Xue, Ying; Tuttle, Jane
Nurse practitioners are increasingly being integrated into primary care delivery to help meet the growing demand for primary care. It is therefore important to understand nurse practitioners' productivity in primary care practice. We examined nurse practitioners' clinical productivity in regard to number of patients seen per week, whether they had a patient panel, and patient panel size. We further investigated practice characteristics associated with their clinical productivity. We conducted cross-sectional analysis of the 2012 National Sample Survey of Nurse Practitioners. The sample included full-time primary care nurse practitioners in ambulatory settings. Multivariable survey regression analyses were performed to examine the relationship between practice characteristics and nurse practitioners' clinical productivity. Primary care nurse practitioners in ambulatory settings saw an average of 80 patients per week (95% confidence interval [CI]: 79-82), and 64% of them had their own patient panel. The average patient panel size was 567 (95% CI: 522-612). Nurse practitioners who had their own patient panel spent a similar percent of time on patient care and documentation as those who did not. However, those with a patient panel were more likely to provide a range of clinical services to most patients. Nurse practitioners' clinical productivity was associated with several modifiable practice characteristics such as practice autonomy and billing and payment policies. The estimated number of patients seen in a typical week by nurse practitioners is comparable to that by primary care physicians reported in the literature. However, they had a significantly smaller patient panel. Nurse practitioners' clinical productivity can be further improved. Copyright © 2016 Elsevier Inc. All rights reserved.
Dréano-Hartz, Soazic; Rhondali, Wadih; Ledoux, Mathilde; Ruer, Murielle; Berthiller, Julien; Schott, Anne-Marie; Monsarrat, Léa; Filbet, Marilène
Burnout syndrome is a work-related professional distress. Palliative care physicians often have to deal with complex end-of-life situations and are at risk of presenting with burnout syndrome, which has been little studied in this population. Our study aims to identify the impact of clinical settings (in a palliative care unit (PCU) or on a palliative care mobile team (PCMT)) on palliative care physicians. We undertook a cross-sectional study using a questionnaire that included the Maslach Burnout Inventory (MBI), and we gathered sociodemographic and professional data. The questionnaire was sent to all 590 physicians working in palliative care in France between July of 2012 and February of 2013. The response rate was 61, 8% after three reminders. Some 27 (9%) participants showed high emotional exhaustion, 12 (4%) suffered from a high degree of depersonalization, and 71 (18%) had feelings of low personal accomplishment. Physicians working on a PCMT tended (p = 0.051) to be more likely to suffer from emotional exhaustion than their colleagues. Physicians working on a PCMT worked on smaller teams (fewer physicians, p < 0.001; fewer nonphysicians, p < 0.001). They spent less time doing research (p = 0.019), had fewer resources (p = 0.004), and their expertise seemed to be underrecognized by their colleagues (p = 0.023). The prevalence of burnout in palliative care physicians was low and in fact lower than that reported in other populations (e.g., oncologists). Working on a palliative care mobile team can be a more risky situation, associated with a lack of medical and paramedical staff.
Leigh, Andrew James; O'Hanlon, Katie; Sheldrick, Russell; Surr, Claire; Hare, Dougal Julian
Person-centred care can improve the well-being of patients and is therefore a key driver in healthcare developments in the UK. The current study aims to investigate the complex relationship between cognitive impairment, dependency and well-being in people with a wide range of acquired brain and spinal injuries. Sixty-five participants, with varied acquired brain and spinal injuries, were selected by convenience sampling from six inpatient clinical neuroscience settings. Participants were observed using Dementia Care Mapping - Neurorehabilitation (DCM-NR) and categorised based on severity of cognitive impairment. A significant difference in the behaviours participants engaged in, their well-being and dependency was found between the severe cognitive impairment group and the mild, moderate or no cognitive impairment groups. Dependency and cognitive impairment accounted for 23.9% of the variance in well-ill-being scores and 17.2% of the variance in potential for positive engagement. The current study highlights the impact of severe cognitive impairment and dependency on the behaviours patients engaged in and their well-being. It also affirms the utility of DCM-NR in providing insights into patient experience. Consideration is given to developing DCM-NR as a process that may improve person-centred care in neuroscience settings.
Montgomery, Guy H; Schnur, Julie B; David, Daniel
Hypnotic suggestibility has been described as a powerful predictor of outcomes associated with hypnotic interventions. However, there have been no systematic approaches to quantifying this effect across the literature. This meta-analysis evaluates the magnitude of the effect of hypnotic suggestibility on hypnotic outcomes in clinical settings. PsycINFO and PubMed were searched from their inception through July 2009. Thirty-four effects from 10 studies and 283 participants are reported. Results revealed a statistically significant overall effect size in the small to medium range (r = .24; 95% Confidence Interval = -0.28 to 0.75), indicating that greater hypnotic suggestibility led to greater effects of hypnosis interventions. Hypnotic suggestibility accounted for 6% of the variance in outcomes. Smaller sample size studies, use of the SHCS, and pediatric samples tended to result in larger effect sizes. The authors question the usefulness of assessing hypnotic suggestibility in clinical contexts.
Arnett, Kelly; Sudore, Rebecca L; Nowels, David; Feng, Cindy X; Levy, Cari R; Lum, Hillary D
Interprofessional health care team members consider advance care planning (ACP) to be important, yet gaps remain in systematic clinical routines to support ACP. A clearer understanding of the interprofessional team members' perspectives on ACP clinical routines in diverse settings is needed. One hundred eighteen health care team members from community-based clinics, long-term care facilities, academic clinics, federally qualified health centers, and hospitals participated in a 35-question, cross-sectional online survey to assess clinical routines, workflow processes, and policies relating to ACP. Respondents were 53% physicians, 18% advanced practice nurses, 11% nurses, and 18% other interprofessional team members including administrators, chaplains, social workers, and others. Regarding clinical routines, respondents reported that several interprofessional team members play a role in facilitating ACP (ie, physician, social worker, nurse, others). Most (62%) settings did not have, or did not know of, policies related to ACP documentation. Only 14% of settings had a patient education program. Two-thirds of the respondents said that addressing ACP is a high priority and 85% felt that nonphysicians could have ACP conversations with appropriate training. The clinical resources needed to improve clinical routines included training for providers and staff, dedicated staff to facilitate ACP, and availability of patient/family educational materials. Although interprofessional health care team members consider ACP a priority and several team members may be involved, clinical settings lack systematic clinical routines to support ACP. Patient educational materials, interprofessional team training, and policies to support ACP clinical workflows that do not rely solely on physicians could improve ACP across diverse clinical settings.
Thompson, Patricia; Lulham, Kevin
More than 90 members of the American Association of Colleges of Nursing and 190 practice sites have partnered to develop the clinical nurse leader (CNL) role. The partnership has created synergy between education and practice and nurtured innovation and diffusion of learning on a national basis. In this ongoing department, the editor, Jolene Tornabeni, MA, RN, FAAN, FACHE, showcases a variety of nurse leaders who discuss their new patient care delivery models in preparation for the CNL role and CNLs who highlight partnerships with their clinical colleagues to improve patient care. In this article, the authors explore differences and similarities between the CNL and the clinical nurse specialist roles, describing the working strategies between a CNL and clinical nurse specialist, and role delineations that have resulted from their cooperation, collaboration, and planning.
Asmaningrum, Nurfika; Tsai, Yun-Fang
To gain an understanding towards the perspectives of hospitalized inpatients in Indonesia regarding maintaining dignity during clinical care. Dignity is a basic human right that is crucial for an individual's well-being. Respect for a person as a valuable human is a concept that is comparable to treating a person with dignity. Maintaining patient's dignity is an ethical goal of nursing care. Nevertheless, the concept is highly dependent on cultural context. This issue has not been well studied in Indonesia. This study used a qualitative descriptive design. Thirty-five participants were recruited by purposive sampling from medical to surgical wards of six public hospitals in Eastern Java, Indonesia. Data were collected in 2016 through individual face-to-face semi-structured interviews. Inductive content analysis was applied to the data. Four major categories which described qualities of nursing care essential for maintaining a patient's dignity in clinical care settings were revealed: (1) responsiveness; (2) respectful nurse-patient relationships; (3) caring characteristics and (4) personalized service. Our findings provide a cultural viewpoint of dignity for care recipients in Indonesia. The findings provide empirical support for linking dignified care and person-centred care principles with regards to cultural sensitivity. Nurses must not only be clinically competent but also culturally competent. The ability to provide culturally competent care is important for nurses as a strategy to maintain patient dignity during hospitalized care. © 2017 John Wiley & Sons Ltd.
Full Text Available Abstract Background Population ageing, the emergence of chronic illness, and the shift away from institutional care challenge conventional approaches to assessment systems which traditionally are problem and setting specific. Methods From 2002, the interRAI research collaborative undertook development of a suite of assessment tools to support assessment and care planning of persons with chronic illness, frailty, disability, or mental health problems across care settings. The suite constitutes an early example of a "third generation" assessment system. Results The rationale and development strategy for the suite is described, together with a description of potential applications. To date, ten instruments comprise the suite, each comprising "core" items shared among the majority of instruments and "optional" items that are specific to particular care settings or situations. Conclusion This comprehensive suite offers the opportunity for integrated multi-domain assessment, enabling electronic clinical records, data transfer, ease of interpretation and streamlined training.
Gray, Leonard C; Berg, Katherine; Fries, Brant E; Henrard, Jean-Claude; Hirdes, John P; Steel, Knight; Morris, John N
Background Population ageing, the emergence of chronic illness, and the shift away from institutional care challenge conventional approaches to assessment systems which traditionally are problem and setting specific. Methods From 2002, the interRAI research collaborative undertook development of a suite of assessment tools to support assessment and care planning of persons with chronic illness, frailty, disability, or mental health problems across care settings. The suite constitutes an early example of a "third generation" assessment system. Results The rationale and development strategy for the suite is described, together with a description of potential applications. To date, ten instruments comprise the suite, each comprising "core" items shared among the majority of instruments and "optional" items that are specific to particular care settings or situations. Conclusion This comprehensive suite offers the opportunity for integrated multi-domain assessment, enabling electronic clinical records, data transfer, ease of interpretation and streamlined training. PMID:19402891
Karen E. Hamilton
Full Text Available Purpose: To investigate the set up and operation of a Managed Clinical Network for cardiac services and assess its impact on patient care. Methods: This single case study used process evaluation with observational before and after comparison of indicators of quality of care and costs. The study was conducted in Dumfries and Galloway, Scotland and used a three-level framework. Process evaluation of the network set-up and operation through a documentary review of minutes; guidelines and protocols; transcripts of fourteen semi-structured interviews with health service personnel including senior managers, general practitioners, nurses, cardiologists and members of the public. Outcome evaluation of the impact of the network through interrupted time series analysis of clinical data of 202 patients aged less than 76 years admitted to hospital with a confirmed myocardial infarction one-year pre and one-year post, the establishment of the network. The main outcome measures were differences between indicators of quality of care targeted by network protocols. Economic evaluation of the transaction costs of the set-up and operation of the network and the resource costs of the clinical care of the 202 myocardial infarction patients from the time of hospital admission to 6 months post discharge through interrupted time series analysis. The outcome measure was different in National Health Service resource use. Results: Despite early difficulties, the network was successful in bringing together clinicians, patients and managers to redesign services, exhibiting most features of good network management. The role of the energetic lead clinician was crucial, but the network took time to develop and ‘bed down’. Its primary “modus operand” was the development of a myocardial infarction pathway and associated protocols. Of sixteen clinical care indicators, two improved significantly following the launch of the network and nine showed improvements, which were
Stc Hamilton, Karen E; Sullivan, Frank M; Donnan, Peter T; Taylor, Rex; Ikenwilo, Divine; Scott, Anthony; Baker, Chris; Wyke, Sally
To investigate the set up and operation of a Managed Clinical Network for cardiac services and assess its impact on patient care. This single case study used process evaluation with observational before and after comparison of indicators of quality of care and costs. The study was conducted in Dumfries and Galloway, Scotland and used a three-level framework. Process evaluation of the network set-up and operation through a documentary review of minutes; guidelines and protocols; transcripts of fourteen semi-structured interviews with health service personnel including senior managers, general practitioners, nurses, cardiologists and members of the public. Outcome evaluation of the impact of the network through interrupted time series analysis of clinical data of 202 patients aged less than 76 years admitted to hospital with a confirmed myocardial infarction one-year pre and one-year post, the establishment of the network. The main outcome measures were differences between indicators of quality of care targeted by network protocols. Economic evaluation of the transaction costs of the set-up and operation of the network and the resource costs of the clinical care of the 202 myocardial infarction patients from the time of hospital admission to 6 months post discharge through interrupted time series analysis. The outcome measure was different in National Health Service resource use. Despite early difficulties, the network was successful in bringing together clinicians, patients and managers to redesign services, exhibiting most features of good network management. The role of the energetic lead clinician was crucial, but the network took time to develop and 'bed down'. Its primary "modus operand" was the development of a myocardial infarction pathway and associated protocols. Of sixteen clinical care indicators, two improved significantly following the launch of the network and nine showed improvements, which were not statistically significant. There was no difference
Kotecha, Aachal; Baldwin, Alex; Brookes, John; Foster, Paul J
This article describes the development of a virtual glaucoma clinic, whereby technicians collect information for remote review by a consultant specialist. This was a hospital-based service evaluation study. Patients suitable for the stable monitoring service (SMS) were low-risk patients with "suspect", "early"-to-"moderate" glaucoma who were deemed stable by their consultant care team. Three technicians and one health care assistant ran the service. Patients underwent tests in a streamlined manner in a dedicated clinical facility, with virtual review of data by a consultant specialist through an electronic patient record. Feasibility of developing a novel service within a UK National Health Service setting and improvement of patient journey time within the service were studied. Challenges to implementation of virtual clinic include staffing issues and use of information technology. Patient journey time within the SMS averaged 51 minutes, compared with 92 minutes in the glaucoma outpatient department. Patient satisfaction with the new service was high. Implementing innovation into existing services of the National Health Service is challenging. However, the virtual clinic showed an improved patient journey time compared with that experienced within the general glaucoma outpatient department. There exists a discrepancy between patient management decisions of reviewers, suggesting that some may be more risk averse than others when managing patients seen within this model. Future work will assess the ability to detect progression of disease in this model compared with the general outpatient model of care.
Full Text Available Aachal Kotecha,1,2 Alex Baldwin,1 John Brookes,1 Paul J Foster1,2 1Glaucoma Service, Moorfields Eye Hospital National Health Service Foundation Trust, 2NIHR BRC, Moorfields Eye Hospital, NHS Foundation Trust and UCL Institute of Ophthalmology, University College London, London, UK Background: This article describes the development of a virtual glaucoma clinic, whereby technicians collect information for remote review by a consultant specialist.Design and Methods: This was a hospital-based service evaluation study. Patients suitable for the stable monitoring service (SMS were low-risk patients with “suspect”, “early”-to-“moderate” glaucoma who were deemed stable by their consultant care team. Three technicians and one health care assistant ran the service. Patients underwent tests in a streamlined manner in a dedicated clinical facility, with virtual review of data by a consultant specialist through an electronic patient record.Main outcome measure: Feasibility of developing a novel service within a UK National Health Service setting and improvement of patient journey time within the service were studied.Results: Challenges to implementation of virtual clinic include staffing issues and use of information technology. Patient journey time within the SMS averaged 51 minutes, compared with 92 minutes in the glaucoma outpatient department. Patient satisfaction with the new service was high.Conclusion: Implementing innovation into existing services of the National Health Service is challenging. However, the virtual clinic showed an improved patient journey time compared with that experienced within the general glaucoma outpatient department. There exists a discrepancy between patient management decisions of reviewers, suggesting that some may be more risk averse than others when managing patients seen within this model. Future work will assess the ability to detect progression of disease in this model compared with the general
Nadal, Núria; de Batlle, Jordi; Barbé, Ferran; Marsal, Josep Ramon; Sánchez-de-la-Torre, Alicia; Tarraubella, Nuria; Lavega, Merce; Sánchez-de-la-Torre, Manuel
Good adherence to continuous positive airway pressure (CPAP) treatment improves the patient's quality of life and decreases the risk of cardiovascular disease. Previous studies that have analyzed the adherence to CPAP were performed in a sleep unit (SU) setting. The involvement of primary care (PC) in the management of obstructive sleep apnea (OSA) patients receiving CPAP treatment could introduce factors related to the adherence to treatment. The objective was to compare the baseline predictors of CPAP compliance in SU and PC settings. OSA patients treated with CPAP were followed for 6 months in SU or PC setting. We included baseline clinical and anthropometrical variables, the Epworth Sleep Scale (ESS) score, the quality of life index, and the Charlson index. A logistic regression was performed for each group to determine the CPAP compliance predictors. Discrimination and calibration were performed using the area under the curve and Hosmer-Lemeshow tests. We included 191 patients: 91 in the PC group and 100 in the SU group. In 74.9% of the patients, the compliance was ≥ 4 h per day, with 80% compliance in the SU setting and 69.2% compliance in the PC setting (p = 0.087). The predictors of CPAP compliance were different between SU and PC settings. Body mass index, ESS, and CPAP pressure were predictors in the SU setting, and ESS, gender, and waist circumference were predictors in the PC setting. The predictors of adequate CPAP compliance vary between SU and PC settings. Detecting compliance predictors could help in the planning of early interventions to improve CPAP adherence.
Clarke, Christina M; Persaud, Drepaul David
Many contemporary acute care facilities lack safe and effective clinical handover practices resulting in patient transitions that are vulnerable to discontinuities in care, medical errors, and adverse patient safety events. This article is intended to supplement existing handover improvement literature by providing practical guidance for leaders and managers who are seeking to improve the safety and the effectiveness of clinical handovers in the acute care setting. A 4-stage change model has been applied to guide the application of strategies for handover improvement. Change management and quality improvement principles, as well as concepts drawn from safety science and high-reliability organizations, were applied to inform strategies. A model for handover improvement respecting handover complexity is presented. Strategies targeted to stages of change include the following: 1. Enhancing awareness of handover problems and opportunities with the support of strategic directions, accountability, end user involvement, and problem complexity recognition. 2. Identifying solutions by applying and adapting best practices in local contexts. 3. Implementing locally adapted best practices supported by communication, documentation, and training. 4. Institutionalizing practice changes through integration, monitoring, and active dissemination. Finally, continued evaluation at every stage is essential. Although gaps in handover process and function knowledge remain, efforts to improve handover safety and effectiveness are still possible. Continued evaluation is critical in building this understanding and to ensure that practice changes lead to improvements in patient safety, organizational effectiveness, and patient and provider satisfaction. Through handover knowledge building, fundamental changes in handover policies and practices may be possible.
A peculiar paradox that has been observed in previous studies of antenatal care is where patients are satisfied with the services despite obvious lack of basic facilities. Qualitative methods were used to describe the experience of perinatal care in the Western province with the objective of demonstrating application of this method in a clinical setting. This paper used a 'naturalistic' approach of qualitative methods. In-depth interviews conducted with 20 postnatal mothers delivering in tertiary care institutions in the Western province was tape recorded, transcribed and content analysed. To ensure objectivity and validity of results, the principle investigator received only the anonymised data to prevent any prejudices or pre-conceptions affecting the results. The main themes emerging from the text demonstrated 'naïve trust' in the carer and a state of 'hero worship' where patients were distanced and therefore unable and unwilling to query the decisions made by the carers. This is similar to a state of patient-carer relationship described in a published model known as guarded alliance, where the relationship develops though four phases based on the level of trust and confidence in the relationship. This state explains not only why patients fail to recognise and report any deficiencies in the services but also the need for them to justify the behaviour of caregivers even when it amounts to incompetence and negligence. Qualitative methods allow the researcher to capture experiences in its 'natural' form rather than based on pre-determined protocols or plans, which may be limited to our own understanding and expectations and therefore unable to explain many idiosyncrasies of the programmes. This paper argues favourably for the use of qualitative methods in other clinical settings.
Eshein, Adam; Nguyen, The-Quyen; Radosevich, Andrew J.; Gould, Bradley; Wu, Wenli; Konda, Vani; Yang, Leslie W.; Koons, Ann; Feder, Seth; Valuckaite, Vesta; Roy, Hemant K.; Backman, Vadim
While there are a plethora of in-vivo spectroscopic techniques that have demonstrated the ability to detect a number of diseases in research trials, very few techniques have successfully become a fully realized clinical technology. This is primarily due to the stringent demands on a clinical device for widespread implementation. Some of these demands include: simple operation requiring minimal or no training, safe for in-vivo patient use, no disruption to normal clinic workflow, tracking of system performance, warning for measurement abnormality, and meeting all FDA guidelines for medical use. Previously, our group developed a fiber optic probe-based optical sensing technique known as low-coherence enhanced backscattering spectroscopy (LEBS) to quantify tissue ultrastructure in-vivo. Now we have developed this technique for the application of prescreening patients for colonoscopy in a primary care (PC) clinical setting. To meet the stringent requirements for a viable medical device used in a PC clinical setting, we developed several novel components including an automated calibration tool, optical contact sensor for signal acquisition, and a contamination sensor to identify measurements which have been affected by debris. The end result is a state-of-the-art medical device that can be realistically used by a PC physician to assess a person's risk for harboring colorectal precancerous lesions. The pilot study of this system shows great promise with excellent stability and accuracy in identifying high-risk patients. While this system has been designed and optimized for our specific application, the system and design concepts are universal to most in-vivo fiber optic based spectroscopic techniques.
INVITED ARTICLE James M. Hughes and Mary E. Wilson, Section Editors Health Care Workers and Researchers Traveling to Developing-World Clinical...for risk mitigation. Few data on the epidemiology of infectious diseases occurring among traveling health care workers (HCWs) exist. Surveillance... Health Care Workers and Researchers Traveling to Developing-World Clinical Settings: Disease Transmission Risk and Mitigation 5a. CONTRACT NUMBER 5b
Frey, Rosemary; Gott, Merryn; Raphael, Deborah; O'Callaghan, Anne; Robinson, Jackie; Boyd, Michal; Laking, George; Manson, Leigh; Snow, Barry
Central to appropriate palliative care management in hospital settings is ensuring an adequately trained workforce. In order to achieve optimum palliative care delivery, it is first necessary to create a baseline understanding of the level of palliative care education and support needs among all clinical staff (not just palliative care specialists) within the acute hospital setting. The objectives of the study were to explore clinical staff: perceptions concerning the quality of palliative care delivery and support service accessibility, previous experience and education in palliative care delivery, perceptions of their own need for formal palliative care education, confidence in palliative care delivery and the impact of formal palliative care training on perceived confidence. A purposive sample of clinical staff members (598) in a 710-bed hospital were surveyed regarding their experiences of palliative care delivery and their education needs. On average, the clinical staff rated the quality of care provided to people who die in the hospital as 'good' (x̄=4.17, SD=0.91). Respondents also reported that 19.3% of their time was spent caring for end-of-life patients. However, only 19% of the 598 respondents reported having received formal palliative care training. In contrast, 73.7% answered that they would like formal training. Perceived confidence in palliative care delivery was significantly greater for those clinical staff with formal palliative care training. Formal training in palliative care increases clinical staff perceptions of confidence, which evidence suggests impacts on the quality of palliative care provided to patients. The results of the study should be used to shape the design and delivery of palliative care education programmes within the acute hospital setting to successfully meet the needs of all clinical staff. 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.
Eltahir A.G. Khalil
Full Text Available Background: Tuberculosis is a major health problem in developing countries. The distinction between tuberculous lymphadenitis, non-specific lymphadenitis and malignant lymph node enlargement has to be made at primary health care levels using easy, simple and cheap methods. Objective: To develop a reliable clinical algorithm for primary care settings to triage cases ofnon-specific, tuberculous and malignant lymphadenopathies. Methods: Calculation of the odd ratios (OR of the chosen predictor variables was carried out using logistic regression. The numerical score values of the predictor variables were weighed against their respective OR. The performance of the score was evaluated by the ROC (ReceiverOperator Characteristic curve. Results: Four predictor variables; Mantoux reading, erythrocytes sedimentation rate (ESR,nocturnal fever and discharging sinuses correlated significantly with TB diagnosis and were included in the reduced model to establish score A. For score B, the reduced model included Mantoux reading, ESR, lymph-node size and lymph-node number as predictor variables for malignant lymph nodes. Score A ranged 0 to 12 and a cut-off point of 6 gave a best sensitivity and specificity of 91% and 90% respectively, whilst score B ranged -3 to 8 and a cut-off point of3 gave a best sensitivity and specificity of 83% and 76% respectively. The calculated area underthe ROC curve was 0.964 (95% CI, 0.949 – 0.980 and -0.856 (95% CI, 0.787 ‑ 0.925 for scores Aand B respectively, indicating good performance. Conclusion: The developed algorithm can efficiently triage cases with tuberculous andmalignant lymphadenopathies for treatment or referral to specialised centres for furtherwork-up.
The utility of personal digital assistants (PDA) as a point of care resource in health care practice and education presents new challenges for nursing faculty. While there is a plethora of PDA resources available, little is known about the variables that effect student learning and technology adoption. In this study nursing students used PDA software programs which included a drug guide, medical dictionary, laboratory manual and nursing diagnosis manual during acute care clinical experiences. Analysis of student journals comparative reflective statements about the PDA as an adjunct to other available resources in clinical practice are presented. The benefits of having a PDA included readily available data, validation of thinking processes, and facilitation of care plan re-evaluation. Students reported increased frequency of use and independence. Significant correlations between user perceptions and computer self-efficacy suggested greater confidence in abilities with technology resulting in increased self-awareness and achievement of learning outcomes.
Background Several organizations and individual authors have been proposing quality indicators for the assessment of clinical care in HIV/AIDS patients. Nevertheless, the definition of a consensual core set of indicators remains controversial and its practical use is largely limited. This study aims not only to identify and characterize these indicators through a systematic literature review but also to propose a parsimonious model based on those most used. Methods MEDLINE, SCOPUS, Cochrane databases and ISI Web of Knowledge, as well as official websites of organizations dealing with HIV/AIDS care, were searched for articles and information proposing HIV/AIDS clinical care quality indicators. The ones that are on patient’s perspective and based on services set were excluded. Data extraction, using a predefined data sheet based on Cochrane recommendations, was done by one of the authors while a second author rechecked the extracted data for any inconsistency. Results A total of 360 articles were identified in our search query but only 12 of them met the inclusion criteria. We also identified one relevant site. Overall, we identified 65 quality indicators for HIV/AIDS clinical care distributed as following: outcome (n=15) and process-related (n=50) indicators; generic (n=36) and HIV/AIDS disease-specific (n=29) indicators; baseline examinations (n=19), screening (n=9), immunization (n=4), prophylaxis (n=5), HIV monitoring (n=16), and therapy (=12) indicators. Conclusions There are several studies that set up HIV clinical care indicators, with only a part of them useful to assess the HIV clinical care. More importantly, HIV/AIDS clinical care indicators need to be valid, reliable and most of all feasible. PMID:23809537
Iddins, Brenda W; Frank, Jennifer Sandson; Kannar, Pegah; Curry, William A; Mullins, Melissa; Hites, Lisle; Selleck, Cynthia
This article reports the experiences of a school of nursing, academic health center, and community-based organization working via an interprofessional collaborative practice model to meet the mutual goal of serving the health care needs of an indigent, largely minority population in Birmingham, Alabama. The population suffers disproportionately from chronic health problems including diabetes, obesity, cardiovascular disease, asthma, and mental health disorders. The program emphasizes diabetes management because the academic health center recognized the need for transitional and primary care, including mental health services, for the increasing numbers of uninsured patients with diabetes and its comorbidities. Half of the clinicians involved in this project had no prior experience with interprofessional collaborative practice, and there was confusion regarding the roles of team members from the partnering institutions. Activities involving care coordination consistently received low scores on weekly rating scales leading to the creation of positions for a nurse care manager and pharmaceutical patient assistance program coordinator. Conversely, shared decision making and cooperation ratings were consistently high. Evaluation identified the need for reliable, accessible data and data analysis to target clinically effective interventions and care coordination and to assess cost effectiveness. The strengths, challenges, lessons learned, and next steps required for sustainability of this alignment are discussed.
Full Text Available Abstract Background Integrative health care (IHC is an interdisciplinary blending of conventional medicine and complementary and alternative medicine (CAM with the purpose of enhancing patients' health. In 2006, we designed a study to assess outcomes that are relevant to people using such care. However, we faced major challenges in conducting this study and hypothesized that this might be due to the lack of a research climate in these clinics. To investigate these challenges, we initiated a further study in 2008, to explore the reasons why IHC clinics are not conducting outcomes research and to identify strategies for conducting successful in-house outcomes research programs. The results of the latter study are reported here. Methods A total of 25 qualitative interviews were conducted with key participants from 19 IHC clinics across Canada. Basic content analysis was used to identify key themes from the transcribed interviews. Results Barriers identified by participants fell into four categories: organizational culture, organizational resources, organizational environment and logistical challenges. Cultural challenges relate to the philosophy of IHC, organizational leadership and practitioner attitudes and beliefs. Participants also identified significant issues relating to their organization's lack of resources such as funding, compensation, infrastructure and partnerships/linkages. Environmental challenges such as the nature of a clinic's patient population and logistical issues such as the actual implementation of a research program and the applicability of research data also posed challenges to the conduct of research. Embedded research leadership, integration of personal and professional values about research, alignment of research activities and clinical workflow processes are some of the factors identified by participants that support IHC clinics' ability to conduct outcomes research. Conclusions Assessing and enhancing the broader
McMahon, S; Cusack, T; O'Donoghue, G
With the global shift in health care from secondary to primary care, employment opportunities for newly qualified physiotherapists are likely to be in the primary care setting. However, to date, undergraduate physiotherapy clinical education has been centred around secondary care, focusing on acute services in large teaching hospitals. For contemporary physiotherapists to become effective first-contact primary care providers, they need to be exposed to the primary care environment during their undergraduate education. To explore the concept and identify perceived barriers and facilitators to providing physiotherapy undergraduate clinical placements in the primary healthcare setting A three-round Delphi survey was used. Participants were asked to answer open-ended questions with regard to: (i) student preparation for and (ii) provision of primary care placements (Round 1). Content analysis was employed to identify key themes. These themes generated statements for Round 2. In Round 2, participants were asked to rate their level of agreement/disagreement with the generated statements. In Round 3, a final rating process was conducted. Level of consensus was established as ≥70% agreement, with an interquartile range of ≤1. One hundred and ninety-eight primary care physiotherapy staff. Barriers identified included shortage of resources (e.g. staff) and a lack of tradition; in other words, students are not traditionally educated in the primary care setting. Response rates were 60% (120/198), 70% (84/120) and 76% (64/84) for Rounds 1, 2 and 3, respectively. All seven key facilitators identified reached consensus. They included additional support for staff taking students and motivated students. This study revealed that there is support for the provision of physiotherapy clinical education in the primary care setting. Through careful consideration with clear planning and collaboration with all stakeholders, it may be possible to convert the main barriers identified into
Brady, Anne-Marie; Ennis, Shauna; Prendergast, Maebh; Quirke, Mary; Bhangu, Jas; Lynch, Aine; Byrne, Gobnait
Introduction: The out-of-hours period is associated with less favourable patient health outcomes as well as unpredictable workloads and reduced support structures for clinical activity. In particular, appropriate skill mix, staff numbers, resources, communication structures and access to diagnostic services can influence patient safety and risk. As part of continued efforts to improve patient care and hospital management, one major academic hospital is in Ireland has been engaged in work re-d...
Full Text Available Aim: Catatonia is caused by a variety of psychiatric and organic conditions. The onset, clinical profile, and response to treatment may vary depending on the underlying cause. The study is an attempt to explore clinical profile, possible etiological correlates with neurotic/psychotic spectrum illnesses, and response to treatment and outcome in patients of catatonia. Materials and Methods: Retrospective chart analysis by using semistructured data sheet for the analysis of sociodemographic data, clinical profile, precipitating event, and response to treatment in patients with catatonic symptoms admitted to IHBAS (Institute of Human Behaviour and Allied Sciences, New Delhi, India from January 2009 to December 2010 was undertaken. Results: Catatonia was commonly observed in patients with the following profile - late twenties, female, Hindu religion, urban background, and housewives. Psychotic spectrum disorder (57%, N=35 was the most commonly entertained diagnosis and affective disorder (18%, N=11 being the second common. Thirty four percent of the subjects responded to lorazepam treatment and rest required modified electroconvulsive therapy (MECT. Conclusion: Catatonia is more likely to be associated with Schizophrenia and Other Psychotic Disorders in Indian settings. Majority of patients responded to therapy either by lorazepam alone or to its augmentation with modified ECT. The study being a retrospective one, the sample being representative of the treatment seeking group only, and unavailability of the follow up data were the limitations of the study
Chan, Raymond J; Marx, Wolfgang; Bradford, Natalie; Gordon, Louisa; Bonner, Ann; Douglas, Clint; Schmalkuche, Diana; Yates, Patsy
With the increasing burden of chronic and age-related diseases, and the rapidly increasing number of patients receiving ambulatory or outpatient-based care, nurse-led services have been suggested as one solution to manage increasing demand on the health system as they aim to reduce waiting times, resources, and costs while maintaining patient safety and enhancing satisfaction. The aims of this review were to assess the clinical effectiveness, economic outcomes and key implementation characteristics of nurse-led services in the ambulatory care setting. A systematic review was conducted using the standard Cochrane Collaboration methodology and was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE EBSCO, CINAHL EBSCO, and PsycINFO Ovid (from inception to April 2016). Data were extracted and appraisal undertaken. We included randomised controlled trials; quasi-randomised controlled trials; controlled and non-controlled before-and-after studies that compared the effects of nurse-led services in the ambulatory or community care setting with an alternative model of care or standard care. Twenty-five studies of 180,308 participants were included in this review. Of the 16 studies that measured and reported on health-related quality of life outcomes, the majority of studies (n = 13) reported equivocal outcomes; with three studies demonstrating superior outcomes and one demonstrating inferior outcomes in comparison with physician-led and standard care. Nurse-led care demonstrated either equivalent or better outcomes for a number of outcomes including symptom burden, self-management and behavioural outcomes, disease-specific indicators, satisfaction and perception of quality of life, and health service use. Benefits of nurse-led services remain inconclusive in terms of economic outcomes. Nurse
Dunn Lopez, Karen; Gephart, Sheila M; Raszewski, Rebecca; Sousa, Vanessa; Shehorn, Lauren E; Abraham, Joanna
To report on the state of the science of clinical decision support (CDS) for hospital bedside nurses. We performed an integrative review of qualitative and quantitative peer-reviewed original research studies using a structured search of PubMed, Embase, Cumulative Index to Nursing and Applied Health Literature (CINAHL), Scopus, Web of Science, and IEEE Xplore (Institute of Electrical and Electronics Engineers Xplore Digital Library). We included articles that reported on CDS targeting bedside nurses and excluded in stages based on rules for titles, abstracts, and full articles. We extracted research design and methods, CDS purpose, electronic health record integration, usability, and process and patient outcomes. Our search yielded 3157 articles. After removing duplicates and applying exclusion rules, 28 articles met the inclusion criteria. The majority of studies were single-site, descriptive or qualitative (43%) or quasi-experimental (36%). There was only 1 randomized controlled trial. The purpose of most CDS was to support diagnostic decision-making (36%), guideline adherence (32%), medication management (29%), and situational awareness (25%). All the studies that included process outcomes (7) and usability outcomes (4) and also had analytic procedures to detect changes in outcomes demonstrated statistically significant improvements. Three of 4 studies that included patient outcomes and also had analytic procedures to detect change showed statistically significant improvements. No negative effects of CDS were found on process, usability, or patient outcomes. Clinical support systems targeting bedside nurses have positive effects on outcomes and hold promise for improving care quality; however, this research is lagging behind studies of CDS targeting medical decision-making in both volume and level of evidence. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions
Entwistle, Paul Andrew
Despite the continued debate and lack of a clear consensus about the true nature of the hypnotic phenomenon, hypnosis is increasingly being utilized successfully in many medical, health, and psychological spheres as a research method, motivational tool, and therapeutic modality. Significantly, however, although hypnotherapy is widely advertised, advocated, and employed in the private medical arena for the management and treatment of many physical and emotional disorders, too little appears to be being done to integrate hypnosis into primary care and national health medical services. This article discusses some of the reasons for the apparent reluctance of medical and scientific health professionals to consider incorporating hypnosis into their medical practice, including the practical problems inherent in using hypnosis in a medical context and some possible solutions.
Stoicea, Nicoleta; Baddigam, Ramya; Wajahn, Jennifer; Sipes, Angela C; Arias-Morales, Carlos E; Gastaldo, Nicholas; Bergese, Sergio D
The elderly population in the United States is increasing exponentially in tandem with risk for frailty. Frailty is described by a clinically significant state where a patient is at risk for developing complications requiring increased assistance in daily activities. Frailty syndrome studied in geriatric patients is responsible for an increased risk for falls, and increased mortality. In efforts to prepare for and to intervene in perioperative complications and general frailty, a universal scale to measure frailty is necessary. Many methods for determining frailty have been developed, yet there remains a need to define clinical frailty and, therefore, the most effective way to measure it. This article reviews six popular scales for measuring frailty and evaluates their clinical effectiveness demonstrated in previous studies. By identifying the most time-efficient, criteria comprehensive, and clinically effective scale, a universal scale can be implemented into standard of care and reduce complications from frailty in both non-surgical and surgical settings, especially applied to the perioperative surgical home model. We suggest further evaluation of the Edmonton Frailty Scale for inclusion in patient care.
Full Text Available The elderly population in the United States is increasing exponentially in tandem with risk for frailty. Frailty is described by a clinically significant state where a patient is at risk for developing complications requiring increased assistance in daily activities. Frailty syndrome studied in geriatric patients is responsible for an increased risk for falls, and increased mortality. In efforts to prepare for and to intervene in perioperative complications and general frailty, a universal scale to measure frailty is necessary. Many methods for determining frailty have been developed, yet there remains a need to define clinical frailty and therefore the most effective way to measure it. This article reviews six popular scales for measuring frailty and evaluates their clinical effectiveness demonstrated in previous studies. By identifying the most time-efficient, criteria comprehensive, and clinically effective scale, a universal scale can be implemented into standard of care and reduce complications from frailty in both non-surgical and surgical settings, especially applied to the perioperative surgical home model. We suggest further evaluation of the Edmonton Frailty Scale for inclusion in patient care.
Heffler, Enrico; Terranova, Giovanni; Chessari, Carlo; Frazzetto, Valentina; Crimi, Claudia; Fichera, Silvia; Picardi, Giuseppe; Nicolosi, Giuliana; Porto, Morena; Intravaia, Rossella; Crimi, Nunzio
One of the main severe asthma phenotypes is severe eosinophilic or eosinophilic refractory asthma for which novel biologic agents are emerging as therapeutic options. In this context, blood eosinophil counts are one of the most reliable biomarkers. To evaluate the performance of a point-of-care peripheral blood counter in a patients with severe asthma. The blood eosinophil counts of 76 patients with severe asthma were evaluated by point-of-care and standard analyzers. A significant correlation between blood eosinophils assessed by the 2 devices was found (R 2 = 0.854, P asthma and the ELEN index, a composite score useful to predict sputum eosinophilia. The results of our study contribute to the validation of a point-of-care device to assess blood eosinophils and open the possibility of using this device for the management of severe asthma management. Copyright © 2017 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Full Text Available Background and Aims: Assessment of patient satisfaction is an important tool for monitoring the quality of care in hospitals. The aim of this survey was to develop a reliable tool to assess patient satisfaction with acute pain management service (APMS and identify variables affecting this so that care can be improved. Methods: A questionnaire was developed and administered to patients after being discharged from APMS care by an unbiased person. Data collected from record included patient demographics, surgical procedure, analgesic modality, co-analgesics and dynamic and static pain scores. Questions included pain expected and pain experienced, APMS response time, quality of pain relief with treatment, professionalism of APMS team, overall experience of pain relief and choosing/suggesting same modality for themselves/family/friends again. Five-point Likert scale was used for most of the options. Statistical analysis was done using SPSS 19. Results: Frequency and percentages were computed for qualitative observation and presented on pie chart and histogram. Seventy-one per cent patients expected severe pain while 43% actually experienced it. About 79.4% would choose same analgesia modality in future for self/family/friends. Ninety-nine per cent found APMS staff courteous and professional. About 89% rated their experience of pain management as excellent to very good. Conclusion: The survey of patients′ satisfaction to monitor the quality of care provided by APMS provided positive inputs on its role. This also helps to identify areas requiring improvement in care and as a tool to gauge the quality of care.
Fennell Mary L
Full Text Available Abstract Background In this article, we describe the National Cancer Institute (NCI Community Cancer Centers Program (NCCCP pilot and the evaluation designed to assess its role, function, and relevance to the NCI's research mission. In doing so, we describe the evolution of and rationale for the NCCCP concept, participating sites' characteristics, its multi-faceted aims to enhance clinical research and quality of care in community settings, and the role of strategic partnerships, both within and outside of the NCCCP network, in achieving program objectives. Discussion The evaluation of the NCCCP is conceptualized as a mixed method multi-layered assessment of organizational innovation and performance which includes mapping the evolution of site development as a means of understanding the inter- and intra-organizational change in the pilot, and the application of specific evaluation metrics for assessing the implementation, operations, and performance of the NCCCP pilot. The assessment of the cost of the pilot as an additional means of informing the longer-term feasibility and sustainability of the program is also discussed. Summary The NCCCP is a major systems-level set of organizational innovations to enhance clinical research and care delivery in diverse communities across the United States. Assessment of the extent to which the program achieves its aims will depend on a full understanding of how individual, organizational, and environmental factors align (or fail to align to achieve these improvements, and at what cost.
Clauser, Steven B; Johnson, Maureen R; O'Brien, Donna M; Beveridge, Joy M; Fennell, Mary L; Kaluzny, Arnold D
In this article, we describe the National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP) pilot and the evaluation designed to assess its role, function, and relevance to the NCI's research mission. In doing so, we describe the evolution of and rationale for the NCCCP concept, participating sites' characteristics, its multi-faceted aims to enhance clinical research and quality of care in community settings, and the role of strategic partnerships, both within and outside of the NCCCP network, in achieving program objectives. The evaluation of the NCCCP is conceptualized as a mixed method multi-layered assessment of organizational innovation and performance which includes mapping the evolution of site development as a means of understanding the inter- and intra-organizational change in the pilot, and the application of specific evaluation metrics for assessing the implementation, operations, and performance of the NCCCP pilot. The assessment of the cost of the pilot as an additional means of informing the longer-term feasibility and sustainability of the program is also discussed. The NCCCP is a major systems-level set of organizational innovations to enhance clinical research and care delivery in diverse communities across the United States. Assessment of the extent to which the program achieves its aims will depend on a full understanding of how individual, organizational, and environmental factors align (or fail to align) to achieve these improvements, and at what cost.
Hoerbst, A; Schweitzer, M
Clinical Information Systems (CIS) have ever since the introduction of information technology in healthcare played an important role to support healthcare professionals and the process of treatment. With the rise of the concept of integrated care organizational borders, the sole focus on data aggregation or healthcare professionals as users disappear more and more. The manuscript discusses the concept of CISs and investigates critical success factors for CISs in the context of integrated care and in the course of time. In order to identify critical success factors and barriers for CISs a systematic literature review was conducted based on the results from PubMed and Cochrane, using MaxQDA. Search results were thereby limited to reviews or meta-analysis. We have found 1919 references of which 40 met the inclusion criteria. The analysis of the manuscripts resulted in a comprehensive list of success factors and barriers related to CISs in integrated care settings. Most barriers were user-related whereas for the success factors an even distribution of organizational, technical and user-related factors was observed. The vast majority of publications was focused on healthcare professionals. It is important to incorporate experiences made/ collected over time, as the problems encountered seem to remain almost unvaried. In order to support further systematic investigations on the topic it is necessary to rethink existing concepts and definitions to realign them with the ideas of integrated care.
The clinical effectiveness of a treatment for children with dyslexia was examined, as well as the moderating impact of plausible cognitive and socio-economic factors on treatment success. Results revealed that the treatment group accrued significant greater gains than the control group in reading and spelling skills. The treatment group obtained a…
Nightingale, Suzanne; Spiby, Helen; Sheen, Kayleigh; Slade, Pauline
Over recent years there has been criticism within the United Kingdom's health service regarding a lack of care and compassion, resulting in adverse outcomes for patients. The impact of emotional intelligence in staff on patient health care outcomes has been recently highlighted. Many recruiters now assess emotional intelligence as part of their selection process for health care staff. However, it has been argued that the importance of emotional intelligence in health care has been overestimated. To explore relationships between emotional intelligence in health care professionals, and caring behaviour. To further explore any additional factors related to emotional intelligence that may impact upon caring behaviour. An integrative review design was used. Psychinfo, Medline, CINAHL Plus, Social Sciences Citation Index, Science Citation Index, and Scopus were searched for studies from 1995 to April 2017. Studies providing quantitative or qualitative exploration of how any healthcare professionals' emotional intelligence is linked to caring in healthcare settings were selected. Twenty two studies fulfilled the inclusion criteria. Three main types of health care professional were identified: nurses, nurse leaders, and physicians. Results indicated that the emotional intelligence of nurses was related to both physical and emotional caring, but emotional intelligence may be less relevant for nurse leaders and physicians. Age, experience, burnout, and job satisfaction may also be relevant factors for both caring and emotional intelligence. This review provides evidence that developing emotional intelligence in nurses may positively impact upon certain caring behaviours, and that there may be differences within groups that warrant further investigation. Understanding more about which aspects of emotional intelligence are most relevant for intervention is important, and directions for further large scale research have been identified. Copyright © 2018 Elsevier Ltd. All
Butt, Debra A; Lock, Michael; Harvey, Bart J
Little evidence exists to guide investigators on the effectiveness and cost-effectiveness of various recruitment strategies in primary care research. The purpose of this study is to describe the effectiveness and cost-effectiveness of eight clinical trial recruitment methods for postmenopausal women in a community-based setting. A retrospective analysis of the yield and cost of eight different recruitment methods: 1) family physician (FP) recruiters, 2) FP referrals, 3) community presentations, 4) community events, 5) newsletters, 6) direct mailings, 7) posters, and 8) newspaper advertisements that were used to recruit postmenopausal women to a randomized clinical trial (RCT) evaluating the effectiveness of gabapentin in treating hot flashes. We recruited 197 postmenopausal women from a total of 904 screened, with 291 of the remainder being ineligible and 416 declining to participate. Of the 904 women screened, 34 (3.8%) were from FP recruiters and 35 (3.9%) were from other FP referrals while 612 (67.7%) resulted from newspaper advertisements. Of the 197 women enrolled, 141 (72%) were from newspaper advertisements, with 26 (13%) following next from posters. Word of mouth was identified as an additional unanticipated study recruitment strategy. Metropolitan newspaper advertising at $112.73 (Canadian) per enrolled participant and posters at $119.98 were found to be cost-effective recruitment methods. Newspaper advertisements were the most successful method to recruit postmenopausal women into a community-based, primary care RCT. Copyright 2010 Elsevier Inc. All rights reserved.
Full Text Available Motivation is a process that influences and directs behaviour in order to satisfy a need. It links with goal 3 of the sustainable development goals that focus on ensuring healthy lives and promoting well-being at all ages. Motivation of nurses is important in the primary health care environment of, for instance, mine settings; since low levels of motivation among Primary Health Care (PHC nurses could have a negative effect on the achievement of high standards in health service delivery. The study was conducted within the theoretical framework of McClelland's Acquired Motivation Theory which consists of three basic needs, – the need for achievement, the need for power, and the need for affiliation. One of the research questions posed was “What are the motivational needs of PHC nurses to acquire power in the workplace at mine clinic settings?” A quantitative, explorative, descriptive design was followed. The accessible population in this study was PHC nurses (N = 30 working at 13 mine clinics, that also served as the total sample. A 7 point Likert scale was used in a self-administered structured questionnaire that was developed from a literature review. Ethical considerations were adhered to and respondents gave written informed consent. Data was analysed by using descriptive and inferential statistics. TheManne Whitney test compared the mean ranks and a p-value of p < 0.05 was indicative of a significant difference between male and female groups. Validity and reliability principles were applied during the entire research process. The results indicated that PHC nurses needed acknowledgement, organisational responsibility, strategic planning and promotion, as well as support. Significant differences between gender were not found in relation to the need to acquire power.
Pieper, Matthew S; Pulido, Juan; Gajic, Ognjen
Objective Recruitment of patients into time sensitive clinical trials in intensive care units (ICU) poses a significant challenge. Enrollment is limited by delayed recognition and late notification of research personnel. The objective of the present study was to evaluate the effectiveness of the implementation of electronic screening (septic shock sniffer) regarding enrollment into a time sensitive (24 h after onset) clinical study of echocardiography in severe sepsis and septic shock. Design We developed and tested a near-real time computerized alert system, the septic shock sniffer, based on established severe sepsis/septic shock diagnostic criteria. A sniffer scanned patients' data in the electronic medical records and notified the research coordinator on call through an institutional paging system of potentially eligible patients. Measurement The performance of the septic shock sniffer was assessed. Results The septic shock sniffer performed well with a positive predictive value of 34%. Electronic screening doubled enrollment, with 68 of 4460 ICU admissions enrolled during the 9 months after implementation versus 37 of 4149 ICU admissions before sniffer implementation (p<0.05). Efficiency was limited by study coordinator availability (not available at nights or weekends). Conclusions Automated electronic medical records screening improves the efficiency of enrollment and should be a routine tool for the recruitment of patients into time sensitive clinical trials in the ICU setting. PMID:21508415
Herasevich, Vitaly; Pieper, Matthew S; Pulido, Juan; Gajic, Ognjen
Recruitment of patients into time sensitive clinical trials in intensive care units (ICU) poses a significant challenge. Enrollment is limited by delayed recognition and late notification of research personnel. The objective of the present study was to evaluate the effectiveness of the implementation of electronic screening (septic shock sniffer) regarding enrollment into a time sensitive (24 h after onset) clinical study of echocardiography in severe sepsis and septic shock. We developed and tested a near-real time computerized alert system, the septic shock sniffer, based on established severe sepsis/septic shock diagnostic criteria. A sniffer scanned patients' data in the electronic medical records and notified the research coordinator on call through an institutional paging system of potentially eligible patients. The performance of the septic shock sniffer was assessed. The septic shock sniffer performed well with a positive predictive value of 34%. Electronic screening doubled enrollment, with 68 of 4460 ICU admissions enrolled during the 9 months after implementation versus 37 of 4149 ICU admissions before sniffer implementation (p<0.05). Efficiency was limited by study coordinator availability (not available at nights or weekends). Automated electronic medical records screening improves the efficiency of enrollment and should be a routine tool for the recruitment of patients into time sensitive clinical trials in the ICU setting.
Lin, Jay; Zhou, Steve; Wei, Wenhui; Pan, Chunshen; Lingohr-Smith, Melissa; Levin, Philip
Clinical inertia is defined as failure to initiate or intensify therapy despite an inadequate treatment response. We assessed the prevalence and identified the predictors of clinical inertia among patients with type 2 diabetes (T2DM) based on personalized goals. Three hemoglobin A1c (A1C) targets (American Diabetes Association A1C inertia was defined as no intensification of treatment during the response period. Demographic and clinical characteristics were analyzed to identify predictors of treatment intensification. Irrespective of A1C target, the majority of patients with T2DM (70.4 to 72.8%) experienced clinical inertia in the 6 months following the index event, with 5.3 to 6.2% of patients intensifying treatment with insulin. Patients with a lower likelihood of intensification were older, used >1 oral antidiabetes drug during the baseline period, and had an above-target A1C more recently. Treatment intensification was associated with patients who had point-of-service insurance, mental illness, an endocrinologist visit in the baseline period, or higher index A1C. The prevalence of clinical inertia among patients with T2DM in a U.S. managed-care setting is high and has increased over more recent years. Factors predicting increased risk of clinical inertia may help identify "at-risk" populations and assist in developing strategies to improve their management.
McCobb, Emily; Rozanski, Elizabeth A; Malcolm, Elizabeth L; Wolfus, Gregory; Rush, John E
Providing veterinary students with opportunities to develop clinical skills in a realistic, hands-on environment remains a challenge for veterinary education. We have developed a novel approach to teaching clinical medicine to fourth-year veterinary students and technical high school students via development of a primary care clinic embedded within a technical high school. The primary care clinic targets an underserved area of the community, which includes many of the participating high school students. Support from the veterinary community for the project has been strong as a result of communication, the opportunity for veterinarians to volunteer in the clinic, and the careful targeting of services. Benefits to veterinary students include the opportunity to build clinical competencies and confidence, as well as the exposure to a diverse client population. The financial model of the clinic is described and initial data on outcomes for case load, clinic income, veterinary student evaluations, and high school students' success in passing the veterinary assisting examination are reported. This clinical model, involving a partnership between a veterinary school and a technical high school, may be adoptable to other clinical teaching situations.
Gomez-Parra, Myrna; Romero-Arrieta, Lydis; Vasquez-Trespalacios, Elsa Maria; Palacio-Jaramillo, Veronica; Valencia-Martinez, Andrea
Shift work is common in health care settings and has been hypothesized as a risk factor for being overweight or obese. We examined the relation between shift work and being overweight or obese, adjusting for stress and lifestyle habits in Colombian health care workers. The aim of this study was to assess the association between shift work and being overweight/obese in employees of a health care setting in Medellin, Colombia. This cross-sectional study was carried out among 200 workers in a health care setting. Participants completed a demographic, occupational, work-related stress and life style questionnaire. Their Body Mass Index (BMI) and waist to hip ratio were also measured. The study sample consisted of 160 (80%) females and 40 (20%) males. Mean age was 35.1±9.1 years and mean BMI was 25±3.9. After adjusting for potential confounders, multivariate logistic regression revealed no statistically significant association between being overweight, being obese or waist to hip ratio and shift work; 95% CI OR: 1.08 (0.62-1.89), 1.33 (0.44-3.99) and 1.2 (0.8-1.9), respectively. Day workers were statistically more likely to smoke, work more hours, and have a higher educational level than shift workers. No significant associations between shift work and being overweight/obese were observed in health care workers in a Colombian setting. These findings need to be confirmed through longitudinal studies.
Fisher, Jeffrey D; Amico, K Rivet; Fisher, William A; Cornman, Deborah H; Shuper, Paul A; Trayling, Cynthia; Redding, Caroline; Barta, William; Lemieux, Anthony F; Altice, Frederick L; Dieckhaus, Kevin; Friedland, Gerald
We evaluated the efficacy of LifeWindows, a theory-based, computer-administered antiretroviral (ARV) therapy adherence support intervention, delivered to HIV + patients at routine clinical care visits. 594 HIV + adults receiving HIV care at five clinics were randomized to intervention or control arms. Intervention vs. control impact in the intent-to-treat sample (including participants whose ARVs had been entirely discontinued, who infrequently attended care, or infrequently used LifeWindows) did not reach significance. Intervention impact in the On Protocol sample (328 intervention and control arm participants whose ARVs were not discontinued, who attended care and were exposed to LifeWindows regularly) was significant. On Protocol intervention vs. control participants achieved significantly higher levels of perfect 3-day ACTG-assessed adherence over time, with sensitivity analyses maintaining this effect down to 70% adherence. This study supports the utility of LifeWindows and illustrates that patients on ARVs who persist in care at clinical care sites can benefit from adherence promotion software.
Heffner, John E; Brower, Kathleen; Ellis, Rosemary; Brown, Shirley
The high cost of computerized physician order entry (CPOE) and physician resistance to standardized care have delayed implementation. An intranet-based order set system can provide some of CPOE's benefits and offer opportunities to acculturate physicians toward standardized care. INTRANET CLINICIAN ORDER FORMS (COF): The COF system at the Medical University of South Carolina (MUSC) allows caregivers to enter and print orders through the intranet at points of care and to access decision support resources. Work on COF began in March 2000 with transfer of 25 MUSC paper-based order set forms to an intranet site. Physician groups developed additional order sets, which number more than 200. Web traffic increased progressively during a 24-month period, peaking at more than 6,400 hits per month to COF. Decision support tools improved compliance with Centers for Medicare & Medicaid Services core indicators. Clinicians demonstrated a willingness to develop and use order sets and decision support tools posted on the COF site. COF provides a low-cost method for preparing caregivers and institutions to adopt CPOE and standardization of care. The educational resources, relevant links to external resources, and communication alerts will all link to CPOE, thereby providing a head start in CPOE implementation.
Corrigan, Dale M; Walker, Mary P; Liu, Ying; Mitchell, Tanya Villalpando
The purpose of this study was to identify predictors and/or factors associated with medically compromised patients seeking dental care in the oncology dental support clinic (ODSC) at the University of Missouri-Kansas City (UMKC) School of Dentistry. An 18-item survey was mailed to 2,541 patients who were new patients to the clinic from 2006 to 2011. The response rate was approximately 18% (n = 450). Analyses included descriptive statistics of percentages/frequencies as well as predictors based on correlations. Fifty percent of participants, 100 females and 119 males, identified their primary medical diagnosis as cancer. Total household income (p dental care (p dental health. Perceived overall health (p Care Dentistry Association and Wiley Periodicals, Inc.
Kortepeter, Mark G; Seaworth, Barbara J; Tasker, Sybil A; Burgess, Timothy H; Coldren, Rodney L; Aronson, Naomi E
With the recent emphasis on funding and training opportunities for global health and humanitarian aid and the increased interest in the field, many health care workers and medical researchers are traveling from resource-replete to resource-limited settings. This type of travel brings unique disease risks not routinely considered for the business or vacationing traveler. This review provides practical advice for this special population of travelers, targeted to specific health care-related risks (needlestick, hemorrhagic fever viruses, severe viral respiratory disease, and tuberculosis), with suggestions for risk mitigation.
Mohd Mydin, Fadzilah Hanum; Othman, Sajaratulnisah
This qualitative study attempts to explore the definition, perceptions, practice experience, and barriers of primary care physicians (PCPs) in identifying and intervening in cases of elder abuse and neglect at the primary care level. Semistructured in-depth interview was conducted among 10 PCPs. Participants were selected by purposive sampling. The interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. In general, PCPs showed consistency in defining elder abuse and neglect. PCPs considered that they were optimally positioned to intervene in cases of elder abuse and neglect, but indicated the potential of overlooking such problems. The hurdles faced by PCPs in the identification and intervention of elder abuse were determined to be occurring at three levels: clinical, organizational, and policy. At the clinical level, PCPs recognize that they are lacking both the confidence and knowledge of elder abuse and neglect intervention. PCPs' conflicting personal and professional beliefs create barriers during the clinical practice. Time constraints, patients' other clinical problems, and, in addition, the preservation of a good doctor-patient relationship overshadow the importance of addressing and intervening in elder abuse and neglect issues during the consultation. This is further exacerbated by the barriers perceived by the patients: their nondisclosure and reluctance to accept outside intervention. At the organizational level, the lack of efficient interagency networks or support for the health system poses barriers. At the policy level, the absence of legislation specifically addressing elder abuse also creates considerable difficulties. However, PCPs gave differing responses when asked about a law concerning the elderly and mandatory reporting. Addressing these multilevel barriers is critical for ensuring that opportunities arising at the primary care level for elder maltreatment intervention are correctly utilized.
Full Text Available Edwin Chandrasekar,1 Ravneet Kaur,1 Sharon Song,1 Karen E Kim2 1Asian Health Coalition, Chicago, IL, USA; 2Division of the Biological Sciences and Office of Community Engagement and Cancer Disparities, University of Chicago, Chicago, IL, USA Abstract: Hepatitis B (HBV is an urgent, unmet public health issue that affects Asian Americans disproportionately. Of the estimated 1.2 million living with chronic hepatitis B in USA, more than 50% are of Asian ethnicity, despite the fact that Asian Americans constitute less than 6% of the total US population. The Centers for Disease Control and Prevention recommends HBV screening of persons who are at high risk for the disease. Yet, large numbers of Asian Americans have not been diagnosed or tested, in large part because of perceived cultural and linguistic barriers. Primary care physicians are at the front line of the US health care system, and are in a position to identify individuals and families at risk. Clinical settings integrated into Asian American communities, where physicians are on staff and wellness care is emphasized, can provide testing for HBV. In this study, the Asian Health Coalition and its community partners conducted HBV screenings and follow-up linkage to care in both clinical and nonclinical settings. The nonclinic settings included health fair events organized by churches and social services agencies, and were able to reach large numbers of individuals. Twice as many Asian Americans were screened in nonclinical settings than in health clinics. Chi-square and independent samples t-test showed that participants from the two settings did not differ in test positivity, sex, insurance status, years of residence in USA, or education. Additionally, the same proportion of individuals found to be infected in the two groups underwent successful linkage to care. Nonclinical settings were as effective as clinical settings in screening for HBV, as well as in making treatment options available to
Zaforteza, Concha; Gastaldo, Denise; Moreno, Cristina; Bover, Andreu; Miró, Rosa; Miró, Margalida
This study focuses on change strategies generated through a dialogical-reflexive-participatory process designed to improve the care of families of critically ill patients in an intensive care unit (ICU) using a participatory action research in a tertiary hospital in the Balearic Islands (Spain). Eleven professionals (representatives) participated in 11 discussion groups and five in-depth interviews. They represented the opinions of 49 colleagues (participants). Four main change strategies were created: (i) Institutionally supported practices were confronted to make a shift from professional-centered work to a more inclusive, patient-centered approach; (ii) traditional power relations were challenged to decrease the hierarchical power differences between physicians and nurses; (iii) consensus was built about the need to move from an individual to a collective position in relation to change; and (iv) consensus was built about the need to develop a critical attitude toward the conservative nature of the unit. The strategies proposed were both transgressive and conservative; however, when compared with the initial situation, they enhanced the care offered to patients' relatives and patient safety. Transforming conservative settings requires capacity to negotiate positions and potential outcomes. However, when individual critical capacities are articulated with a new approach to micropolitics, transformative proposals can be implemented and sustained. © 2015 John Wiley & Sons Ltd.
Tierney, William M; Brunt, Margaret; Kesterson, Joseph; Zhou, Xiao-Hua; L'Italien, Gil; Lapuerta, Pablo
Hypertension is often uncontrolled. One reason might be physicians' reticence to modify therapy in response to single office measurements of vital signs. Using electronic records from an inner-city primary care practice, we extracted information about vital signs, diagnoses, test results, and drug therapy available on the first primary care visit in 1993 for patients with hypertension. We then identified multivariable predictors of subsequent vascular complications in the ensuing 5 years. Of 5,825 patients (mean age 57 years) previously treated for hypertension for 5.6 years, 7% developed myocardial infarctions, 17% had strokes, 24% developed ischemic heart disease, 22% had heart failure, 12% developed renal insufficiency, and 13% died in 5 years. Controlling for other clinical data, a 10-mmHg increase in systolic blood pressure was associated with 13% increased risk (95% confidence interval [CI], 6%-21%) of renal insufficiency, 9% (95% CI, 3%-15%) increased risk of ischemic heart disease, 7% (95% CI, 3%-11%) increased risk of stroke, and 6% (95% CI, 2%-9%) increased risk of first stroke or myocardial infarction. A 10-mmHg elevation in mean blood pressure predicted a 12% (95% CI, 5%-20%) increased risk of heart failure. An increase in heart rate of 10 beats per minute predicted a 16% (95% CI, 2%-5%) increased risk of death. Diastolic blood pressure predicted only a 13% (95% CI, 4%-23%) increased risk of first stroke. Vital signs-especially systolic blood pressure-recorded routinely during a single primary care visit had significant prognostic value for multiple adverse clinical events among patients treated for hypertension and should not be ignored by clinicians.
Nazi, Kim M
documents revealed a multidimensional dynamic between the trajectory of secure messaging implementation and its impact on organizational actors and their use of technology, influencing workflow, practices, and the flow of information. In effect, secure messaging was the missing element of complex information ecology and its implementation acted as a catalyst for change. Secure messaging was found to have important consequences for access, communication, patient self-report, and patient/provider relationships. Study findings have direct implications for the development and implementation of PHR systems to ensure adequate training and support for health care professionals, alignment with clinical workflow, and features that enable information sharing and communication. Study findings highlight the importance of clinician endorsement and engagement, and the need to further examine both intended and unintended consequences of use. This research provides an integral step toward better understanding the social and organizational context and impact of PHR and secure messaging use in clinical practice settings.
Winik, Connie L; Bonham, C Elizabeth
Obesity is a rapidly growing health problem reaching epidemic levels around the world (World Health Organization, 2014). According to the World Health Organization, the current incident rate of obesity makes it the leading risk for deaths across the globe. The United States (USA) is amidst in this growing global epidemic. The obesity epidemic is a nondiscriminatory health problem affecting millions of individuals from a variety of backgrounds and social status. One group impacted by this disease is the US military. The health-related consequences of overweight and obesity has increased our military health care expenditures and has a direct impact on our nation's military readiness (Veterans Affairs/Department of Defense, 2014). The purpose of this Doctor of Nursing Practice project was to implement the Veterans Affairs/Department of Defense's Clinical Practice Guideline on Screening and Management of Overweight and Obesity at a military treatment facility in the Midwest. The goal of the project was to reduce the incidence rate of overweight and obese active duty military service members assigned to a military installation in the Midwest. With institutional review board approval, project implementation results were analyzed with descriptive and inferential statistics (paired t- tests). The goal to reduce the incident rate of overweight and obese by 5% was not achieved, but in turn the rate of overweight and obese increased by 1.57% over the 6-mo period. There were decreases in the normal with an increase in the overweight and obesity rate. This inverse outcome was unexpected and concerning. Based on the project's finding, there is a need to address the perceived barriers to maintaining healthy behaviors to plan future activities. An in-depth look at whether there is a knowledge deficit, a perceived lack of self-efficacy, competing life priorities preventing engagement in health promotion behaviors, or some other element influencing the motivation to change would be
Full Text Available Understanding human filovirus hemorrhagic fever (FHF clinical manifestations and evaluating treatment strategies require the collection of clinical data in outbreak settings, where clinical documentation has been limited. Currently, no consensus among filovirus outbreak-response organisations guides best practice for clinical documentation and data transfer. Semi-structured interviews were conducted with health care workers (HCWs involved in FHF outbreaks in sub-Saharan Africa, and with HCWs experienced in documenting and transferring data from high-risk areas (isolation wards or biosafety level 4 laboratories. Methods for data documentation and transfer were identified, described in detail and categorised by requirement for electricity and ranked by interviewee preference. Some methods involve removing paperwork and other objects from the filovirus disease ward without disinfection. We believe that if done properly, these methods are reasonably safe for certain settings. However, alternative methods avoiding the removal of objects, or involving the removal of paperwork or objects after non-damaging disinfection, are available. These methods are not only safer, they are also perceived as safer and likely more acceptable to health workers and members of the community. The use of standardised clinical forms is overdue. Experiments with by sunlight disinfection should continue, and non-damaging disinfection of impregnated paper, suitable tablet computers and underwater cameras should be evaluated under field conditions.
Bradley, E H; Bogardus, S T; Tinetti, M E; Inouye, S K
The process of setting goals for medical care in the context of chronic disease has received little attention in the medical literature, despite the importance of goal-setting in the achievement of desired outcomes. Using qualitative research methods, this paper develops a theory of goal-setting in the care of patients with dementia. The theory posits several propositions. First, goals are generated from embedded values but are distinct from values. Goals vary based on specific circumstances and alternatives whereas values are person-specific and relatively stable in the face of changing circumstances. Second, goals are hierarchical in nature, with complex mappings between general and specific goals. Third, there are a number of factors that modify the goal-setting process, by affecting the generation of goals from values or the translation of general goals to specific goals. Modifying factors related to individuals include their degree of risk-taking, perceived self-efficacy, and acceptance of the disease. Disease factors that modify the goal-setting process include the urgency and irreversibility of the medical condition. Pertinent characteristics of the patient-family-clinician interaction include the level of participation, control, and trust among patients, family members, and clinicians. The research suggests that the goal-setting process in clinical medicine is complex, and the potential for disagreements regarding goals substantial. The nature of the goal-setting process suggests that explicit discussion of goals for care may be necessary to promote effective patient-family-clinician communication and adequate care planning.
Waycaster, Curtis; Milne, Catherine
The purpose of this study is to determine the cost-effectiveness of collagenase ointment relative to autolysis with a hydrogel dressing when debriding necrotic pressure ulcers in a long-term care setting. A Markov decision process model with 2 states (necrotic nonviable wound bed transitioning to a granulated viable wound bed) was developed using data derived from a prospective, randomized, 6-week, single-center trial of 27 institutionalized subjects with pressure ulcers that were ≥ 85% necrotic nonviable tissue. Direct medical costs from the payer perspective included study treatments, wound treatment supplies, and nursing time. Clinical benefit was measured as "granulation days" and was derived from the time-dependent debridement rates of the alternative products. The average cost per patient for 42 days of pressure ulcer care was $1,817 in 2012 for the collagenase group and $1,611 for the hydrogel group. Days spent with a granulated wound were 3.6 times higher for collagenase (23.4 vs 6.5) than with the hydrogel. The estimated cost per granulation day was > 3.2 times higher for hydrogel ($249) vs collagenase ($78). In this economic analysis based on a randomized, controlled clinical trial, collagenase ointment resulted in a faster time to complete debridement and was more cost-effective than hydrogel autolysis for pressure ulcers in a long-term care setting. Even though collagenase ointment has a higher acquisition cost than hydrogel, the clinical benefit offsets the initial cost difference, resulting in lower cost per granulation day to the nursing home over the course of the 42-day analysis.
Waters, Cerith S; Frude, Neil; Flaxman, Paul E; Boyd, Jane
To examine the effects of a 1-day acceptance and commitment therapy (ACT) workshop on the mental health of clinically distressed health care employees, and to explore ACT's processes of change in a routine practice setting. A quasi-controlled design, with participants block allocated to an ACT intervention or waiting list control group based on self-referral date. Participants were 35 health care workers who had self-referred for the ACT workshop via a clinical support service for staff. Measures were completed by ACT and control group participants at pre-intervention and 3 months post-intervention. Participants allocated to the waitlist condition went on to receive the ACT intervention and were also assessed 3 months later. At 3 months post-intervention, participants in the ACT group reported a significantly lower level of psychological distress compared to the control group (d = 1.41). Across the 3-month evaluation period, clinically significant change was exhibited by 50% of ACT participants, compared to 0% in the control group. When the control group received the same ACT intervention, 69% went on to exhibit clinically significant change. The ACT intervention also resulted in significant improvements in psychological flexibility, defusion, and mindfulness skills, but did not significantly reduce the frequency of negative cognitions. Bootstrapped mediation analyses indicated that the reduction in distress in the ACT condition was primarily associated with an increase in mindfulness skills, especially observing and non-reactivity. These findings provide preliminary support for providing brief ACT interventions as part of routine clinical support services for distressed workers. A 1-day ACT workshop delivered in the context of a routine staff support service was effective for reducing psychological distress among health care workers. The brief nature of this group intervention means it may be particularly suitable for staff support and primary care mental
Emily P Hyle
Full Text Available Point-of-care CD4 tests at HIV diagnosis could improve linkage to care in resource-limited settings. Our objective is to evaluate the clinical and economic impact of point-of-care CD4 tests compared to laboratory-based tests in Mozambique.We use a validated model of HIV testing, linkage, and treatment (CEPAC-International to examine two strategies of immunological staging in Mozambique: (1 laboratory-based CD4 testing (LAB-CD4 and (2 point-of-care CD4 testing (POC-CD4. Model outcomes include 5-y survival, life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs. Input parameters include linkage to care (LAB-CD4, 34%; POC-CD4, 61%, probability of correctly detecting antiretroviral therapy (ART eligibility (sensitivity: LAB-CD4, 100%; POC-CD4, 90% or ART ineligibility (specificity: LAB-CD4, 100%; POC-CD4, 85%, and test cost (LAB-CD4, US$10; POC-CD4, US$24. In sensitivity analyses, we vary POC-CD4-specific parameters, as well as cohort and setting parameters to reflect a range of scenarios in sub-Saharan Africa. We consider ICERs less than three times the per capita gross domestic product in Mozambique (US$570 to be cost-effective, and ICERs less than one times the per capita gross domestic product in Mozambique to be very cost-effective. Projected 5-y survival in HIV-infected persons with LAB-CD4 is 60.9% (95% CI, 60.9%-61.0%, increasing to 65.0% (95% CI, 64.9%-65.1% with POC-CD4. Discounted life expectancy and per person lifetime costs with LAB-CD4 are 9.6 y (95% CI, 9.6-9.6 y and US$2,440 (95% CI, US$2,440-US$2,450 and increase with POC-CD4 to 10.3 y (95% CI, 10.3-10.3 y and US$2,800 (95% CI, US$2,790-US$2,800; the ICER of POC-CD4 compared to LAB-CD4 is US$500/year of life saved (YLS (95% CI, US$480-US$520/YLS. POC-CD4 improves clinical outcomes and remains near the very cost-effective threshold in sensitivity analyses, even if point-of-care CD4 tests have lower sensitivity/specificity and higher cost than published
Halman, Marc A.; Szerlag, Chester
Objective: Identify the business practices necessary to develop a successful radiation oncology department in the current health care environment. Course content will be of interest to new practitioners establishing first time programs or joining existing groups as well as experienced radiation oncologists who are challenged with redesigning programs to be competitive. Course Content: During this session, the following topics will be discussed: 1) Space planning and equipment selection 2) Personnel; creating efficiencies while promoting productivity 3) Professional and Technical Billing; establishing proper fee structures and coding procedures 4) Utilizing benchmarking as a tool to improve operations 5) Information technology in radiation oncology 6) Current and Future Trends: a) Oncology networks b) Reimbursement: managed care and capitation c) Downsizing d) Relative Value Units
Ruiz Oropeza, Athamaica; Lassen, Annmarie; Halken, Susanne
BACKGROUND: Current data on anaphylaxis is based on retrospective and register based studies. The objective of this study was to describe the epidemiology of anaphylaxis in a 1 year prospective study at the emergency care setting, Odense University Hospital, Denmark (2013-2014). METHODS: Prospect......BACKGROUND: Current data on anaphylaxis is based on retrospective and register based studies. The objective of this study was to describe the epidemiology of anaphylaxis in a 1 year prospective study at the emergency care setting, Odense University Hospital, Denmark (2013-2014). METHODS......: Prospective study at the emergency care setting, Odense University Hospital, Denmark (2013-2014). To identify anaphylaxis cases, records from all patients with clinical suspicion on anaphylaxis or a related diagnosis according to the International Classification of Diseases 10 and from patients treated...... at the emergency care setting or at prehospital level with adrenaline, antihistamines or glucocorticoids were reviewed daily. The identified cases were referred to the Allergy Center, where a standardized interview regarding the anaphylactic reaction was conducted. International guidelines were applied...
Newland, P L
The modern clinical practice setting presents nurses with challenges about which they must think critically and develop increasingly autonomous problem-solving approaches. It is essential to provide nursing students with opportunities to practice critical thinking so that they can develop this crucial skill. Cooperative learning strategies are interactive teaching methods that stimulate students to think critically, communicate effectively with peers, and accept responsibility for learning through group process activities. Group care planning is one such cooperative strategy that also promotes a positive attitude about care planning and sharpens time management skills. Cooperative assessment and care planning foster the development of critical thinking and effective problem resolution, preparing students for patient care problems they will likely encounter in future positions.
Carnes, Debra; Kilpatrick, Sue; Iedema, Rick
This study aims to determine the likelihood that rural nurses perceive a hypothetical medication error would be reported in their workplace. This employs cross-sectional survey using hypothetical error scenario with varying levels of harm. Clinical settings in rural Tasmania. Participants were 116 eligible surveys received from registered and enrolled nurses. Frequency of responses indicating the likelihood that severe, moderate and near miss (no harm) scenario would 'always' be reported or disclosed. Eighty per cent of nurses viewed a severe error would 'always' be reported, 64.8% a moderate error and 45.7% a near-miss error. In regards to disclosure, 54.7% felt this was 'always' likely to occur for a severe error, 44.8% for a moderate error and 26.4% for a near miss. Across all levels of severity, aged-care nurses were more likely than nurses in other settings to view error to 'always' be reported (ranging from 72-96%, P = 0.010 to 0.042,) and disclosed (68-88%, P = 0.000). Those in a management role were more likely to view error to 'always' be disclosed compared to those in a clinical role (50-77.3%, P = 0.008-0.024). Further research in rural clinical settings is needed to improve the understanding of error management and disclosure. © 2015 The Authors. Australian Journal of Rural Health published by Wiley Publishing Asia Pty Ltd on behalf of National Rural Health Alliance.
Full Text Available Nonalcoholic fatty liver disease (NALFD is a leading cause of liver disease. Weight loss improves clinical features of NAFLD; however, maintenance of weight loss outside of investigational protocols is poor. The goals of this study were to characterize patterns and clinical predictors of long-term weight loss in ambulatory patients with NAFLD.We retrospectively reviewed 924 non-cirrhotic patients with NAFLD presenting to a liver clinic from May 1st 2007 to April 30th 2013. Overweight and obese patients were counseled on lifestyle modifications for weight loss as per USPSTF guidelines. The primary outcome was percent weight change between the first and last recorded visits: % weight change = (weightinitial - weightfinal/(weightinitial. Baseline BMI and percent BMI change were secondary measures. Predictors of weight loss were determined using logistic regression.The mean baseline BMI was 33.3±6.6 kg/m2, and the mean follow-up duration was 17.3±17.6 months. Most patients with NAFLD were in either overweight (26.1% or class I obesity (30.5% categories at baseline, while the prevalence of underweight and class III obesity was lower (0.2% and 15.4%, respectively. Overall, there was no change in mean weight or BMI during the follow-up period, and only 183 patients (19.8% lost at least 5% body weight during the follow up period. Independent predictors of weight loss included number of clinic visits and baseline BMI, and patients with higher baseline BMI required more clinic visits to lose weight.Weight loss is largely unsuccessful in NAFLD patients in the ambulatory care setting. Frequent clinical encounters are associated with weight reduction, especially among individuals with high baseline BMI. Future studies are required to define effective weight loss strategies in NAFLD patients.
Pérez, Concepción; Navarro, Ana; Saldaña, María T; Masramón, Xavier; Pérez, María; Rejas, Javier
To describe clinical and resource utilization patterns in patients with refractory neuropathic pain (NeP) who were prescribed pregabalin for the first time in routine medical practice in primary care settings. Post-hoc analysis of a 12-week prospective observational study including pregabalin naïve adult patients with refractory chronic NeP of at least 6-months duration. Self-reported pain intensity, disability, sleep disturbances, symptoms of anxiety and depression, disability, health-related quality of life (HRQoL), health care resource utilization, and corresponding costs were assessed in this post-hoc analysis. One thousand three hundred fifty-four patients were enrolled in the study, and three treatment groups were identified: (1) 598 patients replaced prior pain treatments with pregabalin as monotherapy; (2) 589 added pregabalin to their existing pain treatments; and (3) 167 other pain treatments were prescribed according with physician routine medical practice. Statistically significant differences were reported at baseline for intensity of pain, patient disability, severity of depressive symptoms, and HRQoL (P use of direct and indirect resources vs the other groups, resulting in significantly higher quarterly overall costs per patient: €2,397 (2,308), €2,470 (1,857), and €3,110 (2,496), respectively (P < 0.001). These findings suggest that primary care physicians chose pregabalin as an option for treating refractory patients who tended to have much more severe NeP profiles, costing society more than when they chose other therapeutic strategies not including pregabalin. Wiley Periodicals, Inc.
Margaret B. Harrison
Full Text Available This study followed a cohort of community-dwelling individuals receiving wound-care in a large urban-rural region. During a randomized control trial (RCT evaluating outcomes of receiving care in a nurse-clinic or at home, many approached were willing to participate if they could choose their location of care. This provided a unique opportunity to enroll them as a “choice” cohort, following them in the same manner as the trial participants but allowing them to select their setting of care. The objective was to investigate the role of preference and location of care on care outcomes, including satisfaction with care, healing, health-related quality of life (HRQL, pain, and resource use. This is a secondary analysis of a prospective cohort of 126 individuals enrolled in an RCT to receive care at home or in a nurse-clinic (Allocated group, and an additional 104 who received care at home or in a nurse-clinic based on their preference (Choice group. Mobile individuals with a leg ulcer of venous or mixed venous etiology, referred for community leg ulcer care, were eligible. Specially-trained nurses provided care to both groups using an evidence-informed protocol. Baseline data included socio-demographic, circumstance-of-living and a detailed wound assessment. Mean age of the cohort was 68 years. Satisfaction, healing, recurrence, pain, HRQL, and resource utilization did not differ between groups. If available, individuals should have an option of care venue given almost half of those approached indicated a clear preference for clinic or home. With outcomes being similar, health care planners and decision-makers, as well as individuals and their families, can feel confident that the setting of care will not impact the outcomes. However, larger studies in other contexts are needed to explore the interaction between choice and setting.
Harrison, Margaret B; VanDenKerkhof, Elizabeth G; Hopman, Wilma M; Carley, Meg E
This study followed a cohort of community-dwelling individuals receiving wound-care in a large urban-rural region. During a randomized control trial (RCT) evaluating outcomes of receiving care in a nurse-clinic or at home, many approached were willing to participate if they could choose their location of care. This provided a unique opportunity to enroll them as a "choice" cohort, following them in the same manner as the trial participants but allowing them to select their setting of care. The objective was to investigate the role of preference and location of care on care outcomes, including satisfaction with care, healing, health-related quality of life (HRQL), pain, and resource use. This is a secondary analysis of a prospective cohort of 126 individuals enrolled in an RCT to receive care at home or in a nurse-clinic (Allocated group), and an additional 104 who received care at home or in a nurse-clinic based on their preference (Choice group). Mobile individuals with a leg ulcer of venous or mixed venous etiology, referred for community leg ulcer care, were eligible. Specially-trained nurses provided care to both groups using an evidence-informed protocol. Baseline data included socio-demographic, circumstance-of-living and a detailed wound assessment. Mean age of the cohort was 68 years. Satisfaction, healing, recurrence, pain, HRQL, and resource utilization did not differ between groups. If available, individuals should have an option of care venue given almost half of those approached indicated a clear preference for clinic or home. With outcomes being similar, health care planners and decision-makers, as well as individuals and their families, can feel confident that the setting of care will not impact the outcomes. However, larger studies in other contexts are needed to explore the interaction between choice and setting.
Niknami, Marzieh; Mirbalouchzehi, Ali; Zareban, Iraj; Kalkalinia, Elahibakhsh; Rikhtgarha, Gasem; Hosseinzadeh, Hassan
This study explores the potential association of health literacy with type 2 diabetes mellitus (T2DM) self-management and clinical outcomes in the primary care setting of Iran. A total of 347 T2DM patients, mostly female (52.4%), 50 years old or younger (63.1%), unemployed (53.6%) and rural residents (55.6%) participated in this study. Most of the respondents had type 2 diabetes mellitus (T2DM) for 2-5 years (63.1%) and did not receive any T2DM education (52.2%). Approximately 19.0% were hospitalised due to uncontrolled T2DM. Participants mainly found managing T2DM self-management behaviours difficult. Approximately half of the participants had poor fasting blood sugar (FBS) (47.0%) and haemoglobin A1c (HbA1c) (59.4%) control and were overweight or obese (77.6%). The level of health literacy was poor and most of the participants had difficulties reading hospital materials (66.0%), understanding medical materials (62.5%) and engaging in medical conversations (63.7%). Health literacy could predict 22.5% variance in difficulty of T2DM self-management and 3.8-23.3% variance in T2DM clinical outcomes after controlling for sociodemographic factors. Participants with higher health literacy were more likely to find managing T2DM less challenging and their clinical outcomes were within the normal range. This implies that interventions targeting patient's health literacy can be a promising tool for addressing the burden of T2DM.
Abdelaziz, Adel; Hany, Mohamed; Atwa, Hani; Talaat, Wagdy; Hosny, Somaya
In ordinary circumstances, objective structured clinical examination (OSCE) is a resource-intensive assessment method. In case of developing and implementing multidisciplinary OSCE, there is no doubt that the cost will be greater. Through this study a research project was conducted to develop, implement and evaluate a multidisciplinary OSCE model within limited resources. This research project went through the steps of blueprinting, station writing, resources reallocation, implementation and finally evaluation. The developed model was implemented in the Primary Health Care (PHC) program which is one of the pillars of the Community-Based undergraduate curriculum of the Faculty of Medicine, Suez Canal University (FOM-SCU). Data for evaluation of the implemented OSCE model were derived from two resources. First, feedback of the students and assessors through self-administered questionnaires was obtained. Second, evaluation of the OSCE psychometrics was done. The deliverables of this research project included a set of validated integrated multi-disciplinary and low cost OSCE stations with an estimated reliability index of 0.6. After having this experience, we have a critical mass of faculty members trained on blueprinting and station writing and a group of trained assessors, facilitators and role players. Also there is a state of awareness among students on how to proceed in this type of OSCE which renders future implementation more feasible.
Smeltzer, Matthew P.; Rugless, Fedoria E.; Jackson, Bianca M.; Berryman, Courtney L.; Faris, Nicholas R.; Ray, Meredith A.; Meadows, Meghan; Patel, Anita A.; Roark, Kristina S.; Kedia, Satish K.; DeBon, Margaret M.; Crossley, Fayre J.; Oliver, Georgia; McHugh, Laura M.; Hastings, Willeen; Osborne, Orion; Osborne, Jackie; Ill, Toni; Ill, Mark; Jones, Wynett; Lee, Hyo K.; Signore, Raymond S.; Fox, Roy C.; Li, Jingshan; Robbins, Edward T.; Ward, Kenneth D.; Klesges, Lisa M.
Background Responsible for 25% of all US cancer deaths, lung cancer presents complex care-delivery challenges. Adoption of the highly recommended multidisciplinary care model suffers from a dearth of good quality evidence. Leading up to a prospective comparative-effectiveness study of multidisciplinary vs. serial care, we studied the implementation of a rigorously benchmarked multidisciplinary lung cancer clinic. Methods We used a mixed-methods approach to conduct a patient-centered, combined implementation and effectiveness study of a multidisciplinary model of lung cancer care. We established a co-located multidisciplinary clinic to study the implementation of this care-delivery model. We identified and engaged key stakeholders from the onset, used their input to develop the program structure, processes, performance benchmarks, and study endpoints (outcome-related process measures, patient- and caregiver-reported outcomes, survival). In this report, we describe the study design, process of implementation, comparative populations, and how they contrast with patients within the local and regional healthcare system. Trial Registration: ClinicalTrials.gov Identifier: NCT02123797. Results Implementation: the multidisciplinary clinic obtained an overall treatment concordance rate of 90% (target >85%). Satisfaction scores were high, with >95% of patients and caregivers rating themselves as being “very satisfied” with all aspects of care from the multidisciplinary team (patient/caregiver response rate >90%). The Reach of the multidisciplinary clinic included a higher proportion of minority patients, more women, and younger patients than the regional population. Comparative effectiveness: The comparative effectiveness trial conducted in the last phase of the study met the planned enrollment per statistical design, with 178 patients in the multidisciplinary arm and 348 in the serial care arm. The multidisciplinary cohort had older age and a higher percentage of racial
Geber, Jean; Parra, David; Beckey, Nick P; Korman, Lisa
We evaluated the effectiveness of pharmacist-managed pharmacotherapy clinics in implementing and maximizing therapy with agents known to reduce the morbidity and mortality associated with cardiovascular disease. This was a retrospective chart review of 150 patients who were treated for coronary artery disease in primary care clinics. Appropriate treatment of hypercholesterolemia occurred in 96% of patients referred to a clinical pharmacy specialist, compared with 68% of those followed by primary care providers alone (p<0.0001). Eighty-five percent and 50%, respectively, achieved goal low-density lipoprotein (LDL) values below 105 mg/dl (p<0.0001). Appropriate therapy with aspirin or other antiplatelet or anticoagulant drugs was prescribed in 97% and 92%, respectively (p=0.146). As appropriate therapy with these agents was high in both groups, the ability to detect a difference between groups was limited. Among patients with an ejection fraction below 40%, appropriate therapy with an angiotensin-converting enzyme inhibitor or acceptable alternative was 89% and 69%, respectively (p<0.05). Twenty-seven cardiac events were documented in the clinical pharmacy group, versus 22 in the primary care group (p=0.475). Despite the relatively high percentage of patients reaching goal LDL in the primary care group, referral to clinical pharmacy specialists resulted in statistically significant increases in the number of patients appropriately treated for hypercholesterolemia and achieving goal LDL.
Harrison, Margaret B.; VanDenKerkhof, Elizabeth G.; Hopman, Wilma M.; Carley, Meg E.
This study followed a cohort of community-dwelling individuals receiving wound-care in a large urban-rural region. During a randomized control trial (RCT) evaluating outcomes of receiving care in a nurse-clinic or at home, many approached were willing to participate if they could choose their location of care. This provided a unique opportunity to enroll them as a “choice” cohort, following them in the same manner as the trial participants but allowing them to select their setting of care. Th...
Gosselin, Emilie; Bourgault, Patricia; Lavoie, Stephan; Coleman, Robin-Marie; Méziat-Burdin, Anne
Pain management in the intensive care unit is often inadequate. There is no tool available to assess nursing pain management practices. The aim of this study was to develop and validate a measuring tool to assess nursing pain management in the intensive care unit during standardized clinical simulation. A literature review was performed to identify relevant components demonstrating optimal pain management in adult intensive care units and to integrate them in an observation tool. This tool was submitted to an expert panel and pretested. It was then used to assess pain management practice during 26 discrete standardized clinical simulation sessions with intensive care nurses. The Nursing Observation Tool for Pain Management (NOTPaM) contains 28 statements grouped into 8 categories, which are grouped into 4 dimensions: subjective assessment, objective assessment, interventions, and reassessment. The tool's internal consistency was calculated at a Cronbach's alpha of 0.436 for the whole tool; the alpha varies from 0.328 to 0.518 for each dimension. To evaluate the inter-rater reliability, intra-class correlation coefficient was used, which was calculated at 0.751 (p nurses' pain management in a standardized clinical simulation. The NOTPaM is the first tool created for this purpose. Copyright © 2014 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
U.S. Department of Health & Human Services — The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive...
Conclusion Although there is validation that CDSS has the potential to produce statistically significant improvement in outcomes, there is much variability among the types and methods of CDSS implementation and resulting effectiveness. As CDSS will likely continue to be at the forefront of the march toward effective standards-based care, more work needs to be done to determine effective implementation strategies for the use of CDSS across multiple settings and patient populations.
M de Wet
Full Text Available One of the challenges facing primary health care in South Africa is the delivery of quality eye care to all South Africans. In this regard the role of the primary health care worker, as the first point of contact, is crucial. This paper reports on the problems primary health care workers experience in providing quality eye care in Region B of the Free State. Problems identified by those involved in the study include the cumbersome referral system, the unavailability of appropriate medicine at clinics, the insufficient knowledge of primary health care workers regarding eye conditions and the lack of communication between the various eye care service providers. Suggestions to address the problems identified included more in-service training of primary health care workers regarding eye conditions, liaison with NGO’s providing eye care, decentralisation of services and the establishment of an eye care committee in the region.
Leppert, Wojciech; Majkowicz, Mikolaj; Ahmedzai, Sam H
Assessment of the needs of advanced cancer patients is a very important issue in palliative care. The aim of the study was to adapt the Sheffield Profile for Assessment and Referral for Care (SPARC) to the Polish environment and evaluate its usefulness in needs assessment of patients with advanced cancer. A forward-back translation of the SPARC to Polish was done. The SPARC was used once in 58 consecutive patients with advanced cancer during follow-up. The patients were enrolled from a palliative care unit (25 patients), home care (18 patients), and a day care center (15 patients). The reliability was evaluated by establishing the internal consistency using Cronbach's alpha coefficients. Content validity was analyzed in accordance with the theories of needs by Murray and Maslow as a nonstatistical method of validity assessment. Factor analysis with principal components extraction and varimax rotation of raw data was used to reduce the set of data and assess the construct validity. There were differences regarding religious and spiritual issues and independence and activity between patients in the palliative care unit (worse results) and those at the day care center (better scores). Communication and need for more information items were associated with psychological, social, spiritual, and treatment issues. Cronbach's alpha coefficients and factor analysis demonstrated, respectively, satisfactory reliability and construct validity of the tool. The study demonstrated that the Polish version of the SPARC is a valid and reliable tool recommended for the needs assessment and symptom evaluation of patients with advanced cancer. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Kelly, R. Patrick; Stoll, Shelley C.; Bryant-Stephens, Tyra; Janevic, Mary R.; Lara, Marielena; Ohadike, Yvonne U.; Persky, Victoria; Ramos-Valencia, Gilberto; Uyeda, Kimberly; Malveaux, Floyd J.
Asthma affects 7.1 million children in the United States, disproportionately burdening African American and Latino children. Barriers to asthma control include insufficient patient education and fragmented care. Care coordination represents a compelling approach to improve quality of care and address disparities in asthma. The sites of The Merck Childhood Asthma Network Care Coordination Programs implemented different models of care coordination to suit specific settings—school district, clinic or health care system, and community—and organizational structures. A variety of qualitative data sources were analyzed to determine the role setting played in the manifestation of care coordination at each site. There were inherent strengths and challenges of implementing care coordination in each of the settings, and each site used unique strategies to deliver their programs. The relationship between the lead implementing unit and entities that provided (1) access to the priority population and (2) clinical services to program participants played a critical role in the structure of the programs. The level of support and infrastructure provided by these entities to the lead implementing unit influenced how participants were identified and how asthma care coordinators were integrated into the clinical care team. PMID:26232778
Dickstein, Yaakov; Neuberger, Ami; Golus, Miri; Schwartz, Eli
This study examined the demographic and epidemiological differences between patient populations presenting to a rural and an urban clinic in Haiti. A primary health clinic was established in urban Leogane, and a once-weekly clinic was established in Magandou, a rural village. Patient data were recorded for all individuals presenting to each clinic. Over 7 months, 6632 patients (median age 25) were seen in the urban clinic, and 567 (median age 47) in the rural clinic. There was a female majority at both sites. Hypertension was diagnosed in 41.9% (238/567) of the rural population over 40 years of age, while 29.5% (1956/6632) of patients in the urban setting had the same diagnosis (pHaiti must address the wide rural prevalence. STDs are a major urban health issue requiring treatment for both patients and their partners. Vector-borne disease was unseen in the rural clinic, despite an altitude insufficient to prevent mosquito-borne illness. © The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: email@example.com.
Aguilar-Duran, S; Ahmed, A; Taylor, R; Bewley, A
Psychodermatology is a recognized subspecialty, but lack of awareness among dermatologists and limitation of resources make the management of these patients challenging. Clinicians are often unsure about the practicalities of setting up a psychodermatology service. There is confusion about which model is best suited to which service, and about the development of a psychodermatology multidisciplinary team. To identify the necessary steps in setting up a psychodermatology clinic. The study was based on the experience of a UK-based psychodermatology unit and the recently published standards by the UK Psychodermatology Working Party. The type of service provision will depend on the type of patients seen in the unit. The core team will be composed of a psychodermatologist and a psychologist. Access to a psychiatrist is essential if patients present with primary psychiatric conditions or primary cutaneous conditions with suicidal or other psychiatric risks. Adequate training of the healthcare staff is advised. The premises and time allocation should be adequate, and this translates into higher tariffs. Using business care tariffs for people with mental health conditions might be more appropriate, as the consultations are longer and involve more members of staff; however, the overall cost remains lower than if these patients were seen in a general dermatology service or in the community. Psychodermatology services are globally limited, and yet the demand for psychodermatology care is high. There is evidence that dedicated psychodermatology services are cost-effective. Healthcare professionals need to be aware of the steps necessary to establish and maintain psychodermatology services. © 2014 British Association of Dermatologists.
Onders, Robert; Spillane, James; Reilley, Brigg; Leston, Jessica
The Kodiak Area Native Association (KANA) provides primary health care in Kodiak, Alaska and 6 outlying villages. KANA sought to actively improve key preventive screening rates for its patients. KANA adopted an electronic health record in 2008 and deployed national clinical reminders from the Indian Health Service for 5 key preventive screenings: tobacco use, alcohol use, depression, intimate partner violence, and a comprehensive cardiovascular exam. Clinical reminders were deployed in a 5-step process: (a) establish clinical demand, (b) pilot test reminder, (c) expand reminder to all providers, (d) measure outcomes and share results, and (e) delegate clinical reminder follow-up (primarily to nurses). Data from 2007-2011 show screening rates for all 5 measures improved considerably, to levels significantly above the national average for Indian Health Service facilities. Clinical reminders have been a key part of a multistep process to improve screening for depression, tobacco cessation, intimate partner violence, alcohol use, and cardiovascular disease. If deployed correctly, reminders are valuable tools in identifying patients who are overdue for preventive health screenings.
Paliwoda, Michelle; New, Karen; Bogossian, Fiona
All newborns are at risk of deterioration as a result of failing to make the transition to extra uterine life. Signs of deterioration can be subtle and easily missed. It has been postulated that the use of an Early Warning Tool may assist clinicians in recognising and responding to signs of deterioration earlier in neonates, thereby preventing a serious adverse event. To examine whether observations from a Standard Observation Tool, applied to three neonatal Early Warning Tools, would hypothetically trigger an escalation of care more frequently than actual escalation of care using the Standard Observation Tool. A retrospective case-control study. A maternity unit in a tertiary public hospital in Australia. Neonates born in 2013 of greater than or equal to 34(+0) weeks gestation, admitted directly to the maternity ward from their birthing location and whose subsequent deterioration required admission to the neonatal unit, were identified as cases from databases of the study hospital. Each case was matched with three controls, inborn during the same period and who did not experience deterioration and neonatal unit admission. Clinical and physiological data recorded on a Standard Observation Tool, from time of admission to the maternity ward, for cases and controls were charted onto each of three Early Warning Tools. The primary outcome was whether the tool 'triggered an escalation of care'. Descriptive statistics (n, %, Mean and SD) were employed. Cases (n=26) comprised late preterm, early term and post-term neonates and matched by gestational age group with 3 controls (n=78). Overall, the Standard Observation Tool triggered an escalation of care for 92.3% of cases compared to the Early Warning Tools; New South Wales Health 80.8%, United Kingdom Newborn Early Warning Chart 57.7% and The Australian Capital Territory Neonatal Early Warning Score 11.5%. Subgroup analysis by gestational age found differences between the tools in hypothetically triggering an escalation of
Dubovsky, Amelia N; Kiefer, Meghan M
Borderline personality disorder is estimated to be present in approximately 6% of outpatient primary care settings. However, the time and energy spent on this population can greatly exceed what primary care doctors are able to spend. This article gives an overview of borderline personality disorder, including the clinical characteristics, epidemiology, and comorbidities, as well as pharmacologic and most important behavioral management. It is our hope that, with improved understanding of the disorder and skills for managing this population, caring for patients with the disorder can be more satisfying and less taxing for both primary care doctors and their patients. Copyright © 2014 Elsevier Inc. All rights reserved.
Liu, Min; Liu, Keh-Min
In a clinical skills assessment, the decision to pass or fail an examinee should be based on the test content or on the examinees' performance. The process of deciding a pass score is known as setting a standard of the examination. This requires a properly selected panel of expert judges and a suitable standard setting method, which best fits the purpose of the examination. Six standard setting methods that are often used in clinical skills assessment are described to provide an overview of the standard setting process.
Full Text Available In a clinical skills assessment, the decision to pass or fail an examinee should be based on the test content or on the examinees' performance. The process of deciding a pass score is known as setting a standard of the examination. This requires a properly selected panel of expert judges and a suitable standard setting method, which best fits the purpose of the examination. Six standard setting methods that are often used in clinical skills assessment are described to provide an overview of the standard setting process.
Polo García, J; Barrios Alonso, V; Escobar Cervantes, C; Prieto Valiente, L; Lobos Bejarano, J M; Vargas Ortega, D; Prieto Díaz, M Á; Alonso Moreno, F J; Barquilla García, A
To determine the differences between regions in the level of control of patients with non-valvular atrial fibrillation treated with vitamin K antagonists, included in the PAULA study. Observational, and coss-sectional/retrospective study, including 139 Primary Care physicians from 99 Health Care centres in all autonomous communities (except La Rioja). Anticoagulation control was defined as the time in therapeutic range assessed by either the direct method (poor control <60%), or the Rosendaal method (poor control <65%). A total of 1,524 patients were included. Small differences in baseline characteristics of the patients were observed. Differences in the percentage of time in therapeutic range were observed, according to the Rosendaal method (mean 69.0±17.7%), from 78.1%±16.6 (Basque Country) to 61.5±14% (Balearic Islands), by the direct method (mean 63.2±17.9%) from 73.6%±16.6 (Basque Country) to 57.5±15.7% (Extremadura). When comparing regions, in those where the Primary Care physicians assumed full control without restrictions on prescription, the percentage of time in therapeutic range by the direct method was 63.89 vs. 60.95% in those with restrictions (p=.006), by Rosendaal method, 69.39% compared with 67.68% (p=.1036). There are significant differences in the level of control between some regions are still inadequate. Regions in which the Primary Care physicians assumed the management of anticoagulation and without restrictions, time in therapeutic range was somewhat higher, and showed a favourable trend for better control. These findings may have clinical implications, and deserve consideration and specific analysis. Copyright © 2016 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Ginex, Pamela K; Hernandez, Marisol; Vrabel, Mark
Nurses in clinical settings in which evidence-based, individualized care is expected are often the best resource to identify important clinical questions and gaps in practice. These nurses are frequently challenged by a lack of resources to fully develop their questions and identify the most appropriate methods to answer them. A strategic and ongoing partnership between medical library services and nursing can support nurses as they embark on the process of answering these questions and, ultimately, improving patient care and clinical outcomes
Pressure ulcer prevention in the care home setting can be challenging and is often compromised by a lack of access to education and resources. There are measures that have been shown to consistently improve outcomes in pressure ulcer prevention including assessment of the patient and their individual risks, delivery of a consistent plan of care that meets patients' needs, and regular evaluation to identify shortfalls. In addition, there should be a robust approach to investigating events that lead to a person developing a pressure ulcer and that information should be used to improve future practice. Pressure ulcer prevention in care homes is achievable and nurses should all be aware of the necessary measures detailed in this article.
Baldonado, Analiza; Hawk, Ofelia; Ormiston, Thomas; Nelson, Danielle
Patients who are high risk high cost (HRHC), those with severe or multiple medical issues, and the chronically ill elderly are major drivers of rising health care costs.1 The HRHC patients with complex health conditions and functional limitations may likely go to emergency rooms and hospitals, need more supportive services, and use long-term care facilities.2 As a result, these patient populations are vulnerable to fragmented care and "falling through the cracks".2 A large county health and hospital system in California, USA introduced evidence-based interventions in accordance with the Triple AIM3 focused on patient-centered health care, prevention, health maintenance, and safe transitions across the care continuum. The pilot program embedded a Transitional Care Manager (TCM) within an outpatient Family Medicine clinic to proactively assist HRHC patients with outreach assistance, problem-solving and facilitating smooth transitions of care. This initiative is supported by a collaborative team that included physicians, nurses, specialists, health educator, and pharmacist. The initial 50 patients showed a decrease in Emergency Department (ED) encounters (pre-vs post intervention: 33 vs 17) and hospital admissions (pre-vs post intervention: 32 vs 11), improved patient outcomes, and cost saving. As an example, one patient had 1 ED visit and 5 hospital admission with total charges of $217,355.75 in the 6 months' pre-intervention with no recurrence of ED or hospital admissions in the 6 months of TCM enrollment. The preliminary findings showed improvement of patient-centered outcomes, quality of care, and resource utilization however more data is required.
Treatment with glucocorticoids is the leading cause of drug-induced osteoporosis. National Osteoporosis Guideline Group (NOGG) 2017 guidelines advise a case-finding strategy for patients at risk. The aims of the audit were to evaluate the implementation of the NOGG 2017 guidelines for patients receiving long-term glucocorticoid therapy in a suburban general practice, to instigate changes to ensure 90% of patients are investigated and treated appropriately, and to evaluate impact at a 6-mo re-audit. Reporting Analysis and Intelligence Delivering Results (RAIDR) is a health-care intelligence tool accessing primary care clinical data. Using RAIDR, data on relevant osteoporotic risk factors were combined to produce FRAX scores for patients who had been prescribed glucocorticoids 3 or more times in the past 12 months. FRAX data were displayed in a NOGG guidance graph for major osteoporotic fracture probability. Patients were assessed as high, intermediate, or low risk. High- and intermediate-risk patients above the NOGG threshold were recommended to start bisphosphonates; these patients were sent a prescription for alendronate and a letter of explanation. There were no intermediate patients below the NOGG threshold. Low-risk patients were recommended to have lifestyle advice; a leaflet was produced and sent to these patients. Initial results showed that only 25% of patients recommended to be on bisphosphonates were taking them. Steps were taken to educate the general practitioners in the FRAX tool and NOGG guidelines; the chronic obstructive pulmonary disease annual template was amended to aid adherence by alerting the nurse to the number of glucocorticoid courses prescribed, with additional boxes for prescribing alendronate and printing the lifestyle leaflet; and 2-monthly RAIDR searches by the practice pharmacist were started. A re-audit 6 mo later showed improvement to 92%. This audit showed that education, reminders, and simple computer prompts can greatly improve
S. M. Yasir Arafat
Full Text Available Background. Bangladesh is a country in South Asia with about 160 million people and achieved health related Millennium Development Goals (MDG significantly. But sexual health is still an untapped issue with predominant myths and misconception. Objective. We aimed to look into the proportions of patients attending sexual health care services due to misconceptions. Methods. The descriptive, cross-sectional study was conducted among 110 patients attending Psychiatric Sex Clinic (PSC of Bangabandhu Sheikh Mujib Medical University. Respondents were included in the study with convenient sampling from November 2016 to March 2017. Data were collected through face-to-face interview with semistructured preformed, pretested questionnaire and analyzed by SPSS software 16.0 version. Results. Most of the patients (93% were male, 60% were married, 62% were urban habitant, 42% were under grade 10, and 33% were service holder. Total 55% of the patients had misconceptions and 29% visited only for misconception; 14% had Premature Ejaculation; and 12% had desire disorder. 32% of the patients had psychiatric disorders and among them depression was most common, 13%. Conclusion. Positive openness in sexual health and appropriate strategy should be taken to improve the quality of sexual life as well as reduce the misconception in the people of Bangladesh.
Wensaas, Knut-Arne; Hungin, Amrit Pali
Diverticular disease is a chronic and common condition, and yet the impact of diverticular disease in primary care is largely unknown. The diagnosis of diverticular disease relies on the demonstration of diverticula in the colon, and the necessary investigations are often not available in primary care. The specificity and sensitivity of symptoms, clinical signs and laboratory tests alone are generally low and consequently the diagnostic process will be characterized by uncertainty. Also, the criteria for symptomatic uncomplicated diverticular disease in the absence of macroscopic inflammation are not clearly defined. Therefore both the prevalence of diverticular disease and the incidence of diverticulitis in primary care are unknown. Current recommendations for treatment and follow-up of patients with acute diverticulitis are based on studies where the diagnosis has been verified by computerized tomography. The results cannot be directly transferred to primary care where the diagnosis has to rely on the interpretation of symptoms and signs. Therefore, one must allow for greater diagnostic uncertainty, and safety netting in the event of unexpected development of the condition is an important aspect of the management of diverticulitis in primary care. The highest prevalence of diverticular disease is found among older patients, where multimorbidity and polypharmacy is common. The challenge is to remember the possible contribution of diverticular disease to the patient's overall condition and to foresee its implications in terms of advice and treatment in relation to other diseases.
Siegrist, Monika; Freiberger, Ellen; Geilhof, Barbara; Salb, Johannes; Hentschke, Christian; Landendoerfer, Peter; Linde, Klause; Halle, Martin; Blank, Wolfgang A
Falls and fall-related injuries are common in community-dwelling elderly people. Effective multifactorial fall prevention programs in the primary care setting may be a promising approach to reduce the incidence rate of falls. In a cluster randomized trial in 33 general practices 378 people living independently and at high risk of falling (65 to 94 years old; 285 women) were allocated to either a 16 week exercise-based fall prevention program including muscle strengthening and challenging balance training exercises, combined with a 12 week home-based exercise program (222 participants), or to usual care (156 participants). The main outcome was number of falls over a period of 12 months. Secondary outcomes were the number of fall-related injuries, physical function (Timed-Up-and-Go-Test, TUG, Chair-Stand-Test, CST, modified Romberg Test), and fear of falling. In the intervention group (n=222 patients in 17 general practices) 291 falls occurred, compared to 367 falls in the usual care group (n=156 patients in 16 general practices). We observed a lower incidence rate for falls in the intervention group (incidence rate ratio/IRR: 0.54; 95% confidence interval (CI): [0.35; 0.84], p=0.007) and for fall-related injuries (IRR: 0.66; [0.42; 0.94], p=0.033). Additionally, patients in the intervention group showed significant improvements in secondary endpoints (TUG: -2.39 s, [-3.91; -0.87], p=0.014; mRomberg: 1.70 s, [0.35; 3.04], p=0.037; fear of falling: -2.28 points, [-3.87; -0.69], p=0.022) compared to usual care. A complex falls prevention program in a primary care setting was effective in reducing falls and fall-related injuries in community dwelling older adults at risk.
Full Text Available Background and Objective: Appropriate clinical environment has an important role in preparing students to use learned knowledge in practice through providing learning opportunities. Since the students’ experiences in the clinical setting affect on quality of their learning, the current study aimed to explain the experiences of nursing students concerning clinical education setting. Materials and Method: The current study was conducted based on conventional content analysis. Sampling was done purposively and the participants were 13 last year nursing students in Zabol Nursing and Midwifery School in 2013-2014. Data collection was done through in-depth semi-structured interviews. Data analysis was conducted through qualitative content analysis approach. Results: Based on the results, five major categories including threats, vision, dual forces, mindset and students’ action to clinical education and also10 subcategorie were identified. Conclusion: Since the formation of students’ experiences in these environments is one of the predictive factors in achieving their learning and in facilitating the professionalization process, thus the attention of managers in clinical settings is very important for decreasing the threats and concerns for students. In this way, the marred prospects of profession can be recovered through the meeting students’ expectations, attractiveness of the profession can be increased and the positive belief, actions and feelings can be created in students.
Mathews, J J
The communication of information in clinical settings is fraught with problems despite avowed common aims of practitioners and patients. Some reasons for the problematic nature of clinical communication are incongruent frames of reference about what information ought to be shared, sociolinguistic differences and social distance between practitioners and patients. Communication between doctors and nurses is also problematic, largely due to differences in ideology between the professions about what ought to be communicated to patients about their illness and who is ratified to give such information. Recent social changes, such as the Patient Bill of Rights and informed consent which assure access to information, and new conceptualizations of the nurse's role, warrant continued study of the communication process especially in regard to what constitutes appropriate and acceptable information about a patient's illness and who ought to give such information to patients. The purpose of this paper is to outline characteristics of communication in clinical settings and to provide a literature review of patient and practitioner interaction studies in order to reflect on why information exchange is problematic in clinical settings. A framework for presentation of the problems employs principles from interaction and role theory to investigate clinical communication from three viewpoints: (1) the level of shared knowledge between participants; (2) the effect of status, role and ideology on transactions; and (3) the regulation of communication imposed by features of the institution.
Vyoma Grandhi Venkatesh
Full Text Available Introduction: Movement-disabled individuals require oral health care like everyone else. However, they face a multitude of accessibility issues. Since private dental clinics are the most commonly utilized type of oral health care in India, it becomes pertinent to know how accessible these clinics are for movement-disabled individuals. Aim: To assess the accessibility of private dental clinics in Bengaluru city to movement-disabled people. Materials and Methods: A cross-sectional survey was conducted among a random sample of 250 dentists practicing at private dental clinics in Bengaluru city using a structured questionnaire. The data were entered into the Microsoft Office Excel 2007 and were analyzed. Chi-square test was done to assess the association of dentists' previous experience in treating mobility-disabled patients and their attitude toward treating such patients. Results: In the current study, 81.2% (203 of the respondents expressed willingness to treat mobility-disabled individuals. However, wheelchair provision was present in only 15.6% (39 of the clinic, and only one-fifth of the clinics had a slope or ramp for facilitating entry of wheelchair-bound individuals. Gurneys, stretchers, and ceiling-mounted lifts were present in < 10% of the private dental clinics. The reasons for poor accessibility to movement disabled were reported as lack of financial resources followed by lack of utilization of facilities by movement-disabled individuals. Conclusion: The dentists displayed favorable attitude toward treating movement-disabled individuals. However, only a few private dental clinics met the architectural requirements and were equipped for treating such patients.
Burnet, Deborah L; Elliott, Lorrie D; Quinn, Michael T; Plaut, Andrea J; Schwartz, Mindy A; Chin, Marshall H
Translating lessons from clinical trials on the prevention or delay of type 2 diabetes to populations in nonstudy settings remains a challenge. The purpose of this paper is to review, from the perspective of practicing clinicians, available evidence on lifestyle interventions or medication to prevent or delay the onset of type 2 diabetes. A MEDLINE search identified 4 major diabetes prevention trials using lifestyle changes and 3 using prophylactic medications. We reviewed the study design, key components, and outcomes for each study, focusing on aspects of the interventions potentially adaptable to clinical settings. The lifestyle intervention studies set modest goals for weight loss and physical activity. Individualized counseling helped participants work toward their own goals; behavioral contracting and self-monitoring were key features, and family and social context were emphasized. Study staff made vigorous follow-up efforts for subjects having less success. Actual weight loss by participants was modest; yet, the reduction in diabetes incidence was quite significant. Prophylactic medication also reduced diabetes risk; however, lifestyle changes were more effective and are recommended as first-line strategy. Cost-effectiveness analyses have shown both lifestyle and medication interventions to be beneficial, especially as they might be implemented in practice. Strong evidence exists for the prevention or delay of type 2 diabetes through lifestyle changes. Components of these programs may be adaptable for use in clinical settings. This evidence supports broader implementation and increased reimbursement for provider services related to nutrition and physical activity to forestall morbidity from type 2 diabetes.
Payne, Sarah; Cole, Elaine
Many patients with minor burns present at emergency departments and urgent care centres, where their management is often undertaken by experienced nurses rather than experts in treating burns. This article describes a small study of the clinical decision making that underpins nurses' management of minor burns in these non-specialist settings. The results suggest that, due to a lack of relevant research, nurses base their decisions on previous experience or expert colleagues' opinions and advice rather than on the evidence.
Navarro Soler, I M; Ignacio García, E; Masjuan Vallejo, J; Gállego Culleré, J; Mira Solves, J J
This study proposes a set of quality indicators for care outcomes in patients with acute cerebral infarction. These indicators are understandable and relevant from a clinical viewpoint, as well as being acceptable and feasible in terms of time required, ease of data capture, and interpretability. The method consisted of reaching consensus among doctors after having reviewed the literature on quality indicators in stroke. We then designed and conducted a field study to assess the understandability and feasibility of the set of indicators. Consensus yielded 8 structural indicators, 5 process indicators, and 12 result indicators. Additionally, standards of reference were established for each indicator. This set of indicators can be used to monitor the quality care for stroke patients, identify strengths, and potentially to identify areas needing improvement. Copyright © 2017 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.
Hendry, Charles; Walker, Anne
Time is a valuable resource. When nurses experience demands on their services which exceed their available time, then 'rationing' must occur. In clinical practice such rationing requires practitioners to set priorities for care. The aim of this paper is establish what is currently known about priority setting in nursing, including how nurses set priorities and what factors influence this. CINAHL, Medline, ASSIA, and PsychLit databases for the years 1982-2002 were searched, using the terms (clinical decision-making or problem-solving or planning) and (setting priorities or prioriti*). The publications found were used in a selective, descriptive review. Priority setting is an important skill in nursing, and a skill deficit can have serious consequences for patients. Recent studies have suggested that it is a difficult skill for newly qualified nurses to acquire and may not be given sufficient attention in nurse education. Priority setting can be defined as the ordering of nursing problems using notions of urgency and/or importance, in order to establish a preferential order for nursing actions. A number of factors that may impact on priority setting have been identified in the literature. These include: the expertise of the nurse; the patient's condition; the availability of resources; ward organization; philosophies and models of care; the nurse-patient relationship; and the cognitive strategy used by the nurse to set priorities. However, very little empirical work has been conducted in this area. Further study of priority setting in a range of clinical practice settings is necessary. This could inform both practice and education, promote better use of limited resources and maximize patient outcomes.
Lammon, Carol Ann Barnett; Stanton, Marietta P; Blakney, John L
The American Association of Colleges of Nursing in collaboration with leaders in the health care arena has developed a new role in nursing, the clinical nurse leader (CNL). The CNL is a master's-prepared advanced nurse generalist, accountable for providing high-quality, cost-effective care for a cohort of patients in a specific microsystem. Although initial implementation of the CNL has been predominantly in urban acute care settings, the skill set of the CNL role is equally applicable to diverse clinical settings, such as smaller rural hospitals, home-based home care providers, long-term care facilities, schools, Veteran's Administration facilities, and public health settings. This article reports the strategies used and the progress made at The University of Alabama Capstone College of Nursing in the development of innovative partnerships to develop the role of the CNL in diverse clinical settings. With academia and practice working in partnership, the goal of transforming health care and improving patient outcomes can be achieved. Copyright © 2010 Elsevier Inc. All rights reserved.
Slaughter-Smith, Cheryl; Helms, Jennifer E; Burris, Rebecca
Because nursing is a practice discipline, students are placed in clinical settings to collaborate with professional nurses in caring for patients. This descriptive study aimed to explore the benefits and limitations of undergraduate nursing students in the clinical setting. A 54-item instrument, Nursing Students' Contributions to Clinical Agencies, was used to collect data from staff nurses (N = 84) at three hospitals. The instrument also provided space for participants to share qualitative data, which revealed perceptions with which staff nurses were likely to agree and three key themes: Eager to Learn, Willing to Help, and Serving Their Time. The major implication for students is that they are often judged on their assertiveness skills and should offer assistance so they appear eager to learn. Faculty must ascertain that students understand their objectives for the clinical rotation and share those objectives with the staff nurses to enhance their learning experience. Copyright 2012, SLACK Incorporated.
Suikkala, Arja; Kivelä, Eeva; Käyhkö, Pirjo
This study deals with student nurses' experiences of collaborative learning in gerontological clinical settings where aged people are involved as age-experts in students' learning processes. The data were collected in 2012 using the contents of students' reflective writing assignments concerning elderly persons' life history interviews and the students' own assessments of their learning experiences in authentic elder care settings. The results, analyzed using qualitative content analysis, revealed mostly positive learning experiences. Interaction and collaborative learning activities in genuine gerontological clinical settings contributed to the students' understanding of the multiple age-related and disease-specific challenges as well as the issues of functional decline that aged patients face. Three types of factors influenced the students' collaborative learning experiences in gerontological clinical settings: student-related, patient-related and learning environment-related factors. According to the results, theoretical studies in combination with collaboration, in an authentic clinical environment, by student nurses, elderly patients, representatives of the elder care staff and nurse educators provide a feasible method for helping students transform their experiences with patients into actual skills. Their awareness of and sensitivity to the needs of the elderly increase as they learn. Copyright © 2016 Elsevier Ltd. All rights reserved.
Ombelet, Sien; Ronat, Jean-Baptiste; Walsh, Timothy; Yansouni, Cedric P; Cox, Janneke; Vlieghe, Erika; Martiny, Delphine; Semret, Makeda; Vandenberg, Olivier; Jacobs, Jan
Low-resource settings are disproportionately burdened by infectious diseases and antimicrobial resistance. Good quality clinical bacteriology through a well functioning reference laboratory network is necessary for effective resistance control, but low-resource settings face infrastructural, technical, and behavioural challenges in the implementation of clinical bacteriology. In this Personal View, we explore what constitutes successful implementation of clinical bacteriology in low-resource settings and describe a framework for implementation that is suitable for general referral hospitals in low-income and middle-income countries with a moderate infrastructure. Most microbiological techniques and equipment are not developed for the specific needs of such settings. Pending the arrival of a new generation diagnostics for these settings, we suggest focus on improving, adapting, and implementing conventional, culture-based techniques. Priorities in low-resource settings include harmonised, quality assured, and tropicalised equipment, consumables, and techniques, and rationalised bacterial identification and testing for antimicrobial resistance. Diagnostics should be integrated into clinical care and patient management; clinically relevant specimens must be appropriately selected and prioritised. Open-access training materials and information management tools should be developed. Also important is the need for onsite validation and field adoption of diagnostics in low-resource settings, with considerable shortening of the time between development and implementation of diagnostics. We argue that the implementation of clinical bacteriology in low-resource settings improves patient management, provides valuable surveillance for local antibiotic treatment guidelines and national policies, and supports containment of antimicrobial resistance and the prevention and control of hospital-acquired infections. Copyright © 2018 Elsevier Ltd. All rights reserved.
Responding to changes in health care financing, government policy, technology, and clinical judgment, and the rise of managed care, hospitals are shifting services from inpatient to outpatient settings and moving them into the community. Institutions are evolving into integrated delivery systems, developing the capacity to provide a continuum of coordinated services in an array of settings and to share financial risk with physicians and managed care organizations. Over the past several years, hospitals in New York City have shifted considerable resources into ambulatory care. In their drive to expand and enhance services, however, they face serious challenges, including a well-established focus on hospitals as inpatient centers of tertiary care and medical education, a heavy reliance upon residents as providers of medical care, limited access to capital, and often inadequate physical plants. In 1995, the United Hospital Fund awarded $600,000 through its Ambulatory Care Services Initiative to support hospitals' efforts to meet the challenges of reorganizing services, compete in a managed care environment, and provide high-quality ambulatory care in more efficient ways. Through the initiative, 12 New York City hospitals started projects to reorganize service delivery and build an infrastructure of systems, technology, and personnel. Among the projects undertaken by the hospitals were:--broad-based reorganization efforts employing primary care models to improve and expand existing ambulatory care services, integrate services, and better coordinate care;--projects to improve information management, planning and testing new systems for scheduling appointments, registering patients, and tracking ambulatory care and its outcomes;--training programs to increase the supply of primary care providers (both nurse practitioners and primary care physicians), train clinical and support staff in the skills needed to deliver more efficient and better ambulatory care, prepare staff
Smith, Alexander K; Thai, Julie N; Bakitas, Marie A; Meier, Diane E; Spragens, Lynn H; Temel, Jennifer S; Weissman, David E; Rabow, Michael W
Many health care organizations are interested in instituting a palliative care clinic. However, there are insufficient published data regarding existing practices to inform the development of new programs. Our objective was to obtain in-depth information about palliative care clinics. We conducted a cross-sectional survey of 20 outpatient palliative care practices in diverse care settings. The survey included both closed- and open-ended questions regarding practice size, utilization of services, staffing, referrals, services offered, funding, impetus for starting, and challenges. Twenty of 21 (95%) practices responded. Practices self-identified as: hospital-based (n=7), within an oncology division/cancer center (n=5), part of an integrated health system (n=6), and hospice-based (n=2). The majority of referred patients had a cancer diagnosis. Additional common diagnoses included chronic obstructive pulmonary disease, neurologic disorders, and congestive heart failure. All practices ranked "pain management" and "determining goals of care" as the most common reasons for referrals. Twelve practices staffed fewer than 5 half-days of clinic per week, with 7 operating only one half-day per week. Practices were staffed by a mixture of physicians, advanced practice nurses or nurse practitioners, nurses, or social workers. Eighteen practices expected their practice to grow within the next year. Eleven practices noted a staffing shortage and 8 had a wait time of a week or more for a new patient appointment. Only 12 practices provide 24/7 coverage. Billing and institutional support were the most common funding sources. Most practices described starting because inpatient palliative providers perceived poor quality outpatient care in the outpatient setting. The most common challenges included: funding for staffing (11) and being overwhelmed with referrals (8). Once established, outpatient palliative care practices anticipate rapid growth. In this context, outpatient practices
Faller, H S; Dowell, M A; Jackson, M A
Healthcare restructuring in the wake of healthcare reform places greater emphasis on primary healthcare. Clinical education in acute care settings and existing community health agencies are not compatible with teaching basic concepts, principles and skills fundamental to nursing. Problems of clients in acute care settings are too complex and clients in the community are often too dispersed for necessary faculty support and supervision of beginning nursing students. Nontraditional learning settings offer the baccalaureate student the opportunity to practice fundamental skills of care and address professional skills of negotiation, assertiveness, organization, collaboration and leadership. An overview of faculty designed clinical learning experiences in nontraditional sites such as McDonald's restaurants, inner city churches, YWCA's, the campus community and homes are presented. The legal, ethical and academic issues associated with nontraditional learning settings are discussed in relation to individual empowerment, decision making and evaluation. Implications for the future address the role of the students and faculty as they interact with the community in which they live and practice.
Patterson, C; Sinkewich, M; Short, J; Callas, E
The first step in redesigning the health care delivery process for ambulatory care begins with the patient and the business processes that support the patient. Patient-related business processes include patient access, service documentation, billing, follow-up, collection, and payment. Access is the portal to the clinical delivery and care management process. Service documentation, charge capture, and payment and collection are supporting processes to care delivery. Realigned provider networks now demand realigned patient business services to provide their members/customers/patients with improved service delivery at less cost. Purchaser mandates for cost containment, health maintenance, and enhanced quality of care have created an environment where every aspect of the delivery system, especially ambulatory care, is being judged. Business processes supporting the outpatient are therefore being reexamined for better efficiency and customer satisfaction. Many health care systems have made major investments in their ambulatory care environment, but have pursued traditional supporting business practices--such as multiple access points, lack of integrated patient appointment scheduling and registration, and multiple patient bills. These are areas that are appropriate for redesign efforts--all with the customer's needs and convenience in mind. Similarly, setting unrealistic expectations, underestimating the effort required, and ignoring the human elements of a patient-focused business service redesign effort can sabotage the very sound reasons for executing such an endeavor. Pitfalls can be avoided if a structured methodology, coupled with a change management process, are employed. Deloitte & Touche Consulting Group has been involved in several major efforts, all with ambulatory care settings to assist with the redesign of their business practices to consider the patient as the driver, instead of the institution providing the care.
González-Clemente, José Miguel; Font, Beatriu; Lahoz, Raquel; Llauradó, Gemma; Gambús, Gemma
To study clinical inertia in the management of oral hypoglycemic agents (OHA) in non-insulin treated patients with type 2 diabetes mellitus (T2DM) in Spain. Epidemiological, cross-sectional, retrospective (2 years), multicenter study. Clinical inertia was measured as the total number of patients without OHA treatment intensification divided by the total number of patients with inadequate HbA1c values (≥7%), multiplied by 100. Total clinical inertia (TCI) was the absence of OHA treatment intensification in all visits with a HbA1c≥7% values in the previous 2 years; partial clinical inertia (PCI) occurred when this absence only occurred in some of these visits. We assessed OHA treatment compliance with the Morisky-Green test. We included 2,971 patients, 1,416 adequately controlled (HbA1c<7%) and 1,555 inadequately controlled (HbA1c≥7%). PCI prevalence was 52.5%(95% confidence interval [95% CI] 52.4-52.6%) while TCI prevalence was 12.8% (95% CI 12.2-13.8%). PCI was lower in patients adequately controlled as compared with those inadequately controlled (31.4% vs. 71.8%; P<.001). PCI was associated with sedentary lifestyle, hypertension and higher prevalence of micro and macrovascular complications. Only 38.0% of patients were compliant with the OHA treatment, being this percentage even lower in subjects with ICP. Two variables were independently associated with ICP: female sex (odds ratio [OR] 1.43; 95% CI 1.09-1.86%) and a shorter duration of DM2 (OR 0.98; 95% CI 0.95-0.99). One out of 2 patients with T2DM and treated with OHA without insulin suffer from PCI. Only 4 out of 10 patients are compliant with OHA treatment. Female sex and a shorter duration of T2DM are independently associated with PCI. Copyright © 2012 Elsevier España, S.L. All rights reserved.
Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings.
Ostroff, Jamie S; Li, Yuelin; Shelley, Donna R
Although dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence. Guided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines-staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers' tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence. We hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings
The use and impact of quality of life assessment tools in clinical care settings for cancer patients, with a particular emphasis on brain cancer: insights from a systematic review and stakeholder consultations.
King, Sarah; Exley, Josephine; Parks, Sarah; Ball, Sarah; Bienkowska-Gibbs, Teresa; MacLure, Calum; Harte, Emma; Stewart, Katherine; Larkin, Jody; Bottomley, Andrew; Marjanovic, Sonja
Patient-reported data are playing an increasing role in health care. In oncology, data from quality of life (QoL) assessment tools may be particularly important for those with limited survival prospects, where treatments aim to prolong survival while maintaining or improving QoL. This paper examines the use and impact of using QoL measures on health care of cancer patients within a clinical setting, particularly those with brain cancer. It also examines facilitators and challenges, and provides implications for policy and practice. We conducted a systematic literature review, 15 expert interviews and a consultation at an international summit. The systematic review found no relevant intervention studies specifically in brain cancer patients, and after expanding our search to include other cancers, 15 relevant studies were identified. The evidence on the effectiveness of using QoL tools was inconsistent for patient management, but somewhat more consistent in favour of improving patient-physician communication. Interviews identified unharnessed potential and growing interest in QoL tool use and associated challenges to address. Our findings suggest that the use of QoL tools in cancer patients may improve patient-physician communication and have the potential to improve care, but the tools are not currently widely used in clinical practice (in brain cancer nor some other cancer contexts) although they are in clinical trials. There is a need for further research and stakeholder engagement on how QoL tools can achieve most impact across cancer and patient contexts. There is also a need for policy, health professional, research and patient communities to strengthen information exchange and debate, support awareness raising and provide training on tool design, use and interpretation.
Connolly, Josaleen; Milligan, Stuart; Stevens, Elaine; Jackson, Susan; Rooney, Kevin
To evaluate the effects of implementing an advance care planning process within pilot sites in North Ayrshire in 2010, focusing on people with palliative care needs. Data were collected from participants in advance care planning training using a questionnaire. Semi-structured interviews were conducted and an audit of documentation was undertaken. Thirty nine questionnaires were returned, a response rate of 16%. Twenty four out of 25 (96%) participants rated the training as having improved their understanding of the advance care planning process. The general consensus in interviews was that advance care planning is a worthwhile process. Participants reported patients achieving their preferred place of end of life care and greater consultation regarding hospitalisation. Within the pilot sites, advance care planning training enhanced the ability of professionals to implement the advance care planning process and record the wishes of patients and residents.
Full Text Available We review the utility of centrifugal microfluidic technologies applied to point-of-care diagnosis in extremely under-resourced environments. The various challenges faced in these settings are showcased, using areas in India and Africa as examples. Measures for the ability of integrated devices to effectively address point-of-care challenges are highlighted, and centrifugal, often termed CD-based microfluidic technologies, technologies are presented as a promising platform to address these challenges. We describe the advantages of centrifugal liquid handling, as well as the ability of a standard CD player to perform a number of common laboratory tests, fulfilling the role of an integrated lab-on-a-CD. Innovative centrifugal approaches for point-of-care in extremely resource-poor settings are highlighted, including sensing and detection strategies, smart power sources and biomimetic inspiration for environmental control. The evolution of centrifugal microfluidics, along with examples of commercial and advanced prototype centrifugal microfluidic systems, is presented, illustrating the success of deployment at the point-of-care. A close fit of emerging centrifugal systems to address a critical panel of tests for under-resourced clinic settings, formulated by medical experts, is demonstrated. This emphasizes the potential of centrifugal microfluidic technologies to be applied effectively to extremely challenging point-of-care scenarios and in playing a role in improving primary care in resource-limited settings across the developing world.
Low, Andrew J; Swenson, Luke C; Harrigan, P Richard
The introduction of CCR5 antagonists increases the options available for constructing antiretroviral regimens. However, this option is coupled with the caveat that patients should be tested for HIV coreceptor tropism prior to initiating CCR5 antagonist-based therapy. Failure to screen for CXCR4 usage increases the risk of using an ineffective drug, thus reducing the likelihood of viral suppression and increasing their risk for developing antiretroviral resistance. This review discusses current and future methods of determining HIV tropism, with a focus on their utility in the clinical setting for screening purposes. Some of these methods include recombinant phenotypic tests, such as the Monogram Trofile assay, as well as genotype-based predictors, heteroduplex tracking assays, and flow cytometry based methods. Currently, the best evidence supports the use of phenotypic methods, although other methods of screening for HIV coreceptor usage prior to the administration of CCR5 antagonists may reduce costs and increase turnaround time over phenotypic methods. The presence of low levels of X4 virus is a challenge to all assay methods, resulting in reduced sensitivity in clinical, patient-derived samples when compared to clonally derived samples. Gaining a better understanding of the output of these assays and correlating them with clinical progression and therapy response will provide some indication on how both genotype-based, and phenotypic assays for determining HIV coreceptor usage can be improved. In addition, leveraging new technologies capable of detecting low-level minority species may provide the most significant advances in ensuring that individuals with low levels of dual/mixed tropic virus are not inadvertently prescribed CCR5 antagonists.
Bjørk, Ida T; Berntsen, Karin; Brynildsen, Grethe; Hestetun, Margrete
To explore students' opinions of the learning environment during clinical placement in settings outside traditional hospital settings. Clinical placement experiences may influence positively on nursing students attitudes towards the clinical setting in question. Most studies exploring the quality of clinical placements have targeted students' experience in hospital settings. The number of studies exploring students' experiences of the learning environment in healthcare settings outside of the hospital venue does not match the growing importance of such settings in the delivery of health care, nor the growing number of nurses needed in these venues. A survey design was used. The Clinical Learning Environment Inventory was administered to two cohorts of undergraduate nursing students (n = 184) after clinical placement in mental health care, home care and nursing home care. Nursing students' overall contentment with the learning environment was quite similar across all three placement areas. Students in mental health care had significantly higher scores on the subscale individualisation, and older students had significantly higher scores on the total scale. Compared with other studies where the Clinical Learning Environment Inventory has been used, the students' total scores in this study are similar or higher than scores in studies including students from hospital settings. Results from this study negate the negative views on clinical placements outside the hospital setting, especially those related to placements in nursing homes and mental healthcare settings. Students' experience of the learning environment during placements in mental health care, home care and nursing homes indicates the relevance of clinical education in settings outside the hospital setting. © 2014 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.
Hysong, Sylvia J; Smitham, Kristen; SoRelle, Richard; Amspoker, Amber; Hughes, Ashley M; Haidet, Paul
Audit and feedback has been shown to be instrumental in improving quality of care, particularly in outpatient settings. The mental model individuals and organizations hold regarding audit and feedback can moderate its effectiveness, yet this has received limited study in the quality improvement literature. In this study we sought to uncover patterns in mental models of current feedback practices within high- and low-performing healthcare facilities. We purposively sampled 16 geographically dispersed VA hospitals based on high and low performance on a set of chronic and preventive care measures. We interviewed up to 4 personnel from each location (n = 48) to determine the facility's receptivity to audit and feedback practices. Interview transcripts were analyzed via content and framework analysis to identify emergent themes. We found high variability in the mental models of audit and feedback, which we organized into positive and negative themes. We were unable to associate mental models of audit and feedback with clinical performance due to high variance in facility performance over time. Positive mental models exhibit perceived utility of audit and feedback practices in improving performance; whereas, negative mental models did not. Results speak to the variability of mental models of feedback, highlighting how facilities perceive current audit and feedback practices. Findings are consistent with prior research in that variability in feedback mental models is associated with lower performance.; Future research should seek to empirically link mental models revealed in this paper to high and low levels of clinical performance.
Carey, Mariko; Noble, Natasha; Mansfield, Elise; Waller, Amy; Henskens, Frans; Sanson-Fisher, Rob
Modifiable health risk behaviors such as smoking, overweight and obesity, risky alcohol consumption, physical inactivity, and poor nutrition contribute to a substantial proportion of the world's morbidity and mortality burden. General practitioners (GPs) play a key role in identifying and managing modifiable health risk behaviors. However, these are often underdetected and undermanaged in the primary care setting. We describe the potential of eHealth to help patients and GPs to overcome some of the barriers to managing health risk behaviors. In particular, we discuss (1) the role of eHealth in facilitating routine collection of patient-reported data on lifestyle risk factors, and (2) the role of eHealth in improving clinical management of identified risk factors through provision of tailored feedback, point-of-care reminders, tailored educational materials, and referral to online self-management programs. Strategies to harness the capacity of the eHealth medium, including the use of dynamic features and tailoring to help end users engage with, understand, and apply information need to be considered and maximized. Finally, the potential challenges in implementing eHealth solutions in the primary care setting are discussed. In conclusion, there is significant potential for innovative eHealth solutions to make a contribution to improving preventive care in the primary care setting. However, attention to issues such as data security and designing eHealth interfaces that maximize engagement from end users will be important to moving this field forward.
Pryor, Marie; White, David; Potter, Bronwyn; Traill, Roger
Clinical decision support tools available at the point of care are an effective adjunct to support clinicians to make clinical decisions and improve patient outcomes. We developed a methodology and applied it to evaluate commercially available online clinical diagnostic decision support (DDS) tools for use at the point of care. We identified 11 commercially available DDS tools and assessed these against an evaluation instrument that included 6 categories; general information, content, quality control, search, clinical results and other features. We developed diagnostically challenging clinical case scenarios based on real patient experience that were commonly missed by junior medical staff. The evaluation was divided into 2 phases; an initial evaluation of all identified and accessible DDS tools conducted by the Clinical Information Access Portal (CIAP) team and a second phase that further assessed the top 3 tools identified in the initial evaluation phase. An evaluation panel consisting of senior and junior medical clinicians from NSW Health conducted the second phase. Of the eleven tools that were assessed against the evaluation instrument only 4 tools completely met the DDS definition that was adopted for this evaluation and were able to produce a differential diagnosis. From the initial phase of the evaluation 4 DDS tools scored 70% or more (maximum score 96%) for the content category, 8 tools scored 65% or more (maximum 100%) for the quality control category, 5 tools scored 65% or more (maximum 94%) for the search category, and 4 tools score 70% or more (maximum 81%) for the clinical results category. The second phase of the evaluation was focused on assessing diagnostic accuracy for the top 3 tools identified in the initial phase. Best Practice ranked highest overall against the 6 clinical case scenarios used. Overall the differentiating factor between the top 3 DDS tools was determined by diagnostic accuracy ranking, ease of use and the confidence and
Flynn, Greir Ander Huck; Polivka, Barbara; Behr, Jodi Herron
The use of smartphones in acute care settings remains controversial due to security concerns and personal use. The purposes of this study were to determine (1) the current rates of personal smartphone use by nurses in acute care settings, (2) nurses' preferences regarding the use of smartphone functionality at work, and (3) nurse perceptions of the benefits and drawbacks of smartphone use at work. An online survey of nurses from six acute care facilities within one healthcare system assessed the use of personal smartphones in acute care settings and perceptions of the benefits and drawbacks of smartphone use at work. Participants (N = 735) were primarily point-of-care nurses older than 31 years. Most participants (98%) used a smartphone in the acute care setting. Respondents perceived the most common useful and beneficial smartphone functions in acute care settings as allowing them to access information on medications, procedures, and diseases. Participants older than 50 years were less likely to use a smartphone in acute care settings and to agree with the benefits of smartphones. There is a critical need for recognition that smartphones are used by point-of-care nurses for a variety of functions and that realistic policies for smartphone use are needed to enhance patient care and minimize distractions.
Kruschitz, Renate; Wallner-Liebmann, Sandra Johanna; Lothaller, Harald; Luger, Maria; Schindler, Karin; Hoppichler, Friedrich; Ludvik, Bernhard
The purpose of this study was the evaluation of a weight loss program in primary care settings with respect to the European Clinical Practice Guidelines for the Management of Obesity in Adults with regard to the long-term success of changes in body weight and composition. Overweight and obese patients (n = 1167) who underwent a standardized meal replacement-based weight loss program (myLINE(®), AENGUS, Austria) in primary care settings were included in this evaluation. Body composition was measured by conventional anthropometry and bioelectrical impedance analysis (AKERN BIA101(®), BIACORPUS RX4000(®), SoftwareBodycomp Version 8.4 Professional). Data of patients who participated at least 12 months in the program were analyzed retrospectively and compared with their baseline data. After 12 months, a weight loss of 8.6 ± 7.5 kg (mean ± standard deviation) or 8.2 ± 7.8 % from baseline was seen (p < 0.001). In all, 71.9 % of all patients achieved a minimal weight loss of 5 %, and 18.8 % lost 15 % of their initial weight. In comparison with the baseline (35.7 ± 11.5 kg), body fat decreased to 29.6 ± 10.7 kg, which is 83.7 ± 18.9 % from baseline (100 %; p < 0.001). Body cell mass showed an absolute reduction of - 1.4 ± 2.2 kg (p < 0.001), although a relative increase of 1.5 ± 2.5 % (p < 0.001). There were no significant differences between male and female subjects regarding changes in weight, body fat, and body cell mass. The evaluated program complies with the European Clinical Practice Guidelines for Management of Obesity in Adults (2008), which recommend a weight reduction of 5-15 % from initial weight within 6 months. Furthermore, the data showed a significant reduction of body fat and a relative increase of body cell mass.
A pragmatic cluster randomised controlled trial to evaluate the safety, clinical effectiveness, cost effectiveness and satisfaction with point of care testing in a general practice setting - rationale, design and baseline characteristics.
Laurence, Caroline; Gialamas, Angela; Yelland, Lisa; Bubner, Tanya; Ryan, Philip; Willson, Kristyn; Glastonbury, Briony; Gill, Janice; Shephard, Mark; Beilby, Justin
Point of care testing (PoCT) may be a useful adjunct in the management of chronic conditions in general practice (GP). The provision of pathology test results at the time of the consultation could lead to enhanced clinical management, better health outcomes, greater convenience and satisfaction for patients and general practitioners (GPs), and savings in costs and time. It could also result in inappropriate testing, increased consultations and poor health outcomes resulting from inaccurate results. Currently there are very few randomised controlled trials (RCTs) in GP that have investigated these aspects of PoCT. The Point of Care Testing in General Practice Trial (PoCT Trial) was an Australian Government funded multi-centre, cluster randomised controlled trial to determine the safety, clinical effectiveness, cost effectiveness and satisfaction of PoCT in a GP setting.The PoCT Trial covered an 18 month period with the intervention consisting of the use of PoCT for seven tests used in the management of patients with diabetes, hyperlipidaemia and patients on anticoagulant therapy. The primary outcome measure was the proportion of patients within target range, a measure of therapeutic control. In addition, the PoCT Trial investigated the safety of PoCT, impact of PoCT on patient compliance to medication, stakeholder satisfaction, cost effectiveness of PoCT versus laboratory testing, and influence of geographic location. The paper provides an overview of the Trial Design, the rationale for the research methodology chosen and how the Trial was implemented in a GP environment. The evaluation protocol and data collection processes took into account the large number of patients, the broad range of practice types distributed over a large geographic area, and the inclusion of pathology test results from multiple pathology laboratories.The evaluation protocol developed reflects the complexity of the Trial setting, the Trial Design and the approach taken within the funding
A pragmatic cluster randomised controlled trial to evaluate the safety, clinical effectiveness, cost effectiveness and satisfaction with point of care testing in a general practice setting – rationale, design and baseline characteristics
Full Text Available Abstract Background Point of care testing (PoCT may be a useful adjunct in the management of chronic conditions in general practice (GP. The provision of pathology test results at the time of the consultation could lead to enhanced clinical management, better health outcomes, greater convenience and satisfaction for patients and general practitioners (GPs, and savings in costs and time. It could also result in inappropriate testing, increased consultations and poor health outcomes resulting from inaccurate results. Currently there are very few randomised controlled trials (RCTs in GP that have investigated these aspects of PoCT. Design/Methods The Point of Care Testing in General Practice Trial (PoCT Trial was an Australian Government funded multi-centre, cluster randomised controlled trial to determine the safety, clinical effectiveness, cost effectiveness and satisfaction of PoCT in a GP setting. The PoCT Trial covered an 18 month period with the intervention consisting of the use of PoCT for seven tests used in the management of patients with diabetes, hyperlipidaemia and patients on anticoagulant therapy. The primary outcome measure was the proportion of patients within target range, a measure of therapeutic control. In addition, the PoCT Trial investigated the safety of PoCT, impact of PoCT on patient compliance to medication, stakeholder satisfaction, cost effectiveness of PoCT versus laboratory testing, and influence of geographic location. Discussion The paper provides an overview of the Trial Design, the rationale for the research methodology chosen and how the Trial was implemented in a GP environment. The evaluation protocol and data collection processes took into account the large number of patients, the broad range of practice types distributed over a large geographic area, and the inclusion of pathology test results from multiple pathology laboratories. The evaluation protocol developed reflects the complexity of the Trial setting
As the health care revolution progresses, so must the management styles of today's leaders. The authors must ask ourselves if we are managing tomorrow's work force or the work force of the past. Participatory management may better meet the needs of today's work force. This paper identifies the reasons participatory management is a more effective management style, the methods used to implement a participatory management program, its benefits (such as higher productivity and more efficient, effective implementation and acceptance of change), and the difficulties experienced
Miller, Carla K; Bauman, Jennifer
Goal setting is a widely used behavior change tool in diabetes education and training. Prior research found specific relatively difficult but attainable goals set within a specific timeframe improved performance in sports and at the workplace. However, the impact of goal setting in diabetes self-care has not received extensive attention. This review examined the mechanisms underlying behavioral change according to goal setting theory and evaluated the impact of goal setting in diabetes intervention studies. Eight studies were identified, which incorporated goal setting as the primary strategy to promote behavioral change in individual, group-based, and primary care settings among patients with type 2 diabetes. Improvements in diabetes-related self-efficacy, dietary intake, physical activity, and A1c were observed in some but not all studies. More systematic research is needed to determine the conditions and behaviors for which goal setting is most effective. Initial recommendations for using goal setting in diabetes patient encounters are offered.
da Silva, Rafael Celestino; Ferreira, Márcia de Assunção; Apostolidis, Thémistoklis; Brandão, Marcos Antônio Gomes
to propose a conceptual framework for clinical nursing care in intensive care. descriptive and qualitative field research, carried out with 21 nurses from an intensive care unit of a federal public hospital. We conducted semi-structured interviews and thematic and lexical content analysis, supported by Alceste software. the characteristics of clinical intensive care emerge from the specialized knowledge of the interaction, the work context, types of patients and nurses characteristic of the intensive care and care frameworks. the conceptual framework of the clinic's intensive care articulates elements characteristic of the dynamics of this scenario: objective elements regarding technology and attention to equipment and subjective elements related to human interaction, specific of nursing care, countering criticism based on dehumanization.
Poor nursing documentation of patient care was identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. The purpose of this evidence-based project was to determine the impact of a retraining program on the…
Casey, Jessica T; Brinton, Thomas S; Gonzalez, Chris M
The principles of 'lean management' have permeated many sectors of today's business world, secondary to the success of the Toyota Production System. This management method enables workers to eliminate mistakes, reduce delays, lower costs, and improve the overall quality of the product or service they deliver. These lean management principles can be applied to health care. Their implementation within the ambulatory care setting is predicated on the continuous identification and elimination of waste within the process. The key concepts of flow time, inventory and throughput are utilized to improve the flow of patients through the clinic, and to identify points that slow this process -- so-called bottlenecks. Nonessential activities are shifted away from bottlenecks (i.e. the physician), and extra work capacity is generated from existing resources, rather than being added. The additional work capacity facilitates a more efficient response to variability, which in turn results in cost savings, more time for the physician to interact with patients, and faster completion of patient visits. Finally, application of the lean management principle of 'just-in-time' management can eliminate excess clinic inventory, better synchronize office supply with patient demand, and reduce costs.
Sussman, Andrew; Dunham, Lisette; Snower, Kristen; Hu, Min; Matlin, Olga S; Shrank, William H; Choudhry, Niteesh K; Brennan, Troyen
To better understand the impact of retail clinic use on a patient's annual total cost of care. A propensity score matched-pair, cohort design was used to analyze healthcare spending patterns among CVS Caremark employees in the year following a visit to a MinuteClinic, the retail clinics inside CVS pharmacies. De-identified medical and pharmacy claims for CVS Caremark employees and their dependents who received care at a retail clinic between June 1, 2009, and May 31, 2010, were matched to those of subjects who received care elsewhere. High-dimensional propensity score and greedy matching techniques were used to create a 1-to-1 matched cohort that was analyzed using generalized linear regression models. Individuals using a retail clinic had a lower total cost of care (-$262; 95% confidence interval, -$510 to -$31; P = .025) in the year following their clinic visit than individuals who received care in other settings. This savings was primarily due to lower medical expenses at physicians' offices ($77 savings, P = .008) and hospital inpatient care ($121 savings, P = .049). The 6022 retail clinic users also had 142 (12%) fewer emergency department visits (P = .01), though this was not related to significant cost savings. This study found that retail clinic use was associated with lower overall total cost of care compared with that at alternative sites. Savings may extend beyond the retail clinic visit itself to other types of medical utilization.
Wald, John T; Lowery-Schrandt, Sherri; Hayes, David L; Kotsenas, Amy L
By leveraging its experience and expertise as a consultative clinical partner, the Mayo Clinic developed an innovative, scalable care model to accomplish several strategic goals: (1) create and sustain high-value relationships that benefit patients and providers, (2) foster relationships with like-minded partners to act as a strategy against the development of narrow health care networks, and (3) increase national and international brand awareness of Mayo Clinic. The result was the Mayo Clinic Care Network. Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.
Huefner, Jonathan C.; Ringle, Jay L.
There has been ongoing concern about the negative impact of residential treatment on youth in care. Research examining the impact of negative peer influence in juvenile justice, education, and residential care settings is reviewed. A study was conducted to examine the impact of negative peer contagion on the level of problem behavior in a…
Zhang, Rui; Pakhomov, Serguei V S; Arsoniadis, Elliot G; Lee, Janet T; Wang, Yan; Melton, Genevieve B
Automated methods for identifying clinically relevant new versus redundant information in electronic health record (EHR) clinical notes is useful for clinicians and researchers involved in patient care and clinical research, respectively. We evaluated methods to automatically identify clinically relevant new information in clinical notes, and compared the quantity of redundant information across specialties and clinical settings. Statistical language models augmented with semantic similarity measures were evaluated as a means to detect and quantify clinically relevant new and redundant information over longitudinal clinical notes for a given patient. A corpus of 591 progress notes over 40 inpatient admissions was annotated for new information longitudinally by physicians to generate a reference standard. Note redundancy between various specialties was evaluated on 71,021 outpatient notes and 64,695 inpatient notes from 500 solid organ transplant patients (April 2015 through August 2015). Our best method achieved at best performance of 0.87 recall, 0.62 precision, and 0.72 F-measure. Addition of semantic similarity metrics compared to baseline improved recall but otherwise resulted in similar performance. While outpatient and inpatient notes had relatively similar levels of high redundancy (61% and 68%, respectively), redundancy differed by author specialty with mean redundancy of 75%, 66%, 57%, and 55% observed in pediatric, internal medicine, psychiatry and surgical notes, respectively. Automated techniques with statistical language models for detecting redundant versus clinically relevant new information in clinical notes do not improve with the addition of semantic similarity measures. While levels of redundancy seem relatively similar in the inpatient and ambulatory settings in the Fairview Health Services, clinical note redundancy appears to vary significantly with different medical specialties.
Lundqvist, Anita; Nilstun, Tore
Since the 1990s, numerous studies on the relationship between parents and their children have been reported on in the literature and implemented as a philosophy of care in most paediatric units. The purpose of this article is to understand the process of nurses' care for children in a paediatric setting by using Noddings's caring ethics theory. Noddings's theory is in part described from a theoretical perspective outlining the basic idea of the theory followed by a critique of her work. Important conceptions in her theory are natural caring (reception, relation, engrossment, motivational displacement, reciprocity) and ethical caring (physical self, ethical self, and ethical ideal). As a nurse one holds a duty of care to patients and, in exercising this duty, the nurse must be able to develop a relationship with the patient including giving the patient total authenticity in a 'feeling with' the patient. Noddings's theory is analysed and described in three examples from the paediatrics. In the first example, the nurse cared for the patient in natural caring while in the second situation, the nurse strived for the ethical caring of the patient. In the third example, the nurse rejected the impulse to care and deliberately turned her back to ethics and abandoned her ethical caring. According to the Noddings's theory, caring for the patient enables the nurse to obtain ethical insights from the specific type of nursing care which forms an important contribution to an overall increase of an ethical consciousness in the nurse.
Neitch, Shirley M; Meadows, Charles; Patton-Tackett, Eva; Yingling, Kevin W
Every day, patients with dementia, their families, and their physicians face the enormous challenges of this pervasive life-changing condition. Seeking help, often grasping at straws, victims, and their care providers are confronted with misinformation and myths when they search the internet or other sources. When Persons with Dementia (PWD) and their caregivers believe and/or act on false information, proper treatment may be delayed, and ultimately damage can be done. In this paper, we review commonly misunderstood issues encountered in caring for PWD. Our goal is to equip Primary Care Practitioners (PCPs) with accurate information to share with patients and families, to improve the outcomes of PWD to the greatest extent possible. While there are innumerable myths about dementia and its causes and treatments, we are going to focus on the most common false claims or misunderstandings which we hear in our Internal Medicine practice at Marshall Health. We offer suggestions for busy practitioners approaching some of the more common issues with patients and families in a clinic setting.
Group clinics for young adults with diabetes in an ethnically diverse, socioeconomically deprived setting (TOGETHER study): protocol for a realist review, co-design and mixed methods, participatory evaluation of a new care model.
Papoutsi, Chrysanthi; Hargreaves, Dougal; Colligan, Grainne; Hagell, Ann; Patel, Anita; Campbell-Richards, Desirée; Viner, Russell M; Vijayaraghavan, Shanti; Marshall, Martin; Greenhalgh, Trisha; Finer, Sarah
Young adults with diabetes often report dissatisfaction with care and have poor diabetes-related health outcomes. As diabetes prevalence continues to rise, group-based care could provide a sustainable alternative to traditional one-to-one consultations, by engaging young people through life stage-, context- and culturally-sensitive approaches. In this study, we will co-design and evaluate a group-based care model for young adults with diabetes and complex health and social needs in socioeconomically deprived areas. This participatory study will include three phases. In phase 1, we will carry out a realist review to synthesise the literature on group-based care for young adults with diabetes. This theory-driven understanding will provide the basis for phase 2, where we will draw on experience-based co-design methodologies to develop a new, group-based care model for young adults (aged researcher-in-residence approach to implement and evaluate the co-designed group clinic model and compare with traditional care. We will employ qualitative (observations in clinics, patient and staff interviews and document analysis) and quantitative methods (eg, biological markers, patient enablement instrument and diabetes distress scale), including a cost analysis. National Health Service ethics approval has been granted (reference 17/NI/0019). The project will directly inform service redesign to better meet the needs of young adults with diabetes in socioeconomically deprived areas and may guide a possible cluster-randomised trial, powered to clinical and cost-effectiveness outcomes. Findings from this study may be transferable to other long-term conditions and/or age groups. Project outputs will include briefing statements, summaries and academic papers, tailored for different audiences, including people living with diabetes, clinicians, policy makers and strategic decision makers. PROSPERO (CRD42017058726). © Article author(s) (or their employer(s) unless otherwise stated in the
Fan, Sheng-Yu; Lin, Wei-Chun; Lin, I-Mei
The aim of this study was to explore the works of clinical psychologists in palliative care in Taiwan. Clinical psychologists who were working or had experience in palliative care were recruited. A 2-stage qualitative method study was conducted, including semistructured interviews and a focus group. The following 4 main themes were identified: (1) the essential nature of the psychologists' care were caring and company; (2) the dynamic process included psychological assessment, intervention, and evaluation based on psychological knowledge; (3) they needed to modify their care using an integrative framework, by setting practical goals and using techniques with flexibility; and (4) they faced external and internal challenges in this field. Clinical psychologists have beneficial contributions but have to modify psychosocial care based on the patients' needs and clinical situations. © The Author(s) 2014.
Full Text Available The potential impact of breast cancer-related lymphedema (LE is quite extensive, yet it often remains under-diagnosed until the later stages. This project examines the effectiveness of prospective surveillance in post-surgical breast cancer patients. A retrospective analysis of 49 out of 100 patients enrolled in a longitudinal prospective study at a Midwestern breast center evaluates: (1 time required for completion of bilateral limb measurements and Lymphedema Breast Cancer Questionnaire (LBCQ; (2 referral to LE management with limb volume increase (LVI and/or LBCQ symptoms; and (3 cost of LE management at lower LVI (≥5%–≤10% versus traditional (≥10%. Findings revealed a visit timeframe mean of 40.3 min (range = 25–60; 43.6% of visits were ≤30-min timeframe. Visit and measurement times decreased as clinic staff gained measurement experience; measurement time mean was 17.9 min (range = 16.9–18.9. LBCQ symptoms and LVI were significantly (p < 0.001 correlated to LE referral; six of the nine patients referred (67% displayed both LBCQ symptoms/LVI. Visits with no symptoms reported did not result in referral, demonstrating the importance of using both indicators when assessing early LE. Lower threshold referral provides compelling evidence of potential cost savings over traditional threshold referral with reported costs of: $3755.00 and $6353.00, respectively (40.9% savings.
Rehnsfeldt, Arne; Arman, Maria; Lindström, Unni Å
Clinical caring science will be described from a theory of science perspective. The aim of this theoretical article to give a comprehensive overview of clinical caring science as a human science-based discipline grounded in a theory of science argumentation. Clinical caring science seeks idiographic or specific variations of the ontology, concepts and theories, formulated by caring science. The rationale is the insight that the research questions do not change when they are addressed in different contexts. The academic subject contains a concept order with ethos concepts, core and basic concepts and practice concepts that unites systematic caring science with clinical caring science. In accordance with a hermeneutic tradition, the idea of the caring act is based on the degree to which the theory base is hermeneutically appropriated by the caregiver. The better the ethos, essential concepts and theories are understood, the better the caring act can be understood. In order to understand the concept order related to clinical caring science, an example is given from an ongoing project in a disaster context. The concept order is an appropriate way of making sense of the essence of clinical caring science. The idea of the concept order is that concepts on all levels need to be united with each other. A research project in clinical caring science can start anywhere on the concept order, either in ethos, core concepts, basic concepts, practice concepts or in concrete clinical phenomena, as long as no parts are locked out of the concept order as an entity. If, for example, research on patient participation as a phenomenon is not related to core and basic concepts, there is a risqué that the research becomes meaningless. © 2016 Nordic College of Caring Science.
Mazur, H; Beeston, J J; Yerxa, E J
With increasing concern for teamwork in clinical practice in health care settings, the need to identify the concepts, methods, and learning processes for improving interdisciplinary team skills is apparent. This paper describes patient-centered, clinical-research-demonstration programs for teams of students, preceptors, and faculty members from six disciplines who provided patient care in a long-term rehabilitation setting. The teams were involved in the theory and practice of team-building, including weekly sessions on leadership styles, communication, group decision-making, and team effectiveness assessment. Objective and subjective measurements were administered throughout the program. The results indicate that task-oriented patient care favors the learning of team skills, especially when all levels of administration support and participate in the processes. Question are raised concerning the effect of clinical teams on the quality of patient care, their cost-effectiveness, and the low priority given to teaching interdisciplinary team skills in professional education.
Siu, Natalie P Y; Too, L C; Tsang, Caroline S H; Young, Betty W Y
There is increasing evidence that supports the close relationship between childhood and adult health. Fostering healthy growth and development of children deserves attention and effort. The Reference Framework for Preventive Care for Children in Primary Care Settings has been published by the Task Force on Conceptual Model and Preventive Protocols under the direction of the Working Group on Primary Care. It aims to promote health and prevent disease in children and is based on the latest research, and contributions of the Clinical Advisory Group that comprises primary care physicians, paediatricians, allied health professionals, and patient groups. This article highlights the comprehensive, continuing, and patient-centred preventive care for children and discusses how primary care physicians can incorporate the evidence-based recommendations into clinical practice. It is anticipated that the adoption of this framework will contribute to improved health and wellbeing of children.
Lagomasino, Isabel T; Dwight-Johnson, Megan; Green, Jennifer M; Tang, Lingqi; Zhang, Lily; Duan, Naihua; Miranda, Jeanne
Quality improvement interventions for depression care have been shown to be effective for improving quality of care and depression outcomes in settings with primarily insured patients. The aim of this study was to determine the impact of a collaborative care intervention for depression that was tailored for low-income Latino patients seen in public-sector clinics. A total of 400 depressed patients from three public-sector primary care clinics were enrolled in a randomized controlled trial of a tailored collaborative care intervention versus enhanced usual care. Social workers without previous mental health experience served as depression care specialists for the intervention patients (N=196). Depending on patient preference, they delivered a cognitive-behavioral therapy (CBT) intervention or facilitated antidepressant medication given by primary care providers or both. In enhanced usual care, patients (N=204) received a pamphlet about depression, a letter for their primary care provider stating that they had a positive depression screen, and a list of local mental health resources. Intent-to-treat analyses examined clinical and process-of-care outcomes at 16 weeks. Compared with patients in the enhanced usual care group, patients in the intervention group had significantly improved depression, quality of life, and satisfaction outcomes (ppublic-sector clinics. Social workers without prior mental health experience can effectively provide CBT and manage depression care.
Gulmans, J.; Gulmans, J.; Vollenbroek-Hutten, Miriam Marie Rosé; van Gemert-Pijnen, Julia E.W.C.; van Harten, Willem H.
Background. Owing to the involvement of multiple professionals from various institutions, integrated care settings are prone to suboptimal patient care communication. To assure continuity, communication gaps should be identified for targeted improvement initiatives. However, available assessment
Douma, Johanna G.; Volkers, Karin M.; Engels, Gwenda; Sonneveld, Marieke H.; Goossens, Richard H. M.; Scherder, Erik J. A.
Background: Despite the detrimental effects of physical inactivity for older adults, especially aged residents of residential care settings may spend much time in inactive behavior. This may be partly due to their poorer physical condition; however, there may also be other, setting-related factors
Bassett, Alaina M; Siu, Ka-Chun; Honaker, Julie A
This review explores the evidence pertaining to the use of functional ability measures for fall risk in the acute care setting. We included studies from six bibliographic databases that investigated fall risk functional ability measures in hospitalized older adults (≥55 years). We utilized the following search terms: acute care, subacute care, critical care, inpatient, fall, and fall prevention. Nineteen articles met the inclusion criteria. Timed "Up and Go" (TUG) was identified as a feasible fall risk functional ability measure for clinicians; it demonstrated clinical performance of fair sensitivity (56%-68%) and good specificity (74%-80%). Clinical performance of other measures (Berg Balance Scale and Functional Reach test) was not as favorable as the TUG. Functional ability measures are underutilized in the acute care setting, potentially due to limited knowledge and training on administration. Combining functional measures with subjective screening tools may optimize performance and accuracy of identifying fall risk identification.
Chiarotto, Alessandro; Ostelo, Raymond W.; Turk, Dennis C.; Buchbinder, Rachelle; Boers, Maarten
Background This masterclass introduces the topic of core outcome sets, describing rationale and methods for developing them, and providing some examples that are relevant for clinical research and practice. Method A core outcome set is a minimum consensus-based set of outcomes that should be
Buckley, Catherine; McCormack, Brendan; Ryan, Assumpta
To report on the development of a framework of narrative practice, in residential care settings for older people. Residential care settings for older people provide care for people who are no longer able to live in their own home. To date, the impact and structure of nursing practice on care provision in these settings has proved difficult to conceptualise within a specific nursing theory framework. A hermeneutic approach incorporating narrative methods was used. Forty-six narrative interviews with older people in residential care were secondary-analysed for key themes through a three-stage process: by the first author, four focus groups of 12 clinical nurse managers and two independent experts. Themes were also derived from a focus group of eight residents who explored person-centredness and narrative. Finally, the combined findings were used to derive a single set of themes. The secondary data analysis process led to the development of a framework of narrative practice for the care of older people in residential settings. The framework is influenced by narrative enquiry, person-centred practice and practice development. It has four pillars, prerequisites, care processes, care environment and narrative aspects of care. To operationalise the framework of narrative practice, three narrative elements, narrative knowing, narrative being and narrative doing, need to be considered. Working with the foundational pillars and the narrative elements would enable staff to 'work in a storied way' and provide person-centred outcomes and a narrative informed philosophy of care for older adults in residential care. This framework provides nurses with a template that confirms the identity of the older person taking account of their biography. The framework outlines an approach that provides staff with a template on how to provide person-centred care in a narrative way. © 2013 John Wiley & Sons Ltd.
The effect of expectation of recovery on the recovery rate of whiplash patients in the primary care setting is not known. Whiplash patients were assessed in a primary care setting within 1 week of their collision for their expectations of recovery and were re-examined 3 months later for recovery. Initial expectations of recovery predicted recovery. According to adjusted odds ratios, subjects who expected 'to get better slowly' had a recovery rate that was nearly 1.9 times that of subjects with poor recovery expectations. Subjects who expected 'to get better soon' had a recovery rate that was 2.6 times greater than either of those with poor recovery expectations. In the primary care setting, asking patients with whiplash about their expectations of recovery is a useful predictor of their outcome.
Full Text Available Background: Infectious disease and malnutrition are common in children. Primary health care came into being to decrease the morbidity. Quality assessment is neither clinical research nor technology assessment. It is primarily an administrative device used to monitor performance to determine whether it continues to remain within acceptable bounds. Aims and Objectives: To assess the quality of service in the delivery of child health care in a primary health care setting. To evaluate client satisfaction. To assess utilization of facilities by the community. Materials and Methods: Study Type: Cross-sectional community-based study. Quality assessment was done by taking 30-50%, of the service provider. Client satisfaction was determined with 1 Immunization and child examination-90 clients each. Utilization of services was assessed among 478 households. Statistical Analysis: Proportions, Likert′s scale to grade the services and Chi-square. Results: Immunization service: Identification of needed vaccine, preparation and care was average. Vaccination technique, documentation, EPI education, maintenance of cold chain and supplies were excellent. Client satisfaction was good. Growth monitoring: It was excellent except for mother′s education andoutreach educational session . Acute respiratory tract infection care: History, physical examination, ARI education were poor. Classification, treatment and referral were excellent. Client satisfaction was good. Diarrheal disease care: History taking was excellent. But examination, classification, treatment, ORT education were poor. Conclusion: Mothers education was not stressed by service providers. Service providers′ knowledge do not go with the quality of service rendered. Physical examination of the child was not good. Except for immunization other services were average.
Hooper, Lisa M; Tomek, Sara; Newman, Caroline R
Mental health researchers, clinicians and clinical psychologists have long considered a good provider-patient relationship to be an important factor for positive treatment outcomes in a range of therapeutic settings. However, primary care physicians have been slow to consider how attachment theory may be used in the context of patient care in medical settings. In the current article, John Bowlby's attachment theory and proposed attachment styles are proffered as a framework to better understand patient behaviors, patient communication styles with physicians and the physician-patient relationship in medical settings. The authors recommend how primary care physicians and other health care providers can translate attachment theory to enhance practice behaviors and health-related communications in medical settings.
Vlasblom, J.P.; Steen, van der J.T.; Jochemsen, H.
The Trent Universities Interprofessional Learning in Practice (TUILIP) project aimed to establish interprofessional learning (IPL) for healthcare students in clinical practice settings. Ten IPL facilitators were employed in eight varied practice setting pilot sites for up to a year to research,
O'Malley, Donna M; Randell, Kimberly A; Dowd, M Denise
Adverse childhood experiences (ACEs) impact health across the life course. The purpose of this study was to identify caregiver ACEs, current adversity, and resilience in families seeking care in pediatric acute care settings. Study aims included identifying demographic characteristics, current adversities, and resilience measures associated with caregiver ACEs ≥4. A cross-sectional survey study design was used and a convenience sample (n = 470) recruited at emergency and urgent care settings of a large Midwest pediatric hospital system. Measures were self-reported. The original 10-item ACEs questionnaire measured caregiver past adversity. Current adversity was measured using the 10-item IHELP. The six-item Brief Resiliency Scale measured resilience, and WHO-5 Well-Being Index was used to measure depressive affect. Compared to participants with ACEs score of 0-3 participants with ACEs ≥4 were more likely to have multiple current adversities, increased risk of depression, and lower resilience. Caregivers using pediatric acute care settings carry a high burden of ACEs and current adversities. Caregiver ACEs are associated with current child experiences of adversity. Caregivers socioeconomic status and education level may not be an accurate indicator of a family's risks or needs. Pediatric acute care settings offer opportunities to access, intervene, and prevent childhood adversity. © 2016 Wiley Periodicals, Inc.
Douma, Johanna G; Volkers, Karin M; Engels, Gwenda; Sonneveld, Marieke H; Goossens, Richard H M; Scherder, Erik J A
Despite the detrimental effects of physical inactivity for older adults, especially aged residents of residential care settings may spend much time in inactive behavior. This may be partly due to their poorer physical condition; however, there may also be other, setting-related factors that influence the amount of inactivity. The aim of this review was to review setting-related factors (including the social and physical environment) that may contribute to the amount of older adults' physical inactivity in a wide range of residential care settings (e.g., nursing homes, assisted care facilities). Five databases were systematically searched for eligible studies, using the key words 'inactivity', 'care facilities', and 'older adults', including their synonyms and MeSH terms. Additional studies were selected from references used in articles included from the search. Based on specific eligibility criteria, a total of 12 studies were included. Quality of the included studies was assessed using the Mixed Methods Appraisal Tool (MMAT). Based on studies using different methodologies (e.g., interviews and observations), and of different quality (assessed quality range: 25-100%), we report several aspects related to the physical environment and caregivers. Factors of the physical environment that may be related to physical inactivity included, among others, the environment's compatibility with the abilities of a resident, the presence of equipment, the accessibility, security, comfort, and aesthetics of the environment/corridors, and possibly the presence of some specific areas. Caregiver-related factors included staffing levels, the available time, and the amount and type of care being provided. Inactivity levels in residential care settings may be reduced by improving several features of the physical environment and with the help of caregivers. Intervention studies could be performed in order to gain more insight into causal effects of improving setting-related factors on
Full Text Available Razatul Shima,1,3 Mohd Hairi Farizah,1,2 Hazreen Abdul Majid1,2 1Department of Social and Preventive Medicine; 2Centre for Population Health, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 3Ministry of Health Malaysia, Putrajaya, Malaysia Purpose: The aim of this study was to explore patients’ experiences with their illnesses and the reasons which influenced them in not following hypertensive care recommendations (antihypertensive medication intake, physical activity, and diet changes in primary health clinic settings. Patients and methods: A qualitative methodology was applied. The data were gathered from in-depth interviews with 25 hypertensive patients attending follow-up in nine government primary health clinics in two districts (Hulu Langat and Klang in the state of Selangor, Malaysia. The transcribed data were analyzed using thematic analysis.Results: There was evidence of lack of patient self-empowerment and community support in Malaysian society. Most of the participants did not take their antihypertensive medication or change their physical activity and diet after diagnosis. There was an agreement between the patients and the health care professionals before starting the treatment recommendation, but there lacked further counseling and monitoring. Most of the reasons given for not taking antihypertensive medication, not doing physical activity and not following diet recommendations were due to side effects or fear of the side effects of antihypertensive medication, patients’ attitudes, lack of information from health care professionals and insufficient social support from their surrounding environment. We also observed the differences on these reasons for nonadherence among the three ethnic groups.Conclusion: Health care professionals should move toward supporting adherence in the management of hypertensive patients by maintaining a dialogue. Patients need to be given time to enable them to overcome their
de Mul, Marleen; Alons, Peter; van der Velde, Peter; Konings, Ilse; Bakker, Jan; Hazelzet, Jan
There are relatively few institutions that have developed clinical data warehouses, containing patient data from the point of care. Because of the various care practices, data types and definitions, and the perceived incompleteness of clinical information systems, the development of a clinical data warehouse is a challenge. In order to deal with managerial and clinical information needs, as well as educational and research aims that are important in the setting of a university hospital, Erasmus Medical Center Rotterdam, The Netherlands, developed a data warehouse incrementally. In this paper we report on the in-house development of an integral part of the data warehouse specifically for the intensive care units (ICU-DWH). It was modeled using Atos Origin Metadata Frame method. The paper describes the methodology, the development process and the content of the ICU-DWH, and discusses the need for (clinical) data warehouses in intensive care. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.
Katerndahl, David A.; Bell, Iris R.; Palmer, Raymond F.; Miller, Claudia S.
PURPOSE This study extends previous community-based studies on the prevalence and clinical characteristics of chemical intolerance in a sample of primary care clinic patients. We evaluated comorbid medical and psychiatric disorders, functional status, and rates of health care use. METHODS A total of 400 patients were recruited from 2 family medicine clinic waiting rooms in San Antonio, Texas. Patients completed the validated Quick Environmental Exposure and Sensitivity Inventory (QEESI) to assess chemical intolerance; the Primary Care Evaluation of Mental Disorders (PRIME-MD) screen for possible psychiatric disorders; the Dartmouth–Northern New England Primary Care Cooperative Information Project (Dartmouth COOP) charts for functional status; and the Healthcare Utilization Questionnaire. RESULTS Overall, 20.3% of the sample met criteria for chemical intolerance. The chemically intolerant group reported significantly higher rates of comorbid allergies and more often met screening criteria for possible major depressive disorder, panic disorder, generalized anxiety disorder, and alcohol abuse disorder, as well as somatization disorder. The total number of possible mental disorders was correlated with chemical intolerance scores (P intolerance were significantly more likely to have poorer functional status, with trends toward increased medical service use when compared with non–chemically intolerant patients. After controlling for comorbid psychiatric conditions, the groups differed significantly only regarding limitations of social activities. CONCLUSIONS Chemical intolerance occurs in 1 of 5 primary care patients yet is rarely diagnosed by busy practitioners. Psychiatric comorbidities contribute to functional limitations and increased health care use. Chemical intolerance offers an etiologic explanation. Symptoms may resolve or improve with the avoidance of salient chemical, dietary (including caffeine and alcohol), and drug triggers. Given greater medication
Defechereux, T.; Paolucci, F.; Mirelman, A.; Youngkong, S.; Botten, G.; Hagen, T.P.; Niessen, L.W.
BACKGROUND: Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and
de Guzman, Allan B.; Satuito, James Cyril B.; Satumba, Miko Anne E.; Segui, Diego Rey A.; Serquina, Faith Evelyn C.; Serrano, Lawrence Jan P.; Sevilla, Madelyn D.
The use of traditional art in recreational therapies is unexplored. This paper, thus, attempts to surface the unique power of traditional Filipino arts (TFA) as synergizing lens in capturing the individual and the collective experiences of a select group of Filipino elderly in an institutionalized care setting relative to their feelings of…
Dewar, Belinda; Nolan, Mike
This study actively involved older people, staff and relatives in agreeing a definition of compassionate relationship-centred care and identifying strategies to promote such care in acute hospital settings for older people. It was a major component of a three year programme (the Leadership in Compassionate Care Programme, LCCP) seeking to integrate compassionate care across practice and educational environments. Compassionate caring and promoting dignity are key priorities for policy, practice and research worldwide, being central to the quality of care for patients and families, and job satisfaction for staff. Therapeutic relationships are essential to achieving excellence in care but little is known about how to develop and sustain such relationships in a culture that increasingly focuses on throughput and rapid turnover. The study used appreciative inquiry and a range of methods including participant observation, interviews, story telling and group discussions to actively engage older people, relatives and staff. A process of immersion crystallization was used to analyze data with staff as co-analysts. The study adds considerably to the conceptualization of compassionate, relationship-centred care and provides a model to aid staff deliver such care in practice, based on 'appreciative caring conversations' that enable all parties to gain two forms of 'person and relational knowledge' about 'who people are and what matters to them' and 'how people feel about their experience'. Such knowledge enables staff, patients and carers to 'work together to shape the way things are done'. The study generated a model called the 7 'C's that captures in detail the factors necessary to promote 'appreciative caring conversations'. The study demonstrates that engaging in 'appreciative caring conversations' promotes compassionate, relationship-centred care but that these conversations involve practitioners taking risks. Such 'relational practices' must therefore be valued and
Schram, Andrew W; Hougham, Gavin W; Meltzer, David O; Ruhnke, Gregory W
There is an emerging literature on the physician competencies most meaningful to patients and their families. However, there has been no systematic review on physician competency domains outside direct clinical care most important for patient- and family-centered outcomes in critical care settings at the end of life (EOL). Physician competencies are an essential component of palliative care (PC) provided at the EOL, but the literature on those competencies relevant for patient and family satisfaction is limited. A systematic review of this important topic can inform future research and assist in curricular development. Review of qualitative and quantitative empirical studies of the impact of physician competencies on patient- and family-reported outcomes conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews. The data sources used were PubMed, MEDLINE, Web of Science, and Google Scholar. Fifteen studies (5 qualitative and 10 quantitative) meeting inclusion and exclusion criteria were identified. The competencies identified as critical for the delivery of high-quality PC in critical care settings are prognostication, conflict mediation, empathic communication, and family-centered aspects of care, the latter being the competency most frequently acknowledged in the literature identified. Prognostication, conflict mediation, empathic communication, and family-centered aspects of care are the most important identified competencies for patient- and family-centered PC in critical care settings. Incorporation of education on these competencies is likely to improve patient and family satisfaction with EOL care.
Zarkowski, Pamela; Aksu, Mert N
Direct access care provided by dental hygienists can reduce oral health disparities for the underserved, yet legal, regulatory, and ethical considerations create complexities and limits. Individual state dental practice acts regulate the scope of practice and level of supervision required when dental hygienists deliver care. Yet, inconsistent state practice act regulations contribute to ethical and legal limitations and dilemmas for practitioners. The dental hygienist is positioned to assume an increasingly larger role in the management of oral health disparities. However, there are several legal and ethical considerations that impact both dental hygienists and dentists providing care in complex community settings. This article informs dental hygienists and other related constituencies about conundrums that are encountered when providing care 'beyond the operatory.' An evidence-based view of ways in which dental hygienists are reducing oral health disparities illustrates the complex issues involved in providing such care. Potential scenarios that can occur during care provision in underserved settings provide the basis for a discussion of legal and other associated issues impacting dental hygiene practice. Copyright © 2016 Elsevier Inc. All rights reserved.
Christakis, Dimitri A; Garrison, Michelle M
The goal was to quantify television viewing in day care settings and to investigate the characteristics of programs that predict viewing. A telephone survey of licensed child care programs in Michigan, Washington, Florida, and Massachusetts was performed. The frequency and quantity of television viewing for infants, toddlers, and preschool-aged children were assessed. With the exception of infants, children in home-based child care programs were exposed to significantly more television on an average day than were children in center-based programs (infants: 0.2 vs 0 hours; toddlers: 1.6 vs 0.1 hours; preschool-aged children: 2.4 vs 0.4 hours). In a regression analysis of daily television time for preschool-aged children in child care, center-based programs were found to have an average of 1.84 fewer hours of television each day, controlling for the other covariates. Significant effect modification was found, in that the impact of home-based versus center-based child care programs differed somewhat depending on educational levels for staff members; having a 2- or 4-year college degree was associated with 1.41 fewer hours of television per day in home-based programs, but no impact of staff education on television use was observed in center-based programs. For many children, previous estimates of screen time significantly underestimated actual amounts. Pediatricians should council parents to minimize screen time in child care settings.
Lelli, Vanessa R; Hickman, Ronald L; Savrin, Carol L; Peterson, Rachel A
To examine if differences exist in the levels of autonomy and job satisfaction among primary care nurse practitioners (NPs) employed in retail clinics versus traditional primary care settings. Data were collected from 310 primary care NPs who attended the American Association of NP's 28th Annual Conference in June 2013. Participants completed a demographic form, the Misener NP Job Satisfaction Scale, and the Dempster Practice Behavior Scale. Overall, there were no differences in job satisfaction or autonomy among NPs by practice setting. Retail NPs felt less valued and were less satisfied with social interaction, but more satisfied with benefits compared to NPs in traditional settings. NPs working in retail clinics were less likely to have intentions to leave current position compared to NPs in traditional practice settings. The results of this study enhance our current understanding of the linkages between levels of autonomy, job satisfaction, and practice setting among primary care NPs. The findings of this descriptive study offer valuable insights for stakeholders devoted to the development of the primary care workforce and identify modifiable factors that may influence retention and turnover rates among NPs. ©2015 American Association of Nurse Practitioners.
Waduthantri, Samanthila; Yong, Siew Sian; Tan, Chien Hua; Shen, Liang; Lee, Man Xin; Nagarajan, Sangeetha; Hla, Mynt Htoon; Tong, Louis
To estimate the cost and patterns of expenditure of dry eye treatment. We retrieved data on the type and cost of dry eye treatment in Singapore National Eye Centre from pharmacy and clinic inventory databases over a 2 year period (2008-2009) retrospectively. According to the type of treatment, data were sorted into 7 groups; meibomien gland disease (MGD) treatment, preservative free lubricant eye drops, preserved lubricant eye drops, lubricant ointments and gels, cyclosporine eye drops, oral supplements and non-pharmacological treatments/procedures. Each recorded entry was considered as one patient episode (PE). Comparisons in each group between two years were carried out using Pearson Chi-Square test. Significance level was set at alpha = 0.05. Cost data from 54,052 patients were available for analysis. Total number of recorded PEs was 132,758. Total annual expenditure on dry eye treatment for year 2008 and 2009 were US$1,509,372.20 and US$1,520,797.80 respectively. Total expenditure per PE in year 2008 and 2009 were US$22.11 and US$23.59 respectively. From 2008 to 2009, there was a 0.8% increase in total annual expenditure and 6.69% increase in expenditure per PE. Pharmacological treatment attributes to 99.2% of the total expenditure with lubricants accounting for 79.3% of the total pharmacological treatment expenditure. Total number of units purchased in preservative free lubricants, cyclosporine eye drops and MGD therapy have increased significantly (pDry eye imposes a significant direct burden to health care expenditure even without considering indirect costs. Health care planners should be aware that these direct costs appear to increase over the time and more so for particular types of medications. Given the limitations of socio-economic data, true societal costs of Dry eye syndrome are likely to be much higher than estimated.
Quanjel, Tessa C C; Struijs, Jeroen N; Spreeuwenberg, Marieke D; Baan, Caroline A; Ruwaard, Dirk
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).
Maluka, Stephen; Kamuzora, Peter; Sebastiån, Miguel San
Priority-setting has become one of the biggest challenges faced by health decision-makers worldwide. Fairness is a key goal of priority-setting and Accountability for Reasonableness has emerged as a guiding framework for fair priority-setting. This paper describes the processes of setting health...... care priorities in Mbarali district, Tanzania, and evaluates the descriptions against Accountability for Reasonableness. Key informant interviews were conducted with district health managers, local government officials and other stakeholders using a semi-structured interview guide. Relevant documents...... no formal mechanisms in place to ensure that this information reached the public. There were neither formal mechanisms for challenging decisions nor an adequate enforcement mechanism to ensure that decisions were made in a fair and equitable manner. Therefore, priority-setting in Mbarali district did...
Spigolon, Dandara Novakowski; Moro, Claudia Maria Cabral
This study aimed to develop an Essential Data Set for Nursing Care of Patients with Endometriosis (CDEEPE), represented by archetypes. An exploratory applied research with specialists' participation that was carried out at Heath Informatics Laboratory of PUCPR, between February and November of 2010. It was divided in two stages: CDEEPE construction and evaluation including Nursing Process phases and Basic Human Needs, and archetypes development based on this data set. CDEEPE was evaluated by doctors and nurses with 95.9% of consensus and containing 51 data items. The archetype "Perception of Organs and Senses" was created to represents this data set. This study allowed identifying important information for nursing practices contributing to computerization and application of nursing process during care. The CDEEPE was the basis for archetype creation, that will make possible structured, organized, efficient, interoperable, and semantics records.
Thomas L. Lenz
Full Text Available Chronic diseases continue to be a significant burden to the health care system. Pharmacists have been able to show that drug therapy for patients with chronic diseases can be improved through medication therapy management (MTM services but have yet to become significantly involved in implementing lifestyle modification programs to further control and prevent chronic conditions. A novel and innovative lifestyle medicine program was started by pharmacists in a community pharmacy in 2008 to more comprehensively prevent and manage chronic conditions. The lifestyle medicine program consists of designing seven personalized programs for patients to address physical activity, nutrition, alcohol consumption, weight control, stress management, sleep success, and tobacco cessation (if needed. The lifestyle medicine program complements existing MTM services for patients with hypertension, dyslipidemia, and/or diabetes. This program is innovative because pharmacists have developed and implemented a method to combine lifestyle medicine with MTM services to not only manage chronic conditions, but prevent the progression of those conditions and others. Several innovative tools have also been developed to enhance the effectiveness of a lifestyle medicine program. This manuscript describes the program's pharmacy setting, pharmacy personnel, participants and program details as well as the tools used to integrate a lifestyle medicine program with MTM services. Type: Clinical Experience
Children represent the most vulnerable members of our global society, a truth that is magnified when they are physically wounded. In much of the developed world, society has responded by offering protection in the form of law, injury prevention guidelines, and effective trauma systems to provide care for the injured child. Much of our world, though, remains afflicted by poverty and a lack of protective measures. As the globe becomes smaller by way of ease of travel and technology, surgeons are increasingly able to meet these children where they live and in doing so offer their hands and voices to care and protect these young ones. This article is intended as an overview of current issues in pediatric trauma care in the developing world as well as to offer some tips for the volunteer surgeon who may be involved in the care of the injured child in a setting of limited resource availability. Published by Elsevier Inc.
Godfrey, Emily M; Tepper, Naomi K; Curtis, Kathryn M; Moskosky, Susan B; Gavin, Loretta E
The provision of family planning services has important health benefits for the U.S. Approximately 25 million women in the U.S. receive contraceptive services annually and 44 million make at least one family planning-related clinical visit each year. These services are provided by private clinicians, as well as publicly funded clinics, including specialty family planning clinics, health departments, Planned Parenthoods, community health centers, and primary care clinics. Recommendations for providing quality family planning services have been published by CDC and the Office of Population Affairs of the DHHS. This paper describes the process used to develop the women's clinical services portion of the new recommendations and the rationale underpinning them. The recommendations define family planning services as contraceptive care, pregnancy testing and counseling, achieving pregnancy, basic infertility care, sexually transmitted disease services, and preconception health. Because many women who seek family planning services have no other source of care, the recommendations also include additional screening services related to women's health, such as cervical cancer screening. These clinical guidelines are aimed at providing the highest-quality care and are designed to establish a national standard for family planning in the U.S. Published by Elsevier Inc.
Karthikeyan, Balasubramanian; Kadhiravan, Tamilarasu; Deepanjali, Surendran; Swaminathan, Rathinam Palamalai
Mechanical ventilation is a resource intensive organ support treatment, and historical studies from low-resource settings had reported a high mortality. We aimed to study the outcomes in patients receiving mechanical ventilation in a contemporary low-resource setting. We prospectively studied the characteristics and outcomes (disease-related, mechanical ventilation-related, and process of care-related) in 237 adults mechanically ventilated for a medical illness at a teaching hospital in southern India during February 2011 to August 2012. Vital status of patients discharged from hospital was ascertained on Day 90 or later. Mean age of the patients was 40 ± 17 years; 140 (51%) were men. Poisoning and envenomation accounted for 98 (41%) of 237 admissions. In total, 87 (37%) patients died in-hospital; 16 (7%) died after discharge; 115 (49%) were alive at 90-day assessment; and 19 (8%) were lost to follow-up. Weaning was attempted in 171 (72%) patients; most patients (78 of 99 [79%]) failing the first attempt could be weaned off. Prolonged mechanical ventilation was required in 20 (8%) patients. Adherence to head-end elevation and deep vein thrombosis prophylaxis were 164 (69%) and 147 (62%) respectively. Risk of nosocomial infections particularly ventilator-associated pneumonia was high (57.2 per 1,000 ventilator-days). Higher APACHE II score quartiles (adjusted HR [95% CI] quartile 2, 2.65 [1.19-5.89]; quartile 3, 2.98 [1.24-7.15]; quartile 4, 5.78 [2.45-13.60]), and new-onset organ failure (2.98 [1.94-4.56]) were independently associated with the risk of death. Patients with poisoning had higher risk of reintubation (43% vs. 20%; P = 0.001) and ventilator-associated pneumonia (75% vs. 53%; P = 0.001). But, their mortality was significantly lower compared to the rest (24% vs. 44%; P = 0.002). The case-mix considerably differs from other settings. Mortality in this low-resource setting is similar to high-resource settings. But, further improvements in care processes
Full Text Available Mechanical ventilation is a resource intensive organ support treatment, and historical studies from low-resource settings had reported a high mortality. We aimed to study the outcomes in patients receiving mechanical ventilation in a contemporary low-resource setting.We prospectively studied the characteristics and outcomes (disease-related, mechanical ventilation-related, and process of care-related in 237 adults mechanically ventilated for a medical illness at a teaching hospital in southern India during February 2011 to August 2012. Vital status of patients discharged from hospital was ascertained on Day 90 or later.Mean age of the patients was 40 ± 17 years; 140 (51% were men. Poisoning and envenomation accounted for 98 (41% of 237 admissions. In total, 87 (37% patients died in-hospital; 16 (7% died after discharge; 115 (49% were alive at 90-day assessment; and 19 (8% were lost to follow-up. Weaning was attempted in 171 (72% patients; most patients (78 of 99 [79%] failing the first attempt could be weaned off. Prolonged mechanical ventilation was required in 20 (8% patients. Adherence to head-end elevation and deep vein thrombosis prophylaxis were 164 (69% and 147 (62% respectively. Risk of nosocomial infections particularly ventilator-associated pneumonia was high (57.2 per 1,000 ventilator-days. Higher APACHE II score quartiles (adjusted HR [95% CI] quartile 2, 2.65 [1.19-5.89]; quartile 3, 2.98 [1.24-7.15]; quartile 4, 5.78 [2.45-13.60], and new-onset organ failure (2.98 [1.94-4.56] were independently associated with the risk of death. Patients with poisoning had higher risk of reintubation (43% vs. 20%; P = 0.001 and ventilator-associated pneumonia (75% vs. 53%; P = 0.001. But, their mortality was significantly lower compared to the rest (24% vs. 44%; P = 0.002.The case-mix considerably differs from other settings. Mortality in this low-resource setting is similar to high-resource settings. But, further improvements in care processes
Topazian, Rachel J; Hook, C Christopher; Mueller, Paul S
Staff and students working in health care settings are sometimes reluctant to speak up when they perceive patients to be at risk for harm. In this article, we describe four incidents that occurred at our institution (Mayo Clinic). In two of them, health care professionals failed to speak up, which resulted in harm; in the other two, they did speak up, which prevented harm and improved patient care. We analyzed each scenario using the Physician's Charter on Medical Professionalism and prima facie ethics principles to determine whether principles were violated or upheld. We conclude that anyone who works in a health care setting has a duty to speak up when a patient faces harm. We also provide guidance for health care institutions on promoting a culture in which speaking up is encouraged and integrated into routine practice.
Schryer, Catherine; McDougall, Allan; Tait, Glendon R.; Lingard, Lorelei
This article investigates an emerging practice in palliative care: dignity therapy. Dignity therapy is a psychotherapeutic intervention that its proponents assert has clinically significant positive impacts on dying patients. Dignity therapy consists of a physician asking a patient a set of questions about his or her life and returning to the…
Liza Van Eenoo
Full Text Available Introduction: Since the European population is ageing, a growing number of elderly will need home care. Consequently, high quality home care for the elderly remains an important challenge. Job satisfaction among care professionals is regarded as an important aspect of the quality of home care. Aim: This paper describes a research protocol to identify elements that have an impact on job satisfaction among care professionals and on quality of care for older people in the home care setting of six European countries. Methods: Data on elements at the macro-level (policy, meso-level (care organisations and micro-level (clients are of importance in determining job satisfaction and quality of care. Macro-level indicators will be identified in a previously published literature review. At meso- and micro-level, data will be collected by means of two questionnaires utilsed with both care organisations and care professionals, and by means of interRAI Home Care assessments of clients. The client assessments will be used to calculate quality of care indicators. Subsequently, data will be analysed by means of linear and stepwise multiple regression analyses, correlations and multilevel techniques. Conclusions and Discussion: These results can guide health care policy makers in their decision making process in order to increase the quality of home care in their organisation, in their country or in Europe.
van der Roest, Henriëtte; van Hout, Hein; Declercq, Anja
Introduction: Since the European population is ageing, a growing number of elderly will need home care. Consequently, high quality home care for the elderly remains an important challenge. Job satisfaction among care professionals is regarded as an important aspect of the quality of home care. Aim: This paper describes a research protocol to identify elements that have an impact on job satisfaction among care professionals and on quality of care for older people in the home care setting of six European countries. Methods: Data on elements at the macro-level (policy), meso-level (care organisations) and micro-level (clients) are of importance in determining job satisfaction and quality of care. Macro-level indicators will be identified in a previously published literature review. At meso- and micro-level, data will be collected by means of two questionnaires utilsed with both care organisations and care professionals, and by means of interRAI Home Care assessments of clients. The client assessments will be used to calculate quality of care indicators. Subsequently, data will be analysed by means of linear and stepwise multiple regression analyses, correlations and multilevel techniques. Conclusions and Discussion: These results can guide health care policy makers in their decision making process in order to increase the quality of home care in their organisation, in their country or in Europe. PMID:28435423
Lazarus, Jeffery V.; Laut, Kamilla Grønborg; Safreed-Harmon, Kelly
Background: Although advances in HIV medicine have yielded increasingly better treatment outcomes in recent years, HIV-positive people with access to antiretroviral therapy (ART) still face complex health challenges. The EuroSIDA Study Group surveyed its clinics to explore regional differences...... in clinic services. Methods: The EuroSIDA study is a prospective observational cohort study that began enrolling patients in 1994. In early 2014, we conducted a 59-item survey of the 98 then-active EuroSIDA clinics. The survey covered HIV clinical care and other aspects of patient care. The EuroSIDA East...... Europe study region (Belarus, Estonia, Lithuania, the Russian Federation and Ukraine) was compared to a "non-East Europe" study region comprised of all other EuroSIDA countries. Results: A larger proportion of clinics in the East Europe group reported deferring ART in asymptomatic patients until the CD4...
Trish A Gray
Full Text Available People with complex wounds are more likely to be elderly, living with multimorbidity and wound related symptoms. A variety of products are available for managing complex wounds and a range of healthcare professionals are involved in wound care, yet there is a lack of good evidence to guide practice and services. These factors create uncertainty for those who deliver and those who manage wound care. Formal priority setting for research and implementation topics is needed to more accurately target the gaps in treatment and services. We solicited practitioner and manager uncertainties in wound care and held a priority setting workshop to facilitate a collaborative approach to prioritising wound care-related uncertainties.We recruited healthcare professionals who regularly cared for patients with complex wounds, were wound care specialists or managed wound care services. Participants submitted up to five wound care uncertainties in consultation with their colleagues, via an on-line survey and attended a priority setting workshop. Submitted uncertainties were collated, sorted and categorised according professional group. On the day of the workshop, participants were divided into four groups depending on their profession. Uncertainties submitted by their professional group were viewed, discussed and amended, prior to the first of three individual voting rounds. Participants cast up to ten votes for the uncertainties they judged as being high priority. Continuing in the professional groups, the top 10 uncertainties from each group were displayed, and the process was repeated. Groups were then brought together for a plenary session in which the final priorities were individually scored on a scale of 0-10 by participants. Priorities were ranked and results presented. Nominal group technique was used for generating the final uncertainties, voting and discussions.Thirty-three participants attended the workshop comprising; 10 specialist nurses, 10 district
Dumville, Jo C.; Christie, Janice; Cullum, Nicky A.
Introduction People with complex wounds are more likely to be elderly, living with multimorbidity and wound related symptoms. A variety of products are available for managing complex wounds and a range of healthcare professionals are involved in wound care, yet there is a lack of good evidence to guide practice and services. These factors create uncertainty for those who deliver and those who manage wound care. Formal priority setting for research and implementation topics is needed to more accurately target the gaps in treatment and services. We solicited practitioner and manager uncertainties in wound care and held a priority setting workshop to facilitate a collaborative approach to prioritising wound care-related uncertainties. Methods We recruited healthcare professionals who regularly cared for patients with complex wounds, were wound care specialists or managed wound care services. Participants submitted up to five wound care uncertainties in consultation with their colleagues, via an on-line survey and attended a priority setting workshop. Submitted uncertainties were collated, sorted and categorised according professional group. On the day of the workshop, participants were divided into four groups depending on their profession. Uncertainties submitted by their professional group were viewed, discussed and amended, prior to the first of three individual voting rounds. Participants cast up to ten votes for the uncertainties they judged as being high priority. Continuing in the professional groups, the top 10 uncertainties from each group were displayed, and the process was repeated. Groups were then brought together for a plenary session in which the final priorities were individually scored on a scale of 0–10 by participants. Priorities were ranked and results presented. Nominal group technique was used for generating the final uncertainties, voting and discussions. Results Thirty-three participants attended the workshop comprising; 10 specialist nurses
Richard, Edo; Kuiper, Roy; Dijkgraaf, Marcel G. W.; van Gool, Willem A.
OBJECTIVES: To investigate whether vascular care slows dementia progression in patients with Alzheimer's disease with cerebrovascular lesions on neuroimaging. DESIGN: Multicenter randomized controlled clinical trial with 2-year follow-up. SETTING: Neurological and geriatric outpatient clinics in 10
Montano, Blanca San José; Garcia Carretero, Rafael; Varela Entrecanales, Manuel; Pozuelo, Paz Martin
Research in hospital settings faces several difficulties. Information technologies and certain Web 2.0 tools may provide new models to tackle these problems, allowing for a collaborative approach and bridging the gap between clinical practice, teaching and research. We aim to gather a community of researchers involved in the development of a network of learning and investigation resources in a hospital setting. A multi-disciplinary work group analysed the needs of the research community. We studied the opportunities provided by Web 2.0 tools and finally we defined the spaces that would be developed, describing their elements, members and different access levels. WIKINVESTIGACION is a collaborative web space with the aim of integrating the management of all the hospital's teaching and research resources. It is composed of five spaces, with different access privileges. The spaces are: Research Group Space 'wiki for each individual research group', Learning Resources Centre devoted to the Library, News Space, Forum and Repositories. The Internet, and most notably the Web 2.0 movement, is introducing some overwhelming changes in our society. Research and teaching in the hospital setting will join this current and take advantage of these tools to socialise and improve knowledge management.
Ibrahim, Ahmed; Aro, Arja R.; Rasch, Vibeke
/119 (73.9%) were positive for cervical intraepithelial neoplasia. VIA had higher sensitivity than Pap smear (74.2% versus 72.9%; P = 0.05) respectively. Out of 88 confirmed positive cases, 22 (25.0%) cases were invasive cervical cancer in stage 1, of which 19 versus three were detected by VIA and Pap......OBJECTIVE: To determine the feasibility of visual inspection with the use of acetic acid (VIA) as a screening method for cervical cancer, an alternative to the Pap smear used in primary health care setting in Sudan, and to compare sensitivity, specificity, positive and negative predictive values...... of this study showed that VIA has higher sensitivity and lower specificity compared to Pap smear, but a combination of both tests has greater sensitivity and specificity than each test independently. It indicates that VIA is useful for screening of cervical cancer in the primary health care setting in Sudan...
Currently small electronic devices capable of producing high quality images are available. The massive use of these devices has become common in the clinical setting as medical images represent a useful tool to document relevant clinical conditions for patient diagnosis, treatment and follow-up. Besides, clinical images are beneficial for legal, scientific and academic purposes. The extended practice without proper ethical guidelines might represent a significant risk for the protection of patient rights and clinical practice. This document discusses risks and duties when obtaining medical images, and presents some arguments on institutional and professional responsibilities around the definition of policies regarding the protection of privacy and dignity of the patient.
Boehringer, Stefan; Guenther, Manuel; Sinigerova, Stella; Wurtz, Rolf P; Horsthemke, Bernhard; Wieczorek, Dagmar
Computer systems play an important role in clinical genetics and are a routine part of finding clinical diagnoses but make it difficult to fully exploit information derived from facial appearance. So far, automated syndrome diagnosis based on digital, facial photographs has been demonstrated under study conditions but has not been applied in clinical practice. We have therefore investigated how well statistical classifiers trained on study data comprising 202 individuals affected by one of 14 syndromes could classify a set of 91 patients for whom pictures were taken under regular, less controlled conditions in clinical practice. We found a classification accuracy of 21% percent in the clinical sample representing a ratio of 3.0 over a random choice. This contrasts with a 60% accuracy or 8.5 ratio in the training data. Producing average images in both groups from sets of pictures for each syndrome demonstrates that the groups exhibit large phenotypic differences explaining discrepancies in accuracy. A broadening of the data set is suggested in order to improve accuracy in clinical practice. In order to further this goal, a software package is made available that allows application of the procedures and contributions toward an improved data set. Copyright © 2011 Wiley-Liss, Inc.
The approach to nursing in long-term care settings for people living with dementia continues to evolve from a traditional, task-oriented culture to one that is person-centred. Such change can be difficult to manage and may encounter considerable opposition; having an understanding of change management and leadership styles may help to make this transition easier. This article discusses the differences between task-oriented and person-centred care, theories of management, motivation and leadership styles, and focuses on those that are most appropriate for this type of change. An improved understanding of these theories will enable nurses to support others in the delivery of person-centred care.
Baldwin, Susie B; Eisenman, David P; Sayles, Jennifer N; Ryan, Gery; Chuang, Kenneth S
An estimated 18,000 individuals are trafficked into the United States each year from all over the world, and are forced into hard labor or commercial sex work. Despite their invisibility, some victims are known to have received medical care while under traffickers' control. Our project aimed to characterize trafficking victims' encounters in US health care settings. The study consisted of semi-structured interviews with six Key Informants who work closely with trafficking victims (Phase I) and 12 female trafficking survivors (Phase II). All survivors were recruited through the Coalition to Abolish Slavery and Trafficking, an NGO in Los Angeles, and all were trafficked into Los Angeles. Interviews were conducted in English and six other languages, with the assistance of professional interpreters. Using a framework analysis approach that focused on victims' encounters in health care settings, we assessed interview transcript content and coded for themes. We used an exploratory pile-sorting technique to aggregate similar ideas and identify overarching domains. The survivors came from 10 countries. Eight had experienced domestic servitude, three had survived sex trafficking, and one had experienced both. Half the survivors reported that they had visited a physician while in their traffickers' control, and another worked in a health care facility. All Key Informants described other victims who had received medical care. For domestic servants, medical visits were triggered by injury and respiratory or systemic illness, while sex trafficking victims were seen by health professionals for sexually transmitted infections and abortion. Trafficking victims were prevented from disclosing their status to health care providers by fear, shame, language barriers, and limited interaction with medical personnel, among other obstacles. This exploration of survivors' experiences in health care settings supports anecdotal reports that US health care providers may unwittingly encounter
Stilos, Kalli; Daines, Pat
Demand for palliative care services in Canada will increase owing to an aging population and the evolving role of palliative care in non-malignant illness. Increasing healthcare demands continue to shape the clinical nurse specialist (CNS) role, especially in the area of palliative care. Clinical nurse specialists bring specialized knowledge, skills and leadership to the clinical setting to enhance patient and family care. This paper highlights the clinical leadership role of the CNS as triage leader for a hospital-based palliative care consulting team. Changes to the team's referral and triage processes are emphasized as key improvements to team efficiency and timely access to care for patients and families.
Funderburk, Jennifer S; Shepardson, Robyn L; Wray, Jennifer; Acker, John; Beehler, Gregory P; Possemato, Kyle; Wray, Laura O; Maisto, Stephen A
Health care organizations are embracing integrated primary care (IPC), in which mental health and behavioral health are addressed as part of routine care within primary care settings. Behavioral medicine concerns, which include health behavior change and coping with medical conditions, are common in primary care populations. Although there are evidence-based behavioral interventions that target a variety of behavioral medicine concerns, integrated behavioral health providers need interventions that are sufficiently brief (i.e., ≤6 appointments) to be compatible with IPC. We conducted a literature review of published studies examining behavioral interventions that target prevalent behavioral medicine concerns and can feasibly be employed by IPC providers in adult primary care settings. A total of 67 published articles representing 63 original studies met eligibility criteria. We extracted data on the behavioral interventions employed, results comparing the active intervention to a comparison group, general fit with IPC, and methodological quality. The vast majority of studies examined brief interventions targeting sleep difficulties and physical activity. The most commonly employed interventions were derived from cognitive-behavioral therapy and motivational interviewing. Outcomes were generally statistically significantly in favor of the active intervention relative to comparison, with highly variable methodological quality ratings (range = 0-5; M = 2.0). Results are discussed in relation to the need for further evidence for brief behavioral interventions targeting other behavioral medicine concerns beyond sleep and physical activity, as well as for more specificity regarding the compatibility of such interventions with IPC practice. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Babenko-Mould, Yolanda; Laschinger, Heather K S
To examine the relationship between nursing students' exposure to various forms of incivility in acute care practice settings and their experience of burnout. Given that staff nurses and new nurse graduates are experiencing incivility and burnout in the workplace, it is plausible that nursing students share similar experiences in professional practice settings. A cross-sectional survey design was used to assess Year 4 nursing students' (n=126) perceptions of their experiences of incivility and burnout in the clinical learning environment. Students completed instruments to assess frequency of uncivil behaviors experienced during the past six months from nursing staff, clinical instructors, and other health professionals in the acute care practice setting and to measure student burnout. Reported incidences of incivility in the practice setting were related to burnout. Higher rates of incivility, particularly from staff nurses, were associated with higher levels of both components of burnout (emotional exhaustion and cynicism).
Nerminathan, Arany; Harrison, Amanda; Phelps, Megan; Alexander, Shirley; Scott, Karen M
Mobile device use has become almost ubiquitous in daily life and therefore includes use by doctors in clinical settings. There has been little study as to the patterns of use and impact this has on doctors in the workplace and how negatively or positively it impacts at the point of care. To explore how doctors use mobile devices in the clinical setting and understand drivers for use. A mixed methods study was used with doctors in a paediatric and adult teaching hospital in 2013. A paper-based survey examined mobile device usage data by doctors in the clinical setting. Focus groups explored doctors' reasons for using or refraining from using mobile devices in the clinical setting, and their attitudes about others' use. The survey, completed by 109 doctors, showed that 91% owned a smartphone and 88% used their mobile devices frequently in the clinical setting. Trainees were more likely than consultants to use their mobile devices for learning and accessing information related to patient care, as well as for personal communication unrelated to work. Focus group data highlighted a range of factors that influenced doctors to use personal mobile devices in the clinical setting, including convenience for medical photography, and factors that limited use. Distraction in the clinical setting due to use of mobile devices was a key issue. Personal experience and confidence in using mobile devices affected their use, and was guided by role modelling and expectations within a medical team. Doctors use mobile devices to enhance efficiency in the workplace. In the current environment, doctors are making their own decisions based on balancing the risks and benefits of using mobile devices in the clinical setting. There is a need for guidelines around acceptable and ethical use that is patient-centred and that respects patient privacy. © 2016 Royal Australasian College of Physicians.
Subramanian, Pathmawathi; Allcock, Nick; James, Veronica; Lathlean, Judith
To explore nurses' challenges in managing pain among ill patients in critical care. Pain can lead to many adverse medical consequences and providing pain relief is central to caring for ill patients. Effective pain management is vital since studies show patients admitted to critical care units still suffer from significant levels of acute pain. The effective delivery of care in clinical areas remains a challenge for nurses involved with care which is dynamic and constantly changing in critically ill. Qualitative prospective exploratory design. This study employed semi structured interviews with nurses, using critical incident technique. Twenty-one nurses were selected from critical care settings from a large acute teaching health care trust in the UK. A critical incident interview guide was constructed from the literature and used to elicit responses. Framework analysis showed that nurses perceived four main challenges in managing pain namely lack of clinical guidelines, lack of structured pain assessment tool, limited autonomy in decision making and the patient's condition itself. Nurses' decision making and pain management can influence the quality of care given to critically ill patients. It is important to overcome the clinical problems that are faced when dealing with pain experience. There is a need for nursing education on pain management. Providing up to date and practical strategies may help to reduce nurses' challenges in managing pain among critically ill patients. Broader autonomy and effective decision making can be seen as beneficial for the nurses besides having a clearer and structured pain management guidelines. © 2011 Blackwell Publishing Ltd.
Fraher, Erin P; Richman, Erica Lynn; Zerden, Lisa de Saxe; Lombardi, Brianna
Social workers are increasingly being deployed in integrated medical and behavioral healthcare settings but information about the roles they fill in these settings is not well understood. This study sought to identify the functions that social workers perform in integrated settings and identify where they acquired the necessary skills to perform them. Master of social work students (n=21) and their field supervisors (n=21) who were part of a Health Resources and Services Administration-funded program to train and expand the behavioral health workforce in integrated settings were asked how often they engaged in 28 functions, where they learned to perform those functions, and the degree to which their roles overlapped with others on the healthcare team. The most frequent functions included employing cultural competency, documenting in the electronic health record, addressing patient social determinants of health, and participating in team-based care. Respondents were least likely to engage in case conferences; use Screening, Brief Intervention and Referral to Treatment; use stepped care to determine necessary level of treatment; conduct functional assessments of daily living skills; use behavioral activation; and use problem-solving therapy. A total of 80% of respondents reported that their roles occasionally, often, very often, or always overlapped with others on the healthcare team. Students reported learning the majority of skills (76%) in their Master of Social Work programs. Supervisors attributed the majority (65%) of their skill development to on-the-job training. Study findings suggest the need to redesign education, regulatory, and payment to better support the deployment of social workers in integrated care settings. This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services
McGilton, Katherine S.; Guruge, Sepali; Librado, Ruby; Bloch, Lois; Boscart, Veronique
Research on the relationships between health care aides (HCAs) and families of clients has been situated mainly in long-term care settings and includes scant findings about the perceptions of HCAs. Based on the findings of a larger qualitative study using a grounded theory approach, this paper addresses the topic of HCA-family relationships in…
Radwin, Laurel E; Castonguay, Denise; Keenan, Carolyn B; Hermann, Cherice
For many patients, high-quality, patient-centered, and cost-effective health care requires coordination among multiple clinicians and settings. Ensuring optimal care coordination requires a clear understanding of how clinician activities and continuity during transitions affect patient-centeredness and quality outcomes. This article describes an expanded theoretical framework to better understand care coordination. The framework provides clear articulation of concepts. Examples are provided of ways to measure the concepts.
Bakitas, Marie A; Elk, Ronit; Astin, Meka; Ceronsky, Lyn; Clifford, Kathleen N; Dionne-Odom, J Nicholas; Emanuel, Linda L; Fink, Regina M; Kvale, Elizabeth; Levkoff, Sue; Ritchie, Christine; Smith, Thomas
Many of the world's population live in rural areas. However, access and dissemination of the advances taking place in the field of palliative care to patients living in rural areas have been limited. We searched 2 large databases of the medical literature and found 248 relevant articles; we also identified another 59 articles through networking and a hand search of reference lists. Of those 307 articles, 39 met the inclusion criteria and were grouped into the following subcategories: intervention (n = 4), needs assessment (n = 2), program planning (n = 3), program evaluation (n = 4), education (n = 7), financial (n = 8), and comprehensive/systematic literature reviews (n = 11). We synthesized the current state of rural palliative care research and practice to identify important gaps for future research. Studies were conducted in the United States, Australia, Canada, Africa, Sweden, and India. Two randomized control trials were identified, both of which used telehealth approaches and had positive survival outcomes. One study demonstrated positive patient quality of life and depression outcomes. Research to guide rural palliative care practice is sparse. Approaches to telehealth, community- academic partnerships, and training rural health care professionals show promise, but more research is needed to determine best practices for providing palliative care to patients living in rural settings.
LeBlanc, Thomas W; Lodato, Jordan E; Currow, David C; Abernethy, Amy P
Palliative care is increasingly viewed as a necessary component of cancer care, especially for patients with advanced disease. Rigorous clinical trials are thus needed to build the palliative care evidence base, but clinical research-especially participant recruitment-is difficult. Major barriers include (1) patient factors, (2) "gatekeeping," and (3) ethical concerns. Here we discuss an approach to overcoming these barriers, using the Palliative Care Trial (PCT) as a case study. The PCT was a 2 × 2 × 2 factorial randomized controlled trial (RCT) of different service delivery models to improve pain control in the palliative setting. It used a recruitment protocol that fused evidence-based strategies with principles of "social marketing," an approach involving the systematic application of marketing techniques. Main components included (1) an inclusive triage algorithm, (2) information booklets targeting particular stakeholders, (3) a specialized recruitment nurse, and (4) standardization of wording across all study communications. From an eligible pool of 607 patients, the PCT enrolled 461 patients over 26 months. Twenty percent of patients referred to the palliative care service were enrolled (76% of those eligible after screening). Several common barriers were minimized; among those who declined participation, family disinterest was uncommon (5%), as was the perception of burden imposed (4%). Challenges to clinical trial recruitment in palliative care are significant but not insurmountable. A carefully crafted recruitment and retention protocol can be effective. Our experience with designing and deploying a social-marketing-based protocol shows the benefits of such an approach.
Govranos, Melissa; Newton, Jennifer M
Health care systems demand that nurses are flexible skilful workers who maintain currency and competency in order to deliver safe effective patient centered care. Nurses must continually build best practice into their care and acquire lifelong learning. Often this learning is acquired within the work environment and is facilitated by the clinical nurse educator. Understanding clinical nurses' values and needs of continuing education is necessary to ensure appropriate education service delivery and thus enhance patient care. To explore clinical ward-based nurses' values and perceptions towards continuing education and what factors impact on continuing education in the ward. A case study approach was utilized. A major teaching hospital in Melbourne, Australia. A range of clinical nursing staff (n=23). Four focus groups and six semi-structured individual interviews were undertaken. Focus group interviews explored participants' values and perceptions on continuing education through a values clarification tool. Thematic analysis of interviews was undertaken to identify themes and cluster data. Three central themes: 'culture and attitudes', 'what is learning?' and 'being there-being seen', emerged reflecting staffs' values and perceptions of education and learning in the workplace. Multiple factors influence ward nurses' ability and motivation to incorporate lifelong learning into their practice. Despite variance in nurses' values and perceptions of CE in clinical environments, CE was perceived as important. Nurses yearned for changes to facilitate lifelong learning and cultivate a learning culture. Clinical nurse educators need to be cognizant of adult learners' characteristics such as values, beliefs, needs and potential barriers, to effectively facilitate support in a challenging and complex learning environment. Organizational support is essential so ward managers in conjunction with educational departments can promote and sustain continuing education, lifelong
Full Text Available OBJECTIVES: To estimate the cost and patterns of expenditure of dry eye treatment. METHODOLOGY: We retrieved data on the type and cost of dry eye treatment in Singapore National Eye Centre from pharmacy and clinic inventory databases over a 2 year period (2008-2009 retrospectively. According to the type of treatment, data were sorted into 7 groups; meibomien gland disease (MGD treatment, preservative free lubricant eye drops, preserved lubricant eye drops, lubricant ointments and gels, cyclosporine eye drops, oral supplements and non-pharmacological treatments/procedures. Each recorded entry was considered as one patient episode (PE. Comparisons in each group between two years were carried out using Pearson Chi-Square test. Significance level was set at alpha = 0.05. RESULTS: Cost data from 54,052 patients were available for analysis. Total number of recorded PEs was 132,758. Total annual expenditure on dry eye treatment for year 2008 and 2009 were US$1,509,372.20 and US$1,520,797.80 respectively. Total expenditure per PE in year 2008 and 2009 were US$22.11 and US$23.59 respectively. From 2008 to 2009, there was a 0.8% increase in total annual expenditure and 6.69% increase in expenditure per PE. Pharmacological treatment attributes to 99.2% of the total expenditure with lubricants accounting for 79.3% of the total pharmacological treatment expenditure. Total number of units purchased in preservative free lubricants, cyclosporine eye drops and MGD therapy have increased significantly (p<0.001 whereas number of units purchased in preserved lubricants and ointments/gels have reduced significantly (p<0.001 from 2008 to 2009. CONCLUSION: Dry eye imposes a significant direct burden to health care expenditure even without considering indirect costs. Health care planners should be aware that these direct costs appear to increase over the time and more so for particular types of medications. Given the limitations of socio-economic data, true
The Affordable Care Act (ACA) may be the most important health law statute in American history, yet much of the most prominent legal scholarship examining it has focused on the merits of the court challenges it has faced rather than delving into the details of its priority-setting provisions. In addition to providing an overview of the ACA's provisions concerning priority setting and their developing interpretations, this Article attempts to defend three substantive propositions. First, I argue that the ACA is neither uniformly hostile nor uniformly friendly to efforts to set priorities in ways that promote cost and quality. Second, I argue that the ACA does not take a single, unified approach to priority setting; rather, its guidance varies depending on the aspect of the healthcare system at issue (Patient Centered Outcomes Research Institute, Medicare, essential health benefits) and the factors being excluded from priority setting (age, disability, life expectancy). Third, I argue that cost-effectiveness can be achieved within the ACA's constraints, but that doing so will require adopting new approaches to cost-effectiveness and priority setting. By limiting the use of standard cost-effectiveness analysis, the ACA makes the need for workable rivals to cost-effectiveness analysis a pressing practical concern rather than a mere theoretical worry.
Abbate-Daga, Giovanni; Buzzichelli, Sara; Marzola, Enrica; Amianto, Federico; Fassino, Secondo
While evidence continues to accumulate on the relevance of cognitive inflexibility in anorexia nervosa (AN), its clinical correlates remain unclear. We aimed at examining the relationship between set-shifting and clinical variables (i.e., eating psychopathology, depression, and personality) in AN. Ninety-four individuals affected by AN and 59 healthy controls (HC) were recruited. All participants were assessed using: Eating Disorders Inventory-2 (EDI-2), Temperament and Character Inventory (TCI), Beck Depression Inventory (BDI), and Wisconsin Card Sorting Test (WCST). The AN group scored worse than HCs on set-shifting. According to their neuropsychological performances, AN patients were split into two groups corresponding to poor (N=30) and intact (N=64) set-shifting subtypes. Interoceptive awareness, impulse regulation, and maturity fears on the EDI-2 and depression on the BDI differed across all groups (HC, intact, and poor set-shifting subtype). Self-directedness on the TCI differed significantly among all groups. Cooperativeness and reward dependence differed instead only between HC and AN poor set-shifting subtype. After controlling for depression, only interoceptive awareness remained significant with reward dependence showing a trend towards statistical significance. These findings suggest that multiple clinical variables may be correlated with set-shifting performances in AN. The factors contributing to impaired cognitive inflexibility could be more complex than heretofore generally considered. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Gable, Eileen M.
Describes the innovative content and structure of an introductory course on clinical patient care at the Illinois College of Optometry. Critiques its success based on student grades and feedback, concluding that it was successful in imparting skills of data analysis but had minimal impact on students' ability to empathize with patients. (EV)
Chavez, Krista S; Dwyer, Andrew A; Ramelet, Anne-Sylvie
To identify and summarize the common clinical settings, interventions, and outcomes of nurse practitioner care specific to older people. Scoping review of the international published and grey literature. A structured literature search was conducted of CINAHL, EMBASE, MEDLINE, Google Scholar, and Cochrane Collaboration and Joanna Briggs Institute databases. Following the Arksey and O'Malley framework, randomized controlled and quasi-experimental studies of Masters-prepared nurse practitioners providing care for patients over 65 years were included. Studies were reviewed independently by two investigators. Data were extracted, collated by setting, summarized in tables and synthesized for analysis. In total, 56 primary research studies from four countries and 23 systematic reviews were identified. Primary studies were conducted in primary care (n=13), home care (n=14), long-term care (n=10), acute/hospital care (n=9), and transitional care (n=10). Nurse practitioner interventions included substitutive as well as a supplementation NP role elements to meet specific unmet patient care needs. Studies examined six main outcome measures: service utilization (n=41), cost (n=24), length of stay (n=14), health indices (n=44), satisfaction (n=14) and quality of life (n=7). Cumulatively, nurse practitioners demonstrated enhanced results in 83/144 (58%) of outcomes compared to physician-only or usual care. The most commonly measured financial-related outcome was service utilization (n=41) and benefits were frequently reported in home care (8/9, 89%) and long-term care (7/10, 70%) settings. Among patient and care-related outcomes health indices were most frequently measured (n=44). Primary care most frequently reported improved health indices (11/13, 85%). Transitional care reported improved outcomes across all measures, except for service utilization. This review demonstrates improved or non-inferiority results of nurse practitioner care in older people across settings. More well
Haynes, Jack P.; Atkinson, David
Factor-analyzed the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) scores of emotionally disturbed children (N=181). The results suggested that the structure of intelligence for emotionally disturbed children is similar to that for normal children. WPPSI profile analysis that uses subtest scores may be invalid in clinical settings.…
Nöstlinger, Christiana; Rojas Castro, Daniela; Platteau, Tom; Dias, Sonia; Le Gall, Jean
This cross-sectional European study assessed self-reported HIV-related discrimination and its associated factors in health care settings. Socio-demographics, health status, support needs relating to sexual and reproductive health (SRH), and self-reported HIV-related discrimination were measured using an anonymous survey in a sample of 1549 people living with HIV from 14 countries. Thirty-two per cent of the participants had experienced HIV-related discrimination during the previous 3 years; almost half of them felt discriminated against by health care providers. For this type of discrimination, logistic regression analysis revealed significant associations with not being a migrant (OR: 2.0; IC 1.0-3.7; psex practices (OR: 1.8; IC 1.0-3.2; pgender had a protective effect (OR: 0.2; IC 0.0-0.9; pdiscrimination. Improving health care providers' communication skills, and fostering openness about SRH topics in HIV care could contribute to destigmatization of PLHIV.
Sices, Laura; Pawlowski, Katherine; Farfel, Laura; Phillips, Deirdre; Howe, Yamini; Cochran, David M; Choueiri, Roula; Forbes, Peter W; Brewster, Stephanie J; Frazier, Jean A; Neumeyer, Ann; Bridgemohan, Carolyn
Recruitment and completion of research activities during regular clinical care has the potential to increase research participation in complex neurodevelopmental disorders. We evaluated the feasibility, and effect on clinical care, of conducting biomarker research within a subspecialty clinical visit for autism spectrum disorder (ASD). Children, aged 5 to 10 years, were recruited by providers in ASD clinics at 5 institutions. Biomarkers collected were growth measurements, head circumference, neurologic and dysmorphology examinations, digit ratio (2D:4D) measurement, and platelet serotonin and urinary melatonin sulfate excretion levels. Parents completed the Aberrant Behavior Checklist-Community and a medical/demographic questionnaire. Cognitive level was abstracted from the medical record. Parents and clinicians completed surveys on the effect of the study on the clinical visit. Eighty-three children and their caregivers participated. Factors limiting participation included difficulty reaching families by phone and parent concern about the study blood draw requirement. All children completed at least 4 of 7 planned research activities. Demographic factors, educational placement, and child behavior were not associated with completion of study activities. Lower nonverbal cognitive function was weakly associated with fewer activities completed. Forty-four percent of clinicians reported an effect of the research study on the clinical visit. However, neither parent-reported nor clinician-reported effect was associated with the degree of study activity completion. Recruiting study participants in the context of scheduled ASD clinical visits required significant effort. However, once recruited, participants completed most study activities, regardless of behavioral symptom severity. Research activities did not adversely affect the clinical visit.
Nielsen, Kirsten; Pedersen, Birthe D.; Helms, Niels Henrik
Literature shows several benefits of implementing ePortfolio and focusing on learning styles within nursing education. However, there is some ambiguity, so the aim was to investigate learning mediated by the mandatory part of ePortfolio in clinical settings. The design takes a phenomenological......-hermeneutic approach. The setting was a ten-week clinical course in Basic Nursing, and participants were 11 first-year students randomly assigned. Data was generated by participant observations, narrative interviews and portfolio documents. The entire data material was interpreted according to the French philosopher...... Paul Ricoeurs theory of interpretation. This paper reports that the mandatory part promotes consciousness of own learning and competencies in clinical nursing and raises students` consciousness of nurse identity. It gives preceptors the opportunity to differentiate their supervision for individual...
Reimer Kirkham, Sheryl; Van Hofwegen, Lynn; Hoe Harwood, Catherine
The nursing profession has renewed its commitment to social and political mandates, resulting in increasing attention to issues pertaining to diversity, vulnerable populations, social determinants of health, advocacy and activism, and social justice in nursing curricula. Narratives from a qualitative study examining undergraduate nursing student learning in five innovative clinical settings (corrections, international, parish, rural, and aboriginal) resonate with these curricular emphases. Data were derived from focus groups and interviews with 65 undergraduate nursing students, clinical instructors, and RN mentors. Findings of this study reveal how students in innovative clinical placements bear witness to poverty, inequities, and marginalization (critical awareness), often resulting in dissonance and soul-searching (critical engagement), and a renewed commitment to social transformation (social change). These findings suggest the potential for transformative learning in these settings.
Vayne-Bossert, P; Richard, E; Good, P; Sullivan, K; Hardy, J R
Integration of oncology and palliative care (PC) should be the standard model of care for patients with advanced cancer. An expert panel developed criteria that constitute integration. This study determined whether the PC service within this Health Service, which is considered to be fully "integrated", could be benchmarked against these criteria. A survey was undertaken to determine the perceived level of integration of oncology and palliative care by all health care professionals (HCPs) within our cancer centre. An objective determination of integration was obtained from chart reviews of deceased patients. Integration was defined as >70% of all respondents answered "agree" or "strongly agree" to each indicator and >70% of patient charts supported each criteria. Thirty-four HCPs participated in the survey (response rate 69%). Over 90% were aware of the outpatient PC clinic, interdisciplinary and consultation team, PC senior leadership, and the acceptance of concurrent anticancer therapy. None of the other criteria met the 70% agreement mark but many respondents lacked the necessary knowledge to respond. The chart review included 67 patients, 92% of whom were seen by the PC team prior to death. The median time from referral to death was 103 days (range 0-1347). The level of agreement across all criteria was below our predefined definition of integration. The integration criteria relating to service delivery are medically focused and do not lend themselves to interdisciplinary review. The objective criteria can be audited and serve both as a benchmark and a basis for improvement activities.
Service user involvement in mental health has gained considerable momentum. Evidence from the literature suggests that it remains largely theoretical rather than being put into practice. The current nature of acute inpatient mental health units creates various challenges for nurses to put this concept into practice. Recovery clinics were introduced to bridge this gap and to promote service user involvement practice within the current care delivery model at Kent and Medway NHS and Social Care Partnership Trust. It has shaped new ways of working for nurses with a person-centred approach as its philosophy. Service users and nurses were involved in implementing a needs-led and bottom-up initiative using Kotter's change model. Initial results suggest that it has been successful in meeting its objectives evidenced through increased meaningful interactions and involvement in care by service users and carers. The clinics have gained wide recognition and have highlighted a need for further research into care delivery models to promote service user involvement in these units.
Philip, Swetha Sara
The aim of this study is to describe the setting up of a cerebral visual impairment (CVI) clinic in a tertiary care hospital in South India and to describe the spectrum of cases seen. The CVI clinic, set up in February 2011, receives interdisciplinary input from a core team involving a pediatrician, neurologist, psychiatrist, occupational therapist, pediatric ophthalmologist, and an optometrist. All children, children (45%) had moderate CP. Forty percent of CVI was due to birth asphyxia, but about 20% did not have any known cause for CVI. Seventy percent of patients, who came back for follow-up, were carrying out the habilitation strategies suggested. Average attendance of over 300 new patients a year suggests a definite need for CVI clinics in the country. These children need specialized care to handle their complex needs. Although difficult to coordinate, an interdisciplinary team including the support groups and voluntary organizations is needed to facilitate the successful implementation of such specialized service.
Chen, Jonathan H; Goldstein, Mary K; Asch, Steven M; Mackey, Lester; Altman, Russ B
Build probabilistic topic model representations of hospital admissions processes and compare the ability of such models to predict clinical order patterns as compared to preconstructed order sets. The authors evaluated the first 24 hours of structured electronic health record data for > 10 K inpatients. Drawing an analogy between structured items (e.g., clinical orders) to words in a text document, the authors performed latent Dirichlet allocation probabilistic topic modeling. These topic models use initial clinical information to predict clinical orders for a separate validation set of > 4 K patients. The authors evaluated these topic model-based predictions vs existing human-authored order sets by area under the receiver operating characteristic curve, precision, and recall for subsequent clinical orders. Existing order sets predict clinical orders used within 24 hours with area under the receiver operating characteristic curve 0.81, precision 16%, and recall 35%. This can be improved to 0.90, 24%, and 47% ( P sets tend to provide nonspecific, process-oriented aid, with usability limitations impairing more precise, patient-focused support. Algorithmic summarization has the potential to breach this usability barrier by automatically inferring patient context, but with potential tradeoffs in interpretability. Probabilistic topic modeling provides an automated approach to detect thematic trends in patient care and generate decision support content. A potential use case finds related clinical orders for decision support. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association.
Barr, J E; Cuzzell, J
A clinical pathway is a written sequence of clinical processes or events that guides a patient with a defined problem toward an expected outcome. Clinical pathways are tools to assist with the cost-effective management of clinical outcomes related to specific problems or disease processes. The primary obstacles to developing clinical pathways for wound care are the chronic natures of some wounds and the many variables that can delay healing. The pathway introduced in this article was modeled upon the three phases of tissue repair: inflammatory, proliferative, and maturation. This physiology-based model allows clinicians to identify and monitor outcomes based on observable and measurable clinical parameters. The pathway design, which also includes educational and behavioral outcomes, allows the clinician to individualize the expected timeframe for outcome achievement based on individual patient criteria and expert judgement. Integral to the pathway are the "4P's" which help standardize the clinical processes by wound type: Protocols, Policies, Procedures, and Patient education tools. Four categories into which variances are categorized based on the cause of the deviation from the norm are patient, process/system, practitioner, and planning/discharge. Additional research is warranted to support the value of this clinical pathway in the clinical arena.
Niven, Daniel J; McCormick, T Jared; Straus, Sharon E; Hemmelgarn, Brenda R; Jeffs, Lianne; Barnes, Tavish R M; Stelfox, Henry T
The ability to reproduce experiments is a defining principle of science. Reproducibility of clinical research has received relatively little scientific attention. However, it is important as it may inform clinical practice, research agendas, and the design of future studies. We used scoping review methods to examine reproducibility within a cohort of randomized trials examining clinical critical care research and published in the top general medical and critical care journals. To identify relevant clinical practices, we searched the New England Journal of Medicine, The Lancet, and JAMA for randomized trials published up to April 2016. To identify a comprehensive set of studies for these practices, included articles informed secondary searches within other high-impact medical and specialty journals. We included late-phase randomized controlled trials examining therapeutic clinical practices in adults admitted to general medical-surgical or specialty intensive care units (ICUs). Included articles were classified using a reproducibility framework. An original study was the first to evaluate a clinical practice. A reproduction attempt re-evaluated that practice in a new set of participants. Overall, 158 practices were examined in 275 included articles. A reproduction attempt was identified for 66 practices (42%, 95% CI 33-50%). Original studies reported larger effects than reproduction attempts (primary endpoint, risk difference 16.0%, 95% CI 11.6-20.5% vs. 8.4%, 95% CI 6.0-10.8%, P = 0.003). More than half of clinical practices with a reproduction attempt demonstrated effects that were inconsistent with the original study (56%, 95% CI 42-68%), among which a large number were reported to be efficacious in the original study and to lack efficacy in the reproduction attempt (34%, 95% CI 19-52%). Two practices reported to be efficacious in the original study were found to be harmful in the reproduction attempt. A minority of critical care practices with research published
Perry, Rachel; Murphy, Molly; Haider, Sadia; Harwood, Bryna
We sought to explore the experiences of women who disclosed that their pregnancies resulted from rape in the abortion care setting, as well as the experiences of professionals involved in care of women with rape-related pregnancy. In-depth interviews were conducted with 9 patients who had terminated rape-related pregnancies and 12 professionals working in abortion care or rape crisis advocacy (5 abortion providers, 4 rape crisis center advocates, 2 social workers, and 1 clinic administrator). Transcribed interviews were coded and analyzed for themes related to the experiences of disclosing rape and the consequences of disclosure in the abortion care setting. Patients and professionals involved in care of women with rape-related pregnancy described opportunities arising from disclosure, including interpersonal (explaining abortion decision making in the context of assault, belief, and caring by providers), as well as structural opportunities (funding assistance, legal options, and mental health options). Whereas most patients did not choose to pursue all three structural opportunities, both patients and professionals emphasized the importance of offering them. The most important consequence of disclosure for patients was being believed and feeling that providers cared about them. Rape-related pregnancy disclosure in the abortion care setting can lead to opportunities for interpersonal support and open options for funding, legal recourse, and mental health care. Those working in abortion care should create environments conducive to disclosure and opportunities for rape survivors to access these additional options if they desire. Copyright © 2015 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
Perry, Rachel; Murphy, Molly; Rankin, Kristin M; Cowett, Allison; Harwood, Bryna
We aimed to explore current practices regarding screening for rape and response to disclosure of rape-related pregnancy in the abortion care setting. We performed a cross-sectional, nonprobability survey of U.S. abortion providers. Individuals were recruited in person and via emailed invitations to professional organization member lists. Questions in this web-based survey pertained to providers' practice setting, how they identify rape-related pregnancy, the availability of support services, and their experiences with law enforcement. Providers were asked their perceptions of barriers to care for women who report rape-related pregnancy. Surveys were completed by 279 providers (21% response rate). Most respondents were female (93.1%), and the majority were physicians in a clinical role (69.4%). One-half (49.8%) reported their practice screens for pregnancy resulting from rape, although fewer (34.8%) reported that screening is the method through which most patients with this history are identified. Most (80.6%) refer women with rape-related pregnancy to support services such as rape crisis centers. Relatively few (19.7%) have a specific protocol for care of women who report rape-related pregnancy. Clinics that screen were 79% more likely to have a protocol for care than centers that do not screen. Although the majority (67.4%) reported barriers to identification of women with rape-related pregnancy, fewer (33.3%) reported barriers to connecting them to support services. Practices for identifying and providing care to women with rape-related pregnancy in the abortion care setting are variable. Further research should address barriers to care provision, as well as identifying protocols for care. Copyright © 2016 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
Wessinger, Matthew H; Hennink, Monique M; Kaiser, Bonnie N; Mangal, Jed P; Gokhale, Runa H; Ruchin, Lauren; Moanna, Abeer; Rimland, David; Farber, Eugene W; Marconi, Vincent C
Institutional barriers in HIV primary care settings can contribute substantially to disparities in retention in HIV treatment and HIV-related outcomes. This qualitative study compared the perceptions of clinic experiences of persons living with HIV (PLWH) in a Veterans Affairs HIV primary care clinic setting who were retained in care with the experiences of those who were not retained in care. Qualitative data from 25 in-depth interviews were analyzed to identify facilitators and barriers to retention in HIV care. Results showed that participants not retained in care experienced barriers to retention involving dissatisfaction with clinic wait times, low confidence in clinicians, and customer service concerns. For participants retained in care, patience with procedural issues, confidence in clinicians, and interpersonal connections were factors that enhanced retention despite the fact that these participants recognized the same barriers as those who were not retained in care. These findings can inform interventions aimed at improving retention in HIV care.
Darnell, Doyanne; O'Connor, Stephen; Wagner, Amy; Russo, Joan; Wang, Jin; Ingraham, Leah; Sandgren, Kirsten; Zatzick, Douglas
Injured patients presenting to acute care medical settings have high rates of posttraumatic stress disorder (PTSD) and comorbidities, such as depression and substance use disorders. Integrating behavioral interventions that target symptoms of PTSD and comorbidities into the acute care setting can overcome common barriers to obtaining mental health care. This study examined the feasibility and acceptability of embedding elements of cognitive-behavioral therapy (CBT) in the delivery of routine postinjury care management. The investigation also explored the potential effectiveness of completion of CBT element homework that targeted PTSD symptom reduction. This study was a secondary analysis of data from a U.S. clinical trial of the effectiveness of a stepped collaborative care intervention versus usual care for injured inpatients. The investigation examined patients' willingness at baseline (prerandomization) to engage in CBT and pre- and postrandomization mental health service utilization among 115 patients enrolled in the clinical trial. Among intervention patients (N=56), the investigation examined acceptability of the intervention and used multiple linear regression to examine the association between homework completion as reported by the care manager and six-month PTSD symptom reduction as assessed by the PTSD Checklist-Civilian DSM-IV Version. Patients in the intervention condition reported obtaining significantly more psychotherapy or counseling than patients in the control group during the six-month follow-up, as well as a high degree of intervention acceptability. Completion of CBT element homework assignments was associated with improvement in PTSD symptoms. Integrating behavioral interventions into routine acute care service delivery may improve the reach of evidence-based mental health care targeting PTSD.
Herrera-Añazco, Percy; Taype-Rondan, Alvaro; Lazo-Porras, María; Alberto Quintanilla, E; Ortiz-Soriano, Victor Manuel; Hernandez, Adrian V
Chronic Kidney Disease (CKD) is a worldwide public health problem. There are few studies in Latin America, especially in primary care settings. Our objective was to determine the prevalence, stages, and associated factors of CKD in primary care setting. We did a retrospective secondary analysis of a database from the Diabetes and Hypertension Primary Care Center of the Peruvian Social Security System (EsSalud) in Lima, Peru. We defined CKD as the presence of eGFR 30 mg/day in 24 h, according to Kidney Disease: Improving Global Outcomes (KDIGO). Factors associated with CKD were evaluated with Poisson Regression models; these factors included age, gender, type 2 diabetes mellitus (DM2), hypertension (HTN), body mass index (BMI), and uric acid. Associations were described as crude and adjusted prevalence ratios (PR) and their 95% confidence intervals (95% CI). We evaluated 1211 patients (women [59%], mean age 65.8 years [SD: 12.7]). Prevalence of CKD was 18%. Using the estimated glomerular filtration rate (eGFR), the prevalence was 9.3% (95% CI 5.3 - 13.3) in patients without HTN or DM2; 20.2% (95% CI 17.6 - 22.8) in patients with HTN, and 23.9% (95% CI 19.4 - 28.4) in patients with DM2. The most common stages were 1 and 2 with 41.5% and 48%, respectively. Factors associated with CKD in the adjusted analysis were: age in years (PR = 1.03, 95% CI 1.01 - 1.04), DM2 (PR = 3.37, 95% CI 1.09 - 10.39), HTN plus DM2 (PR = 3.90, 95% CI 1.54 - 9.88), and uric acid from 5 to DM2, older age and hyperuricemia have higher prevalence of CKD.
Sippel, J M; Osborne, M L; Bjornson, W; Goldberg, B; Buist, A S
To document smoking cessation rates achieved by applying the 1996 Agency for Health Care Policy and Research (AHCPR) smoking cessation guidelines for primary care clinics, compare these quit rates with historical results, and determine if quit rates improve with an additional motivational intervention that includes education as well as spirometry and carbon monoxide measurements. Randomized clinical trial. Two university-affiliated community primary care clinics. Two hundred five smokers with routinely scheduled appointments. All smokers were given advice and support according to AHCPR guidelines. Half of the subjects received additional education with spirometry and carbon monoxide measurements. Quit rate was evaluated at 9-month follow-up. Eleven percent of smokers were sustained quitters at follow-up. Sustained quit rate was no different for intervention and control groups (9% vs 14%; [OR] 0.6; 95% [CI] 0.2, 1.4). Nicotine replacement therapy was strongly associated with sustained cessation (OR 6.7; 95% CI 2.3, 19.6). Subjects without insurance were the least likely to use nicotine replacement therapy ( p =.05). Historical data from previously published studies showed that 2% of smokers quit following physician advice, and additional support similar to AHCPR guidelines increased the quit rate to 5%. The sustained smoking cessation rate achieved by following AHCPR guidelines was 11% at 9 months, which compares favorably with historical results. Additional education with spirometry did not improve the quit rate. Nicotine replacement therapy was the strongest predictor of cessation, yet was used infrequently owing to cost. These findings support the use of AHCPR guidelines in primary care clinics, but do not support routine spirometry for motivating patients similar to those studied here.
Full Text Available The study was made to determine violence experienced by nurse students in clinical settings. It was applied to the School of Health Nursing Student of a university during a week in June, 2010. There were 360 students, 53 of whom were senior, 60 of whom were thirdyear, 114 of whom were sophomore, 79 of whom were first-year and 102 of whom were prep-school students, at the school. Students in preparatory classes were not included in the scope of the study since they didn't take applied courses. 70,58% of the students were reached. It was determined that the students were often exposed to verbal abuse and sexism in clinical setting and the abuse was performed by their colleagues.
Pearson, William S; Gift, Thomas L; Leichliter, Jami S; Jenkins, Wiley D
Chlamydia trachomatis (CT) is the most commonly reported sexually transmitted infection (STI) in the US and timely, correct treatment can reduce CT transmission and sequelae. Emergency departments (ED) are an important location for diagnosing STIs. This study compared recommended treatment of CT in EDs to treatment in physician offices. Five years of data (2006-2010) were analyzed from the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Surveys (NHAMCS), including the Outpatient survey (NHAMCS-OPD) and Emergency Department survey (NHAMCS-ED). All visits with a CT diagnosis and those with a diagnosis of unspecified venereal disease were selected for analysis. Differences in receipt of recommended treatments were compared between visits to physician offices and emergency departments using Chi square tests and logistic regression models. During the 5 year period, approximately 3.2 million ambulatory care visits had diagnosed CT or an unspecified venereal disease. A greater proportion of visits to EDs received the recommended treatment for CT compared to visits to physician offices (66.1 vs. 44.9 %, p < .01). When controlling for patients' age, sex and race/ethnicity, those presenting to the ED with CT were more likely to receive the recommended antibiotic treatment than patients presenting to a physician's office (OR 2.16; 95 % CI 1.04-4.48). This effect was attenuated when further controlling for patients' expected source of payment. These analyses demonstrate differences in the treatment of CT by ambulatory care setting as well as opportunities for increasing use of recommended treatments for diagnosed cases of this important STI.
Full Text Available Abstract Background De-identification is a common way to protect patient privacy when disclosing clinical data for secondary purposes, such as research. One type of attack that de-identification protects against is linking the disclosed patient data with public and semi-public registries. Uniqueness is a commonly used measure of re-identification risk under this attack. If uniqueness can be measured accurately then the risk from this kind of attack can be managed. In practice, it is often not possible to measure uniqueness directly, therefore it must be estimated. Methods We evaluated the accuracy of uniqueness estimators on clinically relevant data sets. Four candidate estimators were identified because they were evaluated in the past and found to have good accuracy or because they were new and not evaluated comparatively before: the Zayatz estimator, slide negative binomial estimator, Pitman’s estimator, and mu-argus. A Monte Carlo simulation was performed to evaluate the uniqueness estimators on six clinically relevant data sets. We varied the sampling fraction and the uniqueness in the population (the value being estimated. The median relative error and inter-quartile range of the uniqueness estimates was measured across 1000 runs. Results There was no single estimator that performed well across all of the conditions. We developed a decision rule which selected between the Pitman, slide negative binomial and Zayatz estimators depending on the sampling fraction and the difference between estimates. This decision rule had the best consistent median relative error across multiple conditions and data sets. Conclusion This study identified an accurate decision rule that can be used by health privacy researchers and disclosure control professionals to estimate uniqueness in clinical data sets. The decision rule provides a reliable way to measure re-identification risk.
Full Text Available Background: Clinical risk management focuses on improving the quality and safety of health care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks. The goal of this study is to identify and assess the failure modes in the ICU of Qazvin′s Social Security Hospital (Razi Hospital through Failure Mode and Effect Analysis (FMEA. Methods: This was a qualitative-quantitative research by Focus Discussion Group (FDG performed in Qazvin Province, Iran during 2011. The study population included all individuals and owners who are familiar with the process in ICU. Sampling method was purposeful and the FDG group members were selected by the researcher. The research instrument was standard worksheet that has been used by several researchers. Data was analyzed by FMEA technique. Results: Forty eight clinical errors and failure modes identified, results showed that the highest risk probability number (RPN was in respiratory care "Ventilator′s alarm malfunction (no alarm" with the score 288, and the lowest was in gastrointestinal "not washing the NG-Tube" with the score 8. Conclusions: Many of the identified errors can be prevented by group members. Clinical risk assessment and management is the key to delivery of effective health care.
Full Text Available Objective: To determine the overall perception and utilization of the pharmacist managed medication therapy management (MTM clinic services, by healthcare professionals in a large, urban, university medical care setting.Methods: This was a cross-sectional, anonymous survey sent to 195 healthcare professionals, including physicians, nurses, and pharmacists at The University of Illinois Outpatient Care Center to determine their perception and utilization of the MTM clinic. The survey consisted of 12 questions and was delivered through a secure online application. Results: Sixty-two healthcare professionals (32% completed the survey. 82% were familiar with the MTM clinic, and 63% had referred patients to the clinic. Medication adherence and disease state management was the most common reason for referral. Lack of knowledge on the appropriate referral procedure was the prominent reason for not referring patients to the MTM clinic. Of the providers that were aware of MTM services, 44% rated care as ‘excellent’, 44% as ‘good’, 5% as ‘fair’, and 0% stated ‘poor’. Strengths of MTM clinic identified by healthcare providers included in-depth education to patients, close follow-up, and detailed medication reconciliation provided by MTM clinic pharmacists. Of those familiar with MTM clinic, recommendations included; increase marketing efforts to raise awareness of the MTM clinic service, create collaborative practice agreements between MTM pharmacists and physicians, and ensure that progress notes are more concise.Conclusion: In a large, urban, academic institution MTM clinic is perceived as a valuable resource to optimize patient care by providing patients with in-depth education as it relates to their prescribed medications and disease states. These identified benefits of MTM clinic lead to frequent patient referrals specifically for aid with medication adherence and disease state management.
Ogrinc, G S; Headrick, L A; Boex, J R
In an era of competition in health care delivery, those who pay for care are interested in supporting primarily those activities that add value to the clinical enterprise. The authors report on their 1998 project to develop a conceptual model for assessing the value added to clinical care by educational activities. Through interviews, nine key stakeholders in patient care identified five ways in which education might add value to clinical care: education can foster higher-quality care, improve work satisfaction of clinicians, have trainees provide direct clinical services, improve recruitment and retention of clinicians, and contribute to the future of health care. With this as a base, an expert panel of 13 clinical educators and investigators defined six perspectives from which the value of education in clinical care might be studied: the perspectives of health-care-oriented organizations, clinician-teachers, patients, education organizations, learners, and the community. The panel adapted an existing model to create the "Education Compass" to portray education's effects on clinical care, and developed a new set of definitions and research questions for each of the four major aspects of the model (clinical, functional, satisfaction, and cost). Working groups next drafted proposals to address empirically those questions, which were critiqued at a national conference on the topic of education's value in clinical care. The next step is to use the methods developed in this project to empirically assess the value added by educational activities to clinical care.
Brugnolli, Anna; Benaglio, Carla
. Teaching Methods for clinical settings: a review. The teaching process during internship requires several methods to promote the acquisition of more complex technical skills such as relational, decisional and planning abilities. To describe effective teaching methods to promote the learning of relational, decisional and planning skills. A literature review of the teaching methods that have proven most effective, most appreciated by students, and most frequently used in Italian nursing schools. Clinical teaching is a central element to transform clinical experiences during internship in professional competences. The students are gradually brought to become more independent, because they are offered opportunities to practice in real contexts, to receive feedback, to have positive role models, to become more autonomous: all elements that facilitate and potentiate learning. Clinical teaching should be based on a variety of methods. The students value a gradual progression both in clinical experiences and teaching strategies from more supervised methods to methods more oriented towards reflecting on clinical practice and self-directed learning.
Hwang, Jamie M; Clemente, Jennifer; Sharma, Krishna P; Taylor, Thomas N; Garwood, Candice L
Patients being managed on warfarin make frequent or regular visits to anticoagulation monitoring appointments. International studies have evaluated transportation cost and associated time related to anticoagulation clinic visits. To our knowledge, no studies have evaluated the cost of transportation to such clinic visits in the United States. To describe the methods of transportation and estimate the average total cost of transportation to and from an anticoagulation clinic in an urban setting. We prospectively conducted a survey of patients treated at the Harper Anticoagulation Clinic located in Detroit, Michigan, during November 2010. The survey was given to patients while waiting at their regularly scheduled clinic appointments and included questions regarding mode of transportation, distance traveled in miles, parking payment, and time missed from work for clinic appointments. The mean distance traveled was translated into cost assuming 50 cents per mile based on 2010 estimates by the Internal Revenue Service. Sixty patients responded to the 11-item survey; response rates for individual items varied because participants were instructed to skip questions that did not pertain to them. Of the 47 participants responding to demographic questions, 70.2% were female, and 46.8% were older than 60 years. Transportation by private vehicle (80.0%), either driven by patients (41.7%) or someone else (38.3%), was the most common method reported. Use of private automobile translated into a cost of $11.19 per round trip. Other means of transportation identified include a ride from a medical transportation service (10.0%), bus (5.0%), walking (3.3%), and taxi (1.7%). The mean (SD) distance traveled to the clinic for all methods of transportation was 8.34 (7.7) miles. We estimated the average cost of round-trip transportation to be $10.78 weighted for all transportation modes. This is a direct nonmedical cost that is paid for by most patients out of pocket. However, 9 of 44 (20
Pedro Ordúñez García
more flexible when it comes to the use of diuretics at the start of treatment for high blood pressure. Chronic disease management should take place in health systems with primary care approach, where the epidemiology of such diseases and scientific advances in prevention offer an excellent opportunity for redesigning the health services and making them more effective. High blood pressure, as a public health problem, demands health interventions aimed not only at reducing harm but modifying its etiologic determinants. The challenge is to recognize that an integrated approach to clinical medicine, health services, and public health would offer an attractive opportunity to interrupt and prevent the continuous and costly vicious circle that managing high blood pressure and its complications implies.
Abakumova, T R; Safina, A F; Ziganshina, L E
Clinical conferences are generally defined as scheduled events at which practicing physicians themselves present to their colleagues interesting clinical cases, share their new experiences and learn about the latest achievements of medical science and practice. The value of a clinical conference is thought to be in direct communication between physicians, in analysis of topical issues in a given specialty with the aim to improve the quality of care. Speakers based on their own observations and studies reveal the most urgent problems, analyze results and offer potential decisions to their colleagues interested in the same questions. The event format may be different: workshops, highly specialized sections, round tables and seminars with participation of the leading specialists in a given field. These conferences are generally organised by the Ministries and Departments of Health, by leading research and/or educational institutions in the field, by recognised medical centres and other institutions. Recently pharmaceutical companies got actively involved in medical events, acting as sponsors of various scientific conferences and congresses, however threatening the mission of these events . This brings up some uneasy questions: who are the medical conferences for? Who is in charge of setting the conference agenda? Do they contribute to evidence-based medicine; do they contribute to better health? Unfortunately, there is a trend to duplication or multiplication of conferences: various agencies and departments deliver the same conferences, presentations at which are often pre-arranged by pharmaceutical companies and do not have clear scientific novelty, while the conferences themselves have largely transformed into advertising of new pharmaceuticals or new technologies . Pharmaceutical corporations sponsor invited speakers paying for their trips and paying honoraria, organising cocktail parties as part of medical activities. With the help of leading experts with
Laleci Erturkmen, Gokce Banu; Yuksel, Mustafa; Sarigul, Bunyamin; Lilja, Mikael; Chen, Rong; Arvanitis, Theodoros N
Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans.
Vukic, Adele; Keddy, Barbara
This paper explicates the nature of outpost nursing work, and/or the day-to-day realities of northern nursing practice in a primary health care setting in Canada. The study was carried out to systematically explore the work of nurses in an indigenous setting. Institutional ethnography, pioneered by Dorothy Smith was the methodology used to guide this research. The theoretical perspective of this methodology does not seek causes or links but intends to explicate visible practices. It is intended to explicate the social organization of specific discourses that inform work processes of nurses working in remote indigenous communities. The data originated from various sources including spending 2 weeks in a northern remote community shadowing experienced nurses, taking field notes and audio taping interviews with these nurses. One of the two researchers was a northern practice nurse for many years and has had taught in an outpost nursing programme. As part of the process, texts were obtained from the site as data to be incorporated in the analysis. The lived experiences have added to the analytical understanding of the work of nurses in remote areas. Data uncovered documentary practices inherent to the work setting which were then analysed along with the transcribed interviews and field notes derived from the on-site visit. Identifying disjuncture in the discourse of northern nursing and the lived experience of the nurses in this study was central to the research process. The results indicated that the social organization of northern community nursing work required a broad generalist knowledge base for decision making to work effectively within this primary health care setting. The nurse as 'other' and the invisibility of nurses' work of building a trusting relationship with the community is not reflected in the discourse of northern nursing. Trust cannot be quantified or measured yet it is fundamental to working effectively with the community. The nurses in this study
Full Text Available Abstract Background Pediatrics ethics education should enhance medical students' skills to deal with ethical problems that may arise in the different settings of care. This study aimed to analyze the ethical problems experienced by physicians who have medical education and pediatric care responsibilities, and if those problems are associated to their workplace, medical specialty and area of clinical practice. Methods A self-applied semi-structured questionnaire was answered by 88 physicians with teaching and pediatric care responsibilities. Content analysis was performed to analyze the qualitative data. Poisson regression was used to explore the association of the categories of ethical problems reported with workplace and professional specialty and activity. Results 210 ethical problems were reported, grouped into five areas: physician-patient relationship, end-of-life care, health professional conducts, socioeconomic issues and health policies, and pediatric teaching. Doctors who worked in hospitals as well as general and subspecialist pediatricians reported fewer ethical problems related to socioeconomic issues and health policies than those who worked in Basic Health Units and who were family doctors. Conclusions Some ethical problems are specific to certain settings: those related to end-of-life care are more frequent in the hospital settings and those associated with socioeconomic issues and public health policies are more frequent in Basic Health Units. Other problems are present in all the setting of pediatric care and learning and include ethical problems related to physician-patient relationship, health professional conducts and the pediatric education process. These findings should be taken into consideration when planning the teaching of ethics in pediatrics. Trial registration This research article didn't reports the results of a controlled health care intervention. The study project was approved by the Institutional Ethical Review
Pires, Carolina; Silva, Dina; Maroco, João; Ginó, Sandra; Mendes, Tiago; Schmand, Ben A.; Guerreiro, Manuela; de Mendonça, Alexandre
Diagnosis of mild cognitive impairment relies on the presence of memory complaints. However, memory complaints are very frequent in healthy people. The objective of this study was to determine the severity and type of memory difficulties presented by elderly patients who seek for clinical help, as compared to the memory difficulties reported by subjects in the community. Assessment of subjective memory complaints was done with the subjective memory complaints scale (SMC). The mini-mental state examination was used for general cognitive evaluation and the geriatric depression scale for the assessment of depressive symptoms. Eight-hundred and seventy-one nondemented subjects older than 50 years were included. Participants in the clinical setting had a higher total SMC score (10.3 ± 4.2) than those in the community (5.1 ± 3.0). Item 3 of the SMC, Do you ever forget names of family members or friends? contributed significantly more to the variance of the total SMC score in the clinical sample (18%) as compared to the community sample (11%). Forgetting names of family members or friends plays an important role in subjective memory complaints in the clinical setting. This symptom is possibly perceived as particularly worrisome and likely drives people to seek for clinical help. PMID:22536537
Barbezat, Isabelle; Willener, Rita; Jenni, Giovanna; Hürlimann, Barbara; Geese, Franziska; Spichiger, Elisabeth
Background: People with an indwelling urinary catheter often suffer from complications and health care professionals are regularly confronted with questions about catheter management. Clinical guidelines are widely accepted to promote evidence-based practice. In the literature, the adaptation of a guideline is described as a valid alternative to the development of a new one. Aim: To translate a guideline for the care for adults with an indwelling urinary catheter in the acute and long term care setting as well as for home care. To adapt the guideline to the Swiss context. Method: In a systematic and pragmatic process, clinical questions were identified, guidelines were searched and evaluated regarding clinical relevance and quality. After each step, the next steps were defined. Results: An English guideline was translated, adapted to the local context and supplemented. The adapted guideline was reviewed by experts, adapted again and approved. After 34 months and an investment of a total of 145 man working days, a guideline for the care for people with an indwelling urinary catheter is available for both institutions. Conclusions: Translation and adaptation of a guideline was a valuable alternative to the development of a new one; nevertheless, the efforts necessary should not be underestimated. For such a project, sufficient professional and methodological resources should be made available to achieve efficient guideline work by a constant team.
Bukhary, Zakeya A.; Alrajhi, Abdulrahman A.
The outcome of the chemotherapy for pulmonary, extraplumonary and disseminated tuberculosis is not well documented, especially in developing countries. This study assessed tuberculosis treatment outcome, cure-to-treatment ratio and mortality among all types of tuberculosis patients in a tertiary care setting in Saudi Arabia. All cases diagnosed and treated for active Mycobacterium tuberculosis infection between 1991 and 2000 were included retrospectively. Data collected included type of tuberculosis involvement, treatment outcome, relapse and co-morbidities. Over a ten-year period, 535 case of tuberculosis were diagnosed and treated. Isolated pulmonary tuberculosis was identified in 141 cases (26.4%), extrapulmonary tuberculosis in 339 cases (63.3%). Co-morbidities were noted in 277 (52%) patients. Immunosuppression was found in 181 (34%) cases. The cure rate was 82%. The cure-to-treatment ratio was 86% in extrapulmonary tuberculosis and 65% in disseminated tuberculosis. Overall mortality was 18%. Disseminated tuberculosis had the highest mortality (34.9%), followed by pulmonary (21.8%), the extrapulmonary tuberculosis (13.6%). Forty-seven percent of all mortalities were directly related to tuberculosis. Relapse was documented in 14 out of 349 patients (4%) who had 24 months of follow-up. Despite tertiary care support, complicated tuberculosis carries a high mortality. Earlier diagnosis and complete appropriate chemotherapy are essential for improved outcome. (author)
Robinson, Nuriya; Stoffel, Cynthia; Haider, Sadia
Women's health care efforts in low-resource settings are often focused primarily on prenatal and obstetric care. However, women all over the world experience significant morbidity and mortality related to cervical cancer, sexually transmitted infections, and urogynecologic conditions as well as gynecologic care provision including insufficient and ineffective family planning services. Health care providers with an interest in clinical care in low-resource settings should be aware of the scope of the burden of gynecologic issues and strategies in place to combat the problems. This review article discusses the important concerns both in the developing world as well as highlights similar disparities that exist in the United States by women's age, race and ethnicity, and socioeconomic status. Ultimately, this review article aims to inform and update health care providers on critical gynecologic issues in low-resource settings.
Henning, Jolene M; Weidner, Thomas G; Jones, James
Context: Athletic training educators often anecdotally suggest that athletic training students enhance their learning by teaching their peers. However, peer-assisted learning (PAL) has not been examined within athletic training education in order to provide evidence for its current use or as a pedagogic tool. Objective: To describe the prevalence of PAL in athletic training clinical education and to identify students' perceptions of PAL. Design: Descriptive. Setting: “The Athletic Training Student Seminar” at the National Athletic Trainers' Association 2002 Annual Meeting and Clinical Symposia. Patients or Other Participants: A convenience sample of 138 entry-level male and female athletic training students. Main Outcome Measure(s): Students' perceptions regarding the prevalence and benefits of and preferences for PAL were measured using the Athletic Training Peer-Assisted Learning Assessment Survey. The Survey is a self-report tool with 4 items regarding the prevalence of PAL and 7 items regarding perceived benefits and preferences. Results: A total of 66% of participants practiced a moderate to large amount of their clinical skills with other athletic training students. Sixty percent of students reported feeling less anxious when performing clinical skills on patients in front of other athletic training students than in front of their clinical instructors. Chi-square analysis revealed that 91% of students enrolled in Commission on Accreditation of Allied Health Education Programs–accredited athletic training education programs learned a minimal to small amount of clinical skills from their peers compared with 65% of students in Joint Review Committee on Educational Programs in Athletic Training–candidacy schools (χ2 3 = 14.57, P < .01). Multiple analysis of variance revealed significant interactions between sex and academic level on several items regarding benefits and preferences. Conclusions: According to athletic training students, PAL is occurring in
Celi, Leo Anthony; Moseley, Edward; Moses, Christopher; Ryan, Padhraig; Somai, Melek; Stone, David; Tang, Kai-Ou
In order to ensure the continued, safe administration of pharmaceuticals, particularly those agents that have been recently introduced into the market, there is a need for improved surveillance after product release. This is particularly so because drugs are used by a variety of patients whose particular characteristics may not have been fully captured in the original market approval studies. Even well-conducted, randomized controlled trials are likely to have excluded a large proportion of individuals because of any number of issues. The digitization of medical care, which yields rich and accessible drug data amenable to analytic techniques, provides an opportunity to capture the required information via observational studies. We propose the development of an open, accessible database containing properly de-identified data, to provide the substrate for the required improvement in pharmacovigilance. A range of stakeholders could use this to identify delayed and low-frequency adverse events. Moreover, its power as a research tool could extend to the detection of complex interactions, potential novel uses, and subtle subpopulation effects. This far-reaching potential is demonstrated by our experience with the open Multi-parameter Intelligent Monitoring in Intensive Care (MIMIC) intensive care unit database. The new database could also inform the development of objective, robust clinical practice guidelines. Careful systematization and deliberate standardization of a fully digitized pharmacovigilance process is likely to save both time and resources for healthcare in general.
Omidvari, Amir-Houshang; Vali, Yasaman; Murray, Susan M; Wonderling, David; Rashidian, Arash
Given the prevalence of under-nutrition and reports of inadequate nutritional management of patients in hospitals and the community, nutritional screening may play a role in reducing the risks of malnutrition. Screening programmes can invoke costs to health systems and patients. It is therefore important to assess the effectiveness of nutritional screening programmes. To examine the effectiveness of nutritional screening in improving quality of care (professional practice) and patient outcomes compared with usual care. We searched the following databases: CENTRAL (The Cochrane Library), MEDLINE, EMBASE and CINAHL up to June 2012 to find relevant studies. Randomised controlled studies, controlled clinical trials, controlled before-after studies and interrupted time series studies assessing the effectiveness of nutritional screening were eligible for inclusion in the review. We considered process outcomes (for example patient identification, referral to dietitian) and patient outcomes (for example mortality, change in body mass index (BMI)). Participants were adult patients aged 16 years or over. We included studies conducted in different settings, including hospitals, out-patient clinics, primary care or long term care settings. We independently assessed the risk of bias and extracted data from the included studies. Meta-analysis was considered but was not conducted due to the discrepancies between the studies. The studies were heterogeneous in their design, setting, intervention and outcomes. We analysed the data using a narrative synthesis approach. After conducting initial searches and screening the titles and abstracts of the identified literature, 77 full text papers were retrieved and read. Ultimately three studies were included. Two controlled before-after studies were conducted in hospital settings (one in the UK and one in the Netherlands) and one cluster randomised controlled trial was conducted in a primary care setting (in the USA).The study conducted in
Valentijn, Pim P; Biermann, Claus; Bruijnzeels, Marc A
Integrated care services are considered a vital strategy for improving the Triple Aim values for people with chronic kidney disease. However, a solid scholarly explanation of how to develop, implement and evaluate such value-based integrated renal care services is limited. The aim of this study was to develop a framework to identify the strategies and outcomes for the implementation of value-based integrated renal care. First, the theoretical foundations of the Rainbow Model of Integrated Care and the Triple Aim were united into one overarching framework through an iterative process of key-informant consultations. Second, a rapid review approach was conducted to identify the published research on integrated renal care, and the Cochrane Library, Medline, Scopus, and Business Source Premier databases were searched for pertinent articles published between 2000 and 2015. Based on the framework, a coding schema was developed to synthesis the included articles. The overarching framework distinguishes the integrated care domains: 1) type of integration, 2) enablers of integration and the interrelated outcome domains, 3) experience of care, 4) population health and 5) costs. The literature synthesis indicated that integrated renal care implementation strategies have particularly focused on micro clinical processes and physical outcomes, while little emphasis has been placed on meso organisational as well as macro system integration processes. In addition, evidence regarding patients' perceived outcomes and economic outcomes has been weak. These results underscore that the future challenge for researchers is to explore which integrated care implementation strategies achieve better health and improved experience of care at a lower cost within a specific context. For this purpose, this study's framework and evidence synthesis have set a developmental agenda for both integrated renal care practice and research. Accordingly, we plan further work to develop an implementation
Full Text Available Abstract Background Delirium is a common and serious condition, which affects many of our older hospitalised patients. It is an indicator of severe underlying illness and requires early diagnosis and prompt treatment, associated with poor survival, functional outcomes with increased risk of institutionalisation following the delirium episode in the acute care setting. We describe a new model of delirium care in the acute care setting, titled Geriatric Monitoring Unit (GMU where the important concepts of delirium prevention and management are integrated. We hypothesize that patients with delirium admitted to the GMU would have better clinical outcomes with less need for physical and psychotropic restraints compared to usual care. Methods/Design GMU models after the Delirium Room with adoption of core interventions from Hospital Elder Life Program and use of evening bright light therapy to consolidate circadian rhythm and improve sleep in the elderly patients. The novelty of this approach lies in the amalgamation of these interventions in a multi-faceted approach in acute delirium management. GMU development thus consists of key considerations for room design and resource planning, program specific interventions and daily core interventions. Assessments undertaken include baseline demographics, comorbidity scoring, duration and severity of delirium, cognitive, functional measures at baseline, 6 months and 12 months later. Additionally we also analysed the pre and post-GMU implementation knowledge and attitude on delirium care among staff members in the geriatric wards (nurses, doctors and undertook satisfaction surveys for caregivers of patients treated in GMU. Discussion This study protocol describes the conceptualization and implementation of a specialized unit for delirium management. We hypothesize that such a model of care will not only result in better clinical outcomes for the elderly patient with delirium compared to usual geriatric care
Shrader, Sarah; Kern, Donna; Zoller, James; Blue, Amy
Teaching interprofessional (IP) teamwork skills is a goal of interprofessional education. The purpose of this study was to examine the relationship between IP teamwork skills, attitudes and clinical outcomes in a simulated clinical setting. One hundred-twenty health professions students (medicine, pharmacy, physician assistant) worked in interprofessional teams to manage a "patient" in a health care simulation setting. Students completed the Interdisciplinary Education Perception Scale (IEPS) attitudinal survey instrument. Students' responses were averaged by team to create an IEPS attitudes score. Teamwork skills for each team were rated by trained observers using a checklist to calculate a teamwork score (TWS). Clinical outcome scores (COS) were determined by summation of completed clinical tasks performed by the team based on an expert developed checklist. Regression analyses were conducted to determine the relationship of IEPS and TWS with COS. IEPS score was not a significant predictor of COS (p=0.054), but TWS was a significant predictor (pstudents' interprofessional teamwork skills are significant predictors of positive clinical outcomes. Interprofessional curricular models that produce effective teamwork skills can improve student performance in clinical environments and likely improve teamwork practice to positively affect patient care outcomes.
Larocca-Pitts, Mark A
Healthcare clinicians need a good tool for taking spiritual histories in a clinical setting. A spiritual history provides important clinical information and any properly trained clinician can take one. Professionally trained chaplains follow-up with more in-depth spiritual assessments if indicated. A spiritual history tool's effectiveness depends on five criteria: brevity, memorability, appropriateness, patient-centeredness, and credibility (Koenig, 2007). The chaplain-developed FACT stands for: F-Faith (and/or Belief); A-Active (and/or Available, Accessible, Applicable); C-Coping (and/or Comfort)/Conflict (and/or Concern); and T-Treatment. FACT compares favorably, if not better in some categories, with three physician-developed spiritual history tools: Koenig's (2007) CSI-MEMO, American College of Physicians' tool (Lo, Quill, & Tulsky, 1999), and Puchalski's and Romer's (2000) FICA.
Schumann Scheel, Linda; Peters, Micah D J; Meinertz Møbjerg, Anna Christine
REVIEW QUESTION/OBJECTIVE: This scoping review will seek to find answers for the following questions which will focus on the use of reflection in the education of nurses in clinical settings:The review will also extract and map data regarding: i) what outcomes have been found in relation to the use...... (e.g. first or second year undergraduate nursing students etc.); and v) barriers/challenges to the use of reflection approaches/tools. Additional details may also be extracted and mapped during the process of the scoping review and this will be explained in the final scoping review report....
... (specialty) health care: At your clinical facility, how is the patient's work information collected... the Clinical Setting: Electronic Health Records AGENCY: The National Institute for Occupational Safety... Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC), Department of...
Adjemian, Daniela; Arendt, Bianca M; Allard, Johane P
Parenteral nutrition (PN) prescription can be challenging in patients with complex conditions and has potential complications. To assess PN prescription, monitoring, and PN-related complications in a Canadian acute care setting. This was a prospective cohort study in which patients receiving PN were assessed by an auditor for nutritional status, PN-related prescription, monitoring, and complications. In addition, length of stay and mortality were recorded. 147 patients (mean ± SD 56.1 ± 16.4 y) with complex diseases (Charlson comorbidity index, median [p25-p75] 2 [1-4]) were enrolled. Before starting PN, 18.6%, 63.9%, and 17.5% of patients were classified as subjective global assessment A, B, and C, respectively. Body mass index remained unchanged during the period on PN. On average, 89% and 73% of patients received <90% of their energy and protein requirements, respectively, but 65% received oral or enteral nutrition at some point during PN. The average daily energy provided by PN increased and stabilized on day 10, reaching 87.2 ± 20.1% of the requirements. Line sepsis (6.8% of patients) and hyperglycemia (6.9%) were the most common complications. The overall mortality was 15.6%. For those alive, length of stay was 30 (range: 4-268) d. PN was discontinued because of transitioning to an oral diet (56.6%), enteral nutrition (17.6%), home PN (14.7%), palliative care (5.1%), death (4.4%), or other (1.5%). Most patients were malnourished at the start of PN. Energy and protein provided from PN were less than requirements, and the goals were reached with delay. Mortality was high, possibly as a result of complex diseases. Copyright © 2017 Elsevier Inc. All rights reserved.
Beaulieu, Marie-Dominique; Geneau, Robert; Del Grande, Claudio; Denis, Jean-Louis; Hudon, Eveline; Haggerty, Jeannie L; Bonin, Lucie; Duplain, Réjean; Goudreau, Johanne; Hogg, William
To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care. Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices. Three regions of Quebec. Health care professionals and staff of 5 PC practices. Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed. The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters. Irrespective of their models, PC practices' pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care. Copyright© the College of Family Physicians of Canada.
Doering, G T
The focus of the study was to prioritize six emergency medical service treatment factors in terms of their impact upon patient satisfaction in the prehospital setting. The six treatment areas analyzed were: EMS response time; medical care provided on scene; explanation of care by the provider; the provider's ability to reduce patient anxiety; the provider's ability to meet the patient's non-medical needs; and the level of courtesy/politeness shown by the EMS provider toward the patient. Telephone interviews were conducted with both patients and bystanders to obtain their perception of how well the system met their needs. The study analyzed how the six issues were rated and then evaluated the impact an individual's low score in a category had on that person's overall rating of the service provided. The overall satisfaction rating is not a calculated score, but an overall score specified by the respondent. The effect each issue had on the respondent's overall rating was determined by averaging the overall ratings for a category's low scorers, averaging the overall ratings for high scorers and then measuring the difference. Results of the study indicate that the factor with the greatest negative impact on patient satisfaction came from a perceived lack of crew courtesy and politeness. Respondents who indicated a fair to poor score in this category decreased their overall score by 60.2%. Ratings in other categories yielded the following results: When respondents rated the response time as fair to poor, their average overall rating showed an 18.4% decrease. When respondents rated the quality of medical care as fair to poor, their average overall rating showed a decrease of 22.6%. When the crew's ability to explain what was happening to the patient was rated as fair to poor, the average overall score dropped 33.6%. When the EMT's and medic's ability to reduce the patient's anxiety was rated fair to poor, average overall score declined by 32.6%. Finally, when the crew
Ssonko, Charles; Gonzalez, Lucia; Mesic, Anita; da Fonseca, Marcio Silveira; Achar, Jay; Safar, Nadia; Martin, Beatriz; Wong, Sidney; Casas, Esther C
Countries in the West and Central African regions struggle to offer quality HIV care at scale, despite HIV prevalence being relatively low. In these challenging operating environments, basic health care needs are multiple, systems are highly fragile and conflict disrupts health care. Médecins Sans Frontières (MSF) has been working to integrate HIV care in basic health services in such settings since 2000. We review the implementation of differentiated HIV care and treatment approaches in MSF-supported programmes in South Sudan (RoSS), Central African Republic (CAR) and Democratic Republic of Congo (DRC). A descriptive analysis from CAR, DRC and RoSS programmes reviewing methodology and strategies of HIV care integration between 2010 and 2015 was performed. We describe HIV care models integrated within the provision of general health care and highlight best practices and challenges. Services included provision of general health care, with out-patient care (range between countries 43,343 and 287,163 consultations/year in 2015) and in-patient care (range 1076-16,595 in 2015). By the end of 2015 antiretroviral therapy (ART) initiations reached 12-255 patients/year. A total of 1101 and 1053 patients were on ART in CAR and DRC, respectively. In RoSS 186 patients were on ART when conflict recommenced late in 2013. While ART initiation and monitoring were mostly clinically driven in the early phase of the programmes, DRC implemented CD4 monitoring and progressively HIV viral load (VL) monitoring during study period. Attacks to health care facilities in CAR and RoSS disrupted service provision temporarily. Programmatic challenges include: competing health priorities influencing HIV care and need to integrate within general health services. Differentiated care approaches that support continuity of care in these programmes include simplification of medical protocols, multi-month ART prescriptions, and community strategies such as ART delivery groups, contingency plans and
Conflicts in the clinical setting can spiral downward with remarkable speed, as parties become ever more incensed and entrenched in their positions. Productive conversations seem unlikely at best. Nevertheless, such situations can sometimes be turned into collaborative problem solving with equally remarkable speed. For this to happen, those providing conflict-resolution services such as mediation need to bring, not just a set of skills, but also some key norms: the process must be voluntary for all; the mediator must abjure giving advice or taking sides, and must honor the privacy of privately offered thoughts. This article describes a conflict that had reached the point of a hospital's requesting judicial coercion. However, a conflict-resolution process was then initiated that, in the end, led to amicable resolution and mended relationships, obviating the need for court orders. This article describes that conflict and the resolution process in detail, along the way annotating specific strategies that are often highly effective. Copyright 2016 The Journal of Clinical Ethics. All rights reserved.
Overholser, Linda S; Moss, Kerry M; Kilbourn, Kristin; Risendal, Betsy; Jones, Alison F; Greffe, Brian S; Garrington, Timothy; Leonardi-Warren, Kristin; Yamashita, Traci E; Kutner, Jean S
Describe the development and evolution of a primary-care-based, multidisciplinary clinic to support the ongoing care of adult survivors of childhood cancer. A consultative clinic for adult survivors of childhood cancer has been developed that is located in an adult, academic internal medicine setting and is based on a long-term follow-up clinic model available at Children's Hospital Colorado. The clinic opened in July 2008. One hundred thirty-five patients have been seen as of April 2014. Referrals and clinic capacity have gradually increased over time, and a template has been developed in the electronic medical record to help facilitate completion of individualized care plan letters. A primary care-based, multidisciplinary consultative clinic for adults with a history of childhood cancer survivor is feasible and actively engages adult primary care resources to provide risk-based care for long-term pediatric cancer survivors. This model of care planning can help support adult survivors of pediatric cancer and their primary care providers in non-academic, community settings as well. Copyright © 2015 Elsevier Inc. All rights reserved.
Ahmed, Arif; Fincham, Jack E
Retail clinics are a relatively new phenomenon in the United States, offering cheaper and convenient alternatives to physician offices for minor illness and wellness care. The objective of this study was to investigate the effects of cost of care and appointment wait time on care-seeking decisions at retail clinics or physician offices. As part of a statewide random-digit-dial survey of households, adult residents of Georgia were interviewed to conduct a discrete choice experiment with 2 levels each of 4 attributes: price ($59; $75), appointment wait time (same day; 1 day or longer), care setting-clinician combination (nurse practitioner in retail clinic; physician in private office), and acute illness (urinary tract infection [UTI]; influenza). The respondents indicated whether they would seek care under each of the 16 resulting choice scenarios. A cooperation rate of 33.1% yielded 493 completed telephone interviews. The respondents preferred to seek care for both conditions; were less likely to seek care for UTI (beta = -0.149; P = .008); preferred to seek care from a physician (beta = 1.067; P clinic and $82.12 to wait 1 day or more. Time and cost savings offered by retail clinics are attractive to patients, and they are likely to seek care there given sufficient cost savings. Appointment wait time is the most important factor in care-seeking decisions and should be considered carefully in setting appointment policies in primary care practices.
Broadbent, Elizabeth; Kerse, Ngaire; Peri, Kathryn; Robinson, Hayley; Jayawardena, Chandimal; Kuo, Tony; Datta, Chandan; Stafford, Rebecca; Butler, Haley; Jawalkar, Pratyusha; Amor, Maddy; Robins, Ben; MacDonald, Bruce
This study investigated whether multiple health-care robots could have any benefits or cause any problems in an aged care facility. Fifty-three residents and 53 staff participated in a non-randomised controlled trial over 12 weeks. Six robots provided entertainment, communication and health-monitoring functions in staff rooms and activity lounges. These settings were compared to control settings without robots. There were no significant differences between groups in resident or staff outcomes, except a significant increase in job satisfaction in the control group only. The intervention group perceived the robots had more agency and experience than the control group did. Perceived agency of the robots decreased over time in both groups. Overall, we received very mixed responses with positive, neutral and negative comments. The robots had no major benefits or problems. Future research could give robots stronger operational roles, use more specific outcome measures, and perform cost-benefit analyses. © 2015 AJA Inc.
Full Text Available Abstract Background Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and treatment. This study compares the values of the country's health policy makers with these three official principles. Methods In total 34 policy makers participated in a discrete choice experiment, weighting the relative value of six policy criteria. We used multi-variate logistic regression with selection as dependent valuable to derive odds ratios for each criterion. Next, we constructed a composite league table - based on the sum score for the probability of selection - to rank potential interventions in five major disease areas. Results The group considered cost effectiveness, large individual benefits and severity of disease as the most important criteria in decision making. Priority interventions are those related to cardiovascular diseases and respiratory diseases. Less attractive interventions rank those related to mental health. Conclusions Norwegian policy makers' values are in agreement with principles formulated in national health laws. Multi-criteria decision approaches may provide a tool to support explicit allocation decisions.
Defechereux, Thierry; Paolucci, Francesco; Mirelman, Andrew; Youngkong, Sitaporn; Botten, Grete; Hagen, Terje P; Niessen, Louis W
Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and treatment. This study compares the values of the country's health policy makers with these three official principles. In total 34 policy makers participated in a discrete choice experiment, weighting the relative value of six policy criteria. We used multi-variate logistic regression with selection as dependent valuable to derive odds ratios for each criterion. Next, we constructed a composite league table - based on the sum score for the probability of selection - to rank potential interventions in five major disease areas. The group considered cost effectiveness, large individual benefits and severity of disease as the most important criteria in decision making. Priority interventions are those related to cardiovascular diseases and respiratory diseases. Less attractive interventions rank those related to mental health. Norwegian policy makers' values are in agreement with principles formulated in national health laws. Multi-criteria decision approaches may provide a tool to support explicit allocation decisions.
Barbé, B; Yansouni, C P; Affolabi, D; Jacobs, J
The declining trend of malaria and the recent prioritization of containment of antimicrobial resistance have created a momentum to implement clinical bacteriology in low-resource settings. Successful implementation relies on guidance by a quality management system (QMS). Over the past decade international initiatives were launched towards implementation of QMS in HIV/AIDS, tuberculosis and malaria. To describe the progress towards accreditation of medical laboratories and to identify the challenges and best practices for implementation of QMS in clinical bacteriology in low-resource settings. Published literature, online reports and websites related to the implementation of laboratory QMS, accreditation of medical laboratories and initiatives for containment of antimicrobial resistance. Apart from the limitations of infrastructure, equipment, consumables and staff, QMS are challenged with the complexity of clinical bacteriology and the healthcare context in low-resource settings (small-scale laboratories, attitudes and perception of staff, absence of laboratory information systems). Likewise, most international initiatives addressing laboratory health strengthening have focused on public health and outbreak management rather than on hospital based patient care. Best practices to implement quality-assured clinical bacteriology in low-resource settings include alignment with national regulations and public health reference laboratories, participating in external quality assurance programmes, support from the hospital's management, starting with attainable projects, conducting error review and daily bench-side supervision, looking for locally adapted solutions, stimulating ownership and extending existing training programmes to clinical bacteriology. The implementation of QMS in clinical bacteriology in hospital settings will ultimately boost a culture of quality to all sectors of healthcare in low-resource settings. Copyright © 2017 The Authors. Published by
Chan, WoanYi; Niranjan, Niri; Ramakrishnan, Venkat
Microsurgery is an essential component in plastic surgery training. Competence has become an important issue in current surgical practice and training. The complexity of microsurgery requires detailed assessment and feedback on skills components. This article proposes a method of Structured Assessment of Microsurgery Skills (SAMS) in a clinical setting. Three types of assessment (i.e., modified Global Rating Score, errors list and summative rating) were incorporated to develop the SAMS method. Clinical anastomoses were recorded on videos using a digital microscope system and were rated by three consultants independently and in a blinded fashion. Fifteen clinical cases of microvascular anastomoses performed by trainees and a consultant microsurgeon were assessed using SAMS. The consultant had consistently the highest scores. Construct validity was also demonstrated by improvement of SAMS scores of microsurgery trainees. The overall inter-rater reliability was strong (alpha=0.78). The SAMS method provides both formative and summative assessment of microsurgery skills. It is demonstrated to be a valid, reliable and feasible assessment tool of operating room performance to provide systematic and comprehensive feedback as part of the learning cycle. Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Benign prostate hyperplasia (BPH) occurs in up to 50% of men by age 50, and the incidence increases with age. This common clinical problem is diagnosed by history, including the International Prostate Symptom Score (IPSS) questionnaire, and physical examination by digital rectal examination (DRE). Initial management for BPH includes lifestyle modification, and smooth muscle relaxant alpha blocker therapy. Alpha blockers usually take effect quickly within 3-5 days, and have minimal side effects. Current commonly used alpha blockers include the selective alpha blockers tamsulosin (Flomax), alfusosin (Xatral), and silodosin (Rapaflo). For patients with larger prostates, the 5-alpha reductase inhibitor class (finasteride (Proscar) and dutasteride (Avodart)) work effectively to shrink prostate stroma resulting in improved voiding. The 5-ARI class of drugs, in addition to reducing prostate size, also reduce the need for future BPH-related surgery, and reduce the risk of future urinary retention. Drugs from the phosphodiesterase-5 (PDE-5) inhibitor class may now be considered for treating BPH. Once daily 5 mg tadalafil has been shown to improve BPH-related symptoms and is currently approved to treat patients with BPH. Referral to a urologist can be considered for patients with a rising prostate-specific antigen (PSA), especially while on 5-ARI, failure of urinary symptom control despite maximal medical therapy, suspicion of prostate cancer, hematuria, recurrent urinary infections, urinary retention, or renal failure. Currently the primary care physician is armed with multiple treatment options to effectively treat men with symptomatic BPH.
Iserson, Kenneth V
Hypnosis has been used in medicine for nearly 250 years. Yet, emergency clinicians rarely use it in emergency departments or prehospital settings. This review describes hypnosis, its historical use in medicine, several neurophysiologic studies of the procedure, its uses and potential uses in emergency care, and a simple technique for inducing hypnosis. It also discusses reasons why the technique has not been widely adopted, and suggests methods of increasing its use in emergency care, including some potential research areas. A limited number of clinical studies and case reports suggest that hypnosis may be effective in a wide variety of conditions applicable to emergency medical care. These include providing analgesia for existing pain (e.g., fractures, burns, and lacerations), providing analgesia and sedation for painful procedures (e.g., needle sticks, laceration repair, and fracture and joint reductions), reducing acute anxiety, increasing children's cooperation for procedures, facilitating the diagnosis and treatment of acute psychiatric conditions, and providing analgesia and anxiolysis for obstetric/gynecologic problems. Although it is safe, fast, and cost-effective, emergency clinicians rarely use hypnosis. This is due, in part, to the myths surrounding hypnosis and its association with alternative-complementary medicine. Genuine barriers to its increased clinical use include a lack of assured effectiveness and a lack of training and training requirements. Based on the results of further research, hypnosis could become a powerful and safe nonpharmacologic addition to the emergency clinician's armamentarium, with the potential to enhance patient care in emergency medicine, prehospital care, and remote medical settings. Copyright © 2014 Elsevier Inc. All rights reserved.
Mann, F.A.; Stewart, N.R.; Terrell, C.B.
This paper determines the characteristics of misinterpretations of musculoskeletal radiographs by internal medicine residents (IMRs) in an ambulatory care setting. Discordances between IMRs and staff radiologists were prospectively identified and retrospectively reviewed to assess type of error and patient outcome. The setting was an acute ambulatory care clinic at a large university hospital staffed by board-certified emergency medicine faculty and IMRs. Of 541 patients radiographed, 321 (59%) had adequate follow-up to establish outcome. Error characteristics examined included nature and site, type (false negative ([F-] or false positive [F+]), clinical significance, interpreter responsible, and level of interpreter training
Hoover, Karen W; Parsell, Bradley W; Leichliter, Jami S; Habel, Melissa A; Tao, Guoyu; Pearson, William S; Gift, Thomas L
We assessed the characteristics of sexually transmitted disease (STD) clinic patients, their reasons for seeking health services in STD clinics, and their access to health care in other venues. In 2013, we surveyed persons who used publicly funded STD clinics in 21 US cities with the highest STD morbidity. Of the 4364 STD clinic patients we surveyed, 58.5% were younger than 30 years, 72.5% were non-White, and 49.9% were uninsured. They visited the clinic for STD symptoms (18.9%), STD screening (33.8%), and HIV testing (13.6%). Patients chose STD clinics because of walk-in, same-day appointments (49.5%), low cost (23.9%), and expert care (8.3%). Among STD clinic patients, 60.4% had access to another type of venue for sick care, and 58.5% had access to another type of venue for preventive care. Most insured patients (51.6%) were willing to use insurance to pay for care at the STD clinic. Despite access to other health care settings, patients chose STD clinics for sexual health care because of convenient, low-cost, and expert care. Policy Implication. STD clinics play an important role in STD prevention by offering walk-in care to uninsured patients.
Bindels, J.; Cox, K.; De La Haye, J.; Mevissen, G.; Heijing, S.; van Schayck, O.C.P.; Widdershoven, G.; Abma, T.A.
Aims and objectives: The objective of this study was to evaluate whether care provided in the care programmes matched the needs of older people. Background: Care programmes were implemented in primary-care settings in the Netherlands to identify frail older people and to prevent further
Full Text Available Telemedicine refers to the delivery of clinical services using technology that allows two-way, real time, interactive communication between the patient and the clinician at a distant site. Commonly, telemedicine is used to improve access to general and specialty care for patients in rural areas. This review aims to provide an overview of existing telemedicine models involving the delivery of care by pharmacists via telemedicine (including telemonitoring and video, but excluding follow-up telephone calls and to highlight the main areas of chronic-disease management where these models have been applied. Studies within the areas of hypertension, diabetes, asthma, anticoagulation and depression were identified, but only two randomized controlled trials with adequate sample size demonstrating the positive impact of telemonitoring combined with pharmacist care in hypertension were identified. The evidence for the impact of pharmacist-based telemedicine models is sparse and weak, with the studies conducted presenting serious threats to internal and external validity. Therefore, no definitive conclusions about the impact of pharmacist-led telemedicine models can be made at this time. In the Unites States, the increasing shortage of primary care providers and specialists represents an opportunity for pharmacists to assume a more prominent role managing patients with chronic disease in the ambulatory care setting. However, lack of reimbursement may pose a barrier to the provision of care by pharmacists using telemedicine.
Skaane, Per; Gullien, Randi; Eben, Ellen B.; Haakenaasen, Unni; Naess Jebsen, Ingvild; Krager, Mona; Bjoerndal, Hilde; Ekseth, Ulrika; Jahr, Gunnar
Background: Digital breast tomosynthesis (DBT) is a promising new technology. Some experimental clinical studies have shown positive results, but the future role and indications of this new technique, whether in a screening or clinical setting, need to be evaluated. Purpose: To compare digital mammography and DBT in a side-by-side feature analysis for cancer conspicuity, and to assess whether there is a potential additional value of DBT to standard state-of-the-art conventional imaging work-up with respect to detection of additional malignancies. Material and Methods: The study had ethics committee approval. A total of 129 women underwent 2D digital mammography including supplementary cone-down and magnification views and breast ultrasonography if indicated, as well as digital breast tomosynthesis. The indication for conventional imaging in the clinical setting included a palpable lump in 30 (23%), abnormal mammographic screening findings in 54 (42%), and surveillance in 45 (35%) of the women. The women were examined according to present guidelines, including spot-magnification views, ultrasonography, and needle biopsies, if indicated. The DBT examinations were interpreted several weeks after the conventional imaging without knowledge of the conventional imaging findings. In a later session, three radiologists performed a side-by-side feature analysis for cancer conspicuity in a sample of 50 cases. Results: State-of-the-art conventional imaging resulted in needle biopsy of 45 breasts, of which 20 lesions were benign and a total of 25 cancers were diagnosed. The remaining 84 women were dismissed with a normal/definitely benign finding and without indication for needle biopsy. The subsequent DBT interpretation found suspicious findings in four of these 84 women, and these four women had to be called back for repeated work-up with knowledge of the tomosynthesis findings. These delayed work-ups resulted in two cancers (increasing the cancer detection by 8%) and two
Grant, Suzanne J; Bensoussan, Alan
There is a lack of research on the organisational operations of integrative healthcare (IHC) practices. IHC is a therapeutic strategy integrating conventional and complementary medicine in a shared context to administer individualized treatment. To better understand the process of care in IHC - the way in which patients are triaged and treatment plans are constructed, interviews were conducted with integrative health care leaders and practitioners in the US. Semi-structured interviews were conducted with a pragmatic group of fourteen leaders and practitioners from nine different IHC settings. All interviews were conducted face-to-face with the exception of one phone interview. Questions focussed on understanding the "process of care" in an integrative healthcare setting. Deductive categories were formed from the aims of the study, focusing on: organisational structure, processes of care (subcategories: patient intake, treatment and charting, use of guidelines or protocols), prevalent diseases or conditions treated, and the role of research in the organisation. The similarities and differences of the ITH entities emerged from this process. On an organisational level, conventional and CM services and therapies were co-located in all nine settings. For patients, this means there is more opportunity for 'seamless care'. Shared information systems enabled easy communication using internal messaging or email systems, and shared patient intake information. But beyond this infrastructure alignment for integrative health care was less supported. There were no use of protocols or guidelines within any centre, no patient monitoring mechanism beyond that which occurred within one-on-one appointments. Joint planning for a patient treatment was typically ad hoc through informal mechanisms. Additional duties typically come at a direct financial cost to fee-for-service practitioners. In contrast, service delivery and the process of care within hospital inpatient services followed
Full Text Available Background: Southeast Asian countries with better-skilled primary care physicians have been shown to have better health outcomes. However, in Indonesia, there has been a large number of inappropriate referrals, leading to suboptimal health outcomes. This study aimed to examine the reasons underlying the unnecessary referrals as related to Indonesian physicians′ standard of abilities. Materials and Methods: This was a multiple-case study that explored physicians′ self-evaluation of their abilities. Self-evaluation questionnaires were constructed from the Indonesian Standards of Physicians Competences of 2006-2012 (ISPC, which is a list of 155 diseases. This study was undertaken in three cities, three towns, and one "border-less developed" area during 2011-2014. The study involved 184 physicians in those seven districts. Data were collected using one-on-one, in-depth interviews, focus group discussions (FGDs, and clinical observations. Results: This study found that primary care physicians in Indonesia felt that they were competent to handle less than one-third of "typical" primary care cases. The reasons were limited understanding of person-centered care principles and limited patient care services to diagnosis and treatment of common biomedical problems. Additionally, physical facilities in primary care settings are lacking. Discussions and Conclusions: Strengthening primary health care in Indonesia requires upscaling doctors′ abilities in managing health problems through more structured graduate education in family medicine, which emphasizes the bio-psycho-socio-cultural background of persons; secondly, standardizing primary care facilities to support physicians′ performance is critical. Finally, a strong national health policy that recognizes the essential role of primary care physicians in health outcomes is an urgent need.
Istiono, Wahyudi; Claramita, Mora; Ekawati, Fitriana Murriya; Gayatri, Aghnaa; Sutomo, Adi Heru; Kusnanto, Hari; Graber, Mark Alan
Southeast Asian countries with better-skilled primary care physicians have been shown to have better health outcomes. However, in Indonesia, there has been a large number of inappropriate referrals, leading to suboptimal health outcomes. This study aimed to examine the reasons underlying the unnecessary referrals as related to Indonesian physicians' standard of abilities. This was a multiple-case study that explored physicians' self-evaluation of their abilities. Self-evaluation questionnaires were constructed from the Indonesian Standards of Physicians Competences of 2006-2012 (ISPC), which is a list of 155 diseases. This study was undertaken in three cities, three towns, and one "border-less developed" area during 2011-2014. The study involved 184 physicians in those seven districts. Data were collected using one-on-one, in-depth interviews, focus group discussions (FGDs), and clinical observations. This study found that primary care physicians in Indonesia felt that they were competent to handle less than one-third of "typical" primary care cases. The reasons were limited understanding of person-centered care principles and limited patient care services to diagnosis and treatment of common biomedical problems. Additionally, physical facilities in primary care settings are lacking. Strengthening primary health care in Indonesia requires upscaling doctors' abilities in managing health problems through more structured graduate education in family medicine, which emphasizes the bio-psycho-socio-cultural background of persons; secondly, standardizing primary care facilities to support physicians' performance is critical. Finally, a strong national health policy that recognizes the essential role of primary care physicians in health outcomes is an urgent need.
David C. Currow
Full Text Available AbstractIn Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary. The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two ‘plain English’ booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers. The resources are intended to facilitate home care that acknowledges and plans for the client’s deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations
Toye, Christine; Blackwell, Scott; Maher, Sean; Currow, David C; Holloway, Kristi; Tieman, Jennifer; Hegarty, Meg
In Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary.The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two 'plain English' booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers.The resources are intended to facilitate home care that acknowledges and plans for the client's deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations or residential placements and
Peltier, Wendy L; Gani, Faiz; Blissitt, Jennifer; Walczak, Katherine; Opper, Kristi; Derse, Arthur R; Johnston, Fabian M
Although previous research on advance care planning (ACP) has associated ACP with improved quality of care at the end of life, the appropriate use of ACP remains limited. To evaluate the impact of a pilot program using the "Honoring Choices Wisconsin" (HCW) model for ACP in a tertiary care setting, and to understand barriers to system-wide implementation. Retrospective review of prospectively collected data. Patients who received medical or surgical oncology care at Froedtert and the Medical College of Wisconsin. Patient demographics, disease characteristics, patient satisfaction, and clinical outcomes. Data from 69 patients who died following the implementation of the HCW program were reviewed; 24 patients were enrolled in the HCW program while 45 were not. Patients enrolled in HCW were proportionally less likely to be admitted to the ICU (12.5% vs. 17.8%) and were more likely to be "do not resuscitate" (87.5% vs. 80.0%), as well as have a completed ACP (83.3% vs. 79.1%). Furthermore, admission to a hospice was also higher among patients who were enrolled in the HCW program (79.2% vs. 25.6%), with patients enrolled in HCW more likely to die in hospice (70.8% vs. 53.3%). The HCW program was favorably viewed by patients, patient caregivers, and healthcare providers. Implementation of a facilitator-based ACP care model was associated with fewer ICU admissions, and a higher use of hospice care. System-level changes are required to overcome barriers to ACP that limit patients from receiving end-of-life care in accordance with their preferences.
Valkema, R.; Blokland, J.A.K.; Pauwels, E.K.J.; Papapoulos, S.E.; Bijvoet, O.L.M.
The reproducibility of single photon absorptiometry (SPA) results for detection of changes in bone mineral content (BMC) was evaluated in a clinical setting. During a period of 18 months with 4 different sources, the calibration scans of an aluminium standard had a variation of less than 1% unless the activity of the 125 I source was low. The calibration procedure was performed weekly and this was sufficient to correct for drift of the system. The short term reproducibility in patients was assessed with 119 duplicate measurements made in direct succession. The best reproducibility (CV=1.35%) was found for fat corrected BMC results expressed in g/cm, obtained at the site proximal to the 8 mm space between the radius and ulna. Analysis of all SPA scans made during 1 year (487 scans) showed a failure of the automatic procedure to detect the space of 8 mm between the forearm bones in 19 scans (3.9%). A space adjacent to the ulnar styloid was taken as the site for the first scan in these examinations. This problem may be recognized and corrected relatively easy. A significant correlation was found between BMC at the lower arm and BMC of the lumbar spine assessed with dual photon absorptiometry. However, the error of estimation of proximal BMC (SEE=20%) and distal BMC (SEE=19.4%) made these measurements of little value to predict BMC at the lumbar spine in individuals. The short term reproducibility in patients combined with long term stability of the equipment in our clinical setting showed that SPA is a reliable technique to assess changes in bone mass at the lower arm of 4% between 2 measurements with a confidence level of 95%. (orig.)
Farmer Andrew J
Full Text Available Abstract Background Trial research has predominantly focused on patient and staff understandings of trial concepts and/or motivations for taking part, rather than why treatment recommendations may or may not be followed during trial delivery. This study sought to understand why there was limited attainment of the glycaemic target (HbA1c ≤6.5% among patients who participated in the Treating to Target in Type 2 Diabetes Trial (4-T. The objective was to inform interpretation of trial outcomes and provide recommendations for future trial delivery. Methods In-depth interviews were conducted with 45 patients and 21 health professionals recruited from 11 of 58 trial centres in the UK. Patients were broadly representative of those in the main trial in terms of treatment allocation, demographics and glycaemic control. Both physicians and research nurses were interviewed. Results Most patients were committed to taking insulin as recommended by 4-T staff. To avoid hypoglycaemia, patients occasionally altered or skipped insulin doses, normally in consultation with staff. Patients were usually unaware of the trial's glycaemic target. Positive staff feedback could lead patients to believe they had been 'successful' trial participants even when their HbA1c exceeded 6.5%. While some staff felt that the 4-T automated insulin dose adjustment algorithm had increased their confidence to prescribe larger insulin doses than in routine clinical practice, all described situations where they had not followed its recommendations. Staff regarded the application of a 'one size fits all' glycaemic target during the trial as contradicting routine clinical practice where they would tailor treatments to individuals. Staff also expressed concerns that 'tight' glycaemic control might impose an unacceptably high risk of hypoglycaemia, thus compromising trust and safety, especially amongst older patients. To address these concerns, staff tended to adapt the trial protocol to
Sivaranjini, R; Jaisankar, Tj; Thappa, Devinder Mohan; Kumari, Rashmi; Chandrasekhar, Laxmisha; Malathi, M; Parija, Sc; Habeebullah, S
Vaginal discharge is one of the common reasons for gynecological consultation. Many of the causes of vaginitis have a disturbed vaginal microbial ecosystem associated with them. Effective treatment of vaginal discharge requires that the etiologic diagnosis be established and identifying the same offers a precious input to syndromic management and provides an additional strategy for human immunodeficiency virus prevention. The present study was thus carried out to determine the various causes of vaginal discharge in a tertiary care setting. A total of 400 women presenting with vaginal discharge of age between 20 and 50 years, irrespective of marital status were included in this study and women who had used antibiotics or vaginal medication in the previous 14 days and pregnant women were excluded. Of the 400 women with vaginal discharge studied, a diagnosis was established in 303 women. Infectious causes of vaginal discharge were observed in 207 (51.75%) women. Among them, bacterial vaginosis was the most common cause seen in 105 (26.25%) women. The other infections observed were candidiasis alone (61, 15.25%), trichomoniasis alone (12, 3%), mixed infections (22, 5.5%) and mucopurulent cervicitis (7 of the 130 cases looked for, 8.46%). Among the non-infectious causes, 72 (18%) women had physiological vaginal discharge and 13 (3.3%) women had cervical in situ cancers/carcinoma cervix. The pattern of infectious causes of vaginal discharge observed in our study was comparable with the other studies in India. Our study emphasizes the need for including Papanicolaou smear in the algorithm for evaluation of vaginal discharge, as it helps establish the etiology of vaginal discharge reliably and provides a valuable opportunity to screen for cervical malignancies.
Weissman, David E; Morrison, R Sean; Meier, Diane E
Data collection and analysis are vital for strategic planning, quality improvement, and demonstration of palliative care program impact to hospital administrators, private funders and policymakers. Since 2000, the Center to Advance Palliative Care (CAPC) has provided technical assistance to hospitals, health systems and hospices working to start, sustain, and grow nonhospice palliative care programs. CAPC convened a consensus panel in 2008 to develop recommendations for specific clinical and customer metrics that programs should track. The panel agreed on four key domains of clinical metrics and two domains of customer metrics. Clinical metrics include: daily assessment of physical/psychological/spiritual symptoms by a symptom assessment tool; establishment of patient-centered goals of care; support to patient/family caregivers; and management of transitions across care sites. For customer metrics, consensus was reached on two domains that should be tracked to assess satisfaction: patient/family satisfaction, and referring clinician satisfaction. In an effort to ensure access to reliably high-quality palliative care data throughout the nation, hospital palliative care programs are encouraged to collect and report outcomes for each of the metric domains described here.
Clark Patrick Heard
Full Text Available Background: Leadership is vital to clinical, organizational, and professional success. This has compelled a high volume of research primarily related to formal leadership concepts. However, as organizations flatten, eliminate departmental structures, or decentralize leadership structures the relevance of informal leaders has markedly enhanced. Methods: Using a qualitative phenomenological methodology consistent with interpretative phenomenological analysis, this study examines the impact of informal leadership in the clinical setting for occupational therapists. Data was collected through the completion of semi-structured interviews with 10 peer-identified informal occupational therapy leaders in Ontario, Canada. Collected data was transcribed verbatim and coded for themes by multiple coders. Several methods were employed to support trustworthiness. Results: The results identify that informal leaders are collaborative, accessible, and considered the “go to” staff. They demonstrate professional competence knowledge, experience, and accountability and are inspirational and creative. Practically, informal leaders organically shape the practice environment while building strength and capacity among their peers. Conclusion: Recommendations for supporting informal leaders include acknowledgement of the role and its centrality, enabling informal leaders time to undertake the role, and supporting consideration of informal leadership concepts at the curriculum and professional level.
Battistella, Giuseppe; Berto, Giuliana; Bazzo, Stefania
To explore perceptions and unconscious psychological processes underlying handwashing behaviours of intensive care nurses, to implement organisational innovations for improving hand hygiene in clinical practice. An action-research intervention was performed in 2012 and 2013 in the intensive care unit of a public hospital in Italy, consisting of: structured interviews, semantic analysis, development and validation of a questionnaire, team discussion, project design and implementation. Five general workers, 16 staff nurses and 53 nurse students participated in the various stages. Social handwashing emerged as a structured and efficient habit, which follows automatically the pattern "cue/behaviour/gratification" when hands are perceived as "dirty". The perception of "dirt" starts unconsciously the process of social washing also in professional settings. Professional handwashing is perceived as goal-directed. The main concern identified is the fact that washing hands requires too much time to be performed in a setting of urgency. These findings addressed participants to develop a professional "habit-directed" hand hygiene procedure, to be implemented at beginning of workshifts. Handwashing is a ritualistic behaviour driven by deep and unconscious patterns, and social habits affect professional practice. Creating professional habits of hand hygiene could be a key solution to improve compliance in intensive care settings. Copyright © 2016. Published by Elsevier Ltd.
Morton, Katie; Beauchamp, Mark; Prothero, Anna; Joyce, Lauren; Saunders, Laura; Spencer-Bowdage, Sarah; Dancy, Bernadette; Pedlar, Charles
Motivational interviewing (MI) is a patient-centred approach to behaviour change that was originally developed in the addiction field but has increasingly been applied to public health settings with a focus on health promotion. The purpose of this review was to examine the evidence base for MI interventions in primary care settings with non-clinical populations to achieve behaviour change for physical activity, dietary behaviours and/or alcohol intake. We also sought to explore the specific behaviour change techniques included in MI interventions within primary care. Electronic databases were searched for relevant articles and 33 papers met inclusion criteria and were included. Approximately 50% of the included studies (n = 18) demonstrated positive effects in relation to health behaviour change. The efficacy of MI approaches is unclear given the inconsistency of MI descriptions and intervention components. Furthermore, research designs that do not isolate the effects of MI make it difficult to determine the effectiveness of such approaches. We offer a number of recommendations for researchers and practitioners seeking to include MI within behaviour change interventions to help improve the quality of the research and the effectiveness of MI-based interventions within primary care settings.
Al-Hussein, Fahad Abdullah
Diabetes constitutes a major burden of disease globally. Both primary and secondary prevention need to improve in order to face this challenge. Improving management of diabetes in primary care is therefore of fundamental importance. The objective of these series of audits was to find means of improving diabetes management in chronic disease mini-clinics in primary health care. In the process, we were able to study the effect and practical usefulness of different audit designs - those measuring clinical outcomes, process of care, or both. King Saud City Family and Community Medicine Centre, Saudi National Guard Health Affairs in Riyadh city, Saudi Arabia. Simple random samples of 30 files were selected every two weeks from a sampling frame of file numbers for all diabetes clients seen over the period. Information was transferred to a form, entered on the computer and an automated response was generated regarding the appropriateness of management, a criterion mutually agreed upon by care providers. The results were plotted on statistical process control charts, p charts, displayed for all employees. Data extraction, archiving, entry, analysis, plotting and design and preparation of p charts were managed by nursing staff specially trained for the purpose by physicians with relevant previous experience. Audit series with mixed outcome and process measures failed to detect any changes in the proportion of non-conforming cases over a period of one year. The process measures series, on the other hand, showed improvement in care corresponding to a reduction in the proportion non-conforming by 10% within a period of 3 months. Non-conformities dropped from a mean of 5.0 to 1.4 over the year (P process audits and feedbacks. Frequent process audits in the context of statistical process control should be supplemented with concurrent outcome audits, once or twice a year.
Vickers, Kristin S; Ridgeway, Jennifer L; Hathaway, Julie C; Egginton, Jason S; Kaderlik, Angela B; Katzelnick, David J
This evaluation assessed the opinions and experiences of primary care providers and their support staff before and after implementation of expanded on-site mental health services and related system changes in a primary care clinic. Individual semistructured interviews, which contained a combination of open-ended questions and rating scales, were used to elicit opinions about mental health services before on-site system and resource changes occurred and repeated following changes that were intended to improve access to on-site mental health care. In the first set of interviews, prior to expanding mental health services, primary care providers and support staff were generally dissatisfied with the availability and scheduling of on-site mental health care. Patients were often referred outside the primary care clinic for mental health treatment, to the detriment of communication and coordinated care. Follow-up interviews conducted after expansion of mental health services, scheduling refinements and other system changes revealed improved provider satisfaction in treatment access and coordination of care. Providers appreciated immediate and on-site social worker availability to triage mental health needs and help access care, and on-site treatment was viewed as important for remaining informed about patient care the primary care providers are not delivering directly. Expanding integrated mental health services resulted in increased staff and provider satisfaction. Our evaluation identified key components of satisfaction, including on-site collaboration and assistance triaging patient needs. The sustainability of integrated models of care requires additional study. © 2013.
Drain, Paul K; Hyle, Emily P; Noubary, Farzad; Freedberg, Kenneth A; Wilson, Douglas; Bishai, William; Rodriguez, William; Bassett, Ingrid V
Diagnostic point-of-care (POC) testing is intended to minimize the time to obtain a test result, thereby allowing clinicians and patients to make an expeditious clinical decision. As POC tests expand into resource-limited settings (RLS), the benefits must outweigh the costs. To optimize POC testing in RLS, diagnostic POC tests need rigorous evaluations focused on relevant clinical outcomes and operational costs, which differ from evaluations of conventional diagnostic tests. Here, we reviewed published studies on POC testing in RLS, and found no clearly defined metric for the clinical utility of POC testing. Therefore, we propose a framework for evaluating POC tests, and suggest and define the term “test efficacy” to describe a diagnostic test’s capacity to support a clinical decision within its operational context. We also proposed revised criteria for an ideal diagnostic POC test in resource-limited settings. Through systematic evaluations, comparisons between centralized diagnostic testing and novel POC technologies can be more formalized, and health officials can better determine which POC technologies represent valuable additions to their clinical programs. PMID:24332389
Cooke, Heather A
This article aims to examine RCAs' own experiences of personhood in dementia care settings. Conceptually, person-centred care entails fostering the personhood of residents and the residential care aides (RCAs) who provide much of their hands-on care. To date, however, staff personhood has been overlooked in the empirical literature. The study was part of a larger focused ethnographic project exploring how the organisational care environment impedes or facilitates the provision of quality dementia care. Semi-structured interviews with 23 RCAs and more than 230 hours of participant observation were conducted in two nursing homes with specialised dementia units in British Columbia, Canada. Two overarching themes, "personhood undermined-management-staff relations" and "personhood undermined-workplace policies and practices" emerged, illustrating how, despite exposure to features believed beneficial to their working environment (e.g., favourable staffing ratios, relatively good remuneration), RCAs encountered repeated affronts to their personhood. The first theme encompasses the importance of being known (i.e., as persons and of their job demands) and valued (i.e., appreciated for their work in non-monetary terms). The second highlights the salience of work-life balance, full-staffing coverage and supportive human resource practices. RCAs' experiences reveal how the ongoing search for cost-efficiencies, cost-containment and cost-accountability overshadows their individuality, indicating a key disconnect between conceptual ideals and workplace realities. Organisations are encouraged to consider creating person-centred management and workplace practices that provide tangible evidence that RCAs, and their work, matter. © 2018 John Wiley & Sons Ltd.
Hou, Wen-Li; Kuo, Ya-Wen; Huang, Mei-Chih
Marital violence or intimate partner violence is a serious and recurring public health issue. In the clinical setting, battered women often seek medical advice, because of the health problems that result from marital violence. Thus, nursing staff are the first persons to come into contact with the battered women. Can nurses execute their notify responsibility to prevent continued injury before obtained the woman's agreement? Will this action violate the principle of autonomy or not? Nurses would face an ethical dilemma when they care for battered women. The purpose of this article is to use Aroskar's ethical decision making model to analyze and clarify the ethical dilemmas involved in managing marital violence, including: under the value systems of the person, the profession, and time to illustrate the basic information, decision theory dimensions, and ethical theories or positions. It is hoped that this article provides an ethical decision making model for the ethical dilemmas facing nurses who manage marital violence in the clinical setting.
Ganz, Freda DeKeyser; Ofra, Raanan; Khalaila, Rabia; Levy, Hadassa; Arad, Dana; Kolpak, Orly; Ben Nun, Maureen; Drori, Yardena; Benbenishty, Julie
found to be significant with the time of participation (2004-2005 vs. 2012) and priority level of oral care significantly contributing to the regression model. The national effort was partially successful in improving evidence-based oral care practices; however, increased awareness to EBP also might have come from other sources. Other strategies related to knowledge translation need to be attempted and researched in this clinical setting such as the use of opinion leaders, audits and feedback, small group consensus, provider reminder systems, incentives, clinical information systems, and computer decision support systems. This national effort to improve EBP did reap some rewards; however, other knowledge translation strategies should be used to further improve clinical practice. © 2013 Sigma Theta Tau International.
Patients and their families have rights to respect, compassion, attentive and skilled physical and psychosocial care, and spiritual support provided in a holistic manner by the health care team. The four bioethical principles of beneficence, autonomy, non-maleficence and justice should form the framework upon which ...
Katon, Wayne J.; Ludman, Evette J.
Women have a higher prevalence of depressive disorders compared to men. The current system of care for women with depressive disorders provides significant financial barriers for patients with lower incomes to access mental health services. Primary care systems are used extensively by women and have the potential to diagnose patients at early…
Ayranci, Unal; Yenilmez, Cinar; Balci, Yasemin; Kaptanoglu, Cem
This study sought to investigate the contributing factors to and frequency of violence against health care workers (HCWs) working in western Turkey. The population is composed of a random sample of 1,209 HCWs from 34 health care workplaces. Written questionnaires were given to HCWs at all sites, where staff were instructed to register all types of…
Foust, Terry; Eiserman, William; Shisler, Lenore; Geroso, Amy
Otoacoustic emissions (OAE) technology, used widely in newborn hearing screening programs and validated by professional organizations as a reliable and objective tool, is beginning to be recognized as superior to subjective methods when screening young children in a variety of settings. This study examines the efficacy of integrating OAE hearing screening into services routinely provided in health care settings. Three federally funded clinics serving low-income and uninsured people in a metropolitan area participated in the 10-month study. Subjects included 846 children (842 in the target population children did not pass the initial screening. Audiological evaluation was sought for children not passing a subsequent OAE screening. Of the 846 children screened, 814 (96%) ultimately passed the screening or audiological assessment and 29 (3%) exited the study. Three children (1 was 5) were identified with permanent hearing loss. The rate of identification of permanent hearing loss in this study is similar to findings from a study of OAE screening in early childhood educational settings. OAE screening holds the potential for being an effective method for helping to identify young children with permanent hearing loss in primary care settings.
Nicolae, Alexandra; Levin, Leo; Wong, Peter D; Dave, Malini G; Taras, Jillian; Mistry, Chetna; Ford-Jones, Elizabeth L; Wong, Michele; Schroth, Robert J
Early childhood caries (ECC) is the most common chronic disease affecting young children in Canada. ECC may lead to pain and infection, compromised general health, decreased quality of life and increased risk for dental caries in primary and permanent teeth. A multidisciplinary approach to prevent and identify dental disease is recommended by dental and medical national organizations. Young children visit primary care providers at regular intervals from an early age. These encounters provide an ideal opportunity for primary care providers to educate clients about their children's oral health and its importance for general health. We designed an office-based oral health screening guide to help primary care providers identify ECC, a dental referral form to facilitate dental care access and an oral health education resource to raise parental awareness. These resources were reviewed and trialled with a small number of primary care providers.
Gill, Preetinder Singh
Background Engaged employees are an asset to any organization. They are instrumental in ensuring good commercial outcomes through continuous innovation and incremental improvement. A health care facility is similar to a regular work setting in many ways. A health care provider and a patient have roles akin to a team leader and a team member/stakeholder, respectively. Hence it can be argued that the concept of employee engagement can be applied to patients in health care settings in order to improve health outcomes. Methods Patient engagement data were collected using a survey instrument from a primary care clinic in the northern Indian state of Punjab. Canonical correlation equations were formulated to identify combinations which were strongly related to each other. In addition, the cause-effect relationship between patient engagement and patient-perceived health outcomes was described using structural equation modeling. Results Canonical correlation analysis showed that the first set of canonical variables had a fairly strong relationship, ie, a magnitude > 0.80 at the 95% confidence interval, for five dimensions of patient engagement. Structural equation modeling analysis yielded a β ≥ 0.10 and a Student’s t statistic ≥ 2.96 for these five dimensions. The threshold Student’s t statistic was 1.99. Hence it was found the β values were significant at the 95% confidence interval for all census regions. Conclusion A scaled reliable survey instrument was developed to measured patient engagement. Better patient engagement is associated with better patient-perceived health outcomes. This study provides preliminary evidence that patient engagement has a causal relationship with patient-perceived health outcomes. PMID:23515133
Queen, Alexander H.; Ehrenreich-May, Jill; Hershorin, Eugene R.
This study examines the validity of a brief screening tool for adolescent panic disorder (PD) in a primary care setting. A total of 165 participants (ages 12-17 years) seen in two pediatric primary care clinics completed the Autonomic Nervous System Questionnaire (ANS; Stein et al. in Psychosomatic Med 61:359-364, 40). A subset of those screening…
Rañola, John Michael O; Liu, Quanhui; Rosenthal, Elisabeth A; Shirts, Brian H
Quantitative cosegregation analysis can help evaluate the pathogenicity of genetic variants. However, genetics professionals without statistical training often use simple methods, reporting only qualitative findings. We evaluate the potential utility of quantitative cosegregation in the clinical setting by comparing three methods. One thousand pedigrees each were simulated for benign and pathogenic variants in BRCA1 and MLH1 using United States historical demographic data to produce pedigrees similar to those seen in the clinic. These pedigrees were analyzed using two robust methods, full likelihood Bayes factors (FLB) and cosegregation likelihood ratios (CSLR), and a simpler method, counting meioses. Both FLB and CSLR outperform counting meioses when dealing with pathogenic variants, though counting meioses is not far behind. For benign variants, FLB and CSLR greatly outperform as counting meioses is unable to generate evidence for benign variants. Comparing FLB and CSLR, we find that the two methods perform similarly, indicating that quantitative results from either of these methods could be combined in multifactorial calculations. Combining quantitative information will be important as isolated use of cosegregation in single families will yield classification for less than 1% of variants. To encourage wider use of robust cosegregation analysis, we present a website ( http://www.analyze.myvariant.org ) which implements the CSLR, FLB, and Counting Meioses methods for ATM, BRCA1, BRCA2, CHEK2, MEN1, MLH1, MSH2, MSH6, and PMS2. We also present an R package, CoSeg, which performs the CSLR analysis on any gene with user supplied parameters. Future variant classification guidelines should allow nuanced inclusion of cosegregation evidence against pathogenicity.
Resnick, Daniel K; Tosteson, Anna N A; Groman, Rachel F; Ghogawala, Zoher
Topic review. Describe value measurement in spine care and discuss the motivation for, methods for, and limitations of such measurement. Spinal disorders are common and are an important cause of pain and disability. Numerous complementary and competing treatment strategies are used to treat spinal disorders, and the costs of these treatments is substantial and continue to rise despite clear evidence of improved health status as a result of these expenditures. The authors present the economic and legislative imperatives forcing the assessment of value in spine care. The definition of value in health care and methods to measure value specifically in spine care are presented. Limitations to the utility of value judgments and caveats to their use are presented. Examples of value calculations in spine care are presented and critiqued. Methods to improve and broaden the measurement of value across spine care are suggested, and the role of prospective registries in measuring value is discussed. Value can be measured in spine care through the use of appropriate economic measures and patient-reported outcomes measures. Value must be interpreted in light of the perspective of the assessor, the duration of the assessment period, the degree of appropriate risk stratification, and the relative value of treatment alternatives.
Turley, Ryan S; Mi, Xiaojuan; Qualls, Laura G; Vemulapalli, Sreekanth; Peterson, Eric D; Patel, Manesh R; Curtis, Lesley H; Jones, W Schuyler
Modifications in reimbursement rates by Medicare in 2008 have led to peripheral vascular interventions (PVI) being performed more commonly in outpatient and office-based clinics. The objective of this study was to determine the effects of this shift in clinical care setting on clinical outcomes after PVI. Modifications in reimbursement have led to peripheral vascular intervention (PVI) being more commonly performed in outpatient hospital settings and office-based clinics. Using a 100% national sample of Medicare beneficiaries from 2010 to 2012, we examined 30-day and 1-year rates of all-cause mortality, major lower extremity amputation, repeat revascularization, and all-cause hospitalization by clinical care location of index PVI. A total of 218,858 Medicare beneficiaries underwent an index PVI between 2010 and 2012. Index PVIs performed in inpatient settings were associated with higher 1-year rates of all-cause mortality (23.6% vs. 10.4% and 11.7%; p index revascularization and geographic region on the occurrence of all-cause hospitalization, repeat revascularization, and lower extremity amputation. Index PVI performed in office-based settings was associated with a higher hazard of repeat revascularization when compared with other settings. Differences in clinical outcomes across treatment settings and geographic regions suggest that inconsistent application of PVI may exist and highlights the need for studies to determine optimal delivery of PVI in clinical practice. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Tandon, Pooja S; Zhou, Chuan; Christakis, Dimitri A
Given that more than 34% of U.S. children are cared for in home-based child care settings and outdoor play is associated with physical activity and other health benefits, we sought to characterize the outdoor play frequency of preschoolers cared for at home-based child care settings and factors associated with outdoor play. Cross-sectional study of 1900 preschoolers (representing approximately 862,800 children) cared for in home-based child care settings (including relative and nonrelative care) using the nationally representative Early Childhood Longitudinal Study, Birth Cohort. Only 50% of home-based child care providers reported taking the child outside to walk or play at least once/day. More than one-third of all children did not go outside to play daily with either their parent(s) or home-based child care provider. There were increased odds of going outside daily for children cared for by nonrelatives in the child's home compared with care from a relative. Children with ≥3 regular playmates had greater odds of being taken outdoors by either the parents or child care provider. We did not find statistically significant associations between other child level (age, sex, screen-time), family level (highest education in household, mother's race, employment, exercise frequency), and child care level (hours in care, provider's educational attainment, perception of neighborhood safety) factors and frequency of outdoor play. At a national level, the frequency of outdoor play for preschoolers cared for in home-based child care settings is suboptimal. Further study and efforts to increase outdoor playtime for children in home-based child care settings are needed. Copyright © 2012 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
Chua, Siew Siang; Kok, Li Ching; Yusof, Faridah Aryani Md; Tang, Guang Hui; Lee, Shaun Wen Huey; Efendie, Benny; Paraidathathu, Thomas
The roles of pharmacists have evolved from product oriented, dispensing of medications to more patient-focused services such as the provision of pharmaceutical care. Such pharmacy service is also becoming more widely practised in Malaysia but is not well documented. Therefore, this study is warranted to fill this information gap by identifying the types of pharmaceutical care issues (PCIs) encountered by primary care patients with diabetes mellitus, hypertension or hyperlipidaemia in Malaysia. This study was part of a large controlled trial that evaluated the outcomes of multiprofessional collaboration which involved medical general practitioners, pharmacists, dietitians and nurses in managing diabetes mellitus, hypertension and hyperlipidaemia in primary care settings. A total of 477 patients were recruited by 44 general practitioners in the Klang Valley. These patients were counselled by the various healthcare professionals and followed-up for 6 months. Of the 477 participants, 53.7% had at least one PCI, with a total of 706 PCIs. These included drug-use problems (33.3%), insufficient awareness and knowledge about disease condition and medication (20.4%), adverse drug reactions (15.6%), therapeutic failure (13.9%), drug-choice problems (9.5%) and dosing problems (3.4%). Non-adherence to medications topped the list of drug-use problems, followed by incorrect administration of medications. More than half of the PCIs (52%) were classified as probably clinically insignificant, 38.9% with minimal clinical significance, 8.9% as definitely clinically significant and could cause patient harm while one issue (0.2%) was classified as life threatening. The main causes of PCIs were deterioration of disease state which led to failure of therapy, and also presentation of new symptoms or indications. Of the 338 PCIs where changes were recommended by the pharmacist, 87.3% were carried out as recommended. This study demonstrates the importance of pharmacists working in
Full Text Available Abstract Background The roles of pharmacists have evolved from product oriented, dispensing of medications to more patient-focused services such as the provision of pharmaceutical care. Such pharmacy service is also becoming more widely practised in Malaysia but is not well documented. Therefore, this study is warranted to fill this information gap by identifying the types of pharmaceutical care issues (PCIs encountered by primary care patients with diabetes mellitus, hypertension or hyperlipidaemia in Malaysia. Methods This study was part of a large controlled trial that evaluated the outcomes of multiprofessional collaboration which involved medical general practitioners, pharmacists, dietitians and nurses in managing diabetes mellitus, hypertension and hyperlipidaemia in primary care settings. A total of 477 patients were recruited by 44 general practitioners in the Klang Valley. These patients were counselled by the various healthcare professionals and followed-up for 6 months. Results Of the 477 participants, 53.7% had at least one PCI, with a total of 706 PCIs. These included drug-use problems (33.3%, insufficient awareness and knowledge about disease condition and medication (20.4%, adverse drug reactions (15.6%, therapeutic failure (13.9%, drug-choice problems (9.5% and dosing problems (3.4%. Non-adherence to medications topped the list of drug-use problems, followed by incorrect administration of medications. More than half of the PCIs (52% were classified as probably clinically insignificant, 38.9% with minimal clinical significance, 8.9% as definitely clinically significant and could cause patient harm while one issue (0.2% was classified as life threatening. The main causes of PCIs were deterioration of disease state which led to failure of therapy, and also presentation of new symptoms or indications. Of the 338 PCIs where changes were recommended by the pharmacist, 87.3% were carried out as recommended. Conclusions This study
Kornstein, Susan G; Kunovac, Jelena L; Herman, Barry K; Culpepper, Larry
Review the clinical skills needed to recognize, diagnose, and manage binge-eating disorder (BED) in a primary care setting. A PubMed search of English-language publications (January 1, 2008-December 11, 2014) was conducted using the term binge-eating disorder . Relevant articles known to the authors were also included. Publications focusing on preclinical topics (eg, characterization of receptors and neurotransmitter systems) without discussing clinical relevance were excluded. A total of 101 publications were included in this review. Although BED is the most prevalent eating disorder, it is underdiagnosed and undertreated. BED can be associated with medical (eg, type 2 diabetes and metabolic syndrome) and psychiatric (eg, depression and anxiety) comorbidities that, if left untreated, can impair quality of life and functionality. Primary care physicians may find diagnosing and treating BED challenging because of insufficient knowledge of its new diagnostic criteria and available treatment options. Furthermore, individuals with BED may be reluctant to seek treatment because of shame, embarrassment, and a lack of awareness of the disorder. Several short assessment tools are available to screen for BED in primary care settings. Pharmacotherapy and psychotherapy should focus on reducing binge-eating behavior, thereby reducing medical and psychiatric complications. Overcoming primary care physician- and patient-related barriers is critical to accurately diagnose and appropriately treat BED. Primary care physicians should take an active role in the initial recognition and assessment of suspected BED based on case-finding indicators (eg, eating habits and being overweight), the initial treatment selection, and the long-term follow-up of patients who meet DSM-5 BED diagnostic criteria.
Kornstein, Susan G.; Kunovac, Jelena L.; Herman, Barry K.; Culpepper, Larry
Objective: Review the clinical skills needed to recognize, diagnose, and manage binge-eating disorder (BED) in a primary care setting. Data Sources: A PubMed search of English-language publications (January 1, 2008–December 11, 2014) was conducted using the term binge-eating disorder. Relevant articles known to the authors were also included. Study Selection/Data Extraction: Publications focusing on preclinical topics (eg, characterization of receptors and neurotransmitter systems) without discussing clinical relevance were excluded. A total of 101 publications were included in this review. Results: Although BED is the most prevalent eating disorder, it is underdiagnosed and undertreated. BED can be associated with medical (eg, type 2 diabetes and metabolic syndrome) and psychiatric (eg, depression and anxiety) comorbidities that, if left untreated, can impair quality of life and functionality. Primary care physicians may find diagnosing and treating BED challenging because of insufficient knowledge of its new diagnostic criteria and available treatment options. Furthermore, individuals with BED may be reluctant to seek treatment because of shame, embarrassment, and a lack of awareness of the disorder. Several short assessment tools are available to screen for BED in primary care settings. Pharmacotherapy and psychotherapy should focus on reducing binge-eating behavior, thereby reducing medical and psychiatric complications. Conclusions: Overcoming primary care physician– and patient-related barriers is critical to accurately diagnose and appropriately treat BED. Primary care physicians should take an active role in the initial recognition and assessment of suspected BED based on case-finding indicators (eg, eating habits and being overweight), the initial treatment selection, and the long-term follow-up of patients who meet DSM-5 BED diagnostic criteria. PMID:27733955
Goytia, Elliott J; Lounsbury, David W; McCabe, Mary S; Weiss, Elisa; Newcomer, Meghan; Nelson, Deena J; Brennessel, Debra; Rapkin, Bruce D; Kemeny, M Margaret
Many cancer centers and community hospitals are developing novel models of survivorship care. However, few are specifically focused on services for socio-economically disadvantaged cancer survivors. To describe a new model of survivorship care serving culturally diverse, urban adult cancer patients and to present findings from a feasibility evaluation. Adult cancer patients treated at a public city hospital cancer center. The clinic provides comprehensive medical and psychosocial services for patients within a public hospital cancer center where they receive their oncology care. Longitudinal data collected over a 3-year period were used to describe patient demographics, patient needs, and services delivered. Since inception, 410 cancer patients have been served. Demand for services has grown steadily. Hypertension was the most frequent comorbid condition treated. Pain, depression, cardiovascular disease, hyperlipidemia, and bowel dysfunction were the most common post-treatment problems experienced by the patients. Financial counseling was an important patient resource. This new clinical service has been well-integrated into its public urban hospital setting and constitutes an innovative model of health-care delivery for socio-economically challenged, culturally diverse adult cancer survivors.
Galfalvy, H C; Reddy, S M; Niewiadomska-Bugaj, M; Friedman, S; Merkin, B
Concurrent Engineering Research Center (CERC), under the sponsorship of NLM (National Library of Medicine) is in the process of developing a computerized patient record system for a clinical environment distributed in rural West Virginia. This realization of the CCN (Community Care Network), besides providing computer-based patient records accessible from a chain of clinics and one hospital, supports collaborative health care processes like referral and consulting. To evaluate the effectiveness of the system, a study was designed and is in the process of being executed. Three surveys were designed to provide subjective measures, and four experiments for collecting objective data. Data collection is taking place in several phases: baseline data are collected before the system is deployed; the process is repeated with minimal changes three, then six months later or as often as new versions of the system are installed. Results are then to be compared, using whenever possible matching techniques (i.e. the preliminary data collected on a provider will be matched with the data collected later on the same provider). Surveys are conducted through questionnaires distributed to providers and nurses and person-to-person interviews of the patients. The time spent on patient-chart related activities is measured by work-sampling, aided by a computer application running on a laptop PC. Information about missing patient record parts is collected by the providers, the frequency by which new features of the computerized system are used will be logged by the system itself and clinical outcome measures will be studied from the results of the clinics' own patient chart audits. Preliminary results of the surveys and plans for the immediate and distant future are discussed at the end of the paper.
Full Text Available Srikar Adhikari,1 Richard Amini,1 Lori A Stolz,1 Michael Blaivas2 1Department of Emergency Medicine, University of Arizona Medical Center, Tucson, AZ, 2Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, SC, USA Abstract: The use of point-of-care (POC ultrasonography has rapidly expanded in recent years, in both academic and community settings. It is one of the few diagnostic modalities that can be performed rapidly at the bedside by a physician and has significant impact on patient outcomes. It is portable, readily accessible, and cost-effective, and has no risk of ionizing radiation. There is an abundance of evidence that supports the use of POC ultrasound by physicians in different subspecialties. Multiple studies have documented the diagnostic accuracy of POC ultrasound and its ability to decrease the time to definitive treatment. As ultrasound technology has advanced, POC ultrasound applications have also evolved from being used solely in patients with blunt abdominal trauma to applications for nearly every clinical scenario imaginable. From performing procedures more safely to diagnosing pathology more quickly, POC ultrasound is radically changing clinical practice, patient outcomes, and the overall quality of patient care a clinician can provide. Recently, there has been a paradigm shift involving a symptom-based approach to POC ultrasound. This unique symptom-based ultrasound approach has led to improved quality of care in a variety of clinical settings. Keywords: point-of-care ultrasound, ultrasonography, bedside ultrasound, emergency physician, emergency department, quality, symptom-based
Sayarifard, Fatemeh; Imcheh, Fereshteh Bakhshi; Badri, Shirinsadat; Faghihi, Toktam; Qorbani, Mostafa; Radfar, Mania
One of the main problems facing public health providers and administrators in many countries is ensuring the rational use of high-cost drugs. In this regard, on-going process of medication use evaluation can be considered as a useful tool. In this study, we evaluated certain usage aspects of a highly-cost medication, that is, recombinant growth hormone (GH). This cross-sectional study conducted from August 2012 to August 2014. Children receiving GH ± gonadotropin releasing hormone (GnRH) analogs were included in the study. A researcher-designed checklist was developed to evaluate the GH utilization in these patients. Baseline demographic characteristics and background clinical and growth data, as well as any aspects of drug therapy including indications, dosing, monitoring, and discontinuation were collected from the patients' medical records. Seventy children receiving GH entered the study, of which 23 patients (32.85%) received GH and GnRH analogs simultaneously. At the baseline, 67 children (95.7%) had GH stimulation test, whereas serum insulin-like growth factor-1 (IGF-1) levels were measured in 63 (90%) patients. Sixty-seven patients (95.71%) had thyroid function test, whereas bone age was determined in 68 children (97.14%). The mean ± standard deviation of GH dose for idiopathic short stature, GH deficiency, Turner's syndrome and born small for gestational age in our study was 0.22 ± 0.025 mg/kg/week, 0.23 ± 0.04 mg/kg/week, 0.22 ± 0.015 mg/kg/week, and 0.23 ± 0.02 mg/kg/week, respectively. Height and weight of all patients were followed every 3-6 months, regularly. Thirty patients were treated with GH for at least 1 year, of which thyroid hormones and IGF-1 levels were measured annually in 25 (83.33%) and 26 (86.66%) patients, respectively; while bone age was evaluated in 13 (43.33%) children, annually. GH treatment was discontinued in 15 patients (21.42%), while financial problem was the major reason. Diagnostic tests and monitoring of height, weight
Håkonsen, Sasja Jul; Pedersen, Preben Ulrich; Bjerrum, Merete; Bygholm, Ann; Peters, Micah D J
. Multiple databases (PubMed, CINAHL, Embase, Scopus, Swemed+, MedNar, CDC, MEDION, Health Technology Assessment Database, TRIP database, NTIS, ProQuest Dissertations and Theses, Google Scholar, Current Contents) were searched from their inception to September 2016. The results from the studies were extracted using pre-developed extraction tools to all three questions, and have been presented narratively and by using figures to support the text. Twenty-nine nutritional screening tools that were validated within a primary care setting, and two documents on consensus statements regarding expert opinion were identified. No studies on the patients or relatives views were identified. The nutritional screening instruments have solely been validated in an over-55 population. Construct validity was the type of validation most frequently used in the validation process covering a total of 25 of the 29 tools. Two studies were identified in relation to the third review question. These two documents are both consensus statement documents developed by experts within the geriatric and nutritional care field. Overall, experts find it appropriate to: i) conduct a comprehensive geriatric assessment, ii) use a validated nutritional screening instrument, and iii) conduct a history and clinical diagnosis, physical examination and dietary assessment when assessing primarily the elderly's nutritional status in primary health care.
Full Text Available Bruce Charlesworth,1 Claire Pilling,1 Paul Chadwick,2 Martyn Butcher31Adelphi Values, Macclesfield, 2Salford Royal Foundation Trust, Salford, 3Northern Devon Healthcare Trust, Devon, UKBackground: Dressings are the mainstay of wound care management; however, adherence of the dressing to the wound or periwound skin is common and can lead to dressing-related pain and trauma. Dressing-related trauma is recognized as a clinical and economic burden to patients and health care providers. This study was conducted to garner expert opinion on clinical sequelae and resource use associated with dressing-related trauma in a UK setting.Methods: This was an exploratory study with two phases: qualitative pilot interviews with six wound care specialists to explore dressing-related trauma concepts, sequelae, and resource utilization; and online quantitative research with 30 wound care specialists to validate and quantify the concepts, sequelae, and resource utilization explored in the first phase of the study. Data were collected on mean health care professional time, material costs, pharmaceutical costs, and inpatient management per sequela occurrence until resolution. Data were analyzed to give total costs per sequela and concept occurrence.Results: The results demonstrate that dressing-related trauma is a clinically relevant concept. The main types of dressing-related trauma concepts included skin reactions, adherence to the wound, skin stripping, maceration, drying, and plugging of the wound. These were the foundation for a number of clinical sequelae, including wound enlargement, increased exudate, bleeding, infection, pain, itching/excoriation, edema, dermatitis, inflammation, and anxiety. Mean total costs range from £56 to £175 for the complete onward management of each occurrence of the six main concepts.Conclusion: These results provide insight into the hidden costs of dressing-related trauma in a UK setting. This research successfully conceptualized
Full Text Available Medically unexplained symptoms (MUS are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 (d = 0.4. A statistically significant (23% decrease in family physicians’ visits was found in the 6 months after attending the MUS service compared to the 6 months prior. Both patients and primary care clinicians reported a high degree of satisfaction with the service. Whilst further research is needed, these findings suggest that a direct psychology service maintained within the family practice clinic may assist patient and clinician function while reducing healthcare utilization. Challenges and further service developments are discussed, including the potential benefits of re-branding the service to become a ‘Primary Care Psychological Consultation and Treatment Service’.
Cooper, Angela; Abbass, Allan; Town, Joel
Medically unexplained symptoms (MUS) are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP) with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 ( d = 0.4). A statistically significant (23%) decrease in family physicians' visits was found in the 6 months after attending the MUS service compared to the 6 months prior. Both patients and primary care clinicians reported a high degree of satisfaction with the service. Whilst further research is needed, these findings suggest that a direct psychology service maintained within the family practice clinic may assist patient and clinician function while reducing healthcare utilization. Challenges and further service developments are discussed, including the potential benefits of re-branding the service to become a 'Primary Care Psychological Consultation and Treatment Service'.
Shah, Adil A; Latif, Asad; Zogg, Cheryl K; Zafar, Syed Nabeel; Riviello, Robert; Halim, Muhammad Sohail; Rehman, Zia; Haider, Adil H; Zafar, Hasnain
Emergency general surgery (EGS) has emerged as an important component of frontline operative care. Efforts in high-income settings have described its burden but have yet to consider low- and middle-income health care settings in which emergent conditions represent a high proportion of operative need. The objective of this study was to describe the disease spectrum of EGS conditions and associated factors among patients presenting in a low-middle income context. March 2009-April 2014 discharge data from a university teaching hospital in South Asia were obtained for patients (≥16 years) with primary International Classification of Diseases, 9(th) revision, Clinical Modification diagnosis codes consistent with an EGS condition as defined by the American Association for the Surgery of Trauma. Outcomes included in-hospital mortality and occurrence of ≥1 major complication(s). Multivariable analyses were performed, adjusting for differences in demographic and case-mix factors. A total of 13,893 discharge records corresponded to EGS conditions. Average age was 47.2 years (±16.8, standard deviation), with a male preponderance (59.9%). The majority presented with admitting diagnoses of biliary disease (20.2%), followed by soft-tissue disorders (15.7%), hernias (14.9%), and colorectal disease (14.3%). Rates of death and complications were 2.7% and 6.6%, respectively; increasing age was an independent predictor of both. Patients in need of resuscitation (n = 225) had the greatest rates of mortality (72.9%) and complications (94.2%). This study takes an important step toward quantifying outcomes and complications of EGS, providing one of the first assessments of EGS conditions using American Association for the Surgery of Trauma definitions in a low-middle income health care setting. Further efforts in varied settings are needed to promote representative benchmarking worldwide. Copyright © 2016 Elsevier Inc. All rights reserved.
Godfrey, Emily M.; Bordoloi, Anita; Moorthie, Mydhili; Pela, Emily
Objective: Medication abortion with mifepristone and misoprostol has been available in the United States since 2000. The authors reviewed the first 46 medication abortion cases conducted at a university-based student health care clinic to determine the safety and feasibility of medication abortion in this type of clinical setting. Participants:…
Full Text Available At a recent conference, a definition was drawn up that is most appropriate to the South African situation: “ Primary health care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation, and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus, and of the overall social and economic development of the community.”
Full Text Available A variety of clinical process indicators exists to measure the quality of care provided by maternal and neonatal health (MNH programs. To allow comparison across MNH programs in low- and middle-income countries (LMICs, a core set of essential process indicators is needed. Although such a core set is available for emergency obstetric care (EmOC, the 'EmOC signal functions', a similar approach is currently missing for MNH routine care evaluation. We describe a strategy for identifying core process indicators for routine care and illustrate their usefulness in a field example.We first developed an indicator selection strategy by combining epidemiological and programmatic aspects relevant to MNH in LMICs. We then identified routine care process indicators meeting our selection criteria by reviewing existing quality of care assessment protocols. We grouped these indicators into three categories based on their main function in addressing risk factors of maternal or neonatal complications. We then tested this indicator set in a study assessing MNH quality of clinical care in 33 health facilities in Malawi.Our strategy identified 51 routine care processes: 23 related to initial patient risk assessment, 17 to risk monitoring, 11 to risk prevention. During the clinical performance assessment a total of 82 cases were observed. Birth attendants' adherence to clinical standards was lowest in relation to risk monitoring processes. In relation to major complications, routine care processes addressing fetal and newborn distress were performed relatively consistently, but there were major gaps in the performance of routine care processes addressing bleeding, infection, and pre-eclampsia risks.The identified set of process indicators could identify major gaps in the quality of obstetric and neonatal care provided during the intra- and immediate postpartum period. We hope our suggested indicators for essential routine care processes will contribute to streamlining
Brenner, Stephan; De Allegri, Manuela; Gabrysch, Sabine; Chinkhumba, Jobiba; Sarker, Malabika; Muula, Adamson S
A variety of clinical process indicators exists to measure the quality of care provided by maternal and neonatal health (MNH) programs. To allow comparison across MNH programs in low- and middle-income countries (LMICs), a core set of essential process indicators is needed. Although such a core set is available for emergency obstetric care (EmOC), the 'EmOC signal functions', a similar approach is currently missing for MNH routine care evaluation. We describe a strategy for identifying core process indicators for routine care and illustrate their usefulness in a field example. We first developed an indicator selection strategy by combining epidemiological and programmatic aspects relevant to MNH in LMICs. We then identified routine care process indicators meeting our selection criteria by reviewing existing quality of care assessment protocols. We grouped these indicators into three categories based on their main function in addressing risk factors of maternal or neonatal complications. We then tested this indicator set in a study assessing MNH quality of clinical care in 33 health facilities in Malawi. Our strategy identified 51 routine care processes: 23 related to initial patient risk assessment, 17 to risk monitoring, 11 to risk prevention. During the clinical performance assessment a total of 82 cases were observed. Birth attendants' adherence to clinical standards was lowest in relation to risk monitoring processes. In relation to major complications, routine care processes addressing fetal and newborn distress were performed relatively consistently, but there were major gaps in the performance of routine care processes addressing bleeding, infection, and pre-eclampsia risks. The identified set of process indicators could identify major gaps in the quality of obstetric and neonatal care provided during the intra- and immediate postpartum period. We hope our suggested indicators for essential routine care processes will contribute to streamlining MNH program
Mastal, Margaret; Levine, June
Ambulatory care settings employ 25% of the three million registered nurses in the United States. The American Academy of Ambulatory Care Nursing (AAACN) is committed to improving the quality of health care in ambulatory settings, enhancing patient outcomes, and realizing greater health care efficiencies. A survey of ambulatory care registered nurses indicates they are well positioned to lead and facilitate health care reform activities with organizational colleagues. They are well schooled in critical thinking, triage, advocating for patients, educating patients and families, collaborating with medical staff and other professionals, and care coordination. The evolving medical home concept and other health care delivery models reinforces the critical need for registered nurses to provide chronic disease management, care coordination, health risk appraisal, care transitions, health promotion, and disease prevention services. Recommendations are offered for organizational leaders, registered nurses, and AAACN to utilize nursing knowledge and skills in the pursuit of leading change and advancing health.
Barnes, Thomas A; Fromer, Len
Objective: To describe a practical method for family practitioners to stage chronic obstructive pulmonary disease (COPD) by the use of office spirometry. Methods: This is a review of the lessons learned from evaluations of the use of office spirometry in the primary care setting to identify best practices using the most recent published evaluations of office spirometry and the analysis of preliminary data from a recent spirometry mass screening project. A mass screening study by the American Association for Respiratory Care and the COPD Foundation was used to identify the most effective way for general practitioners to implement office spirometry in order to stage COPD. Results: A simple three-step method is described to identify people with a high pre-test probability in an attempt to detect moderate to severe COPD: COPD questionnaire, measurement of peak expiratory flow, and office spirometry. Clinical practice guidelines exist for office spirometry basics for safety, use of electronic peak flow devices, and portable spirometers. Conclusion: Spirometry can be undertaken in primary care offices with acceptable levels of technical expertise. Using office spirometry, primary care physicians can diagnose the presence and severity of COPD. Spirometry can guide therapies for COPD and predict outcomes when used in general practice. PMID:21472091
Mitchell, Pamela R.
Background: Communication skills are important to the pursuit of increased self-determination in individuals with disabilities. The aim of this investigation was to gather information about communication supports in state-run residential care facilities in Ohio, and to compare findings with a previous investigation on this topic examining such…
Heilmann, Rachel M F; Campbell, Stephanie M; Kroner, Beverly A; Proksel, Jenel R; Billups, Sarah J; Witt, Daniel M; Helling, Dennis K
The impact of the declining number of primary care physicians is exacerbated by a growing elderly population in need of chronic disease management. Primary care clinical pharmacy specialists, with their unique knowledge and skill set, are well suited to address this gap. At Kaiser Permanente of Colorado (KPCO), primary care clinical pharmacy specialists have a long history of integration with medical practices and are located in close proximity to physicians, nurses, and other members of the health care team. Since 1992, Primary Care Clinical Pharmacy Services (PCCPS) has expanded from 4 to 30 full-time equivalents (FTEs) to provide services in all KPCO medical office buildings. With this growth in size, PCCPS has evolved to play a vital role in working with primary care medical teams to ensure that drug therapy is effective, safe, and affordable. In addition, PCCPS specialists provide ambulatory teaching sites for pharmacy students and pharmacy residents. There is approximately 1 specialist FTE for every 13,000 adult KPCO members and every 9 clinical FTEs of internal medicine and family medicine physicians. All clinical pharmacy specialists in the pharmacy department are required to have a PharmD degree, to complete postgraduate year 2 residencies, and, as a condition of employment, to become board certified in an applicable specialty. The evolution, current structure, and role of PCCPS at KPCO, including factors facilitating successful integration within the medical team, are highlighted. Patient and nonpatient care responsibilities are described.
Depression in the elderly presenting at primary care settings is usually under- detected by primary care physicians. This study assessed the prevalence of depression and the utility of the Geriatric Depression Scale (Short Form) in detecting depression in elderly patients in primary care populations in Ilorin, Nigeria. This was ...
Salvolini, Luca [Radiology Department, ' Umberto I' Hospital - Ospedali Riuniti - ' Politecnica delle Marche' University, Via Conca, 60020 Ancona (Italy)], E-mail: firstname.lastname@example.org; Scaglione, Mariano [Emergency and Trauma CT Section, Department of Radiology, Cardarelli Hospital, Via G. Merliani 31, 80127 Naples (Italy); Giuseppetti, Gian Marco; Giovagnoni, Andrea [Radiology Department, ' Umberto I' Hospital - Ospedali Riuniti - ' Politecnica delle Marche' University, Via Conca, 60020 Ancona (Italy)
Both pulmonary arterial and peripheral venous sides of venous thromboembolism (VTE) can now be efficiently and safely investigated by multi-detector CT (MDCT) at the same time by a combined CT angiography/CT venography protocol. In the emergency setting, the use of such a single test for patients suspected of suffering from VTE on a clinical grounds may considerably shorten and simplify diagnostic algorithms. The selection of patients to be submitted to MDCT must follow well-established clinical prediction rules in order to avoid generalized referral to CT on a generic clinical suspicion basis and excessive population exposure to increased ionizing radiation dose, especially in young patients. Clinical and anatomical wide-panoramic capabilities of MDCT allow identification of underlying disease that may explain patients' symptoms in a large number of cases in which VTE is not manifest. The analysis of MDCT additional findings on cardiopulmonary status and total thrombus burden can lead to better prognostic stratification of patients and influence therapeutic options. Some controversial points such as optimal examination parameters, clinical significance of subsegmentary emboli, CT pitfalls and/or possible falsely positive diagnoses, and outcome of untreated patients in which VTE has been excluded by MDCT without additional testing, must of course be taken into careful consideration before the definite role of comprehensive MDCT VTE 'one-stop-shop' diagnosis in everyday clinical practice can be ascertained.
Salvolini, Luca; Scaglione, Mariano; Giuseppetti, Gian Marco; Giovagnoni, Andrea
Both pulmonary arterial and peripheral venous sides of venous thromboembolism (VTE) can now be efficiently and safely investigated by multi-detector CT (MDCT) at the same time by a combined CT angiography/CT venography protocol. In the emergency setting, the use of such a single test for patients suspected of suffering from VTE on a clinical grounds may considerably shorten and simplify diagnostic algorithms. The selection of patients to be submitted to MDCT must follow well-established clinical prediction rules in order to avoid generalized referral to CT on a generic clinical suspicion basis and excessive population exposure to increased ionizing radiation dose, especially in young patients. Clinical and anatomical wide-panoramic capabilities of MDCT allow identification of underlying disease that may explain patients' symptoms in a large number of cases in which VTE is not manifest. The analysis of MDCT additional findings on cardiopulmonary status and total thrombus burden can lead to better prognostic stratification of patients and influence therapeutic options. Some controversial points such as optimal examination parameters, clinical significance of subsegmentary emboli, CT pitfalls and/or possible falsely positive diagnoses, and outcome of untreated patients in which VTE has been excluded by MDCT without additional testing, must of course be taken into careful consideration before the definite role of comprehensive MDCT VTE 'one-stop-shop' diagnosis in everyday clinical practice can be ascertained
Full Text Available Background and Aim. Reflection is known as a skill that is central to nursing students’ professional development. Due to the importance and the role of reflection in clinical areas of nursing, it is important to know how to achieve it. However, nursing trainers face the challenge of how to help their students to improve reflection in clinical settings. The aim of this study was to investigate the nursing students’ experiences of facilitating reflection during clinical practice. This qualitative study was conducted by qualitative content analysis approach. Twenty nursing students during the second to eighth semester of their educational program were selected for participation using purposive sampling. Data were collected through in-depth semistructured interviews. The interview was transcribed verbatim, and qualitative content analysis was used to analyze the data. From the data analysis, four main themes were extracted. Motivation to reflect, complex experiences, efficient trainer, and effective relations were four main themes obtained from study that, in interaction with each other, had facilitating roles in students’ reflective process on experiences. The findings revealed that the nursing students’ reflection in clinical settings is effective in personal and professional level. Reflection of nursing students depends on motivational and educational factors and these factors increase the quality of care in patients. Furthermore, nursing educators need to create nurturing climate as well as supporting reflective behaviors of nursing students.
Yeh, Vivian M.; Schnur, Julie B.; Montgomery, Guy H.
Hypnosis is a brief intervention ready for wider dissemination in medical contexts. Overall, hypnosis remains underused despite evidence supporting its beneficial clinical impact. This review will evaluate the evidence supporting hypnosis for dissemination using guidelines formulated by Glasgow and colleagues (1999). Five dissemination dimensions will be considered: Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM). Reach In medical settings, hypnosis is capable of helping a diverse range of individuals with a wide variety of problems. Efficacy There is evidence supporting the use of hypnosis for chronic pain, acute pain and emotional distress arising from medical procedures and conditions, cancer treatment-related side-effects and irritable bowel syndrome. Adoption Although hypnosis is currently not a part of mainstream clinical practices, evidence suggests that patients and healthcare providers are open to trying hypnosis, and may become more so when educated about what hypnosis can do. Implementation Hypnosis is a brief intervention capable of being administered effectively by healthcare providers. Maintenance Given the low resource needs of hypnosis, opportunities for reimbursement, and the ability of the intervention to potentially help medical settings reduce costs, the intervention has the qualities necessary to be integrated into routine care in a self-sustaining way in medical settings. In sum, hypnosis is a promising candidate for further dissemination. PMID:25267941
Hirdes, John P; Poss, Jeffrey W; Mitchell, Lori; Korngut, Lawrence; Heckman, George
Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions. Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940), complex continuing care hospitals/units (n = 88,721), and nursing homes (n = 185,309) in seven Canadian provinces/territories. CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings. CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.
John P Hirdes
Full Text Available Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions.Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940, complex continuing care hospitals/units (n = 88,721, and nursing homes (n = 185,309 in seven Canadian provinces/territories.CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings.CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.
Williams, Evelyn; Curtis, Ashley
Physicians lack clear guidance about adaptation of clinical practice guidelines for elderly institutionalized patients with diabetes. In a large long-term care facility, a diabetes management flow sheet was trialed to determine which clinical parameters were found useful by clinicians in the management of diabetes in that setting. Clinical practice guidelines for diabetes management were reviewed with attending physicians. Diabetes management flow sheets were distributed for all patients coded as having diabetes on their most recent minimum data sets. After a period of 14 months, flow sheet completion rates were ascertained and physicians were surveyed regarding the utility of the flow sheet. Initial flow sheet data were completed in full or in part for only 57% of the 121 study subjects; 39% of the subjects died within 14 months. Quarterly follow-up data were completed for 58% of the flow sheets. The diabetes management flow sheet was not found to be useful by attending physicians as a chronic-disease management tool. Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
Hartshorn, Christopher M; Bradbury, Michelle S; Lanza, Gregory M; Nel, Andre E; Rao, Jianghong; Wang, Andrew Z; Wiesner, Ulrich B; Yang, Lily; Grodzinski, Piotr
Ongoing research into the application of nanotechnology for cancer treatment and diagnosis has demonstrated its advantages within contemporary oncology as well as its intrinsic limitations. The National Cancer Institute publishes the Cancer Nanotechnology Plan every 5 years since 2005. The most recent iteration helped codify the ongoing basic and translational efforts of the field and displayed its breadth with several evolving areas. From merely a technological perspective, this field has seen tremendous growth and success. However, an incomplete understanding of human cancer biology persists relative to the application of nanoscale materials within contemporary oncology. As such, this review presents several evolving areas in cancer nanotechnology in order to identify key clinical and biological challenges that need to be addressed to improve patient outcomes. From this clinical perspective, a sampling of the nano-enabled solutions attempting to overcome barriers faced by traditional therapeutics and diagnostics in the clinical setting are discussed. Finally, a strategic outlook of the future is discussed to highlight the need for next-generation cancer nanotechnology tools designed to address critical gaps in clinical cancer care.
Chen, Jonathan H; Alagappan, Muthuraman; Goldstein, Mary K; Asch, Steven M; Altman, Russ B
Determine how varying longitudinal historical training data can impact prediction of future clinical decisions. Estimate the "decay rate" of clinical data source relevance. We trained a clinical order recommender system, analogous to Netflix or Amazon's "Customers who bought A also bought B..." product recommenders, based on a tertiary academic hospital's structured electronic health record data. We used this system to predict future (2013) admission orders based on different subsets of historical training data (2009 through 2012), relative to existing human-authored order sets. Predicting future (2013) inpatient orders is more accurate with models trained on just one month of recent (2012) data than with 12 months of older (2009) data (ROC AUC 0.91 vs. 0.88, precision 27% vs. 22%, recall 52% vs. 43%, all P<10 -10 ). Algorithmically learned models from even the older (2009) data was still more effective than existing human-authored order sets (ROC AUC 0.81, precision 16% recall 35%). Training with more longitudinal data (2009-2012) was no better than using only the most recent (2012) data, unless applying a decaying weighting scheme with a "half-life" of data relevance about 4 months. Clinical practice patterns (automatically) learned from electronic health record data can vary substantially across years. Gold standards for clinical decision support are elusive moving targets, reinforcing the need for automated methods that can adapt to evolving information. Prioritizing small amounts of recent data is more effective than using larger amounts of older data towards future clinical predictions. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.
Full Text Available Background: Caring is the core of nursing and should be cultivated in student nurses. However, there are serious concerns about the caring concern in the clinical environment and in nursing education. Clinical instructors are ideally positioned to care for student nurses so that they in turn, can learn to care for their patients. Methods: A descriptive, comparative, cross-sectional and correlational quantitative research design with convenience sampling was conducted to describe the perceptions of junior student nurses (n = 148 and senior student nurses (n = 168 regarding clinicalin structor caring. A structured self administered questionnaire using the Nursing Student Perceptions of Instructor Caring (NSPIC (Wade & Kasper, 2006 was used. Descriptive statistics and hypotheses testing using parametric and non parametric methods were conducted. The reliability of the NSPIC was determined. Results: Respondents had a positive perception of their clinical instructors' caring. No relationship could be found between the course the respondents were registered for, the frequency of contact with a clinical instructor, the ages of the respondents and their perceptions of clinical instructor caring. The NSPIC was found to be reliable if one item each from two of the subscales were omitted. Conclusions: Student nurses perceived most strongly that a caring clinical instructor made them feel confident, specifically when he/she showed genuine interest in the patients and their care, and when he/she made them feel that they could be successful.
George R Bergus
Full Text Available George R Bergus1–3, Jerold C Woodhead4, Clarence D Kreiter2,51Performance Based Assessment Program, Office of Student Affairs and Curriculum, 2Department of Family Medicine, 3Department of Psychiatry, 4Department of Pediatrics, 5Office of Consultation and Research in Medical Education, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, IA, USAIntroduction: The Objective Structured Clinical Examination (OSCE is widely used to assess the clinical performance of medical students. However, concerns related to cost, availability, and validity, have led educators to investigate alternatives to the OSCE. Some alternatives involve assessing students while they provide care to patients – the mini-CEX (mini-Clinical Evaluation Exercise and the Long Case are examples. We investigated the psychometrics of systematically observed clinical encounters (SOCEs, in which physicians are supplemented by lay trained observers, as a means of assessing the clinical performances of medical students.Methods: During the pediatrics clerkship at the University of Iowa, trained lay observers assessed the communication skills of third-year medical students using a communication checklist while the students interviewed and examined pediatric patients. Students then verbally presented their findings to faculty, who assessed students’ clinical skills using a standardized form. The reliability of the combined communication and clinical skills scores was calculated using generalizability theory.Results: Fifty-one medical students completed 199 observed patient encounters. The mean combined clinical and communication skills score (out of a maximum 45 points was 40.8 (standard deviation 3.3. The calculated reliability of the SOCE scores, using generalizability theory, from 10 observed patient encounters was 0.81. Students reported receiving helpful feedback from faculty after 97% of their observed clinical encounters.Conclusion: The SOCE can
Blain, Elizabeth A; Craig, Timothy J
Elizabeth A Blain, Timothy J CraigPenn State Hershey Medical Center, Hershey, PA, USAObjective: To determine the use of spirometry in family practice, internal medicine, and pediatric outpatient settings.Methods: Data were collected from 45 outpatient offices in the central Pennsylvania area via phone survey that asked a set of four questions: 1) Do you have spirometry in your office? 2) Do you use spirometry for asthma patients? 3) In what situation do you use spirometry for? 4) Do you use s...
Chad S. Kessler
Full Text Available Introduction: The goal of this study was to characterize current practices in the transition of care between the emergency department and primary care setting, with an emphasis on the use of the electronic medical record (EMR. Methods: Using literature review and modified Delphi technique, we created and tested a pilot survey to evaluate for face and content validity. The final survey was then administered face-to-face at eight different clinical sites across the country. A total of 52 emergency physicians (EP and 49 primary care physicians (PCP were surveyed and analyzed. We performed quantitative analysis using chi-square test. Two independent coders performed a qualitative analysis, classifying answers by pre-defined themes (inter-rater reliability > 80%. Participants’ answers could cross several pre-defined themes within a given question. Results: EPs were more likely to prefer telephone communication compared with PCPs (30/52 [57.7%] vs. 3/49 [6.1%] P < 0.0001, whereas PCPs were more likely to prefer using the EMR for discharge communication compared with EPs (33/49 [67.4%] vs. 13/52 [25%] p < 0.0001. EPs were more likely to report not needing to communicate with a PCP when a patient had a benign condition (23/52 [44.2%] vs. 2/49 [4.1%] p < 0.0001, but were more likely to communicate if the patient required urgent follow-up prior to discharge from the ED (33/52 [63.5%] vs. 20/49 [40.8%] p = 0.029. When discussing barriers to effective communication, 51/98 (52% stated communication logistics, followed by 49/98 (50% who reported setting/environmental constraints and 32/98 (32% who stated EMR access was a significant barrier. Conclusion: Significant differences exist between EPs and PCPs in the transition of care process. EPs preferred telephone contact synchronous to the encounter whereas PCPs preferred using the EMR asynchronous to the encounter. Providers believe EP-to-PCP contact is important for improving patient care, but report varied
Johnson, Jennifer Leigh; Beard, Joyce; Evans, Dena
Annually, over 80,000 refugees enter the United States as a result of political or religious persecution. Of these, approximately 35% to 40% are children and adolescents. Refugees are faced with challenges associated with living conditions, cultural and social norms, and socioeconomic status due to problems occurring in their homelands. These challenges include but are not limited to malnutrition, communicable disease, questionable immunization status, lack of formal education, sexual abuse, violence, torture, human trafficking, homelessness, poverty, and a lack of access to health care. Moreover, the psychological impact of relocation and the stress of acculturation may perpetuate many of these existing challenges, particularly for refugee youth, with limited or underdeveloped coping skills. School nurses are uniquely poised to support refugee youth in the transition process, improve overall health, and facilitate access to primary health services. The purpose of this article is to provide an overview of the unique refugee experience, examine the key health care needs of the population, and present school nurses with timely and relevant resources to assist in caring for refugee youth.
Moore Ainsley E
Full Text Available Abstract The World Health Organization has recently added Interprofessional Education (IPE to its global health agenda recognizing it as a necessary component of all health professionals' education. We suggest mandatory interprofessional shadowing experiences as a mechanism to be used by chiropractic institutions to address this agenda. IPE initiatives of other professions (pharmacy and medicine are described along with chiropractic. This relative comparison of professions local to our jurisdiction in Ontario, Canada is made so that the chiropractic profession may take note that they are behind other health care providers in implementing IPE. Interprofessional shadowing experiences would likely take place in a multi-disciplinary clinical setting. We offer an example of how two separate professions within a Family Health Team (FHT can work together in such a setting to enhance both student learning and patient care. For adult learners, using interprofessional shadowing experiences with learner-derived and active objectives across diverse health professional groups may help to improve the educational experience. Mandatory interprofessional shadowing experiences for chiropractors during their training can enhance future collaborative practice and provide success in reaching a goal common to each profession - improved patient care.
ClinicalKey is a new point-of-care resource for health care professionals. Through controlled vocabulary, ClinicalKey offers a cross section of resources on diseases and procedures, from journals to e-books and practice guidelines to patient education. A sample search was conducted to demonstrate the features of the database, and a comparison with similar tools is presented.
Campbell, Grace B; Skidmore, Elizabeth R; Whyte, Ellen M; Matthews, Judith T
There is a shortage of published empirical studies conducted in acute inpatient stroke rehabilitation, though such studies are greatly needed in order to shed light on the most efficacious inpatient stroke rehabilitation interventions. The inherent challenges of inpatient research may dissuade researchers from undertaking this important work. This paper describes our institution's experience devising practical solutions to research barriers in this setting. Through concentrated efforts to overcome research barriers, such as by cultivating collaborative relationships and capitalizing on unanticipated benefits, we successfully facilitated conduct of five simultaneous inpatient stroke studies. Tangible benefits realized include increased effectiveness of research participant identification and enrollment, novel collaborative projects, innovative clinical care initiatives, and enhanced emotional and practical support for patients and their families. We provide recommendations based on lessons learned during our experience, and discuss benefits of this collaboration for our research participants, clinical staff, and the research team.
Mercadante, Sebastiano; Aielli, Federica; Adile, Claudio; Ferrera, Patrizia; Valle, Alessandro; Cartoni, Claudio; Pizzuto, Massimo; Caruselli, Amanda; Parsi, Renato; Cortegiani, Andrea; Masedu, Francesco; Valenti, Marco; Ficorella, Corrado; Porzio, Giampiero
Information regarding sleep disturbances in the population with advanced cancer is meager. To assess the prevalence of sleep disturbances and possible correlations with associated factors in a large number of patients with advanced cancer admitted to different palliative care settings. This was an observational study performed in different settings of palliative care. A consecutive sample of patients with advanced cancer was prospectively assessed for a period of six months. Epidemiological and clinical data, treatments received in the last month, Karnofsky status, Edmonton Symptom Assessment System scores, and concomitant medical treatment were recorded. Patients were administered the Athens Insomnia Scale and the Hospital Anxiety and Depression Scale (HADS). A total of 820 patients were surveyed. Mean age was 69.7 years (SD 12.7), and 429 patients were males. Consistent sleep disturbances (moderate to maximum) were found in 60.8% of patients. Aged patients were less likely to have sleep disturbances, whereas a poor Karnofsky level was significantly associated with sleep problems. Breast, gastrointestinal, head and neck, lung, and prostate cancers were associated with sleep problems. Patients who had a secondary school or undergraduate education had less sleep disturbances. Hormone therapy and use of opioids and corticosteroids were positively associated with sleep disturbances, and there was a positive correlation of HADS-Anxiety and HADS-Depression scores with sleep disturbances. More than 60% of palliative care patients have relevant sleep disturbances. Several factors associated with sleep disorders have been identified and should prompt physicians to make a careful examination and subsequent treatment of these disturbances. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Bender, Miriam; Spiva, LeeAnna; Su, Wei; Hites, Lisle
To determine the power of a conceptual clinical nurse leader practice model to explain the care model's enactment and trajectory in real world settings. How nursing, organised into specific models of care, functions as an organisational strategy for quality is not well specified. Clinical nurse leader integrated care delivery is one emerging model with growing adoption. A recently validated clinical nurse leader practice model conceptualizes the care model's characteristics and hypothesizes their mechanisms of action. Pattern matching case study design and mixed methods were used to determine how the care model's constructs were operationalized in one regional United States health system that integrated clinical nurse leaders into their care delivery system in 2010. The findings confirmed the empirical presence of all clinical nurse leader practice model constructs and provided a rich description of how the health system operationalized the constructs in practice. The findings support the hypothesized model pathway from Clinical Nurse Leader structuring to Clinical Nurse Leader practice and outcomes. The findings indicate analytic generalizability of the clinical nurse leader practice model. Nursing practice organised to focus on microsystem care processes can catalyse multidisciplinary engagement with, and consistent enactment of, quality practices. The model has great potential for transferability across diverse health systems. © 2018 John Wiley & Sons Ltd.
Grant, Julian; Lines, Lauren; Darbyshire, Philip; Parry, Yvonne
This scoping review explores the work of nurse practitioners in primary health care settings in developed countries and critiques their contribution to improved health outcomes. A scoping review design was employed and included development of a research question, identification of potentially relevant studies, selection of relevant studies, charting data, collating, summarising and reporting findings. An additional step was added to evaluate the methodological rigor of each study. Data sources included literature identified by a search of electronic databases conducted in September 2015 (CINAHL, Informit, Web of Science, Scopus and Medline) and repeated in July 2016. Additional studies were located through hand searching and authors' knowledge of other relevant studies. 74 articles from eight countries were identified, with the majority emanating from the United States of America. Nurse practitioners working in communities provided care mostly in primary care centres (n=42), but also in community centres (n=6), outpatient departments (n=6), homes (n=5), schools (n=3), child abuse clinics (n=1), via communication technologies (n=6), and through combined face-to-face and communication technologies (n=5). The scope of nurse practitioner work varied on a continuum from being targeted towards a specific disease process or managing individual health and wellbeing needs in a holistic manner. Enhanced skills included co-ordination, collaboration, education, counselling, connecting clients with services and advocacy. Measures used to evaluate outcomes varied widely from physiological data (n=25), hospital admissions (n=10), use of health services (n=15), self-reported health (n=13), behavioural change (n=14), patient satisfaction (n=17), cost savings (n=3) and mortality/morbidity (n=5). The majority of nurse practitioners working in community settings did so within a selective model of primary health care with some examples of nurse practitioners contributing to
Ring, Melinda; Mahadevan, Rupa
Integrative Medicine has been described as "healing oriented medicine that takes account of the whole person (body, mind, and spirit) including all aspects of lifestyle. It emphasizes therapeutic relationships and makes use of all appropriate therapies, both conventional and alternative." National surveys consistently report that approximately one-third of adults and 12% of children use complementary and integrative medicine approaches. Although there are barriers to primary care professionals engaging in discussions about lifestyle change and complementary and integrative medicine options, there is also great potential to impact patient well-being. Copyright © 2017 Elsevier Inc. All rights reserved.
Neves, Marilia G; Leanza, Francesco
The primary care setting is considered the entry point of adolescents with mental illness in the health care system. This article informs primary care providers about the diagnostic features and differential of mood disorders in adolescents, screening and assessment, as well as evidence-based psychosocial and psychopharmacologic therapies. The article also provides a framework for decision making regarding initiating treatment in the primary care setting and referral to mental health services. Furthermore, the article highlights the importance of the collaboration between primary care and mental health providers to facilitate engagement of adolescents with mood disorders and adherence to treatment. Copyright © 2014 Elsevier Inc. All rights reserved.
Full Text Available The burden of neurological disorders is high in developing countries. Real life data from neurologists as to how they practice in Thailand are limited in literature. Practices of neurologists in a university hospital clinical setting in Thailand were studied. A prospective study was performed at the ambulatory neurology clinic, Khon Kaen University Hospital, between 1 February and 31 October 2009. The following data were recorded: numbers of patients, characteristics of patients, consultation notes, and time spent for each patient. There were three neurologists, each of whom ran one afternoon clinic, once a week. There were 6137 visits during the 9 months, with an average of 681 visits per month. The total number of patients was 2834. The three most common diseases were cerebrovascular diseases (33%, epilepsy (16%, and movement disorders (non-Parkinson’s disease, 12%. Neurologists spent an average of 6.34 minutes per patient. In conclusion, neurologists in medical schools have limited time to take care of each patient. Several strategies are needed in medical education and neurology training to improve the quality of care.
Prochaska, John D; Mier, Nelda; Bolin, Jane N; Hora, Kerrie L; Clark, Heather R; Ory, Marcia G
Many recommended best practices exist for clinical and community diabetes management and prevention. However, in many cases, these recommendations are not being fully utilized. It is useful to gain a sense of currently utilized and needed practices when beginning a partnership building effort to ameliorate such practice problems. The purpose of this study was to assess current practices in clinical settings within the Brazos Valley in preparation for beginning a community-based participatory research project on improving diabetes prevention and management in this region. Fifty-seven physicians with admission privileges to a regional health system were faxed a survey related to current diabetes patient loads, knowledge and implementation of diabetes-related best practices, and related topics. Both qualitative and quantitative examination of the data was conducted. Fifteen percent of responding providers indicated they implemented diabetes prevention best practices, with significant differences between primary-care physicians and specialists. Respondents indicated a need for educational and counseling resources, as well as an increased health-care workforce in the region. The utilization of a faxed-based survey proved an effective means for assessing baseline data as well as serving as a catalyst for further discussion around coalition development. Results indicated a strong need for both clinical and community-based services regarding diabetes prevention and management, and provided information and insight to begin focused community dialogue around diabetes prevention and management needs across the region. Other sites seeking to begin similar projects may benefit from a similar process.
Full Text Available Psychiatric and psychosocial disorders among cancer patients have been reported as a major consequence of the disease and treatment. The problems in applying a pure psychiatric approach have determined the need for structuring more defined methods, including screening for distress and emotional symptoms and a more specific psychosocial assessment, to warrant proper care to cancer patients with psychosocial problems. This review examines some of the most significant issues related to these two steps, screening and assessment of psychosocial morbidity in cancer and palliative care. With regard to this , the many different variables, such as the factors affecting individual vulnerability (e.g. life events, chronic stress and allostatic load, well-being, and health attitudes and the psychosocial correlates of medical disease (e.g. psychiatric disturbances, psychological symptoms, illness behavior, and quality of life which are possibly implicated not only in classical psychiatric disorders but more broadly in psychosocial suffering. Multidimensional tools (e.g. and specific psychosocially oriented interview (e.g. the Diagnostic Criteria for Psychosomatic Research - DCPR represent a way to screen for and assess emotional distress, anxiety and depression, maladaptive coping, dysfunctional attachment, as well as other significant psychosocial dimensions secondary to cancer, such as demoralization and health anxiety. Cross-cultural issues, such as language, ethnicity, race, and religion, are also discussed as possible factors influencing the patients and families perception of illness, coping mechanisms, psychological response to a cancer diagnosis.
Andrew M. Harrison
Full Text Available Background Electronic Health Record (EHR-based sepsis alert systems have failed to demonstrate improvements in clinically meaningful endpoints. However, the effect of implementation barriers on the success of new sepsis alert systems is rarely explored. Objective To test the hypothesis time to severe sepsis alert acknowledgement by critical care clinicians in the ICU setting would be reduced using an EHR-based alert acknowledgement system compared to a text paging-based system. Study Design In one arm of this simulation study, real alerts for patients in the medical ICU were delivered to critical care clinicians through the EHR. In the other arm, simulated alerts were delivered through text paging. The primary outcome was time to alert acknowledgement. The secondary outcomes were a structured, mixed quantitative/qualitative survey and informal group interview. Results The alert acknowledgement rate from the severe sepsis alert system was 3% (N = 148 and 51% (N = 156 from simulated severe sepsis alerts through traditional text paging. Time to alert acknowledgement from the severe sepsis alert system was median 274 min (N = 5 and median 2 min (N = 80 from text paging. The response rate from the EHR-based alert system was insufficient to compare primary measures. However, secondary measures revealed important barriers. Conclusion Alert fatigue, interruption, human error, and information overload are barriers to alert and simulation studies in the ICU setting.
O'Neill, Samuel; McAndrew, Darryl J
The assessment of visual acuity is indicated in a number of clinical circumstances. It is commonly conducted through the use of a Snellen wall chart. Mobile technology developments and adoption rates by clinicians may potentially provide more convenient methods of assessing visual acuity. Limited data exist on the validity of these devices and applications. The objective of this study was to evaluate the assessment of distance visual acuity using mobile technology devices against the commonly used 3-metre Snellen chart in a primary care setting. A prospective quantitative comparative study was conducted at a regional medical practice. The visual acuity of 60 participants was assessed on a Snellen wall chart and two mobile technology devices (iPhone, iPad). Visual acuity intervals were converted to logarithm of minimum angle of resolution (logMAR) scores and subjected to intraclass correlation coefficient (ICC) assessment. The results show a high level of general agreement between testing modality (ICC 0.917 with a 95% confidence interval of 0.887-0.940). The high level of agreement of visual acuity results between the Snellen wall chart and both mobile technology devices suggests that clinicians can use this technology with confidence in the primary care setting.
Bai, Jinbing; Hsu, Lily; Zhang, Qing
To translate and evaluate the psychometric properties of the Essentials of Magnetism II tool (EOM II) for Chinese nurses in critical care settings. The EOM II is a reliable and valid scale for measuring the healthy work environment (HWE) for nurses in Western countries, however, it has not been validated among Chinese nurses. The translation of the EOM II followed internationally recognized guidelines. The Chinese version of the Essentials of Magnetism II tool (C-EOM II) was reviewed by an expert panel for culturally semantic equivalence and content validity. Then, 706 nurses from 28 intensive care units (ICUs) affiliated with 14 tertiary hospitals participated in this study. The reliability of the C-EOM II was assessed using the Cronbach's alpha coefficient; the content validity of this scale was assessed using the content validity index (CVI); and the construct validity was assessed using the confirmatory factor analysis (CFA). The C-EOM II showed excellent content validity with a CVI of 0·92. All the subscales of the C-EOM II were significantly correlated with overall nurse job satisfaction and nurse-assessed quality of care. The CFA showed that the C-EOM II was composed of 45 items with nine factors, accounting for 46·51% of the total variance. Cronbach's alpha coefficients for these factors ranged from 0·56 to 0·89. The C-EOM II is a promising scale to assess the HWE for Chinese ICU nurses. Nursing administrators and health care policy-makers can use the C-EOM II to evaluate clinical work environment so that a healthier work environment can be created and sustained for staff nurses. © 2013 British Association of Critical Care Nurses.
Waters, Richard C; Toy, Jennifer M; Drechsler, Adam
Translating clinical evidence to daily practice remains a challenge and may improve with clinical pathways. We assessed interest in and usability of clinical pathways by primary care professionals. An online survey was created. Interest in pathways for patient care and learning was assessed at start and finish. Participants completed baseline questions then pathway-associated question sets related to management of 2 chronic diseases. Perceived pathway usability was assessed using the system usability scale. Accuracy and confidence of answers was compared for baseline and pathway-assisted questions. Of 115 participants, 17.4% had used clinical pathways, the lowest of decision support tool types surveyed. Accuracy and confidence in answers significantly improved for all pathways. Interest in using pathways daily or weekly was above 75% for the respondents. There is low utilization of, but high interest in, clinical pathways by primary care clinicians. Pathways improve accuracy and confidence in answering written clinical questions.
Full Text Available Patients with acute stroke have better outcomes in terms of survival or regaining independence if they receive organized inpatient care in a specific setting (Stroke Unit, SU where a coordinated multidisciplinary team can ensure the best level of care. The clinical governance of an SU requires a systematic monitoring of diagnostic, clinical and therapeutic processes through a structured audit. The entire project and set up of a new SU in Bentivoglio, Italy, were based on a model that focused on multidisciplinary teamwork and clinical governance. An audit based on the Benjamin audit cycle followed every step of the set up of the new SU. Markers from national and international guidelines and from the Italian Regional Audit, together with a specific database were used. The audit showed a high level of care and a significant improvement in the majority of clinical, diagnostic and therapeutic parameters. Only a few markers (i.e. waiting times for ultrasound tomography and prescription of oral anticoagulation therapy required specific projects in order to improve the results. Our experience confirmed that a structured audit can support clinical governance of an SU by monitoring clinical processes and quality of care. Such an audit involves the whole professional team and shows the effects of any single actions. It also helps integration and co-operation among staff. Furthermore, a structured audit is a useful instrument for professional accountability for both qualitative and quantitative aspects of care.
Stribling, Judy C; Richardson, Joshua E
The authors explored the feasibility and possible benefit of tablet-based educational materials for patients in clinic waiting areas. We distributed eight tablets preloaded with diagnosis-relevant information in two clinic waiting areas. Patients were surveyed about satisfaction, usability, and effects on learning. Technical issues were resolved. Thirty-seven of forty patients completed the survey. On average, the patients were satisfied in all categories. Placing tablet-based educational materials in clinic waiting areas is relatively easy to implement. Patients using tablets reported satisfaction across three domains: usability, education, and satisfaction.
Judy C. Stribling, MA, MLS
Full Text Available Objective: The authors explored the feasibility and possible benefit of tablet-based educational materials for patients in clinic waiting areas. Methods: We distributed eight tablets preloaded with diagnosis-relevant information in two clinic waiting areas. Patients were surveyed about satisfaction, usability, and effects on learning. Technical issues were resolved. Results: Thirty-seven of forty patients completed the survey. On average, the patients were satisfied in all categories. Conclusions: Placing tablet-based educational materials in clinic waiting areas is relatively easy to implement. Patients using tablets reported satisfaction across three domains: usability, education, and satisfaction.
Jespersen, Astrid Pernille; Bønnelycke, Julie; Eriksen, Hanne Hellerup
Concern about obesity has prompted numerous public health campaigns that urge people to be more physically active. The campaigns often include normative statements and attempt to impose restrictions on individuals' lives without considering the complexities of daily life. We suggest that broadening...... into different exercise groups. In this article we analyse the scientific work of the trial as representing entangled processes of bodywork, where data are extracted and objectified bodies are manipulated and care practices address the emotional, social and mundane aspects of the participants' everyday lives....... Care practices are an inherent part of producing scientific facts but they are removed from the recognised results of scientific practice and thus from common public health recommendations. However, knowledge about the strategic use of care practices in lifestyle interventions is important for public...
Full Text Available Hemichorea hemiballismus (HCHB is a rare and debilitating presentation of hyperglycemia and subcortical stroke. Early identification, proper assessment and management of HCHB can lead to complete symptom relief. We describe a case of HCHB presenting to a palliative care setting. A 63-year-old diabetic and hypertensive lady, with history of ovarian cancer presented to Palliative Medicine outpatient clinic with two days history of right HCHB. Blood investigations and brain imaging showed high blood sugar levels and lacunar subcortical stroke. Blood sugar levels were controlled with human insulin and Aspirin. Clopidogrel and Atorvastatin were prescribed for the management of lacunar stroke. HCHB reduced markedly post-treatment, leading to significant reduction in morbidity and improvement in quality of life. The symptoms completely resolved within one week of starting the treatment and the patient was kept on regular home and outpatient follow up for further monitoring. Acute palliative care (APC approach deals with the management of comorbidities and their complications along with supportive care. Prompt assessment and management of such complications lead to better patient outcomes.
Alberti, Traci L; Morris, Nancy J
An increasing number of Americans are using urgent care (UC) clinics due to: improved health insurance coverage, the need to decrease cost, primary care offices with limited appointment availability, and a desire for convenient care. Patients are treated by providers they may not know for episodic illness or injuries while in pain or not feeling well. Treatment instructions and follow-up directions are provided quickly. To examine health literacy in the adult UC population and identify patient characteristics associated with health literacy risk. As part of a larger cross-sectional study, UC patients seen between October 2013 and January 2014 completed a demographic questionnaire and the Newest Vital Sign. Descriptive, nonparametric analyses, and a multinomial logistic regression were done to assess health literacy, associated and predictive factors. A total of 57.5% of 285 participants had adequate health literacy. The likelihood of limited health literacy was associated with increased age (p literacy is common in a suburban UC setting, increasing the risk that consumers may not understand vital health information. Clear provider communication and confirmation of comprehension of discharge instructions for self-management is essential to optimize outcomes for UC patients. ©2017 American Association of Nurse Practitioners.
Full Text Available Introduction: The Ramsay Hunt syndrome is characterized by combination of herpes infection and lower motor neuron type of facial nerve palsy. The disease is caused by a reactivation of Varicella Zoster virus and can be unrepresentative since the herpetic lesions may not be always be present (zoster sine herpete and might mimic other severe neurological illnesses. Case Report: A 63-year-old man known case of carcinoma of gall bladder with liver metastases, post surgery and chemotherapy with no scope for further disease modifying treatment, was referred to palliative care unit for best supportive care. He was on regular analgesics and other supportive treatment. He presented to Palliative Medicine outpatient with 3 days history of ipsilateral facial pain of neuropathic character, otalgia, diffuse vesciculo-papular rash over ophthalmic and maxillary divisions of left trigeminal nerve distribution of face and ear, and was associated with secondary bacterial infection and unilateral facial edema. He was clinically diagnosed to have Herpes Zoster with superadded bacterial infection. He was treated with tablet Valacyclovir 500 mg four times a day, Acyclovir cream for local application, Acyclovir eye ointment for prophylactic treatment of Herpetic Keratitis, low dose of Prednisolone, oral Amoxicillin and Clindamycin for 7 days, and Pregabalin 150 mg per day. After 7 days of treatment, the rash and vesicles had completely resolved and good improvement of pain and other symptoms were noted. Conclusion: Management of acute infections and its associated complications in an acute palliative care setting improves both quality and length of life.
Kim, Seon-Young; Kim, Jae-Min; Kim, Sung-Wan; Kang, Hee-Ju; Shin, Il-Seon; Shim, Hyun-Jeong; Cho, Sang-Hee; Chung, Ik-Joo; Yoon, Jin-Sang
This study investigated the determinants of a hopeful attitude among family caregivers involved with palliative care. We investigated a broad range of factors for the patient-family dyad in a palliative care setting using a cross-sectional design. The patients' sociodemographic, clinical and psychological factors were evaluated, as well as caregiver-related sociodemographic and psychological factors, including depressive symptoms, burden, coping style and religiosity. Caregivers were divided into two groups based on a hopeful or nonhopeful attitude and assessed using the abbreviated version of the seven-item Beck Hopelessness Scale (BHS-7). Of 304 analyzed dyads, 210 (69.1%) caregivers showed a hopeful attitude, with a BHS-7 score of 0. The adjusted logistic regression analyses showed that caregivers' hopeful attitude was determined by only their psychological status: less depressive symptoms [odds ratio (OR), 0.86; 95% confidence interval (CI), 0.83-0.90], active coping strategy (OR, 1.12; 95% CI, 1.07-1.18) and lower burden (OR, 0.93; 95% CI, 0.88-0.99). In a subpopulation analysis (n=200), higher religiosity was a significantly associated factor. Healthcare providers need to pay attention to the psychological vulnerability of caregivers to encourage a hopeful attitude. Additional studies of longitudinal design for hopeful attitude throughout the trajectory of palliative care are necessary. Copyright © 2014 Elsevier Inc. All rights reserved.
Montano, C Brendan; Rasgon, Natalie L; Herman, Barry K
Binge eating disorder (BED), now recognized as a distinct eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is the most prevalent eating disorder. Although nearly half of individuals with BED are obese, BED also occurs in nonobese individuals. Despite the relatively high percentage of weight loss treatment-seeking individuals meeting BED criteria, primary care physicians may not be familiar with or have ever diagnosed BED. Many providers may also have difficulty distinguishing BED as a contributory factor in obesity. This review differentiates BED from other causes of obesity by describing how obese individuals with BED differ from obese individuals without BED and from nonobese individuals with BED in areas including psychopathology, behavior, genetics, physiology, quality of life and productivity. The ways in which health-care providers can identify individuals who may have BED are also highlighted so the proper course of treatment is pursued. Overall, obese individuals with BED demonstrate a number of key characteristics that differentiate them from obese individuals without eating disorders, including increased impulsivity in response to food stimuli with loss of control over eating, resulting in the consumption of more calories. They also experience significant guilt and other negative emotions following a meal. In addition, individuals with BED patients have more psychiatric comorbidity, display more psychopathology, exhibit longer binge durations, consume more meals as snacks during the day and have less dietary restraint compared with individuals with BED who are not obese. However, the differences between individuals with BED who are obese versus not obese are not as prominent. Taken together, the evidence appears to support the conclusion that BED is a unique and treatable neurobehavioral disorder associated with distinct behavioral and psychological profiles and distinct medical and functional outcomes, and that
Sarabia-Cobo, Carmen María; Alconero-Camarero, Ana Rosa; Lavín-Alconero, Lucía; Ibáñez-Rementería, Isabel
Major deficiencies exist in undergraduate nursing education for Palliative Care. Opportunities to care for dying patients are often unavailable to students in traditional clinical settings. Palliative care simulation is an innovative strategy that may help to prepare undergraduate nursing students to provide quality palliative/end of life care. It is valuable to explore the student nurses' beliefs, feelings and satisfaction regarding the impact that simulation clinic applied to palliative care has and how it influenced their overall experience of caring for a dying patient and the patient's family. This study aimed to evaluate a learning intervention in palliative care using a low-fidelity clinical simulation for undergraduate nursing students from a Spanish university, based on the analytics of their expectations and learning objectives. Sixty-eight students participated in this mixed descriptive design study, they participated in a palliative care simulation scenario and completed three questionnaires which assess the knowledge and expectations before the simulation and the subsequent satisfaction with the performance and learning received. The intervention in question met students' learning expectations, singling out social abilities as important tools in palliative care training, and the students were satisfied with the presented case studies. Our results suggest that low-fidelity clinical simulation intervention training in palliative care is an appropriate and low-cost tool for acquiring competitive skills. Learning in the simulation scenarios provides a mechanism for students to improve student communication skills. Copyright © 2016 Elsevier Ltd. All rights reserved.
Cornelissen, Evelyn; Mitton, Craig; Davidson, Alan; Reid, Colin; Hole, Rachelle; Visockas, Anne-Marie; Smith, Neale
Purpose - Program budgeting and marginal analysis (PBMA) is a priority setting approach that assists decision makers with allocating resources. Previous PBMA work establishes its efficacy and indicates that contextual factors complicate priority setting, which can hamper PBMA effectiveness. The purpose of this paper is to gain qualitative insight into PBMA effectiveness. Design/methodology/approach - A Canadian case study of PBMA implementation. Data consist of decision-maker interviews pre (n=20), post year-1 (n=12) and post year-2 (n=9) of PBMA to examine perceptions of baseline priority setting practice vis-à-vis desired practice, and perceptions of PBMA usability and acceptability. Findings - Fit emerged as a key theme in determining PBMA effectiveness. Fit herein refers to being of suitable quality and form to meet the intended purposes and needs of the end-users, and includes desirability, acceptability, and usability dimensions. Results confirm decision-maker desire for rational approaches like PBMA. However, most participants indicated that the timing of the exercise and the form in which PBMA was applied were not well-suited for this case study. Participant acceptance of and buy-in to PBMA changed during the study: a leadership change, limited organizational commitment, and concerns with organizational capacity were key barriers to PBMA adoption and thereby effectiveness. Practical implications - These findings suggest that a potential way-forward includes adding a contextual readiness/capacity assessment stage to PBMA, recognizing organizational complexity, and considering incremental adoption of PBMA's approach. Originality/value - These insights help us to better understand and work with priority setting conditions to advance evidence-informed decision making.
Ida Torunn Bjørk; Glenys A. Hamilton
This study analyzed nurses' perceptions of clinical decision making (CDM) in their clinical practice and compared differences in decision making related to nurse demographic and contextual variables. A cross-sectional survey was carried out with 2095 nurses in four hospitals in Norway. A 24-item Nursing Decision Making Instrument based on cognitive continuum theory was used to explore how nurses perceived their CDM when meeting an elective patient for the first time. Data were analyzed with d...
Kim, J; Arrandale, V H; Kudla, I; Mardell, K; Lougheed, D; Holness, D L
Farmers are at increased risk of developing work-related respiratory diseases including asthma, but little is known about their occupational health and safety (OHS) knowledge and exposure prevention practices. Educational interventions may improve knowledge and practice related to prevention. To determine the feasibility of an educational intervention for farmers in a community health centre setting. This was a pilot study. Farmers were recruited by the community health centre and completed a questionnaire on symptoms, OHS knowledge and exposure prevention practices. The intervention group received education on work-related asthma and exposure control strategies, and was offered spirometry and respirator fit testing. All subjects were asked to repeat the questionnaire 6 months later. There were 68 study participants of whom 38 formed the intervention group. At baseline, almost 60% of farmers reported having received OHS training and were familiar with material safety data sheets (MSDSs); fewer (approximately 40%) reported knowledge of OHS legislation and availability of MSDSs. Approximately, two-thirds of subjects reported using respiratory protection. The response rate for repeating the questionnaire was 76% in the intervention group and 77% in the controls. Among the intervention subjects, statistically significant increases were observed in reported safety training, familiarity and availability of MSDSs and knowledge of OHS legislation. Gaps in OHS knowledge were observed. The educational intervention on OHS knowledge and exposure prevention practices in the community health centre setting was feasible. Larger, more-controlled studies should be undertaken as this study suggests a positive effect on OHS knowledge and prevention practices.
Van Baalen, Mary; Mason, Sara S.; Taiym, Wafa; Wear, Mary L.; Moynihan, Shannan; Alexander, David; Hart, Steve; Tarver, William
Prior to 2010, several ISS crewmembers returned from spaceflight with changes to their vision, ranging from a mild hyperopic shift to frank disc edema. As a result, NASA expanded clinical vision testing to include more comprehensive medical imaging, including Optical Coherence Tomography and 3 Tesla Brain and Orbit MRIs. The Space and Clinical Operations (SCO) Division developed a clinical practice guideline that classified individuals based on their symptoms and diagnoses to facilitate clinical care. For the purposes of clinical surveillance, this classification was applied retrospectively to all crewmembers who had sufficient testing for classification. This classification is also a tool that has been leveraged for researchers to identify potential risk factors. In March 2014, driven in part by a more comprehensive understanding of the imaging data and increased imaging capability on orbit, the SCO Division revised their clinical care guidance to outline in-flight care and increase post-flight follow up. The new clinical guidance does not include a classification scheme
Full Text Available Robert McSherry,1 Paddy Pearce2 1School of Health and Social Care, University of Teesside, Middlesbrough, 2PKP Consulting, Yarm, United Kingdom Abstract: The presence and/or absence of effective leaders in health care can have a stark consequence on the quality and outcomes of care. The delivery of safe, quality, compassionate health care is dependent on having effective clinical leaders at the frontline. In light of the Kirkup and Francis reports, this article explores some ways of translating clinical leadership into health care quality improvement. This is achieved by exploring what is clinical leadership and why and how this is important to health care quality improvement, clinical leadership, and a duty of candor, along with the importance clinical leadership plays in the provision of quality care improvement and outcomes. Clinical leaders are not predefined roles but emerge from the complex clinical setting by gaining an acquired expertise and from how they then internalize this to develop and facilitate sound relationships within a team. Clinical leaders are effective in facilitating innovation and change through improvement. This is achieved by recognizing, influencing, and empowering individuals through effective communication in order to share and learn from and with each other in practice. The challenge for health care organizations in regard to creating organizational cultures where a duty of candor exists is not to reinvent the wheel by turning something that is simple into something complex, which can become confusing to health care workers, patients, and the public. By focusing on the clinical leader's role and responsibilities we would argue they play a crucial and pivotal role in influencing, facilitating, supporting, and monitoring that this duty of candor happens in practice. This may be possible by highlighting where and how the duty of candor can be aligned within existing clinical governance frameworks. Keywords: governance
Gulmans, J.; Gulmans, J.; Vollenbroek-Hutten, Miriam Marie Rosé; van Gemert-Pijnen, Julia E.W.C.; van Harten, Willem H.
Objective. In this study, we evaluated patient care communication in the integrated care setting of children with cerebral palsy in three Dutch regions in order to identify relevant communication gaps experienced by both parents and involved professionals. - Design. A three-step mixed method
Neergaard, Mette Asbjørn; Olesen, Frede; Jensen, Anders Bonde
care setting to explore barriers and facilitators for delivery of good palliative home care. Methods: Three focus group interviews with fourteen bereaved relatives in Aarhus County, Denmark. Results: Three main categories of experience were identified: 1) The health professionals' management, where...
Jabbour, Mona; Curran, Janet; Scott, Shannon D; Guttman, Astrid; Rotter, Thomas; Ducharme, Francine M; Lougheed, M Diane; McNaughton-Filion, M Louise; Newton, Amanda; Shafir, Mark; Paprica, Alison; Klassen, Terry; Taljaard, Monica; Grimshaw, Jeremy; Johnson, David W
The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways. We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process
Rojas, Natalia; Laguë-Beauvais, Maude; Belisle, Arielle; Lamoureux, Julie; AlSideiri, Ghusn; Marcoux, Judith; Maleki, Mohammed; Alturki, Abdulrahman Y; Anchouche, Sonia; Alquraini, Hanan; Feyz, Mitra; Guise, Elaine de
The Frontal Assessment Battery (FAB) has been shown to be useful in several clinical settings. The aim of the present study was to examine the performance of patients with traumatic brain injury (TBI) on the FAB and to predict their acute outcome. The FAB was administered to 89 patients with mild (27 = uncomplicated and 39 = complicated) and moderate (n = 23) TBI during hospitalization in an acute care setting. The length of stay in days (LOS), Glasgow Outcome Scale-Revised score (GOSE) and Disability Rating Scale (DRS) score were collected. Results showed no significant differences between the three groups on the FAB score, but age and education were significantly associated with the FAB score. Parietal lesions were associated with lower total FAB score, and with the Similarities, Motor series and Conflicting instructions subscales, while frontal lesions were associated with lower performance on the Motor series and Conflicting instructions subscales. Total FAB score was significantly correlated with all outcome measures, and together the FAB total score and the Glasgow Coma Scale (GCS) score explained 30.8% of the variance in the DRS score. The FAB may be useful clinically to acutely assess frontal and parietal lobe functions at bedside in patients with TBI and, in combination with the GCS score to measure TBI severity, can enable clinicians to predict early outcome.
Davey, Christopher J; Slade, Sarah V; Shickle, Darren
To identify a minimum list of metrics of international relevance to public health, research and service development which can be extracted from practice management systems and electronic patient records in primary optometric practice. A two stage modified Delphi technique was used. Stage 1 categorised metrics that may be recorded as being part of a primary eye examination by their importance to research using the results from a previous survey of 40 vision science and public health academics. Delphi stage 2 then gauged the opinion of a panel of seven vision science academics and achieved consensus on contentious metrics and methods of grading/classification. A consensus regarding inclusion and response categories was achieved for nearly all metrics. A recommendation was made of 53 metrics which would be appropriate in a minimum data set. This minimum data set should be easily integrated into clinical practice yet allow vital data to be collected internationally from primary care optometry. It should not be mistaken for a clinical guideline and should not add workload to the optometrist. A pilot study incorporating an additional Delphi stage prior to implementation is advisable to refine some response categories. © 2017 The Authors. Ophthalmic and Physiological Optics published by John Wiley & Sons Ltd on behalf of College of Optometrists.
Wilson, Jo Ellen; Nian, Hui; Heckers, Stephan
The term schizoaffective was introduced to describe the co-occurrence of both psychotic and affective symptoms. Overtime, as the diagnosis schizoaffective disorder was added to diagnostic manuals, significant concerns were raised as to the reliability and clinical utility of the diagnosis. We recruited 134 psychiatrically hospitalized subjects who had received a diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder with psychotic features by their treating clinician. The subjects were also diagnosed by trained research personnel with the Structured Clinical Interview of the DSM-IV-TR, employing an explicit time threshold for criterion C of the schizoaffective disorder diagnosis. We found significant differences between the clinical and research diagnoses. Clinicians diagnosed 48 patients (36%) with schizophrenia, 50 patients (37%) with schizoaffective disorder and 36 patients (27%) with psychotic bipolar disorder. In contrast, researchers diagnosed 64 patients (48%) with schizophrenia, 38 patients (28%) with schizoaffective disorder and 32 patients (24%) with psychotic bipolar disorder. This was a statistically significant disagreement between the research and clinical diagnoses (p = 0.003) and indicates that clinicians choose the less severe diagnosis for psychotic patients. We conclude that a more stringent criterion C for the schizoaffective disorder diagnosis will address an implicit bias in clinical practice and will affect the prevalence of the psychotic disorder diagnoses.
Rega, Maria Luisa; Diano, Pasquale; Damiani, Gianfranco; De Vito, Corrado; Galletti, Caterina; Talucci, Carlo
To examine the current state of empowerment of nurses in Italy. Empowerment is a broad concept that is also relevant to the field of nursing practice. Its comprehension and use are important because empowerment allows nurses to take control of their own practice. A clear understanding of empowerment is necessary for nurses to take advantage of this important tool. Focus groups were conducted. A literature review was performed, and two focus groups were selected between January and February 2014. Sixteen nurses participated in the research. Empowerment is seen as being strongly connected to autonomy and is not associated with power, as the word itself suggests. Italian nurses define empowerment as the creation of conditions that help to establish the possibility for people to develop and express their value and potential. Empowerment is defined as a condition in which the individual nurse takes control of his/her own practice and thereby provides awareness and confidence to a group. Italian nurses need to feel appreciated and supported by their own organisations. If warranted, empowerment would allow them to contribute to enhance care, which is the core of the nursing profession. © 2017 John Wiley & Sons Ltd.
Full Text Available Abstract Background Good clinical handover is critical to safe medical care. Little research has investigated handover in rural settings. In a remote setting where nurses and medical students give telephone handover to an aeromedical retrieval service, we developed a tool by which the receiving clinician might assess the handover; and investigated factors impacting on the reliability and validity of that assessment. Methods Researchers consulted with clinicians to develop an assessment tool, based on the ISBAR handover framework, combining validity evidence and the existing literature. The tool was applied ‘live’ by receiving clinicians and from recorded handovers by academic assessors. The tool’s performance was analysed using generalisability theory. Receiving clinicians and assessors provided feedback. Results Reliability for assessing a call was good (G = 0.73 with 4 assessments. The scale had a single factor structure with good internal consistency (Cronbach’s alpha = 0.8. The group mean for the global score for nurses and students was 2.30 (SD 0.85 out of a maximum 3.0, with no difference between these sub-groups. Conclusions We have developed and evaluated a tool to assess high-stakes handover in a remote setting. It showed good reliability and was easy for working clinicians to use. Further investigation and use is warranted beyond this setting.
Elizabeth Wong, MT-BC presents tools and information designed to arm the entry-level music therapist (or an experienced MT-BC new to rehabilitation settings) with basic knowledge and materials to develop or work in a music therapy program treating people with stroke, brain injury, and those who are ventilator dependent. Ms. Wong offers goals and…
GeneXpert in the diagnosis of smear-negative PTB: a case report ... Background: The Xpert MTB/RIF test (GeneXpert) has recently been endorsed for use in resource-limited settings for the ... normochromic anemia (9.2g/dl), hypoalbuminemia.
Sarikaya, Ozlem; Civaner, Murat; Vatansever, Kevser
It is known that interaction between pharmaceutical companies and medical professionals may lead to corruption of professional values, irrational use of medicine, and negative effects on the patient-physician relationship. Medical students frequently interact with pharmaceutical company representatives and increasingly accept their gifts. Considering the move toward early clinical encounters and community-based education, which expose students early to pharmaceutical representatives, the influence of those gifts is becoming a matter of concern. This study examines the frequency and influence of student exposure to drug marketing in primary care settings, as well as student perceptions of physician-pharmaceutical company relationships. This was a two-phase study consisting of qualitative research followed by a cross-sectional survey. Clinical experience logbooks of 280 second-year students in one school were analysed, and the themes that emerged were used to develop a survey that was administered to 308 third-year students from two medical schools. Survey results showed a 91.2% exposure to any type of marketing, and 56.8% of students were exposed to all classes of marketing methods studied. Deliberate targeting of students by pharmaceutical representatives, in particular, was correlated with being less sensitive to the negative effects of and having positive opinions about interactions with pharmaceutical companies. The vast majority of students are exposed to drug marketing in primary care settings, and may become more vulnerable to that strategy. Considering that medical students are vulnerable and are targeted deliberately by pharmaceutical companies, interventions aimed at developing skills in the rational use of medicines and in strategies for coping with drug marketing should be devised.
Harris Katherine I
Full Text Available Abstract Background The increasing prevalence of obesity is a significant health threat and a major public health challenge. A critical need exists to develop and evaluate practical methods for the treatment of obesity in the clinical setting. One of the factors contributing to the obesity epidemic is food portion sizes. Limited data are available on the efficacy of visual or tactile devices designed to enhance patient understanding and control of portion sizes. A portion control plate is a commercially-available product that can provide visual cues of portion size and potentially contribute to weight loss by enhancing portion size control among obese patients. This tool holds promise as a useful adjunct to dietary counseling. Our objective was to evaluate a portion control intervention including dietary counseling and a portion control plate to facilitate weight loss among obese patients in a primary care practice. Findings We randomized 65 obese patients [body mass index (BMI ≥ 30 and vs. -0.5% ± 2.2%; p = 0.041 and a non significant trend in weight change from baseline at 6 months (-2.1% ± 3.8% vs. -0.7% ± 3.7%; p = 0.232 compared with usual care. Nearly one-half of patients assigned to the portion control intervention who completed the study reported the overall intervention was helpful and the majority would recommend it to others. Conclusions Our findings suggest that a portion control intervention incorporating dietary counseling and a portion control plate may be effective for enhancing weight loss among obese subjects. A portion control intervention deserves further evaluation as a weight control strategy in the primary care setting. Trial registration Current controlled trials NCT01451554
McFarland, Marilyn M; Eipperle, Marilyn K
Leininger's Theory of Culture Care Diversity and Universality is presented as a foundational basis for the educational preparation, primary care contextual practice, and outcomes-focused research endeavours of advanced practice nursing. Discussion emphasises the value of care and caring as the essence of advanced practice nursing through the use of three modes of care, use of the Sunrise and other enablers, and the ethnonursing method. Education, research, practice, and key concepts of the theory are connected as essential components toward the provision of culturally congruent care to meet the healthcare needs of diverse individuals, families, groups, and communities by family nurse practitioners.
Grimsmo, Anders; Løhre, Audhild; Røsstad, Tove; Gjerde, Ingunn; Heiberg, Ina; Steinsbekk, Aslak
To explore the feasibility of disease-specific clinical pathways when used in primary care. A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings. Primary care and specialist care collaborating to manage care coordination. Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year. The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting. Key points Clinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs. Patients most frequently admitted to hospitals, i.e. patients with COPD
Davtyan, Mariam; Olshansky, Ellen F; Brown, Brandon; Lakon, Cynthia
Despite progress made in the treatment and care of people living with HIV (PLWH), HIV-related stigma has remained persistent. Health care settings and workers have been identified as important sources of stigma. Studies have addressed the construct of stigma in U.S. health care settings, but mainly from the perspectives of PLWH. We used Grounded Theory to understand how health care workers conceptualized HIV-related stigma and to develop a model to project a purposive view of stigma in health care settings. Our model indicates that stigma may be rooted in historically derogatory representations of HIV and intensified by power inequalities. Stigma may be triggered by fear, inadequate clinical education and training, unintentional behaviors, and limited contact with PLWH. Study participants perceived stigma as injurious to patient and provider health outcomes. Additional research on provider perceptions of stigma and programs that encourage empowerment, communication, and training may be necessary for stigma reduction. Copyright © 2017 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.
Bosma, Liesbeth; Jansman, Frank G. A.; Franken, Anton M.; Harting, Johannes W.; Van den Bemt, Patricia M. L. A.
Objective Assessing the relevance of a clinically active pharmacist method compared to the traditional working method. Method The study was carried out in a general internal/gastro-enterology unit during two 8-weeks periods in 2004. It was an observational, non-randomized prospective study. Outcome
Conclusion: In conclusion, this study inferred that among patients with relatively higher magnitude of astigmatism attending to the clinics in Maldives, younger patients are affected more, which could possibly link to the environment, genetics and nutrition. The probable association between nutrition and astigmatism needs to be investigated to fill the gap in literature.
Tharek, Zahirah; Ramli, Anis Safura; Whitford, David Leonard; Ismail, Zaliha; Mohd Zulkifli, Maryam; Ahmad Sharoni, Siti Khuzaimah; Shafie, Asrul Akmal; Jayaraman, Thevaraajan
Self-efficacy has been shown to be positively correlated with self-care behaviour and glycaemic control among patients with type 2 diabetes mellitus. However, such evidence is lacking in the Malaysian primary care setting. The objectives of this study were to i) determine the levels of self-efficacy, self-care behaviour and glycaemic control among patients with type 2 diabetes mellitus in the Malaysian primary care setting ii) determine the relationship between self-efficacy, self-care behaviour and glycaemic control iii) determine the factors associated with glycaemic control. This was a cross-sectional study involving patients with type 2 diabetes mellitus from two public primary care clinics in Malaysia. Self-efficacy and self-care behaviour levels were measured using previously translated and validated DMSES and SDSCA questionnaires in Malay versions, respectively. Glycaemic control was measured using HbA 1c. RESULTS: A total of 340 patients with type 2 diabetes mellitus were recruited. The total mean (±SD) of self-efficacy and self-care behaviour scores were 7.33 (±2.25) and 3.76 (±1.87), respectively. A positive relationship was found between self-efficacy and self-care behaviour (r 0.538, P self-efficacy score was shown to be correlated with lower HbA 1c (r - 0.41, P self-efficacy scores (b - 0.398; 95% CI: -0.024, - 0.014; P diabetes (b 0.177; 95% CI: 0.002, 0.007; P self-efficacy was correlated with improved self-care behaviour and better glycaemic control. Findings of this study suggest the importance of including routine use of self-efficacy measures in the management of type 2 diabetes mellitus in primary care.
Background In response to the increasing demand for better chronic disease management and improved health care efficiency in Ontario, nursing roles have expanded in the primary health care setting. Objectives To determine the effectiveness of specialized nurses who have a clinical role in patient care in optimizing chronic disease management among adults in the primary health care setting. Data Sources and Review Methods A literature search was performed using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database. Results were limited to randomized controlled trials and systematic reviews and were divided into 2 models: Model 1 (nurse alone versus physician alone) and Model 2 (nurse and physician versus physician alone). Effectiveness was determined by comparable outcomes between groups in Model 1, or improved outcomes or efficiency in Model 2. Results Six studies were included. In Model 1, there were no significant differences in health resource use, disease-specific measures, quality of life, or patient satisfaction. In Model 2, there was a reduction in hospitalizations and improved management of blood pressure and lipids among patients with coronary artery disease. Among patients with diabetes, there was a reduction in hemoglobin A1c but no difference in other disease-specific measures. There was a trend toward improved process measures, including medication prescribing and clinical assessments. Results related to quality of life were inconsistent, but patient satisfaction with the nurse-physician team was improved. Overall, there were more and longer visits to the nurse, and physician workload did not change. Limitations There was heterogeneity across patient populations, and in the titles, roles, and scope of practice of the specialized nurses. Conclusions Specialized nurses with
Nomura, Kyoko; Ohno, Maiko; Fujinuma, Yasuki; Ishikawa, Hirono
To investigate autonomy preferences and the factors to promote active patient participation in a primary care setting in Japan. Ninety-two hypertensive outpatients who consecutively visited a Japanese hospital between January and May of 2005 in Tokyo, Japan. This cross-sectional study was conducted by using a self-administered questionnaire. The main outcome measures were patient preferences for autonomy (i.e., decision-making and information-seeking preferences), measured by the Autonomy Preference Index (API). The variables studied were patient sociodemographic characteristics, physician characteristics based on patient preference (i.e., ability to communicate, extent of clinical experience, qualifications, educational background, gender, and age), and the Multidimensional Health Locus of Control. On the API scale from 0 to 100, the patients had an intermediate desire for decision-making (median: 51) and a greater desire for information (median: 95). A multivariate regression model indicated that decision-making preference increased when patients were woman and decreased as physician age increased, and information-seeking preference was positively associated with good communication skills, more extensive clinical experience, physicians of middle age, and patient beliefs that they were responsible for their own health, and was negatively associated with a preference for man physicians. Physicians may need to understand that patient autonomy preferences pertain to physician age and gender, physician communication ability and extent of clinical experience, and patient beliefs about self-responsibility toward health, and could use the information to promote reliable patient-physician relationships.
Tursi, Antonio; Elisei, Walter; Picchio, Marcello
The incidence of inflammatory bowel diseases (IBDs) has markedly increased over the last years, but no epidemiological study has been performed in gastroenterology primary care setting. We describe the epidemiology of IBD in a gastroenterology primary care unit using its records as the primary data source. Case finding used predefined read codes to systematically search computer diagnostic and prescribing records from January 2009 to December 2012. A specialist diagnosis of Ulcerative colitis (UC), Crohn's disease (CD), inflammatory bowel disease unclassified (IBDU) or segmental colitis associated with diverticulosis (SCAD), based on clinical, histological or radiological findings, was a prerequisite for the inclusion in the study. Secondary, infective and apparent acute self-limiting colitis were excluded. We identified 176 patients with IBD in a population of 94,000 with a prevalence 187.2/100,000 (95% CI: 160.6-217.0). Between 2009 and 2012 there were 61 new cases. In particular, there were 23 new cases of UC, 19 new cases of CD, 15 new cases of SCAD, and 4 new cases of IBDU. The incidence of IBD was 16.2/100,000 (95% CI 12.5-20.7) per year. The incidence per year was 6/100,000 (95% CI 3.8 to 8.9) for UC, 5/100,000 (95% CI 3.0-7.7) for CD, 4/100,000 (95% CI 2.3-6.5) for SCAD, and 1/100,000 (95% CI 0.3-2.6) for IBDU. We assessed for the first time which is the prevalence and incidence of IBD in a gastroenterology primary care unit. This confirms that specialist primary care unit is a key factor in providing early diagnosis of chronic diseases. Copyright © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
McSherry, Robert; Pearce, Paddy
The presence and/or absence of effective leaders in health care can have a stark consequence on the quality and outcomes of care. The delivery of safe, quality, compassionate health care is dependent on having effective clinical leaders at the frontline. In light of the Kirkup and Francis reports, this article explores some ways of translating clinical leadership into health care quality improvement. This is achieved by exploring what is clinical leadership and why and how this is important to health care quality improvement, clinical leadership, and a duty of candor, along with the importance clinical leadership plays in the provision of quality care improvement and outcomes. Clinical leaders are not predefined roles but emerge from the complex clinical setting by gaining an acquired expertise and from how they then internalize this to develop and facilitate sound relationships within a team. Clinical leaders are effective in facilitating innovation and change through improvement. This is achieved by recognizing, influencing, and empowering individuals through effective communication in order to share and learn from and with each other in practice. The challenge for health care organizations in regard to creating organizational cultures where a duty of candor exists is not to reinvent the wheel by turning something that is simple into something complex, which can become confusing to health care workers, patients, and the public. By focusing on the clinical leader's role and responsibilities we would argue they play a crucial and pivotal role in influencing, facilitating, supporting, and monitoring that this duty of candor happens in practice. This may be possible by highlighting where and how the duty of candor can be aligned within existing clinical governance frameworks.
McKneally, Martin F.; Singer, Peter A.
BIOETHICS IS NOW TAUGHT IN EVERY CANADIAN MEDICAL SCHOOL. Canada needs a cadre of teachers who can help clinicians learn bioethics. Our purpose is to encourage clinician teachers to accept this important responsibility and to provide practical advice about teaching bioethics to clinicians as an integral part of good clinical medicine. We use 5 questions to focus the discussion: Why should I teach? What should I teach? How should I teach? How should I evaluate? How should I learn? PMID:11338804
McIlfatrick, Sonja; Connolly, Michael; Collins, Rita; Murphy, Tara; Johnston, Bridget; Larkin, Philip
To evaluate a dignity care intervention provided by community nurses seeking to address dignity concerns for people with advanced and life-limiting conditions. Evidence would suggest that dying people fear a loss of dignity and a central focus of palliative care is to assist people to die with dignity. Whilst community nurses have a key role to play in the delivery of palliative care, specific interventions for dignity are lacking. A mixed methods study using online survey and focus group interviews and thematic analysis to examine data. Twenty four community nurses implemented the dignity care intervention for people with advanced and life-limiting conditions were recruited from four pilot sites across Ireland. Four focus group interviews and on line survey were conducted between March-June 2015. The community nurses found the dignity care intervention useful. It helped the nurses to provide holistic end-of-life care and assisted in the overall assessment of palliative care patients, identifying areas that might not otherwise have been noted. Whilst it was a useful tool for communication, they noted that it stimulated some emotionally sensitive conversations for which they felt unprepared. Implementing the dignity care intervention in practice was challenging. However, the dignity care intervention facilitated holistic assessment and identified patient dignity-related concerns that may not have been otherwise identified. Further support is required to overcome barriers and enable dignity-conserving care. Ensuring dignity is a key aspect of palliative and end-of-life care; however, community nurses may not feel equipped to address this aspect of care. Implementing a dignity care intervention can assist in identifying patient dignity-related concerns and provision of holistic care. Community nurses need more training to assist in difficult conversations relating to dignity and end-of-life care. © 2017 John Wiley & Sons Ltd.
There is mounting public awareness of an increasing number of adverse clinical incidents within the National Health Service (NHS), but at the same time, large health care projects like the National Programme for IT (NPFIT) are claiming that safer care is one of the benefits of the project and that health software systems in particular have the potential to reduce the likelihood of accidental or unintentional harm to patients. This paper outlines the approach to clinical safety management taken by CSC, a major supplier to NPFIT; discusses acceptable levels of risk and clinical safety as an end-to-end concept; and touches on the future for clinical safety in health systems software.
Slaughter, Susan E; Estabrooks, Carole A; Jones, C Allyson; Wagg, Adrian S; Eliasziw, Misha
of older Albertans. The project's reach extends to both supportive living and long-term care settings. Furthermore, START has the potential to introduce and sustain a broad range of innovations in various care areas, such as dementia care, wound care, and pain management - domains where the uptake and sustainability of innovations also encounter significant challenges. By identifying the optimal frequency and intensity of knowledge translation interventions, we hope to enable continuing care organizations to efficiently integrate care innovations into the day-to-day care of residents. ClinicalTrials.gov, NCT01746459.
Delour, M; Caparros, N; Rufat, P; Desplanques, L; Bonnefoi, M-C; Patris, S; Brodin, M
This study analyzes the organisational factors linked with episodes of infections in children attending child day-care setting in Paris. A sample of children who attended parisian municipal child day-care setting, stratified on the type and the size of the day-care setting, was achieved. This cohort was followed from September 2000 to June 2001. We compared the risk of repeated infections according to the type of day-care setting (family day-care or day-care centre), and for the day-care centre according to the size (60 places) and the structure of groups (mixing age groups or not). The events studied were the occurrence of at least: 6 episodes of any infection, 2 otitis, 2 gastroenteritis, 2 conjunctivitis or 5 upper respiratory tract infections. Nine hundred and ninety-three children were included in this study. The 878 children attending a day-care centre had a significant higher risk of infections compare to children in family day-care (RR = 2.92[1.58-5.38]) except for gastroenteritis and conjunctivitis. This relationship between the type of day-care setting and the repeated infections was especially shown for children younger than 1 year. The mixing of ages only increased the risk of conjunctivitis (RR = 1.98[1.15-3.42]). No significant relationship between the size of the day care centre and the repetition of every studied infection was found. This study strengthens the orientation of the more vulnerable children towards the family day-care centers.
... on treatment outcome. Keywords: Patient satisfaction, TB care clinical consultations, cross sectional study. ... Background: Tuberculosis (TB) remains a major global ... Measurement of outcome: Variables considered were; how long the ... Key: ART= Antiretroviral Therapy. Characteristic. Parameter n (%). Sex. Female.
Ab Rahman, Norazida; Sivasampu, Sheamini; Mohamad Noh, Kamaliah; Khoo, Ee Ming
The world population has become more globalised with increasing number of people residing in another country for work or other reasons. Little is known about the health profiles of foreign population in Malaysia. The aim of this study was to provide a detailed description of the health problems presented by foreigners attending primary care clinics in Malaysia. Data were derived from the 2012 National Medical Care Survey (NMCS), a cross sectional survey of primary care encounters from public and private primary care clinics sampled from five regions in Malaysia. Patients with foreign nationality were identified and analysed for demographic profiles, reasons for encounter (RFEs), diagnosis, and provision of care. Foreigners accounted for 7.7 % (10,830) of all patient encounters from NMCS. Most encounters were from private clinics (90.2 %). Median age was 28 years (IQR: 24.0, 34.8) and 69.9 % were male. Most visits to the primary care clinics were for symptom-based complaints (69.5 %), followed by procedures (23.0 %) and follow-up visit (7.4 %). The commonest diagnosis in public clinics was antenatal care (21.8 %), followed by high risk pregnancies (7.5 %) and upper respiratory tract infection (URTI) (6.8 %). Private clinics had more cases for general medical examination (13.5 %), URTI (13.1 %) and fever (3.9 %). Medications were prescribed to 76.5 % of these encounters. More foreigners were seeking primary medical care from private clinics and the encounters were for general medical examinations and acute minor ailments. Those who sought care from public clinics were for obstetric problems and chronic diseases. Medications were prescribed to two-thirds of the encounters while other interventions: laboratory investigations, medical procedures and follow-up appointment had lower rates in private clinics. Foreigners are generally of young working group and are expected to have mandatory medical checks. The preponderance of obstetrics seen in public
Full Text Available With advances in breast cancer (BC gene panel testing, risk counseling has become increasingly complex, potentially leading to unmet psychosocial needs. We assessed psychosocial needs and correlates in women initiating testing for high genetic BC risk in clinics in France and Germany, and compared these results with data from a literature review. Among the 442 counselees consecutively approached, 212 (83% in France and 180 (97% in Germany, mostly BC patients (81% and 92%, respectively, returned the ‘Psychosocial Assessment in Hereditary Cancer’ questionnaire. Based on the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA BC risk estimation model, the mean BC lifetime risk estimates were 19% and 18% in France and Germany, respectively. In both countries, the most prevalent needs clustered around the “living with cancer” and “children-related issues” domains. In multivariate analyses, a higher number of psychosocial needs were significantly associated with younger age (b = −0.05, higher anxiety (b = 0.78, and having children (b = 1.51, but not with country, educational level, marital status, depression, or loss of a family member due to hereditary cancer. These results are in line with the literature review data. However, this review identified only seven studies that quantitatively addressed psychosocial needs in the BC genetic counseling setting. Current data lack understandings of how cancer risk counseling affects psychosocial needs, and improves patient-centered care in that setting.
Ozolins, Lise-Lotte; Hörberg, Ulrica; Dahlberg, Karin
This study describes the phenomenon of caring touch from the patients' perspective in an anthroposophic clinical context where caring touch is often used to promote health and alleviate suffering. The aim of the study was to explore and phenomenologically describe the phenomenon of caring touch from the patients' perspectives. The study has been carried out with a Reflective Lifeworld Research approach in order to understand and describe human existential phenomena. Ten female patients were interviewed in an anthroposophic clinic in Sweden. The findings show how caring touch has multifaceted meanings and makes the patients' feel present and anchored in a meaningful context. The patients' feel that they are seen, accepted and confirmed. Furthermore, touch creates a caring space where the patients become receptive for care and has the power to alleviate the patients' suffering, as well as to frighten and cause or worsen the suffering. In order to take advantage of the caring potential, the patient needs to be invited to a respectful and sensitive form of touch. An interpersonal flexible space is necessary where the touch can be effective, and where a dynamic interplay can develop. In conclusion, caring touch is an opportunity for carers to support well-being and health. The carers need to approach their patients in both a sensitive and reflective way. A caring science perspective can serve as a help to further understand touch as a unique caring act. © 2015 Nordic College of Caring Science.
Pajenda, Sahra; Ilhan-Mutlu, Aysegül; Preusser, Matthias; Roka, Sebastian; Druml, Wilfred; Wagner, Ludwig
Acute kidney injury is frequently observed at the intensive care unit, after surgery, and after toxic drug administration. A rise in serum creatinine and a fall in urine output are consequences of much earlier injury to the most sensitive part of tubular cells located at the proximal tubule. The aim of the present study was to investigate the course of two cell-cycle arrest urinary biomarkers compared to serum creatinine in four clinical settings: ischemic reperfusion injury, cardiac failure, severe acute kidney injury, and chemotherapy-induced kidney injury. A recently developed bedside test known as NephroCheck measures two urinary parameters: insulin-like growth factor binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinase-2 (TIMP-2). The test is based on a sandwich immunoassay technique. The final test output, labeled AKIRisk, is shown as a numeric result. This report revealed that [IGFBP7] · [TIMP-2] in urine rise rapidly prior to any change in serum creatinine. A unique feature of all four clinical settings is that a rapid decline predicts the recovery of kidney function. Besides, a subclinical kidney injury might be detected by the test. This bedside test detects biomarkers of renal injury. A rapid decline in AKIRisk was associated with the restoration of kidney function, whereas a prolonged high AKIRisk score was associated with end-stage renal disease. However, the dynamics seem to differ, depending on the cause and the extent of injury. Further studies will be needed to clarify the issue.
Helfrich, Christian D; Dolan, Emily D; Fihn, Stephan D; Rodriguez, Hector P; Meredith, Lisa S; Rosland, Ann-Marie; Lempa, Michele; Wakefield, Bonnie J; Joos, Sandra; Lawler, Lauren H; Harvey, Henry B; Stark, Richard; Schectman, Gordon; Nelson, Karin M
Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care. We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, Pteam processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics. Published by Elsevier Inc.
Mullen, Antony; Drinkwater, Vincent; Lewin, Terry J
To implement and evaluate the care zoning model in an eight-bed psychiatric intensive care unit and, specifically, to examine the model's ability to improve the documentation and communication of clinical risk assessment and management. Care zoning guides nurses in assessing clinical risk and planning care within a mental health context. Concerns about the varying quality of clinical risk assessment prompted a trial of the care zoning model in a psychiatric intensive care unit within a regional mental health facility. The care zoning model assigns patients to one of 3 'zones' according to their clinical risk, encouraging nurses to document and implement targeted interventions required to manage those risks. An implementation trial framework was used for this research to refine, implement and evaluate the impact of the model on nurses' clinical practice within the psychiatric intensive care unit, predominantly as a quality improvement initiative. The model was trialled for three months using a pre- and postimplementation staff survey, a pretrial file audit and a weekly file audit. Informal staff feedback was also sought via surveys and regular staff meetings. This trial demonstrated improvement in the quality of mental state documentation, and clinical risk information was identified more accurately. There was limited improvement in the quality of care planning and the documentation of clinical interventions. Nurses' initial concerns over the introduction of the model shifted into overall acceptance and recognition of the benefits. The results of this trial demonstrate that the care zoning model was able to improve the consistency and quality of risk assessment information documented. Care planning and evaluation of associated outcomes showed less improvement. Care zoning remains a highly applicable model for the psychiatric intensive care unit environment and is a useful tool in guiding nurses to carry out routine patient risk assessments. © 2013 John Wiley & Sons
Poghosyan, Lusine; Chaplin, William F; Shaffer, Jonathan A
Favorable organizational climate in primary care settings is necessary to expand the nurse practitioner (NP) workforce and promote their practice. Only one NP-specific tool, the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), measures NP organizational climate. We confirmed NP-PCOCQ's factor structure and established its predictive validity. A crosssectional survey design was used to collect data from 314 NPs in Massachusetts in 2012. Confirmatory factor analysis and regression models were used. The 4-factor model characterized NP-PCOCQ. The NP-PCOCQ score predicted job satisfaction (beta = .36; p organizational climate in their clinics. Further testing of NP-PCOCQ is needed.
Winifred Aitalegbe Ojieabu
Full Text Available Background: Nigeria had the highest number of people living with diabetes mellitus in the African region in year 2013. Previous researchers have found that patients with knowledge of their diseases including their treatment methods have a high likelihood to succeed in managing the disease conditions. Many pharmaceutical care programmes which have been successfully applied in various countries to enhance clinical outcomes and health-related quality of life are not very common in Nigeria. Objective: This study was to evaluate pharmacist's educational and counselling impact on diabetic patients' outcomes in a diabetic setting. Materials and Methods: The 4-month randomised controlled study involved 150 elderly Type 2 diabetic patients. Sociodemographic and clinical parameters were measured. We educated and counselled the 75 patients in our intervention group at least four times during the study period, but the control group was deprived of the pharmacist's intervention. Results: Female to male participants was in the ratio of 9:6 and 9:5 in both control and intervention groups, respectively. Majority (>40% of the patients in both groups had primary education. Baseline and 4-month mean fasting blood sugar in the control group was 162.2 ± 69.1 and 159.9 ± 57.2, respectively (P = 0.825, whereas the intervention group had 156.7 ± 30.5 and 131.8 ± 40.4, respectively (P < 0.001. Mean systolic blood pressure in both groups was 146.4 ± 13.9 and 133.8 ± 18.5 (P < 0.001, respectively. Adherence levels to medication taking in both groups were 42.7%:94.7%, respectively (P = 0.001. Conclusion: This study encourages the inclusion of clinical pharmacists into multidisciplinary healthcare groups in hospital and clinic settings as well as incorporation of this type of intervention into diabetic management programmes for optimal patients' outcomes.
Garbers, Samantha; Bell, D L; Ogaye, K; Marcell, A V; Westhoff, C L; Rosenthal, S L
To explore the acceptability of advance provision of emergency contraceptive pills (ECPs) to young men seeking health care. For this exploratory study in a clinic setting, we approached young men aged 16-35 to participate in a survey eliciting socio-demographics, sexual and contraceptive history, and knowledge about ECPs. We offered young men advance provision of ECPs and compared characteristics of 126 young men who did and did not accept the ECPs. Most (76%) of the participants accepted advance provision and left with an ECP pack, with even higher proportions among males whose sexual histories were suggestive of increased risk of involvement in an unintended pregnancy. This study holds promise to inform scale up of advance provision of ECPs among young men. Copyright © 2018 Elsevier Inc. All rights reserved.
Jeon, Yun-Hee; Conway, Jane; Chenoweth, Lynn; Weise, Janelle; Thomas, Tamsin Ht; Williams, Anna
To establish validity of a clinical leadership framework for aged care middle managers (The Aged care Clinical Leadership Qualities Framework). Middle managers in aged care have responsibility not only for organisational governance also and operational management but also quality service delivery. There is a need to better define clinical leadership abilities in aged care middle managers, in order to optimise their positional authority to lead others to achieve quality outcomes. A Delphi method. Sixty-nine experts in aged care were recruited, representing rural, remote and metropolitan community and residential aged care settings. Panellists were asked to rate the proposed framework in terms of the relevance and importance of each leadership quality using four-point Likert scales, and to provide comments. Three rounds of consultation were conducted. The number and corresponding percentage of the relevance and importance rating for each quality was calculated for each consultation round, as well as mean scores. Consensus was determined to be reached when a percentage score reached 70% or greater. Twenty-three panellists completed all three rounds of consultation. Following the three rounds of consultation, the acceptability and face validity of the framework was confirmed. The study confirmed the framework as useful in identifying leadership requirements for middle managers in Australian aged care settings. The framework is the first validated framework of clinical leadership attributes for middle managers in aged care and offers an initial step forward in clarifying the aged care middle manager role. The framework provides clarity in the breadth of role expectations for the middle managers and can be used to inform an aged care specific leadership program development, individuals' and organisations' performance and development processes; and policy and guidelines about the types of activities required of middle managers in aged care. © 2014 John Wiley & Sons Ltd.
Full Text Available Preetinder S Gill,1 Ashwini Kamath,2 Tejkaran S Gill31College of Technology, Eastern Michigan University, Ypsilanti, MI, USA; 2School of Information, University of Texas, Austin, TX, USA; 3College of Engineering, University of Michigan, Ann Arbor, MI, USAAbstract: Smartphone use in health care work settings presents both opportunities and challenges. The benefits could be severely undermined if abuse and overuse are not kept in check. This practice-focused research paper examines the current panorama of health software applications. Findings from existing research are consolidated to elucidate the level and effects of distraction in health care work settings due to smartphone use. A conceptual framework for crafting guidelines to regulate the use of smartphones in health care work settings is then presented. Finally, specific guidelines are delineated to assist in creating policies for the use of smartphones in a health care workplace.Keywords: smartphone, health care, distraction, workplace, mobile apps, health informatics
Miller, James S; Mhalu, Aisa; Chalamilla, Guerino; Siril, Hellen; Kaaya, Silvia; Tito, Justina; Aris, Eric; Hirschhorn, Lisa R
Health system responsiveness (HSR) measures quality of care from the patient's perspective, an important component of ensuring adherence to medication and care among HIV patients. We examined HSR in private clinics serving HIV patients in Dar es Salaam, Tanzania. We surveyed 640 patients, 18 or older receiving care at one of 10 participating clinics, examining socioeconomic factors, HIV regimen, and self-reported experience with access and care at the clinic. Ordered logistic regression, adjusted for clustering of the clinic sites, was used to measure the relationships between age, gender, education, site size, and overall quality of care rating, as well as between the different HSR domains and overall rating. Overall, patients reported high levels of satisfaction with care received. Confidentiality, communication, and respect were particularly highly rated, while timeliness received lower ratings despite relatively short wait times, perhaps indicating high expectations when receiving care at a private clinic. Respect, confidentiality, and promptness were significantly associated with overall rating of health care, while provider skills and communication were not significantly associated. Patients reported that quality of service and confidentiality, rather than convenience of location, were the most important factors in their choice of a clinic. Site size (patient volume) was also positively correlated with patient satisfaction. Our findings suggest that, in the setting of urban private-sector clinics, flexible clinics hours, prompt services, and efforts to improve respect, privacy and confidentiality may prove more helpful in increasing visit adherence than geographic accessibility. While a responsive health system is valuable in its own right, more work is needed to confirm that improvements in HSR in fact lead to improved adherence to care.
Bridgeman, Mary Barna; Abazia, Daniel T
The authors review the historical use of medicinal cannabis and discuss the agent's pharmacology and pharmacokinetics, select evidence on medicinal uses, and the implications of evolving regulations on the acute care hospital setting.
Bridgeman, Mary Barna; Abazia, Daniel T.
The authors review the historical use of medicinal cannabis and discuss the agent?s pharmacology and pharmacokinetics, select evidence on medicinal uses, and the implications of evolving regulations on the acute care hospital setting.
Ida Torunn Bjørk
Full Text Available This study analyzed nurses' perceptions of clinical decision making (CDM in their clinical practice and compared differences in decision making related to nurse demographic and contextual variables. A cross-sectional survey was carried out with 2095 nurses in four hospitals in Norway. A 24-item Nursing Decision Making Instrument based on cognitive continuum theory was used to explore how nurses perceived their CDM when meeting an elective patient for the first time. Data were analyzed with descriptive frequencies, t-tests, Chi-Square test, and linear regression. Nurses' decision making was categorized into analytic-systematic, intuitive-interpretive, and quasi-rational models of CDM. Most nurses reported the use of quasi-rational models during CDM thereby supporting the tenet that cognition most often includes properties of both analysis and intuition. Increased use of intuitive-interpretive models of CDM was associated with years in present job, further education, male gender, higher age, and working in predominantly surgical units.
Sieng, Sokha; Hurst, Cameron
This study compares a combination of processes of care and clinical targets among patients with type 2 diabetes mellitus (T2DM) between specialist diabetes clinics (SDCs) and general medical clinics (GMCs), and how differences between these two types of clinics differ with hospital type (community, provincial and regional). Type 2 diabetes mellitus patient medical records were collected from 595 hospitals (499 community, 70 provincial, 26 regional) in Thailand between April 1 to June 30, 2012 resulting in a cross-sectional sample of 26,860 patients. Generalized linear mixed modeling was conducted to examine associations between clinic type and quality of care. The outcome variables of interest were split into clinical targets and process of care. A subsequent subgroup analysis was conducted to examine if the nature of clinical target and process of care differences between GMCs and SDCs varied with hospital type (regional, provincial, community). Regardless of the types of hospitals (regional, provincial, or community) patients attending SDCs were considerably more likely to have eye and foot exam. In terms of larger hospitals (regional and provincial) patients attending SDCs were more likely to achieve HbA1c exam, All FACE exam, BP target, and the Num7Q. Interestingly, SDCs performed better than GMCs at only provincial hospitals for LDL-C target and the All7Q. Finally, patients with T2DM who attended community hospital-GMCs had a better chance of achieving the blood pressure target than patients who attended community hospital-SDCs. Specialized diabetes clinics outperform general medical clinics for both regional and provincial hospitals for all quality of care indicators and the number of quality of care indicators achieved was never lower. However, this better performance of SDC was not observed in community hospital. Indeed, GMCs outperformed SDCs for some quality of care indicators in the community level setting.
Transmucosal is an alternative route for administering medications (ie, dexmedetomidine, midazolam, naloxone) that can be effective for procedural or moderate sedation in patients with special needs when other routes are not practical or are contraindicated. Special needs populations include children, older adults, pregnant and breast-feeding women, and people with disabilities or conditions that limit their ability to function and cope. Understanding the perioperative nurse's role in the care of patients receiving medications via the transmucosal route can lead to better clinical outcomes. Successful use of the transmucosal route requires knowledge of when to administer a medication, how often and how much of a medication should be administered, the onset and duration of action, the adverse effects or contraindications, and the key benefits. In addition, a case study approach suggests that transmucosal sedation can decrease patient stress and anxiety related to undergoing medical procedures or surgery in the ambulatory care setting. Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Full Text Available Background. This pilot study examined the feasibility and efficacy of providing Qigong treatment in a health center to Chinese Americans with major depressive disorder (MDD. Methods. Fourteen Chinese Americans with MDD were enrolled, and they received a 12-week Qigong intervention. The key outcome measurement was the 17-item Hamilton Rating Scale for Depression (HAM-D17; the Clinical Global Impressions-Severity (CGI-S and -Improvement (CGI-I, the Quality of Life Enjoyment and Satisfaction Questionnaire, Short Form (Q-LES-Q-SF, and the Multidimensional Scale of Perceived Social Support (MSPSS were also administered. Positive response was defined as a decrease of 50% or more on the HAM-D17, and remission was defined as HAM-D17 ≤ 7. Patients' outcome measurements were compared before and after the Qigong intervention. Results. Participants (N=14 were 64% female, with a mean age of 53 (±14. A 71% of participants completed the intervention. The Qigong intervention resulted in a positive treatment-response rate of 60% and a remission rate of 40% and statistically significant improvement, as measured by the HAM-D17, CGI-S, CGI-I, Q-LES-Q-SF, and the family support subscale of the MSPSS. Conclusions. The Qigong intervention provided at a health care setting for the treatment of primary care patients with MDD is feasible. Further studies with larger sample sizes are warranted.
Mitsios, John V; Ashby, Lori A; Haverstick, Doris M; Bruns, David E; Scott, Mitchell G
Maintaining appropriate glycemic control in critically ill patients reduces morbidity and mortality. The use of point-of-care (POC) glucose devices is necessary to obtain rapid results at the patient's bedside. However, the devices should be thoroughly tested in the intended population before implementation. The use of POC glucose meters in critically ill patients has been questioned both in the literature and by regulatory agencies. The aim of this study was to determine if the ACCU-CHEK® Inform II system (Roche Diagnostics) POC glucose meter demonstrated the desired accuracy and precision, as defined by Clinical and Laboratory Standards Institute guideline POCT12-A3, in a large number of critically ill patients from multiple intensive care settings at two academic medical centers. A total of 1200 whole blood meter results from 600 patients were compared with central laboratory plasma values. Whole blood aliquots from venous samples were used to obtain duplicate meter results with the remaining sample being processed to obtain plasma for central laboratory testing within 5 min of meter testing. A total of 1185 (98.8%) of the new meter's glucose values were within ± 12.5% (± 12 mg/dl for values ≥ 100 mg/dl) of the comparative laboratory glucose values, and 1198 (99.8%) were within ± 20% (± 20 mg/dl for values meter system appears to have sufficient analytic accuracy for use in critically ill patients. © 2013 Diabetes Technology Society.
Demir, Yurdanur; Korhan, Esra Akin; Eser, Ismet; Khorshid, Leyla
To determine the factors affecting a patient's intensive care experience. The descriptive study was conducted at an intensive care unit in the Aegean Region of Turkey, and comprised 158 patients who spent at least 48 hours at the unit between June and November 2009. A questionnaire form and the Intensive Care Experience Scale were used as data collection tools. SPSS 11.5 was used for statistical analysis of the data. Of the total, 86 (54.4%) patients related to the surgical unit, while 72 (45.5%) spent time at the intensive care unit. Most of the subjects (n=113; 71.5%) reported that they constantly experienced pain during hospitalisation. Patients receiving mechanical ventilation support and patients reporting no pain had significantly higher scores on the intensive care experience scale. Patients who reported pain remembered their experiences less than those having no pain. Interventions are needed to make the experiences of patients in intensive care more positive.
Talib, Zohray; van Schalkwyk, Susan; Couper, Ian; Pattanaik, Swaha; Turay, Khadija; Sagay, Atiene S; Baingana, Rhona; Baird, Sarah; Gaede, Bernhard; Iputo, Jehu; Kibore, Minnie; Manongi, Rachel; Matsika, Antony; Mogodi, Mpho; Ramucesse, Jeremais; Ross, Heather; Simuyeba, Moses; Haile-Mariam, Damen
African medical schools are expanding, straining resources at tertiary health facilities. Decentralizing clinical training can alleviate this tension. This study assessed the impact of decentralized training and contribution of undergraduate medical students at health facilities. Participants were from 11 Medical Education Partnership Initiative-funded medical schools in 10 African countries. Each school identified two clinical training sites-one rural and the other either peri-urban or urban. Qualitative and quantitative data collection tools were used to gather information about the sites, student activities, and staff perspectives between March 2015 and February 2016. Interviews with site staff were analyzed using a collaborative directed approach to content analysis, and frequencies were generated to describe site characteristics and student experiences. The clinical sites varied in level of care but were similar in scope of clinical services and types of clinical and nonclinical student activities. Staff indicated that students have a positive effect on job satisfaction and workload. Respondents reported that students improved the work environment, institutional reputation, and introduced evidence-based approaches. Students also contributed to perceived improvements in quality of care, patient experience, and community outreach. Staff highlighted the need for resources to support students. Students were seen as valuable resources for health facilities. They strengthened health care quality by supporting overburdened staff and by bringing rigor and accountability into the work environment. As medical schools expand, especially in low-resource settings, mobilizing new and existing resources for decentralized clinical training could transform health facilities into vibrant service and learning environments.
Cappelli, M; Esplen, M J; Wilson, B J; Dorval, M; Bottorff, J L; Ly, M; Carroll, J C; Allanson, J; Humphreys, E; Rayson, D
The purpose of this study was to examine the mental health needs of individuals at risk for adult onset hereditary disorder (AOHD) from the perspective of their genetic service providers, as it is unknown to what extent psychosocial services are required and being met. A mail-out survey was sent to 281 providers on the membership lists of the Canadian Association of Genetic Counsellors and the Canadian College of Medical Geneticists. The survey assessed psychosocial issues that were most commonly observed by geneticists, genetic counsellors (GCs), and nurses as well as availability and types of psychosocial services offered. Of the 129 respondents, half of genetic service providers reported observing signs of depression and anxiety, while 44% noted patients' concerns regarding relationships with family and friends. In terms of providing counselling to patients, as the level of psychological risk increased, confidence in dealing with these issues decreased. In addition, significantly more GCs reported that further training in psychosocial issues would be most beneficial to them if resources were available. As a feature of patient care, it is recommended that gene-based predictive testing include an integrative model of psychosocial services as well as training for genetic service providers in specific areas of AOHD mental health.
Unal, Sevim; Bilgin, Leyla; Gunduz, Mehmet; Uncu, Nermin; Azili, Mujdem Nur; Tiryaki, Tugrul
To investigate etiology, outcome and complications related to neonatal peritoneal dialysis (PD). Neonates treated with PD in our neonatal intensive care unit during 2007-2010 were analyzed retrospectively. Among 4036 hospitalized neonates; 20 neonates (0.5%) who underwent 21 cycles of PD [7 preterm, 13 term; 13 female, 7 male] were included. The mean birth weight was 2930.2 ± 720.6 g (1120-4570), mean gestational age was 37.5 ± 3.5 weeks (27-41). The etiologic disorders included inborn errors of metabolism (propionic acidemia, methylmalonic acidemia, citrullinemia, glutaric aciduria type 2, maple syrup urine disease, 10), or acute renal failure secondary to perinatal asphyxia (4), sepsis (2), prematurity (2), hypoplastic left heart syndrome (1), kernicterus (1). The complications included peritonitis (2), early leakage (4), hemorrhage (1), catheter removal (3) and occlusion (2). The mortality rate was 50%. The gestational ages and birth weights of surviving neonates were higher (p neonates, chronic renal failure (1), severe (4) and moderate neuromotor impairment (2) developed within 4-43 months. PD, although invasive, is an effective therapy in neonates. The complexity and invasiveness of the procedure is probably responsible for high rate of complications and mortality. If appropriate catheter selection and technique in the placement should be done, PD might improve outcome.
Kazis, Lewis E; Sheridan, Robert L; Shapiro, Gabriel D; Lee, Austin F; Liang, Matthew H; Ryan, Colleen M; Schneider, Jeffrey C; Lydon, Martha; Soley-Bori, Marina; Sonis, Lily A; Dore, Emily C; Palmieri, Tina; Herndon, David; Meyer, Walter; Warner, Petra; Kagan, Richard; Stoddard, Frederick J; Murphy, Michael; Tompkins, Ronald G
There has been little systematic examination of variation in pediatric burn care clinical practices and its effect on outcomes. As a first step, current clinical care processes need to be operationally defined. The highly specialized burn care units of the Shriners Hospitals for Children system present an opportunity to describe the processes of care. The aim of this study was to develop a set of process-based measures for pediatric burn care and examine adherence to them by providers in a cohort of pediatric burn patients. We conducted a systematic literature review to compile a set of process-based indicators. These measures were refined by an expert panel of burn care providers, yielding 36 process-based indicators in four clinical areas: initial evaluation and resuscitation, acute excisional surgery and critical care, psychosocial and pain control, and reconstruction and aftercare. We assessed variability in adherence to the indicators in a cohort of 1,076 children with burns at four regional pediatric burn programs in the Shriners Hospital system. The percentages of the cohort at each of the four sites were as follows: Boston, 20.8%; Cincinnati, 21.1%; Galveston, 36.0%; and Sacramento, 22.1%. The cohort included children who received care between 2006 and 2010. Adherence to the process indicators varied both across sites and by clinical area. Adherence was lowest for the clinical areas of acute excisional surgery and critical care, with a range of 35% to 48% across sites, followed by initial evaluation and resuscitation (range, 34%-60%). In contrast, the clinical areas of psychosocial and pain control and reconstruction and aftercare had relatively high adherence across sites, with ranges of 62% to 93% and 71% to 87%, respectively. Of the 36 process indicators, 89% differed significantly in adherence between clinical sites (p measures represents an important step in the assessment of clinical practice in pediatric burn care. Substantial variation was observed
Eggenberger, Eva; Heimerl, Katharina; Bennett, Michael I
Caring for and caring about people with dementia require specific communication skills. Healthcare professionals and family caregivers usually receive little training to enable them to meet the communicative needs of people with dementia. This review identifies existent interventions to enhance communication in dementia care in various care settings. We searched MEDLINE, AMED, EMBASE, PsychINFO, CINAHL, The Cochrane Library, Gerolit, and Web of Science for scientific articles reporting interventions in both English and German. An intervention was defined as communication skills training by means of face-to-face interaction with the aim of improving basic communicative skills. Both professional and family caregivers were included. The effectiveness of such training was analyzed. Different types of training were defined. Didactic methods, training content, and additional organizational features were qualitatively examined. This review included 12 trials totaling 831 persons with dementia, 519 professional caregivers, and 162 family caregivers. Most studies were carried out in the USA, the UK, and Germany. Eight studies took place in nursing homes; four studies were located in a home-care setting. No studies could be found in an acute-care setting. We provide a list of basic communicative principles for good communication in dementia care. Didactic methods included lectures, hands-on training, group discussions, and role-play. This review shows that communication skills training in dementia care significantly improves the quality of life and wellbeing of people with dementia and increases positive interactions in various care settings. Communication skills training shows significant impact on professional and family caregivers' communication skills, competencies, and knowledge. Additional organizational features improve the sustainability of communication interventions.
Voldby, Anders Winther; Brandstrup, Birgitte
BACKGROUND: Perioperative hypovolemia and fluid overload have effects on both complications following surgery and on patient survival. Therefore, the administration of intravenous fluids before, during, and after surgery at the right time and in the right amounts is of great importance. This review...... aims to analyze the literature concerning perioperative fluid therapy in abdominal surgery and to provide evidence-based recommendations for clinical practice. RESULTS: Preoperative oral or intravenous administration of carbohydrate containing fluids has been shown to improve postoperative well...... for most patients. It is less expensive and simpler than the zero-balance GDT approach and therefore recommended in this review. In outpatient surgery, 1-2 L of balanced crystalloids reduces postoperative nausea and vomiting and improves well-being....
The norms and practices of clinical ethics took form relative to the environment and relationships of hospital care. These practices do not easily translate into the outpatient context because the environment and relational dynamics differ. Yet, as outpatient care becomes the center of health care delivery, the experiences of ethical tension for outpatient clinicians warrant greater responses. Although a substantial body of literature on the nature of the doctor-physician relationship has been developed and could provide theoretical groundwork for an outpatient ethics, this literature is not sufficient to support outpatient caregivers in practical dilemmas. For physicians who are employed by or affiliated with a larger organization, a stronger alliance between clinical ethics and organizational ethics, identity, and mission will promote expansion of ethics resources in outpatient settings and address structural constraints in outpatient clinical care.
Jency Maria Koshy
Full Text Available Introduction: Cerebral malaria (CM is one of the most common causes for non-traumatic encephalopathy in the world. It affects both the urban and rural population. It is a challenge to treat these patients in a resource limited setting; where majority of these cases present. Materials and Methods: This was a prospective study carried out from September 2005 to December 2006 at Jiwan Jyoti Christian Hospital in Eastern Uttar Pradesh in India. This is a secondary level care with limited resources. We studied the clinical profile, treatment and outcome of all the patients above the age of 14 years diagnosed with CM. Results: There were a total of 53 patients with CM of which 38 (71.7% of them were females. Among them, 35 (66% patients were less than 30 years of age. The clinical features noted were seizure (39.62%, anemia (84.9%, icterus (16.98%, hypotension (13.2%, bleeding (3.7%, hepatomegaly (5.66%, splenomegaly (5.66%, non-cardiogenic pulmonary edema (16.98% and renal dysfunction (37.36%. Co-infection with Plasmodium vivax was present in 13 (24.53% of them. Treatment received included artesunin compounds or quinine. Median time of defervescence was 2 (interquartile range1-3. Complete recovery was achieved in 43 (81% of them. Two (3.7% of them died. Conclusion: CM, once considered to be a fatal disease has shown remarkable improvement in the outcome with the wide availability of artesunin and quinine components. To combat the malaria burden, physicians in resource limited setting should be well trained to manage these patients especially in the endemic areas. The key to management is early diagnosis and initiation of treatment based on a high index of suspicion. Anticipation and early recognition of the various complications are crucial.
N Ann Scott
Full Text Available OBJECTIVE: To ascertain knowledge gaps in the diagnosis and treatment of acute and chronic low back pain (LBP in the primary care setting to prepare a scoping survey for identifying knowledge gaps in LBP management among Alberta’s primary care practitioners, and to identify potential barriers to implementing a multidisciplinary LBP guideline.
Adams, Carolyn D.; Hinojosa, Sara; Armstrong, Kathleen; Takagishi, Jennifer; Dabrow, Sharon
This article discusses an innovative example of integrated care in which doctoral level school psychology interns and residents worked alongside pediatric residents and pediatricians in the primary care settings to jointly provide services to patients. School psychologists specializing in pediatric health are uniquely trained to recognize and…
Drum, David; Becker, Martin Swanbrow; Hess, Elaine
Changes in the health care arena and within the specialty of group work are contributing to the increased utilization of groups in health care settings. Psychoeducational, theme, and interpersonal therapy groups are highlighted for their contributions to treating challenging health conditions. An understanding of the evolution of these group…
Level of health care and services in a tertiary health setting in Nigeria. ... Background: There is a growing awareness and demand for quality health care across the world; hence the ... Doctors and nurses formed 64.3% of the study population.
Graça, João; Calheiros, Maria Manuela; Patrício, Joana Nunes; Magalhães, Eunice Vieira
There have been calls for uncovering the "black box" of residential care services, with a particular need for research focusing on emergency care settings for children and youth in danger. In fact, the strikingly scant empirical attention that these settings have received so far contrasts with the role that they often play as gateway into the child welfare system. To answer these calls, this work presents and tests a framework for assessing a service model in residential emergency care. It comprises seven studies which address a set of different focal areas (e.g., service logic model; care experiences), informants (e.g., case records; staff; children/youth), and service components (e.g., case assessment/evaluation; intervention; placement/referral). Drawing on this process-consultation approach, the work proposes a set of key challenges for emergency residential care in terms of service improvement and development, and calls for further research targeting more care units and different types of residential care services. These findings offer a contribution to inform evidence-based practice and policy in service models of residential care. Copyright © 2017 Elsevier Ltd. All rights reserved.
Lim, Christopher T; Tadmor, Avia; Fujisawa, Daisuke; MacDonald, James J; Gallagher, Emily R; Eusebio, Justin; Jackson, Vicki A; Temel, Jennifer S; Greer, Joseph A; Hagan, Teresa; Park, Elyse R
While vast opportunities for using qualitative methods exist within palliative care research, few studies provide practical advice for researchers and clinicians as a roadmap to identify and utilize such opportunities. To provide palliative care clinicians and researchers descriptions of qualitative methodology applied to innovative research questions relative to palliative care research and define basic concepts in qualitative research. Body: We describe three qualitative projects as exemplars to describe major concepts in qualitative analysis of early palliative care: (1) a descriptive analysis of clinician documentation in the electronic health record, (2) a thematic content analysis of palliative care clinician focus groups, and (3) a framework analysis of audio-recorded encounters between patients and clinicians as part of a clinical trial. This study provides a foundation for undertaking qualitative research within palliative care and serves as a framework for use by other palliative care researchers interested in qualitative methodologies.
McCreaddie, May; Lyons, Imogen; Watt, Debbie; Ewing, Elspeth; Croft, Jeanette; Smith, Marion; Tocher, Jennifer
This study reviewed the perceptions and strategies of drug users and nurses with regard to pain management in acute care settings. Drug users present unique challenges in acute care settings with pain management noted to be at best suboptimal, at worst non-existent. Little is known about why and specifically how therapeutic effectiveness is compromised. Qualitative: constructivist grounded theory. A constructivist grounded theory approach incorporating a constant comparative method of data collection and analysis was applied. The data corpus comprised interviews with drug users (n = 11) and five focus groups (n = 22) of nurses and recovering drug users. Moral relativism as the core category both represents the phenomenon and explains the basic social process. Nurses and drug users struggle with moral relativism when addressing the issue of pain management in the acute care setting. Drug users lay claim to expectations of compassionate care and moralise via narration. Paradoxically, nurses report that the caring ideal and mutuality of caring are diminished. Drug users' individual sensitivities, anxieties and felt stigma in conjunction with opioid-induced hyperalgesia complicate the processes. Nurses' and hospitals' organisational routines challenge drug user rituals and vice versa leading both protagonists to become disaffected. Consequently, key clinical issues such as preventing withdrawal and managing pain are left unaddressed and therapeutic effectiveness is compromised. This study provides a robust account of nurses' and drug users' struggle with pain management in the acute care setting. Quick technological fixes such as urine screens, checklists or the transient effects of (cognitive-based) education (or training) are not the answer. This study highlights the need for nurses to engage meaningfully with this perceptibly 'difficult' group of patients. The key aspects likely to contribute to problematic interactions with this patient cohort are outlined so that
Chaisson, Nicole; Shore, William B
Adolescence is marked by complex physical, cognitive, social, and emotional development, which can be stressful for families and adolescents. Before the onset of puberty, providers should clearly lay the groundwork for clinical care and office visits during the adolescent years. This article addresses the guidelines and current legal standards for confidentiality in adolescent care, the most frequently used psychosocial screening tools, and current recommendations for preventive health services and immunizations. Through the creation of teen-friendly clinics, primary care providers are well positioned to offer guidance and support to teens and their parents during this time of transition and growth. Copyright © 2014 Elsevier Inc. All rights reserved.
Teng, Cheong Lieng; Tong, Seng Fah; Khoo, Ee Ming; Lee, Verna; Zailinawati, Abu Hassan; Mimi, Omar; Chen, Wei Seng; Nordin, Salleh
Overprescription of antibiotics is a continuing problem in primary care. This study aims to assess the antibiotic prescribing rates and antibiotic choices for upper respiratory tract infections (URTI) and urinary tract infections (UTI) in Malaysian primary care. Antibiotic prescribing data for URTI and UTI was extracted from a morbidity survey of randomly selected primary care clinics in Malaysia. Analysis was performed of 1,163 URTI and 105 UTI encounters. Antibiotic prescribing rates for URTI and UTI were 33.8% and 57.1% respectively. Antibiotic prescribing rates were higher in private clinics compared to public clinics for URTI, but not for UTI. In URTI encounters, the majority of antibiotics prescribed were penicillins and macrolides, but penicillin V was notably underused. In UTI encounters, the antibiotics prescribed were predominantly penicillins or cotrimoxazole. Greater effort is needed to bring about evidence based antibiotic prescribing in Malaysian primary care, especially for URTIs in private clinics.
Justin K. Benzer
Full Text Available Objective. There is limited theory regarding the real-world implementation of mental health care in the primary care setting: a type of organizational coordination intervention. The purpose of this study was to develop a theory to conceptualize the potential causes of barriers and facilitators to how local sites responded to this mandated intervention to achieve coordinated mental health care. Methods. Data from 65 primary care and mental health staff interviews across 16 sites were analyzed to identify how coordination was perceived one year after an organizational mandate to provide integrated mental health care in the primary care setting. Results. Standardized referral procedures and communication practices between primary care and mental health were influenced by the organizational factors of resources, training, and work design, as well as provider-experienced organizational boundaries between primary care and mental health, time pressures, and staff participation. Organizational factors and provider experiences were in turn influenced by leadership. Conclusions. Our emergent theory describes how leadership, organizational factors, and provider experiences affect the implementation of a mandated mental health coordination intervention. This framework provides a nuanced understanding of the potential barriers and facilitators to implementing interventions designed to improve coordination between professional groups.
Selim, Heba Sayed; Abaza, Amani Farouk
This study aimed at investigating the microbial contamination of mobile phones in a hospital setting. Swab samples were collected from 40 mobile phones of patients and health care workers at the Alexandria University Students' Hospital. They were tested for their bacterial contamination at the microbiology laboratory of the High Institute of Public Health. Quantification of bacteria was performed using both surface spread and pour plate methods. Isolated bacterial agents were identified using standard microbiological methods. Methicillin-resistant Staphylococcus aureus was identified by disk diffusion method described by Bauer and Kirby. Isolated Gram-negative bacilli were tested for being extended spectrum beta lactamase producers using the double disk diffusion method according to the Clinical and Laboratory Standards Institute recommendations. All of the tested mobile phones (100%) were contaminated with either single or mixed bacterial agents. The most prevalent bacterial contaminants were methicillin-resistant S. aureus and coagulase-negative staphylococci representing 53% and 50%, respectively. The mean bacterial count was 357 CFU/ml, while the median was 13 CFU/ml using the pour plate method. The corresponding figures were 2,192 and 1,720 organisms/phone using the surface spread method. Mobile phones usage in hospital settings poses a risk of transmission of a variety of bacterial agents including multidrug-resistant pathogens as methicillin-resistant S. aureus. The surface spread method is an easy and useful tool for detection and estimation of bacterial contamination of mobile phones.
Full Text Available Within the past decade, there has been a surge of interest in investigating the effects of clown intervention in a large variety of clinical settings. Many studies have focused on the effects of clown intervention on children. However, few studies have investigated clowning effects on adults. This paper presents an overview of the concept of medical clowning followed by a literature review conducted on the empirical studies drawn from three data bases (PubMed, PsycINFO, and Google Scholar, with the aim of mapping and discussing the evidence of clowning effects on non-children, namely adults. The following areas were investigated: Adult and elderly patients (mainly those with dementia, observers of clowning, namely non-hospitalized adults who are at the hospital as relatives of patients or health-care staff, and finally clowns themselves. The main results are that 1 clown intervention induces positive emotions, thereby enhancing the patient’s well-being, reduces psychological symptoms and emotional reactivity, and prompts a decrease in negative emotions, such as anxiety and stress; 2 clown doctors are also well-perceived by relatives and healthcare staff and their presence appears to be useful in creating a lighter atmosphere in the health setting; 3 few pilot studies have been conducted on clown doctors and this lacuna represents a subject for future research.
McFarland, M R
The purpose of this study was to discover the care expressions, practices, and patterns of elderly Anglo- and African American elders. The domain of inquiry was the cultural care of elderly residents within the environmental context of a long-term care institution. The ethnonursing qualitative research method was used to conduct the study which was conceptualized within Leininger's theory of culture care diversity and universality. Four major themes were discovered: (a) Residents expressed and lived generic care to maintain their preadmission lifeways; (b) The nursing staff provided aspects of professional care to support satisfying lifeways for residents; (c) Institutional care patterns and expressions were viewed as a continuing life experience but with major differences between the apartment section and nursing home units; and (d) An institutional culture of the retirement home was discovered which reflected unique lifeways and shared care and health expressions and practices. These themes substantiated the culture care theory and revealed new modes of care for the elderly in an institutional setting.
Sheward, Karen; Clark, Jean; Marshall, Bridget; Allan, Simon
Understanding current end of life (EOL) care delivery in acute care is an important prerequisite to positively influencing practice, and published New Zealand (NZ) and international data are limited. Therefore, staff perceptions of EOL care in the hospital setting were investigated via survey. This article presents key findings. A total of 610 staff members in a 194-bed regional hospital were surveyed regarding their perceptions of EOL care, which yielded a response rate of 29% with 179 surveys returned. Respondents were from medical, nursing, and allied health staff working in medical, surgical, elder health, and a regional cancer treatment service. Responses to Likert scale statements regarding the Care of the dying, Communication, Teamwork, Documentation, Attitudes to death and dying in the workplace, and Barriers to the care of patients, their whānau (a NZ Māori word that refers to extended family or family group), and families frequently contrasted with additional and explanatory comments. The thematic analysis of written text identified five themes: The reality of care, The team dynamic, The direction of care, Knowledge and education, and Environmental and organizational factors. The quality and timeliness of EOL care was significantly influenced by the elements informing the themes and the pervasive nature and importance of communication. Meeting the needs of dying patients in acute care was complex but a significant priority for staff.
Suppa, Per; Anker, Ulrich; Spies, Lothar; Bopp, Irene; Rüegger-Frey, Brigitte; Klaghofer, Richard; Gocke, Carola; Hampel, Harald; Beck, Sacha; Buchert, Ralph
Hippocampal volume is a promising biomarker to enhance the accuracy of the diagnosis of dementia due to Alzheimer's disease (AD). However, whereas hippocampal volume is well studied in patient samples from clinical trials, its value in clinical routine patient care is still rather unclear. The aim of the present study, therefore, was to evaluate fully automated atlas-based hippocampal volumetry for detection of AD in the setting of a secondary care expert memory clinic for outpatients. One-hundred consecutive patients with memory complaints were clinically evaluated and categorized into three diagnostic groups: AD, intermediate AD, and non-AD. A software tool based on open source software (Statistical Parametric Mapping SPM8) was employed for fully automated tissue segmentation and stereotactical normalization of high-resolution three-dimensional T1-weighted magnetic resonance images. Predefined standard masks were used for computation of grey matter volume of the left and right hippocampus which then was scaled to the patient's total grey matter volume. The right hippocampal volume provided an area under the receiver operating characteristic curve of 84% for detection of AD patients in the whole sample. This indicates that fully automated MR-based hippocampal volumetry fulfills the requirements for a relevant core feasible biomarker for detection of AD in everyday patient care in a secondary care memory clinic for outpatients. The software used in the present study has been made freely available as an SPM8 toolbox. It is robust and fast so that it is easily integrated into routine workflow.
Murphy, Jill; Quillinan, Bernie; Carolan, Mary
Leadership in nursing plays a crucial part in the provision of good patient care. However, the terms 'nursing leadership' and 'nursing management' are often confused. This article discusses the difficulties in defining 'clinical leadership', outlines its development in the Republic of Ireland, and identifies issues that must be addressed if clinical nurse leaders are to be effective.
Hansen, Morten Rix; Kuhlmann, Ida Berglund; Pottegård, Anton
Venlafaxine is a commonly used antidepressant agent. We aimed to provide detailed information on the associations between venlafaxine dose and concentrations of venlafaxine, by patient age and sex. From a therapeutic drug monitoring (TDM) database located at Odense University Hospital, Denmark, we...... identified all adults for whom the treating physician had requested clinical advice on the TDM result for venlafaxine between 2002 and 2012. We identified 1,077 TDM samples of venlafaxine from 334 males and 743 females (median age 45 years), and the median daily dose was 225 mg. Median plasma concentration...... of venlafaxine and o-desmethyvenlafaxine (ODV) were 306 nmol/L and 861 nmol/L, respectively. The median dose-corrected serum level for venlafaxine was 1.49 nmol/L/mg., while the dose-corrected serum level of men and women were 1.21 nmol/L/mg and 1.60 nmol/L/mg, respectively. The dose-corrected sum of venlafaxine...
M S, Ajimsha; Kooven, Smithesh; Al-Mudahka, Noora
Clinical guidelines are systematically developed statements designed to help practitioners and patients to make decisions about appropriate health care. Clinical practice guideline adherence analysis is the best way to fine tune the best practices in a health care industry with international benchmarks. To assess the physical therapist's adherence to structured stroke clinical practice guidelines in an active inpatient rehabilitation center in Qatar. Department of Physical therapy in the stroke rehabilitation tertiary referral hospital in Qatar. A retrospective chart audit was performed on the clinical records of 216 stroke patients discharged from the active inpatient stroke rehabilitation unit with a diagnosis of stroke in 2016. The audit check list was structured to record the adherence of the assessment, goal settings and the management domains as per the "Physical Therapy After Acute Stroke" (PAAS) guideline. Of the 216 case files identified during the initial search, 127 files were ultimately included in the audit. Overall adherence to the clinical practice guideline was 71%, a comparable rate with the studies analyzing the same in various international health care facilities. Domains which were shared by interdisciplinary teams than managed by physical therapy alone and treatments utilizing sophisticated technology had lower adherence with the guideline. A detailed strength and weakness breakdown were then conducted. This audit provides an initial picture of the current adherence of physical therapy assessment and management with the stroke physical therapy guideline at a tertiary rehabilitation hospital in the state of Qatar. An evaluation of the guideline adherence and practice variations helps to fine tune the physical therapy care to a highest possible standard of practice. Implications for Rehabilitation • An evaluation of the guideline adherence and practice variations helps to fine tune the rehabilitation care to the highest possible standard
Thanveer, Fibin; Khunger, Niti
Context: A distressing pre-occupation with an imagined or slight defect in appearance with a marked negative effect on the patient's life is the core symptom of body dysmorphic disorder (BDD). Aim: To screen the patients attending a dermatology clinic at a tertiary care centre for BDD using the BDD-dermatology version (DV) questionnaire. Settings and Design: This cross-sectional study enrolled 245 consecutive patients from the dermatology outpatients clinic. Methods: The demographic details were collected and the DV of BDD screening questionnaire was administered. A 5-point Likert scale was used for objective scoring of the stated concern and patients who scored ≥3 were excluded from the study. Statistical Analysis Used: The results were statistically analysed. Differences between the groups were investigated by Chi-square analysis for categorical variables, and Fisher exact test wherever required. Results: A total of 177 patients completed the study, and of these, eight patients screened positive for BDD. The rate of BDD in patients presenting with cosmetic complaints was 7.5% and in those with general dermatology, complaints were 2.1%, with no significant difference between the two groups (P = 0.156). Facial flaws (62.5%) were the most common concern followed by body asymmetry (25%). Conclusion: The rates of BDD found in this study are comparable but at a lower rate than that reported in literature data. PMID:27761090
Kierkegaard, Patrick; Kaushal, Rainu; Vest, Joshua R
To determine which health information exchange (HIE) technologies and information retrieval pathways healthcare professionals relied on to meet their information needs in the context of laboratory test results, radiological images and reports, and medication histories. Primary data was collected over a 2-month period across 3 emergency departments, 7 primary care practices, and 2 public health clinics in New York state. Qualitative research methods were used to collect and analyze data from semi-structured interviews and participant observation. The study reveals that healthcare professionals used a complex combination of information retrieval pathways for HIE to obtain clinical information from external organizations. The choice for each approach was setting- and information-specific, but was also highly dynamic across users and their information needs. Our findings about the complex nature of information sharing in healthcare provide insights for informatics professionals about the usage of information; indicate the need for managerial support within each organization; and suggest approaches to improve systems for organizations and agencies working to expand HIE adoption.
Full Text Available Context: A distressing pre-occupation with an imagined or slight defect in appearance with a marked negative effect on the patient's life is the core symptom of body dysmorphic disorder (BDD. Aim: To screen the patients attending a dermatology clinic at a tertiary care centre for BDD using the BDD-dermatology version (DV questionnaire. Settings and Design: This cross-sectional study enrolled 245 consecutive patients from the dermatology outpatients clinic. Methods: The demographic details were collected and the DV of BDD screening questionnaire was administered. A 5-point Likert scale was used for objective scoring of the stated concern and patients who scored ≥3 were excluded from the study. Statistical Analysis Used: The results were statistically analysed. Differences between the groups were investigated by Chi-square analysis for categorical variables, and Fisher exact test wherever required. Results: A total of 177 patients completed the study, and of these, eight patients screened positive for BDD. The rate of BDD in patients presenting with cosmetic complaints was 7.5% and in those with general dermatology, complaints were 2.1%, with no significant difference between the two groups (P = 0.156. Facial flaws (62.5% were the most common concern followed by body asymmetry (25%. Conclusion: The rates of BDD found in this study are comparable but at a lower rate than that reported in literature data.
Al Eidan, Eidan; Ur Rahman, Saeed; Al Qahtani, Saeed; Al Farhan, Ali I; Abdulmajeed, Imad
Background and objectives : Subclinical hypothyroidism is an asymptomatic condition with normal thyroxin and raised thyroid stimulating hormone (TSH) level. The objective of the study was to determine the prevalence of subclinical hypothyroidism in primary health care (PHC) settings in Riyadh and explore the relationship of TSH level with age, gender, family history, body mass index, and co-morbid conditions. Subjects and methods : A cross-sectional study of adult visitors to nine satellites PHC clinics in military housing in Riyadh was carried out. TSH concentration and free T4 levels were measured. Data were collected by nurses and physicians during routine clinical practice in primary care. Descriptive analysis was performed on all variables in study, and relationships were explored using chi-square, t -test, analysis of variance, and linear regression. Results : A total of 340 out of 394 participants in the study gave blood samples. Subclinical hyperthyroidism was identified in 2.1% ( p = .001) and subclinical hypothyroidism in 10.3% ( p = .001) of the PHC visitors. TSH levels were found to be significantly higher ( p = .047) in elderly population of ≥60 years and those with family history of thyroid disease. Non-significant upward trends were noted in TSH levels with hyperlipidemia and increasing blood pressure. No overt hyperthyroidism or hypothyroidism was found in our study sample. Conclusion : Subclinical hypothyroidism has a prevalence of 10% of adults visiting PHC's. TSH levels are higher in the elderly, which warrants screening of those aged 60 years and above.
Tøttenborg, Sandra Søgaard; Lange, Peter; Thomsen, Reimar W
Objective: Socioeconomic differences in quality of care have been suggested to contribute to inequality in clinical prognosis of COPD. We examined socioeconomic differences in the quality of COPD outpatient care and the potential of a systematic quality improvement initiative in reducing potentia...
Talita Rocha Passos
Full Text Available Summary Since 2010, the Clinical Gastroenterology and Hepatology Division of the Central Institute of Hospital das Clínicas of