of abnormalities, with our audit showing that the patients received appropriate management. The total referrals to the service increased 10 fold over the 4 year period of the study. The proportion of abnormal hearts detected by echocardiography, however, dropped from 90 per cent to 16 per cent over the same period. The numbers of patients seen in the outreach cardiology clinic remained unaltered. Having been proved to be an effective model for the triage of children with suspected congenital cardiac disease, adoption of a cardiac technician led echocardiographic service has seen a dramatic increase in the numbers of echocardiograms requested, without decreasing the workload of the visiting paediatric cardiologist.

The process, logistics and challenges of implementing clinical supervision in a generalist tertiary referral hospital.

PubMed

Brunero, Scott; Lamont, Scott

2012-03-01

Clinical supervision (CS) has been identified within nursing as a process for improving clinical practice and reducing the emotional burden of nursing practice. Little is known about its implementation across large tertiary referral hospitals. The purpose of this study is to evaluate the implementation of clinical supervision across several different nursing specialities at a teaching hospital in Sydney, Australia. Using a model of nursing implementation science, a process was developed at the study site that facilitated the development, implementation and evaluation of the project. After a 6-month study period, the CS groups were postevaluated using a survey tool developed for the project. A total of nine CS groups were in operation over the 6-month study period. A predominant focus within the sessions was one of the collegial support and developing standards of practice. The process was able to achieve wide hospital-based support for the role of CS from the senior nurse executives to junior nurses. Whilst there was overall positive support for the CS groups, logistical and resource challenges remain, in the effective roll out of CS to large numbers of nurses. © 2011 The Authors. Scandinavian Journal of Caring Sciences © 2011 Nordic College of Caring Science.

Using geospatial techniques to develop an emergency referral transport system for suspected sepsis patients in Bangladesh

PubMed Central

Haider, Rafiqul; Abdullah, Abu Yousuf Md; Christou, Aliki; Ali, Nabeel Ashraf; Rahman, Ahmed Ehsnaur; Iqbal, Afrin; Bari, Sanwarul; Hoque, D. M. Emdadul; Arifeen, Shams El; Kissoon, Niranjan; Larson, Charles P.

2018-01-01

Background A geographic information system (GIS)-based transport network within an emergency referral system can be the key to reducing health system delays and increasing the chances of survival, especially during an emergency. We employed a GIS to design an emergency transport system for the rapid transfer of pregnant or early post-partum women, newborns, and children under 5 years of age with suspected sepsis under the Interrupting Pathways to Sepsis Initiative (IPSI) project. Methods A GIS database was developed by mapping the villages, roads, and relevant physical features of the study area. A travel-time algorithm was developed to incorporate the time taken by different modes of local transport to reach the health complexes. These were used in a network analysis to identify the shortest routes to the hospitals from the villages, which were categorized into green, yellow, and red zones based on their proximity to the nearest hospitals to provide transport facilities. An emergency call-in centre established for the project managed the transport system, and its data was used to assess the uptake of this transport system amongst distant communities. Results Fifteen pre-existing and two new routes were identified as the shortest routes to the health complexes. The call-in centre personnel used this route information to direct both patients and transport drivers to the nearest transport hubs or pick-up points. Adherence with referral advice was high in areas where the IPSI transport operated. Over the study period, the utilisation of the project’s transport doubled and referral compliance from distant zones similarly increased. Conclusions The GIS system created for this study facilitated rapid referral of patients in emergency from distant zones, using locally available transport and resources. The methodology described in this study to develop and implement an emergency transport system can be applied in similar, rural, low-income country settings. PMID:29338012

Lessons learned during implementation of therapeutic hypothermia for neonatal hypoxic ischemic encephalopathy in a regional transport program in Ontario

PubMed Central

Khurshid, Faiza; Lee, Kyong-Soon; McNamara, Patrick J; Whyte, Hilary; Mak, Wendy

2011-01-01

BACKGROUND: Therapeutic hypothermia (TH) is the first intervention to consistently show improved neurological outcomes in neonates with hypoxic ischemic encephalopathy (HIE). Since the recent introduction of TH for HIE in many centres, reviews of practices during the implementation of TH in Canada have not been published. OBJECTIVE: To determine if eligible neonates are being offered TH and to identify any barriers to the effective implementation of TH. METHODS: A retrospective review of neonates referred to a regional tertiary centre at a gestational age of 35 weeks or more with HIE was conducted. RESULTS: Among 41 neonates referred, 29 (71%) were eligible for TH; among eligible patients, five were moribund and excluded, and TH was initiated in 16 (67%) of the remaining 24. Reasons for not cooling in eight eligible patients included a delay in referral (n=5, median age at referral was 14 h) and a failure to recognize the severity of HIE (n=3). Among cooled patients, median times were the following: 116 min for age at referral; 80 min for time from referral to transport team arrival; and 358 min for age at initiation of cooling. Seven (44%) patients had cooling initiated after 6 h of age. CONCLUSION: A significant proportion of eligible patients were not offered TH, and in many cooled patients, initiation of cooling was delayed beyond the recommended 6 h. For eligible patients to benefit from TH, it is imperative that all birthing centres be made aware that TH is now widely available as an important treatment option, but also that TH is a time-sensitive therapy requiring rapid identification and referral. In the region studied, for eligible patients, referring hospitals should initiate passive cooling before arrival of the transport team. Referring hospitals should be prepared to provide early, yet safe initiation of passive cooling by having the appropriate equipment, and having staff trained in the use and monitoring of rectal temperatures. PMID:22379379

Using geospatial techniques to develop an emergency referral transport system for suspected sepsis patients in Bangladesh.

PubMed

Chowdhury, Atique Iqbal; Haider, Rafiqul; Abdullah, Abu Yousuf Md; Christou, Aliki; Ali, Nabeel Ashraf; Rahman, Ahmed Ehsnaur; Iqbal, Afrin; Bari, Sanwarul; Hoque, D M Emdadul; Arifeen, Shams El; Kissoon, Niranjan; Larson, Charles P

2018-01-01

A geographic information system (GIS)-based transport network within an emergency referral system can be the key to reducing health system delays and increasing the chances of survival, especially during an emergency. We employed a GIS to design an emergency transport system for the rapid transfer of pregnant or early post-partum women, newborns, and children under 5 years of age with suspected sepsis under the Interrupting Pathways to Sepsis Initiative (IPSI) project. A GIS database was developed by mapping the villages, roads, and relevant physical features of the study area. A travel-time algorithm was developed to incorporate the time taken by different modes of local transport to reach the health complexes. These were used in a network analysis to identify the shortest routes to the hospitals from the villages, which were categorized into green, yellow, and red zones based on their proximity to the nearest hospitals to provide transport facilities. An emergency call-in centre established for the project managed the transport system, and its data was used to assess the uptake of this transport system amongst distant communities. Fifteen pre-existing and two new routes were identified as the shortest routes to the health complexes. The call-in centre personnel used this route information to direct both patients and transport drivers to the nearest transport hubs or pick-up points. Adherence with referral advice was high in areas where the IPSI transport operated. Over the study period, the utilisation of the project's transport doubled and referral compliance from distant zones similarly increased. The GIS system created for this study facilitated rapid referral of patients in emergency from distant zones, using locally available transport and resources. The methodology described in this study to develop and implement an emergency transport system can be applied in similar, rural, low-income country settings.

Clients as Teachers.

ERIC Educational Resources Information Center

Journal of Counseling and Development, 1988

1988-01-01

Contains eight accounts: "But Kids Don't Commit Suicide" (Sharon Andreozzi); "Learning from Multiplicity" (Kathryn Ellis); "Autonomy, Control, and Affiliation: Your Issues or Mine?" (Claudia Haferkamp); "Role Players" (Dennis Heitzmann); "Grief Counseling: Facilitating the Healing Process" (Rosemary Hughes); "Hospital Referral: A Test of Counselor…

Hospital-based chiropractic integration within a large private hospital system in Minnesota: a 10-year example.

PubMed

Branson, Richard A

2009-01-01

The purpose of this article is to describe a model of chiropractic integration developed over a 10-year period within a private hospital system in Minnesota. Needs were assessed by surveying attitudes and behaviors related to chiropractic and complementary and alternative medicine (CAM) of physicians associated with the hospital. Analyzing referral and utilization patterns assessed chiropractic integration into the hospital system. One hundred five surveys were returned after 2 mailings for a response rate of 74%. Seventy-four percent of respondents supported integration of CAM into the hospital system, although 45% supported the primary care physician as the gatekeeper for CAM use. From 2006 to 2008, there were 8294 unique new patients in the chiropractic program. Primary care providers (medical doctors and physician assistants) were the most common referral source, followed by self-referred patients, sports medicine physicians, and orthopedic physicians. Overall examination of the program identified that facilitators of chiropractic integration were (1) growth in interest in CAM, (2) establishing relationships with key administrators and providers, (3) use of evidence-based practice, (4) adequate physical space, and (5) creation of an integrated spine care program. Barriers were (1) lack of understanding of chiropractic professional identity by certain providers and (2) certain financial aspects of third-party payment for chiropractic. This article describes the process of integrating chiropractic into one of the largest private hospital systems in Minnesota from a business and professional perspective and the results achieved once chiropractic was integrated into the system. This study identified key factors that facilitated integration of services and demonstrates that chiropractic care can be successfully integrated within a hospital system.

Outcome following inhalation anesthesia in birds at a veterinary referral hospital: 352 cases (2004-2014).

PubMed

Seamon, Amanda B; Hofmeister, Erik H; Divers, Stephen J

2017-10-01

OBJECTIVE To determine the outcome in birds undergoing inhalation anesthesia and identify patient or procedure variables associated with an increased likelihood of anesthesia-related death. DESIGN Retrospective case series. ANIMALS 352 birds that underwent inhalation anesthesia. PROCEDURES Medical records of birds that underwent inhalation anesthesia from January 1, 2004, through December 31, 2014, at a single veterinary referral hospital were reviewed. Data collected included date of visit, age, species, sex, type (pet, free ranging, or wild kept in captivity), body weight, body condition score, diagnosis, procedure, American Society of Anesthesiologists status, premedication used for anesthesia, drug for anesthetic induction, type of maintenance anesthesia, route and type of fluid administration, volumes of crystalloid and colloid fluids administered, intraoperative events, estimated blood loss, duration of anesthesia, surgery duration, recovery time, recovery notes, whether birds survived to hospital discharge, time of death, total cost of hospitalization, cost of anesthesia, and nadir and peak values for heart rate, end-tidal partial pressure of carbon dioxide, concentration of inhaled anesthetic, and body temperature. Comparisons were made between birds that did and did not survive to hospital discharge. RESULTS Of 352 birds, 303 (86%) were alive at hospital discharge, 12 (3.4%) died during anesthesia, 15 (4.3%) died in the intensive care unit after anesthesia, and 22 (6.3%) were euthanatized after anesthesia. Overall, none of the variables studied were associated with survival to hospital discharge versus not surviving to hospital discharge. CONCLUSIONS AND CLINICAL RELEVANCE Results confirmed previous findings that indicated birds have a high mortality rate during and after anesthesia, compared with mortality rates published for dogs and cats.

Epidemiology and molecular typing of VRE bloodstream isolates in an Irish tertiary care hospital.

PubMed

Ryan, L; O'Mahony, E; Wrenn, C; FitzGerald, S; Fox, U; Boyle, B; Schaffer, K; Werner, G; Klare, I

2015-10-01

Ireland has the highest rate of vancomycin-resistant Enterococcus faecium (VREfm) isolated from blood of nosocomial patients in Europe, which rose from 33% (110/330) in 2007 to 45% (178/392) in 2012. No other European country had a VREfm rate from blood cultures of >25%. Our aim was to elucidate the reasons for this significantly higher rate in Ireland. The epidemiology and molecular typing of VRE from bloodstream infections (BSIs) was examined in a tertiary care referral hospital and isolates were compared with those from other tertiary care referral centres in the region. The most common source of VRE BSIs was intra-abdominal sepsis, followed by line-related infection and febrile neutropenia. Most of the isolates were positive for vanA; 52% (43/83) possessed the esp gene and 12% (10/83) possessed the hyl gene. Genotyping by SmaI macrorestriction analysis (PFGE) of isolates revealed clonal relatedness between bloodstream isolates and environmental isolates. VRE BSI isolates from two other tertiary care hospitals in the Dublin region showed relatedness by PFGE analysis. MLST revealed four STs (ST17, ST18, ST78 and ST203), all belonging to the clonal complex of hospital-associated strains. Irish VRE BSI isolates have virulence factor profiles as previously reported from Europe. Typing analysis shows the spread of individual clones within the hospital and between regional tertiary care hospitals. Apart from transmission of VRE within the hospital and transfer of colonized patients between Irish hospitals, no other explanation for the persistently high VREfm BSI rate in Ireland has been found. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Medicare and Medicaid programs: hospital outpatient prospective payment; ambulatory surgical center payment; hospital value-based purchasing program; physician self-referral; and patient notification requirements in provider agreements. Final rule with comment period.

PubMed

2011-11-30

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) for CY 2012 to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we set forth the relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other ratesetting information for the CY 2012 ASC payment system. We are revising the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, adding new requirements for ASC Quality Reporting System, and making additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are allowing eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. Finally, we are making changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.

Makerere University College of Health Sciences’ role in addressing challenges in health service provision at Mulago National Referral Hospital

PubMed Central

2011-01-01

Background Mulago National Referral Hospital (MNRH), Uganda’s primary tertiary and teaching hospital, and Makerere University College of Health Sciences (MakCHS) have a close collaborative relationship. MakCHS students complete clinical rotations at MNRH, and MakCHS faculty partner with Mulago staff in clinical care and research. In 2009, as part of a strategic planning process, MakCHS undertook a qualitative study to examine care and service provision at MNRH, identify challenges, gaps, and solutions, and explore how MakCHS could contribute to improving care and service delivery at MNRH. Methods Key informant interviews (n=23) and focus group discussions (n=7) were conducted with nurses, doctors, administrators, clinical officers and other key stakeholders. Interviews and focus groups were tape recorded and transcribed verbatim, and findings were analyzed through collaborative thematic analysis. Results Challenges to care and service delivery at MNRH included resource constraints (staff, space, equipment, and supplies), staff inadequacies (knowledge, motivation, and professionalism), overcrowding, a poorly functioning referral system, limited quality assurance, and a cumbersome procurement system. There were also insufficiencies in the teaching of professionalism and communication skills to students, and patient care challenges that included lack of access to specialized services, risk of infections, and inappropriate medications. Suggestions for how MakCHS could contribute to addressing these challenges included strengthening referral systems and peripheral health center capacity, and establishing quality assurance mechanisms. The College could also strengthen the teaching of professionalism, communication and leadership skills to students, and monitor student training and develop courses that contribute to continuous professional development. Additionally, the College could provide in-service education for providers on professionalism, communication skills, strategies that promote evidence-based practice and managerial leadership skills. Conclusions Although there are numerous barriers to delivery of quality health services at MNRH, many barriers could be addressed by strengthening the relationship between the Hospital and MakCHS. Strategic partnerships and creative use of existing resources, both human and financial, could improve the quality of care and service delivery at MNRH. Improving services and providing more skills training could better prepare MakCHS graduates for leadership roles in other health care facilities, ultimately improving health outcomes throughout Uganda. PMID:21411007

Consumer product branding strategy and the marketing of physicians' services.

PubMed

Friedrich, H; Witt, J

1995-01-01

Hospitals have traditionally maintained physician referral programs as a means of attracting physicians to their network of affiliated providers. The advent of managed care and impending healthcare reform has altered the relationship of hospitals and physicians. An exploratory study of marketing approaches used by twelve healthcare organizations representing twenty-five hospitals in a large city was conducted. Strategies encountered in the study ranged from practice acquisition to practice promotion. This study suggests that healthcare providers might adopt consumer product branding strategies to secure market-share, build brand equity, and improve profitability.

Practical health co-operation - the impact of a referral template on quality of care and health care co-operation: study protocol for a cluster randomized controlled trial.

PubMed

Wåhlberg, Henrik; Valle, Per Christian; Malm, Siri; Broderstad, Ann Ragnhild

2013-01-07

The referral letter plays a key role both in the communication between primary and secondary care, and in the quality of the health care process. Many studies have attempted to evaluate and improve the quality of these referral letters, but few have assessed the impact of their quality on the health care delivered to each patient. A cluster randomized trial, with the general practitioner office as the unit of randomization, has been designed to evaluate the effect of a referral intervention on the quality of health care delivered. Referral templates have been developed covering four diagnostic groups: dyspepsia, suspected colonic malignancy, chest pain, and chronic obstructive pulmonary disease. Of the 14 general practitioner offices primarily served by University Hospital of North Norway Harstad, seven were randomized to the intervention group. The primary outcome is a collated quality indicator score developed for each diagnostic group. Secondary outcomes include: quality of the referral, health process outcome such as waiting times, and adequacy of prioritization. In addition, information on patient satisfaction will be collected using self-report questionnaires. Outcome data will be collected on the individual level and analyzed by random effects linear regression. Poor communication between primary and secondary care can lead to inappropriate investigations and erroneous prioritization. This study's primary hypothesis is that the use of a referral template in this communication will lead to a measurable increase in the quality of health care delivered. This trial has been registered at ClinicalTrials.gov. The trial registration number is NCT01470963.

The impact of snow on orthopaedic trauma referrals.

PubMed

Weston-Simons, John; Jack, Christopher M; Doctor, Cyrus; Brogan, Kit; Reed, Daniel; Ricketts, David

2012-07-01

Adverse weather has been shown to increase orthopaedic referrals and place strain on services. This retrospective study undertaken at a teaching hospital concerned referrals between April 2009 and April 2010 comparing days when snow fell to days when it did not. Referrals increased significantly on snow days (to 74.9 per day) in comparison to normal weather days (33.5 per day). During snow days there were significant increases in the number of distal radius and ankle fractures referred but not of fractured necks of femur. Complications during the snow fall period were related to procedures performed outside of the trauma unit with further difficulties related to a lack of operating equipment and implant availability. As a result of our study, we recommend that during periods of heavy snow fall orthopaedic and trauma units should place senior orthopaedic trainees in Accident and Emergency to review patients as a triage service, organise trauma lists related to surgeon specific expertise and avoid sending trauma patients outside the unit for operation. Copyright © 2011 Elsevier Ltd. All rights reserved.

Refer prior to biopsy of suspected appendicular soft tissue sarcoma.

PubMed

Elliott, Robert S J; Flint, Michael; French, Gary

2012-11-23

Appendicular soft tissue tumours are rare and inappropriate investigation can result in unnecessary loss of limb or life. We reviewed the investigation and referrals of patients to our institution. This is a review of prospectively collected data stored in a tumour registry database. We included all patients (126) referred to the service for investigation and management with a primary soft tissue tumour in 2006 and 2007. There was a highly significant association (RR=6.2) between pre referral procedures (PRPs) and suffering a complication (P<0.0001) in comparison to non-biopsied referrals (NBRs). Those referred by general surgeons were more likely (RR=2.6) to have undergone PRP (p<0.0017). The median interval between referral and senior author review was 8 days for the PRP group and 10 days for the NBR group (P=0.2574). Biopsy of suspected appendicular soft tissue sarcoma should be performed by a tumour specialist or in prior consultation with, to minimise adverse outcomes. There was minimal delay till review by an orthopaedic tumour specialist at Middlemore Hospital and achieving a tissue diagnosis does not expedite this.

Establishing an Australian nurse practitioner-led colorectal cancer screening clinic.

PubMed

Morcom, Joylene; Dunn, Sandra V; Luxford, Yoni

2005-01-01

In Australia, colorectal cancer is the most commonly occurring internal cancer affecting both men and women, and the second most common cause of cancer-related death. Flexible sigmoidoscopy has not been commonly used as a screening tool in Australia due primarily to lack of resources. Until now, people at average risk of developing bowel cancer frequently undergo colonoscopy after referral to a specialist. To fill an identified need, a nurse practitioner-led colorectal screening service providing fecal occult blood testing and flexible sigmoidoscopy, health education and promotion, patient counseling, information and a referral point for general practitioners, and a referral service for above average-risk patients was established in a South Australian metropolitan teaching hospital. Establishment of this clinic required advanced and extended theoretical and clinical preparation for the nurse practitioner, as well as development of interdisciplinary relationships, referral processes, clinical infrastructure, and a marketing strategy. An audit of the first 100 flexible sigmoidoscopy patients revealed service and procedural outcomes that compared favorably with other colorectal screening services as well as a high level of patient satisfaction.

Utilization of hospital services by cardiovascular patients, Alberta, Canada.

PubMed Central

Bay, K S; Maher, M; Lee, S J

1989-01-01

Using hospital discharge records, and United States DRG (diagnosis related groups) data, we studied hospital utilization by cardiovascular patients, associated hospital expenditures, and the per capita cost of treating cardiovascular diseases in Alberta, Canada between 1971 and 1986. Expressed in constant 1984 Canadian dollars, the estimated total hospital cost increased from $84 million in 1971 to $131 million in 1986; during this period the Province of Alberta spent about $51 Canadian per resident each year for cardiovascular hospital services. It was noted that rural residents consumed a higher volume of resources per capita than their urban counterparts. A patient origin-destination analysis indicated an increasing dependence of rural patients on urban hospitals for secondary or tertiary care, underscoring the effects of medical technology on referral patterns. PMID:2499201

The proposed Nelson Mandela Children's Hospital, Johannesburg: providing the best care for children in the developing world.

PubMed

Bolton, Keith

2011-01-01

Construction will soon commence on the Nelson Mandela Children's Hospital (NMCH) in Johannesburg, South Africa. The Hospital will have 250-300 beds and will provide tertiary and quaternary care to children in specific Centers of Excellence. Admission to this referral facility will be based entirely on medical needs. The disciplines that are catered for include Paediatric surgery, oncology, nephrology, cardiology, intensive care and imaging. The NMCH will be South Africa's first "Private Hospital - Not for Gain". Funding for capital expenditure is currently being raised by the Trust. Operational expenditure will come from the Department of Health, private insurers and neighbouring governments.

Correlation between the reason for referral, clinical, and objective assessment of the risk for dysphagia.

PubMed

Mancopes, Renata; Gonçalves, Bruna Franciele da Trindade; Costa, Cintia Conceição; Favero, Talita Cristina; Drozdz, Daniela Rejane Constantino; Bilheri, Diego Fernando Dorneles; Schumacher, Stéfani Fernanda

2014-01-01

To correlate the reason for referral to speech therapy service at a university hospital with the results of clinical and objective assessment of risk for dysphagia. This is a cross-sectional, observational, retrospective analytical and quantitative study. The data were gathered from the database, and the information used was the reason for referral to speech therapy service, results of clinical assessment of the risk for dysphagia, and also from swallowing videofluoroscopy. There was a mean difference between the variables of the reason for the referral, results of the clinical and objective swallowing assessments, and scale of penetration/aspiration, although the values were not statistically significant. Statistically significant correlation was observed between clinical and objective assessments and the penetration scale, with the largest occurring between the results of objective assessment and penetration scale. There was a correlation between clinical and objective assessments of swallowing and mean difference between the variables of the reason for the referral with their respective assessment. This shows the importance of the association between the data of patient's history and results of clinical evaluation and complementary tests, such as videofluoroscopy, for correct identification of the swallowing disorders, being important to combine the use of severity scales of penetration/aspiration for diagnosis.

A pediatric death audit in a large referral hospital in Malawi.

PubMed

Fitzgerald, Elizabeth; Mlotha-Mitole, Rachel; Ciccone, Emily J; Tilly, Alyssa E; Montijo, Jennie M; Lang, Hans-Joerg; Eckerle, Michelle

2018-02-21

Death audits have been used to describe pediatric mortality in under-resourced settings, where record keeping is often a challenge. This information provides the cornerstone for the foundation of quality improvement initiatives. Malawi, located in sub-Saharan Africa, currently has an Under-5 mortality rate of 64/1000. Kamuzu Central Hospital, in the capital city Lilongwe, is a busy government referral hospital, which admits up to 3000 children per month. A study published in 2013 reported mortality rates as high as 9%. This is the first known audit of pediatric death files conducted at this hospital. A retrospective chart review on all pediatric deaths that occurred at Kamuzu Central Hospital (excluding deaths in the neonatal nursery) during a 13-month period was done using a standardized death audit form. A descriptive analysis was completed, including patient demographics, HIV and nutritional status, and cause of death. Modifiable factors were identified that may have contributed to mortality, including a lack of vital sign collection, poor documentation, and delays in the procurement or results of tests, studies, and specialist review. Seven hundred forty three total pediatric deaths were recorded and 700 deceased patient files were reviewed. The mortality rate by month ranged from a low of 2.2% to a high of 4.4%. Forty-four percent of deaths occurred within the first 24 h of admission, and 59% occurred within the first 48 h. The most common causes of death were malaria, malnutrition, HIV-related illnesses, and sepsis. The mortality rate for this pediatric referral center has dramatically decreased in the 6 years since the last published mortality data, but remains high. Areas identified for continued development include improved record keeping, improved patient assessment and monitoring, and more timely and reliable provision of testing and treatment. This study demonstrates that in low-resource settings, where reliable record keeping is often difficult, death audits are useful tools to describe the sickest patient population and determine factors possibly contributing to mortality that may be amenable to quality improvement interventions.

Point prevalence survey of antibiotic use and resistance at a referral hospital in Kenya: findings and implications.

PubMed

Okoth, Caleb; Opanga, Sylvia; Okalebo, Faith; Oluka, Margaret; Baker Kurdi, Amanj; Godman, Brian

2018-04-27

A substantial amount of antibiotic use in hospitals may be inappropriate, potentially leading to the development and spread of antibiotic resistance, adverse effects, mortality and increased hospital costs. The objective was to assess current patterns of antibiotic use in a leading referral hospital in Western Kenya. This would lead to the identification of opportunities for quality improvement in this hospital and others across Kenya. A point prevalence survey was carried out with data abstracted principally from patient medical records supplemented by interviews from physicians when needed. The pattern of antibiotic use was analyzed by descriptive methods. Differences in antibiotic use and indications between the selected wards were compared using the Chi-square test or Fisher's exact tests. Among the patients surveyed, 67.7% were on antibiotics. The most common classes of antibiotics prescribed were third generation cephalosporins (55%), imidazole derivatives like metronidazole (41.8%) and broad spectrum penicillins (41.8%). The most common indication for antibiotic use was medical prophylaxis (29%), with local guidelines advocating antibiotic prophylaxis in mothers after delivery of their child as well as in neonates with birth asphyxia and low weight at birth. Dosing of antibiotics was seen as generally optimal when assessed against current recommendations. Whilst the dosing of antibiotics seemed adequate, there was high use of antibiotics in this hospital. This needs to be urgently reviewed with currently appreciable empiric antibiotic use. Programmes are being instigated to address these concerns. This includes developing antibiotic guidelines and formularies especially for empiric use as well as implementing antimicrobial stewardship activities.

[Establishment of a nurse-led heart failure clinic. Design and baseline data from the first two years].

PubMed

Galatius, Søren; Gustafsson, Finn; Kistorp, Caroline M N; Nielsen, Per H; Atar, Dan; Hildebrandt, Per Rossen

2003-02-10

Previous studies on the effect of heart failure clinics have shown a reduction in hospitalizations, reduced cost and improved quality of life. We report on the establishment of a heart failure clinic and its impact on heart failure hospitalizations. Since September 1, 1999, a heart failure clinic has been operated at the Frederiksberg University Hospital. The clinic was designed with both a diagnostic and a therapeutic unit. The diagnostic unit offers open access to all patients with suspected heart failure, either through referral from general practitioners or from the medical departments of the hospital. In case of confirmed systolic heart failure, the patient is referred to the therapeutic unit. During the two years of operation, a total of 510 patients were registered in a newly established database (HJERTER+). Of these, 352 (69%) were found to have clinical evidence of heart failure, and 304 (86% of the heart failure patients) had left ventricular (LV) systolic dysfunction (ejection fraction < or = 0.45). Before referral, most patients with LV dysfunction had been treated with no or insufficient dose of ACE inhibitor (55%), and one third received beta-blockers (32%). During the two years of operation of the clinic, there was a 23% decline in heart failure related hospital admissions to the department of cardiology. Patients with systolic heart failure are not always optimally treated. The establishment of a heart failure clinic offering the combination of diagnosing and managing congestive heart failure appears to be effective both in terms of therapy optimization and with respect to a concomitant decline in hospitalization for heart failure.

Implementation of a quality management system according to 9001 standard in a hospital in the home unit: changes and achievements.

PubMed

Rodríguez-Cerrillo, Matilde; Fernández-Diaz, Eddita; Iñurrieta-Romero, Amaia; Poza-Montoro, Ana

2012-01-01

The purpose of this paper is to describe changes and results obtained after implementation of a quality management system (QMS) according to ISO standards in a Hospital in the Home (HIH) Unit. The paper describes changes made and outcomes achieved. This took part in the HiH Unit, Clinico Hospital, Madrid, Spain, and looked at admissions, mean stay, patient satisfaction, adverse events, returns to hospital, no admitted referrals, complaints, compliance to protocols, equipment failures and resolution of urgent consultations. In June 2008, HiH Unit, Clinico Hospital obtained ISO certification. The main results achieved are as follows. There was an increase in patients' satisfaction--in June 2008, assessment of the quality of care provided by staff was scored at 4.7 (on a scale of 1 to 5); in 2010 it has been scored at 4.96. Patient satisfaction rate has increased from 92 percent to 98.8 percent. No complaints from patients were received. Unscheduled returns to hospital have decreased from 7 percent to 3 percent. There were no medical equipment failures. External suppliers' performance has improved. Material and medication needed by staff was available when necessary. The number of admissions has increased. Compliance to protocols has reached 97 percent. Inappropriate referrals have decreased by 8 percent. Six medications-related incidents were detected; in two cases the incident was not due to an error. In the other four cases error could have been detected before reaching the patient. Implementations of an ISO quality management system allow improved quality of care and patient satisfaction in a HIH Unit.

The cost-savings of implementing kangaroo mother care in Nicaragua.

PubMed

Broughton, Edward I; Gomez, Ivonne; Sanchez, Nieves; Vindell, Concepción

2013-09-01

To examine the costs of implementing kangaroo mother care (KMC) in a referral hospital in Nicaragua, including training, implementation, and ongoing operating costs, and to estimate the economic impact on the Nicaraguan health system if KMC were implemented in other maternity hospitals in the country. After receiving clinical training in KMC, the implementation team trained their colleagues, wrote guidelines for clinicians and education material for parents, and ensured adherence to the new guidelines. The intervention began September 2010 The study compared data on infant weight, medication use, formula consumption, incubator use, and hospitalization for six months before and after implementation. Cost data were collected from accounting records of the implementers and health ministry formularies. A total of 46 randomly selected infants before implementation were compared to 52 after implementation. Controlling for confounders, neonates after implementation had lower lengths of hospitalization by 4.64 days (P = 0.017) and 71% were exclusively breastfed (P < 0.001). The intervention cost US$ 23 113 but the money saved with shorter hospitalization, elimination of incubator use, and lower antibiotic and infant formula costs made up for this expense in 1 - 2 months. Extending KMC to 12 other facilities in Nicaragua is projected to save approximately US$ 166 000 (based on the referral hospital incubator use estimate) or US$ 233 000 after one year (based on the more conservative incubator use estimate). Treating premature and low-birth-weight infants in Nicaragua with KMC implemented as a quality improvement program saves money within a short period even without considering the beneficial health effects of KMC. Implementation in more facilities is strongly recommended.

Hospitalizations for asthma: impact of a program for the control of asthma and allergic rhinitis in Feira de Santana, Brazil.

PubMed

Brandão, Heli Vieira; Cruz, Constança Margarida Sampaio; Santos, Ivan da Silva; Ponte, Eduardo Vieira; Guimarães, Armênio; Augusto Filho, Alvaro

2009-08-01

To evaluate the impact of the Programa de Controle da Asma e Rinite Alérgica em Feira de Santana (ProAR-FS, Program for the Control of Asthma and Allergic Rhinitis in Feira de Santana) on the frequency of hospitalizations for asthma in patients monitored at a referral center for one year. This was a historical control study involving 253 consecutive patients with asthma, ages ranging from 4 to 76 years. We compared the frequency of hospital admissions and visits to the emergency room (ER) in the 12 months prior to and after their admission to the ProAR-FS. During the program, patients received free treatment, including inhaled medications and education on asthma. Demographic and socioeconomic aspects were also assessed. There was a significant reduction in the number of hospitalizations (465 vs. 21) and of visits to the ER (2,473 vs. 184) after their admission to ProAR-FS (p < 0.001 for both). Of the 253 patients who had been hospitalized and had had ER visits within the year prior to the admission to ProAR-FS, only 16 were hospitalized and 92 visited the ER during the follow-up year, representing a reduction of 94% and 64%, respectively. Implementing a referral center for the treatment of asthma and rhinitis in the Unified Health Care System, with the free distribution of inhaled corticosteroids and the support of an education program, is a highly effective strategy for the control of asthma.

Paramedic-Initiated Home Care Referrals and Use of Home Care and Emergency Medical Services.

PubMed

Verma, Amol A; Klich, John; Thurston, Adam; Scantlebury, Jordan; Kiss, Alex; Seddon, Gayle; Sinha, Samir K

2018-01-01

We examined the association between paramedic-initiated home care referrals and utilization of home care, 9-1-1, and Emergency Department (ED) services. This was a retrospective cohort study of individuals who received a paramedic-initiated home care referral after a 9-1-1 call between January 1, 2011 and December 31, 2012 in Toronto, Ontario, Canada. Home care, 9-1-1, and ED utilization were compared in the 6 months before and after home care referral. Nonparametric longitudinal regression was performed to assess changes in hours of home care service use and zero-inflated Poisson regression was performed to assess changes in the number of 9-1-1 calls and ambulance transports to ED. During the 24-month study period, 2,382 individuals received a paramedic-initiated home care referral. After excluding individuals who died, were hospitalized, or were admitted to a nursing home, the final study cohort was 1,851. The proportion of the study population receiving home care services increased from 18.2% to 42.5% after referral, representing 450 additional people receiving services. In longitudinal regression analysis, there was an increase of 17.4 hours in total services per person in the six months after referral (95% CI: 1.7-33.1, p = 0.03). The mean number of 9-1-1 calls per person was 1.44 (SD 9.58) before home care referral and 1.20 (SD 7.04) after home care referral in the overall study cohort. This represented a 10% reduction in 9-1-1 calls (95% CI: 7-13%, p < 0.001) in Poisson regression analysis. The mean number of ambulance transports to ED per person was 0.91 (SD 8.90) before home care referral and 0.79 (SD 6.27) after home care referral, representing a 7% reduction (95% CI: 3-11%, p < 0.001) in Poisson regression analysis. When only the participants with complete paramedic and home care records were included in the analysis, the reductions in 9-1-1 calls and ambulance transports to ED were attenuated but remained statistically significant. Paramedic-initiated home care referrals in Toronto were associated with improved access to and use of home care services and may have been associated with reduced 9-1-1 calls and ambulance transports to ED.

A population health approach to reducing observational intensity bias in health risk adjustment: cross sectional analysis of insurance claims

PubMed Central

Sharp, Sandra M; Bevan, Gwyn; Skinner, Jonathan S; Gottlieb, Daniel J

2014-01-01

Objective To compare the performance of two new approaches to risk adjustment that are free of the influence of observational intensity with methods that depend on diagnoses listed in administrative databases. Setting Administrative data from the US Medicare program for services provided in 2007 among 306 US hospital referral regions. Design Cross sectional analysis. Participants 20% sample of fee for service Medicare beneficiaries residing in one of 306 hospital referral regions in the United States in 2007 (n=5 153 877). Main outcome measures The effect of health risk adjustment on age, sex, and race adjusted mortality and spending rates among hospital referral regions using four indices: the standard Centers for Medicare and Medicaid Services—Hierarchical Condition Categories (HCC) index used by the US Medicare program (calculated from diagnoses listed in Medicare’s administrative database); a visit corrected HCC index (to reduce the effects of observational intensity on frequency of diagnoses); a poverty index (based on US census); and a population health index (calculated using data on incidence of hip fractures and strokes, and responses from a population based annual survey of health from the Centers for Disease Control and Prevention). Results Estimated variation in age, sex, and race adjusted mortality rates across hospital referral regions was reduced using the indices based on population health, poverty, and visit corrected HCC, but increased using the standard HCC index. Most of the residual variation in age, sex, and race adjusted mortality was explained (in terms of weighted R2) by the population health index: R2=0.65. The other indices explained less: R2=0.20 for the visit corrected HCC index; 0.19 for the poverty index, and 0.02 for the standard HCC index. The residual variation in age, sex, race, and price adjusted spending per capita across the 306 hospital referral regions explained by the indices (in terms of weighted R2) were 0.50 for the standard HCC index, 0.21 for the population health index, 0.12 for the poverty index, and 0.07 for the visit corrected HCC index, implying that only a modest amount of the variation in spending can be explained by factors most closely related to mortality. Further, once the HCC index is visit corrected it accounts for almost none of the residual variation in age, sex, and race adjusted spending. Conclusion Health risk adjustment using either the poverty index or the population health index performed substantially better in terms of explaining actual mortality than the indices that relied on diagnoses from administrative databases; the population health index explained the majority of residual variation in age, sex, and race adjusted mortality. Owing to the influence of observational intensity on diagnoses from administrative databases, the standard HCC index over-adjusts for regional differences in spending. Research to improve health risk adjustment methods should focus on developing measures of risk that do not depend on observation influenced diagnoses recorded in administrative databases. PMID:24721838

Incidence, characteristics, and survival following cardiopulmonary resuscitation in the quaternary neonatal intensive care unit.

PubMed

Foglia, Elizabeth E; Langeveld, Robert; Heimall, Lauren; Deveney, Alyson; Ades, Anne; Jensen, Erik A; Nadkarni, Vinay M

2017-01-01

The contemporary characteristics and outcomes of cardiopulmonary resuscitation (CPR) in the neonatal intensive care unit (NICU) are poorly described. The objectives of this study were to determine the incidence, interventions, and outcomes of CPR in a quaternary referral NICU. Retrospective observational study of infants who received chest compressions for resuscitation in the Children's Hospital of Philadelphia NICU between April 1, 2011 and June 30, 2015. Patient, event, and survival characteristics were abstracted from the medical record and the hospital-wide resuscitation database. The primary outcome was survival to hospital discharge. Univariable and multivariable analyses were performed to identify patient and event factors associated with survival to discharge. There were 1.2 CPR events per 1000 patient days. CPR was performed in 113 of 5046 (2.2%) infants admitted to the NICU during the study period. The median duration of chest compressions was 2min (interquartile range 1, 6min). Adrenaline was administered in 34 (30%) CPR events. Of 113 infants with at least one CPR event, 69 (61%) survived to hospital discharge. Factors independently associated with decreased survival to hospital discharge were inotrope treatment prior to CPR (adjusted Odds Ratio [aOR] 0.14, 95% Confidence Interval [CI] 0.04, 0.54), and adrenaline administration during CPR (aOR 0.14, 95% CI 0.04, 0.50). Although it was not uncommon, the incidence of CPR was low (<3%) among infants hospitalized in a quaternary referral NICU. Infants receiving inotropic therapy prior to CPR and adrenaline administration during CPR were less likely to survive to hospital discharge. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Clinical and geographic patterns of rheumatic heart disease in outpatients attending cardiology clinic in western Kenya.

PubMed

Lumsden, Rebecca H; Akwanalo, Constantine; Chepkwony, Stella; Kithei, Anne; Omollo, Vincent; Holland, Thomas L; Bloomfield, Gerald S; O'Meara, Wendy P

2016-11-15

Rheumatic heart disease (RHD) remains a leading cause of cardiovascular mortality in sub-Saharan Africa. Identifying high risk populations and geographic patterns of disease is crucial to developing RHD prevention and screening strategies in endemic areas. To identify clinical and geographical trends in RHD throughout western Kenya METHODS: We conducted a retrospective chart review of all patients <50years old attending adult cardiology clinic at a national referral hospital in western Kenya. Demographic information, residential location and cardiac history were collected. We mapped the spatial distribution of cardiac disease rates and analyzed the effect of distance from the hospital on RHD status. Two-thirds (64%) of cardiology clinic patients <50years old (n=906) had RHD. RHD patients were younger (26 vs. 33years, p<0.001) and more often female (69% vs. 59%, p=0.001) than non-RHD patients. Global clustering of disease rates existed within 200km of the hospital with significant clustering of the RHD and non-RHD rate difference surrounding the hospital (Moran's I: 0.3, p=0.001). There was an interaction between ethnicity and distance from the hospital such that the odds of RHD decreased with further distance for Nilotes, but the odds of RHD increased with further distance for non-Nilotes CONCLUSION: Most adult cardiology patients treated at a national referral hospital in western Kenya have RHD. Young people and females are commonly affected. Ethnicity and distance to the hospital interdependently affect the odds of RHD. Future studies in this area should consider the impact of ethnic predisposition to RHD. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Incidence, characteristics, and survival following cardiopulmonary resuscitation in the quaternary neonatal intensive care unit

PubMed Central

Foglia, Elizabeth E.; Langeveld, Robert; Heimall, Lauren; Deveney, Alyson; Ades, Anne; Jensen, Erik A.; Nadkarni, Vinay M.

2016-01-01

Background The contemporary characteristics and outcomes of cardiopulmonary resuscitation (CPR) in the neonatal intensive care unit (NICU) are poorly described. The objectives of this study were to determine the incidence, interventions, and outcomes of CPR in a quaternary referral NICU. Methods Retrospective observational study of infants who received chest compressions for resuscitation in the Children’s Hospital of Philadelphia NICU between April 1, 2011 and June 30, 2015. Patient, event, and survival characteristics were abstracted from the medical record and the hospital-wide resuscitation database. The primary outcome was survival to hospital discharge. Univariable and multivariable analyses were performed to identify patient and event factors associated with survival to discharge. Results There were 1.2 CPR events per 1,000 patient days. CPR was performed in 113 of 5,046 (2.2%) infants admitted to the NICU during the study period. The median duration of chest compressions was 2 minutes (interquartile range 1, 6 minutes). Adrenaline was administered in 34 (30%) CPR events. Of 113 infants with at least one CPR event, 69 (61%) survived to hospital discharge. Factors independently associated with decreased survival to hospital discharge were inotrope treatment prior to CPR (adjusted Odds Ratio [aOR] 0.14, 95% Confidence Interval [CI] 0.04, 0.54), and adrenaline administration during CPR (aOR 0.14, 95% CI 0.04, 0.50). Conclusions Although it was not uncommon, the incidence of CPR was low (<3%) among infants hospitalized in a quaternary referral NICU. Infants receiving inotropic therapy prior to CPR and adrenaline administration during CPR were less likely to survive to hospital discharge. PMID:27984153

Travel time and cancer care: an example of the inverse care law?

PubMed

Baird, G; Flynn, R; Baxter, G; Donnelly, M; Lawrence, J

2008-01-01

There is growing evidence that in rural areas cancer mortality is higher and referral occurs later, indicating different patterns of care. In Scotland services to rural areas have been organized through 'managed clinical networks'. In some cases, these organizational networks have been structured so that the referral hospital is not the one nearest to the patient's home. This study set out to discover if access to cancer specialist care in mainland Scotland altered with distance to tertiary care facilities. The aim was to explore the relationship between hospital admission rates, type of hospital and travel time. Retrospective analysis of all registered cancers in Scotland over the three-year period 2000-2002, examining incidence rates and accessibility of care over 3 years, measured by hospital discharge rates (equivalent to admission rates) and mean bed days for cancer patients. The type of hospital to which a cancer patient was admitted and the duration of admission varied with travel distance from a patient's home. All patients travelling more than one hour had lower admission rates to a specialist cancer centre. Those travelling more than 3 hours were not always admitted to the facility nearest their home address and were admitted for significantly fewer days than all other groups. Differences in tertiary cancer care obtained may explain some of the reasons behind late presentation and higher mortality rates. This study provides evidence that the recognized increased cancer mortality in rural patients is indeed compounded by an increased travel burden.

Comparison of microbial pattern in early and late onset neonatal sepsis in referral center Haji Adam Malik hospital Medan Indonesia

NASA Astrophysics Data System (ADS)

Hasibuan, B. S.

2018-03-01

Neonatal sepsis contributes a significant rate of infants mortality and morbidity. The pathogens are diverse from region to another and change time to time even in the same place. To analyze the microbial pattern in early and late onset neonatal sepsis andthe pattern of antibiotic resistance of the causative microbes at one of referral center hospital in Indonesia, Haji Adam Malik Hospital, a cross-sectional descriptive study was conducted on neonates with sepsis diagnosis proven with positive blood culture within one year period (2015-2016). Among 626 neonates admitted to perinatology unit, the total of 154 neonates was proven to have neonatal sepsis with positive blood culture with the incidence rate 24.6%. Seventy-nine (51.3%) neonates were diagnosed with early onset sepsis while 75 (48,7%) neonates had late-onset sepsis. Klebsiella pneumonia was the most commonly isolated organism in both early and late onset sepsis, encompassing 19.5% of cases. Periodic surveillance of the causative agents of neonatal sepsis is needed to implement the rational, empirical choice of antibiotic prescription while waiting for blood culture result to come out.

Optimizing perioperative Crohn's disease management: role of coordinated medical and surgical care.

PubMed

Bennett, Jennifer L; Ha, Christina Y; Efron, Jonathan E; Gearhart, Susan L; Lazarev, Mark G; Wick, Elizabeth C

2015-01-28

To investigate rates of re-establishing gastroenterology care, colonoscopy, and/or initiating medical therapy after Crohn's disease (CD) surgery at a tertiary care referral center. CD patients having small bowel or ileocolonic resections with a primary anastomosis between 2009-2012 were identified from a tertiary academic referral center. CD-specific features, medications, and surgical outcomes were abstracted from the medical record. The primary outcome measure was compliance rates with medical follow-up within 4 wk of hospital discharge and surveillance colonoscopy within 12 mo of surgery. Eighty-eight patients met study inclusion criteria with 92% (n=81) of patients returning for surgical follow-up compared to only 41% (n=36) of patients with documented gastroenterology follow-up within four-weeks of hospital discharge, P<0.05. Factors associated with more timely postoperative medical follow-up included younger age, longer length of hospitalization, postoperative biologic use and academic center patients. In the study cohort, 75.0% of patients resumed medical therapy within 12 mo, whereas only 53.4% of patients underwent a colonoscopy within 12 mo of surgery. Our study highlights the need for coordinated CD multidisciplinary clinics and structured handoffs among providers to improve of quality of care in the postoperative setting.

Police referrals to a psychiatric hospital: experiences of nurses caring for police-referred admissions.

PubMed

Maharaj, Reshin; O'Brien, Louise; Gillies, Donna; Andrew, Sharon

2013-08-01

Police are a major source of referral to psychiatric hospitals in industrialized countries with mental health legislation. However, little attention has been paid to nurses' experience of caring for police-referred patients to psychiatric hospitals. This study utilized a Heideggerian phenomenological framework to explore the experiences of nine nurses caring for patients referred by the police, through semistructured interviews. Two major themes emerged from the hermeneutic analyses of interviews conducted with nurse participants: (i) 'expecting "the worst" '; and (ii) 'balancing therapeutic care and forced treatment'. Expecting 'the worst' related to the perceptions nurse participants had about patients referred by the police. This included two sub-themes: (i) 'we are here to care for whoever they bring in'; and (ii) 'but who deserves care?' The second theme balancing therapeutic care and forced treatment included the sub-themes: (i) 'taking control, taking care'; and (ii) 'managing power'. The study raises ethical and skill challenges for nursing including struggling with the notion of who deserves care, and balancing the imperatives of legislation with the need to work within a therapeutic framework. © 2012 The Authors; International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.

Musculoskeletal trauma services in Uganda.

PubMed

Naddumba, E K

2008-10-01

Approximately 2000 lives are lost in Uganda annually through road traffic accidents. In Kampala, they account for 39% of all injuries, primarily in males aged 16-44 years. They are a result of rapid motorization and urbanization in a country with a poor economy. Uganda's population is an estimated 28 million with a growth rate of 3.4% per year. Motorcycles and omnibuses, the main taxi vehicles, are the primary contributors to the accidents. Poor roads and drivers compound the situation. Twenty-three orthopaedic surgeons (one for every 1,300,000 people) provide specialist services that are available only at three regional hospitals and the National Referral Hospital in Kampala. The majority of musculoskeletal injuries are managed nonoperatively by 200 orthopaedic officers distributed at the district, regional and national referral hospitals. Because of the poor economy, 9% of the national budget is allocated to the health sector. Patients with musculoskeletal injuries in Uganda frequently fail to receive immediate care due to inadequate resources and most are treated by traditional bonesetters. Neglected injuries typically result in poor outcomes. Possible solutions include a public health approach for prevention of road traffic injuries, training of adequate human resources, and infrastructure development.

Estimating population prevalence of psychiatric conditions by small area with applications to analysing outcome and referral variations.

PubMed

Congdon, Peter

2006-12-01

This paper considers the development of estimates of mental illness prevalence for small areas and applications in explaining psychiatric outcomes and in assessing service provision. Estimates of prevalence are based on a logistic regression analysis of two national studies that provides model based estimates of relative morbidity risk by demographic, socio-economic and ethnic group for major psychiatric conditions; household/marital and area status also figure in the regression. Relative risk estimates are used, along with suitably disaggregated census populations, to make prevalence estimates for 354 English local authorities (LAs). Two applications are considered: the first involves analysis of variations in schizophrenia referrals and suicide mortality over English LAs that takes account of prevalence differences, and the second involves assessing hospital referral and bed use in relation to prevalence (for ages 16-74) for a case study area, Waltham Forest in NE London.

Referral practices and perceived barriers to timely obstetric care among Ugandan traditional birth attendants (TBA).

PubMed

Keri, L; Kaye, D; Sibylle, K

2010-03-01

To assess current beliefs, knowledge and practices of Ugandan traditional birth attendants (TBAs) and their pregnant patients regarding referral of obstructed labors and fistula cases. Six focus groups were held in rural areas surrounding Kampala, the capital city of Uganda. While TBAs, particularly those with previous training, appear willing to refer problematic pregnancies and labors, more serious problems exist that could lessen any positive effects of training. These problems include reported abuse by doctors and nurses, and seeing fistula as a disease caused by hospitals. Training of TBAs can be helpful to standardize knowledge about and encourage timely emergency obstetric referrals, as well as increase knowledge about the causes and preventions of obstetric fistula. However, for full efficacy, training must be accompanied by greater collaboration between biomedical and traditional health personnel, and increased infrastructure to prevent mistreatment of pregnant patients by medical staff.

Intravenous immunoglobulins in severe Guillian-Barre syndrome in childhood.

PubMed

Shanbag, Preeti; Amirtharaj, Cynthia; Pathak, Ashish

2003-07-01

This is a retrospective analysis of 25 children with severe Guillain-Barre syndrome admitted to our PICU. All children were treated with intravenous immunoglobulins (IVIG) in a dose of 2 g/kg body weight over 2-5 days in addition to supportive and respiratory care. Seventeen children were elective admissions to the PICU whereas 8 children were transferred from other hospitals in a critical condition. Five of 8 of the late referrals died as compared to none of the elective admissions. All 8 of the late referrals required mechanical ventilation as against 3 of the 17 elective admissions. Mean duration of PICU stay in the late referrals was 27 days as compared to 15 days in the elective admissions. The authors concur with previously published reports, that early use of IVIG could reduce the mortality and the need for intubation and mechanical ventilation.

The Tanzanian trauma patients' prehospital experience: a qualitative interview-based study

PubMed Central

Kuzma, Kristin; Lim, Andrew George; Kepha, Bernard; Nalitolela, Neema Evelyne; Reynolds, Teri A

2015-01-01

Objectives We sought to characterise the prehospital experience of Tanzanian trauma patients, and identify barriers and facilitators to implement community-based emergency medical systems (EMS). Settings Our study was conducted in the emergency department of an urban national referral hospital in Tanzania. Participants A convenience sample of 34 adult trauma patients, or surrogate family members, presenting or referred to an urban referral emergency department in Tanzania for treatment of injury, participated in the study. Interventions Participation in semistructured, iteratively developed interviews until saturation of responses was reached. Outcomes A grounded theory-based approach to qualitative analysis was used to identify recurrent themes. Results We characterised numerous deficiencies within the existing clinic-to-hospital referral network, including missed/delayed diagnoses, limited management capabilities at pre-referral facilities and interfacility transfer delays. Potential barriers to EMS implementation include patient financial limitations and lack of insurance, limited public infrastructure and resources, and the credibility of potential first aid responders. Potential facilitators of EMS include communities’ tendency to pool resources, individuals’ trust of other community members to be first aid responders, and faith in community leaders to organise EMS response. Participants expressed a strong desire to learn first aid. Conclusions The composite themes generated by the data suggest that there are myriad structural, financial, institutional and cultural barriers to the implementation of a formal prehospital system. However, our analysis also revealed potential facilitators to a first-responder system that takes advantage of close-knit local communities and the trust of recognised leaders in society. The results suggest favourable acceptability for community-based response by trained lay people. There is significant opportunity for care improvements with short trainings and low-cost supply planning. Further research looking at the effects of delay on outcomes in this population is needed. PMID:25916487

Abusive head trauma and accidental head injury: a 20-year comparative study of referrals to a hospital child protection team

PubMed Central

John, Simon; Vincent, Andrea L; Reed, Peter

2015-01-01

Aim To describe children referred for suspected abusive head trauma (AHT) to a hospital child protection team in Auckland, New Zealand. Methods Comparative review of demographics, histories, injuries, investigations and diagnostic outcomes for referrals under 15 years old from 1991 to 2010. Results Records were available for 345 children. Referrals increased markedly (88 in the first decade, 257 in the second), but the diagnostic ratio was stable: AHT 60%, accidental or natural 29% and uncertain cause 11%. The probability of AHT was similar regardless of socio-economic status or ethnicity. In children under 2 years old with accidental head injuries (75/255, 29%) or AHT (180/255, 71%), characteristics of particular interest for AHT included no history of trauma (88/98, 90%), no evidence of impact to the head (84/93, 90%), complex skull fractures with intracranial injury (22/28, 79%), subdural haemorrhage (160/179, 89%) and hypoxic ischaemic injury (38/39, 97%). In children over 2 years old, these characteristics did not differ significantly between children with accidental head injuries (21/47, 45%) and AHT (26/47, 55%). The mortality of AHT was higher in children over 2 years old (10/26, 38%) than under 2 years (19/180, 11%). Conclusions The striking increase in referrals for AHT probably represents increasing incidence. The decision to refer a hospitalised child with a head injury for assessment for possible AHT should not be influenced by socio-economic status or ethnicity. Children over 2 years old hospitalised for AHT are usually injured by mechanisms involving impact and should be considered at high risk of death. PMID:26130384

Reaching out to the forgotten: providing access to medical care for the homeless in Italy

PubMed Central

De Maio, Gianfranco; Van den Bergh, Rafael; Garelli, Silvia; Maccagno, Barbara; Raddi, Freja; Stefanizzi, Alice; Regazzo, Costantina; Zachariah, Rony

2014-01-01

Background A program for outpatient and intermediate inpatient care for the homeless was pioneered by the humanitarian organization Médecins Sans Frontières (MSF) in Milan, Italy, during the winter of 2012-2013. We aimed to document the characteristics and clinical management of inpatients and outpatients seen during this program. Methods A clinic providing outpatient and intermediate inpatient care (24 bed capacity) was set up in an existing homeless hostel. Patients were admitted for post-hospitalization intermediate care or for illnesses not requiring secondary care. This study was a retrospective audit of the routine program data. Results Four hundred and fifty four individuals presented for outpatient care and 123 patients were admitted to inpatient intermediary care. On average one outpatient consultation was conducted per patient per month, most for acute respiratory tract infections (39.8%; 522/1311). Eleven percent of all outpatients suffered from an underlying chronic condition and 2.98% (38/1311) needed referral to emergency services or secondary care facilities. Most inpatients were ill patients referred through public reception centers (72.3%; 89/123), while 27.6% (34/123) were post-hospitalization patients requiring intermediate care. Out of all inpatients, 41.4% (51/123) required more than 1 week of care and 6.5% (8/123) needed counter-referral to secondary care. Conclusions The observed service usage, morbidity patterns, relatively long lengths of stay, high referral completion and need for counter-referrals, all reflect the important gap-filling role played by an intermediate care facility for this vulnerable population. We recommend that in similar contexts, medical non-governmental organizations (NGOs) focus on the setup of inpatient intermediary care services; while outpatient services are covered by the public health system. PMID:24505079

Computerised sepsis protocol management. Description of an early warning system.

PubMed

de Dios, Begoña; Borges, Marcio; Smith, Timothy D; Del Castillo, Alberto; Socias, Antonia; Gutiérrez, Leticia; Nicolás, Jordi; Lladó, Bartolomé; Roche, Jose A; Díaz, Maria P; Lladó, Yolanda

2018-02-01

New strategies need to be developed for the early recognition and rapid response for the management of sepsis. To achieve this purpose, the Multidisciplinary Sepsis Team (MST) developed the Computerised Sepsis Protocol Management (PIMIS). The aim of this study was to evaluate the convenience of using PIMIS, as well as the activity of the MST. An analysis was performed on the data collected from solicited MST consultations (direct activation of PIMIS by attending physician or telephone request) and unsolicited ones (by referral from the microbiology laboratory or an automatic referral via the hospital vital signs recording software [SIDCV]), as well as the hospital department, source of infection, treatment recommendation, and acceptance of this. Of the 1,581 first consultations, 65.1% were solicited consultations (84.1% activation of PIMIS and 15.9% by telephone). The majority of unsolicited consultations were generated by the microbiology laboratory (95.2%), and 4.8% from the SIDCV. Referral from solicited consultations were generated sooner (5.63days vs 8.47days; P<.001) and came from clinical specialties rather than from the surgical ward (73.0% vs 39.1%; P<.001). A recommendation was made for antimicrobial prescription change in 32% of first consultations. The treating physician accepted 78.1% of recommendations. The high rate of solicited consultations and acceptance of recommended prescription changes suggest that a MST is seen as a helpful resource, and that PIMIS software is perceived to be useful and convenient to use, as it is the main source of referral. Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.

Effect of a Brief Outreach Educational Intervention on the Translation of Acute Poisoning Treatment Guidelines to Practice in Rural Sri Lankan Hospitals: A Cluster Randomized Controlled Trial

PubMed Central

Senarathna, Lalith; Buckley, Nick A.; Dibley, Michael J.; Kelly, Patrick J.; Jayamanna, Shaluka F.; Gawarammana, Indika B.; Dawson, Andrew H.

2013-01-01

Background In developing countries, including Sri Lanka, a high proportion of acute poisoning and other medical emergencies are initially treated in rural peripheral hospitals. Patients are then usually transferred to referral hospitals for further treatment. Guidelines are often used to promote better patient care in these emergencies. We conducted a cluster randomized controlled trial (ISRCTN73983810) which aimed to assess the effect of a brief educational outreach (‘academic detailing’) intervention to promote the utilization of treatment guidelines for acute poisoning. Methods and Findings This cluster RCT was conducted in the North Central Province of Sri Lanka. All peripheral hospitals in the province were randomized to either intervention or control. All hospitals received a copy of the guidelines. The intervention hospitals received a brief out-reach academic detailing workshop which explained poisoning treatment guidelines and guideline promotional items designed to be used in daily care. Data were collected on all patients admitted due to poisoning for 12 months post-intervention in all study hospitals. Information collected included type of poison exposure, initial investigations, treatments and hospital outcome. Patients transferred from peripheral hospitals to referral hospitals had their clinical outcomes recorded. There were 23 intervention and 23 control hospitals. There were no significant differences in the patient characteristics, such as age, gender and the poisons ingested. The intervention hospitals showed a significant improvement in administration of activated charcoal [OR 2.95 (95% CI 1.28–6.80)]. There was no difference between hospitals in use of other decontamination methods. Conclusion This study shows that an educational intervention consisting of brief out-reach academic detailing was effective in changing treatment behavior in rural Sri Lankan hospitals. The intervention was only effective for treatments with direct clinician involvement, such as administering activated charcoal. It was not successful for treatments usually administered by non-professional staff such as forced emesis for poisoning. Trial Registration Controlled-Trials.com ISRCTN73983810 ISRCTN73983810 PMID:23990989

Effect of an imaging-based streamlined electronic healthcare process on quality and costs.

PubMed

Bui, Alex A T; Taira, Ricky K; Goldman, Dana; Dionisio, John David N; Aberle, Denise R; El-Saden, Suzie; Sayre, James; Rice, Thomas; Kangarloo, Hooshang

2004-01-01

A streamlined process of care supported by technology and imaging may be effective in managing the overall healthcare process and costs. This study examined the effect of an imaging-based electronic process of care on costs and rates of hospitalization, emergency room (ER) visits, specialist diagnostic referrals, and patient satisfaction. A healthcare process was implemented for an employer group, highlighting improved patient access to primary care plus routine use of imaging and teleconsultation with diagnostic specialists. An electronic infrastructure supported patient access to physicians and communication among healthcare providers. The employer group, a self-insured company, manages a healthcare plan for its employees and their dependents: 4,072 employees were enrolled in the test group, and 7,639 in the control group. Outcome measures for expenses and frequency of hospitalizations, ER visits, traditional specialist referrals, primary care visits, and imaging utilization rates were measured using claims data over 1 year. Homogeneity tests of proportions were performed with a chi-square statistic, mean differences were tested by two-sample t-tests. Patient satisfaction with access to healthcare was gauged using results from an independent firm. Overall per member/per month costs post-implementation were lower in the enrolled population (126 dollars vs 160 dollars), even though occurrence of chronic/expensive diseases was higher in the enrolled group (18.8% vs 12.2%). Lower per member/per month costs were seen for inpatient (33.29 dollars vs 35.59 dollars); specialist referrals (21.36 dollars vs 26.84 dollars); and ER visits (3.68 dollars vs 5.22 dollars). Moreover, the utilization rate for hospital admissions, ER visits, and traditional specialist referrals were significantly lower in the enrolled group, although primary care and imaging utilization were higher. Comparison to similar employer groups showed that the company's costs were lower than national averages (119.24 dollars vs 146.32 dollars), indicating that the observed result was not attributable to normalization effects. Patient satisfaction with access to healthcare ranked in the top 21st percentile. A streamlined healthcare process supported by technology resulted in higher patient satisfaction and cost savings despite improved access to primary care and higher utilization of imaging.

Do women with pelvic floor dysfunction referred by gynaecologists and urologists at hospitals complete a pelvic floor muscle training programme? A retrospective study, 1992-2008.

PubMed

Tibaek, Sigrid; Dehlendorff, Christian

2013-08-01

For decades women with pelvic floor dysfunction (PFD) have been referred to pelvic floor muscle training (PFMT), but there is only little information on whether the women complete the programmes and why. The objectives of this study were to investigate to which extent women completed a PFMT programme to which they were referred by gynaecologists and urologists and to identify associated factors for completion. In a hospital-based, retrospective clinical design women with PFD referred to a free PFMT programme as outpatients were included. The PFMT programme consisted of: (a) vaginal digital palpation test of PFM, (b) individual instructions, (c) introduction (theory), (d) weekly supervised PFMT in groups for 3 months (12 sessions) and (e) progressive home exercises (10 sets). Data were analysed in 1,544 women, mean age 54 (SD 13) years, with PFD (urinary incontinence, n = 1,214; anal incontinence, n = 41; pelvic organ prolapse, n = 162; other PFD, n = 127). In total 747 (48 %) subjects completed (attended ≥8 sessions) the PFMT programme, 466 (30 %) dropped out and 331 (22 %) cancelled or stayed away. Age, year of referral and nationality were significantly different (p < 0.01) between completers and non-completers. Likewise, year of referral, distance from home to hospital, waiting list times and diagnosis were significantly different (p < 0.01) between dropouts and subjects who cancelled or stayed away. The results showed that less than half of the women with PFD completed a PFMT programme to which they were referred by gynaecologists and urologists. The most important associated factors for completion were age, year of referral and nationality.

The value of specialist care-infectious disease specialist referrals-why and for whom? A retrospective cohort study in a French tertiary hospital.

PubMed

Sasikumar, M; Boyer, S; Remacle-Bonnet, A; Ventelou, B; Brouqui, P

2017-04-01

This study evaluated the impact of infectious disease (ID) specialist referrals on outcomes in a tertiary hospital in France. This study tackled methodological constraints (selection bias, endogeneity) using instrumental variables (IV) methods in order to obtain a quasi-experimental design. In addition, we investigated whether certain characteristics of patients have a bearing on the impact of the intervention. We used the payments database and ID department files to obtain data for adults admitted with an ID diagnosis in the North Hospital, Marseille from 2012 to 2014. Comparable cohorts were obtained using coarsened exact matching and analysed using IV models. Mortality, readmissions, cost (payer perspective) and length of stay (LoS) were analysed. We recorded 15,393 (85.97%) stays, of which 2,159 (14.03%) benefited from IDP consultations. The intervention was seen to significantly lower the risk of inpatient mortality (marginal effect (M.E) = -19.06%) and cost of stay (average treatment effect (ATE) = - €5,573.39). The intervention group was seen to have a longer LoS (ATE = +4.95 days). The intervention conferred a higher reduction in mortality and cost for stays that experienced ICU care (mortality: odds ratio (OR) =0.09, M.E cost = -8,328.84 €) or had a higher severity of illness (mortality: OR=0.35, M.E cost = -1,331.92 €) and for patients aged between 50 and 65 years (mortality: OR=0.28, M.E cost = -874.78 €). This study shows that ID referrals are associated with lower risk of inpatient mortality and cost of stay, especially when targeted to certain subgroups.

Tackling Ambulatory Safety Risks Through Patient Engagement: What 10,000 Patients and Families Say About Safety-Related Knowledge, Behaviors, and Attitudes After Reading Visit Notes.

PubMed

Bell, Sigall K; Folcarelli, Patricia; Fossa, Alan; Gerard, Macda; Harper, Marvin; Leveille, Suzanne; Moore, Caroline; Sands, Kenneth E; Sarnoff Lee, Barbara; Walker, Jan; Bourgeois, Fabienne

2018-04-27

Ambulatory safety risks including delayed diagnoses or missed abnormal test results are difficult for clinicians to see, because they often occur in the space between visits. Experts advocate greater patient engagement to improve safety, but strategies are limited. Patient access to clinical notes ("OpenNotes") may help close the safety gap between visits. We surveyed patients and families who logged on to the patient portal and had at least one ambulatory note available in the past 12 months at two academic hospitals during June to September 2016, focusing on patient-reported effects of OpenNotes on safety knowledge, behaviors, and attitudes. A total of 6913 (28%) of 24,722 patients at an adult hospital and 3672 (17%) of 21,579 participants at the children's hospital submitted surveys. Approximately 75% of patients and parents each reported that reading notes helped them understand the reason for both tests and referrals, and approximately 50% felt that it helped them complete tests and referrals. Roughly 75% of participants were more likely to check and understand test results. Overall, 97% of participants reported that trust in the provider, activation, patient-provider goal alignment, and teamwork were each better or the same after reading 1 note or more. Nonwhite participants and those with high school education or less were 30% to 50% more likely to report that reading notes helped them complete tests compared with white and more educated respondents, respectively. Overall, the majority of more than 10,000 patients and parents reported reading notes helped them understand and follow through on tests and referrals. As information transparency spreads, OpenNotes can help activate patients and families, facilitate safety behaviors, and forge stronger partnerships with clinicians.

The spectrum of central nervous system infections in an adult referral hospital in Hanoi, Vietnam.

PubMed

Taylor, Walter R; Nguyen, Kinh; Nguyen, Duc; Nguyen, Huyen; Horby, Peter; Nguyen, Ha L; Lien, Trinh; Tran, Giang; Tran, Ninh; Nguyen, Ha M; Nguyen, Thai; Nguyen, Ha H; Nguyen, Thanh; Tran, Giap; Farrar, Jeremy; de Jong, Menno; Schultsz, Constance; Tran, Huong; Nguyen, Diep; Vu, Bich; Le, Hoa; Dao, Trinh; Nguyen, Trung; Wertheim, Heiman

2012-01-01

To determine prospectively the causative pathogens of central nervous system (CNS) infections in patients admitted to a tertiary referral hospital in Hanoi, Vietnam. From May 2007 to December 2008, cerebrospinal fluid (CSF) samples from 352 adults with suspected meningitis or encephalitis underwent routine testing, staining (Gram, Ziehl-Nielsen, India ink), bacterial culture and polymerase chain reaction targeting Neisseria meningitidis, Streptococcus pneumoniae, S. suis, Haemophilus influenzae type b, Herpes simplex virus (HSV), Varicella Zoster virus (VZV), enterovirus, and 16S ribosomal RNA. Blood cultures and clinically indicated radiology were also performed. Patients were classified as having confirmed or suspected bacterial (BM), tuberculous (TBM), cryptococcal (CRM), eosinophilic (EOM) meningitis, aseptic encephalitis/meningitis (AEM), neurocysticercosis and others. 352 (male: 66%) patients were recruited: median age 34 years (range 13-85). 95/352 (27.3%) diagnoses were laboratory confirmed and one by cranial radiology: BM (n = 62), TBM (n = 9), AEM (n = 19), CRM (n = 5), and neurocysticercosis (n = 1, cranial radiology). S. suis predominated as the cause of BM [48/62 (77.4%)]; Listeria monocytogenese (n = 1), S. pasteurianus (n = 1) and N. meningitidis (n = 2) were infrequent. AEM viruses were: HSV (n = 12), VZV (n = 5) and enterovirus (n = 2). 5 patients had EOM. Of 262/352 (74.4%) patients with full clinical data, 209 (79.8%) were hospital referrals and 186 (71%) had been on antimicrobials. 21 (8%) patients died: TBM (15.2%), AEM (10%), and BM (2.8%). Most infections lacked microbiological confirmation. S. suis was the most common cause of BM in this setting. Improved diagnostics are needed for meningoencephalitic syndromes to inform treatment and prevention strategies.

The Spectrum of Central Nervous System Infections in an Adult Referral Hospital in Hanoi, Vietnam

PubMed Central

Taylor, Walter R.; Nguyen, Kinh; Nguyen, Duc; Nguyen, Huyen; Horby, Peter; Nguyen, Ha L.; Lien, Trinh; Tran, Giang; Tran, Ninh; Nguyen, Ha M.; Nguyen, Thai; Nguyen, Ha H.; Nguyen, Thanh; Tran, Giap; Farrar, Jeremy; de Jong, Menno; Schultsz, Constance; Tran, Huong; Nguyen, Diep; Vu, Bich; Le, Hoa; Dao, Trinh; Nguyen, Trung; Wertheim, Heiman

2012-01-01

Objectives To determine prospectively the causative pathogens of central nervous system (CNS) infections in patients admitted to a tertiary referral hospital in Hanoi, Vietnam. Methods From May 2007 to December 2008, cerebrospinal fluid (CSF) samples from 352 adults with suspected meningitis or encephalitis underwent routine testing, staining (Gram, Ziehl-Nielsen, India ink), bacterial culture and polymerase chain reaction targeting Neisseria meningitidis, Streptococcus pneumoniae, S. suis, Haemophilus influenzae type b, Herpes simplex virus (HSV), Varicella Zoster virus (VZV), enterovirus, and 16S ribosomal RNA. Blood cultures and clinically indicated radiology were also performed. Patients were classified as having confirmed or suspected bacterial (BM), tuberculous (TBM), cryptococcal (CRM), eosinophilic (EOM) meningitis, aseptic encephalitis/meningitis (AEM), neurocysticercosis and others. Results 352 (male: 66%) patients were recruited: median age 34 years (range 13–85). 95/352 (27.3%) diagnoses were laboratory confirmed and one by cranial radiology: BM (n = 62), TBM (n = 9), AEM (n = 19), CRM (n = 5), and neurocysticercosis (n = 1, cranial radiology). S. suis predominated as the cause of BM [48/62 (77.4%)]; Listeria monocytogenese (n = 1), S. pasteurianus (n = 1) and N. meningitidis (n = 2) were infrequent. AEM viruses were: HSV (n = 12), VZV (n = 5) and enterovirus (n = 2). 5 patients had EOM. Of 262/352 (74.4%) patients with full clinical data, 209 (79.8%) were hospital referrals and 186 (71%) had been on antimicrobials. 21 (8%) patients died: TBM (15.2%), AEM (10%), and BM (2.8%). Conclusions Most infections lacked microbiological confirmation. S. suis was the most common cause of BM in this setting. Improved diagnostics are needed for meningoencephalitic syndromes to inform treatment and prevention strategies. PMID:22952590

Prevalence of Common Mental Disorders and Associated Factors among People with Glaucoma Attending Outpatient Clinic at Menelik II Referral Hospital, Addis Ababa, Ethiopia.

PubMed

Bedasso, Kufa; Bedaso, Asres; Feyera, Fetuma; Gebeyehu, Abebaw; Yohannis, Zegeye

2016-01-01

The burden of blindness from glaucoma is high. Therefore, people suffering from a serious eye disease such as glaucoma, which can lead to blindness, usually have an emotional disturbance on the patient. Untreated psychiatric illness is associated with increased morbidity and increased costs of care. This study aimed to assess prevalence of common mental disorders and associated factors among people with Glaucoma attending Menelik II referral hospital, Addis Ababa, Ethiopia, 2014. Institution based Cross-sectional study design was conducted in the Department of Ophthalmology Menelik II Referral Hospital from April 10 to May 15, 2014. 423 participants who had undergone through investigation, examination and diagnosed as patients of glaucoma were selected randomly from the glaucoma clinic. Data were collected through face to face interview using Self Reporting Questionnaire consisted of 20 items. Study subjects who scored ≥11 from SRQ-20 were considered as having common mental disorders. Bivariate and multivariable logistic regression analysis with 95% CI were done and variables with P<0.05 in the final model were identified as independent factors associated with common mental disorders. Four hundred five patients with glaucoma were included in our study with response rate of 95.7% and 64.5% were males. The average age was 59±13.37 years. Common mental disorders were observed in 23.2% of Glaucoma patients. It is quite obvious that levels of CMDs were high among patients with glaucoma. There was a significant association between age, sex, chronic physical illness, income and duration of illness at P < 0.05. Symptoms of common mental disorders were the commonest comorbidities among patients with glaucoma. It will be better to assess and treat Common mental disorders as a separate illness in patients with glaucoma.

PubMed Central

Maziade, Jean; Théorêt, Johanne

2004-01-01

OBJECTIVE: To describe the patients residents see in one hospital's family medicine unit and to determine whether these patients resemble family medicine patients in other Quebec hospitals. DESIGN: Descriptive study. SETTING: Urban teaching hospital. PARTICIPANTS: Patients 20 years and older who were admitted to the family medicine unit at Hôpital du St-Sacrement between April 1, 1999, and March 31, 2000, were compared with all patients admitted in general medicine to Quebec hospitals during this period. MAIN OUTCOME MEASURES: Sex, age, main diagnosis, secondary diagnoses, types of diseases, length of stay, number of consultations and specialties involved, referral after hospitalization. RESULTS: Patients hospitalized in this unit were older, had more secondary diagnoses, and stayed in hospital slightly longer than patients hospitalized in general medicine in Quebec as a whole. Residents were, therefore, exposed to patients who were more medically complex. CONCLUSION: Patients to whom residents were exposed resemble patients they will see in future hospital practice. PMID:15648384

Patient dumping, COBRA, and the public psychiatric hospital.

PubMed

Elliott, R L

1993-02-01

Serious clinical and risk management problems arise when indigent patients with acute medical conditions are transferred from general medical hospitals or emergency departments to public psychiatric hospitals that are ill equipped to provide medical care. To combat such practices, referred to as dumping, Congress included measures in the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) prohibiting such transfers. Because physicians and administrators in public psychiatric hospitals are generally not aware of the potential usefulness of COBRA in reducing dumping, this paper describes its important provisions. The key to preventing dumping is to educate referral sources to limitations on the medical care available at the receiving hospital and to discourage negligent patient transfers by enforcing COBRA. Public hospital staff and legal counsel who become familiar with COBRA's provisions can develop an antidumping strategy.

User Requirements for a Chronic Kidney Disease Clinical Decision Support Tool to Promote Timely Referral.

PubMed

Gulla, Joy; Neri, Pamela M; Bates, David W; Samal, Lipika

2017-05-01

Timely referral of patients with CKD has been associated with cost and mortality benefits, but referrals are often done too late in the course of the disease. Clinical decision support (CDS) offers a potential solution, but interventions have failed because they were not designed to support the physician workflow. We sought to identify user requirements for a chronic kidney disease (CKD) CDS system to promote timely referral. We interviewed primary care physicians (PCPs) to identify data needs for a CKD CDS system that would encourage timely referral and also gathered information about workflow to assess risk factors for progression of CKD. Interviewees were general internists recruited from a network of 14 primary care clinics affiliated with Brigham and Women's Hospital (BWH). We then performed a qualitative analysis to identify user requirements and system attributes for a CKD CDS system. Of the 12 participants, 25% were women, the mean age was 53 (range 37-82), mean years in clinical practice was 27 (range 11-58). We identified 21 user requirements. Seven of these user requirements were related to support for the referral process workflow, including access to pertinent information and support for longitudinal co-management. Six user requirements were relevant to PCP management of CKD, including management of risk factors for progression, interpretation of biomarkers of CKD severity, and diagnosis of the cause of CKD. Finally, eight user requirements addressed user-centered design of CDS, including the need for actionable information, links to guidelines and reference materials, and visualization of trends. These 21 user requirements can be used to design an intuitive and usable CDS system with the attributes necessary to promote timely referral. Copyright © 2017 Elsevier B.V. All rights reserved.

Trends and Variations in the Rates of Hospital Complications, Failure-to-Rescue and 30-Day Mortality in Surgical Patients in New South Wales, Australia, 2002-2009

PubMed Central

Ou, Lixin; Chen, Jack; Assareh, Hassan; Hollis, Stephanie J.; Hillman, Ken; Flabouris, Arthas

2014-01-01

Background Despite the increased acceptance of failure-to-rescue (FTR) as an important patient safety indicator (defined as the percentage of deaths among surgical patients with treatable complications), there has not been any large epidemiological study reporting FTR in an Australian setting nor any evaluation on its suitability as a performance indicator. Methods We conducted a population-based study on elective surgical patients from 82 public acute hospitals in New South Wales, Australia between 2002 and 2009, exploring the trends and variations in rates of hospital complications, FTR and 30-day mortality. We used Poisson regression models to derive relative risk ratios (RRs) after adjusting for a range of patient and hospital characteristics. Results The average rates of complications, FTR and 30-day mortality were 13.8 per 1000 admissions, 14.1% and 6.1 per 1000 admission, respectively. The rates of complications and 30-day mortality were stable throughout the study period however there was a significant decrease in FTR rate after 2006, coinciding with the establishment of national and state-level peak patient safety agencies. There were marked variations in the three rates within the top 20% of hospitals (best) and bottom 20% of hospitals (worst) for each of the four peer-hospital groups. The group comprising the largest volume hospitals (principal referral/teaching hospitals) had a significantly higher rate of FTR in comparison to the other three groups of smaller-sized peer hospital groups (RR = 0.78, 0.57, and 0.61, respectively). Adjusted rates of complications, FTR and 30-day mortality varied widely for individual surgical procedures between the best and worst quintile hospitals within the principal referral hospital group. Conclusions The decrease in FTR rate over the study period appears to be associated with a wide range of patient safety programs. The marked variations in the three rates between- and within- peer hospital groups highlight the potential for further quality improvement intervention opportunities. PMID:24788787

An Examination of Referral Physician Attitudes Toward Brooke Army Medical Center as a Tertiary Care Medical Center

DTIC Science & Technology

1986-09-01

William B. Handbook in Research and Evaluation. San Diego: Edits Publishers, 1977. Kotler , Philip . Marketing for Nonprofit Organizations. 2nd ed. Englewood...Marketing and the Regional Model." Hospital & Health Services Administration 28 (May-June 1983): p. 65. 18 Philip D. Cooper and Larry M. Robinson...34 Hospital & Health Services Administration 23 (Winter 1978): p. 11. 20 Philip 0. Cooper and Larry M. Robinson, Health Care Marketing Management, pp

New Jersey hospitals renew their identities; part of Meridian Health. Raising awareness of the advantages of a healthcare system.

PubMed

Botvin, Judith D

2005-01-01

Meridian Health, Wall, N.J., is a three-hospital system that also includes a network of partner companies. The objectives of this branding campaign were to create a better awareness of the benefits of academic medicine, to close the physician referral loop and to improve internal morale. The objectives were realized by emphasizing the teamwork of the system's doctors and showing their actual faces and voices.

Supporting in- and off-Hospital Patient Management Using a Web-based Integrated Software Platform.

PubMed

Spyropoulos, Basile; Botsivali, Maria; Tzavaras, Aris; Pierros, Vasileios

2015-01-01

In this paper, a Web-based software platform appropriately designed to support the continuity of health care information and management for both in and out of hospital care is presented. The system has some additional features as it is the formation of continuity of care records and the transmission of referral letters with a semantically annotated web service. The platform's Web-orientation provides significant advantages, allowing for easily accomplished remote access.

Progression in children with intestinal failure at a referral hospital in Medellín, Colombia.

PubMed

Contreras-Ramírez, M M; Giraldo-Villa, A; Henao-Roldan, C; Martínez-Volkmar, M I; Valencia-Quintero, A F; Montoya-Delgado, D C; Ruiz-Navas, P; García-Loboguerrero, F

2016-01-01

Patients with intestinal failure are unable to maintain adequate nutrition and hydration due to a reduction in the functional area of the intestine. Different strategies have the potential to benefit these patients by promoting intestinal autonomy, enhancing quality of life, and increasing survival. To describe the clinical characteristics of children with intestinal failure and disease progression in terms of intestinal autonomy and survival. A retrospective study was conducted, evaluating 33 pediatric patients with intestinal failure that were hospitalized within the time frame of December 2005 and December 2013 at a tertiary care referral center. Patient characteristics were described upon hospital admission, estimating the probability of achieving intestinal autonomy and calculating the survival rate. Patient median age upon hospital admission was 2 months (interquartile range [IQR]: 1-4 months) and 54.5% of the patients were boys. Intestinal autonomy was achieved in 69.7% of the cases with a median time of 148 days (IQR: 63 - 431 days), which decreased to 63 days in patients with a spared ileocecal valve. Survival was 91% during a median follow-up of 281 days (IQR: 161 - 772 days). Medical management of patients with intestinal failure is complex. Nutritional support and continuous monitoring are of the utmost importance and long-term morbidity and mortality depends on the early recognition and management of the associated complications. Copyright © 2016. Published by Masson Doyma México S.A.

Greater involvement of HIV-infected peer-mothers in provision of reproductive health services as "family planning champions" increases referrals and uptake of family planning among HIV-infected mothers.

PubMed

Mudiope, Peter; Musingye, Ezra; Makumbi, Carolyne Onyango; Bagenda, Danstan; Homsy, Jaco; Nakitende, Mai; Mubiru, Mike; Mosha, Linda Barlow; Kagawa, Mike; Namukwaya, Zikulah; Fowler, Mary Glenn

2017-06-27

In 2012, Makerere University Johns - Hopkins University, and Mulago National Referral Hospital, with support from the National Institute of Health (under Grant number: NOT AI-01-023) undertook operational research at Mulago National Hospital PMTCT/PNC clinics. The study employed Peer Family Planning Champions to offer health education, counselling, and triage aimed at increasing the identification, referral and family planning (FP) uptake among HIV positive mothers attending the clinic. The Peer Champion Intervention to improve FP uptake was introduced into Mulago Hospital PMTCT/PNC clinic, Kampala Uganda. During the intervention period, peers provided additional FP counselling and education; assisted in identification and referral of HIV Positive mothers in need of FP services; and accompanied referred mothers to FP clinics. We compiled and compared the average proportions of mothers in need that were referred and took up FP in the pre-intervention (3 months), intervention (6 months), and post-intervention(3 months) periods using interrupted time series with segmented regression models with an autoregressive term of one. Overall, during the intervention, the proportion of referred mothers in need of FP increased by 30.4 percentage points (P < 0.001), from 52.7 to 83.2 percentage points. FP uptake among mothers in need increased by over 31 percentage points (P < 0.001) from 47.2 to 78.5 percentage points during the intervention. There was a positive non-significant change in the weekly trend of referral β 3  = 2.9 percentage points (P = 0.077) and uptake β 3  = 1.9 percentage points (P = 0.176) during the intervention as compared to the pre-intervention but this was reversed during the post intervention. Over 57% (2494) mothers took up Depo-Provera injectable-FP method during the study. To support overstrained health care work force in post-natal clinics, peers in trained effective family planning can be a valuable addition to clinic staff in limited-resource settings. The study provides additional evidence on the utilization of peer mothers in HIV care, improves health services uptake including family planning which is a common practice in many donor supported programs. It also provides evidence that may be used to advocate for policy revisions in low-income countries to include peers as support staff especially in busy clinic settings with poor services uptake.

Sleep-disordered breathing: a survey of otolaryngologic practice at military hospitals.

PubMed

Davidson, T M; Do, K L

2000-11-01

We conducted a survey of otolaryngologists at all Veterans Administration and Department of Defense hospitals in the United States to ascertain the nature and scope of their treatment of sleep-disordered breathing. Questionnaire responses indicated that head and neck surgeons in military hospitals have a strong interest in the management of patients with snoring and sleep apnea. Because of the difficulty in obtaining timely sleep test results and the low number of referrals from physicians who perform such testing, many otolaryngologists expressed a desire to be able to perform their own sleep testing.

Five-Year Experience of an Inpatient Palliative Care Unit at an Academic Referral Center.

PubMed

Shinall, Myrick C; Martin, Sara F; Nelson, Jill; Miller, Richard S; Semler, Matthew W; Zimmerman, Eli E; Noblit, Christy C; Ely, E Wesley; Karlekar, Mohana

2018-01-01

Palliative care units (PCUs) staffed by specialty-trained physicians and nurses have been established in a number of medical centers. The purpose of this study is to review the 5-year experience of a PCU at a large, urban academic referral center. We retrospectively reviewed a prospectively collected database of all admissions to the PCU at Vanderbilt University Medical Center in the first 5 years of its existence, from 2012 through 2017. Over these 5 years, there were 3321 admissions to the PCU. No single underlying disease process accounted for the majority of the patients, but the largest single category of patients were those with malignancy, who accounted for 38% of admissions. Transfers from the intensive care unit accounted for 50% of admissions, with 43% of admissions from a hospital floor and 7% coming from the emergency department or a clinic. Median length of stay in the PCU was 3 days. In hospital deaths occurred for 50% of admitted patients, while 38% of patients were discharged from the PCU to hospice. These data show that a successful PCU is enabled by buy in from a wide variety of referring specialists and by a multidisciplinary palliative care team focused on care of the actively dying patient as well as pain and symptom management, advance care planning, and hospice referral since a large proportion of referred patients do not die in house.

Characteristics of clients to a suicide prevention centre--an epidemiological analysis of the users over a 10-year period.

PubMed

Qin, Ping; Madsen, Bente Hjorth; Mortensen, Preben Bo

2009-06-01

Suicide prevention centres play an important role on suicide prevention in communities. A better understanding of clients to these centres is essential and informative to suicide prevention. This study aimed to document the referral pattern of clients to a suicide prevention centre over a 10-year period and to capture their characteristics. All suicidal clients during 1996 to 2005 were included and compared with the regional population. Data were retrieved from longitudinal registers. There were in total 4274 contacts from 3505 individuals because of suicide attempt (38%) or suicide ideation (62%). Source of referral included self-initiation or family (25.4%), psychiatric hospitals (23.5%), general practitioners (21.7%), and somatic hospitals (15.1%). The clients were more likely females and persons at young ages. Compared with regional sex-age-matched counterparts, suicidal clients significantly more often had a history of psychiatric contact, were born by young parents, had no recorded link to a mother or father, had lost a parent, and had a parental psychiatric history. Also, they were often frequent movers and residents with a foreign citizenship. This study provided insights about the referral pattern of suicidal clients as well as client characteristics on selected variables at the birth and during upbringing, which may be informative to suicide intervention targeting at this group of population.

Concurrent hyperthyroidism and papillary thyroid cancer: a fortuitous and ambiguous case report from a resource-poor setting.

PubMed

Kadia, Benjamin Momo; Dimala, Christian Akem; Bechem, Ndemazie Nkafu; Aroke, Desmond

2016-07-26

Concurrent thyroid cancer (TC) and hyperthyroidism (HT) is rare though increasingly being reported. HT due to TC is much rarer and more challenging especially in Africa where TC and HT have significant case fatality rates. We present a 37-year-old Cameroonian female who had been on irregular regimens of propranolol and digoxin as treatment for worsening palpitations for 12 months. She came to our district hospital for her propranolol medication refill. We fortuitously identified features of HT and found a left uninodular goiter with no cervical lymphadenopathy. She was referred for thyroid assessment which suggested primary HT and an enlarged heterogeneous left lobe with a well-defined homogenous solid mass. We restarted her on propranolol and referred her for a course of methimazole. At the referral hospital, she also underwent a left thyroid lobectomy. The resected lobe was sent for histopathology which revealed a neoplastic nodule with features suggestive of a papillary thyroid cancer (PTC) causing HT. The patient's clinical progress postoperatively was good and there was regression of hyperthyroid symptoms. The historical, clinical, and laboratory findings were suggestive of HT due to PTC. A high index of suspicion, prompt referral and counter-referral lead to a positive outcome of such a rare case in a resource poor setting. We advocate for systematic and careful evaluation of all thyroid nodules.

Teleophthalmology with optical coherence tomography imaging in community optometry. Evaluation of a quality improvement for macular patients

PubMed Central

Kelly, Simon P; Wallwork, Ian; Haider, David; Qureshi, Kashif

2011-01-01

Purpose To describe a quality improvement for referral of National Health Service patients with macular disorders from a community optometry setting in an urban area. Methods Service evaluation of teleophthalmology consultation based on spectral domain optical coherence tomography images acquired by the community optometrist and transmitted to hospital eye services. Results Fifty patients with suspected macular conditions were managed via telemedicine consultation over 1 year. Responses were provided by hospital eye service-based ophthalmologists to the community optometrist or patient within the next day in 48 cases (96%) and in 34 (68%) patients on the same day. In the consensus opinion of the optometrist and ophthalmologist, 33 (66%) patients required further “face-to-face” medical examination and were triaged on clinical urgency. Seventeen cases (34%) were managed in the community and are a potential cost improvement. Specialty trainees were supervised in telemedicine consultations. Conclusion Innovation and quality improvement were demonstrated in both optometry to ophthalmology referrals and in primary optometric care by use of telemedicine with spectral domain optical coherence tomography images. E-referral of spectral domain optical coherence tomography images assists triage of macular patients and swifter care of urgent cases. Teleophthalmology is also, in the authors’ opinion, a tool to improve interdisciplinary professional working with community optometrists. Implications for progress are discussed. PMID:22174576

Modelling the resource implications and budget impact of managing cow milk allergy in Australia.

PubMed

Guest, J F; Nagy, E

2009-02-01

To estimate the resource implications and budget impact of current clinical practice for managing cow milk allergy (CMA) in Australia, from the perspective of the publicly funded healthcare system. A decision model was constructed using published clinical outcomes and clinician-derived resource utilisation estimates. The model was used to estimate the expected 6-monthly levels of healthcare resource use and corresponding costs attributable to managing 6150 new CMA sufferers following referral to a specialist. The expected 6-monthly costs of managing 6150 newly-diagnosed infants with CMA following referral to a specialist was an estimated (Australian dollars, AU$) AU$6.5 million at 2006/07 prices. Clinical nutrition preparations were found to be the primary cost driver accounting for 62% of the total 6-monthly cost and clinician visits were the secondary cost driver accounting for up to a further 28% of the total 6-monthly cost. Sensitivity analysis showed there would be fewer visits to hospital-based paediatric gastroenterologists and paediatric immunologists/allergists if all newly-diagnosed patients were prescribed an amino acid formula (AAF) following referral to a specialist, instead of being managed according to current practice. CMA imposes a substantial burden on the publicly funded healthcare system in Australia. However, using an AAF as the initial treatment for CMA can potentially release limited hospital resources for alternative use within the paediatric healthcare system.

Impact of an alcohol misuse intervention for health care workers --2: Employee assistance programme utilization, on-the-job injuries, job loss and health services utilization.

PubMed

Lapham, Sandra C; McMillan, Garnett; Gregory, Cindy

2003-01-01

We evaluated the effects of an enhanced substance misuse (SM) prevention/early intervention programme on referrals to an employee assistance programme, health care utilization rates, on-the-job injury rates and job termination rates among health care professionals employed in a managed care organization. The intervention was implemented at one site, with the remaining sites serving as the comparison group. Existing data from hospital databases were used to compare events occurring in the periods before and after initiation of the intervention. To account for baseline differences in age, gender and job class, logistic regression models produced adjusted means for events per employee month-at-risk. We found that employee assistance referrals and non-SM-related in-patient hospitalizations increased significantly post-intervention, while rates of total out-patient SM-related visits decreased at both the intervention and comparison sites post-intervention. There was a small, statistically significant decrease in the monthly rate (OR = 0.92) of non-SM out-patient utilization at the intervention site, once the intervention was in place. No differences potentially attributable to the intervention were detected in job turnover or injury rates. We conclude that, while the intervention did not appear to affect health care utilization for SM-related problems, it was associated with increased referrals for employee assistance.

Varespladib (LY315920) Appears to Be a Potent, Broad-Spectrum, Inhibitor of Snake Venom Phospholipase A2 and a Possible Pre-Referral Treatment for Envenomation

PubMed Central

Lewin, Matthew; Samuel, Stephen; Merkel, Janie; Bickler, Philip

2016-01-01

Snakebite remains a neglected medical problem of the developing world with up to 125,000 deaths each year despite more than a century of calls to improve snakebite prevention and care. An estimated 75% of fatalities from snakebite occur outside the hospital setting. Because phospholipase A2 (PLA2) activity is an important component of venom toxicity, we sought candidate PLA2 inhibitors by directly testing drugs. Surprisingly, varespladib and its orally bioavailable prodrug, methyl-varespladib showed high-level secretory PLA2 (sPLA2) inhibition at nanomolar and picomolar concentrations against 28 medically important snake venoms from six continents. In vivo proof-of-concept studies with varespladib had striking survival benefit against lethal doses of Micrurus fulvius and Vipera berus venom, and suppressed venom-induced sPLA2 activity in rats challenged with 100% lethal doses of M. fulvius venom. Rapid development and deployment of a broad-spectrum PLA2 inhibitor alone or in combination with other small molecule inhibitors of snake toxins (e.g., metalloproteases) could fill the critical therapeutic gap spanning pre-referral and hospital setting. Lower barriers for clinical testing of safety tested, repurposed small molecule therapeutics are a potentially economical and effective path forward to fill the pre-referral gap in the setting of snakebite. PMID:27571102

Cross-institutional document exchange system using clinical document architecture (CDA) with virtual printing method.

PubMed

Mihara, Naoki; Ueda, Kanayo; Manabe, Shirou; Takeda, Toshihiro; Shimai, Yoshie; Horishima, Hiroyuki; Murata, Taizo; Fujii, Ayumi; Matsumura, Yasushi

2015-01-01

Recently one patient received care from several hospitals at around the same time. When the patient visited a new hospital, the new hospital's physician tried to get patient information the previous hospital. Thus, patient information is frequently exchanged between them. Many types of healthcare facilities have implemented an electronic medical record system, but in Japan, healthcare information exchange is often done by paper. In other words, after a clinical doctor prints a referral document and sends it to another hospital's physician, another hospital's doctor receives it and scans to store the EMR in his own hospital's system. It is a wasteful way to exchange healthcare information about a patient. In order to solve this problem, we have developed a cross-institutional document exchange system using clinical document architecture (CDA) with a virtual printing method.

Listeriosis in pregnancy: a secular trend in a tertiary referral hospital in Barcelona.

PubMed

Sisó, C; Goncé, A; Bosch, J; Salvia, M D; Hernández, S; Figueras, F

2012-09-01

The purpose of this study was to describe the variation in listeriosis infection incidence during pregnancy over a 25-year period based on salient clinical and laboratory features compiled in a tertiary referral hospital and to depict the clinical characteristics of these cases. A cohort was created of all cases of listeriosis in pregnant women or their neonates (early-onset form) diagnosed between 1985 and 2010. Forty-three cases of perinatal listeriosis were diagnosed among the 82,320 hospitalised pregnant women (incidence 0.5‰). Whereas the incidence remained almost constant at 0.24‰ until 2000, an increasing incidence was observed from then on, reaching 0.86‰ during the last years of the study period. A four-fold increase in listeriosis rate during pregnancy has occurred in recent years, with poorer outcome for those cases occurring before 28 weeks and for those in which early antibiotic treatment was not provided. These results should raise the awareness of the agencies and professionals involved in prenatal care.

Case Mix Difference Can Affect Evaluation of Outcome of Treatment for Colorectal Cancer.

PubMed

Ljungman, David; Kodeda, Karl; Derwinger, Kristoffer

2015-07-01

To explore the potential effects of patient selection, for example by organization, on survival as outcome parameter in colorectal cancer treatment. The main cohort was identified in a Hospital-based registry and outcome data of all 2,717 patients operated on for colorectal cancer between 2000-2011 were evaluated. A simulation of different center settings was performed using several potential selection criteria, including emergency cases, referral surgery and palliative resection, and used for comparison of outcome data. Overall survival and cancer-specific survival can be significantly affected in both short-term (30-/90-day) mortality and long-term survival by factors of organizational level. Survival data as an outcome parameter can be affected by the composition of the patient cohort and thus reflect possible selection bias for example due to organization, referral patterns and practice customs. This potential bias should be acknowledged when making inter-hospital comparisons of outcome. Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.

Factors associated with non-reimbursable activity on an inpatient pediatric consultation-liaison service.

PubMed

Bierenbaum, Melanie L; Katsikas, Steven; Furr, Allen; Carter, Bryan D

2013-12-01

The aim of this study was to identify factors contributing to clinician time spent in non-reimbursable activity on an inpatient pediatric consultation-liaison (C-L) service. A retrospective study was conducted using inpatient C-L service data on 1,246 consecutive referrals. For this patient population, the strongest predictor of level of non-reimbursable clinical activity was illness chronicity and the number of contacts with C-L service clinicians during their hospital stay. Patients with acute life-threatening illnesses required the highest mean amount of non-reimbursable service activity. On average, 28 % of total clinician time in completing a hospital consultation was spent in non-reimbursable activity. Effective C-L services require a proportion of time spent in non-reimbursable clinical activity, such as liaison and coordinating care with other providers. Identifying referral and systemic factors contributing to non-reimbursable activity can provide insight into budgeting/negotiating for institutional support for essential clinical and non-clinical functions in providing competent quality patient care.

Quality assurance in health care for the urban poor.

PubMed

Nieto, E P

1989-01-01

New initiatives to bring primary health care to the poor barangays (villages) of Manilla, the capital of the Philippines are described. Manilla had 7.7 million people in 1987, with 2 hospitals, and a health care systems based on the European model. The government per capita health expenditure was $1, while people spent 15% of their income on health care. A household survey showed that many were underserved, that respiratory and skin infections, malnutrition, gastroenteritis and intestinal parasites were common. The Manilla Health Department was reorganized into 4 major services. A new university hospital is planned. Mechanisms are being set up for private physicians to cooperate with public health agencies in 2-way referral. Barangay health Workers and Volunteers are being trained. Root causes of poor health are being attacked by providing public water, laundry and toilet facilities, drainage, skills training and feeding programs. The barangay network has promoted lay referral, child growth monitoring, immunization, collection of vital statistics and environmental sanitation.

Reexploring Differences among For-Profit and Nonprofit Dialysis Providers

PubMed Central

Lee, Donald K K; Chertow, Glenn M; Zenios, Stefanos A

2010-01-01

Objective To determine whether profit status is associated with differences in hospital days per patient, an outcome that may also be influenced by provider financial goals. Data Sources United States Renal Data System Standard Analysis Files and Centers for Medicare and Medicaid Services cost reports. Design We compared the number of hospital days per patient per year across for-profit and nonprofit dialysis facilities during 2003. To address possible referral bias in the assignment of patients to dialysis facilities, we used an instrumental variable regression method and adjusted for selected patient-specific factors, facility characteristics such as size and chain affiliation, as well as metrics of market competition. Data Extraction Methods All patients who received in-center hemodialysis at any time in 2003 and for whom Medicare was the primary payer were included (N=170,130; roughly two-thirds of the U.S. hemodialysis population). Patients dialyzed at hospital-based facilities and patients with no dialysis facilities within 30 miles of their residence were excluded. Results Overall, adjusted hospital days per patient were 17±5 percent lower in nonprofit facilities. The difference between nonprofit and for-profit facilities persisted with the correction for referral bias. There was no association between hospital days per patient per year and chain affiliation, but larger facilities had inferior outcomes (facilities with 73 or more patients had a 14±1.7 percent increase in hospital days relative to facilities with 35 or fewer patients). Differences in outcomes among for-profit and nonprofit facilities translated to 1,600 patient-years in hospital that could be averted each year if the hospital utilization rates in for-profit facilities were to decrease to the level of their nonprofit counterparts. Conclusions Hospital days per patient-year were statistically and clinically significantly lower among nonprofit dialysis providers. These findings suggest that the indirect incentives in Medicare's current payment system may provide insufficient incentive for for-profit providers to achieve optimal patient outcomes. PMID:20403066

Reexploring differences among for-profit and nonprofit dialysis providers.

PubMed

Lee, Donald K K; Chertow, Glenn M; Zenios, Stefanos A

2010-06-01

To determine whether profit status is associated with differences in hospital days per patient, an outcome that may also be influenced by provider financial goals. United States Renal Data System Standard Analysis Files and Centers for Medicare and Medicaid Services cost reports. We compared the number of hospital days per patient per year across for-profit and nonprofit dialysis facilities during 2003. To address possible referral bias in the assignment of patients to dialysis facilities, we used an instrumental variable regression method and adjusted for selected patient-specific factors, facility characteristics such as size and chain affiliation, as well as metrics of market competition. All patients who received in-center hemodialysis at any time in 2003 and for whom Medicare was the primary payer were included (N=170,130; roughly two-thirds of the U.S. hemodialysis population). Patients dialyzed at hospital-based facilities and patients with no dialysis facilities within 30 miles of their residence were excluded. Overall, adjusted hospital days per patient were 17+/-5 percent lower in nonprofit facilities. The difference between nonprofit and for-profit facilities persisted with the correction for referral bias. There was no association between hospital days per patient per year and chain affiliation, but larger facilities had inferior outcomes (facilities with 73 or more patients had a 14+/-1.7 percent increase in hospital days relative to facilities with 35 or fewer patients). Differences in outcomes among for-profit and nonprofit facilities translated to 1,600 patient-years in hospital that could be averted each year if the hospital utilization rates in for-profit facilities were to decrease to the level of their nonprofit counterparts. Hospital days per patient-year were statistically and clinically significantly lower among nonprofit dialysis providers. These findings suggest that the indirect incentives in Medicare's current payment system may provide insufficient incentive for for-profit providers to achieve optimal patient outcomes.

Improving timeliness and efficiency in the referral process for safety net providers: application of the Lean Six Sigma methodology.

PubMed

Deckard, Gloria J; Borkowski, Nancy; Diaz, Deisell; Sanchez, Carlos; Boisette, Serge A

2010-01-01

Designated primary care clinics largely serve low-income and uninsured patients who present a disproportionate number of chronic illnesses and face great difficulty in obtaining the medical care they need, particularly the access to specialty physicians. With limited capacity for providing specialty care, these primary care clinics generally refer patients to safety net hospitals' specialty ambulatory care clinics. A large public safety net health system successfully improved the effectiveness and efficiency of the specialty clinic referral process through application of Lean Six Sigma, an advanced process-improvement methodology and set of tools driven by statistics and engineering concepts.

Prospective audit of gastroscopy under the 'three-day rule': a regional initiative in Italy to reduce waiting time for suspected malignancy.

PubMed

Parente, F; Bargiggia, S; Bianchi Porro, G

2002-05-01

A regional initiative, called the 'three-day rule', has recently been introduced in Italy to facilitate the earlier diagnosis of malignancy. It requires patients with suspected severe diseases to have a diagnostic procedure performed within three working days of referral by a general practitioner. To assess prospectively the effectiveness and compliance with the three-day rule for upper digestive malignancies. We compared patients referred for gastroscopy under the three-day rule initiative with contemporaneous open access referrals over a 12-month period at a single large teaching hospital in west Milan. We compared the prevalence of malignancies and other serious non-neoplastic diseases as well as the waiting times in the two groups. The appropriateness of the indications for each referral was also reviewed by a gastroenterologist blind to the outcome of the test. One hundred and forty-two patients referred for gastroscopy under the three-day rule scheme and 767 routine referrals were studied. Significantly more oesophageal/gastric cancers (6% vs. 1%) and serious benign gastrointestinal lesions (grade II-III oesophagitis or peptic ulcer) were diagnosed in three-day rule patients in comparison with routine referrals (P < 0.05). The rate of inappropriate referral was significantly lower in the three-day rule group than in the open access group (39% vs. 22%) (P < 0.01). The estimated cost of the three-day rule scheme (in extra list examinations alone) was 10 780 euros, with about 1198 euros per diagnosis of cancer, but only 229.5 euros per 'useful' diagnosis (including peptic ulcer disease and oesophagitis). Significantly more upper gastrointestinal cancers and serious benign diseases can be found within a short period to comply with the three-day rule scheme. However, some general practitioners appear to over-interpret alarm symptoms, leading to some inappropriate referrals. Better awareness of appropriate urgent referral criteria is needed in order to ensure that the best use is made of the resources available.

Implementation and effectiveness of 'care navigation', coordinated management for people with complex chronic illness: rationale and methods of a randomised controlled trial.

PubMed

Plant, Natalie; Mallitt, Kylie-Ann; Kelly, Patrick J; Usherwood, Tim; Gillespie, James; Boyages, Steven; Jan, Stephen; McNab, Justin; Essue, Beverley M; Gradidge, Kathy; Maranan, Nereus; Ralphs, David; Aspin, Clive; Leeder, Stephen

2013-05-03

Chronic illness is a significant driver of the global burden of disease and associated health care costs. People living with severe chronic illness are heavy users of acute hospital services; better coordination of their care could potentially improve health outcomes while reducing hospital use. The Care Navigation trial will evaluate an in-hospital coordinated care intervention on health service use and quality of life in chronically ill patients. A randomised controlled trial in 500 chronically ill patients presenting to the emergency department of a hospital in Western Sydney, Australia. Participants have three or more hospital admissions within a previous 12 month period and either aged ≥70 years; or aged ≥45 years and of Aboriginal or Torres Strait Islander descent; or aged ≥ 16 with a diagnosis of a respiratory or cardiology related illness. Patients are randomised to either the coordinated care program (Care Navigation), or to usual care. The Care Navigation program consists of dedicated nurses who conduct patient risk assessments, oversee patient nursing while in hospital, and guide development of a care plan for the management of chronic illness after being discharged from hospital. These nurses also book community appointments and liaise with general practitioners. The main outcome variables are the number of emergency department re-presentations and hospital readmissions, and quality of life during a 24 month follow-up. Secondary outcomes are length of hospital stay, mortality, time to first hospital re-admission, time to first emergency department re-presentation, patient satisfaction, adherence to prescribed medications, amount and type of in-hospital referrals made for consultations and diagnostic testing, and the number and type of community health referrals. A process evaluation and economic analysis will be conducted alongside the randomised trial. A trial of in-hospital care coordination may support recent evidence that engaging primary health services in care plans linked to multidisciplinary team support improves patient outcomes and reduces costs to the health system. This will inform local, national and international health policy. Australia New Zealand Clinical Trials Registry ACTRN12609000554268.

Cost-effectiveness of screening and referral to an alcohol health worker in alcohol misusing patients attending an accident and emergency department: a decision-making approach.

PubMed

Barrett, Barbara; Byford, Sarah; Crawford, Mike J; Patton, Robert; Drummond, Colin; Henry, John A; Touquet, Robin

2006-01-04

We present the cost and cost-effectiveness of referral to an alcohol health worker (AHW) and information only control in alcohol misusing patients. The study was a pragmatic randomised controlled trial conducted from April 2001 to March 2003 in an accident and emergency department (AED) in a general hospital in London, England. A total of 599 adults identified as drinking hazardously according to the Paddington Alcohol Test were randomised to referral to an alcohol health worker who delivered a brief intervention (n = 287) or to an information only control (n = 312). Total societal costs, including health and social services costs, criminal justice costs and productivity losses, and clinical measures of alcohol consumption were measured. Levels of drinking were observably lower in those referred to an AHW at 12 months follow-up and statistically significantly lower at 6 months follow-up. Total costs were not significantly different at either follow-up. Referral to AHWs in an AED produces favourable clinical outcomes and does not generate a significant increase in cost. A decision-making approach revealed that there is at least a 65% probability that referral to an AHW is more cost-effective than the information only control in reducing alcohol consumption among AED attendees with a hazardous level of drinking.

42 CFR 412.96 - Special treatment: Referral centers.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Facilities Under the Prospective Payment System for Inpatient Operating Costs § 412.96 Special treatment... meets the applicable criteria of paragraph (b) or (c) of this section. (b) Criteria for cost reporting... cost reporting period unless the hospital submits written documentation with its application that its...

42 CFR 412.96 - Special treatment: Referral centers.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Facilities Under the Prospective Payment System for Inpatient Operating Costs § 412.96 Special treatment... meets the applicable criteria of paragraph (b) or (c) of this section. (b) Criteria for cost reporting... cost reporting period unless the hospital submits written documentation with its application that its...

42 CFR 412.96 - Special treatment: Referral centers.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Facilities Under the Prospective Payment System for Inpatient Operating Costs § 412.96 Special treatment... meets the applicable criteria of paragraph (b) or (c) of this section. (b) Criteria for cost reporting... cost reporting period unless the hospital submits written documentation with its application that its...

42 CFR 412.96 - Special treatment: Referral centers.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Facilities Under the Prospective Payment System for Inpatient Operating Costs § 412.96 Special treatment... meets the applicable criteria of paragraph (b) or (c) of this section. (b) Criteria for cost reporting... cost reporting period unless the hospital submits written documentation with its application that its...

Surgical volume and postoperative mortality rate at a referral hospital in Western Uganda: Measuring the Lancet Commission on Global Surgery indicators in low-resource settings.

PubMed

Anderson, Geoffrey A; Ilcisin, Lenka; Abesiga, Lenard; Mayanja, Ronald; Portal Benetiz, Noralis; Ngonzi, Joseph; Kayima, Peter; Shrime, Mark G

2017-06-01

The Lancet Commission on Global Surgery recommends that every country report its surgical volume and postoperative mortality rate. Little is known, however, about the numbers of operations performed and the associated postoperative mortality rate in low-income countries or how to best collect these data. For one month, every patient who underwent an operation at a referral hospital in western Uganda was observed. These patients and their outcomes were followed until discharge. Prospective data were compared with data obtained from logbooks and patient charts to determine the validity of using retrospective methods for collecting these metrics. Surgical volume at this regional hospital in Uganda is 8,515 operations/y, compared to 4,000 operations/y reported in the only other published data. The postoperative mortality rate at this hospital is 2.4%, similar to other hospitals in low-income countries. Finding patient files in the medical records department was time consuming and yielded only 62% of the files. Furthermore, a comparison of missing versus found charts revealed that the missing charts were significantly different from the found charts. Logbooks, on the other hand, captured 99% of the operations and 94% of the deaths. Our results describe a simple, reproducible, accurate, and inexpensive method for collection of the Lancet Commission on Global Surgery variables using logbooks that already exist in most hospitals in low-income countries. While some have suggested using risk-adjusted postoperative mortality rate as a more equitable variable, our data suggest that only a limited amount of risk adjustment is possible given the limited available data. Copyright © 2017 Elsevier Inc. All rights reserved.

Patient experiences of in-hospital preparations for follow-up care at home.

PubMed

Keller, Gretchen; Merchant, Alefia; Common, Carol; Laizner, Andrea M

2017-06-01

To examine patient experiences of hospital-based discharge preparation for referral for follow-up home care services. To identify aspects of discharge preparation that will assist patients with their transition from hospital-based care to home-based follow-up care. To improve patients' transitions from hospital-based care to community-based home care, hospitals incorporate home care referral processes into discharge planning. This includes patient preparation for follow-up home care services. While there is evidence to support that such preparation needs to be more patient-centred to be effective, there is little knowledge of patient experiences of preparation that would guide improvements. Qualitative descriptive study. The study was carried out at a supra-regional hospital in Eastern Canada. Findings are based on thematic content analysis of 13 semi-structured interviews of patients requiring home care after hospitalisation on a medical or surgical unit. Most interviews were held within one week of discharge. Patient experiences were associated with patient attitudes and levels of engagement in preparation. Attitudes and levels of engagement were seen as related to one another. Those who 'didn't really think about it', had low engagement, while those with the attitude 'guide me', looked for partnership. Those who had an attitude of 'this is what I want', had a very high level of engagement. Previous experience with home care services influenced patients' level of trust in the health care system, and ultimately shaped their attitudes towards and levels of engagement in preparation. Patient preparation for follow-up home care can be improved by assessing their knowledge of and previous experiences with home care. Patients recognised as using a proactive approach may be highly vulnerable. © 2016 John Wiley & Sons Ltd.

A population-based analysis of time to surgery and travel distances for brachial plexus surgery

PubMed Central

Dy, Christopher J.; Baty, Jack; Saeed, Mohammed J; Olsen, Margaret A.; Osei, Daniel A.

2016-01-01

Purpose Despite the importance of timely evaluation for patients with brachial plexus injuries (BPI), in clinical practice we have noted delays in referral. Because the published BPI experience is largely from individual centers, we used a population-based approach to evaluate the delivery of care for patients with BPI. Methods We used statewide administrative databases from Florida (2007–2013), New York (2008–2012) and North Carolina (2009–2010) to create a cohort of patients who underwent surgery for BPI (exploration, repair, neurolysis, grafting, or nerve transfer). Emergency department and inpatient records were used to determine the time interval between the injury and surgical treatment. The distances between the treating hospitals and between the patient’s home ZIP code and the surgical hospital were recorded. A multivariable logistic regression model was used to determine predictors for time from injury to surgery exceeding 365 days. Results Within the 222 patients in our cohort, the median time from injury to surgery was 7.6 months and exceeded 365 days in 29% of cases. Treatment at a smaller hospital for the initial injury was significantly associated with surgery beyond 365 days after injury. Patient insurance type, travel distance for surgery, the distance between the two treating hospitals, or changing hospitals between injury and surgery did not significantly influence time to surgery. Conclusions Nearly one-third of patients in FL, NY, and NC underwent BPI surgery more than one year after their injury. Patients initially treated at smaller hospitals are at risk for undergoing delayed BPI surgery. Clinical Relevance These findings can inform administrative and policy efforts to expedite timely referral of patients with BPI to experienced centers. PMID:27570225

Evaluation of a program to strengthen general practice care for patients with chronic disease in Germany.

PubMed

Wensing, Michel; Szecsenyi, Joachim; Stock, Christian; Kaufmann Kolle, Petra; Laux, Gunter

2017-01-21

A program to strengthen general practice care for patients with chronic disease was offered in Germany. Enrollment was a free individual choice for both patients and physicians. This study aimed to examine the long-term impact of this program. Two comparative evaluations were done, at 4 and 5 years (T1 and T2) after start of the program. In each year, patients in the program were compared with patients in usual care. Measures were based on routinely collected data and concerned 11 aspects of primary care and hospital care. Study groups were compared, using regression analysis adjusted for confounders and clustering. Data on 1.187.597 and 1.591.017 eligible patients were available for the analysis for T1 and T2, respectively. Compared to usual care, the program was associated with more visits to the GP per patient (adjusted difference at T2: +1.98), more drugs prescribed per patient (+0.071), lower percentage of drugs that should be avoided (-0.699), and lower yearly medication costs per patient (-85.39 euro). The number of referrals to ambulatory specialists, either with or without referral from GP, was reduced at T2. In hospital care, the program was associated with fewer hospital admissions per patient per year (-0.017) and fewer avoidable hospital admissions of all admissions (-1.165%). Total hospital costs were slightly higher in T1, but lower in T2. Days in hospital and number of readmissions were lower at T2 only. The program has increased the role of general practice in healthcare for patients who chose to be included in the program of intensified general practice care.

Antibiotic resistant airborne bacteria and their multidrug resistance pattern at University teaching referral Hospital in South Ethiopia.

PubMed

Solomon, Fithamlak Bisetegen; Wadilo, Fiseha Wada; Arota, Amsalu Amache; Abraham, Yishak Leka

2017-04-12

Hospitals provide a reservoir of microorganisms, many of which are multi-resistant to antibiotics. Emergence of multi-drug resistant strains in a hospital environment, particularly in developing countries is an increasing problem to infection treatment. This study aims at assessing antibiotic resistant airborne bacterial isolates. A cross-sectional study was conducted at Wolaita Sodo university teaching and referral Hospital. Indoor air samples were collected by using passive air sampling method. Sample processing and antimicrobial susceptibility testing were done following standard bacteriological techniques. The data was analyzed using SPSS version 20. Medically important bacterial pathogens, Coagulase negative staphylococci (29.6%), Staphylococcus aureus (26.3%), Enterococci species, Enterococcus faecalis and Enterococcus faecium (16.5%), Acinetobacter species (9.5%), Escherichia coli (5.8%) and Pseudomonas aeruginosa (5.3%) were isolated. Antibiotic resistance rate ranging from 7.5 to 87.5% was detected for all isolates. Acinetobacter species showed a high rate of resistance for trimethoprim-sulfamethoxazole, gentamicin (78.2%) and ciprofloxacin (82.6%), 28 (38.9%) of S. aureus isolates were meticillin resistant, and 7.5% Enterococci isolates of were vancomycin resistant. 75.3% of all bacterial pathogen were multi-drug resistant. Among them, 74.6% were gram positive and 84% were gram negative. Multi-drug resistance were observed among 84.6% of P. aeruginosa, of 82.5% Enterococcii, E. coli 78.6%, S. aureus 76.6%, and Coagulase negative staphylococci of 73.6%. Indoor environment of the hospital was contaminated with airborne microbiotas, which are common cause of post-surgical site infection in the study area. Bacterial isolates were highly resistant to commonly used antibiotics with high multi-drug resistance percentage. So air quality of hospital environment, in restricted settings deserves attention, and requires long-term surveillance to protect both patients and healthcare workers.

A Population-Based Analysis of Time to Surgery and Travel Distances for Brachial Plexus Surgery.

PubMed

Dy, Christopher J; Baty, Jack; Saeed, Mohammed J; Olsen, Margaret A; Osei, Daniel A

2016-09-01

Despite the importance of timely evaluation for patients with brachial plexus injuries (BPIs), in clinical practice we have noted delays in referral. Because the published BPI experience is largely from individual centers, we used a population-based approach to evaluate the delivery of care for patients with BPI. We used statewide administrative databases from Florida (2007-2013), New York (2008-2012), and North Carolina (2009-2010) to create a cohort of patients who underwent surgery for BPI (exploration, repair, neurolysis, grafting, or nerve transfer). Emergency department and inpatient records were used to determine the time interval between the injury and surgical treatment. Distances between treating hospitals and between the patient's home ZIP code and the surgical hospital were recorded. A multivariable logistic regression model was used to determine predictors for time from injury to surgery exceeding 365 days. Within the 222 patients in our cohort, median time from injury to surgery was 7.6 months and exceeded 365 days in 29% (64 of 222 patients) of cases. Treatment at a smaller hospital for the initial injury was significantly associated with surgery beyond 365 days after injury. Patient insurance type, travel distance for surgery, distance between the 2 treating hospitals, and changing hospitals between injury and surgery did not significantly influence time to surgery. Nearly one third of patients in Florida, New York, and North Carolina underwent BPI surgery more than 1 year after the injury. Patients initially treated at smaller hospitals are at risk for undergoing delayed BPI surgery. These findings can inform administrative and policy efforts to expedite timely referral of patients with BPI to experienced centers. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

[Hospital processes and costs in neurology. A study of a referral hospital].

PubMed

Canto-Torán, Esther; Vivas-Consuelo, David; Barrachina-Martinez, Isabel; Escudero-Torrella, Joaquín

2011-11-16

The steady growth of spending on healthcare and the limited availability of resources make it necessary to include cost analysis among the tools used for hospital management. AIMS. To obtain the hospitalisation operating statement of a neurology service and to analyse the differences with regard to costs per process. The study involved an analysis of costs per process in the neurology service of a referral hospital in the Valencian Community (400,000 inhabitants). The data used were those concerning health care activity in 2008 according to the information registered by the Economic Information System of the Valencian Regional Ministry of Health; ABC and top-down methods were applied to calculate the cost per process. The results thus obtained were compared with the fees established for hospital production in the Valencian Regional Government's Law on Fees. For a production of 1092 hospital discharges, with a case-mix index of 0.96 and a mean length of stay of 9.2 days with a case mix of 1.91, hospitalisation costs came to 4,411,643.45 euros, with a mean cost per process of 2,111.46 euros. Taking into account the fees that were applied, the difference between income and expenditure was -12,770.39 euros. The diagnosis-related groups with the greatest difference were numbers 14 (-246,392.49 euros), 533 (-90,292.49 euros) and 15 (-55,139.66 euros). The hospitalisation profit and loss account obtained is negative due to the fact that the mean length of stay in the service is longer than expected, above all in diagnosis-related groups 14, 533 and 15, which are the most inefficient.

Bacterial bloodstream infections in a tertiary infectious diseases hospital in Northern Vietnam: aetiology, drug resistance, and treatment outcome.

PubMed

Dat, Vu Quoc; Vu, Hieu Ngoc; Nguyen The, Hung; Nguyen, Hoa Thi; Hoang, Long Bao; Vu Tien Viet, Dung; Bui, Chi Linh; Van Nguyen, Kinh; Nguyen, Trung Vu; Trinh, Dao Tuyet; Torre, Alessandro; van Doorn, H Rogier; Nadjm, Behzad; Wertheim, Heiman F L

2017-07-12

Bloodstream infections (BSIs) are associated with high morbidity and mortality worldwide. However their aetiology, antimicrobial susceptibilities and associated outcomes differ between developed and developing countries. Systematic data from Vietnam are scarce. Here we present aetiologic data on BSI in adults admitted to a large tertiary referral hospital for infectious diseases in Hanoi, Vietnam. A retrospective study was conducted at the National Hospital for Tropical Diseases between January 2011 and December 2013. Cases of BSI were determined from records in the microbiology department. Case records were obtained where possible and clinical findings, treatment and outcome were recorded. BSI were classified as community acquired if the blood sample was drawn ≤48 h after hospitalization or hospital acquired if >48 h. A total of 738 patients with BSI were included for microbiological analysis. The predominant pathogens were: Klebsiella pneumoniae (17.5%), Escherichia coli (17.3%), Staphylococcus aureus (14.9%), Stenotrophomonas maltophilia (9.6%) and Streptococcus suis (7.6%). The overall proportion of extended spectrum beta-lactamase (ESBL) production among Enterobacteriaceae was 25.1% (67/267 isolates) and of methicillin-resistance in S. aureus (MRSA) 37% (40/108). Clinical data was retrieved for 477 (64.6%) patients; median age was 48 years (IQR 36-60) with 27.7% female. The overall case fatality rate was 28.9% and the highest case fatality was associated with Enterobacteriaceae BSI (34.7%) which accounted for 61.6% of all BSI fatalities. Enterobacteriaceae (predominantly K. pneumoniae and E. coli) are the most common cause of both community and hospital acquired bloodstream infections in a tertiary referral clinic in northern Vietnam.

The geographic distribution of the otolaryngology workforce in the United States.

PubMed

Lango, Miriam N; Handorf, Elizabeth; Arjmand, Ellis

2017-01-01

To describe the deployment of otolaryngologists and evaluate factors associated with the geographic distribution of otolaryngologists in the United States. Cross-sectional study. The otolaryngology physician supply was defined as the number of otolaryngologists per 100,000 in the hospital referral region (HRR). The otolaryngology physician supply was derived from the American Medical Association Masterfile or from the Medicare Enrollment and Provider Utilization Files. Multiple linear regression tested the association of population, physician, and hospital factors on the supply of Medicare-enrolled otolaryngologists/HRR. Two methods of measuring the otolaryngology workforce were moderately correlated across hospital referral regions (Pearson coefficient 0.513, P = .0001); regardless, the supply of otolaryngology providers varies greatly over different geographic regions. Otolaryngologists concentrate in regions with many other physicians, particularly specialist physicians. The otolaryngology supply also increases with regional population income and education levels. Using AMA-derived data, there was no association between the supply of otolaryngologists and staffed acute-care hospital beds and the presence of an otolaryngology residency-training program. In contrast, the supply of otolaryngology providers enrolled in Medicare independently increases for each HRR by 0.8 per 100,000 for each unit increase in supply of hospital beds (P < .0001) and by 0.49 per 100,000 in regions with an otolaryngology residency-training program (P = .006), accounting for all other factors. Irrespective of methodology, the supply of otolaryngologists varies widely across geographic regions in the United States. For Medicare beneficiaries, regional hospital factors-including the presence of an otolaryngology residency program-may improve access to otolaryngology services. NA Laryngoscope, 127:95-101, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

US hospital-based direct access with radiology referral: an administrative case report.

PubMed

Keil, Aaron; Brown, Suzanne Robben

2015-01-01

Legislative gains in the US allow physical therapists to function in expanded scopes of practice including direct access and referral to specialists. The combination of direct access with privileges to order imaging studies directly offers a desirable practice status for many physical therapists, especially in musculoskeletal focused settings. Although direct access is legal in all US jurisdictions, institutional-based physical therapy settings have not embraced these practices. Barriers cited to implementing direct access with advanced practice are concerns over medical and administrative opposition, institutional policies, provider qualifications and reimbursement. This administrative case report describes the process taken to allow therapists to see patients without a referral and to order diagnostic imaging studies at an academic medical center. Nine-month implementation results show 66 patients seen via direct access with 15% referred for imaging studies. Claims submitted to 20 different insurance providers were reimbursed at 100%. While institutional regulations and reimbursement are reported as barriers to direct access, this report highlights the process one academic medical center used to implement direct access and advanced practice radiology referral by updating policies and procedures, identifying advanced competencies and communicating with necessary stakeholder groups. Favorable reimbursement for services is documented.

Kaqchikel midwives, home births, and emergency obstetric referrals in Guatemala: contextualizing the choice to stay at home.

PubMed

Berry, Nicole S

2006-04-01

Maternal mortality is highest in those countries whose health budgets are restricted. Practical strategies employed in the International Safe Motherhood Initiative, therefore, must be both effective and economical. Investing in emergency obstetric care resources has been touted as one such strategy. This investment aims to insure significant improvements are made in regional health centers, and a chain of referral is put into place so that only problem cases are attended by the most skilled health workers. This article examines how this model of referral functions in Sololá, Guatemala, where most Kaqchikel Mayan women give birth at home with a traditional midwife, and no skilled biomedical attendant is available at the birth to make a referral. Ethnographic data is used to explore reasons why women do not go to the hospital at the first sign of difficulty. I argue that the problem frequently is not that Mayan midwives, their clients and families fail to understand the biomedical information about dangers in birth, but rather that this information fails to fit into an already existing social system of understanding birth and birth-related knowledge.

Barriers and Motivators for Referral of Patients with Suspected Lynch Syndrome to Cancer Genetic Services: A Qualitative Study

PubMed Central

Tan, Yen Y.; Fitzgerald, Lisa J.

2014-01-01

This article explores the views of general practitioners and specialists on their referral of patients with suspected Lynch syndrome to cancer genetic services. Using a purposive maximum variation sampling strategy, we conducted semi-structured interviews face-to-face with 28 general practitioners and specialists in public or private hospitals and specialist clinics between March and August 2011. General practitioners and specialists were recruited in a major metropolitan area in Australia. Interview transcripts were reviewed by two independent researchers, and thematic analysis was performed using NVivo10 software. The main barriers and motivators identified were: (1) clinician-related (e.g., familiarity with Lynch syndrome and family history knowledge); (2) patient-related (e.g., patients’ interests and personal experience with cancer); and (3) organizational-related (e.g., access to services, guidelines and referral pathway). Referral of patients with suspected Lynch syndrome to cancer genetic services is motivated and hindered by a range of individual, interpersonal and organizational factors. In order to improve the care and quality of life of patients and family with suspected Lynch syndrome, further research is needed to develop supportive tools for clinicians. PMID:25562140

Psychiatric referral and glycemic control of Egyptian type 2 diabetes mellitus patients with depression.

PubMed

Fawzi, Mounir H; Said, Nagwa S; Fawzi, Maggie M; Kira, Ibrahim A; Fawzi, Mohab M; Abdel-Moety, Hanaa

2016-01-01

To evaluate the relationship between psychiatric referral acceptance for fluoxetine treatment and glycemic control in type 2 diabetes mellitus (T2DM) Egyptian patients with depression. Patients with T2DM who attended the diabetes outpatients clinic at Zagazig University Hospital, Egypt, between May 2013 and April 2015 and who scored ≥20 on screening with the Major Depression Inventory (MDI) (n=196) were offered a psychiatric referral for fluoxetine treatment and monitoring. Decliners (56.1%) received time/attention matched care via diabetologist visits (attentional controls). Fluoxetine patients and controls were compared at the time of the offer (T1) and 8weeks later (T2). Factors that significantly correlated with glycemic control were used in a linear regression analysis as the independent variables. Eighty-six patients (43.9%) accepted psychiatric referral. Most of them (97.7%) remained throughout the study adherent to fluoxetine (mean daily dose=31.9mg). At T2, these patients, in comparison to controls, showed a reduction from baseline in MDI, fasting plasma glucose and glycosylated hemoglobin (HbA1c) levels (P for all comparisons <.001). In the final model of a regression analysis, 65.9% of the variation in percentage change in HbA1c was explained by adherence to antidiabetics, psychiatric referral acceptance and Internalized Stigma of Mental Illness (ISMI) and MDI scores. In T2DM patients with depression, psychiatric referral acceptance for fluoxetine treatment is a significant predictor of both depression and glycemic control improvements. Copyright © 2016 Elsevier Inc. All rights reserved.

Reductions in emergency department visits after primary healthcare use of the UK National Poisons Information Service.

PubMed

Elamin, Muhammad E M O; James, David A; Holmes, Peter; Jackson, Gillian; Thompson, John P; Sandilands, Euan A; Bradberry, Sally; Thomas, Simon H L

2018-05-01

Suspected poisoning is a common cause of hospital admission internationally. In the United Kingdom, the National Poisons Information Service (NPIS), a network of four poisons units, provides specialist advice to health professionals on the management of poisoning by telephone and via its online poisoning information and management database, TOXBASE ® . To demonstrate the impact of NPIS telephone advice and TOXBASE ® guidance on poisoning-related referrals to emergency departments (ED) from primary healthcare settings. A telephone survey of primary healthcare providers calling the NPIS and an online survey of TOXBASE ® primary care users were conducted to evaluate the effect of these services on poisoning-related ED referrals. Enquirers were asked to indicate whether referral was needed before and after using these information sources. The number of cases considered by enquirers appropriate for ED referral was reduced from 1178 (58.1%) before to 819 (40.4%) after the provision of telephone advice for 2028 cases (absolute reduction 17.7%, 95% CI 14.6, 20.7%) and from 410 (48.2%) before to 341 (40.1%) after consideration of TOXBASE ® guidance for 851 cases (absolute reduction 8.1%, 95% CI 3.3, 12.9%). By extrapolating these figures over a full year, it is estimated that these services prevent approximately 41,000 ED referrals annually. The use of NPIS services significantly reduced ED referrals from primary healthcare services with resulting avoided healthcare costs exceeding the current annual NPIS budget. Further studies are needed to evaluate other potential benefits of accessing NPIS services.

Children’s Hospital of Pittsburgh and Diabetes Institute of the Walter Reed Health Care System Genetic Screening in Diabetes: Candidate Gene Analysis for Diabetic Retinopathy

DTIC Science & Technology

2008-05-22

available and consents to be in the study. • In addition to referrals from Diabetes Institute nurse practitioners, endocrinologists, and diabetes ...coronary artery disease in juvenile - onset, insulin dependent diabetes mellitus. Am J Cardiol. 59:750-755, 1987a. Krolewski AS, Warram JH, Rand LI...1-0313 TITLE: Children’s Hospital of Pittsburgh and Diabetes Institute of the Walter Reed Health Care System Genetic Screening in

First outbreak of linezolid-resistant vancomycin-resistant Enterococcus faecium in an Irish hospital, February to September 2014.

PubMed

O'Driscoll, C; Murphy, V; Doyle, O; Wrenn, C; Flynn, A; O'Flaherty, N; Fenelon, L E; Schaffer, K; FitzGerald, S F

2015-12-01

An outbreak of linezolid-resistant vancomycin-resistant Enterococcus faecium (LRVREfm) occurred in the hepatology ward of a tertiary referral hospital in Ireland between February and September 2014. LRVREfm was isolated from 15 patients; pulsed-field gel electrophoresis confirmed spread of a single clone. This is the first report of an outbreak of linezolid-resistant vancomycin-resistant enterococcus in Ireland. Copyright © 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Transmission of methicillin-resistant Staphylococcus aureus in long-term care facilities and their related healthcare networks.

PubMed

Harrison, Ewan M; Ludden, Catherine; Brodrick, Hayley J; Blane, Beth; Brennan, Gráinne; Morris, Dearbháile; Coll, Francesc; Reuter, Sandra; Brown, Nicholas M; Holmes, Mark A; O'Connell, Brian; Parkhill, Julian; Török, M Estee; Cormican, Martin; Peacock, Sharon J

2016-10-03

Long-term care facilities (LTCF) are potential reservoirs for methicillin-resistant Staphylococcus aureus (MRSA), control of which may reduce MRSA transmission and infection elsewhere in the healthcare system. Whole-genome sequencing (WGS) has been used successfully to understand MRSA epidemiology and transmission in hospitals and has the potential to identify transmission between these and LTCF. Two prospective observational studies of MRSA carriage were conducted in LTCF in England and Ireland. MRSA isolates were whole-genome sequenced and analyzed using established methods. Genomic data were available for MRSA isolated in the local healthcare systems (isolates submitted by hospitals and general practitioners). We sequenced a total of 181 MRSA isolates from the two study sites. The majority of MRSA were multilocus sequence type (ST)22. WGS identified one likely transmission event between residents in the English LTCF and three putative transmission events in the Irish LTCF. WGS also identified closely related isolates present in colonized Irish residents and their immediate environment. Based on phylogenetic reconstruction, closely related MRSA clades were identified between the LTCF and their healthcare referral network, together with putative MRSA acquisition by LTCF residents during hospital admission. These data confirm that MRSA is transmitted between residents of LTCF and is both acquired and transmitted to others in referral hospitals and beyond. Our data present compelling evidence for the importance of environmental contamination in MRSA transmission, reinforcing the importance of environmental cleaning. The use of WGS in this study highlights the need to consider infection control in hospitals and community healthcare facilities as a continuum.

Association of hospice utilization and publicly reported outcomes following hospitalization for pneumonia or heart failure: a retrospective cohort study.

PubMed

Lah, Soowhan; Wilson, Emily L; Beesley, Sarah; Sagy, Iftach; Orme, James; Novack, Victor; Brown, Samuel M

2018-01-09

The Center for Medicare and Medicaid Services (CMS) and the Hospital Quality Alliance began collecting and reporting United States hospital performance in the treatment of pneumonia and heart failure in 2008. Whether the utilization of hospice might affect CMS-reported mortality and readmission rates is not known. Hospice utilization (mean days on hospice per decedent) for 2012 from the Dartmouth Atlas (a project of the Dartmouth Institute that reports a variety of public health and policy-related statistics) was merged with hospital-level 30-day mortality and readmission rates for pneumonia and heart failure from CMS. The association between hospice use and outcomes was analyzed with multivariate quantile regression controlling for quality of care metrics, acute care bed availability, regional variability and other measures. 2196 hospitals reported data to both CMS and the Dartmouth Atlas in 2012. Higher rates of hospice utilization were associated with lower rates of 30-day mortality and readmission for pneumonia but not for heart failure. Higher quality of care was associated with lower rates of mortality for both pneumonia and heart failure. Greater acute care bed availability was associated with increased readmission rates for both conditions (p < 0.05 for all). Higher rates of hospice utilization were associated with lower rates of 30-day mortality and readmission for pneumonia as reported by CMS. While causality is not established, it is possible that hospice referrals might directly affect CMS outcome metrics. Further clarification of the relationship between hospice referral patterns and publicly reported CMS outcomes appears warranted.

'Opt-out' referrals after identifying pregnant smokers using exhaled air carbon monoxide: impact on engagement with smoking cessation support.

PubMed

Campbell, Katarzyna A; Cooper, Sue; Fahy, Samantha J; Bowker, Katharine; Leonardi-Bee, Jo; McEwen, Andy; Whitemore, Rachel; Coleman, Tim

2017-05-01

In the UK, free smoking cessation support is available to pregnant women; only a minority accesses this. 'Opt-out' referrals to stop smoking services (SSS) are recommended by UK guidelines. These involve identifying pregnant smokers using exhaled carbon monoxide (CO) and referring them for support unless they object. To assess the impact of 'opt-out' referrals for pregnant smokers on SSS uptake and effectiveness, we conducted a 'before-after' service development evaluation. In the 6-month 'before' period, there was a routine 'opt-in' referral system for self-reported smokers at antenatal 'booking' appointments. In the 6-month 'after' period, additional 'opt-out' referrals were introduced at the 12-week ultrasound appointments; women with CO≥4 ppm were referred to, and outcome data were collected from, local SSS. Approximately 2300 women attended antenatal care in each period. Before the implementation, 536 (23.4%) women reported smoking at 'booking' and 290 (12.7%) were referred to SSS. After the implementation, 524 (22.9%) women reported smoking at 'booking', an additional 156 smokers (6.8%) were identified via the 'opt-out' referrals and, in total, 421 (18.4%) were referred to SSS. Over twice as many women set a quit date with the SSS after 'opt-out' referrals were implemented (121 (5.3%, 95% CI 4.4% to 6.3%) compared to 57 (2.5%, 95% CI 1.9% to 3.2%) before implementation) and reported being abstinent 4 weeks later (93 (4.1%, 95% CI 3.3% to 4.9%) compared to 46 (2.0%, 1.5% to 2.7%) before implementation). In a hospital with an 'opt-in' referral system, adding CO screening with 'opt-out' referrals as women attended ultrasound examinations doubled the numbers of pregnant smokers setting quit dates and reporting smoking cessation. 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/.

Outcome of Chronic Kidney Disease Patients on the Basis of Referral to Nephrologist: A One-Year Follow-up Study.

PubMed

Anees, Muhammad; Hussain, Yasir; Ibrahim, Muhammad; Ilahi, Irfan; Ahmad, Sajjad; Asif, Khushbakht Isma; Jameel, Amina

2018-04-01

To determine the outcome of chronic kidney disease (CKD) patients presenting for dialysis on the basis of referral to nephrologist. Observational study. Nephrology Department of King Edward Medical University/Mayo Hospital, Lahore, from January 2014 to January 2016. All patients who were presented in nephrology outpatients department and with the indication of dialysis were included in study. Patients who refused dialysis, and with acute kidney failure were excluded from the study. Proforma was designed for demographics, vital signs, volume status, and laboratory data (hemoglobin, urea, creatinine, albumin, bicarbonate etc.) of all the patients. On the basis of referral, patients were divided into two groups, i.e. early referral and late referral. Early referrals were those patients who were referred to a nephrologist more than three months before dialysis initiation. Late referrals were those patients who were referred to a nephrologist less than three months before dialysis initiation. Patients were followed up at one, three, six, and 12 months for outcome, i.e. still on dialysis or died. One hundred and seventy-six patients were enrolled in the study, and 141 were followed up to one year. Seventy- two (51.1%) patients were male, 69 (48.9%) were female and most (n=69, 48.9%) were in the middle age group. Major causes of end-stage renal disease (ESRD) were hypertension 70 (49.6%) and diabetes mellitus 66 (46.8%). Seventy-six (53.9%) patients were in fluid overload and acidotic (n=123, 87.2%). Twenty-seven (19.1%) patients were referred early and 114 (80.9%) were referred late. Overall mortality was 78 (55.3%) at one year. Factors affecting mortality were financial status and metabolic acidosis, but not referral. Temporary access for hemodialysis has 1.38 times more risk for mortality than the patients with permanent access. There is no difference on the outcome of dialysis patients on the basis referral to nephrologist. Factors affecting overall mortality in both groups were financial status, metabolic acidosis, and temporary access for dialysis. Most of the patients were referred late to the nephrologists.

Coronary arteriography in a district general hospital: feasibility, safety, and diagnostic accuracy.

PubMed Central

Ranjadayalan, K; Mills, P G; Sprigings, D C; Mourad, K; Magee, P; Timmis, A D

1990-01-01

OBJECTIVE--To determine the feasibility, safety, and diagnostic accuracy of coronary arteriography in the radiology department of a district general hospital using conventional fluoroscopy and videotape recording. DESIGN--Observational study of the feasibility and safety of coronary arteriography in a district general hospital and analysis of its diagnostic accuracy by prospective within patient comparison of the video recordings with cinearteriograms obtained in a catheter laboratory. SETTING--Radiology department of a district general hospital and the catheter laboratory of a cardiological referral centre. SUBJECTS--50 Patients with acute myocardial infarction treated with streptokinase who underwent coronary arteriography in a district general hospital three (two to five) days after admission. 45 Of these patients had repeat coronary arteriography after four (three to seven) days in the catheter laboratory of a cardiological referral centre. MAIN OUTCOME MEASURES--Incidence of complications associated with catheterisation and the sensitivity and specificity of video recordings in the district general hospital (judged by two experienced observers) for identifying the location and severity of coronary stenoses. RESULTS--Coronary arteriograms recorded on videotape in the district general hospital were obtained in 47 cases and apart from one episode of ventricular fibrilation (treated successfully by cardioversion) there were no complications of the procedure. 45 Patients were transferred for investigation in the catheter laboratory, providing 45 paired coronary arteriograms recorded on videotape and cine film. The specificity of the video recordings for identifying the location and severity of coronary stenoses was over 90%. Sensitivity, however, was lower and for one observer fell below 40% for lesions in the circumflex artery. A cardiothoracic surgeon judged that only nine of the 47 video recordings were adequate for assessing revascularisation requirements. CONCLUSIONS--Coronary arteriography in the radiology department of a district general hospital is safe and feasible. Nevertheless, the quality of image with conventional fluoroscopy and video film is inadequate and will need to be improved before coronary arteriography in this setting can be recommended. PMID:2182164

Perinatal regionalization versus hospital competition: the Hartford example.

PubMed

Richardson, D K; Reed, K; Cutler, J C; Boardman, R C; Goodman, K; Moynihan, T; Driscoll, J; Raye, J R

1995-09-01

The increasingly competitive health care environment may undermine effective traditional regional organizations. It is urgent to document the benefits of perinatal regionalization for the emerging health care system. We present a case study that illustrates many of the challenges to and benefits of perinatal regionalization in the 1990s. The controversy in Hartford was sparked by a proposed merger of two major pediatric services into a full-service children's hospital. Community hospitals reacted with plans to upgrade their obstetrics/neonatal facilities toward level II (intermediate) or II+ (intensive) neonatal intensive care units (NICUs). The fear that unrestricted competition would drive up overall health care costs prompted the hospital association and Chamber of Commerce to retain consultants to evaluate the number and location of regional NICU beds. The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges. The existing system worked remarkably well for clinical care, training, referrals, and provider and patient satisfaction. There was a high level of inter-hospital collaboration and regional leadership in obstetrics and pediatrics, but strong and growing competition between their hospitals. Hospital administrators enumerated the competitive threats that obligated them to compete and the financial disincentives to support the regional structures. Business leaders and insurance executives emphasized the need to control costs. Analysis of discharge data showed marginal adequacy of NICU beds but maldistribution between NICUs, particularly between level III and level II units. The consultants recommended no new beds based on population projections, declining lengths of stay nationally, and substantial gains available from aggressive back-transport of convalescing infants. The consultants emphasized the need for all stakeholders to support the regional infrastructure (referral, transport, education, evaluation, quality assurance) and to modify competition when it impaired effective regionalization. Regionalization permits better care at lower cost, yet competition may disrupt this effective system. Active cooperation by stakeholders is vital. Substantial new research is required to define optimal regional organization.

Outreach: the western New York Hospital Library Services Program, 1985-1989.

PubMed Central

Birkinbine, L A; Bertuca, C A

1991-01-01

The Hospital Library Services Program (HLSP) in western New York, during the period covered by its first five-year plan, 1984-1989, is recounted and described. This ongoing program is funded annually by a New York State grant and hospital participation fees. It is designed to support access to biomedical information for health care professionals through a grant program for hospitals with staffed libraries and a circuit program for hospitals without library staffing or without libraries. Hospitals participating in the grant program contribute funds and receive grants for collection development. Hospitals participating in the circuit program pay a participation fee and receive regularly scheduled, documented, circuit librarian visits; a collection development grant; and a grant for contract library services. The program contracts with the State University of New York at Buffalo's (UB) Health Sciences Library to provide computerized literature searches; interlibrary loan (ILL) of journal articles, books, and audiovisuals; and ILL referrals. PMID:1958912

Hospital competition and financial performance: the effects of ambulatory surgery centers.

PubMed

Carey, Kathleen; Burgess, James F; Young, Gary J

2011-05-01

Ambulatory surgery centers (ASCs), limited-service alternatives for treating surgery patients not requiring an overnight stay, are a health-care service innovation that has proliferated in the U.S. and other countries in recent years. This paper examines the effects of ASC competition on revenues, costs, and profit margins of hospitals that also provided these services as a subset of their general services in Arizona, California, and Texas during the period 1997-2004. We identified all ASCs operating during the period in the 49 Dartmouth Hospital Referral Regions in the three states. The results of fixed effects models suggested that ASCs are meaningful competitors to general hospitals. We found downward pressure on revenues, costs, and profits in general hospitals associated with ASC presence. Copyright © 2010 John Wiley & Sons, Ltd.

Effects of Prospective Payment Financing on Rehabilitation Income.

ERIC Educational Resources Information Center

Evans, Ron L.; And Others

1990-01-01

This study compared 187 patients discharged from a Veterans Administration hospital rehabilitation unit with 215 discharges that occurred following implementation of a prospective payment system. There were no significant differences in demographics, self-care ability, or readmissions. Length of stay and referrals for home health care decreased,…

Impact of specialist home-based palliative care services in a tertiary oncology set up: a prospective non-randomized observational study.

PubMed

Dhiliwal, Sunil R; Muckaden, Maryann

2015-01-01

Home-based specialist palliative care services are developed to meet the needs of the patients in advanced stage of cancer at home with physical symptoms and distress. Specialist home care services are intended to improve symptom control and quality of life, enable patients to stay at home, and avoid unnecessary hospital admission. Total 690 new cases registered under home-based palliative care service in the year 2012 were prospectively studied to assess the impact of specialist home-based services using Edmonton symptom assessment scale (ESAS) and other parameters. Out of the 690 registered cases, 506 patients received home-based palliative care. 50.98% patients were cared for at home, 28.85% patients needed hospice referral and 20.15% patients needed brief period of hospitalization. All patients receiving specialist home care had good relief of physical symptoms (P < 0.005). 83.2% patients received out of hours care (OOH) through liaising with local general practitioners; 42.68% received home based bereavement care and 91.66% had good bereavement outcomes. Specialist home-based palliative care improved symptom control, health-related communication and psychosocial support. It promoted increased number of home-based death, appropriate and early hospice referral, and averted needless hospitalization. It improved bereavement outcomes, and caregiver satisfaction.

Family practice obstetrics in a teaching hospital. Does a tertiary care environment make a difference?

PubMed Central

Jordan, J. M.; Gaspar, D.

1995-01-01

OBJECTIVE: To determine referral rates, to study the nature of consultations with obstetricians, and to examine how both patient and physician characteristics affect referrals. DESIGN: Case series. Retrospective review of hospital records. SETTING: Victoria Hospital, a tertiary care centre affiliated with the University of Western Ontario in London, Ont. PARTICIPANTS: Five hundred forty-two women admitted consecutively for delivery under the care of family physicians from October 1, 1990, to September 31, 1991. OUTCOME MEASURE: The number and types of obstetrical consultations obtained for the study population. RESULTS: Of the 50.7% of cases requiring consultation, half were delivered by obstetricians. The most common reasons for consultation were failure to progress in labour, induction of labour, posterior presentation, fetal distress, and pregnancy-induced hypertension. The most common reasons for obstetricians to attend delivery were to perform forceps rotations and cesarean sections. CONCLUSIONS: Parity and risk classification were the two most important factors for predicting whether consultation would occur. The high rate of consultation in this study might relate to ease of access to consultation in a tertiary care environment. More study is needed to examine the reasons for consultation because it seems that some of the situations for which obstetricians were consulted could have been safely managed by family physicians. PMID:7787491

Mild cognitive impairment: Profile of a cohort from a private sector memory clinic.

PubMed

Srinivasan, Srikanth

2014-07-01

Private hospital memory clinics might see a different clientele than university or academic institutes due to referral biases. To characterize the profile of patients with mild cognitive impairment (MCI) from a private sector memory clinic. MCI was diagnosed according to revised clinical criteria of Petersen et al. For a subset of patients with MCI medial temporal atrophy and cerebral small vessel disease (white matter lesions and lacunes) were rated on magnetic resonance imaging (MRI) scans and analyzed for their contribution towards cognitive impairment. Subjects with MCI formed one-third (113/371) of this memory clinic sample from a private hospital. MCI could be effectively diagnosed and subtyped using a brief cognitive scale (Concise Cognitive Test (CONCOG)). The amnestic MCI (single and multiple domains) subtype comprised the majority of cases with MCI. In a subsample of 33 patients, lacunar infarcts were more common than white matter lesions and hippocampal atrophy and were inversely associated with verbal fluency. MCI may be more commonly encountered in private hospital settings probably due to early referrals. It is possible to diagnose and subtype MCI using a brief cognitive instrument such as the CONCOG. In this sample, lacunar infarcts were more commonly encountered than medial temporal atrophy in such patients.

Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors.

PubMed

Mahmood, Mohammad Afzal; Mufidah, Ismi; Scroggs, Steven; Siddiqui, Amna Rehana; Raheel, Hafsa; Wibdarminto, Koentijo; Dirgantoro, Bernardus; Vercruyssen, Jorien; Wahabi, Hayfaa A

2018-01-01

Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.

Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors

PubMed Central

Mufidah, Ismi; Scroggs, Steven; Siddiqui, Amna Rehana; Raheel, Hafsa; Wibdarminto, Koentijo; Dirgantoro, Bernardus; Vercruyssen, Jorien

2018-01-01

Background Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Method Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. Findings The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. Conclusion There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped. PMID:29682538

Psychosocial and nonclinical factors predicting hospital utilization in patients of a chronic disease management program: a prospective observational study.

PubMed

Tran, Mark W; Weiland, Tracey J; Phillips, Georgina A

2015-01-01

Psychosocial factors such as marital status (odds ratio, 3.52; 95% confidence interval, 1.43-8.69; P = .006) and nonclinical factors such as outpatient nonattendances (odds ratio, 2.52; 95% confidence interval, 1.22-5.23; P = .013) and referrals made (odds ratio, 1.20; 95% confidence interval, 1.06-1.35; P = .003) predict hospital utilization for patients in a chronic disease management program. Along with optimizing patients' clinical condition by prescribed medical guidelines and supporting patient self-management, addressing psychosocial and nonclinical issues are important in attempting to avoid hospital utilization for people with chronic illnesses.

Is there a (volunteer) doctor in the house? Free clinics and volunteer physician referral networks in the United States.

PubMed

Isaacs, Stephen L; Jellinek, Paul

2007-01-01

Although community health centers and public hospitals are the most visible safety-net providers, physicians in private practice are the main source of care for the uninsured and Medicaid enrollees. Yet the number of these physicians providing free care is declining, even as the need for their services increases. One promising strategy for halting the decline is to strengthen and increase volunteer health care programs: free clinics and physician-referral networks. This report reviews the state of these programs and suggests ways to improve them. Given the limits of volunteerism, the authors conclude that only national health insurance will solve the problem of the uninsured.

A cross sectional study of maternal 'near-miss' cases in major public hospitals in Egypt, Lebanon, Palestine and Syria.

PubMed

Bashour, Hyam; Saad-Haddad, Ghada; DeJong, Jocelyn; Ramadan, Mohammed Cherine; Hassan, Sahar; Breebaart, Miral; Wick, Laura; Hassanein, Nevine; Kharouf, Mayada

2015-11-13

The maternal near-miss approach has been increasingly used as a tool to evaluate and improve the quality of care in maternal health. We report findings from the formative stage of a World Health Organization (WHO) funded implementation research study that was undertaken to collect primary data at the facility level on the prevalence, characteristics, and management of maternal near-miss cases in four major public referral hospitals - one each in Egypt, Lebanon, Palestine and Syria. We conducted a cross sectional study of maternal near-miss cases in the four contexts beginning in 2011, where we collected data on severe maternal morbidity in the four study hospitals, using the WHO form (Individual Form HRP A65661). In each hospital, a research team including trained hospital healthcare providers carried out the data collection. A total of 9,063 live birth deliveries were reported during the data collection period across the four settings, with a total of 77 cases of severe maternal outcomes (71 maternal near-miss cases and 6 maternal deaths). Higher indices for the maternal mortality index were found in both Al Galaa hospital, in Egypt (8.6%) and Dar Al Tawleed hospital in Syria (14.3%), being large referral hospitals, compared to Ramallah hospital in Palestine and Rafik Hariri University hospital in Lebanon. Compared to the WHO's Multicountry Survey using the same data collection tool, our study's mortality indices are higher than the index of 5.6% among countries with a moderate maternal mortality ratio in the WHO Survey. Overall, haemorrhage-related complications were the most frequent conditions among maternal near-miss cases across the four study hospitals. In all hospitals, coagulation dysfunctions (76.1%) were the most prevalent dysfunction among maternal near-miss cases, followed by cardiovascular dysfunctions. The coverage of key evidence-based interventions among women experiencing a near-miss was either universal or very high in the study hospitals. Findings from this formative stage confirmed the need for quality improvement interventions. The high reported coverage of the main clinical interventions in the study hospitals would appear to be in contradiction with the above findings as the level of coverage of key evidence-based interventions was high.

A treatment-oriented typology of self-identified hypersexuality referrals.

PubMed

Cantor, James M; Klein, Carolin; Lykins, Amy; Rullo, Jordan E; Thaler, Lea; Walling, Bobbi R

2013-07-01

Men and women have been seeking professional assistance to help control hypersexual urges and behaviors since the nineteenth century. Despite that the literature emphasizes that cases of hypersexuality are highly diverse with regard to clinical presentation and comorbid features, the major models for understanding and treating hypersexuality employ a "one size fits all" approach. That is, rather than identify which problematic behaviors might respond best to which interventions, existing approaches presume or assert without evidence that all cases of hypersexuality (however termed or defined) represent the same underlying problem and merit the same approach to intervention. The present article instead provides a typology of hypersexuality referrals that links individual clinical profiles or symptom clusters to individual treatment suggestions. Case vignettes are provided to illustrate the most common profiles of hypersexuality referral that presented to a large, hospital-based sexual behaviors clinic, including: (1) Paraphilic Hypersexuality, (2) Avoidant Masturbation, (3) Chronic Adultery, (4) Sexual Guilt, (5) the Designated Patient, and (6) better accounted for as a symptom of another condition.

Diagnosing and managing anorexia nervosa in UK primary care: a focus group study.

PubMed

Hunt, D; Churchill, R

2013-08-01

Anorexia is a leading cause of adolescent hospital admission and death from psychiatric disorder. Despite the potential role of general practitioners in diagnosis, appropriate referral and coordinating treatment, few existing studies provide fine-grained accounts of GPs' beliefs about anorexia. To identify GPs' understandings and experiences of diagnosing and managing patients with anorexia in primary care. Case-based focus groups with co-working general practitioners in the East Midlands region of England were used to explore attitudes towards issues common to patients with eating disorders. Group discussions were transcribed and analysed using corpus linguistic and discourse analytic approaches. Participants' discussion focused on related issues of making hesitant diagnoses, the utility of the body mass index, making referrals and overcoming patient resistance. Therapeutic relationships with patients with anorexia are considered highly complex, with participants using diagnostic tests as rhetorical strategies to help manage communicative obstacles. Overcoming patient repudiation and securing referrals are particular challenges with this patient group. Successfully negotiating these problems appears to require advanced communication skills.

Colonization of newly arrived house staff by virulent staphylococcal phage types endemic to a hospital environment.

PubMed Central

Ballou, W R; Cross, A S; Williams, D Y; Keiser, J; Zierdt, C H

1986-01-01

The acquisition of hospital strains of Staphylococcus aureus by new house officers was studied in an 800-bed referral hospital over a 1-year period. S. aureus isolates, including three strains with characteristic phage patterns that had previously been documented to cause disease in patients and colonize hospital personnel, were recovered from the anterior nares of 35 of 54 newly arrived house officers. There was a significant correlation (r = 0.7475; P less than 0.02) between colonization with the dominant hospital strain (S) and exposure to the hospital environment over 12 months. No hospital-wide increase in infections owing to the S strain was seen during this period, which suggests that house staff acquired this strain from reservoirs within the hospital. The finding of colonization with virulent endemic S. aureus strains in house officers working on every ward of the hospital suggests that new strategies for control of S. aureus nosocomial infections must be considered and evaluated. PMID:3711293

Healthcare provider and patient perspectives on diagnostic imaging investigations.

PubMed

Makanjee, Chandra R; Bergh, Anne-Marie; Hoffmann, Willem A

2015-05-20

Much has been written about the patient-centred approach in doctor-patient consultations. Little is known about interactions and communication processes regarding healthcare providers' and patients' perspectives on expectations and experiences of diagnostic imaging investigations within the medical encounter. Patients journey through the health system from the point of referral to the imaging investigation itself and then to the post-imaging consultation. AIM AND SETTING: To explore healthcare provider and patient perspectives on interaction and communication processes during diagnostic imaging investigations as part of their clinical journey through a healthcare complex. A qualitative study was conducted, with two phases of data collection. Twenty-four patients were conveniently selected at a public district hospital complex and were followed throughout their journey in the hospital system, from admission to discharge. The second phase entailed focus group interviews conducted with providers in the district hospital and adjacent academic hospital (medical officers and family physicians, nurses, radiographers, radiology consultants and registrars). Two main themes guided our analysis: (1) provider perspectives; and (2) patient dispositions and reactions. Golden threads that cut across these themes are interactions and communication processes in the context of expectations, experiences of the imaging investigations and the outcomes thereof. Insights from this study provide a better understanding of the complexity of the processes and interactions between providers and patients during the imaging investigations conducted as part of their clinical pathway. The interactions and communication processes are provider-patient centred when a referral for a diagnostic imaging investigation is included.

Emergence of community-acquired methicillin-resistant Staphylococcus aureus in an Iranian referral paediatric hospital.

PubMed

Mamishi, S; Mahmoudi, S; Bahador, A; Matini, H; Movahedi, Z; Sadeghi, R H; Pourakbari, B

2015-01-01

The epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals has been changed in recent years due to the arrival of community-associated MRSA (CA-MRSA) strains into healthcare settings. The aim of this study is to investigate the distribution of staphylococcal cassette chromosome mec (SCCmec) type V as well as SCCmec IV subtypes, which have been associated with community-acquired infection among healthcare-associated MRSA (HA-MRSA) isolates. Antimicrobial susceptibility, SCCmec type, spa type and the presence of Panton-Valentine leukocidin (PVL) genes were determined for all HA-MRSA isolates in an Iranian referral hospital. In this study of 48 HA-MRSA isolates, 13 (27%), three (6.2%), five (10.4%) and one (2%) belonged to SCCmec subtypes IVa, IVb, IVc and IVd, respectively. Only two isolates (4.2%) belonged to SCCmec types V Notably, one isolate was found to harbour concurrent SCCmec subtypes IVb and IVd. MRSA containing SCCmec subtype IVb, IVc and IVd as well as type V isolates were all susceptible to chloramphenicol, clindamycin and rifampicin, while the sensitivity to these antibiotics was lower among MRSA containing SCCmec subtype IVa. The most frequently observed spa ttype was t037, accounting for 88% (22/25). Three other spa type was t002, t1816 and t4478. Large reservoirs of MRSA containing type IV subtypes and type V now exist in patients in this Iranian hospital. Therefore, effective infection control management in order to control the spread of CA-MRSA is highly recommended.

Emergency department usage by community step-down facilities--patterns and recommendations.

PubMed

Lee, S W; Goh, C; Chan, Y H

2003-09-01

This study examines the interface between institutional community step-down facilities (CSDFs) and acute hospital's Emergency Department (ED). It also provides a comprehensive description of the usage of an ED's services by CSDFs in its vicinity. This is a prospective 12-week observational study conducted in the Accident and Emergency Department of Changi General Hospital in Singapore. All patients from CSDFs transferred to the department were eligible for the study. Hospital records were used to extract relevant clinical data after admission for the length of stay and final discharge diagnosis. There was a total of 201 referrals to the ED over the 3-month period. The age of the patients ranged from 32 to 107 years, with a median of 83 years. Ninety-two patients (45.8%) were male residents. There were more referrals from CSDF on weekdays than on weekends. In particular, the number of referrals from CSDFs on Mondays were significantly higher (P < 0.05, Poisson regression) than other days of the week. Fifty-one per cent of the ED visits occurred during regular working hours. Eighty-two per cent of the transfers were admitted. The main complaint was shortness of breath with cough, followed by fever and falls. The most common investigation ordered was chest radiograph, followed by electrocardiogram and other radiographs. The most common treatment procedure in the ED was placement of an intravenous line. For those admitted residents, average length of hospital stay was 8.27 +/- 8.19 days (median, 5 days). Seventeen patients (10.3%) died within 3 days of admission, while 31 patients (18.8%) stayed less than 3 days. The admitted residents had an average turnaround time (from time of registration to time of leaving the ED and proceeding to ward) of 97.94 minutes. For patients discharged from the ED, the average turnaround time (time from registration to time of leaving the ED) was 177 minutes. Residents from CSDFs are transferred to the ED for a variety of medical reasons. The most appropriate role of the ED in evaluation of residents of CSDFs is not yet clearly defined. There is increasing need to streamline processes in acute hospitals to cope with an increasing ageing population and to ensure that quality care is delivered to the institutionalised sick.

Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study

PubMed Central

Eastwood, Kathryn; Smith, Karen; Morgans, Amee; Stoelwinder, Johannes

2017-01-01

Objective To investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary telephone triage. Design A pragmatic retrospective cohort analysis of all the planned and unplanned ED presentations within 48 hours of a secondary telephone triage. Setting The secondary telephone triage service, called the Referral Service, and the hospitals were located in metropolitan Melbourne, Australia and operated 24 hours a day, servicing 4.25 million people. The Referral Service provides an in-depth secondary triage of cases classified as low acuity when calling the Australian emergency telephone number. Population Cases triaged by the Referral Service between September 2009 and June 2012 were linked to ED and hospital admission records (N=44,523). Planned ED presentations were cases referred to the ED following the secondary triage, unplanned ED presentations were cases that presented despite being referred to alternative care pathways. Main outcome measures Appropriateness was measured using an ED suitability definition and hospital admission rates. These were compared with mean population data which consisted of all of the ED presentations for the state (termed the ‘average Victorian ED presentation’). Results Planned ED presentations were more likely to be ED suitable than unplanned ED presentations (OR 1.62; 95% CI 1.5 to 1.7; p<0.001) and the average Victorian ED presentation (OR 1.85; 95% CI 1.01 to 3.4; p=0.046). They were also more likely to be admitted to the hospital than the unplanned ED presentation (OR 1.5; 95% CI 1.4 to 1.6; p<0.001) and the average Victorian ED presentation (OR 2.3, 95% CI 2.24 to 2.33; p<0.001). Just under 15% of cases diverted away from the emergency care pathways presented in the ED (unplanned ED attendances), and 9.5% of all the alternative care pathway cases were classified as ED suitable and 6.5% were admitted to hospital. Conclusions Secondary telephone triage was able to appropriately identify many ED suitable cases, and while most cases referred to alternative care pathways did not present in the ED. Further research is required to establish that these were not inappropriately triaged away from the emergency care pathways. PMID:29038180

Silence of male child sexual abuse in India: Qualitative analysis of barriers for seeking psychiatric help in a multidisciplinary unit in a general hospital

PubMed Central

Subramaniyan, Vyjayanthi Kanugodu Srinivasa; Reddy, Praveen; Chandra, Girish; Rao, Chandrika; Rao, T. S. Sathyanarayana

2017-01-01

Introduction: In 2007, Ministry of Women and Child Welfare, supported by United Nations Children's Fund, save the children and Prayas conducted a study to understand the magnitude of child abuse in India, they found that 53.22% children faced one or more forms of sexual abuse; among them, the number of boys abused was 52.94%. Aim: The aim of this study was to explore the barriers for seeking psychiatric help by qualitative analysis of stake holders of male victims of child abuse. Materials and Methods: All the statements made by the stakeholders regarding psychiatric assessment and treatment were recorded in each referral made to the psychiatrist. Semistructured interviews and in-depth interviews were conducted to explore the topic of understanding the need for psychiatric treatment to the victims. Results: Collaborative child response unit, a multidisciplinary team, to tackle child sexual abuse in a general hospital received three referrals of male child abuse among the 27 referrals in 20 months. The main theme of the barrier that was generated by interviewing the stakeholders of male child victims of abuse was the misconception of superiority of a male victim due to gender (patriarchy) an expectation that he will outgrow the experience. In-depth interviews of three cases of homosexual abuse explored the theme. Conclusion: Patriarchy is oppressing male children and acts as a barrier to seek psychiatric help in collaborative child response unit. PMID:28827868

Issues in recruiting community-dwelling stroke survivors to clinical trials: the AMBULATE trial.

PubMed

Lloyd, Gemma; Dean, Catherine M; Ada, Louise

2010-07-01

Recruitment to clinical trials is often slow and difficult, with a growing body of research examining this issue. However there is very little work related to stroke. The aim of this study was to examine the success and efficiency of recruitment of community-dwelling stroke survivors over the first two years of a clinical trial aiming to improve community ambulation. Recruitment strategies fell into 2 broad categories: (i) advertisement (such as newspaper advertising and media releases), and (ii) referral (via hospital and community physiotherapists, a stroke liaison officer and other researchers). Records were kept of the number of people who were screened, were eligible and were recruited for each strategy. The recruitment target of 60 in the first two years was not met. 111 stroke survivors were screened and 57 were recruited (i.e., a recruitment rate of 51%). The most successful strategy was referral via hospital-based physiotherapists (47% of recruited participants) and the least successful were media release and local newspaper advertising. The referral strategies were all more efficient than any of the advertisement strategies. In general, recruitment was inefficient and costly in terms of human resources. Given that stroke research is underfunded, it is important to find efficient ways of recruiting stroke survivors to clinical trials. An Australian national database similar to other disease-specific data bases (such as the National Cancer Database) is under development. In the interim, recruiting for several clinical trials at once may increase efficiency.

Application of teledentistry in oral medicine in a community dental service, N. Ireland.

PubMed

Bradley, M; Black, P; Noble, S; Thompson, R; Lamey, P J

2010-10-23

Currently, patients with oral medicine conditions from all areas of Northern Ireland are referred by dentists and doctors to a small number of specialist services: predominantly, the Regional Oral Medicine Consultant at the School of Dentistry, Belfast. On receipt of the referral the consultant makes an assessment of the urgency of the case and the patient is placed on a waiting list. Until the recent implementation of waiting list initiatives (Elective Access Protocol, Department of Health, N. Ireland, 2006), patients remained on the waiting list for long periods of time. Analysis of these patient profiles highlights that many need both multiple treatment and review appointments of their chronic conditions, and consequently remain in the hospital system for significant periods of time. This increases the waiting time for these services. The idea of using teledentistry to triage referrals, and its potential as a tool to support locally based treatment, poses an alternative approach to the management of oral medicine referrals. It may be of particular interest to practitioners in rural locations where distance from the regional centre is significant. In 2005, to test this theory, a prototype teledentistry system was set up as part of a service improvement scheme by the Community Dental Service of the Homefirst Legacy Trust (now Northern Trust) in partnership with the Oral Medicine Department at the School of Dentistry, Royal Group of Hospitals Legacy Trust (now Belfast Trust). This paper describes the feasibility study.

Continuity of care: what matters to women when they are referred from primary to secondary care during labour? a qualitative interview study in the Netherlands.

PubMed

de Jonge, Ank; Stuijt, Rosan; Eijke, Iva; Westerman, Marjan J

2014-03-17

Continuity of care during labour is important for women. Women with an intrapartum referral from primary to secondary care look back more negatively on their birh experience compared to those who are not referred. It is not clear which aspects of care contribute to this negative birth experience. This study aimed to explore in-depth the experiences of women who were referred during labour from primary to secondary care with regard to the different aspects of continuity of care. A qualitative interview study was conducted in the Netherlands among women who were in primary care at the onset of labour and were referred to secondary care before the baby was born. Through purposive sampling 27 women were selected. Of these, nine women planned their birth at home, two in an alongside midwifery unit and 16 in hospital. Thematic analysis was used. Continuity of care was a very important issue for women because it contributed to their feeling of safety during labour. Important details were sometimes not handed over between professionals within and between primary and secondary care, in particular about women's personal preferences. In case of referral of care from primary to secondary care, it was important for women that midwives handed over the care in person and stayed until they felt safe with the hospital team. Personal continuity of care, in which case the midwife stayed until the end of labour, was highly appreciated but not always expected.Fear of transportion during or after labour was a reason for women to choose hospital birth but also to opt for home birth. Choice of place of birth emerged as a fluid concept; most women planned their place of birth during pregnancy and were aware that they would spend some time at home and possibly some time in hospital. In case of referral from primary to secondary care during labour, midwives should hand over their care in person and preferrably stay with women throughout labour. Planned place of birth should be regarded as a fluid concept rather than a dichotomous choice.