Mayer-Amberg, Norbert; Woltmann, Rainer; Walther, Stefanie
The optimal treatment of schizophrenia patients requires integration of medical and psychosocial inputs. In Germany, various healthcare service providers and institutions are involved in the treatment process. Early and continuous treatment is important but often not possible because of the fragmented medical care system in Germany. The current work is a quality monitoring report of a novel care setting, called Integrated Care Initiative Schizophrenia. It has implemented a networked care con...
Mayer-Amberg, Norbert; Woltmann, Rainer; Walther, Stefanie
The optimal treatment of schizophrenia patients requires integration of medical and psychosocial inputs. In Germany, various health-care service providers and institutions are involved in the treatment process. Early and continuous treatment is important but often not possible because of the fragmented medical care system in Germany. The Integrated Care Initiative Schizophrenia has implemented a networked care concept in the German federal state of Lower Saxony that integrates various stakeholders of the health care system. In this initiative, office-based psychiatrists, specialized nursing staff, psychologists, social workers, hospitals, psychiatric institutional outpatient's departments, and other community-based mental health services work together in an interdisciplinary approach. Much emphasis is placed on psychoeducation. Additional efforts cover socio-therapy, visiting care, and family support. During the period from October 2010 (start of the initiative) to December 2012, first experiences and results of quality indicators were collected of 713 registered patients and summarized in a quality monitoring report. In addition, standardized patient interviews were conducted, and duration of hospital days was recorded in 2013. By the end of 2012, patients had been enrolled for an average of 18.7 months. The overall patient satisfaction measured in a patient survey in June 2013 was high and the duration of hospital days measured in a pre-post analysis in July 2013 was reduced by 44%. Two years earlier than planned, the insurance fund will continue the successfully implemented Integrated Care Initiative and adopt it in the regular care setting. This initiative can serve as a learning case for how to set up and measure integrated care systems that may improve outcomes for patients suffering from schizophrenia.
Full Text Available The optimal treatment of schizophrenia patients requires integration of medical and psychosocial inputs. In Germany, various healthcare service providers and institutions are involved in the treatment process. Early and continuous treatment is important but often not possible because of the fragmented medical care system in Germany. The current work is a quality monitoring report of a novel care setting, called Integrated Care Initiative Schizophrenia. It has implemented a networked care concept in the German federal state of Lower Saxony that integrates various stakeholders of the health care system. In this initiative, office-based psychiatrists, specialised nursing staff, psychologists, social workers, hospitals, psychiatric institutional outpatient’s departments and other community-based mental health services work together in an interdisciplinary approach. Much emphasis is placed on psychoeducation. Additional efforts cover socio-therapy, visiting care, and family support. During the period from October 2010 (start of the initiative to December 2012, first experiences and results of quality indicators were collected of 713 registered patients and summarised in a quality monitoring report. In addition, standardised patient interviews were conducted, and duration of hospital days was recorded in 2013. By the end of 2012, patients had been enrolled for an average of 18.7 months. The overall patient satisfaction measured in a patient survey in June 2013 was high and the duration of hospital days measured in a pre-post analysis in July 2013 was reduced by 44%. Two years earlier than planned, the insurance fund will continue the successfully implemented integrated care initiative and adopt it in the regular care setting. This initiative can serve as a learning case for how to set up and measure integrated care systems that may improve outcomes for patients suffering from schizophrenia.
Kerkhof, P.C.M. van de
The number of tasks required of dermatologists has increased in the last decade. This article discusses potential ways to enhance the efficiency ofdermatological patient care and prevent problems of capacity. A study conducted in the UK found that, for the top 10 skin disorders, the accessibility of
Møller, M H; Larsson, Heidi Jeanet; Rosenstock, S
Mortality and morbidity are considerable after treatment for perforated peptic ulcer (PPU). Since 2003, a Danish nationwide quality-of-care (QOC) improvement initiative has focused on reducing preoperative delay, and improving perioperative monitoring and care for patients with PPU. The present...... study reports the results of this initiative....
Carlsen, Sarah; Perner, A
Fluid is the mainstay of resuscitation of patients with septic shock, but the optimal composition and volume are unknown. Our aim was to evaluate the current initial fluid resuscitation practice in patients with septic shock in the intensive care unit (ICU) and patient characteristics and outcome...
Full Text Available Background. In Haiti, breast cancer patients present at such advanced stages that even modern therapies offer modest survival benefit. Identifying the personal, sociocultural, and economic barriers-to-care delaying patient presentation is crucial to controlling disease. Methods. Patients presenting to the Hôpital Bon Sauveur in Cange were prospectively accrued. Delay was defined as 12 weeks or longer from initial sign/symptom discovery to presentation, as durations greater than this cutoff correlate with reduced survival. A matched case-control analysis with multivariate logistic regression was used to identify factors predicting delay. Results. Of N=123 patients accrued, 90 (73% reported symptom-presentation duration and formed the basis of this study: 52 patients presented within 12 weeks of symptoms, while 38 patients waited longer than 12 weeks. On logistic regression, lower education status (OR = 5.6, P=0.03, failure to initially recognize mass as important (OR = 13.0, P<0.01, and fear of treatment cost (OR = 8.3, P=0.03 were shown to independently predict delayed patient presentation. Conclusion. To reduce stage at presentation, future interventions must educate patients on the recognition of initial breast cancer signs and symptoms and address cost concerns by providing care free of charge and/or advertising that existing care is already free.
Shere-Wolfe Roger F
Full Text Available Abstract Background Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. Methods A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012. Results and conclusion Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.
Fridman, Ilona; Glare, Paul A; Stabler, Stacy M; Epstein, Andrew S; Wiesenthal, Alison; Leblanc, Thomas W; Higgins, E Tory
Negative attitudes toward hospice care might prevent patients with cancer from discussing and choosing hospice as they approach end of life. When making a decision, people often naturally focus on either expected benefits or the avoidance of harm. Behavioral research has demonstrated that framing information in an incongruent manner with patients' underlying motivational focus reduces their negative attitudes toward a disliked option. Our study tests this communication technique with cancer patients, aiming to reduce negative attitudes toward a potentially beneficial but often-disliked option, that is, hospice care. Patients (n = 42) with active cancer of different types and/or stages completed a paper survey. Participants read a vignette about a patient with advanced cancer and a limited prognosis. In the vignette, the physician's advice to enroll in a hospice program was randomized, creating a congruent message or an incongruent message with patients' underlying motivational focus (e.g., a congruent message for someone most interested in benefits focuses on the benefits of hospice, whereas an incongruent message for this patient focuses on avoiding harm). Patients' attitudes toward hospice were measured before and after receiving the physician's advice. Regression analyses indicated that information framing significantly influenced patients with strong initial negative attitudes. Patients were more likely to reduce intensity of their initial negative attitude about hospice when receiving an incongruent message (b = -0.23; P negative reactions toward hospice care. Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Szabo, Christopher Paul; Fine, Jennifer; Mayers, Pat; Naidoo, Shan; Zabow, Tuviah
Mental health leadership is a critical component of patient access to care. More specifically, the ability of mental health professionals to articulate the needs of patients, formulate strategies and engage meaningfully at the appropriate level in pursuit of resources. This is not a skill set routinely taught to mental health professionals. A public-private mental health leadership initiative, emanating from a patient access to care programme, was developed with the aim of building leadership capacity within the South African public mental health sector. The express aim was to equip health care professionals with the requisite skills to more effectively advocate for their patients. The initiative involved participants from various sites within South Africa. Inclusion was based on the proposal of an ongoing "project", i.e. a clinician-initiated service development with a multidisciplinary focus. The projects were varied in nature but all involved identification of and a plan for addressing an aspect of the participants' daily professional work which negatively impacted on patient care due to unmet needs. Six such projects were included and involved 15 participants, comprising personnel from psychiatry, psychology, occupational therapy and nursing. Each project group was formally mentored as part of the initiative, with mentors being senior professionals with expertise in psychiatry, public health and nursing. The programme design thus provided a unique practical dimension in which skills and learnings were applied to the projects with numerous and diverse outcomes. Benefits were noted by participants but extended beyond the individuals to the health institutions in which they worked and the patients that they served. Participants acquired both the skills and the confidence which enabled them to sustain the changes that they themselves had initiated in their institutions. The initiative gave impetus to the inclusion of public mental health as part of the curriculum
Lim, Siew Hoon; Chan, Sally Wai Chi; He, Hong-Gu
With the loss of an important bodily function and the distortion in body image, a stoma patient experiences physical, psychological, and social changes. With limited current studies exploring experiences of patients in the management of their stoma, there is a need to explore their experiences, their needs, and factors that influence their self-management. The aim of this study was to investigate patients' experiences of performing self-care of stomas in the initial postoperative period. This study adopted a descriptive qualitative approach from the interpretive paradigm. Semistructured interviews were conducted with 12 patients 1 month postoperatively in a colorectal ward in a hospital in Singapore. Thematic analysis was applied to the interview data. Five themes were identified: process of acceptance and self-management of stoma, physical limitations, psychological reactions, social support, and need for timely and sufficient stoma preparation and education. This study highlights the importance of health professionals' role in helping patients adjust preoperatively and postoperatively and accept the presence of a stoma. Health professionals need to be aware of the physical, psychological, and social impact of stoma on patients in the initial 30-day postoperative period. Research findings informed the type and level of assistance and support to be offered to patients by nurses and the importance of encouraging patients to be involved in stoma care at an early stage, which will ultimately contribute to effective and independent self-management. Patients can be prepared preoperatively to reduce the psychological and social impact of stoma after creation of their stoma.
Federal Laboratory Consortium — The Surgical Critical Care Initiative (SC2i) is a USU research program established in October 2013 to develop, translate, and validate biology-driven critical care....
Full Text Available Rebecca H LehtoCollege of Nursing, Michigan State University, East Lansing, MI, USAAbstract: Malignant pleural mesothelioma is a relatively rare but aggressive malignancy that is primarily associated with occupational asbestos exposure. While treatment options for mesothelioma have expanded, the disease carries a poor prognosis, with a median of 8 months to 1 year of survival postdiagnosis. This article synthesizes current disease-management practices, including the diagnostic workup, treatment modalities, emerging therapies, and symptom management, and identifies comprehensive nursing strategies that result in the best care based on updated evidence. Multidisciplinary coordination, palliative care initiation, survivorship, and end-of-life care are discussed. Findings may be applied in clinical environments as a resource to help nurses better understand treatment options and care for patients facing malignant pleural mesothelioma. Recommendations for future research are made to move nursing science forward and to improve patient well-being and health-related quality-of-life outcomes for patients and their family members.Keywords: pleural mesothelioma, cancer, symptom management, evidence-based care
Full Text Available Jeff UngerCatalina Research Institute, Chino, CA, USAAbstract: Type 2 diabetes mellitus (T2DM is characterized by both insulin resistance and inadequate insulin secretion. All patients with the disease require treatment to achieve and maintain the target glycosylated hemoglobin (A1C level of 6.5%–7%. Pharmacological management of T2DM typically begins with the introduction of oral medications, and the majority of patients require exogenous insulin therapy at some point in time. Primary care physicians play an essential role in the management of T2DM since they often initiate insulin therapy and intensify regimens over time as needed. Although insulin therapy is prescribed on an individualized basis, treatment usually begins with basal insulin added to a background therapy of oral agents. Prandial insulin injections may be added if glycemic targets are not achieved. Treatments may be intensified over time using patient-friendly titration algorithms. The goal of insulin intensification within the primary care setting is to minimize patients' exposure to chronic hyperglycemia and weight gain, and reduce patients' risk of hypoglycemia, while achieving individualized fasting, postprandial, and A1C targets. Simplified treatment protocols and insulin delivery devices allow physicians to become efficient prescribers of insulin intensification within the primary care arena.Keywords: diabetes, basal, bolus, regimens, insulin analogs, structured glucose testing
Jarrar, Mu?taman; Rahman, Hamzah Abdul; Don, Mohammad Sobri
Background and Objective: Demand for health care service has significantly increased, while the quality of healthcare and patient safety has become national and international priorities. This paper aims to identify the gaps and the current initiatives for optimizing the quality of care and patient safety in Malaysia. Design: Review of the current literature. Highly cited articles were used as the basis to retrieve and review the current initiatives for optimizing the quality of care and patie...
Full Text Available Crystal Watson,1 Christine Prosser,2 Sebastian Braun,2 Pamela B Landsman-Blumberg,3 Erika Gleissner,4 Sarah Naoshy1 1Health Economics and Outcomes Research, Global Market Access, Biogen, Cambridge, MA, USA; 2Real World Evidence, Xcenda GmbH, Hanover, Germany; 3Applied Data Analytics, Xcenda LLC, Palm Harbor, FL, USA; 4Market Access, Biogen, Ismaning, Germany Background: Multiple sclerosis (MS, a progressive neurodegenerative disease, greatly impacts the quality of life and economic status of people affected by this disease. In Germany, the total annual cost of MS is estimated at €40,000 per person with MS. Natalizumab has shown to slow MS disease progression, reduce relapses, and improve the quality of life of people with MS.Objective: To evaluate MS-related and all-cause health care resource utilization and costs among German MS patients during the 12 months before and after initiation of natalizumab in a real-world setting.Methods: The current analysis was conducted using the Health Risk Institute research database. Identified patients were aged ≥18 years with ≥1 diagnosis of MS and had initiated natalizumab therapy (index, with 12-month pre– and post–index-period data. Patients were stratified by prior disease-modifying therapy (DMT usage or no DMT usage in the pre-index period. Outcome measures included corticosteroid use and number of sick/disability days, inpatient stays, and outpatient visits. Health care costs were calculated separately for pre- and post-index periods on a per-patient basis and adjusted for inflation.Results: In a final sample of 193 natalizumab-treated patients, per-patient MS-related corticosteroid use was reduced by 62.3%, MS-related sick days by 27.6%, and inpatient costs by 78.3% from the pre- to post-index period. Furthermore, the proportion of patients with MS-related hospitalizations decreased from 49.7% to 14.0% (P<0.001; this reduction was seen for patients with and without prior DMT use
Olson, Robert A; Howard, Fuchsia; Lapointe, Vincent; Schellenberg, Devin; Nichol, Alan; Bowering, Gale; Curtis, Susan; Walter, Allison; Brown, Steven; Thompson, Corinne; Bergin, Jackie; Lomas, Sheri; French, John; Halperin, Ross; Tyldesley, Scott; Beckham, Wayne
The BC Cancer Agency Radiotherapy (RT) program started the Prospective Outcomes and Support Initiative (POSI) at all six centres to utilize patient-reported outcomes for immediate clinical care, quality improvement, and research. Patient-reported outcomes were collected at time of computed tomography simulation via tablet and 2 to 4 weeks post-RT via either tablet or over the phone by a registered nurse. From 2013 to 2016, patients were approached on 20,150 attempts by POSI for patients treated with RT for bone metastases (52%), brain metastases (11%), lung cancer (17%), gynecological cancer (16%), head and neck cancer (2%), and other pilots (2%). The accrual rate for all encounters was 85% (n = 17,101), with the accrual rate varying between the lowest and the highest accruing centre from 78% to 89% ( P < .001) and varying by tumour site ( P < .001). Using the POSI database, we have performed research and quality improvement initiatives that have changed practice.
Bagley, Kimberly A; Dunn, Sarah E; Chuang, Eliseu Y; Dorr, Victoria J; Thompson, Julie A; Smith, Sophia K
A community hospital combined its medical and surgical patients with cancer on one unit, which resulted in nurses not trained in oncology caring for this patient population. The Oncology Intensives Initiative (ONCii) involved the (a) design and implementation of a daylong didactic boot camp class and a four-hour simulation session and (b) the examination of nurses' worries, attitudes, self-efficacy, and perception of interdisciplinary teamwork. A two-group, pre-/post-test design was implemented. Group 1 consisted of nurses who attended the didactic boot camp classes alone, whereas group 2 was comprised of nurses who attended the didactic boot camp classes and the simulation sessions. Results of data analysis showed a decrease in worries and an increase in positive attitudes toward chemotherapy administration in both groups, as well as an increase in self-efficacy among members of group 2.
Eory, Ajandek; Rozsa, Sandor; Gonda, Xenia; Dome, Peter; Torzsa, Peter; Simavorian, Tatevik; Fountoulakis, Konstantinos N; Pompili, Maurizio; Serafini, Gianluca; Akiskal, Knarig K; Akiskal, Hagop S; Rihmer, Zoltan; Kalabay, Laszlo
Smoking behaviour and its course is influenced by personality factors. Affective temperaments could allow a more specific framework of the role trait affectivity plays in this seriously harmful health-behaviour. The aim of our study was to investigate if such an association exists in an ageing population with a special emphasis on gender differences. 459 primary care patients completed the TEMPS-A, Beck Depression Inventory (BDI) and Hamilton Anxiety Rating Scale (HAM-A). Subjects were characterized according to their smoking behaviour as current, former or never smokers. Univariate analysis ANOVA and logistic regression were performed to analyse differences in the three smoking subgroups to predict smoking initiation and maintenance. Current smokers were younger and less educated than former or never smokers. Males were more likely to try tobacco during their lifetime and were more successful in cessation. Depressive, cyclothymic and irritable temperament scores showed significant differences between the three smoking subgroups. Irritable temperament was a predictor of smoking initiation in females whereas depressive temperament predicted smoking maintenance in males with a small, opposite effect of HAM-A scores independent of age, education, lifetime depression and BDI scores. Whereas smoking initiation was exclusively predicted by a higher BDI score in males, smoking maintenance was predicted by younger age and lower education in females. The cross-sectional nature of the study design may lead to selective survival bias and hinder drawing causal relationships. Affective temperaments contribute to smoking initiation and maintenance independently of age, education, and depression. The significant contribution of depressive temperament in males and irritable temperament in females may highlight the role of gender-discordant temperaments in vulnerable subgroups. Copyright © 2014 Elsevier B.V. All rights reserved.
Jarrar, Mu'taman; Abdul Rahman, Hamzah; Don, Mohammad Sobri
Demand for health care service has significantly increased, while the quality of healthcare and patient safety has become national and international priorities. This paper aims to identify the gaps and the current initiatives for optimizing the quality of care and patient safety in Malaysia. Review of the current literature. Highly cited articles were used as the basis to retrieve and review the current initiatives for optimizing the quality of care and patient safety. The country health plan of Ministry of Health (MOH) Malaysia and the MOH Malaysia Annual Reports were reviewed. The MOH has set four strategies for optimizing quality and sustaining quality of life. The 10th Malaysia Health Plan promotes the theme "1 Care for 1 Malaysia" in order to sustain the quality of care. Despite of these efforts, the total number of complaints received by the medico-legal section of the MOH Malaysia is increasing. The current global initiatives indicted that quality performance generally belong to three main categories: patient; staffing; and working environment related factors. There is no single intervention for optimizing quality of care to maintain patient safety. Multidimensional efforts and interventions are recommended in order to optimize the quality of care and patient safety in Malaysia.
Jarrar, Mu’taman; Rahman, Hamzah Abdul; Don, Mohammad Sobri
Background and Objective: Demand for health care service has significantly increased, while the quality of healthcare and patient safety has become national and international priorities. This paper aims to identify the gaps and the current initiatives for optimizing the quality of care and patient safety in Malaysia. Design: Review of the current literature. Highly cited articles were used as the basis to retrieve and review the current initiatives for optimizing the quality of care and patient safety. The country health plan of Ministry of Health (MOH) Malaysia and the MOH Malaysia Annual Reports were reviewed. Results: The MOH has set four strategies for optimizing quality and sustaining quality of life. The 10th Malaysia Health Plan promotes the theme “1 Care for 1 Malaysia” in order to sustain the quality of care. Despite of these efforts, the total number of complaints received by the medico-legal section of the MOH Malaysia is increasing. The current global initiatives indicted that quality performance generally belong to three main categories: patient; staffing; and working environment related factors. Conclusions: There is no single intervention for optimizing quality of care to maintain patient safety. Multidimensional efforts and interventions are recommended in order to optimize the quality of care and patient safety in Malaysia. PMID:26755459
Full Text Available Timely diagnosis and treatment initiation are critical to reduce the chain of transmission of Tuberculosis (TB in places like Mumbai, where almost 60% of the inhabitants reside in overcrowded slums. This study documents the pathway from the onset of symptoms suggestive of TB to initiation of TB treatment and examines factors responsible for delay among uncomplicated pulmonary TB patients in Mumbai.A population-based retrospective survey was conducted in the slums of 15 high TB burden administrative wards to identify 153 self-reported TB patients. Subsequently in-depth interviews of 76 consenting patients that fit the inclusion criteria were undertaken using an open-ended interview schedule. Mean total, first care seeking, diagnosis and treatment initiation duration and delays were computed for new and retreatment patients. Patients showing defined delays were divided into outliers and non-outliers for all three delays using the median values.The mean duration for the total pathway was 65 days with 29% of patients being outliers. Importantly the mean duration of first care seeking was similar in new (24 days and retreatment patients (25 days. Diagnostic duration contributed to 55% of the total pathway largely in new patients. Treatment initiation was noted to be the least among the three durations with mean duration in retreatment patients twice that of new patients. Significantly more female patients experienced diagnostic delay. Major shift of patients from the private to public sector and non-allopaths to allopaths was observed, particularly for treatment initiation.Achieving positive behavioural changes in providers (especially non-allopaths and patients needs to be considered in TB control strategies. Specific attention is required in counselling of TB patients so that timely care seeking is effected at the time of relapse. Prioritizing improvement of environmental health in vulnerable locations and provision of point of care diagnostics
Mistry, Nerges; Rangan, Sheela; Dholakia, Yatin; Lobo, Eunice; Shah, Shimoni; Patil, Akshaya
Timely diagnosis and treatment initiation are critical to reduce the chain of transmission of Tuberculosis (TB) in places like Mumbai, where almost 60% of the inhabitants reside in overcrowded slums. This study documents the pathway from the onset of symptoms suggestive of TB to initiation of TB treatment and examines factors responsible for delay among uncomplicated pulmonary TB patients in Mumbai. A population-based retrospective survey was conducted in the slums of 15 high TB burden administrative wards to identify 153 self-reported TB patients. Subsequently in-depth interviews of 76 consenting patients that fit the inclusion criteria were undertaken using an open-ended interview schedule. Mean total, first care seeking, diagnosis and treatment initiation duration and delays were computed for new and retreatment patients. Patients showing defined delays were divided into outliers and non-outliers for all three delays using the median values. The mean duration for the total pathway was 65 days with 29% of patients being outliers. Importantly the mean duration of first care seeking was similar in new (24 days) and retreatment patients (25 days). Diagnostic duration contributed to 55% of the total pathway largely in new patients. Treatment initiation was noted to be the least among the three durations with mean duration in retreatment patients twice that of new patients. Significantly more female patients experienced diagnostic delay. Major shift of patients from the private to public sector and non-allopaths to allopaths was observed, particularly for treatment initiation. Achieving positive behavioural changes in providers (especially non-allopaths) and patients needs to be considered in TB control strategies. Specific attention is required in counselling of TB patients so that timely care seeking is effected at the time of relapse. Prioritizing improvement of environmental health in vulnerable locations and provision of point of care diagnostics would be
Kok, Maaike; van der Werff, Gertruud F M; Geerling, Jenske I; Ruivenkamp, Jaap; Groothoff, Wies; van der Velden, Annette W G; Thoma, Monique; Talsma, Jaap; Costongs, Louk G P; Gans, Reinold O B; de Graeff, Pauline; Reyners, Anna K L
Advance Care Planning (ACP) and its documentation, accessible to healthcare professionals regardless of where patients are staying, can improve palliative care. ACP is usually performed by trained facilitators. However, ACP conversations would be more tailored to a patient's specific situation if held by a patient's clinical healthcare team. This study assesses the feasibility of ACP by a patient's clinical healthcare team, and analyses the documented information including current and future problems within the palliative care domains. This multicentre study was conducted at the three Groningen Palliative Care Network hospitals in the Netherlands. Patients discharged from hospital with a terminal care indication received an ACP document from clinical staff (non-palliative care trained staff at hospitals I and II; specialist palliative care nurses at hospital III) after they had held ACP conversations. An anonymised copy of this ACP document was analysed. Documentation rates of patient and contact details were investigated, and documentation of current and future problems were analysed both quantitatively and qualitatively. One hundred sixty ACP documents were received between April 2013 and December 2014, with numbers increasing for each consecutive 3-month time period. Advance directives were frequently documented (82%). Documentation rates of current problems in the social (24%), psychological (27%) and spiritual (16%) domains were low compared to physical problems (85%) at hospital I and II, but consistently high (> 85%) at hospital III. Of 545 documented anticipated problems, 92% were physical or care related in nature, 2% social, 5% psychological, and will improve identification and documentation of non-physical problems remains to be investigated.
Walker, Mark S; Weinstein, Laura; Luo, Roger; Marino, Ingrid
Time to treatment and pretreatment costs may be affected by unknown primary tumor site. This retrospective study used electronic medical record data from patients in ten US community oncology practices. Eligible patients were ≥18 years, diagnosed with cancer of unknown primary (CUP) or known metastatic solid tumor, and presented between 1 January 2012 and 30 June 2014. Patients with CUP (n = 294) had a longer interval than non-CUP patients (n = 92) from presentation to treatment initiation (1.18 vs 0.49 months, p < 0.0001), and had higher pretreatment costs (US$27,882 vs US$20,449, p = 0.0075). When analyzed as monthly cost, the difference between groups in log-cost per month was nonsignificant. Higher pretreatment costs in CUP patients appeared attributable to significantly longer time to initiation of therapy.
Wai, Pyae Phyo; Shewade, Hemant Deepak; Kyaw, Nang Thu Thu; Thein, Saw; Si Thu, Aung; Kyaw, Khine Wut Yee; Aye, Nyein Nyein; Phyo, Aye Mon; Maung, Htet Myet Win; Soe, Kyaw Thu; Aung, Si Thu
The Union in collaboration with national TB programme (NTP) started the community-based MDR-TB care (CBMDR-TBC) project in 33 townships of upper Myanmar to improve treatment initiation and treatment adherence. Patients with MDR-TB diagnosed/registered under NTP received support through the project staff, in addition to the routine domiciliary care provided by NTP staff. Each township had a project nurse exclusively for MDR-TB and 30 USD per month (max. for 4 months) were provided to the patient as a pre-treatment support. To assess whether CBMDR-TBC project's support improved treatment initiation. In this cohort study (involving record review) of all diagnosed MDR-TB between January 2015 and June 2016 in project townships, CBMDR-TBC status was categorized as "receiving support" if date of project initiation in patient's township was before the date of diagnosis and "not receiving support", if otherwise. Cox proportional hazards regression (censored on 31 Dec 2016) was done to identify predictors of treatment initiation. Of 456 patients, 57% initiated treatment: 64% and 56% among patients "receiving support (n = 208)" and "not receiving support (n = 228)" respectively (CBMDR-TBC status was not known in 20 (4%) patients due to missing diagnosis dates). Among those initiated on treatment (n = 261), median (IQR) time to initiate treatment was 38 (20, 76) days: 31 (18, 50) among patients "receiving support" and 50 (26,101) among patients "not receiving support". After adjusting other potential confounders (age, sex, region, HIV, past history of TB treatment), patients "receiving support" had 80% higher chance of initiating treatment [aHR (0.95 CI): 1.8 (1.3, 2.3)] when compared to patients "not receiving support". In addition, age 15-54 years, previous history of TB and being HIV negative were independent predictors of treatment initiation. Receiving support under CBMDR-TBC project improved treatment initiation: it not only improved the proportion initiated but also
Godycki-Cwirko, Maciek; Esmail, Aneez; Dovey, Susan; Wensing, Michel; Parker, Dianne; Kowalczyk, Anna; Błaszczyk, Honorata; Kosiek, Katarzyna
ABSTRACT Background: Despite patient safety being recognized as an important healthcare issue in the European Union, there has been variable implementation of patient safety initiatives in Central and Eastern Europe (CEE). Objective: To assess the status of patient safety initiatives in countries in CEE; to describe a process of engagement in Poland, which can serve as a template for the implementation of patient safety initiatives in primary care. Methods: A mixed methods design was used. We conducted a review of literature focusing on publications from CEE, an inventory of patient safety initiatives in CEE countries, interviews with key informants, international survey, review of national reporting systems, and pilot demonstrator project in Poland with implementation of patient safety toolkits assessment. Results: There was no published patient safety research from Albania, Belarus, Greece, Latvia, Lithuania, Romania, or Russia. Nine papers were found from Bulgaria, Croatia, the Czech Republic, Poland, Serbia, and Slovenia. In most of the CEE countries, patient safety had been addressed at the policy level although the focus was mainly in hospital care. There was a dearth of activity in primary care. The use of patient improvement strategies was low. Conclusion: International cooperation as exemplified in the demonstrator project can help in the development and implementation of patient safety initiatives in primary care in changing the emphasis away from a blame culture to one where greater emphasis is placed on improvement and learning. PMID:26339839
Souliotis, Kyriakos; Hasardzhiev, Stanimir; Agapidaki, Eirini
Research evidence suggests that access to health care is the key influential factor for improved population health outcomes and health care system sustainability. Although the importance of addressing barriers in access to health care across European countries is well documented, little has been done to improve the situation. This is due to different definitions, approaches and policies, and partly due to persisting disparities in access within and between European countries. To bridge this gap, the Patient Access Partnership (PACT) developed (a) the '5As' definition of access, which details the five critical elements (adequacy, accessibility, affordability, appropriateness, and availability) of access to health care, (b) a multi-stakeholders' approach for mapping access, and (c) a 13-item questionnaire based on the 5As definition in an effort to address these obstacles and to identify best practices. These tools are expected to contribute effectively to addressing access barriers in practice, by suggesting a common framework and facilitating the exchange of knowledge and expertise, in order to improve access to health care between and within European countries. © 2016 S. Karger AG, Basel.
Full Text Available Jeffrey Scott Andrews,1 Ning Wu,2 Shih-Yin Chen,2 Xia Yu,2 Xiaomei Peng,1 Diego Novick1 1Global Health Outcomes, Eli Lilly and Company, Indianapolis, IN, USA; 2Evidera, Lexington, MA, USA Abstract: To describe the use of pain medications in patients with chronic low back pain (CLBP after initiating duloxetine or standard of care (SOC [muscle relaxants, gabapentin, pregabalin, venlafaxine, and tricyclic antidepressants] for pain management, pharmacy and medical claims from Surveillance Data, Inc (SDI Health were analyzed. Adult patients with CLBP who initiated duloxetine or SOC between November 2010 and April 2011 were identified. Treatment initiation was defined as no pill coverage for duloxetine or SOC in the previous 90 days. Included patients had no opioid use in the 90 days before initiation. Propensity score matching was used to select patients with similar baseline demographic and clinical characteristics for duloxetine and SOC cohorts. Compliance with index medication was assessed via medication possession ratio (MPR and proportion of days covered (PDC for 6 months after initiation. The proportion of patients receiving opioids and days on opioids after index date were assessed, and regression models were estimated to compare opioid use between cohorts. A total of 766 patients initiated duloxetine and 6,206 patients initiated SOC. After matching, 743 patients were selected for the duloxetine (mean age 57 years; female 74% and SOC (mean age 57 years; female 75% cohorts, respectively. Of the duloxetine cohort, 92% started on or below recommended daily dose (≤60 mg. The duloxetine cohort had significantly higher MPR (0.78 versus [vs] 0.60 and PDC (0.50 vs 0.31, were less likely to use opioids (45% vs 61%, and had fewer days on opioids (median 0 vs 7 days than the SOC cohort (all P < 0.001. After adjusting for demographic and clinical characteristics, the duloxetine cohort initiated opioids later than the SOC cohort (hazard ratio 0.77, 95
To test the efficacy of a novel intervention to facilitate advance care planning. . Exploratory, quasiexperimental pilot study with two independent groups. . A large hospice located in the southwestern United States. . A convenience sample of 50 participants with terminal cancer enrolled in hospice. . An autobiographical memory (ABM) intervention used the participants' experiences with cancer and end of life for the purpose of directing advance care planning. . Two domains of advance care planning, decision making and communication, were measured in relation to 11 variables. The ABM intervention was nonthreatening, short in duration, and easily completed with participants as they recalled, without hesitation, specific personal memories of family and friends who had died and their advance care plans. The Mann-Whitney nonparametric test revealed that participants in the experimental group had a higher average rank than those in the control group for communicating the decision about antibiotics, as well as exhibited a trend toward significance for five other advance care planning variables. . Findings showed that directive ABMs may be effective in influencing the decision making and communication of advance care planning for terminally ill patients with cancer. . The current level of understanding about using the ABM intervention suggests that nurses can initiate an advance care planning conversation using this approach.
Faught, Edward; Laliberté, François; Wang, Zhixiao; Barghout, Victoria; Haider, Batool; Lejeune, Dominique; Germain, Guillaume; Choi, Jiyoon; Wagh, Aneesha; Duh, Mei Sheng
The purpose of this study was to evaluate changes in health care resource utilization following the initiation of perampanel for the treatment of epilepsy in the United States. Health care claims from Symphony Health's Integrated Dataverse database between December 2012 and November 2015 were analyzed. Patients newly initiated on perampanel, having ≥1 epilepsy (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 345.xx, ICD-10-CM code G40.xxx) or nonfebrile convulsion (ICD-9-CM code 780.39, ICD-10-CM code R56.9) diagnosis, and having ≥6 months of baseline and observation periods were included. Patients <12 years old at perampanel initiation were excluded. Of the 2,508 perampanel patients included in the study, the mean [median] (±standard deviation [SD]) age was 35.8  (±16.0) years and 56.2% were female. The mean [median] (±SD) observation duration was 459.8  (±146.3) days in the postperampanel period. The postperampanel period was associated with significantly lower rates of all health care resource utilization outcomes than the pre-period. For the post- versus pre-period, perampanel users had 42.3 versus 53.8 overall hospitalizations per 100 person-years (rate ratio [RR] = 0.80, p < 0.001) and 1,240.2 versus 1,343.8 outpatient visits per 100 person-years (RR = 0.91, p < 0.001). Epilepsy-related hospitalizations and outpatient visits were 25.2 versus 33.6 per 100 person-years (RR = 0.76, p < 0.001) and 327.0 versus 389.0 per 100 person-years (RR = 0.84, p < 0.001), respectively. Additionally, a significantly lower rate of status epilepticus in the post-period (1.8 events per 100 person-years) was observed compared to the pre-period (4.4 events per 100 person-years; RR = 0.43, p < 0.001). The monthly time trend of hospitalizations showed an increasing trend leading up to the initiation of perampanel, after which the hospitalizations decreased steadily. Use of perampanel for the treatment of epilepsy was
Niranjan, Soumya J; Huang, Chao-Hui S; Dionne-Odom, J Nicholas; Halilova, Karina I; Pisu, Maria; Drentea, Patricia; Kvale, Elizabeth A; Bevis, Kerri S; Butler, Thomas W; Partridge, Edward E; Rocque, Gabrielle B
Respecting Choices is an evidence-based model of facilitating advance care planning (ACP) conversations between health-care professionals and patients. However, the effectiveness of whether lay patient navigators can successfully initiate Respecting Choices ACP conversations is unknown. As part of a large demonstration project (Patient Care Connect [PCC]), a cohort of lay patient navigators underwent Respecting Choices training and were tasked to initiate ACP conversations with Medicare beneficiaries diagnosed with cancer. This article explores PCC lay navigators' perceived barriers and facilitators in initiating Respecting Choices ACP conversations with older patients with cancer in order to inform implementation enhancements to lay navigator-facilitated ACP. Twenty-six lay navigators from 11 PCC cancer centers in 4 states (Alabama, George, Tennessee, and Florida) completed in-depth, one-on-one semistructured interviews between June 2015 and August 2015. Data were analyzed using a thematic analysis approach. This evaluation identifies 3 levels-patient, lay navigator, and organizational factors in addition to training needs that influence ACP implementation. Key facilitators included physician buy-in, patient readiness, and navigators' prior experience with end-of-life decision-making. Lay navigators' perceived challenges to initiating ACP conversations included timing of the conversation and social and personal taboos about discussing dying. Our results suggest that further training and health system support are needed for lay navigators playing a vital role in improving the implementation of ACP among older patients with cancer. The lived expertise of lay navigators along with flexible longitudinal relationships with patients and caregivers may uniquely position this workforce to promote ACP.
de Korte, J; Van Onselen, J; Kownacki, S; Sprangers, M A G; Bos, J D
Patients with psoriasis have to cope with their disease for many years or even throughout their entire life. To provide optimal care, a disease management programme was developed. This programme consisted of disease education, disease management training, and psychological support, together with topical treatment. To test a disease management programme in dermatological practice, to assess patients' satisfaction with this programme, and adherence to topical treatment. Additionally, disease severity and quality of life were assessed. An initial clinical investigation was conducted in 10 European treatment centres. A total of 330 patients were included. Patient satisfaction, adherence, disease severity and quality of life were measured with study-specific and standardized self-report questionnaires. Patients reported a high degree of satisfaction with the programme, and a high degree of adherence to topical treatment. Disease severity and quality of life significantly improved. The programme was well received by the participating professionals. The disease management programme was found to be a useful tool in the management of psoriasis, providing patients with relief from the burden of psoriasis in everyday life. A full-scale evaluation is recommended.
Stockdale, Susan E; Zuchowski, Jessica; Rubenstein, Lisa V; Sapir, Negar; Yano, Elizabeth M; Altman, Lisa; Fickel, Jacqueline J; McDougall, Skye; Dresselhaus, Timothy; Hamilton, Alison B
Although the patient-centered medical home endorses quality improvement principles, methods for supporting ongoing, systematic primary care quality improvement have not been evaluated. We introduced primary care quality councils at six Veterans Health Administration sites as an organizational intervention with three key design elements: (a) fostering interdisciplinary quality improvement leadership, (b) establishing a structured quality improvement process, and (c) facilitating organizationally aligned frontline quality improvement innovation. Our evaluation objectives were to (a) assess design element implementation, (b) describe implementation barriers and facilitators, and (c) assess successful quality improvement project completion and spread. We analyzed administrative records and conducted interviews with 85 organizational leaders. We developed and applied criteria for assessing design element implementation using hybrid deductive/inductive analytic techniques. All quality councils implemented interdisciplinary leadership and a structured quality improvement process, and all but one completed at least one quality improvement project and a toolkit for spreading improvements. Quality councils were perceived as most effective when service line leaders had well-functioning interdisciplinary communication. Matching positions within leadership hierarchies with appropriate supportive roles facilitated frontline quality improvement efforts. Two key resources were (a) a dedicated internal facilitator with project management, data collection, and presentation skills and (b) support for preparing customized data reports for identifying and addressing practice level quality issues. Overall, quality councils successfully cultivated interdisciplinary, multilevel primary care quality improvement leadership with accountability mechanisms and generated frontline innovations suitable for spread. Practice level performance data and quality improvement project management support
Loureiro, Luiz Victor Maia; Pontes, Lucíola de Barros; Callegaro-Filho, Donato; Koch, Ludmila de Oliveira; Weltman, Eduardo; Victor, Elivane da Silva; Santos, Adrialdo José; Borges, Lia Raquel Rodrigues; Segreto, Roberto Araújo; Malheiros, Suzana Maria Fleury
The aim of this study was to describe the epidemiological and survival features of patients with glioblastoma multiforme treated in 2 health care scenarios--public and private--in Brazil. We retrospectively analyzed clinical, treatment, and outcome characteristics of glioblastoma multiforme patients from 2003 to 2011 at 2 institutions. The median age of the 171 patients (117 public and 54 private) was 59.3 years (range, 18-84). The median survival for patients treated in private institutions was 17.4 months (95% confidence interval, 11.1-23.7) compared with 7.1 months (95% confidence interval, 3.8-10.4) for patients treated in public institutions (P public setting (median of 64 days for the public hospital and 31 days for the private institution; P = .003). The patients at the private hospital received radiotherapy concurrent with chemotherapy in 59.3% of cases; at the public hospital, only 21.4% (P Brazil is critical.
Mahmut Yaşar Çeliker
Full Text Available Cancer care with curative intent remains difficult to manage in many resource-limited settings such as Cambodia. Cambodia has a small workforce with limited financial and health-care resources resulting in delayed diagnoses and availability of limited therapeutic tools. Thus, palliative care becomes the primary form of care in most cases. Although palliative care is becoming an integral part of medical care in developed countries, this concept remains poorly understood and utilized in developing countries. Angkor Hospital for Children serves a relatively large pediatric population in northern Cambodia. According to the modern definition of palliative care, approximately two-thirds of the patients admitted to the hospital were deemed candidates to receive palliative care. In an effort to develop a pediatric palliative care team utilizing existing resources and intensive training, our focus group recruited already existing teams with different health-care expertise and other motivated members of the hospital. During this process, we have also formed a palliative care training team of local experts to maintain ongoing palliative care education. Feedback from patients and health-care providers confirmed the effectiveness of these efforts. In conclusion, palliative and sustainable care was offered effectively in a resource-limited setting with adequately trained and motivated local providers. In this article, the steps and systems used to overcome challenges in Cambodia are summarized in the hope that our experience urges governmental and non-governmental agencies to support similar initiatives.
Çeliker, Mahmut Yaşar; Pagnarith, Yos; Akao, Kazumi; Sophearin, Dim; Sorn, Sokchea
Cancer care with curative intent remains difficult to manage in many resource-limited settings such as Cambodia. Cambodia has a small workforce with limited financial and health-care resources resulting in delayed diagnoses and availability of limited therapeutic tools. Thus, palliative care becomes the primary form of care in most cases. Although palliative care is becoming an integral part of medical care in developed countries, this concept remains poorly understood and utilized in developing countries. Angkor Hospital for Children serves a relatively large pediatric population in northern Cambodia. According to the modern definition of palliative care, approximately two-thirds of the patients admitted to the hospital were deemed candidates to receive palliative care. In an effort to develop a pediatric palliative care team utilizing existing resources and intensive training, our focus group recruited already existing teams with different health-care expertise and other motivated members of the hospital. During this process, we have also formed a palliative care training team of local experts to maintain ongoing palliative care education. Feedback from patients and health-care providers confirmed the effectiveness of these efforts. In conclusion, palliative and sustainable care was offered effectively in a resource-limited setting with adequately trained and motivated local providers. In this article, the steps and systems used to overcome challenges in Cambodia are summarized in the hope that our experience urges governmental and non-governmental agencies to support similar initiatives. PMID:28804708
Full Text Available The article looks at how for severe trauma, the outcome of treatment depends on the initial medical care. This has now also been accepted for whiplash associated disorders, underlining the importance of a proper initial assessment. Once major injury has been excluded and the diagnosis of whiplash associated disorder has been established, the initial treatment of whiplash in the emergency room can be started. The four key points to remember are described, including reassuring the patient about evolution, no soft collar, nonsteroidal anti-inflammatory drugs and early mobilisation.
Decreased health care utilization and health care costs in the inpatient and emergency department setting following initiation of ketogenic diet in pediatric patients: The experience in Ontario, Canada.
Whiting, Sharon; Donner, Elizabeth; RamachandranNair, Rajesh; Grabowski, Jennifer; Jetté, Nathalie; Duque, Daniel Rodriguez
To assess the change in inpatient and emergency department utilization and health care costs in children on the ketogenic diet for treatment of epilepsy. Data on children with epilepsy initiated on the ketogenic diet (KD) Jan 1, 2000 and Dec 31, 2010 at Ontario pediatric hospitals were linked to province wide inpatient, emergency department (ED) data at the Institute for Clinical Evaluative Sciences. ED and inpatient visits and costs for this cohort were compared for a maximum of 2 years (730days) prior to diet initiation and for a maximum of 2 years (730days) following diet initiation. KD patient were compared to matched group of children with epilepsy who did not receive the ketogenic diet (no KD). Children on the KD experienced a mean decrease in ED visits of 2.5 visits per person per year [95% CI (1.5-3.4)], and a mean decrease of 0.8 inpatient visits per person per year [95% CI (0.3-1.3)], following diet initiation. They had a mean decrease in ED costs of $630 [95% CI (249-1012)] per person per year and a median decrease in inpatient costs of $1059 [IQR: 7890; pdiet experienced a mean reduction of 2.1 ED visits per child per year [95% CI (1.0-3.2)] and a mean decrease of 0.6 [95% CI (0.1-1.1)] inpatient visits per child per year. Patients on the KD experienced a reduction of $442 [95% CI (34.4-850)] per child per year more in ED costs than the matched group. The ketogenic diet group had greater median decrease in inpatient costs per child per year than the matched group [pketogenic diet, experienced decreased ED and inpatient visits as well as costs following diet initiation in Ontario, Canada. Copyright © 2017 Elsevier B.V. All rights reserved.
Full Text Available Purpose: The aims of this study were to determine the acceptability levels of different styles of the doctors′ dress and the expectations from the initial phases of physician-patient encounter. Methods: The study design was a cross-sectional descriptive type using the survey methodology. A survey based on a five-point questionnaire was performed on all consecutive patients or their caregivers, aged ≥15, visiting the ophthalmic plastics outpatient clinics at a tertiary eye care institute. The participants were shown three sets of photographs and were required to answer a questionnaire which consisted of five questions. Data collected include participant demographics and their preferences with regards to the physician′s attire and initial communications. Results: A total of 300 consecutive responses were analyzed. The mean age of the participants was 37.2 years. Among the participants, 87.6% (263/300 and 90.3% (271/300 preferred a white coat for the male and female physicians, respectively (P < 0.001. The most common second preference was scrubs for both the males and female physicians. 92.3% (277/300 preferred the attire to have an identification display. The overwhelming majority of respondents (95.6%, 287/300 preferred the physicians to address them by their name and 98.6% (296/300 liked if their physicians smiled while addressing them. Conclusions: White coat was the main preferred attire among respondents. Increased awareness of the patient′s expectations plays a crucial role in enhancing their satisfaction.
Balcou-Debussche, M; Debussche, X
This study focused on issues in the education of type 2 diabetes patients in primary care on Reunion Island which, in a medical context, is broadly similar to metropolitan France, but with a much greater prevalence of diabetes. The aim was to assess the perceptions, training, reported practices and needs of health care providers in the field of patient education in advance of the initiation of a health care management network for diabetic patients. A total of 74 physicians and 63 nurses completed a detailed questionnaire comprising 52 items divided into six parts: professional activity, initial and postgraduate training, educational practices, objectives of patient education, perceived barriers and prospects for optimization. Educational activities for patients are almost nonexistent. Information and explanations given during a face-to-face encounter with the physician or nurse that combine technical and caring approaches are the main reasons reported for patient education. The obstacles reported by professionals that need to be overcome are limited available time, patient passivity and inadequate staff training. Practitioners and nurses are poorly taught as regards patient education and self-management of chronic diseases. The suggested improvements include professional acknowledgement, more convenient and available tools and improved postgraduate training. Patient education in primary care is still mostly an illusion, with many gaps that hinder education for both patients and professionals. The training of health professionals needs to meet the challenge of chronic diseases by integrating aspects from the fields of education and the social sciences.
Gajic, Ognjen; Malinchoc, Michael; Comfere, Thomas B.; Harris, Marcelline R.; Achouiti, Ahmed; Yilmaz, Murat; Schultz, Marcus J.; Hubmayr, Rolf D.; Afessa, Bekele; Farmer, J. Christopher
OBJECTIVE: Unplanned readmission of hospitalized patients to an intensive care unit (ICU) is associated with a worse outcome, but our ability to identify who is likely to deteriorate after ICU dismissal is limited. The objective of this study is to develop and validate a numerical index, named the
Asiimwe, Stephen B; Kanyesigye, Michael; Bwana, Bosco; Okello, Samson; Muyindike, Winnie
In sub-Saharan Africa (SSA), antiretroviral therapy (ART) can prolong life for HIV-infected patients. However, patients initiating ART, especially in routine treatment programs, commonly dropout from care either due to death or loss to follow-up. In a cohort of HIV-infected patients initiating ART at a public sector clinic in Uganda, we assessed predictors of dropout from care (a composite outcome combining death and loss to follow-up). From a large set of socio-demographic, clinical, and laboratory variables routinely collected at ART initiation, we selected those predicting dropout at P dropout at P dropout was 26.9% (established cumulative mortality = 2.3%, loss to follow-up = 24.6%), 5.6% were transferred to other service providers, and 67.5% were retained in care. A diagnosis of Kaposi's sarcoma (hazard ratio (HR) = 3.3, 95% CI 2.5 to 4.5); HIV-associated dementia (HR = 2.6, 95% CI 1.5 to 4.6); history of cryptococcosis (HR = 2.2, 95% CI 1.4 to 3.3); and reduced hemoglobin concentration (dropout. Other independent predictors of dropout were: year of ART initiation; weight loss ≥10%; reduced total lymphocyte count; chronic diarrhea; male sex; young age (≤28 years); and marital status. Among HIV-infected patients initiating ART at a public sector clinic in SSA, biological factors that usually predict death were especially predictive of dropout. As most of the dropouts were lost to follow-up, this observation suggests that many losses to follow-up may have died. Future studies are needed to identify appropriate interventions that may improve both individual-level patient outcomes and outcome ascertainment among HIV-infected ART initiators in this setting.
Jan L. Losby
Full Text Available Objectives: Increasing demands on primary care providers have created a need for systems-level initiatives to improve primary care delivery. The purpose of this article is to describe and present outcomes for 2 such initiatives: the Pennsylvania Academy of Family Physicians’ Residency Program Collaborative (RPC and the St Johnsbury Vermont Community Health Team (CHT. Methods: Researchers conducted case studies of the initiatives using mixed methods, including secondary analysis of program and electronic health record data, systematic document review, and interviews. Results: The RPC is a learning collaborative that teaches quality improvement and patient centeredness to primary care providers, residents, clinical support staff, and administrative staff in residency programs. Results show that participation in a higher number of live learning sessions resulted in a significant increase in patient-centered medical home recognition attainment and significant improvements in performance in diabetic process measures including eye examinations (14.3%, P = .004, eye referrals (13.82%, P = .013, foot examinations (15.73%, P = .003, smoking cessation (15.83%, P = .012, and self-management goals (25.45%, P = .001. As a community-clinical linkages model, CHT involves primary care practices, community health workers (CHWs, and community partners. Results suggest that CHT members successfully work together to coordinate comprehensive care for the individuals they serve. Further, individuals exposed to CHWs experienced increased stability in access to health insurance ( P = .001 and prescription drugs ( P = .000 and the need for health education counseling ( P = .000. Conclusion: Findings from this study indicate that these 2 system-level strategies have the promise to improve primary care delivery. Additional research can determine the extent to which these strategies can improve other health outcomes.
Berkhof, Farida F; van den Berg, Jan W K; Uil, Steven M; Kerstjens, Huib A M
Telemedicine, care provided by electronic communication, may serve as an alternative or extension to traditional outpatient visits. This pilot study determined the effects of telemedicine on health-care utilization and health status of chronic obstructive pulmonary disease (COPD) patients. One hundred and one patients were randomized, 52 patients received telemedicine care and 49 had traditional outpatient visits. The primary outcome was COPD-specific health status, measured with the Clinical COPD Questionnaire (CCQ). Secondary outcomes included St. George's Respiratory Questionnaire (SGRQ) and the Short Form-36 (SF-36) and resource use in primary and secondary care. The mean age of the participants was 68 ± 9 years and the mean per cent of predicted forced expiratory volume in 1 s was 40.4 ± 12.5. The CCQ total score deteriorated by 0.14 ± 0.13 in the telemedicine group, and improved by -0.03 ± 0.14 in the control group (difference 0.17 ± 0.19, 95% confidence interval (CI): -0.21-0.55, P = 0.38). The CCQ symptom domain showed a significant and clinically relevant difference in favour of the control group, 0.52 ± 0.24 (95% CI: 0.04-0.10, P = 0.03). Similar results were found for the SGRQ, whereas results for SF-36 were inconsistent. Patients in the control group had significantly fewer visits to the pulmonologist in comparison to patients in the telemedicine group (P = 0.05). The same trend, although not significant, was found for exacerbations after 6 months. This telemedicine model of initiated phone calls by a health-care provider had a negative effect on health status and resource use in primary and secondary care, in comparison with usual care and therefore cannot be recommended in COPD patients in its current form. © 2014 Asian Pacific Society of Respirology.
McClellan, Sean R; Panattoni, Laura; Chan, Albert S; Tai-Seale, Ming
Few studies have examined the association between patient-initiated electronic messaging (e-messaging) and clinical outcomes in fee-for-service settings. To estimate the association between patient-initiated e-messages and quality of care among patients with diabetes and hypertension. Longitudinal observational study from 2009 to 2013. In March 2011, the medical group eliminated a $60/year patient user fee for e-messaging and established a provider payment of $3-5 per patient-initiated e-message. Quality of care for patients initiating e-messages was compared before and after March 2011, relative to nonmessaging patients. Propensity score weighting accounted for differences between e-messaging and nonmessaging patients in generalized estimating equations. Large multispecialty practice in California compensating providers' fee-for-service. Patients with diabetes (N=4232) or hypertension (N=15,463) who had activated their online portal but not e-messaged before e-messaging became free. Quality of care included HEDIS-based process measures for hemoglobin (Hb) A1c, blood pressure, low-density lipoprotein (LDL), nephropathy, and retinopathy tests, and outcome measures for HbA1c, blood pressure, and LDL. E-messaging was measured as counts of patient-initiated e-message threads sent to providers. Patients were categorized into quartiles by e-messaging frequency. The probability of annually completing indicated tests increased by 1%-7% for e-messaging patients, depending on the outcome and e-messaging frequency. E-messaging was associated with small improvements in HbA1c and LDL for some patients with diabetes. Patient-initiated e-messaging may increase the likelihood of completing recommended tests, but may not be sufficient to improve clinical outcomes for most patients with diabetes or hypertension without additional interventions.
Full Text Available OBJECTIVE: To describe patient antiretroviral therapy (cART outcomes associated with intensive decentralization of services in a rural HIV program in Malawi. METHODS: Longitudinal analysis of data from HIV-infected patients starting cART between August 2001 and December 2008 and of a cross-sectional immunovirological assessment conducted 12 (±2 months after therapy start. One-year mortality, lost to follow-up, and attrition (deaths and lost to follow-up rates were estimated with exact Poisson 95% confidence intervals (CI by type of care delivery and year of initiation. Association of virological suppression (<50 copies/mL and immunological success (CD4 gain ≥100 cells/µL, with type of care was investigated using multiple logistic regression. RESULTS: During the study period, 4322 cART patients received centralized care and 11,090 decentralized care. At therapy start, patients treated in decentralized health facilities had higher median CD4 count levels (167 vs. 130 cell/µL, P<0.0001 than other patients. Two years after cART start, program attrition was lower in decentralized than centralized facilities (9.9 per 100 person-years, 95% CI: 9.5-10.4 vs. 20.8 per 100 person-years, 95% CI: 19.7-22.0. One year after treatment start, differences in immunological success (adjusted OR=1.23, 95% CI: 0.83-1.83, and viral suppression (adjusted OR=0.80, 95% CI: 0.56-1.14 between patients followed at centralized and decentralized facilities were not statistically significant. CONCLUSIONS: In rural Malawi, 1- and 2-year program attrition was lower in decentralized than in centralized health facilities and no statistically significant differences in one-year immunovirological outcomes were observed between the two health care levels. Longer follow-up is needed to confirm these results.
Thengilsdóttir, G; Pottegård, Anton; Linnet, K
BACKGROUND: Primary non-adherence occurs when a drug has been prescribed but the patient fails to have it dispensed at the pharmacy. AIMS: To assess primary non-adherence to statins and antidepressants in Iceland, the association of demographic factors with primary non-adherence, and the time fro...
Fradgley, Elizabeth A; Paul, Christine L; Bryant, Jamie; Roos, Ian A; Henskens, Frans A; Paul, David J
With increasing attention given to the quality of chronic disease care, a measurement approach that empowers consumers to participate in improving quality of care and enables health services to systematically introduce patient-centered initiatives is needed. A Web-based survey with complex adaptive questioning and interactive survey items would allow consumers to easily identify and prioritize detailed service initiatives. The aim was to develop and test a Web-based survey capable of identifying and prioritizing patient-centered initiatives in chronic disease outpatient services. Testing included (1) test-retest reliability, (2) patient-perceived acceptability of the survey content and delivery mode, and (3) average completion time, completion rates, and Flesch-Kincaid reading score. In Phase I, the Web-based Consumer Preferences Survey was developed based on a structured literature review and iterative feedback from expert groups of service providers and consumers. The touchscreen survey contained 23 general initiatives, 110 specific initiatives available through adaptive questioning, and a relative prioritization exercise. In Phase II, a pilot study was conducted within 4 outpatient clinics to evaluate the reliability properties, patient-perceived acceptability, and feasibility of the survey. Eligible participants were approached to complete the survey while waiting for an appointment or receiving intravenous therapy. The age and gender of nonconsenters was estimated to ascertain consent bias. Participants with a subsequent appointment within 14 days were asked to complete the survey for a second time. A total of 741 of 1042 individuals consented to participate (71.11% consent), 529 of 741 completed all survey content (78.9% completion), and 39 of 68 completed the test-retest component. Substantial or moderate reliability (Cohen's kappa>0.4) was reported for 16 of 20 general initiatives with observed percentage agreement ranging from 82.1%-100.0%. The majority of
Paul, Christine L; Bryant, Jamie; Roos, Ian A; Henskens, Frans A; Paul, David J
Background With increasing attention given to the quality of chronic disease care, a measurement approach that empowers consumers to participate in improving quality of care and enables health services to systematically introduce patient-centered initiatives is needed. A Web-based survey with complex adaptive questioning and interactive survey items would allow consumers to easily identify and prioritize detailed service initiatives. Objective The aim was to develop and test a Web-based survey capable of identifying and prioritizing patient-centered initiatives in chronic disease outpatient services. Testing included (1) test-retest reliability, (2) patient-perceived acceptability of the survey content and delivery mode, and (3) average completion time, completion rates, and Flesch-Kincaid reading score. Methods In Phase I, the Web-based Consumer Preferences Survey was developed based on a structured literature review and iterative feedback from expert groups of service providers and consumers. The touchscreen survey contained 23 general initiatives, 110 specific initiatives available through adaptive questioning, and a relative prioritization exercise. In Phase II, a pilot study was conducted within 4 outpatient clinics to evaluate the reliability properties, patient-perceived acceptability, and feasibility of the survey. Eligible participants were approached to complete the survey while waiting for an appointment or receiving intravenous therapy. The age and gender of nonconsenters was estimated to ascertain consent bias. Participants with a subsequent appointment within 14 days were asked to complete the survey for a second time. Results A total of 741 of 1042 individuals consented to participate (71.11% consent), 529 of 741 completed all survey content (78.9% completion), and 39 of 68 completed the test-retest component. Substantial or moderate reliability (Cohen’s kappa>0.4) was reported for 16 of 20 general initiatives with observed percentage agreement
McGuire, Megan; Pinoges, Loretxu; Kanapathipillai, Rupa; Munyenyembe, Tamika; Huckabee, Martha; Makombe, Simon; Szumilin, Elisabeth; Heinzelmann, Annette; Pujades-Rodríguez, Mar
To describe patient antiretroviral therapy (cART) outcomes associated with intensive decentralization of services in a rural HIV program in Malawi. Longitudinal analysis of data from HIV-infected patients starting cART between August 2001 and December 2008 and of a cross-sectional immunovirological assessment conducted 12 (±2) months after therapy start. One-year mortality, lost to follow-up, and attrition (deaths and lost to follow-up) rates were estimated with exact Poisson 95% confidence intervals (CI) by type of care delivery and year of initiation. Association of virological suppression (centralized care and 11,090 decentralized care. At therapy start, patients treated in decentralized health facilities had higher median CD4 count levels (167 vs. 130 cell/µL, Pdecentralized than centralized facilities (9.9 per 100 person-years, 95% CI: 9.5-10.4 vs. 20.8 per 100 person-years, 95% CI: 19.7-22.0). One year after treatment start, differences in immunological success (adjusted OR=1.23, 95% CI: 0.83-1.83), and viral suppression (adjusted OR=0.80, 95% CI: 0.56-1.14) between patients followed at centralized and decentralized facilities were not statistically significant. In rural Malawi, 1- and 2-year program attrition was lower in decentralized than in centralized health facilities and no statistically significant differences in one-year immunovirological outcomes were observed between the two health care levels. Longer follow-up is needed to confirm these results.
Burger, Charles D; Ozbay, A Burak; Lazarus, Howard M; Riehle, Ellen; Montejano, Leslie B; Lenhart, Gregory; White, R James
Despite multiple treatment options, the prognosis of pulmonary arterial hypertension (PAH) remains poor. PAH patients experience a high economic burden due to comorbidities, hospitalizations, and medication costs. Although combination therapy has been shown to reduce hospitalizations, the relationship between treatment, health care utilization, and costs remains unclear. To provide a characterization of health care utilization and costs in real-world settings by comparing periods before and after initiating PAH-specific treatment. This retrospective study identified PAH patients in the Truven Health MarketScan Commercial and Medicare Supplemental Databases between 2010 and 2014 who initiated treatment with endothelin receptor antagonists (ERAs), phosphodiesterase-5 inhibitors (PDE-5Is), or soluble guanylate cyclase (sGC) stimulators. The index date was the date of the first PAH pharmacy claim. We included patients with ≥ 2 medical claims with diagnoses for PAH (ICD-9-CM: 416.0, 416.8) or PAH-related conditions and continuous enrollment in medical and pharmacy benefits for the 6 months before and after the index date. Treatment patterns were assessed at the drug class level (ERAs, PDE-5Is, sGC stimulators, and prostacyclins) from outpatient pharmacy claims during the 6-month post-index period. All-cause and PAH-related utilization and costs were measured. McNemar's and paired t-tests were used to compare patients' health care resource utilization and costs in the 6-month pre- and posttreatment periods. A total of 3,908 patients met the selection criteria. The study sample was 63% female with a mean age of 63 ± 15 years. Only 5% of patients began initial combination therapy for PAH, defined as claims for ≥ 2 medication classes within the first 30 days of treatment. Treatment interruption (≥ 30-day gap in days supply) of any PAH-specific medication was observed in 38% of patients. Compared with the 6-month pre-index period, the proportion of patients in the 6
Interpretation & conclusions: This study identified some socio-demographic and clinical variables which might predict treatment attrition in substance use disorders. Clinician's awareness towards these factors and tailor-made intervention might improve initial treatment retention. Future research could be directed to find the validity of this assumption.
Full Text Available Aim: to analyze the safety and efficacy of early insulin initiation therapy for patients with type 2 diabetes mellitus (T2DM in primary health care provided by general practitioners (GPs in Surabaya, East Java, Indonesia. Methods: pre-post study of ninety nine diabetic patients without previous insulin treatment with HbA1c levels >8% were involved in this study. The study was conducted in 10 primary health care centers in Surabaya between October 2011 to June 2012. Each patient received insulin therapy for 12 weeks. Laboratory examination was performed for each patient including fasting plasma glucose (FPG, 2 hours post-prandial plasma glucose (2hPPG and HbA1c examination before and after the study. Self monitoring blood glucose (SMBG examination was conducted in order to adjust the insulin dose and prevent the incidence of hypoglycemia. Data was statistically analyzed using paired-T test. Results: FPG level was decreased from baseline data (209 mg/dL to 152.07 mg/dL at the end of the study (Δ56.93 mg/dl; p=0.0001. The average of 2hPPG level was also decreased from 313.00 mg/dl to 220.72 mg/dL (Δ 92.28 mg/dL; p=0.0001. HbA1c was reduced from 11.60% at baseline to 8.95% at the end of study (Δ 2.65%; p=0.0001. Hypoglycemia was found in 6 patients (6.06% in this study, but all events were mild and did not need to be admitted to hospital. Conclusion: the safety of insulin therapy iniatiation might be provided by GPs at primary health centers with significant efficacy and minimal side effects. Key words: insulin, general practioner, primary health center.
Bro Brask, Kirsten; Birkelund, Regner
The aim of this study was to research how the staff experience care expressed during the brief encounter with the patients in a diagnostic imaging department. This was a qualitative study with a phenomenological and hermeneutical frame of reference. The data were collected using field observation...... was electronically forwarded. And, care expressed in between was perceived as care in the traditional sense and termed as “patient care in radiology.”...
Woestelandt, Laure; Touhami, Fatima; Radjack, Rahmeth; Moro, Marie Rose; Lachal, Jonathan
The various traumatic events experienced by young isolated foreigners can weaken them psychologically and cause psychiatric decompensation. A qualitative study, carried out by the Maison de Solenn and the Avicenne hospital, aimed to provide better understanding of the conditions for initiating psychiatric care with these adolescents. The different results show that this type of care for these young migrants must be cross-cultural and multi-disciplinary. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
...] Medicare Program; Comprehensive Primary Care Initiative AGENCY: Centers for Medicare & Medicaid Services... organizations to participate in the Comprehensive Primary Care initiative (CPC), a multipayer model designed to... the Comprehensive Primary Care initiative or the application process. SUPPLEMENTARY INFORMATION: I...
Ilknur Can, MD
Full Text Available Syncope is a common clinical problem, but nevertheless is but one element of the broader issue of ‘transient loss of consciousness’ (TLOC. The first step is to ascertain whether the patient actually suffered a syncopal episode, and thereafter the goal must be to determine the basis of symptoms with sufficient confidence to assess prognosis and initiate an effective treatment strategy. The initial evaluation of these patients, which usually takes place in an emergency department (ED. or acute care facility, is challenging since patients are usually asymptomatic when they come for medical attention, may have little or no recall of the event, and witnesses, if any, often cannot provide reliable information. Given these circumstances, it is understandable that frontline physicians often tend to take a seemingly ‘safe’ approach, and admit both high-risk and intermediate-risk syncope patients to hospital. This strategy has many implications, including life-style and economic concerns for the patient, and health care management issues for physicians, hospital administrators and the overall health care system. The European Society of Cardiology (ESC. guidelines and several clinical studies provide helpful advice regarding “risk stratification” to help guide physicians in selecting patients for either early hospital admission or later oupatient subspeciality evaluation. The utility of syncope management units in the ED, and a guideline-based approach to the syncope patient, has tended to both diminish the number of undiagnosed cases and reduce the hospital admission rate. In this review, we have attempted to both highlight a cost-effective diagnostic pathway beginning with the initial evaluation of the patient with suspected syncope, and to provide criteria which may help frontline physicians better base their decisions regarding need for in-hospital versus outpatient clinic evaluation of syncope patients.
Ehrlich, R.A.; McCloskey, E.D.
This book focuses on patient care procedures for radiographers. The authors focus on the role of the radiographer as a member of the health care team. The authors report on such topics as communication in patient care: safety, medico-legal considerations, transfer and positioning; physical needs; infection control; medication; CPR standards, acute situations; examination of the GI tract; contrast media; special imaging techniques and bedside radiography
opportunities for continuing medical education (CME) and poor patient ... related to insulin therapy, language barriers between doctor and patients, and fear of ..... of primary health care professionals regarding initiation of insulin in primary ...
Impact of participation in the California Healthcare-Associated Infection Prevention Initiative on adoption and implementation of evidence-based practices for patient safety and health care-associated infection rates in a cohort of acute care general hospitals.
Halpin, Helen Ann; McMenamin, Sara B; Simon, Lisa Payne; Jacobsen, Diane; Vanneman, Megan; Shortell, Stephen; Milstein, Arnold
In 2008, hospitals were selected to participate in the California Healthcare-Associated Infection Prevention Initiative (CHAIPI). This research evaluates the impact of CHAIPI on hospital adoption and implementation of evidence-based patient safety practices and reduction of health care-associated infection (HAI) rates. Statewide computer-assisted telephone surveys of California's general acute care hospitals were conducted in 2008 and 2010 (response rates, 80% and 76%, respectively). Difference-in-difference analyses were used to compare changes in process and HAI rate outcomes in CHAIPI hospitals (n = 34) and non-CHAIPI hospitals (n = 149) that responded to both waves of the survey. Compared with non-CHAIPI hospitals, CHAIPI hospitals demonstrated greater improvements between 2008 and 2010 in adoption (P = .021) and implementation (P = .012) of written evidence-based practices for overall patient safety and prevention of HAIs and in assessing their compliance (P = .033) with these practices. However, there were no significant differences in the changes in HAI rates between CHAIPI and non-CHAIPI hospitals over this time period. Participation in the CHAIPI collaborative was associated with significant improvements in evidence-based patient safety practices in hospitals. However, determining how evidence-based practices translate into changes in HAI rates may take more time. Our results suggest that all hospitals be offered the opportunity to participate in an active learning collaborative to improve patient safety. Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.
Background A constructive patient safety culture is a main prerequisite for patient safety and improvement initiatives. Until now, patient safety culture (PSC) research was mainly focused on hospital care, however, it is of equal importance in primary care. Measuring PSC informs practices on their
The ED at Gaston Memorial Hospital in Gastonia, NC, has achieved dramatic results in key department metrics with a Care Initiation Area (CIA) and a physician in triage. Here's how the ED arrived at this winning solution: Leadership was trained in and implemented the Kaizen method, which eliminates redundant or inefficient process steps. Simulation software helped determine additional space needed by analyzing arrival patterns and other key data. After only two days of meetings, new ideas were implemented and tested.
Full Text Available Background: Increase in life expectancy of Indians will require revamping the health-care infrastructure for the elderly. In India, either there are not too many specialized geriatric mental health services available across the country or those that are available have problems of resources and quality. With this perspective, the Department of Psychiatry, Government Medical College and Hospital, Chandigarh, developed the Geriatric Mental Health Clinic (GMHC for the elderly residing in and around Chandigarh. The aim of the study was to study the initial 1-year cohort and assess their satisfaction levels as well as to see whether their functioning improves with the intervention so provided. Materials and Methods: Using the “service evaluation framework,” the patients and caregivers who attended the GMHC over a period of 1 year were evaluated using tools such as Hindi Mental State Examination (HMSE, Everyday Abilities Scale for India (EASI, Global Assessment of Function (GAF scale, World Health Organization quality of life-BREF (WHO-QoL-BREF-Hindi version, and Patient Satisfaction Scale (PAT-SAT. In addition, sociodemographic and clinical profile data of the service users were compiled. Results: A total of 105 cases formed the cohort under study, wherein 70% had functional psychiatric illness and almost more than half of the cases had comorbid physical illness, hypertension being the most common. GAF score of 45.42 and WHO-QoL-BREF score of 78.7 at the time of follow-up suggested that there was “slight impairment in socio-occupational functioning” and “poor QoL,” respectively. However, GAF and HMSE scores were significantly decreased in those with organicity. Overall service users reported good service-cum-clinician satisfaction scores on PAT-SAT; there was also significant reduction of EASI score from that of baseline, suggesting improvement in functioning. Conclusions: Findings show that the newly started GMHC, even though in its
Nedjat-Haiem, Frances R; Carrion, Iraida V; Gonzalez, Krystana; Ell, Kathleen; Thompson, Beti; Mishra, Shiraz I
Numerous factors impede effective and timely end-of-life (EOL) care communication. These factors include delays in communication until patients are seriously ill and/or close to death. Gaps in patient-provider communication negatively affect advance care planning and limit referrals to palliative and hospice care. Confusion about the roles of various health care providers also limits communication, especially when providers do not coordinate care with other health care providers in various disciplines. Although providers receive education regarding EOL communication and care coordination, little is known about the roles of all health care providers, including nonphysician support staff working with physicians to discuss the possibility of dying and help patients prepare for death. This study explores the perspectives of physicians, nurses, social workers, and chaplains on engaging seriously ill patients and families in EOL care communication. Qualitative data were from 79 (medical and nonmedical) providers practicing at 2 medical centers in Central Los Angeles. Three themes that describe providers' perceptions of their roles and responsibility in talking with seriously ill patients emerged: (1) providers' roles for engaging in EOL discussions, (2) responsibility of physicians for initiating and leading discussions, and (3) need for team co-management patient care. Providers highlighted the importance of beginning discussions early by having physicians lead them, specifically due to their medical training and need to clarify medical information regarding patients' prognosis. Although physicians are a vital part of leading EOL communication, and are at the center of communication of medical information, an interdisciplinary approach that involves nurses, social workers, and chaplains could significantly improve patient care.
Latinos comprise nearly 16 percent of the U.S. population, and this proportion is anticipated to increase to 30 percent by 2050. Latinos are a diverse ethnic group that includes many different cultures, races, and nationalities. Barriers to care have resulted in striking disparities in quality of health care for these patients. These barriers include language, lack of insurance, different cultural beliefs, and in some cases, illegal immigration status, mistrust, and illiteracy. The National Standards for Culturally and Linguistically Appropriate Services address these concerns with recommendations for culturally competent care, language services, and organizational support. Latinos have disproportionately higher rates of obesity and diabetes mellitus. Other health problems include stress, neurocysticercosis, and tuberculosis. It is important to explore the use of alternative therapies and belief in traditional folk illnesses, recognizing that health beliefs are dependent on education, socioeconomic status, and degree of acculturation. Many-but not all-folk and herbal treatments can be safely accommodated with conventional therapy. Physicians must be sensitive to Latino cultural values of simpatia (kindness), personalismo (relationship), respeto (respect), and modestia (modesty). The LEARN technique can facilitate cross-cultural interviews. Some cultural barriers may be overcome by using the "teach back" technique to ensure that directions are correctly understood and by creating a welcoming health care environment for Latino patients.
Verma, Amol A; Guo, Yishan; Kwan, Janice L; Lapointe-Shaw, Lauren; Rawal, Shail; Tang, Terence; Weinerman, Adina; Cram, Peter; Dhalla, Irfan A; Hwang, Stephen W; Laupacis, Andreas; Mamdani, Muhammad M; Shadowitz, Steven; Upshur, Ross; Reid, Robert J; Razak, Fahad
The precise scope of hospital care delivered under general internal medicine services remains poorly quantified. The purpose of this study was to describe the demographic characteristics, medical conditions, health outcomes and resource use of patients admitted to general internal medicine at 7 hospital sites in the Greater Toronto Area. This was a retrospective cohort study involving all patients who were admitted to or discharged from general internal medicine at the study sites between Apr. 1, 2010, and Mar. 31, 2015. Clinical data from hospital electronic information systems were linked to administrative data from each hospital. We examined trends in resource use and patient characteristics over the study period. There were 136 208 admissions to general internal medicine involving 88 121 unique patients over the study period. General internal medicine admissions accounted for 38.8% of all admissions from the emergency department and 23.7% of all hospital bed-days. Over the study period, the number of admissions to general internal medicine increased by 32.4%; there was no meaningful change in the median length of stay or cost per hospital stay. The median patient age was 73 (interquartile range [IQR] 57-84) years, and the median number of coexisting conditions was 6 (IQR 3-9). The median acute length of stay was 4.6 (IQR 2.5-8.6) days, and the median total cost per hospital stay was $5850 (IQR $3915-$10 061). Patients received at least 1 computed tomography scan in 52.2% of admissions. The most common primary discharge diagnoses were pneumonia (5.0% of admissions), heart failure (4.7%), chronic obstructive pulmonary disease (4.1%), urinary tract infection (4.0%) and stroke (3.6%). Patients admitted to general internal medicine services represent a large, heterogeneous, resource-intensive and growing population. Understanding and improving general internal medicine care is essential to promote a high-quality, sustainable health care system. Copyright 2017
Full Text Available Abstract Background Both raloxifene and bisphosphonates are indicated for the prevention and treatment of postmenopausal osteoporosis, however these medications have different efficacy and safety profiles. It is plausible that physicians would prescribe these agents to optimize the benefit/risk profile for individual patients. The objective of this study was to compare demographic and clinical characteristics of patients initiating raloxifene with those of patients initiating bisphosphonates for the prevention and treatment of osteoporosis. Methods This study was conducted using a retrospective cohort design. Female beneficiaries (45 years and older with at least one claim for raloxifene or a bisphosphonate in 2003 through 2005 and continuous enrollment in the previous 12 months and subsequent 6 months were identified using a collection of large national commercial, Medicare supplemental, and Medicaid administrative claims databases (MarketScan®. Patients were divided into two cohorts, a combined commercial/Medicare cohort and a Medicaid cohort. Within each cohort, characteristics (demographic, clinical, and resource utilization of patients initiating raloxifene were compared to those of patients initiating bisphosphonate therapy. Group comparisons were made using chi-square tests for proportions of categorical measures and Wilcoxon rank-sum tests for continuous variables. Logistic regression was used to simultaneously examine factors independently associated with initiation of raloxifene versus a bisphosphonate. Results Within both the commercial/Medicare and Medicaid cohorts, raloxifene patients were younger, had fewer comorbid conditions, and fewer pre-existing fractures than bisphosphonate patients. Raloxifene patients in both cohorts were less likely to have had a bone mineral density (BMD screening in the previous year than were bisphosphonate patients, and were also more likely to have used estrogen or estrogen/progestin therapy in the
Granholm, Anders; Møller, Morten Hylander; Kragh, Mette
PURPOSE: Severity scores including the Simplified Acute Physiology Score (SAPS) II and the Sequential Organ Failure Assessment (SOFA) score are used in intensive care units (ICUs) to assess disease severity, predict mortality and in research. We aimed to assess the predictive performance of SAPS II...... compared the discrimination of SAPS II and initial SOFA scores, compared the discrimination of SAPS II in our cohort with the original cohort, assessed the calibration of SAPS II customised to our cohort, and compared the discrimination for 90-day mortality vs. in-hospital mortality for both scores....... Discrimination was evaluated using areas under the receiver operating characteristics curves (AUROC). Calibration was evaluated using Hosmer-Lemeshow's goodness-of-fit Ĉ-statistic. RESULTS: AUROC for in-hospital mortality was 0.80 (95% confidence interval (CI) 0.77-0.83) for SAPS II and 0.73 (95% CI 0...
Klingner, Jill; Moscovice, Ira; Tupper, Judith; Coburn, Andrew; Wakefield, Mary
Implementation of patient safety initiatives can be costly in time and energy. Because of small volumes and limited resources, rural hospitals often are not included in nationally driven patient safety initiatives. This article describes the Tennessee Rural Hospital Patient Safety Demonstration project, whose goal was to strengthen capacity for…
Sheila Z. Chang
Full Text Available Background: Pediatric subspecialists can participate in the care of obese children. Objective: To describe steps to help subspecialty providers initiate quality improvement efforts in obesity care. Methods: An anonymous patient data download, provider surveys and interviews assessed subspecialty providers’ identification and perspectives of childhood obesity and gathered information on perceived roles and care strategies. Participating divisions received summary analyses of quantitative and qualitative data and met with study leaders to develop visions for division/service-specific care improvement. Results: Among 13 divisions/services, subspecialists’ perceived role varied by specialty; many expressed the need for cross-collaboration. All survey informants agreed that identification was the first step, and expressed interest in obtaining additional resources to improve care. Conclusions: Subspecialists were interested in improving the quality and coordination of obesity care for patients across our tertiary care setting. Developing quality improvement projects to achieve greater pediatric obesity care goals starts with engagement of providers toward better identifying and managing childhood obesity.
Geisinger's system of care can be seen as a microcosm of the national delivery of healthcare, with implications for decision makers in other health plans. In this interview, Dr Ronald A. Paulus focuses on Geisinger's unique approach to patient care. In its core, this approach represents a system of quality and value initiatives based on 3 major programs-Proven Health Navigation (medical home); the ProvenCare model; and transitions of care. The goal of such an approach is to optimize disease management by using a rational reimbursement paradigm for appropriate interventions, providing innovative incentives, and engaging patients in their own care as part of any intervention. Dr Paulus explains the reasons why, unlike Geisinger, other stakeholders, including payers, providers, patients, and employers, have no intrinsic reasons to be concerned with quality and value initiatives. In addition, he says, an electronic infrastructure that could be modified as management paradigms evolve is a necessary tool to ensure the healthcare delivery system's ability to adapt to new clinical realities quickly to ensure the continuation of delivering best value for all stakeholders.
This chapter deals with important aspects of patient care, which may become the radiographer's responsibility in the absence of dedicated nursing staff. Although large pediatric centers usually employ nurses for bedside patient management, the general radiographer should be familiar with some aspects of routine patient care. This knowledge guarantees the safety and well-being of children entrusted to the technologist
Balbale, Salva Najib; Turcios, Stephanie; LaVela, Sherri L
Given the importance of health care employees in the delivery of patient-centered care, understanding their unique perspectives is essential for quality improvement. The purpose of this study was to use photovoice to evaluate perceptions and experiences around patient-centered care among U.S. Veterans Affairs (VA) health care employees. We asked participants to take photographs of salient features in their environment related to patient-centered care. We used the photographs to facilitate dialogue during follow-up interviews. Twelve VA health care employees across two VA sites participated in the project. Although most participants felt satisfied with their work environment and experiences at the VA, they identified several areas for improvement. These included a need for more employee health and wellness initiatives and a need for enhanced opportunities for training and professional growth. Application of photovoice enabled us to learn about employees' unique perspectives around patient-centered care while engaging them in an evaluation of care delivery. © The Author(s) 2014.
Egerod, Ingrid; Storli, Sissel Lisa; Åkerman, Eva
Critical illness and intensive care therapy are often followed by psychological problems such as nightmares, hallucinations, delusions, anxiety, depression, and symptoms of posttraumatic stress. Intensive care patient diaries have been kept by nurses and the patients' family since the early 1990s...... in the Scandinavian countries to help critically ill patients come to terms with their illness after hospital discharge. The aim of the study was to describe and compare the emergence and evolution of intensive care patient diaries in Denmark, Norway, and Sweden. The study had a comparative international design using...... secondary analysis of qualitative data generated by key-informant telephone interviews with intensive care nurses (n=114). The study showed that diaries were introduced concurrently in the three Scandinavian countries as a grass-roots initiative by mutual cross-national inspiration. The concept has evolved...
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
Stuurman-Bieze, A G G; Hiddink, E G; van Boven, J F M; Vegter, S
UNLABELLED: Using a protocolled intervention program, pharmacists can decrease nonadherence to osteoporosis medication, by continuous monitoring and tailored counseling sessions, starting at treatment initiation. In the usual care group, 32.8% of patients initiating osteoporosis medication
...] Bundled Payments for Care Improvement Initiative AGENCY: Centers for Medicare & Medicaid Services (CMS...: Letter of Intent Submission Deadline: For Model 1 of this initiative, interested organizations must...-improvement.html . Application Submission Deadline: For Model 1 of this initiative, applications must be...
Abu Al Hamayel, Nebras; Isenberg, Sarina R; Hannum, Susan M; Sixon, Joshua; Smith, Katherine Clegg; Dy, Sydney M
Despite increased focus on measuring and improving quality of serious illness care, there has been little emphasis on the primary care context or incorporation of the patient perspective. To explore older patients' perspectives on the quality of serious illness care in primary care. Qualitative interview study. Twenty patients aged 60 or older who were at risk for or living with serious illness and who had participated in the clinic's quality improvement initiative. We used a semistructured, open-ended guide focusing on how older patients perceived quality of serious illness care, particularly in primary care. We transcribed interviews verbatim and inductively identified codes. We identified emergent themes using a thematic and constant comparative method. We identified 5 key themes: (1) the importance of patient-centered communication, (2) coordination of care, (3) the shared decision-making process, (4) clinician competence, and (5) access to care. Communication was an overarching theme that facilitated coordination of care between patients and their clinicians, empowered patients for shared decision-making, related to clinicians' perceived competence, and enabled access to primary and specialty care. Although access to care is not traditionally considered an aspect of quality, patients considered this integral to the quality of care they received. Patients perceived serious illness care as a key aspect of quality in primary care. Efforts to improve quality measurement and implementation of quality improvement initiatives in serious illness care should consider these aspects of care that patients deem important, particularly communication as an overarching priority.
Full Text Available Marcio Machado,1 Thomas R Einarson21GlaxoSmithKline Brasil Ltd, Rio de Janeiro, Brazil; 2Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, CanadaObjective: To evaluate, from the perspective of the Brazilian public health care system, the cost-effectiveness of lapatinib plus capecitabine (LAP/CAP versus capecitabine alone (CAP or trastuzumab plus capecitabine (TRAST/CAP in the treatment of women with human epidermal growth factor receptor-2-positive metastatic breast cancer previously treated with trastuzumab.Methods: An economic model was developed to compare costs and clinical outcomes over a 5-year time horizon. Both costs and outcomes were discounted at a 5% rate, in accordance with Brazilian pharmacoeconomic guidelines. Clinical inputs were determined using indirect treatment comparisons. Costs were derived from public reimbursement databases and reported in 2010 Brazilian real (R$1 = USD$0.52. Clinical outcomes included progression-free survival years (PFYs, life-years (LYs and quality-adjusted life-years (QALYs. The economic outcome was the incremental cost per LY, PFY, or QALY gained. The impact of variations in individual inputs (eg, drug cost, drug effectiveness was examined using one-way sensitivity analyses. Overall model robustness was tested using probabilistic sensitivity analyses, varying the ranges of all input parameters within their standard distributions.Results: Expected cost per patient was R$41,195 for CAP, R$95,256 for LAP/CAP, and R$113,686 for TRAST/CAP. Respective LYs were 1.406, 1.695, and 1.465; PFYs were 0.473, 0.711, and 0.612; and QALYS were 0.769, 0.958, and 0.827. LAP/CAP dominated TRAST/CAP for all outcomes. Incremental cost-effectiveness ratios of LAP/CAP over CAP were R$186,563 for LYs, R$226,403 for PFYs, and R$284,864 for QALYs. Results remained unchanged in one-way sensitivity analyses. In probabilistic analyses, LAP/CAP was dominant over TRAST/CAP in 93.5% of simulations.Conclusion: LAP
Strömgren, Annette S; Goldschmidt, Dorthe; Groenvold, Mogens
the symptomatology of participating patients and examines differences in symptomatology between patients in three palliative care functions: inpatient, outpatient, and palliative home care. RESULTS: Of 267 eligible patients who were referred to a department of palliative medicine, initial self......-based study of symptomatology in consecutive cancer patients in palliative care, achieving rather complete data from the participants. The symptomatology in these patients was very pronounced. The questionnaires were able to detect clinically important differences between places of service....
Poirier, Therese I
The value of the arts and humanities in becoming an "educated" pharmacist is reviewed in this commentary. The term "patient care literacy" is defined as becoming a more humane pharmacist. This implies not only using heads but HARTSS (humanities, arts and social sciences) for developing the necessary skills. A conceptual framework for curricular reform that focuses on using the arts and humanities is proposed for advancing patient care literacy. Methods for enhancing use of arts and humanities for developing pharmacy graduates is specifically proposed. The need for more empiric research to demonstrate the value of the arts and humanities in developing a patient care literate professional is highlighted.
Huynh, Ho Phi; Sweeny, Kate; Miller, Tricia
Clinicians face the complex challenge of motivating their patients to achieve optimal health while also ensuring their satisfaction. Inspired by transformational leadership theory, we proposed that clinicians' motivational behaviors can be organized into three patient care styles (transformational, transactional, and passive-avoidant) and that these styles differentially predict patient health outcomes. In two studies using patient-reported data and observer ratings, we found that transformational patient care style positively predicted patients' satisfaction and health expectations above and beyond transactional and passive-avoidant patient care style. These findings provide initial support for the patient care style approach and suggest novel directions for the study of clinicians' motivational behaviors.
Team work is required in the treatment of the thermally injured patient--nursing staff being part of the team. The nurses are with the patient for 24 hours a day and they have to understand the objectives of all other members of the team involved in the treatment as well as thoroughly mastering their own work. For the nursing staff the care of the thermally injured patient is a challenge. The work demands strong motivation and interest--it includes at times painful treatment, isolation and also constant alertness. It is important that the nursing staff is given continuous training so that they are able to give the required care efficiently and to keep up active interest. Practical work is the best way of getting aquainted with the complex forms of treatment of the thermally injured patient. It also lessens the fear of a badly burned patient. Nursing care of the thermally injured patient consists of good basic care, local attention and active observation. The basic care consists of basic hygiene, diet, observation of the patient's psychological condition, giving emotional support, encouraging initiative physiotherapy and postural treatment.
Onwumere, Juliana; Grice, Sarah; Garety, Philippa; Bebbington, Paul; Dunn, Graham; Freeman, Daniel; Fowler, David; Kuipers, Elizabeth
Aggressive behaviour in psychosis is not uncommon. Community provision for people with psychosis has left informal caregivers to take on a greater role in their care. However, few studies have explored links between patient-initiated violence in mental health caregiving relationships and caregiver functioning. Our study investigated caregiver reports of aggressive acts committed by their relative with psychosis and their links to caregiver appraisals of the caregiving relationship and caregiver outcomes. Caregivers of patients with a recent relapse of psychosis, recruited to a psychological therapy trial, completed the audiotaped Camberwell Family Interview at baseline. This semi-structured interview includes questions on the quality of the relationship between caregiver and patient, and patient history of violence. Seventy-two transcripts of interviews were assessed for reports of patient-initiated violence. One-half of the caregiver sample (52.9%) reported an incident of patient-initiated violence during their interview; 62.2% of these involved violence toward themselves, and 24.3% toward property. Reports of patient violence were associated with caregiver ratings of hostility expressed toward patients, lower self-esteem, and emotion-focused coping. People caring on their own were more likely to report incidents of patient violence. Younger patients, males, and inpatients were more frequently identified as having a history of this kind of violence. Our findings suggested that caregiver reports of patient-initiated violence in psychosis are not uncommon. Mental health staff need to be aware of the risks of such violence for caregivers of people with psychosis, and consider appropriate procedures for minimizing it.
Schäfer, W.L.A.; Boerma, W.G.W.; Schellevis, F.G.; Groenewegen, P.P.
Background: So far, studies about people’s appreciation of primary care services has shown that patient satisfaction seems to be lower in health care systems with regulated access to specialist services by gate keeping. Nevertheless, international comparative research about patients’ expectations
Department of Veterans Affairs — The National Patient Care Database (NPCD), located at the Austin Information Technology Center, is part of the National Medical Information Systems (NMIS). The NPCD...
Full Text Available Abstract Background Although colorectal cancer screening is recommended by major policy-making organizations, rates of screening remain low. Our aim was to develop a patient-directed, computer-based decision aid about colorectal cancer screening and investigate whether it could increase patient interest in screening. Methods We used content from evidence-based literature reviews and our previous decision aid research to develop a prototype. We performed two rounds of usability testing with representative patients to revise the content and format. The final decision aid consisted of an introductory segment, four test-specific segments, and information to allow comparison of the tests across several key parameters. We then conducted a before-after uncontrolled trial of 80 patients 50–75 years old recruited from an academic internal medicine practice. Results Mean viewing time was 19 minutes. The decision aid improved patients' intent to ask providers for screening from a mean score of 2.8 (1 = not at all likely to ask, 4 = very likely to ask before viewing the decision aid to 3.2 afterwards (difference, 0.4; p Conclusion We conclude that a computer-based decision aid can increase patient intent to be screened and increase interest in screening. Practice Implications: This decision aid can be viewed by patients prior to provider appointments to increase motivation to be screened and to help them decide about which modality to use for screening. Further work is required to integrate the decision aid with other practice change strategies to raise screening rates to target levels.
Eldh, Ann Catrine; Luhr, Kristina; Ehnfors, Margareta
AIMS: To report on the development and initial testing of a clinical tool, The Patient Preferences for Patient Participation tool (The 4Ps), which will allow patients to depict, prioritize, and evaluate their participation in health care. BACKGROUND: While patient participation is vital for high quality health care, a common definition incorporating all stakeholders' experience is pending. In order to support participation in health care, a tool for determining patients' preferences on partic...
Full Text Available South Africa bears the greatest burden of HIV infection globally with the most infected people living in KwaZulu-Natal (KZN. Decentralised medical care for HIV positive patients and antiretroviral therapy (ART delivery to primary health care facilities were proposed nationally to achieve adequate ART coverage for patients in need of treatment. This study described the HIV positive patients who accessed medical care and were initiated on ART at two existing government Primary Health Care (PHC clinics with no added donor support, in Ilembe, KZN. This was an observational descriptive study of ART initiation from 01 April 2008 to 30 April 2009. Data were collected from clinical records kept on site. HIV Testing and the pre-ART programmes which consisted of medical care prior to ART initiation are briefly described. Socio-economic, demographic and clinical characteristics of patients who were initiated on ART were sampled and described. A minority (2.95% of the study population tested for HIV of which 36.0%tested positive. Majority (60.0% of patients who joined the pre-ART programme care did not return. The ART sample consisted of 375 patients of whom 65.0%were women, 85.9%were unmarried, 61.6%were unemployed and 50.4%had a secondary level of education. Tuberculosis (TB prevalence and incidence at ART initiation were 22.1%and 14.7%respectively. The prevalence of Syphilis and Hepatitis B co-infections were 13.1%and 8.6 %respectively. Two thirds of female patients (66.4% received a Pap smear result of which the majority (62.3% were abnormal. Uptake for HIV testing followed by relevant CD4 testing was poor. High TB, Hepatitis B and Syphilis co-infection was noted amongst patients initiated on ART. Cervical cancer screening must be intensified. Although ART initiation with no added external resources was successful, record keeping was suboptimal.
Full Text Available Despite multimodal treatment with surgery, radiotherapy and chemotherapy, glioblastoma is an incurable disease with a poor prognosis. During the disease course, glioblastoma patients may experience progressive neurological deficits, symptoms of increased intracranial pressure such as drowsiness and headache, incontinence, seizures and progressive cognitive dysfunction. These patients not only have cancer, but also a progressive brain disease. This may seriously interfere with their ability to make their own decisions regarding treatment. It is therefore warranted to involve glioblastoma patients early in the disease trajectory in treatment decision-making on their future care, including the end of life (EOL care, which can be achieved with Advance Care Planning (ACP. Although ACP, by definition, aims at timely involvement of patients and proxies in decision-making on future care, the optimal moment to initiate ACP discussions in the disease trajectory of glioblastoma patients remains controversial. Moreover, the disease-specific content of these ACP discussions needs to be established. In this article, we will first describe the history of patient participation in treatment decision-making, including the shift towards ACP. Secondly, we will describe the possible role of ACP for glioblastoma patients, with the specific aim of treatment of disease-specific symptoms such as somnolence and dysphagia, epileptic seizures, headache, and personality changes, agitation and delirium in the EOL phase, and the importance of timing of ACP discussions in this patient population.
Prophet, Colleen M.
The INFORMM Patient Care Planning System provides interdepartmental communication and individualized patient care plans based upon current standards of care. This interdisciplinary system facilitates the identification of patient problems and nursing diagnoses as well as patient care orders. The selected nurses' and physicians' orders are integrated and organized by care plan categories in printouts. As a system by-product, Patient Care Planning automatically generates and calculates patient ...
Dale, Stacy B; Ghosh, Arkadipta; Peikes, Deborah N; Day, Timothy J; Yoon, Frank B; Taylor, Erin Fries; Swankoski, Kaylyn; O'Malley, Ann S; Conway, Patrick H; Rajkumar, Rahul; Press, Matthew J; Sessums, Laura; Brown, Randall
The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support. We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices. During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-$11; 95% confidence interval [CI], -$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, -$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (Pinitiative practices relative to comparison practices (P=0.006 and Pinitiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after
Van Slyck, A; Johnson, K R
This article describes actual reported uses for patient acuity data that go beyond historical uses in determining staffing allocations. These expanded uses include managing patient care outcomes and health care costs. The article offers the patient care executive examples of how objective, valid, and reliable data are used to drive approaches to effectively influence decision making in an increasingly competitive health care environment.
Anna Maria Kostka
Full Text Available Everyone has the right to equal treatment irrespective of color, culture, origin or religion. Jewish patients obey many rules. The use of proper diet, adherence to the principles of purity, prayer, performing rituals is very important for them. Medical staff is committed to providing patients with safety, regardless of the differences. Understanding the most important values, ethics and practices of Judaism will help to provide professional care for the patient of Jewish faith. Appropriate communication, understanding and tolerance are essential for creating a relationship with the patient, through which it will be possible to achieve the desired therapeutic effect and improve the quality of life of patients.
Tulek, Zeliha; Poulsen, Ingrid; Gillis, Katrin
AIMS AND OBJECTIVES: To conduct a survey of the clinical nursing practice in European countries in accordance with the European Stroke Strategies (ESS) 2006, and to examine to what extent the ESS have been implemented in stroke care nursing in Europe. BACKGROUND: Stroke is a leading cause of death...... comprising 61 questions based on the ESS and scientific evidence in nursing practice was distributed to representatives of the European Association of Neuroscience Nurses, who sent the questionnaire to nurses active in stroke care. The questionnaire covered the following areas of stroke care: Organization...... of stroke services, Management of acute stroke and prevention including basic care and nursing, and Secondary prevention. RESULTS: Ninety-two nurses in stroke care in 11 European countries participated in the survey. Within the first 48 hours after stroke onset, 95% monitor patients regularly, 94% start...
Shen, Nelson; Sockalingam, Sanjeev; Abi Jaoude, Alexxa; Bailey, Sharon M; Bernier, Thérèse; Freeland, Alison; Hawa, Aceel; Hollenberg, Elisa; Woldemichael, Bethel; Wiljer, David
The collaborative care model is an approach providing care to those with mental health and addictions disorders in the primary care setting. There is a robust evidence base demonstrating its clinical and cost-effectiveness in comparison with usual care; however, the transitioning to this new paradigm of care has been difficult. While there are efforts to train and prepare healthcare professionals, not much is known about the current state of collaborative care training programmes. The objective of this scoping review is to understand how widespread these collaborative care education initiatives are, how they are implemented and their impacts. The scoping review methodology uses the established review methodology by Arksey and O'Malley. The search strategy was developed by a medical librarian and will be applied in eight different databases spanning multiple disciplines. A two-stage screening process consisting of a title and abstract scan and a full-text review will be used to determine the eligibility of articles. To be included, articles must report on an existing collaborative care education initiative for healthcare providers. All articles will be independently assessed for eligibility by pairs of reviewers, and all eligible articles will be abstracted and charted in duplicate using a standardised form. The extracted data will undergo a 'narrative review' or a descriptive analysis of the contextual or process-oriented data and simple quantitative analysis using descriptive statistics. Research ethics approval is not required for this scoping review. The results of this scoping review will inform the development of a collaborative care training initiative emerging from the Medical Psychiatry Alliance, a four-institution philanthropic partnership in Ontario, Canada. The results will also be presented at relevant national and international conferences and published in a peer-reviewed journal. © Article author(s) (or their employer(s) unless otherwise stated in
Blum, Torsten G; Rich, Anna; Baldwin, David
. The Task Force undertook four projects: 1) a narrative literature search on quality management of lung cancer; 2) a survey of national and local infrastructure for lung cancer care in Europe; 3) a benchmarking project on the quality of (inter)national lung cancer guidelines in Europe; and 4) a feasibility...... study of prospective data collection in a pan-European setting. There is little peer-reviewed literature on quality management in lung cancer care. The survey revealed important differences in the infrastructure of lung cancer care in Europe. The European guidelines that were assessed displayed wide...... countries. The European Initiative for Quality Management in Lung Cancer Care has provided the first comprehensive snapshot of lung cancer care in Europe....
Ferris, Frank D; Moore, Shannon Y; Callaway, Mary V; Foley, Kathleen M
The International Palliative Care Leadership Development Initiative (LDI) was a model demonstration project that aimed to expand the global network of palliative care leaders in low- and moderate-resource countries who are well positioned to apply their new leadership skills. Thirty-nine palliative medicine physicians from 25 countries successfully completed the two-year curriculum that included three thematic residential courses, mentorship, and site visits by senior global palliative care leaders and personal projects to apply their new leadership skills. The focus on self-reflection, leadership behaviors and practices, strategic planning, high-level communication, and teaching skills led to significant personal and professional transformation among the participants, mentors, and the LDI team. The resulting residential course curriculum and the personal leadership stories and biosketches of the leaders are now available open access at IPCRC.net. Already, within their first-year postgraduation, the leaders are using their new leadership skills to grow palliative care capacity through significant changes in policy, improved opioid/other medication availability, new and enhanced educational curricula and continuing education activities, and development/expansion of palliative care programs in their organizations and regions. We are not aware of another palliative care initiative that achieves the global reach and ripple effect that LDI has produced. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Full Text Available X Peng,1 P Sun,2 D Novick,1 J Andrews,1 S Sun2 1Eli Lilly and Company, Indianapolis, IN, USA; 2Kailo Research Group, Indianapolis, IN, USA Objectives: To compare health care utilization of duloxetine initiators and pregabalin initiators among fibromyalgia patients in a real-world setting. Methods: A retrospective cohort study was conducted based on a US national commercial health claims database (2006–2009. Fibromyalgia patients who initiated duloxetine or pregabalin in 2008, aged 18–64 years, and who maintained continuous health insurance coverage 1 year before and 1 year after initiation were assigned to duloxetine or pregabalin cohorts on the basis of their initiated agent. Patients who had pill coverage of the agents over the course of 90 days preceding the initiation were excluded. The two comparative cohorts were constructed using propensity score greedy match methods. Descriptive analysis and paired t-test were performed to compare health care utilization rates in the postinitiation year and the changes of these rates from the preinitiation year to the postinitiation year. Results: Both matched cohorts (n=1,265 pairs had a similar mean initiation age (49–50 years, percentage of women (87%–88%, and prevalence of baseline comorbid conditions (neuropathic pain other than diabetic peripheral neuropathic pain, low back pain, cardiovascular disease, hypertension, headache or migraine, and osteoarthritis. In the preinitiation year, both cohorts had similar inpatient, outpatient, and medication utilization rates (inpatient, 15.7%–16.1%; outpatient, 100.0%; medication, 97.9%–98.7%. The utilization rates diverged in the postinitiation year, with the pregabalin cohort using more fibromyalgia-related inpatient care (3.2% versus 2.2%; P<0.05, any inpatient care (19.3% versus 16.8%; P<0.05, and fibromyalgia-related outpatient care (62.1% versus 51.8%; P<0.05. From the preinitiation period to the postinitiation period, the duloxetine cohort
Sockolow, Paulina; Radhakrishnan, Kavita; Chou, Edgar Y; Wojciechowicz, Christine
Home care agencies are initiating "patient health goal elicitation" activities as part of home care admission planning. We categorized elicited goals and identified "clinically informative" goals at a home care agency. We examined patient goals that admitting clinicians documented in the point-of-care electronic health record; conducted content analysis on patient goal data to develop a coding scheme; grouped goal themes into codes; assigned codes to each goal; and identified goals that were in the patient voice. Of the 1,763 patient records, 16% lacked a goal; only 15 goals were in a patient's voice. Nurse and physician experts identified 12 of the 20 codes as clinically important accounting for 82% of goal occurrences. The most frequent goal documented was safety/falls (23%). Training and consistent communication of the intent and operationalization of patient goal elicitation may address the absence of patient voice and the less than universal recording of home care patients' goals.
Rathert, Cheryl; Huddleston, Nicole; Pak, Youngju
Patient safety has been a highly researched topic in health care since the year 2000. One strategy for improving patient safety has been to encourage patients to take an active role in their safety during their health care experiences. However, little research has shed light on how patients view their roles. This study attempted to address this deficit by inductively exploring the results of a qualitative study in which patients reported their ideas about what they believe their roles should be. Patients with an overnight stay in the previous 90 days at one of three hospitals were surveyed using a mailing methodology. Of 1,040 respondents, 491 provided an open-ended response regarding what they believe the patient role should be. Qualitative analysis found several prominent themes. The largest proportion of responses (23%) suggested that patients should follow instructions given by care providers. Other prominent themes were that patients should ask questions and become informed about their conditions and treatments, and many implied that they should expect competent care. Our results suggest that patients believe they should be able to trust that they are being provided competent care, as opposed to assuming a leadership role in their safety. Our results suggest that engaging patients in safety efforts may be complex, requiring a variety of strategies. Managers must provide environments conducive to staff and patient interactions to support patients in this effort. Different types of patients may require different engagement strategies.
This paper reviews the results of a breast cancer screening program sponsored by organizations at workplace or community locations. A comprehensive mobile breast cancer screening program, including education, breast physical examination, and mammography, was provided to 89 local organizations at $50.00 per examination over an 18-month period. The examination was patient initiated, following the ACS screening guidelines. Estimates of eligible women were provided by each organization. A total of 5,030 women at 89 organizations were screened for breast cancer. Approximately 25,727 women were eligible
Borgès Da Silva, Roxane; Brault, Isabelle; Pineault, Raynald; Chouinard, Maud-Christine; Prud'homme, Alexandre; D'Amour, Danielle
Nurses are identified as a key provider in the management of patients in primary care. The objective of this study was to evaluate patients' experience of care in primary care as it pertained to the nursing role. The aim was to test the hypothesis that, in primary health care organizations (PHCOs) where patients are systematically followed by a nurse, and where nursing competencies are therefore optimally used, patients' experience of care is better. Based on a cross-sectional analysis combining organizational and experience of care surveys, we built 2 groups of PHCOs. The first group of PHCOs reported having a nurse who systematically followed patients. The second group had a nurse who performed a variety of activities but did not systematically follow patients. Five indicators of care were constructed based on patient questionnaires. Bivariate and multivariate linear mixed models with random intercepts and with patients nested within were used to analyze the experience of care indicators in both groups. Bivariate analyses revealed a better patient experience of care in PHCOs where a nurse systematically followed patients than in those where a nurse performed other activities. In multivariate analyses that included adjustment variables related to PHCOs and patients, the accessibility indicator was found to be higher. Results indicated that systematic follow-up of patients by nurses improved patients' experience of care in terms of accessibility. Using nurses' scope of practice to its full potential is a promising avenue for enhancing both patients' experience of care and health services efficiency.
Camara, A; Bah-Sow, O Y; Baldé, N M; Camara, L M; Barry, I S; Bah, B; Diallo, M; Chaperon, J; Riou, F
Complex care pathways can result in detrimental treatment delay particularly in tuberculosis patients. The purpose of this retrospective study was to assess the care pathways followed by tuberculosis patients prior to diagnosis and to assess impact on the delay for initiation of treatment in Conakry, Guinea. A total of 112 patients were interviewed at the time of first admission for pulmonary tuberculosis with positive bacilloscopy. Based on interview data, pathways were classified as conventional (use of health care facilities only) and mixed (use of health care facilities, self-medication, and traditional medicine). The correlation between patient characteristics and type of pathway was assessed by univariate and multivariate analysis and the two groups, i.e., conventional vs. mixed, were compared with regard to delay for initiation of treatment. The care pathway was classified as mixed in two out of three patients. Multivariate analysis showed that this type of pathway was only correlated with schooling (p=0.02). The mean delay for treatment was similar, i.e., 13.4 and 12.8 weeks for conventional and mixed pathways respectively (p<0.68). The percentage of pathways including three consultations at health care facilities was significantly higher in the conventional than mixed group (72% vs. 30%, p<0.001). The main reasons given for delayed use of health care facilities were poor knowledge of tuberculosis symptoms (26%) and high cost of care (12%). The findings of this study indicate that tuberculosis patients follow a variety of care pathways that can lead to delayed treatment. An information campaign is needed to increase awareness among the population and care providers.
Reynolds, Shannon L; Ghate, Sameer R; Sheer, Richard; Gandhi, Pranav K; Moretz, Chad; Wang, Cheng; Sander, Stephen; Costantino, Mary E; Annavarapu, Srinivas; Andrews, George
Novel oral anticoagulants (NOAC) such as dabigatran, when compared to warfarin, have been shown to potentially reduce the risk of stroke in patients with non-valvular atrial fibrillation (NVAF) together with lower healthcare resource utilization (HCRU) and similar total costs. This study expands on previous work by comparing HCRU and costs for patients newly diagnosed with NVAF and newly initiated on dabigatran or warfarin, and is the first study specifically in a Medicare population. A retrospective matched-cohort study was conducted using data from administrative health care claims during the study period 01/01/2010-12/31/2012. Cox regression analyses were used to compare all-cause risk of first hospitalizations and emergency room (ER) visits. Medical, pharmacy, and total costs per-patient-per-month (PPPM) were compared between dabigatran and warfarin users. A total of 1110 patients initiated on dabigatran were propensity score-matched with corresponding patients initiated on warfarin. The mean number of hospitalizations (0.92 vs. 1.13, P = 0.012), ER visits (1.32 vs. 1.56, P warfarin users. Patients initiated on dabigatran had significantly lower risk of first all-cause ER visits [hazard ratio (HR): 0.84, 95% confidence interval (CI): 0.73-0.98] compared to those initiated on warfarin. Adjusted mean pharmacy costs PPPM were significantly greater for dabigatran users ($510 vs. $250, P warfarin users. Dabigatran users had significantly lower HCRU compared to warfarin users. In addition, dabigatran users had lower risk of all-cause ER visits. Despite higher pharmacy costs, the two cohorts did not differ significantly in medical or total all-cause costs.
Full Text Available Francisco José Tarazona-Santabalbina,1,2 Ángel Belenguer-Varea,1,2 Eduardo Rovira,1,2 David Cuesta-Peredó1,21Geriatric Medicine Unit, Internal Medicine Department, Hospital Universitario de la Ribera, 2Medical School, Universidad Católica de Valencia San vicente Mártir, Valencia, SpainAbstract: Hip fractures are a very serious socio-economic problem in western countries. Since the 1950s, orthogeriatric units have introduced improvements in the care of geriatric patients admitted to hospital because of hip fractures. During this period, these units have reduced mean hospital stays, number of complications, and both in-hospital mortality and mortality over the middle term after hospital discharge, along with improvements in the quality of care and a reduction in costs. Likewise, a recent clinical trial has reported greater functional gains among the affected patients. Studies in this field have identified the prognostic factors present upon admission or manifesting themselves during admission and that increase the risk of patient mortality or disability. In addition, improved care afforded by orthogeriatric units has proved to reduce costs. Nevertheless, a number of management issues remain to be clarified, such as the optimum anesthetic, analgesic, and thromboprophylactic protocols; the type of diagnostic and therapeutic approach best suited to patients with cognitive problems; or the efficiency of the programs used in convalescence units or in home rehabilitation care. Randomized clinical trials are needed to consolidate the evidence in this regard. Keywords: hip fractures, geriatric assessment, orthogeriatric care, recovery of function, mortality
Integrated palliative care is about professional networking rather than standardisation of care: A qualitative study with healthcare professionals in 19 integrated palliative care initiatives in five European countries.
den Herder-van der Eerden, Marlieke; van Wijngaarden, Jeroen; Payne, Sheila; Preston, Nancy; Linge-Dahl, Lisa; Radbruch, Lukas; Van Beek, Karen; Menten, Johan; Busa, Csilla; Csikos, Agnes; Vissers, Kris; van Gurp, Jelle; Hasselaar, Jeroen
Integrated palliative care aims at improving coordination of palliative care services around patients' anticipated needs. However, international comparisons of how integrated palliative care is implemented across four key domains of integrated care (content of care, patient flow, information logistics and availability of (human) resources and material) are lacking. To examine how integrated palliative care takes shape in practice across abovementioned key domains within several integrated palliative care initiatives in Europe. Qualitative group interview design. A total of 19 group interviews were conducted (2 in Belgium, 4 in the Netherlands, 4 in the United Kingdom, 4 in Germany and 5 in Hungary) with 142 healthcare professionals from several integrated palliative care initiatives in five European countries. The majority were nurses ( n = 66; 46%) and physicians ( n = 50; 35%). The dominant strategy for fostering integrated palliative care is building core teams of palliative care specialists and extended professional networks based on personal relationships, shared norms, values and mutual trust, rather than developing standardised information exchange and referral pathways. Providing integrated palliative care with healthcare professionals in the wider professional community appears difficult, as a shared proactive multidisciplinary palliative care approach is lacking, and healthcare professionals often do not know palliative care professionals or services. Achieving better palliative care integration into regular healthcare and convincing the wider professional community is a difficult task that will take time and effort. Enhancing standardisation of palliative care into education, referral pathways and guidelines and standardised information exchange may be necessary. External authority (policy makers, insurance companies and professional bodies) may be needed to support integrated palliative care practices across settings.
Simmonds, Anne H
The Canadian Nurses' Association Code of Ethics (2008) and the College of Registered Nurses of Nova Scotia (CRNNS) Standards of Practice for Registered Nurses (CRNNS 2011) identify the provision of safe, compassionate, competent and ethical care as one of nursing's primary values and ethical responsibilities. While compassion has historically been viewed as the essence of nursing, there is concern that this has become an abstract ideal, rather than a true reflection of nursing practice. This paper describes a compassionate care initiative undertaken by the CRNNS and the initial outcomes of these educational workshops. This work is informed by an exploration of the multiplicity of factors that have brought this issue to the fore for nursing regulators, educators, administrators, the public as well as front-line staff. The two most significant areas of learning reported by workshop participants included understanding the connection between mindfulness, non-judgmental care and compassion/self-compassion and recognizing possibilities for action related to compassionate care, even in the face of personal and environmental constraints. Implications for nursing regulators and leaders include consideration of their roles and responsibilities in supporting nurses to meet professional practice standards, such as provision of compassionate care. Copyright © 2015 Longwoods Publishing.
Balbale, Salva Najib; Turcios, Stephanie; LaVela, Sherri L.
Given the importance of health care employees in the delivery of patient-centered care, understanding their unique perspective is essential for quality improvement. The purpose of this study was to use photovoice to evaluate perceptions and experiences around patient-centered care among Veterans Affairs (VA) health care employees. We asked participants to take photographs of salient features in their environment related to patient-centered care. We used the photographs to facilitate dialogue during follow-up interviews. Twelve VA health care employees across two VA sites participated in the project. Although most participants felt satisfied with their work environment and experiences at the VA, several areas for improvement were identified. These included a need for more employee health and wellness initiatives and a need for enhanced opportunities for training and professional growth. Application of photovoice enabled us to learn about employees' unique perspectives around patient-centered care while engaging them in an evaluation of care delivery. PMID:25274626
M. A. Sadovoy
Full Text Available Patients’ evaluation of medical care is becoming more and more important due to expanding patient-centered care. For this purpose a complex index of patient satisfaction with healthcare is used. This parameter reflects the correspondence of actual healthcare services to patient’s expectations that were formed under the influence of cultural, social, economic factors, and personal experience of each patient. Satisfaction is a subjective parameter, thus, a grade of satisfaction is barely connected with quality of healthcare services itself. Moreover, medical organizations should always take into account specific features of each patient, since they can have an influence on customer attitude to medical services.This article comprises the review of publications studying determinants of patient satisfaction. In the course of the study, we analyzed data received by research teams from different countries.According to the review, we made some conclusions. First, determinants of patient satisfaction with healthcare can be divided in two groups. The first group of factors includes patients’ characteristics such as age, gender, ethnical and cultural features. However, researches from different countries revealed that there is a difference in the importance of factors belonging to this group and their influence on satisfaction of certain patient cohorts. The second group includes factors that belong to the process of healthcare services delivery and its organization. Moreover, it was found that patient satisfaction level is changing in a waveform. Thus, medical organization should not only try to increase patient satisfaction level but also maintain it. AS a result, it necessary to monitor patient satisfaction with healthcare services. That is why there is a distinct need for the development of a new tool or adaptation of existing instrument of satisfaction measurement, which would be unitized for all medical organizations in the Russian Federation
The literature suggests that acts of bullying are a root cause of new nurses leaving their units or the profession entirely and have the potential to worsen the nursing shortage. As an effective way to address bullying in the perioperative setting, mentoring benefits the nursing profession. Mentoring can have a direct influence on nurses' longevity in a health care organization, thereby strengthening the nursing workforce. Magnet-designated hospitals support the importance of mentor-mentee relationships for positive employee retention and positive recruitment outcomes. One of the most important tasks that a mentor should undertake is that of a role model. Establishing a culture of mentoring requires authentic leadership, genuine caring and respect for employees, and open communication. The entire nursing profession benefits from a culture of mentoring, as do the patients and families who receive care. Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Solberg, Leif I; Crain, A Lauren; Maciosek, Michael V; Unützer, Jürgen; Ohnsorg, Kris A; Beck, Arne; Rubenstein, Lisa; Whitebird, Robin R; Rossom, Rebecca C; Pietruszewski, Pamela B; Crabtree, Benjamin F; Joslyn, Kenneth; Van de Ven, Andrew; Glasgow, Russell E
Scale-up and spread of evidence-based practices is one of the most important challenges facing health care. We tested whether a statewide initiative, Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND), to implement the collaborative care model for depression in 75 primary care clinics resulted in patient outcome improvements corresponding to those reported in randomized controlled trials. Health plans provided a new monthly payment to participating clinics after a 6-month intensive training program with ongoing data submission, networking, and consultation. Implementation was staggered, with 5 sequences of 10 to 40 clinics every 6 months. Payers provided weekly contact information for members from participating clinics who were filling antidepressant prescriptions, and we conducted baseline and 6-month surveys of 1,578 patients about their care and outcomes. There were 466 patients in DIAMOND clinics who received usual care before implementation (UCB), 559 who received usual care in DIAMOND clinics after implementation (UCA), 245 who received DIAMOND care after implementation (DCA), and 308 who received usual care in comparison clinics (UC). Patients who received DIAMOND care after implementation reported more collaborative care depression services than the 3 comparison groups (10.9 vs 6.4-6.7, on a scale of 0 of 14, where higher numbers indicate more services; P <.001) and more satisfaction with their care (4.0 vs 3.4 on a scale 1 to 5, in which higher scores indicate higher satisfaction; P ≤.001). Depression remission rates, however, were not significantly different among the 4 groups (36.4% DCA vs 35.8% UCB, 35.0% UCA, 33.9% UC; P = .94). Despite the incentive of a supporting payment change and intensive training and support for clinics volunteering to participate, no difference in depression outcomes was documented. Specific unmeasured actions present in trials but not present in these clinics may be critical for successful outcome
Effective communication between doctor and patient is a critical component of high-quality care. The physician's credibility has a significant effect on treatment outcomes. Because changes in medicine and larger cultural trends challenge the ability of clinicians to engage their patients' trust, new kinds of partnerships must be created. To do this effectively, physicians have to sharpen their communication skills and devise strategies for assuring that their patients become informed allies in their own treatment. A number of innovations are helping to build these alliances: training in communication skills; creative uses of the Internet and videotape technologies; improved "customer service" programs; critical pathways for patients; and special educational aids. All these tools promise to be useful, but they require careful development and evaluation.
Tume, Lyvonne N; Coetzee, Minette; Dryden-Palmer, Karen; Hickey, Patricia A; Kinney, Sharon; Latour, Jos M; Pedreira, Mavilde L G; Sefton, Gerri R; Sorce, Lauren; Curley, Martha A Q
To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice. One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical care nursing, nine international nurse researchers presented state-of-the-art lectures. Each identified knowledge gaps in their assigned practice domain and then poised three research questions to fill that gap. Then, meeting participants prioritized the proposed research questions using an interactive multivoting process. Seventh World Congress on Pediatric Intensive and Critical Care in Istanbul, Turkey. Pediatric critical care nurses and nurse scientists attending the open consensus meeting. Systematic review, gap analysis, and interactive multivoting. The participants prioritized 27 nursing research questions in nine content domains. The top four research questions were 1) identifying nursing interventions that directly impact the child and family's experience during the withdrawal of life support, 2) evaluating the long-term psychosocial impact of a child's critical illness on family outcomes, 3) articulating core nursing competencies that prevent unstable situations from deteriorating into crises, and 4) describing the level of nursing education and experience in pediatric critical care that has a protective effect on the mortality and morbidity of critically ill children. The consensus meeting was effective in organizing pediatric critical care nursing knowledge, identifying knowledge gaps and in prioritizing nursing research initiatives that could be used to advance nursing science across world regions.
Thomas, Brittany; Fitzpatrick, Sandra; Sidani, Souraya; Gucciardi, Enza
Routine food insecurity screening is recommended in diabetes care to inform more tailored interventions that better support diabetes self-management among food-insecure patients. This pilot study explored the acceptability and feasibility of a food insecurity screening initiative within a diabetes care setting in Toronto. A systematic literature review informed the development of a food insecurity screening initiative to help health-care providers tailor diabetes management plans and better support food-insecure patients with type 2 diabetes. Interviews with 10 patients and a focus group with 15 care providers elicited feedback on the relevance and acceptance of the food insecurity screening questions and a care algorithm. Subsequently, 5 care providers at 4 sites implemented the screening initiative over 2 weeks, screening 33 patients. After implementation, 7 patients and 5 care providers were interviewed to assess the acceptability and feasibility of the screening initiative. Our findings demonstrate that patients are willing to share their experiences of food insecurity, despite the sensitivity of this topic. Screening elicited information about how patients cope with food insecurity and how this affects their ability to self-manage diabetes. Care providers found this information helpful in directing their care and support for patients. Using a standardized, respectful method of assessing food insecurity can better equip health-care providers to support food-insecure patients with diabetes self-management. Further evaluation of this initiative is needed to determine how food insecurity screening can affect patients' self-management and related health outcomes. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.
Muoto, Ifeoma; Luck, Jeff; Yoon, Jangho; Bernell, Stephanie; Snowden, Jonathan M
Policies at the state and federal levels affect access to health services, including prenatal care. In 2012 the State of Oregon implemented a major reform of its Medicaid program. The new model, called a coordinated care organization (CCO), is designed to improve the coordination of care for Medicaid beneficiaries. This reform effort provides an ideal opportunity to evaluate the impact of broad financing and delivery reforms on prenatal care use. Using birth certificate data from Oregon and Washington State, we evaluated the effect of CCO implementation on the probability of early prenatal care initiation, prenatal care adequacy, and disparities in prenatal care use by type of insurance. Following CCO implementation, we found significant increases in early prenatal care initiation and a reduction in disparities across insurance types but no difference in overall prenatal care adequacy. Oregon's reforms could serve as a model for other Medicaid and commercial health plans seeking to improve prenatal care quality and reduce disparities. Project HOPE—The People-to-People Health Foundation, Inc.
Conclusions: Prevalence of hyponatremia is significant in palliative care patients. A prospective study looking at the causes and clinical outcomes associated with hyponatremia in palliative care patients is needed.
Diette, Gregory B; Fuhlbrigge, Anne L; Allen-Ramey, Felicia; Hopper, April; Sajjan, Shiva G; Markson, Leona E
Asthma treatment guidelines recommend medications based on the level of asthma control. To evaluate differences in asthma control between patients who initiated asthma controller monotherapy versus combination therapy. Children (5-16 years; n = 488) and adults (17-80 years; n = 530) with asthma and no controller therapy in the prior 6 months were included. Telephone surveys were conducted within 5 days of filling a new asthma controller prescription with either the caregiver of children or the adult patient. Demographics, asthma control before therapy, and asthma-related resource use were assessed for patients initiating monotherapy (filling one asthma controller prescription) and combination therapy (filling more than one controller medication or a fixed-dose combination). Mean pediatric age was 10 years; 53% were male. Mean adult age was 47 years; 25% were male. There were no significant differences in asthma control score between patients receiving monotherapy and combination therapy. Children on combination therapy did not have more nighttime awakening or short-acting β-agonist use but were more likely to have been hospitalized due to asthma attack (p = .05) and have more unscheduled (p = .0374) and scheduled (p = .009) physician visits. Adults on combination therapy were more likely to have been hospitalized due to asthma attack (p asthma (p asthma control scores in the 4 weeks before index medication suggests that asthma severity during a treatment-free period did not differ significantly for patients initiating controller monotherapy versus combination therapy. From these findings, it appears that although physicians may not focus on asthma control when choosing the intensity of initial controller therapy, the intensity of health-care encounters may be an influence.
Anglin, Grace; Tu, H A; Liao, Kristie; Sessums, Laura; Taylor, Erin Fries
Policy Points: Collaboration across payers to align financial incentives, quality measurement, and data feedback to support practice transformation is critical, but challenging due to competitive market dynamics and competing institutional priorities. The Centers for Medicare & Medicaid Services or other entities convening multipayer initiatives can build trust with other participants by clearly outlining each participant's role and the parameters of collaboration at the outset of the initiative. Multipayer collaboration can be improved if participating payers employ neutral, proactive meeting facilitators; develop formal decision-making processes; seek input on decisions from practice representatives; and champion the initiative within their organizations. With increasing frequency, public and private payers are joining forces to align goals and resources for primary care transformation. However, sustaining engagement and achieving coordination among payers can be challenging. The Comprehensive Primary Care (CPC) initiative is one of the largest multipayer initiatives ever tested. Drawing on the experience of the CPC initiative, this paper examines the factors that influence the effectiveness of multipayer collaboration. This paper draws largely on semistructured interviews with CPC-participating payers and payer conveners that facilitated CPC discussions and on observation of payer meetings. We coded and analyzed these qualitative data to describe collaborative dynamics and outcomes and assess the factors influencing them. We found that several factors appeared to increase the likelihood of successful payer collaboration: contracting with effective, neutral payer conveners; leveraging the support of payer champions, and seeking input on decisions from practice representatives. The presence of these factors helped some CPC regions overcome significant initial barriers to achieve common goals. We also found that leadership from the Centers for Medicare & Medicaid
Verma, Amol A; Klich, John; Thurston, Adam; Scantlebury, Jordan; Kiss, Alex; Seddon, Gayle; Sinha, Samir K
We examined the association between paramedic-initiated home care referrals and utilization of home care, 9-1-1, and Emergency Department (ED) services. This was a retrospective cohort study of individuals who received a paramedic-initiated home care referral after a 9-1-1 call between January 1, 2011 and December 31, 2012 in Toronto, Ontario, Canada. Home care, 9-1-1, and ED utilization were compared in the 6 months before and after home care referral. Nonparametric longitudinal regression was performed to assess changes in hours of home care service use and zero-inflated Poisson regression was performed to assess changes in the number of 9-1-1 calls and ambulance transports to ED. During the 24-month study period, 2,382 individuals received a paramedic-initiated home care referral. After excluding individuals who died, were hospitalized, or were admitted to a nursing home, the final study cohort was 1,851. The proportion of the study population receiving home care services increased from 18.2% to 42.5% after referral, representing 450 additional people receiving services. In longitudinal regression analysis, there was an increase of 17.4 hours in total services per person in the six months after referral (95% CI: 1.7-33.1, p = 0.03). The mean number of 9-1-1 calls per person was 1.44 (SD 9.58) before home care referral and 1.20 (SD 7.04) after home care referral in the overall study cohort. This represented a 10% reduction in 9-1-1 calls (95% CI: 7-13%, p home care referral and 0.79 (SD 6.27) after home care referral, representing a 7% reduction (95% CI: 3-11%, p home care records were included in the analysis, the reductions in 9-1-1 calls and ambulance transports to ED were attenuated but remained statistically significant. Paramedic-initiated home care referrals in Toronto were associated with improved access to and use of home care services and may have been associated with reduced 9-1-1 calls and ambulance transports to ED.
Mengesha Boko Geta
Full Text Available Antenatal care (ANC is care given to pregnant mothers to timely identify and mitigate pregnancy related problems that can harm mother or fetus. Most of Ethiopian mothers present late for ANC. The aim of this paper was to assess determinants of early antenatal care initiation among pregnant women. Mothers attending Shebedino District Health Centers for ANC between January 12 and February 18, 2015, were invited to the study. Multistage sampling technique and structured questionnaire were used to collect data by trained data collectors. Univariate and bivariate analysis were conducted to study the association between explanatory and outcome variable. Out of 608 women, 132 [21.71%] had their first ANC within the recommended time [before or at 3 months]. Media access [AOR = 2.11 95% CI 1.00, 3.22], knowledge about the correct time of ANC booking [AOR = 4.49 95% CI 2.47, 6.16], and having been advised to book within 12 weeks [AOR = 4.14 95% CI 3.80, 5.21] were determinants of first-trimester booking. Health professionals and care providers should provide full information, advice, and appropriate care about early ANC for every eligible mother.
Sobel, Howard L; Silvestre, Maria Asuncion A; Mantaring, Jacinto Blas V; Oliveros, Yolanda E; Nyunt-U, Soe
Aim A deadly nosocomial outbreak in a Philippine hospital drew nationwide attention to neonatal sepsis. Together with specific infection control measures, interventions that protect newborns against infection-related mortality include drying, skin-to-skin contact, delayed cord clamping, breastfeeding initiation and delayed bathing. This evaluation characterized hospital care in the first hours of life with the intent to drive policy change, strategic planning and hospital reform. Methods Trained physicians observed 481 consecutive deliveries in 51 hospitals using a standardized tool to record practices and timing of immediate newborn care procedures. Results Drying, weighing, eye care and vitamin K injections were performed in more than 90% of newborns. Only 9.6% were allowed skin-to-skin contact. Interventions were inappropriately sequenced, e.g. immediate cord clamping (median 12 sec), delayed drying (96.5%) and early bathing (90.0%). While 68.2% were put to the breast, they were separated two minutes later. Unnecessary suctioning was performed in 94.9%. Doctors trained in neonatal resuscitation were 2.5 (1.1–5.7) times more likely to unnecessarily suction vigorous newborns. Two per cent died and 5.7% developed sepsis/pneumonia. Conclusions This minute-by-minute observational assessment revealed that performance and timing of immediate newborn care interventions are below WHO standards and deprive newborns of basic protections against infection and death. PMID:21375583
Maizes, Victoria; Rakel, David; Niemiec, Catherine
Integrative medicine has emerged as a potential solution to the American healthcare crisis. It provides care that is patient centered, healing oriented, emphasizes the therapeutic relationship, and uses therapeutic approaches originating from conventional and alternative medicine. Initially driven by consumer demand, the attention integrative medicine places on understanding whole persons and assisting with lifestyle change is now being recognized as a strategy to address the epidemic of chronic diseases bankrupting our economy. This paper defines integrative medicine and its principles, describes the history of complementary and alternative medicine (CAM) in American healthcare, and discusses the current state and desired future of integrative medical practice. The importance of patient-centered care, patient empowerment, behavior change, continuity of care, outcomes research, and the challenges to successful integration are discussed. The authors suggest a model for an integrative healthcare system grounded in team-based care. A primary health partner who knows the patient well, is able to addresses mind, body, and spiritual needs, and coordinates care with the help of a team of practitioners is at the centerpiece. Collectively, the team can meet all the health needs of the particular patient and forms the patient-centered medical home. The paper culminates with 10 recommendations directed to key actors to facilitate the systemic changes needed for a functional healthcare delivery system. Recommendations include creating financial incentives aligned with health promotion and prevention. Insurers are requested to consider the total costs of care, the potential cost effectiveness of lifestyle approaches and CAM modalities, and the value of longer office visits to develop a therapeutic relationship and stimulate behavioral change. Outcomes research to track the effectiveness of integrative models must be funded, as well as feedback and dissemination strategies
Bercow, Alexandra S; Chen, Ling; Chatterjee, Sudeshna; Tergas, Ana I; Hou, June Y; Burke, William M; Ananth, Cande V; Neugut, Alfred I; Hershman, Dawn L; Wright, Jason D
To examine the cost of care during the first year after a diagnosis of ovarian cancer, estimate the sources of cost, and explore the out-of-pocket costs. We performed a retrospective cohort study of women with ovarian cancer diagnosed from 2009 to 2012 who underwent both surgery and adjuvant chemotherapy using the Truven Health MarketScan database. This database is comprised of patients covered by commercial insurance sponsored by more than 100 employers in the United States. Medical expenditures, including physician reimbursement, for a 12-month period beginning on the date of surgery were estimated. All payments were examined, including out-of-pocket costs for patients. Payments were divided into expenditures for inpatient care, outpatient care (including chemotherapy), and outpatient drug costs. The 12-month treatment period was divided into three phases: surgery to 30 days (operative period), 1-6 months (adjuvant therapy), and 6-12 months after surgery. The primary outcome was the overall cost of care within the first year of diagnosis of ovarian cancer; secondary outcomes included assessment of factors associated with cost. A total of 26,548 women with ovarian cancer who underwent surgery were identified. After exclusion of patients with incomplete insurance enrollment or coverage, those who did not undergo chemotherapy, and those with capitated plans, our cohort consisted of 5,031 women. The median total medical expenditures per patient during the first year after the index procedure were $93,632 (interquartile range $62,319-140,140). Inpatient services accounted for $30,708 (interquartile range $20,102-51,107; 37.8%) in expenditures, outpatient services $52,700 (interquartile range $31,210-83,206; 58.3%), and outpatient drug costs $1,814 (interquartile range $603-4,402; 3.8%). The median out-of-pocket expense was $2,988 (interquartile range $1,649-5,088). This included $1,509 (interquartile range $705-2,878) for outpatient services, $589 (interquartile range
Sakaguchi, Hideya; Yamashita, Satoshi; Hirano, Teruyuki; Nakajima, Makoto; Kimura, En; Maeda, Yasushi; Uchino, Makoto
The purpose of this report was to investigate predictive factors that necessitate intensive care in myasthenic crisis (MC). We retrospectively reviewed MC patients at our institution and compared ICU and ward management groups. Higher MG-ADL scale scores, non-ocular initial symptoms, infection-triggered findings, and higher MGFA classification were observed more frequently in the ICU group. In patients with these prognostic factors, better outcomes may be obtained with early institution of intensive care. Copyright © 2012 Wiley Periodicals, Inc.
Bridges, Ana J.; Andrews, Arthur R.; Villalobos, Bianca T.; Pastrana, Freddie A.; Cavell, Timothy A.; Gomez, Debbie
Integrated behavioral health care (IBHC) is a model of mental health care service delivery that seeks to reduce stigma and service utilization barriers by embedding mental health professionals into the primary care team. This study explored whether IBHC service referrals, utilization, and outcomes were comparable for Latinos and non-Latino White primary care patients. Data for the current study were collected from 793 consecutive patients (63.8% Latino; M age = 29.02 years [SD = 17.96]; 35.1% under 18 years; 65.3% women; 54.3% uninsured) seen for behavioral health services in 2 primary care clinics during a 10.5 month period. The most common presenting concerns were depression (21.6%), anxiety (18.5%), adjustment disorder (13.0%), and externalizing behavior problems (9.8%). Results revealed that while Latino patients had significantly lower self-reported psychiatric distress, significantly higher clinician-assigned global assessment of functioning scores, and fewer received a psychiatric diagnosis at their initial visit compared to non-Latino White patients, both groups had comparable utilization rates, comparable and clinically significant improvements in symptoms (Cohen’s d values > .50), and expressed high satisfaction with integrated behavioral services. These data provide preliminary evidence suggesting integration of behavioral health services into primary care clinics may help reduce mental health disparities for Latinos. PMID:25309845
Thygesen, Marianne K; Fuglsang, Marie; Miiller, Max Mølgaard
INTRODUCTION: Surveys that include rating scales are commonly used to collect data about patients' experiences. We studied how patients associated their ratings with their experiences of care. METHODS: A survey and a qualitative study were conducted at a Danish hospital. Initially, 19 female pati...
Egerod, Ingrid; Bergbom, Ingegerd; Lindahl, Berit
: Nordic intensive care units. PARTICIPANTS: Patients in Nordic intensive care units. METHODS: We performed a literature search of qualitative studies of the patient experience of intensive care based on Nordic publications in 2000-2013. We searched the following databases: PubMed, CINAHL, Scopus, and Psyc...
Prins, M.A.; Verhaak, P.F.M.; Meer, K. van der; Penninx, B.W.J.H.; Bensing, J.M.
Many anxiety and depression patients receive no care, resulting in unnecessary suffering and high costs. Specific beliefs and the absence of a perceived need for care are major reasons for not receiving care. This study aims to determine the specific perceived need for care in primary care patients
Huynh, Ho P; Sweeny, Kate
A key role of clinicians is to motivate their patients to initiate and maintain beneficial health behaviors. This article integrates research on transformational leadership, clinician-patient communication, and health behavior to introduce a novel approach to understanding and improving clinicians' effectiveness as motivators. We describe three dominant clinician styles or patterned approaches to patient care that derive from leadership theory (in order of least to most effective): laissez-faire, transactional, and transformational. Additionally, we suggest potential mediators and effects of the transformational style of care. Finally, we discuss future research directions for the study of clinician styles of care. © The Author(s) 2013.
Mundkur, Mallika L; Rough, Kathryn; Huybrechts, Krista F; Levin, Raisa; Gagne, Joshua J; Desai, Rishi J; Patorno, Elisabetta; Choudhry, Niteesh K; Bateman, Brian T
The primary objective of this study was to characterize variation in patterns of opioid prescribing within primary care settings at first visits for pain, and to describe variation by condition, geography, and patient characteristics. 2014 healthcare utilization data from Optum's Clinformatics™ DataMart were used to evaluate individuals 18 years or older with an initial presentation to primary care for 1 of 10 common pain conditions. The main outcomes assessed were (1) the proportion of first visits for pain associated with an opioid prescription fill and (2) the proportion of opioid prescriptions with >7 days' supply. We identified 205 560 individuals who met inclusion criteria; 9.1% of all visits were associated with an opioid fill, ranging from 4.1% (headache) to 28.2% (dental pain). Approximately half (46%) of all opioid prescriptions supplied more than 7 days, and 10% of prescriptions supplied ≥30 days. We observed a 4-fold variation in rates of opioid initiation by state, with highest rates of prescribing in Alabama (16.6%) and lowest rates in New York (3.7%). In 2014, nearly half of all patients filling opioid prescriptions received more than 7 days' of opioids in an initial prescription. Policies limiting initial supplies have the potential to substantially impact opioid prescribing in the primary care setting. Copyright © 2017 John Wiley & Sons, Ltd.
Dellenmark-Blom, Michaela; Wigert, Helena
A descriptive study of parents' experiences with neonatal home care following initial care in the neonatal intensive care unit. As survival rates improve among premature and critically ill infants with an increased risk of morbidity, parents' responsibilities for neonatal care grow in scope and degree under the banner of family-centred care. Concurrent with medical advances, new questions arise about the role of parents and the experience of being provided neonatal care at home. An interview study with a phenomenological hermeneutic approach. Parents from a Swedish neonatal (n = 22) home care setting were extensively interviewed within one year of discharge. Data were collected during 2011-2012. The main theme of the findings is that parents experience neonatal home care as an inner emotional journey, from having a child to being a parent. This finding derives from three themes: the parents' experience of leaving the hospital milieu in favour of establishing independent parenthood, maturing as a parent and processing experiences during the period of neonatal intensive care. This study suggests that neonatal home care is experienced as a care structure adjusted to incorporate parents' needs following discharge from a neonatal intensive care unit. Neonatal home care appears to bridge the gap between hospital and home, supporting the family's adaptation to life in the home setting. Parents become empowered to be primary caregivers, having nurse consultants serving the needs of the whole family. Neonatal home care may therefore be understood as the implementation of family-centred care during the transition from NICU to home. © 2013 John Wiley & Sons Ltd.
Smith, Francis Duval
Transgender patients are individuals whose gender identity is not related to their biological sex. Assuming a new gender identity that does not conform to societal norms often results in discrimination and barriers to health care. The exact number of transgender patients is unknown; however, these patients are increasingly seen in health care. Transgender individuals may experience provider-generated discrimination in health care facilities, including refusal of service, disrespect, and abuse, which contribute to depression and low self-esteem. Transgender therapies include mental health counseling for depression and low self-esteem, hormone therapy, and sex reassignment surgery. Health care professionals require cultural competence, an understanding of the different forms of patient identification, and adaptive approaches to care for transgender patients. VA (Veterans Affairs) hospitals provide a model for the care for transgender patients and staff. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Rochon, Andrea; Heale, Roberta; Hunt, Elena; Parent, Michele
The literature suggests that effective teamwork among patient care teams can positively impact work environment, job satisfaction and quality of patient care. The purpose of this study was to determine the perceived level of nursing teamwork by registered nurses, registered practical nurses, personal support workers and unit clerks working on patient care teams in one acute care hospital in northern Ontario, Canada, and to determine if a relationship exists between the staff scores on the Nursing Teamwork Survey (NTS) and participant perception of adequate staffing. Using a descriptive cross-sectional research design, 600 staff members were invited to complete the NTS and a 33% response rate was achieved (N=200). The participants from the critical care unit reported the highest scores on the NTS, whereas participants from the inpatient surgical (IPS) unit reported the lowest scores. Participants from the IPS unit also reported having less experience, being younger, having less satisfaction in their current position and having a higher intention to leave. A high rate of intention to leave in the next year was found among all participants. No statistically significant correlation was found between overall scores on the NTS and the perception of adequate staffing. Strategies to increase teamwork, such as staff education, among patient care teams may positively influence job satisfaction and patient care on patient care units. Copyright © 2015 Longwoods Publishing.
Braun, Kathryn L.; And Others
Examined three-way relationships among patient characteristics, type of care (admission to nursing home or community setting), and 6-month outcomes of 352 long-term care patients. Found that patient characteristics influenced type of care received and that substantial portions of variance in outcomes were attributable to initial differences among…
Gordon, G H; Baker, L; Levinson, W
The quality of physician-patient communication affects important health care outcomes. Managed care presents a number of challenges to physician-patient communication, including shorter visits, decreased continuity, and lower levels of trust. Good communication skills can help physicians create and maintain healthy relationships with patients in the face of these challenges. We describe 5 communication dilemmas that are common in managed care and review possible solutions suggested by recent ...
Eldh, Ann Catrine; Luhr, Kristina; Ehnfors, Margareta
To report on the development and initial testing of a clinical tool, The Patient Preferences for Patient Participation tool (The 4Ps), which will allow patients to depict, prioritize, and evaluate their participation in health care. While patient participation is vital for high quality health care, a common definition incorporating all stakeholders' experience is pending. In order to support participation in health care, a tool for determining patients' preferences on participation is proposed, including opportunities to evaluate participation while considering patient preferences. Exploratory mixed methods studies informed the development of the tool, and descriptive design guided its initial testing. The 4Ps tool was tested with 21 Swedish researcher experts (REs) and patient experts (PEs) with experience of patient participation. Individual Think Aloud interviews were employed to capture experiences of content, response process, and acceptability. 'The 4Ps' included three sections for the patient to depict, prioritize, and evaluate participation using 12 items corresponding to 'Having Dialogue', 'Sharing Knowledge', 'Planning', and 'Managing Self-care'. The REs and PEs considered 'The 4Ps' comprehensible, and that all items corresponded to the concept of patient participation. The tool was perceived to facilitate patient participation whilst requiring amendments to content and layout. A tool like The 4Ps provides opportunities for patients to depict participation, and thus supports communication and collaboration. Further patient evaluation is needed to understand the conditions for patient participation. While The 4Ps is promising, revision and testing in clinical practice is required. © 2014 John Wiley & Sons Ltd.
Piredda, Michela; Matarese, Maria; Mastroianni, Chiara; D'Angelo, Daniela; Hammer, Marilyn J; De Marinis, Maria Grazia
Care dependence can be associated with suffering and humiliation. Nurses' awareness of patients' perception of care dependence is crucial to enable them in helping the dependent persons. This study aimed to describe adult patients' experience of nursing care dependence. A metasynthesis was conducted to integrate qualitative findings from 18 studies published through December 2014 on adult patients' experiences of care dependency. Procedures included the Johanna Briggs Institute approach for data extraction, quality appraisal, and integration of findings. The experience of dependence revealed the concept of the embodied person, particularly in relation to care of the physical body. The relationship between the individual and nurses within the context of care had a major impact for dependent patients. When the care relation was perceived as positive, the experience led to the development of the person in finding new balances in life, but when it was perceived as negative, it increased patient' suffering. Care dependence is manifested mostly as bodily dependence and is consistent with its relational nature. The nurse-patient relationship is important to the dependent patients' experience. A greater understanding of patients' experiences of dependence is crucial to enable nurses in improving care and decreasing patient suffering. © 2015 Sigma Theta Tau International.
Soares-Oliveira, Miguel; Araújo, Fernando
Implementing integrated systems for emergency care of patients with acute ischemic stroke helps reduce morbidity and mortality. We describe the process of organizing and implementing a regional system to cover around 3.7 million people and its main initial results. We performed a descriptive analysis of the implementation process and a retrospective analysis of the following parameters: number of patients prenotified by the pre-hospital system; number of times thrombolysis was performed; door-to-needle time; and functional assessment three months after stroke. The implementation process started in November 2005 and ended in December 2009, and included 11 health centers. There were 3574 prenotifications from the prehospital system. Thrombolysis was performed in 1142 patients. The percentage of patients receiving thrombolysis rose during the study period, with a maximum of 16%. Median door-to-needle time was 62 min in 2009. Functional recovery three months after stroke was total or near total in 50% of patients. The regional system implemented for emergency care of patients with acute ischemic stroke has led to health gains, with progressive improvements in patients' access to thrombolysis, and to greater equity in the health care system, thus helping to reduce mortality from cerebrovascular disease in Portugal. Our results, which are comparable with those of international studies, support the strategy adopted for implementation of this system. Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.
... patient's well-being, comfort, and dignity throughout the dying process. The comprehensive assessment must... and participate in his or her own care. (4) Imminence of death. (5) Severity of symptoms. (6) Drug... their ability to cope with the patient's death. Information gathered from the initial bereavement...
Roberts, Russel J; Alhammad, Abdullah M; Crossley, Lindsay; Anketell, Eric; Wood, LeeAnn; Schumaker, Greg; Garpestad, Erik; Devlin, John W
Delays in antibiotic administration after severe sepsis recognition increases mortality. While physician and pharmacy-related barriers to early antibiotic initiation have been well evaluated, those factors that affect the speed by which critical care nurses working in either the emergency department or the intensive care unit setting initiate antibiotic therapy remains poorly characterized. To evaluate the knowledge, practices and perceptions of critical care nurses regarding antibiotic initiation in patients with newly recognised septic shock. A validated survey was distributed to 122 critical care nurses at one 320-bed academic institution with a sepsis protocol advocating intravenous(IV) antibiotic initiation within 1hour of shock recognition. Among 100 (82%) critical care nurses responding, nearly all (98%) knew of the existence of the sepsis protocol. However, many critical care nurses stated they would optimise blood pressure [with either fluid (38%) or both fluid and a vasopressor (23%)] before antibiotic initiation. Communicated barriers to rapid antibiotic initiation included: excessive patient workload (74%), lack of awareness IV antibiotic(s) ordered (57%) or delivered (69%), need for administration of multiple non-antibiotic IV medications (54%) and no IV access (51%). Multiple nurse-related factors influence IV antibiotic(s) initiation speed and should be incorporated into sepsis quality improvement efforts. Copyright © 2017 Elsevier Ltd. All rights reserved.
Full Text Available Background: A supportive needs assessment is an essential component of any care program. There is no research evidence regarding the supportive care needs of cancer patients in Iran or other Middle Eastern countries. Aims: The aim of this study was to determine the supportive care needs of Iranian cancer patients. Materials and Methods: This descriptive study was conducted in a referral medical center in the northwest of Iran. A total of 274 cancer patients completed the Supportive Care Needs Survey (SCNS-59. Descriptive statistics were used for data analysis. Results: In 18 items of the SCNS, more than 50% of the participants reported that their needs were unmet. Most frequently, unmet needs were related to the health system, information, physical, and daily living domains, and most met needs were related to sexuality, patient care, and support domains. Conclusions: Iranian cancer patients experience many unmet needs and there is an urgent need for establishing additional supportive care services in Iran.
Podlekareva Daria N
Full Text Available Abstract Background State-of-the-art care involving the utilisation of multiple health care interventions is the basis for an optimal long-term clinical prognosis for HIV-patients. We evaluated health care for HIV patients based on four key indicators. Methods Four indicators of health care were assessed: Compliance with current guidelines on initiation of: 1 combination antiretroviral therapy (cART; 2 chemoprophylaxis; 3 frequency of laboratory monitoring; and 4 virological response to cART (proportion of patients with HIV-RNA 90% of time on cART. Results 7097 EuroSIDA patients were included from Northern (n = 923, Southern (n = 1059, West Central (n = 1290 East Central (n = 1366, Eastern (n = 1964 Europe, and Argentina (n = 495. Patients in Eastern Europe with a CD4 3 were less likely to initiate cART and Pneumocystis jiroveci-chemoprophylaxis compared to patients from all other regions, and less frequently had a laboratory assessment of their disease status. The proportion of patients with virological response was highest in Northern, 89% vs. 84%, 78%, 78%, 61%, 55% in West Central, Southern, East Central Europe, Argentina and Eastern Europe, respectively (p Conclusions This assessment of HIV health care utilization revealed pronounced regional differences in adherence to guidelines and can help to identify gaps and direct target interventions. It may serve as a tool for the assessment and benchmarking of the clinical management of HIV patients in any setting worldwide.
Claeys, Coraline; Foulon, Veerle; de Winter, Sabrina; Spinewine, Anne
Patients' transition between hospital and community is a high-risk period for the occurrence of medication-related problems. The objective was to review initiatives, implemented at national and regional levels in seven selected countries, aiming at improving continuity in medication management upon admission and hospital discharge. We performed a structured search of grey literature, mainly through relevant websites (scientific, professional and governmental organizations). Regional or national initiatives were selected. For each initiative data on the characteristics, impact, success factors and barriers were extracted. National experts were asked to validate the initiatives identified and the data extracted. Most initiatives have been implemented since the early 2000 and are still ongoing. The principal actions include: development and implementation of guidelines for healthcare professionals, national information campaigns, education of healthcare professionals and development of information technologies to share data across settings of care. Positive results have been partially reported in terms of intake into practice or process measures. Critical success factors identified included: leadership and commitment to convey national and local forces, tailoring to local settings, development of a regulatory framework and information technology support. Barriers identified included: lack of human and financial resources, questions relative to responsibility and accountability, lack of training and lack of agreement on privacy issues. Although not all initiatives are applicable as such to a particular healthcare setting, most of them convey very interesting data that should be used when drawing recommendations and implementing approaches to optimize continuity of care.
Full Text Available Else Cathrine Rustad,1–4 Bodil Furnes,1 Berit Seiger Cronfalk,2,5,6 Elin Dysvik1 1Department of Health Studies, Faculty of Social Sciences, University of Stavanger, Stavanger, Norway; 2Faculty of Health and Caring Sciences, Stord Haugesund University College, Stord, Norway; 3Research Network on Integrated Health Care in Western Norway, Helse Fonna Local Health Authority, Haugesund, Norway; 4Department of Clinical Medicine, Helse Fonna Local Health Authority, Haugesund, Norway; 5Palliative Research Center, Ersta Sköndal University College, Stockholm, Sweden; 6Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden Background: A fragmented health care system leads to an increased demand for continuity of care across health care levels. Research indicates age-related differences during care transition, with the oldest patients having experiences and needs that differ from those of other patients. To meet the older patients’ needs and preferences during care transition, professionals must understand their experiences.Objective: The purpose of the study was to explore how patients ≥80 years of age experienced the care transition from hospital to municipal health care services.Methods: The study has a descriptive, explorative design, using semistructured interviews. Fourteen patients aged ≥80 participated in the study. Qualitative content analysis was used to describe the individuals’ experiences during care transition.Results: Two complementary themes emerged during the analysis: “Participation depends on being invited to plan the care transition” and “Managing continuity of care represents a complex and challenging process”.Discussion: Lack of participation, insufficient information, and vague responsibilities among staff during care transition seemed to limit the continuity of care. The patients are the vulnerable part of the care transition process, although they possess important
Clair, Andrew J; Evangelista, Perry J; Lajam, Claudette M; Slover, James D; Bosco, Joseph A; Iorio, Richard
The Bundled Payment for Care Improvement (BPCI) Initiative is a Centers for Medicare and Medicaid Services program designed to promote coordinated and efficient care. This study seeks to report costs of readmissions within a 90-day episode of care for BPCI Initiative patients receiving total knee arthroplasty (TKA) or total hip arthroplasty (THA). From January 2013 through December 2013, 1 urban, tertiary, academic orthopedic hospital admitted 664 patients undergoing either primary TKA or THA through the BPCI Initiative. All patients readmitted to our hospital or an outside hospital within 90-days from the index episode were identified. The diagnosis and cost for each readmission were analyzed. Eighty readmissions in 69 of 664 patients (10%) were identified within 90-days. There were 53 readmissions (45 patients) after THA and 27 readmissions (24 patients) after TKA. Surgical complications accounted for 54% of THA readmissions and 44% of TKA readmissions. These complications had an average cost of $36,038 (range, $6375-$60,137) for THA and $38,953 (range, $4790-$104,794) for TKA. Eliminating the TKA outlier of greater than $100,000 yields an average cost of $27,979. Medical complications of THA and TKA had an average cost of $22,775 (range, $5678-$82,940) for THA and $24,183 (range, $3306-$186,069) for TKA. Eliminating the TKA outlier of greater than $100,000 yields an average cost of $11,682. Hospital readmissions after THA and TKA are common and costly. Identifying the causes for readmission and assessing the cost will guide quality improvement efforts. Copyright © 2016 Elsevier Inc. All rights reserved.
Todd, Catherine; Watfa, Mohamed; El Mouden, Yassine; Sahir, Sana; Ali, Afrah; Niavarani, Ali; Lutfi, Aoun; Copiaco, Abigail; Agarwal, Vaibhavi; Afsari, Kiyan; Johnathon, Chris; Okafor, Onyeka; Ayad, Marina
Indoor flight, obstacle avoidance and client-server communication of an Unmanned Aerial Vehicle (UAV) raises several unique research challenges. This paper examines current methods and associated technologies adapted within the literature toward autonomous UAV flight, for consideration in a proposed system for indoor healthcare administration with a quadcopter. We introduce Healthbuddy, a unique research initiative towards overcoming challenges associated with indoor navigation, collision detection and avoidance, stability, wireless drone-server communications and automated decision support for patient care in a GPS-denied environment. To address the identified research deficits, a drone-based solution is presented. The solution is preliminary as we develop and refine the suggested algorithms and hardware system to achieve the research objectives.
Pflugeisen, Bethann Mangel; Mou, Jin
Introduction The importance of patient satisfaction in US healthcare is increasing, in tandem with the advent of new patient care modalities, including virtual care. The purpose of this study was to compare the satisfaction of obstetric patients who received one-third of their antenatal visits in videoconference ("Virtual-care") compared to those who received 12-14 face-to-face visits in-clinic with their physician/midwife ("Traditional-care"). Methods We developed a four-domain satisfaction questionnaire; Virtual-care patients were asked additional questions about technology. Using a modified Dillman method, satisfaction surveys were sent to Virtual-care (N = 378) and Traditional-care (N = 795) patients who received obstetric services at our institution between January 2013 and June 2015. Chi-squared tests of association, t-tests, logistic regression, and ANOVA models were used to evaluate differences in satisfaction and self-reported demographics between respondents. Results Overall satisfaction was significantly higher in the Virtual-care cohort (4.76 ± 0.44 vs. 4.47 ± 0.59; p Virtual-care selection (OR = 2.4, 95% CI: 1.5-3.8; p Virtual-care respondents was not significantly impacted by the incorporation of videoconferencing, Doppler, and blood pressure monitoring technology into their care. The questionnaire demonstrated high internal consistency as measured by domain-based correlations and Cronbach's alpha. Discussion Respondents from both models were highly satisfied with care, but those who had selected the Virtual-care model reported significantly higher mean satisfaction scores. The Virtual-care model was selected by significantly more women who already have children than those experiencing pregnancy for the first time. This model of care may be a reasonable alternative to traditional care.
Full Text Available Successful implementation of treatment in cancer care partially depends on how patients' perspectives are taken into account, as preferences of health care professionals and patients may differ. Objectives of this exploratory research were (I to identify patient preferences and values (PPVs in cancer care as indicated by patient organizations (POs, (II to determine how these PPVs are captured in cancer care guidelines and (III to review how guidelines take into account these PPVs. Based on a survey developed and completed by 19 POs, a literature review was conducted to analyse how patient perspectives are incorporated in oncology treatment guidelines. Based on survey results traditional health technology assessment value propositions of oncology care, such as extended life, treatment-free remission and pain reduction, were also highly rated by POs. However, the heterogeneity of cancer PPVs were clearly reflected in the survey results. PPVs in cancer care guidelines were mostly limited to those micro-level aspects that are strictly related to health care provision, such as side-effects and comorbidities. Patient experience, emotional support and convenience of care were relatively neglected fields in the reviewed guidelines. Patient engagement was rarely presented in the guideline development phase. POs believe that patients should be encouraged to take an active role in their own care due to the heterogeneity of cancer patients and PPVs. Even if patient-centricity is a leading paradigm in cancer policy, based on our research it is not yet standard practice to include patients or POs at all appropriate levels of decision-making processes that are related to their health and well-being. Patient engagement should be an integral part of cancer care decision-making. This complexity must be reflected throughout policy making, avoiding a population level “one-size-fits-all” solution.
Full Text Available INTRODUCTION: To combat the AIDS epidemic and increase HIV treatment access, the South African government implemented a nurse-based, doctor-supported model of care that decentralizes administration of antiretroviral treatment (ART for HIV positive patients through nurse initiated and managed ART. Médecins Sans Frontières (MSF implemented a mentorship programme to ensure successful task-shifting, subsequently assessing the quality of clinical care provided by nurses. METHODS: A before-after cross-sectional study was conducted on nurses completing the mentorship programme in Khayelitsha, South Africa, from February 2011-September 2012. Routine clinical data from 229 patient folders and 21 self-assessment questionnaires was collected to determine the number of patients initiated on ART by nurses; quality of ART management before-after mentorship; patient characteristics for doctor and nurse ART initiations; and nurse self-assessments after mentorship. RESULTS: Twenty one nurses were authorized by one nurse mentor with one part-time medical officer's support, resulting in nurses initiating 77% of ART eligible patients. Improvements in ART management were found for drawing required bloods (91% vs 99%, p = 0.03, assessing adherence (50% vs 78%, p<0.001 and WHO staging (63% vs 91%, p<0.001. Nurse ART initiation indicators were successfully completed at 95-100% for 11 of 16 indicators: clinical presentation; patient weight; baseline blood work (CD4, creatinine, haemoglobin; STI screening; WHO stage, correlating medical history; medications prescribed appropriately; ART start date; and documented return date. Doctors initiated more patients with TB/HIV co-infection and WHO Stage 3 and 4 disease than nurses. Nurse confidence improved for managing HIV-infected children and pregnant women, blood result interpretation and long-term side effects. CONCLUSIONS: Implementation of a clinical mentorship programme in Khayelitsha led to nurse initiation of a
Kissoon, Niranjan; Carcillo, Joseph A; Espinosa, Victor; Argent, Andrew; Devictor, Denis; Madden, Maureen; Singhi, Sunit; van der Voort, Edwin; Latour, Jos
According to World Health Organization estimates, sepsis accounts for 60%-80% of lost lives per year in childhood. Measures appropriate for resource-scarce and resource-abundant settings alike can reduce sepsis deaths. In this regard, the World Federation of Pediatric Intensive Care and Critical Care Societies Board of Directors announces the Global Pediatric Sepsis Initiative, a quality improvement program designed to improve quality of care for children with sepsis. To announce the global sepsis initiative; to justify some of the bundles that are included; and to show some preliminary data and encourage participation. The Global Pediatric Sepsis Initiative is developed as a Web-based education, demonstration, and pyramid bundles/checklist tool (http://www.pediatricsepsis.org or http://www.wfpiccs.org). Four health resource categories are included. Category A involves a nonindustrialized setting with mortality rate 30 of 1,000 children. Category B involves a nonindustrialized setting with mortality rate children. Category C involves a developing industrialized nation. In category D, developed industrialized nation are determined and separate accompanying administrative and clinical parameters bundles or checklist quality improvement recommendations are provided, requiring greater resources and tasks as resource allocation increased from groups A to D, respectively. In the vanguard phase, data for 361 children (category A, n = 34; category B, n = 12; category C, n = 84; category D, n = 231) were successfully entered, and quality-assurance reports were sent to the 23 participating international centers. Analysis of bundles for categories C and D showed that reduction in mortality was associated with compliance with the resuscitation (odds ratio, 0.369; 95% confidence interval, 0.188-0.724; p Initiative is online. Success in reducing pediatric mortality and morbidity, evaluated yearly as a measure of global child health care quality improvement, requires ongoing
Full Text Available Introduction: Patient satisfaction was important aspect that must be considered by health service providers, patients who were not satisfied will leave the hospital and be a competitor's customers so be able caused a decrease in sales of products/services and in turn could reduce and even loss of profit, therefore, the hospital must provided the best service so that it could increase patient satisfaction. The purpose of this study was to exams the effect of Islamic caring model on increase patient satisfaction.. Method: This study was used pre-experimental design, the respondents were 31 patients in the treatment group assigned Islamic caring and 31 patients with a kontrol group that were not given Islamic caring Inpatient Surgical Sultan Agung Islamic Hospital Semarang by using consecutive sampling techniques, patient satisfaction data collected through questionnaires and analyzed with Mann-Whitney test, as for finding out the Islamic caring for patient satisfaction were analyzed with spearmen's rho test. Result: The results showed that there was a significant influence of Islamic caring for perceived disconfirmation (p=0,000 there was a perceived disconfirmation influence on patient satisfaction significantly (p=0,000, there was a significant influence of Islamic caring for patient satisfaction in the treatment group with a kontrol group (p=0.001. Discussion: Discussion of this study was Islamic caring model effect on the increase perceived disconfirmation and patient satisfaction, Perceived disconfirmation effect on patient satisfaction, patient satisfaction who given Islamic caring was increase, patients given Islamic caring had higher satisfaction levels than patients who not given Islamic caring. Suggestions put forward based on the results of the study of Islamic caring model could be applied in Sultan Agung Islamic Hospital as a model of nursing care, Islamic caring behavior can be learned and improved through training and commitment and
Egawa, Akiko; Suwa, Katsuhito
The aim of stoma care and rehabilitation is improving the quality of life of the patient with a stoma. There are more than 1,700 stoma specialist nurses in Japan, eg, enterostomal therapists(ET)and wound, ostomy, and continence nurses(WOCN), who are involved in the care of patients with stomas. In this manuscript, we describe our role in the care of patients with temporary/permanent stomas created for emergency disease and/or palliative care, and the adverse effects of various current chemotherapies.
Tzeng, Huey-Ming; Yin, Chang-Yi; Fitzgerald, Kara
Could engaging patients in their care be a means to oppose obscurantism? Obscurantism is defined by Merriam-Webster as "the practice of keeping knowledge or understanding about something from people". This paper discusses the importance of promoting patient engagement and emphasizes that patients and healthcare providers are equally important stakeholders in health care. The discussion occurs in the context of hospital inpatient care as nurses play a critical role in patients' hospitalization experience, including engaging patients in their own care during hospital stays. Paternalism of healthcare providers is recognized as one of the main barriers to integrating the concepts of patient engagement and patient centeredness into every aspect of the care system. Promoting patient engagement is a two-way responsibility, and it requires the cooperation of both patients and healthcare providers. As scientists and healthcare providers, we have the duty to counter obscurantism by promoting understanding of the health of individual citizens and society at large. A culture change in healthcare systems toward being patient-centric and placing value on patient engagement is warranted, and this change must come from healthcare providers. Patient-centered tools that support patient engagement, patient portals, or personal health records are still needed. © 2014 Wiley Periodicals, Inc.
Procedures are reviewed of therapeutic and preventive care in patients with malignant tumours in the area of the head and neck during radiotherapy and during the subsequent follow-up of patients. As compared with previous views, the care is now more conservative, indications for tooth extractions are now limited, careful oral hygiene is emphasized and, in particular, the long-term use of fluorine gel is recommended. Surgery is only recommended where conservative treatment fails. (author)
Konecny, M [Onkologicky Ustav, Brno (Czechoslovakia). Betatronove Pracoviste
Procedures are reviewed of therapeutic and preventive care in patients with malignant tumours in the area of the head and neck during radiotherapy and during the subsequent follow-up of patients. As compared with previous views, the care is now more conservative, indications for tooth extractions are now limited, careful oral hygiene is emphasized and, in particular, the long-term use of fluorine gel is recommended. Surgery is only recommended where conservative treatment fails.
Hill, Douglas L; Walter, Jennifer K; Casas, Jessica A; DiDomenico, Concetta; Szymczak, Julia E; Feudtner, Chris
Children with advanced cancer are often not referred to palliative or hospice care before they die or are only referred close to the child's death. The goals of the current project were to learn about pediatric oncology team members' perspectives on palliative care, to collaborate with team members to modify and tailor three separate interdisciplinary team-based interventions regarding initiating palliative care, and to assess the feasibility of this collaborative approach. We used a modified version of experience-based codesign (EBCD) involving members of the pediatric palliative care team and three interdisciplinary pediatric oncology teams (Bone Marrow Transplant, Neuro-Oncology, and Solid Tumor) to review and tailor materials for three team-based interventions. Eleven pediatric oncology team members participated in four codesign sessions to discuss their experiences with initiating palliative care and to review the proposed intervention including patient case studies, techniques for managing uncertainty and negative emotions, role ambiguity, system-level barriers, and team communication and collaboration. The codesign process showed that the participants were strong supporters of palliative care, members of different teams had preferences for different materials that would be appropriate for their teams, and that while participants reported frustration with timing of palliative care, they had difficulty suggesting how to change current practices. The current project demonstrated the feasibility of collaborating with pediatric oncology clinicians to develop interventions about introducing palliative care. The procedures and results of this project will be posted online so that other institutions can use them as a model for developing similar interventions appropriate for their needs.
Thorup, Charlotte Brun
Psychosocial care to patients with Malignant Melanoma Intensions: The intension of this project is to link new knowledge with the nurses experience based knowledge within the psychosocial care to patients, who have been diagnosed with Malignant Melanoma (MM), thereby improving the care...... to elaborate the care to these patients. Method: In 2007 the nurses from our ward gained experience from the psychosocial care to these patients. These experiences are a starting point to the study of literature the group has made. A group of five nurses have from this literature study, substantiated...... the psychosocial perspective. Results: After the literature review, the psychosocial aspects have been divided into five main areas: 1. Diagnosis, hospitalisation, and treatment 2. The body with cancer 3. Psychological 4. Social 5. Existential/spiritual Primary results show that patients with MM in general respond...
Kilickaya, Oguz; Gajic, Ognjen
The lung-protective mechanical ventilation strategy has been standard practice for management of acute respiratory distress syndrome (ARDS) for more than a decade. Observational data, small randomized studies and two recent systematic reviews suggest that lung protective ventilation is both safe and potentially beneficial in patients who do not have ARDS at the onset of mechanical ventilation. Principles of lung-protective ventilation include: a) prevention of volutrauma (tidal volume 4 to 8 ...
Long, Lawrence C; Maskew, Mhairi; Brennan, Alana T; Mongwenyana, Constance; Nyoni, Cynthia; Malete, Given; Sanne, Ian; Fox, Matthew P; Rosen, Sydney
Determine the cost and cost-effectiveness of single-visit (same-day) antiretroviral treatment (ART) initiation compared to standard of care initiation. Cost-effectiveness analysis of individually randomized (1 : 1) pragmatic trial of single-visit initiation, which increased viral suppression at 10 months by 26% [relative risk (95% confidence interval) 1.26 (1.05-1.50)]. Primary health clinic in Johannesburg, South Africa. HIV positive, adult, nonpregnant patients not yet on ART or known to be eligible who presented at the clinic 8 May 2013 to 29 August 2014. Same-day ART initiation using point-of-care laboratory instruments and accelerated clinic procedures to allow treatment-eligible patients to receive antiretroviral medications at the same visit as testing HIV positive or having an eligible CD4 cell count. Comparison was to standard of care ART initiation, which typically required three to five additional clinic visits. Average cost per patient enrolled and per patient achieving the primary outcome of initiated 90 days or less and suppressed 10 months or less, and production cost per patient achieving primary outcome (all costs per primary outcome patients). The average cost per patient enrolled, per patient achieving the primary outcome, and production cost were $319, $487, and $738 in the standard arm and $451, $505, and $707 in the rapid arm. Same-day treatment initiation was more effective than standard initiation, more expensive per patient enrolled, and less expensive to produce a patient achieving the primary outcome. Omitting point-of-care laboratory tests at initiation and focusing on high-volume clinics have the potential to reduce costs substantially and should be evaluated in routine settings.
Full Text Available Introduction: The use of observation units (OUs following emergency departments (ED visits as a model of care has increased exponentially in the last decade. About one-third of U.S. hospitals now have OUs within their facilities. While their use is associated with lower costs and comparable level of care compared to inpatient units, there is a wide variation in OUs characteristics and operational procedures. The objective of this research was to explore the variability in the initial costs of care of placing patients with non-specific chest pain in observation units (OUs and the one-year outcomes. Methods: The author retrospectively investigated medical insurance claims of 22,962 privately insured patients (2009-2011 admitted to 41 OUs. Outcomes included the one-year chest pain/cardiovascular related costs and primary and secondary outcomes. Primary outcomes included myocardial infarction, congestive heart failure, stroke or cardiac arrest, while secondary outcomes included revascularization procedures, ED revisits for angina pectoris or chest pain and hospitalization due to cardiovascular diseases. The author aggregated the adjusted costs and prevalence rates of outcomes for patients over OUs, and computed the weighted coefficients of variation (WCV to compare variations across OUs. Results: There was minimal variability in the initial costs of care (WCV=2.2%, while the author noticed greater variability in the outcomes. Greater variability were associated with the adjusted cardiovascular-related costs of medical services (WCV=17.6% followed by the adjusted prevalence odds ratio of patients experiencing primary outcomes (WCV=16.3% and secondary outcomes (WCV=10%. Conclusion: Higher variability in the outcomes suggests the need for more standardization of the observation services for chest pain patients. [West J Emerg Med. 2015;16(3:395–400.
Eijk, M. van der
Patient centeredness means providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions’.The concept assumes that both physicians and patients are experts; physicians in diagnostic and
In addition to recent advances in burn patient care techniques such as maintaining warm circumambient temperature, the early excision of wounds, and the use of closed dressing, providing nutrition support through early feeding has proven instrumental in greatly increasing the survival rate of burn patients. Severe burns complicated by many factors initiate tremendous physiological stress that leads to postburn hypermetabolism that includes enhanced tissue catabolism, the loss of muscle mass, and decreases in the body's reservoirs of protein and energy. These problems have become the focus of burn therapy. Treating severe burns aims not only to enhance survival rates but also to restore normal bodily functions as completely as possible. Recent research evaluating the application of anabolic agents and immune-enhance formula for severe burns therapy has generated significant controversy. Inadequate caloric intake is one of the main differences among the related studies, with the effect of many special nutrients such as bran acid amides not taken into consideration. Therefore, considering the sufficiency of caloric and protein intake is critical in assessing effectiveness. Only after patients receive adequate calories and protein may the effect of special nutrients such as glutamine and supplements be evaluated effectively.
Brady, T J
This article reviews narrative and empiric studies in rheumatology and related literature to explicate the patient's role in rheumatology care. In contrast to early conceptualizations, such as Parsons' sick role that emphasized compliance, current literature describes chronic disease patients as active participants in their care, rather than passive recipients of care. Active patients roles include participant in shared decision making, self-manager, and help and information seeker. All of these roles are colored by the individual's need to preserve a personally defined acceptable lifestyle. Suggestions for strategies that physicians and health professionals can use to engage and support these essential patient roles are also reviewed.
Sparr, H.J; Wierda, J.MKH; Proost, Johannes H.; Keller, C; Khuenl-Brady, K.S
We have studied dose requirements, recovery times and pharmacokinetics of rocuronium in 32 intensive care patients. After an initial dose of 50 mg, rocuronium was administered as maintenance doses of 25 mg whenever two responses to train-of-four (TOF) stimulation reappeared (bolus group; n=27) or by
Emma V. Taylor
Full Text Available Indigenous Australians continue to experience significantly poorer outcomes from cancer than non-Indigenous Australians. Despite the importance of culturally appropriate cancer services in improving outcomes, there is a lack of awareness of current programs and initiatives that are aimed at meeting the needs of Indigenous patients. Telephone interviews were used to identify and describe the Indigenous-specific programs and initiatives that are implemented in a subset of the services that participated in a larger national online survey of cancer treatment services. Fourteen services located across Australia participated in the interviews. Participants identified a number of factors that were seen as critical to delivering culturally appropriate treatment and support, including having a trained workforce with effective cross-cultural communication skills, providing best practice care, and improving the knowledge, attitudes, and understanding of cancer by Indigenous people. However, over a third of participants were not sure how their service compared with others, indicating that they were not aware of how other services are doing in this field. There are currently many Indigenous-specific programs and initiatives that are aimed at providing culturally appropriate treatment and supporting Indigenous people affected by cancer across Australia. However, details of these initiatives are not widely known and barriers to information sharing exist. Further research in this area is needed to evaluate programs and initiatives and showcase the effective approaches to Indigenous cancer care.
Mattingly, T Joseph
To characterize the literature on social media applications used to deliver patient care. A search of the literature was conducted on June 11, 2014, using PubMed, MEDLINE, CINAHL, and Communication Abstracts databases for clinical studies between 2004 and 2014. A combination of the search terms "social media" or "Web 2.0" or "online social networking" or "Facebook" or "Twitter" AND "patient care" or "health care" was used. In addition, 42 additional abstracts were retrieved from www.patientslikeme.com for review. Only published, peer-reviewed journal articles were considered and only publications in English were included. The abstracts from this search were reviewed for relevance to Web-based social media platforms being used in patient care activities. A total of 35 articles were included in the review. A majority of the studies published on social media and patient care used cross-sectional designs and were conducted in the United States. Multiple social media applications were studied, but Facebook was the predominant social media tool found. Patient care opportunities for various diseases with social media have been studied. Recurring themes included overcoming barriers, engaging and empowering patients, enhancing research, providing information for health promotion, scratching the surface, and potential pitfalls. Social media have the potential to help patients and practitioners overcome multiple barriers in the delivery of health care. Maintaining patient privacy, security of information shared in the platform, and integrity of information shared are all concerns when using this type of Web application.
few are going to opt to change health plans. 14. SUBJECT TERMS PATIENT SATISFACTION; CONSUMER SATISFACTION; SURVEY 15. NUMBER OF PAGES 57 16...to address is overall patient satisfaction with Kimbrough’s current health care system. I surveyed customers on: how satisfied or dissatisfied they...research project was designed to determine how satisfied customers are with Kimbrough Ambulatory Care Center. A patient satisfaction survey developed by
Vincent, Jean-Louis; Shehabi, Yahya; Walsh, Timothy S
We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation...... and Delirium guidelines, is conveyed in the mnemonic eCASH-early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical...... requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified...
Durieux-Paillard, S; Dao, M Dominicé; Perron, N Junod
When consulting with migrant patients, general practitioners should pay special attention to the quality of their communication, because language barriers and cultural differences may arise. They must also be aware that life events experienced in the home country, during transit and in the host country can impact negatively on their patients' health, and thus a detailed history must be carefully obtained. Finally, they must be conscious that the migratory policies of the host country can influence the delivery of health care to migrant patients as well as their health status.
Olson, Jody C
Cirrhosis is a major worldwide health problem which results in a high level of morbidity and mortality. Patients with cirrhosis who require intensive care support have high mortality rates of near 50%. The goal of this review is to address the management of common complications of cirrhosis in the ICU. Recent epidemiological studies have shown an increase in hospitalizations due to advanced liver disease with an associated increase in intensive care utilization. Given an increasing burden on the healthcare system, it is imperative that we strive to improve our management cirrhotic patients in the intensive care unit. Large studies evaluating the management of patients in the intensive care setting are lacking. To date, most recommendations are based on extrapolation of data from studies in cirrhosis outside of the ICU or by applying general critical care principles which may or may not be appropriate for the critically ill cirrhotic patient. Future research is required to answer important management questions.
Weiskopf, Constance S
The aim of this paper is to report the findings of a study of the experience of caring for prisoners through examining the everyday experience of nurses' delivering health care to inmate patients in a correctional setting. Prisons are most often viewed as places for punishment, while the goals of health and healing, and prevention of diseases in correctional facilities are often neglected. Nurses who deliver health care to prisoners are challenged to do so in a caring relationship that will facilitate their health and healing. The literature on the nature of prison nursing indicates that delivering health care to inmates must be carefully balanced against the need for security, and is affected by factors such as custody staff values, staff education, nursing management, and organizational practices. In-depth interviews were carried out with nine Registered Nurses who had been employed in a variety of correctional institutions throughout their careers, and analysed thematically using Colaizzi's phenomenological method. Findings. Nurses' caring was experienced as an attempt to negotiate the boundaries between the cultures of custody and caring. Facing complex challenges and a number of limitations on the nurse-patient relationship, nurses strived to find a way to care for their inmate patients. Environmental risk meant that caution and vigilance were essential and these nurses demonstrated courage and persevered for the sake of their inmate patients. The findings make clear the challenging and frustrating experience of nurses' caring for inmate patients in restrictive settings. As a result, there are implications for nursing practice, education, and research to assure the best possible health outcomes for inmate patients, the integrity of caring nursing practice, and the safety of both nurses and patients.
Montie, Mary; Shuman, Clayton; Galinato, Jose; Patak, Lance; Anderson, Christine A; Titler, Marita G
Call light systems remain the primary means of hospitalized patients to initiate communication with their health care providers. Although there is vast amounts of literature discussing patient communication with their health care providers, few studies have explored patients' perceptions concerning call light use and communication. The specific aim of this study was to solicit patients' perceptions regarding their call light use and communication with nursing staff. Patients invited to this study met the following inclusion criteria: proficient in English, been hospitalized for at least 24 hours, aged ≥21 years, and able to communicate verbally (eg, not intubated). Thirty participants provided written informed consent, were enrolled in the study, and completed interviews. Using qualitative descriptive methods, five major themes emerged from patients' perceptions (namely; establishing connectivity, participant safety concerns, no separation: health care and the call light device, issues with the current call light, and participants' perceptions of "nurse work"). Multiple minor themes supported these major themes. Data analysis utilized the constant comparative methods of Glaser and Strauss. Findings from this study extend the knowledge of patients' understanding of not only why inconsistencies occur between the call light and their nurses, but also why the call light is more than merely a device to initiate communication; rather, it is a direct conduit to their health care and its delivery.
Kuschner, Ware G; Gruenewald, David A; Clum, Nancy; Beal, Alice; Ezeji-Okoye, Stephen C
Ethical conflicts are commonly encountered in the course of delivering end-of-life care in the ICU. Some ethical concerns have legal dimensions, including concerns about inappropriate hastening of death. Despite these concerns, many ICUs do not have explicit policies and procedures for withdrawal of life-sustaining treatments. We describe a US Office of Inspector General (OIG) investigation of end-of-life care practices in our ICU. The investigation focused on care delivered to four critically ill patients with terminal diseases and an ICU nurse's concern that the patients had been subjected to euthanasia. The OIG investigation also assessed the validity of allegations that patient flow in and out of our ICU was inappropriately influenced by scheduled surgeries and that end-of-life care policies in our ICU were not clear. Although the investigation did not substantiate the allegations of euthanasia or inappropriate ICU patient flow, it did find that the policies that discuss end-of-life care issues were not clear and allowed for wide-ranging interpretations. Acting on the OIG recommendations, we developed a quality improvement initiative addressing end-of-life care in our ICU, intended to enhance communication and understanding about palliative care practices in our ICU, to prevent ethical conflicts surrounding end-of-life care, and to improve patient care. The initiative included the introduction of newly developed ICU comfort care guidelines, a physician order set, and a physician template note. Additionally, we implemented an educational program for ICU staff. Staff feedback regarding the initiative has been highly favorable, and the nurse whose concerns led to the investigation was satisfied not only with the investigation but also the policies and procedures that were subsequently introduced in our ICU.
Full Text Available The adoption of a standard pharmacists’ patient care process (PPCP for the profession, and inclusion of the PPCP in the ACPE Standards 2016, are positive steps for pharmacy education and creates consistency among pharmacy practitioners, regardless of practice setting. The PPCP, and its implications for practice, needs to continue to be embraced by educators and emphasized with students. The PPCP should be the patient care process taught to students and integrated throughout didactic courses and experiential experiences. However, teaching the PPCP or a particular service, such as Medication Therapy Management (MTM or Comprehensive Medication Management (CMM, is not enough. The patient care process must be taught as one component of pharmaceutical care. Without also learning the philosophy of practice and practice management systems, student pharmacists will not be prepared for the realities of practice. Pharmacists are taking on new roles, getting paid in new ways, and in positions to take responsibility for a patient’s medication-related needs. Student pharmacists need to be in a position to take advantage of these opportunities as they progress throughout their careers. Conflict of Interest We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received, employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties. Type: Idea Paper
Dyrstad, Dagrunn Nåden
PhD thesis in Health, medicine and welfare Background: Older patients often have several health challenges, with multiple medications, which leads to a need of treatment and care from diverse healthcare services. These patients are often in need of transitions from different levels of care, specifically during hospital admission and discharge. Patient participation is highlighted and stated in patients’ rights and healthcare directives, with patients being informed and involved in all trea...
Beach, Wayne A.; Dozier, David M.
New cancer patients frequently raise concerns about fears, uncertainties, and hopes during oncology interviews. This study sought to understand when and how patients raise their concerns, how doctors responded to these patient-initiated actions, and implications for communication satisfaction. A sub-sampling of video recorded and transcribed encounters was investigated involving 44 new patients and 14 oncologists. Patients completed pre-post self-report measures about fears, uncertainties, and hopes as well as post-evaluations of interview satisfaction. Conversation Analysis (CA) was employed to initially identify pairs of patient-initiated and doctor-responsive actions. A coding scheme was subsequently developed, and two independent coding teams, comprised of two coders each, reliably identified patient-initiated and doctor-responsive social actions. Interactional findings reveal that new cancer patients initiate actions much more frequently than previous research had identified, concerns are usually raised indirectly, and with minimal emotion. Doctors tend to respond to these concerns immediately, but with even less affect, and rarely partner with patients. From pre-post results it was determined that the higher patients’ reported fears, the higher their post-visit fears and lower their satisfaction. Patients with high uncertainty were highly proactive (e.g., asked more questions), yet reported even greater uncertainties following encounters. Hopeful patients also exited interviews with high hopes. Overall, new patients were very satisfied: Oncology interviews significantly decreased patients’ fears and uncertainties, while increasing hopes. Discussion raises key issues for improving communication and managing quality cancer care. PMID:26134261
Esperanza Arce Delgado
Full Text Available The initial evaluation of the child, when admitted on the Paediatric Intensive Unit, is a essential tool and key piece as a starting point on the development of a specific Care Plan for each child. Therefore, it is necessary the existence of a protocol, according to a rigorous methodology, so that cares will have quality and thus, it will be avoided that each nursing professional will act in a different way, according to his intuition, beliefs or improvisation capacity.The initial evaluation of the child will allow us not only to coordinate the interventions, but also to give continuity to the cares.The initial evaluation of the child document is a nursing register that is part of the clinical register of the paediatric patient. Nursing registers turn to be the best approximation of what nowadays is our job’s practice, and they are, therefore, necessary for us to be judged by a professional perspective and to make it possible to classify the services we carry out to the society.
Patients undergoing stoma formation encounter many challenges including psychosocial issues, relationship concerns and fear of leakage. Leakage, inappropriate product usage and poor patient adaptation post stoma formation has cost implications for the NHS. Developing good, practical stoma care skills has been identified as improving patient outcomes, promoting the provision of quality care and improving efficiency within the NHS. However, a thorough literature search indicated that there is little research available on patient stoma care education. This is considered surprising by Metcalf (1999), O'Connor (2005) and the author of this article. This article considers and adapts generic educational theory to make it pertinent to patient stoma care education in order to bridge the gap between theory and practice.
Kao, Chia-Chan; Lin, Yu-Hua
Spiritual care is a component of holistic care. Patients with depression often experience body-mind-spirit health problems and may suffer from spiritual crises, particularly during the acute stage of a diseases, due to low self-esteem, negative attitudes toward life goals, daily life issues, and beliefs caused by physical, psychological, and occupational dysfunctions. Nonetheless, psychical care is the main treatment for patients with depression. This paper focuses on patients with depression and addresses the concepts of spiritual needs and spiritual care, identifying the factors that influence spiritual needs, the essentials of spiritual intervention, and the health effects of spiritual intervention outcomes on patients with depression. Courses that teach practical spiritual interventions are recommended for nurses. These courses should address topics such as individual approaches, building trusting relationships, setting diverse goals for spiritual interventions based on disease stage, and spiritual interventions involving the body-mind-spiritual aspects for patients with depression.
Hafner, Gert; Neuhuber, Andreas; Hirtenfelder, Sylvia; Schmedler, Brigitte
Aspiration in critically ill patients frequently causes severe co-morbidity. We evaluated a diagnostic protocol using routine FEES in critically ill patients at risk to develop aspiration following extubation. We instructed intensive care unit physicians on specific risk factors for and clinical signs of aspiration following extubation in critically ill patients and offered bedside FEES for such patients. Over a 45-month period, we were called to perform 913 endoscopic examinations in 553 patients. Silent aspiration or aspiration with acute symptoms (cough or gag reflex as the bolus passed into the trachea) was detected in 69.3% of all patients. Prolonged non-oral feeding via a naso-gastric tube was initiated in 49.7% of all patients. In 13.2% of patients, a percutaneous endoscopic gastrostomy was initiated as a result of FEES findings, and in 6.3% an additional tracheotomy to prevent aspiration had to be initiated. In 59 out of 258 patients (22.9%), tracheotomies were closed, and 30.7% of all 553 patients could be managed with the immediate onset of an oral diet and compensatory treatment procedures. Additional radiological examinations were not required. FEES in critically ill patients allows for a rapid evaluation of deglutition and for the immediate initiation of symptom-related rehabilitation or for an early resumption of oral feeding. PMID:17968575
Jakel, Patricia; Carsten, Cynthia; Carino, Arvie; Braskett, Melinda
Chemotherapy desensitization protocols are safe, but labor-intensive, processes that allow patients with cancer to receive medications even if they initially experienced severe hypersensitivity reactions. Part I of this column discussed the pathophysiology of hypersensitivity reactions and described the development of desensitization protocols in oncology settings. Part II incorporates the experiences of an academic medical center and provides a practical guide for the nursing care of patients undergoing chemotherapy desensitization. .
Evans, William K; Ung, Yee C; Assouad, Nathalie; Chyjek, Anna; Sawka, Carol
Before 2008, Cancer Care Ontario (CCO) undertook provincial cancer control quality-improvement initiatives on a programmatic basis. CCO has now added Disease Pathway Management (DPM) to its quality improvement strategy, with the intent of achieving high-quality care, processes, and patient experience across the patient pathway for specific cancers. The three goals of DPM are: to describe and share evidence-based best practice along the cancer continuum for specific cancers; identify quality-improvement priorities for specific cancers and catalyze action; monitor performance against best practice for specific cancers. The objective of this article is to describe the process by which the CCO lung cancer (LC) DPM was initiated and some of its early successes. In 2009, LC DPM began with a draft LC disease pathway map and the establishment of five multidisciplinary working groups, each focused on a phase of the LC patient journey: prevention, screening, and early detection; diagnosis; treatment; palliative care, end-of-life care, and survivorship; and patient experience. The working groups held 25 meetings of 2-hour duration and developed concepts for 17 quality-improvement projects across the patient journey. Eight were selected for detailed discussion at a provincial consensus conference, which provided input on priorities for action. A report on the priorities for action was prepared and widely circulated, and regional roadshows were held in all 14 regions of the province of Ontario. Region-specific data on incidence, stage, treatment compliance, and wait times among other issues relevant to LC, were shared with the regional care providers at these roadshows. Funding was provided by CCO to address opportunities for regional improvement based on the data and the priorities identified. The LC disease pathways were refined through substantial multidisciplinary discussion, and the diagnostic pathway was posted on CCO's Web site in February 2012. The treatment pathways
Jørgensen, Mette; Mainz, Jan; Svendsen, Marie Louise
BACKGROUND: The effectiveness of systematic quality improvement initiatives in psychiatric care remains unclear. AIMS: To examine whether quality of care has changed following implementation of a systematic monitoring programme of hospital performance measures. METHOD: In a nationwide population.......27-1.62), psychoeducation (RR: 1.33, 95% CI: 1.19-1.48), psychiatric aftercare (RR: 1.06, 95% CI: 1.01-1.11) and suicide risk assessment (RR: 1.31, 95% CI: 1.21-1.42). CONCLUSIONS: Quality of care improved from 2004 to 2011 among patients hospitalised with schizophrenia in Denmark. DECLARATION OF INTEREST: None. COPYRIGHT...
Rademakers, J.J.D.J.M.; Delnoij, D.M.J.; Boer, D. de
Background: Though patient centred care is a somewhat ‘fuzzy’ concept, in general it is considered as something to strive for. However, preliminary evidence suggests that the importance of elements of patient-centred care (PCC), such as communication, information and shared decision making, may vary
Chi, Han-Lin; Cataldo, Janine; Ho, Evelyn Y; Rehm, Roberta S
Health-care providers (HCPs) find facilitating end-of-life (EOL) care discussions challenging, especially with patients whose ethnicities differ from their own. Currently, there is little guidance on how to initiate and facilitate such discussions with older Chinese Americans (≥55 years) and their families. To explore communication strategies for HCPs to initiate EOL care discussions with older Chinese Americans in the San Francisco Bay Area. This qualitative (focused) ethnographic study included field observations and individual semistructured interviews with 14 community-dwelling older Chinese Americans who lived independently at home, 9 adult children, and 7 HCPs. Responses were analyzed using open coding, memos, and comparison across participants. The study participants emphasized the importance of assessing readiness for early EOL care discussions. All recommended using indirect communication approaches to determine older Chinese Americans' readiness. Indirect communication can be culturally targeted and applied at both system-wide (ie, health-care system) and individual (ie, HCP) levels. To institutionalize the practice, health-care facilities should implement EOL care discussion inquiries as part of routine during check-in or intake questionnaires. In individual practice, using depersonalized communication strategies to initiate the discussion was recommended to determine older Chinese Americans' readiness. Assessing readiness should be an essential and necessary action for early EOL care discussions. Culturally targeted assessment of older Chinese Americans includes using indirect communication approaches to initiate an EOL care discussion to determine their readiness. In addition to health-care system integration, providers should implement and evaluate proposed EOL discussion initiation prompts with their older Chinese American patients.
Many treatment sequelae are encountered when treating head and neck cancer patients by means of ionizing radiation therapy. In many cases, these sequelae are compounded by various nutritional and other medical disorders. Many sequelae can eventually result in severe complications of the jaws and teeth. The radiotherapist needs to utilize the help of the dentist (as well as the surgeon) to prevent many of these complications from occurring, to maintain and manage those that do occur, and to contribute to the overall care of head and neck cancer patients. It was thought for many years that problems of the jaws and teeth, such as osteoradionecrosis and post-irradiation caries of the teeth, were an end product of aggressive radiotherapy. Many of these complications can now be prevented. It should be borne in mind that changes that do occur start approximately 2 months after initiation of irradiation, although it sometimes takes a long time to observe the changes. The priorities along which the objectives of dental treatment should be directed, are discussed in this article
Breytenbach, H S [University of the Western Cape, Bellville (South Africa). Stomatology Unit
Many treatment sequelae are encountered when treating head and neck cancer patients by means of ionizing radiation therapy. In many cases, these sequelae are compounded by various nutritional and other medical disorders. Many sequelae can eventually result in severe complications of the jaws and teeth. The radiotherapist needs to utilize the help of the dentist (as well as the surgeon) to prevent many of these complications from occurring, to maintain and manage those that do occur, and to contribute to the overall care of head and neck cancer patients. It was thought for many years that problems of the jaws and teeth, such as osteoradionecrosis and post-irradiation caries of the teeth, were an end product of aggressive radiotherapy. Many of these complications can now be prevented. It should be borne in mind that changes that do occur start approximately 2 months after initiation of irradiation, although it sometimes takes a long time to observe the changes. The priorities along which the objectives of dental treatment should be directed, are discussed in this article.
Prins, Marijn A.; Verhaak, Peter F. M.; van der Meer, Klaas; Penninx, Brenda W. J. H.; Bensing, Jozien M.
Background: Many anxiety and depression patients receive no care, resulting in unnecessary suffering and high costs. Specific beliefs and the absence of a perceived need for care are major reasons for not receiving care. This study aims to determine the specific perceived need for care in primary
Huang, Ching-Chi; Chen, Jih-Yuan; Chiang, Hsien-Hsien
Despite the recent increase in attention to end-of-life hospice care, little empirical evidence regarding the process of emotional or mental transformation in caregivers is available. This study explores the transformative process that occurs in nurses because of the spiritual suffering and conflict associated with after caring for dying patients. A phenomenological approach was used to investigate eight nurses (27-40 years old) working in the hospice ward of a medical center in Taipei. Data were collected through open-ended questions using semistructured interviews and were analyzed reflectively. A three-stage transformation in the emotional processes of participants was observed. In the first stage, the participants experienced acute emotional suffering because of facing the death of their patients, potentially exacerbated by their own memories of losing family members. In the second stage, the participants adopted coping strategies to improve self-care. These strategies included attempting to soothe patients, helping patients face or deal with unfulfilled business, and participating in funeral or memorial services. In the third stage, the participants learned to provide better care through emancipatory reflection and a reassertion of responsibilities toward the self, patients, and patient families. After the third stage, the initial emotional impact morphed into a medium for self-strengthening, and participants became more adept at detecting patient needs and at providing care to complete the transformational process fully. Emotional suffering was the primary factor that induced participants to transform their personal and professional selves. Adequate emotional self-management, dialogue with other nurses, and personal reflection are crucial actions that nurses may use to cultivate personal growth, implement ethical practice, interact with other nurses, and engage in personal reflection. Strategies such as caring for patients, implementing reflective nursing
Zopunyan, Violeta; Krmoyan, Suren; Quinn, Ryan
Since the collapse of the Soviet Union, the Republic of Armenia has undergone an extensive legislative overhaul. Although a number of developments have aimed to improve the quality and accessibility of Armenia's health care system, a host of factors has prevented the country from fully introducing measures to ensure respect for human rights in patient care. In particular, inadequate health care financing continues to oblige patients to make both formal and informal payments to obtain basic medical care and services. More generally, a lack of oversight and monitoring mechanisms has obstructed the implementation of Armenia's commitments to human rights in several international agreements. Within the framework of a broader project on promoting human rights in patient care, research was carried out to examine Armenia’s health care legislation with the aim of identifying gaps in comparison with international and regional standards. This research was designed using the 14 rights enshrined in the European Charter on Patient Rights as guiding principles, along with domestic legal acts relevant to the rights of health care providers. The gaps analysis revealed numerous problems with Armenian legislation governing the relationships between stakeholders in health care service delivery. It also identified several practical inconsistencies with the international legal instruments ratified by the Armenian government. These legislative shortcomings are illustrated by highlighting key health-related rights violations experienced by patients and their health care providers, and by indicating opportunities for improved rights protections. A full list of human rights relevant to patient care and recommendations for promoting them in the Armenian context is provided in Tables 1 and 2. A number of initiatives must be undertaken in order to promote the full spectrum of human rights in patient care in Armenia. This section highlights certain recommendations flowing from the findings of
Rich, Preston B; Adams, Sasha D
National health care expenditures constitute a continuously expanding component of the US economy. Health care resources are distributed unequally among the population, and geriatric patients are disproportionately represented. Characterizing this group of individuals that accounts for the largest percentage of US health spending may facilitate the introduction of targeted interventions in key high-impact areas. Changing demographics, an increasing incidence of chronic disease and progressive disability, rapid technological advances, and systemic market failures in the health care sector combine to drive cost. A multidisciplinary approach will become increasingly necessary to balance the delicate relationship between our constrained supply and increasing demand. Copyright © 2015 Elsevier Inc. All rights reserved.
Lancaster, Michael; McKee, Jerry; Mahan, Amelia
The rate of unintentional deaths from opioid poisoning has reached epidemic proportions. One model of successful intervention is Project Lazarus, an integrated-care pilot program in Wilkes County, North Carolina. Community Care of North Carolina, supported by a grant of $1.3 million from the Kate B. Reynolds Charitable Trust and matching funds of $1.3 million from the North Carolina Office of Rural Health and Community Care, is now expanding the Project Lazarus approach statewide.
Kreindler, Sara A
Despite widespread belief in the importance of patient-centred care, it remains difficult to create a system in which all groups work together for the good of the patient. Part of the problem may be that the issue of patient-centred care itself can be used to prosecute intergroup conflict. This qualitative study of texts examined the presence and nature of intergroup language within the discourse on patient-centred care. A systematic SCOPUS and Google search identified 85 peer-reviewed and grey literature reports that engaged with the concept of patient-centred care. Discourse analysis, informed by the social identity approach, examined how writers defined and portrayed various groups. Managers, physicians and nurses all used the discourse of patient-centred care to imply that their own group was patient centred while other group(s) were not. Patient organizations tended to downplay or even deny the role of managers and providers in promoting patient centredness, and some used the concept to advocate for controversial health policies. Intergroup themes were even more obvious in the rhetoric of political groups across the ideological spectrum. In contrast to accounts that juxtaposed in-groups and out-groups, those from reportedly patient-centred organizations defined a 'mosaic' in-group that encompassed managers, providers and patients. The seemingly benign concept of patient-centred care can easily become a weapon on an intergroup battlefield. Understanding this dimension may help organizations resolve the intergroup tensions that prevent collective achievement of a patient-centred system. © 2013 John Wiley & Sons Ltd.
Sun, Peter; Peng, Xiaomei; Sun, Steve; Novick, Diego; Faries, Douglas E; Andrews, Jeffrey S; Wohlreich, Madelaine M; Wu, Andrew
To assess and compare direct medical costs and medication compliance between patients with fibromyalgia who initiated duloxetine and patients with fibromyalgia who initiated pregabalin in 2008. A retrospective cohort study design was used based on a large US national commercial claims database (2006 to 2009). Patients with fibromyalgia aged 18 to 64 who initiated duloxetine or pregabalin in 2008 and who had continuous health insurance 1 year preceding and 1 year following the initiation were selected into duloxetine cohort or pregabalin cohort based on their initiated agent. Medication compliance was measured by total supply days, medication possession ratio (MPR), and proportion of patients with MPR ≥ 0.8. Direct medical costs were measured by annual costs per patient and compared between the cohorts in the year following the initiation. Propensity score stratification and bootstrapping methods were used to adjust for distribution bias, as well as cross-cohort differences in demographic, clinical and economic characteristics, and medication history prior to the initiation. Both the duloxetine (n = 3,033) and pregabalin (n = 4,838) cohorts had a mean initiation age around 49 years, 89% were women. During the postindex year, compared to the pregabalin cohort, the duloxetine cohort had higher totally annual supply days (273.5 vs. 176.6, P costs ($2,994.9 vs. $4,949.6, P costs ($8,259.6 vs. $10,312.2, P costs ($5,214.6 vs. $5,290.8, P > 0.05), and lower total medical costs ($16,469.1 vs. $20,552.6, P compliance and consumed less inpatient, outpatient, and total medical costs than those who initiated pregabalin. © 2013 The Authors Pain Practice © 2013 World Institute of Pain.
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.
A prototype radiographic system has been developed for use in bedside examinations in multibed trauma or intensive care units and emergency rooms. The system features a single-phase, high-frequency 30-kW ceiling-mounted generator with an x-ray tube extending from a long counterbalanced arm. All movements are servo-assisted for ease of operation. Based on initial experience, the unit allows easier access to the patient around resuscitation and monitoring equipment, occupies less floor space, and yields better quality images than do standard mobile radiographic units
Efficiency and effectiveness of the use of an acenocoumarol pharmacogenetic dosing algorithm versus usual care in patients with venous thromboembolic disease initiating oral anticoagulation: study protocol for a randomized controlled trial
Carcas Antonio J
Full Text Available Abstract Background Hemorrhagic events are frequent in patients on treatment with antivitamin-K oral anticoagulants due to their narrow therapeutic margin. Studies performed with acenocoumarol have shown the relationship between demographic, clinical and genotypic variants and the response to these drugs. Once the influence of these genetic and clinical factors on the dose of acenocoumarol needed to maintain a stable international normalized ratio (INR has been demonstrated, new strategies need to be developed to predict the appropriate doses of this drug. Several pharmacogenetic algorithms have been developed for warfarin, but only three have been developed for acenocoumarol. After the development of a pharmacogenetic algorithm, the obvious next step is to demonstrate its effectiveness and utility by means of a randomized controlled trial. The aim of this study is to evaluate the effectiveness and efficiency of an acenocoumarol dosing algorithm developed by our group which includes demographic, clinical and pharmacogenetic variables (VKORC1, CYP2C9, CYP4F2 and ApoE in patients with venous thromboembolism (VTE. Methods and design This is a multicenter, single blind, randomized controlled clinical trial. The protocol has been approved by La Paz University Hospital Research Ethics Committee and by the Spanish Drug Agency. Two hundred and forty patients with VTE in which oral anticoagulant therapy is indicated will be included. Randomization (case/control 1:1 will be stratified by center. Acenocoumarol dose in the control group will be scheduled and adjusted following common clinical practice; in the experimental arm dosing will be following an individualized algorithm developed and validated by our group. Patients will be followed for three months. The main endpoints are: 1 Percentage of patients with INR within the therapeutic range on day seven after initiation of oral anticoagulant therapy; 2 Time from the start of oral anticoagulant treatment
Efficiency and effectiveness of the use of an acenocoumarol pharmacogenetic dosing algorithm versus usual care in patients with venous thromboembolic disease initiating oral anticoagulation: study protocol for a randomized controlled trial.
Carcas, Antonio J; Borobia, Alberto M; Velasco, Marta; Abad-Santos, Francisco; Díaz, Manuel Quintana; Fernández-Capitán, Carmen; Ruiz-Giménez, Nuria; Madridano, Olga; Sillero, Pilar Llamas
Hemorrhagic events are frequent in patients on treatment with antivitamin-K oral anticoagulants due to their narrow therapeutic margin. Studies performed with acenocoumarol have shown the relationship between demographic, clinical and genotypic variants and the response to these drugs. Once the influence of these genetic and clinical factors on the dose of acenocoumarol needed to maintain a stable international normalized ratio (INR) has been demonstrated, new strategies need to be developed to predict the appropriate doses of this drug. Several pharmacogenetic algorithms have been developed for warfarin, but only three have been developed for acenocoumarol. After the development of a pharmacogenetic algorithm, the obvious next step is to demonstrate its effectiveness and utility by means of a randomized controlled trial. The aim of this study is to evaluate the effectiveness and efficiency of an acenocoumarol dosing algorithm developed by our group which includes demographic, clinical and pharmacogenetic variables (VKORC1, CYP2C9, CYP4F2 and ApoE) in patients with venous thromboembolism (VTE). This is a multicenter, single blind, randomized controlled clinical trial. The protocol has been approved by La Paz University Hospital Research Ethics Committee and by the Spanish Drug Agency. Two hundred and forty patients with VTE in which oral anticoagulant therapy is indicated will be included. Randomization (case/control 1:1) will be stratified by center. Acenocoumarol dose in the control group will be scheduled and adjusted following common clinical practice; in the experimental arm dosing will be following an individualized algorithm developed and validated by our group. Patients will be followed for three months. The main endpoints are: 1) Percentage of patients with INR within the therapeutic range on day seven after initiation of oral anticoagulant therapy; 2) Time from the start of oral anticoagulant treatment to achievement of a stable INR within the therapeutic
Background: Clinically effective interventions that could reduce diabetic patients' risk of long-term complications are needed to contain the rising cost of diabetes care associated with the increasing prevalence of this condition. Good glycaemic control needs to be rapidly attained and maintained by the appropriate initiation ...
Nuclear medicine is the medical specialty best suited to translate the exploding body of knowledge obtained from research in genetics and molecular biology into the care of patients. This fourth annual nuclear oncology conference will address how this can be done and how positron emission tomography (PET) and single photon emission tomography (SPECT) can be used in the care of patients with cancer or with increased genetic risk of developing cancer. The course will include illustrative patient studies showing how PET and SPECT can help in diagnosis, staging and treatment planning and monitoring of patients with cancer
Donker, Marjolein L.; Bakker, Nicolaas A.; Jaspers, Wim J. M.; Verhage, Albert H.
In two patients with osteoporosis, systemic mastocytosis ultimately turned out to be the underlying disease. Both patients had a history of anaphylactic reactions caused by wasp stings but did not have any skin or other symptoms. This observation reflects the need for careful history taking and
According to the international guidelines, a multidisciplinary approach is currently advised for the optimal care of patients with a gastroenteropancreatic neuroendocrine tumor (GEP NET). In our institution (tertiary care center), a systematic multidisciplinary approach was established in May 2007. In this study, we have aimed to assess the initial impact of establishing a systematic multidisciplinary approach to the management of GEP NET patients. We have collected and compared the biochemical, imaging, and pathological data and the therapeutic strategies in GEP NET patients diagnosed, treated, or followed-up from January 1993 to April 2007 versus GEP NET patients attending our institution after the multidisciplinary approach starting, from May 2007 to October 2008. Data of 91 patients before and 42 patients after the establishment of the multidisciplinary approach (total: 133 consecutive GEP NET patients) have been finally collected and analyzed. Before the establishment of the multidisciplinary approach, a lack of consistency in the biochemical, imaging, and pathological findings before treatment initiation as well as during follow-up of GEP NET patients was identified. These inconsistencies have been reduced by the systematic multidisciplinary approach. In addition, the therapeutic management of GEP NET patients has been altered by the multidisciplinary approach and became more consistent with recommended guidelines. We think that a systematic multidisciplinary approach significantly impacts on GEP NET patient care and should be established in all centers dealing with these tumors.
Espaulella, Joan; Escarrabill, Joan; Martí, Tino; Wynne-Jones, Kathryn
Upon the Integrated Care Exchange program initiated between Oldham CCG and Catalan healthcare providers (Hospital Clinic, CHV, CAPSE and CASAP) and co-organised by AQuA and IFIC in 2014-2015, we do aim to continue the learning exchange around a central topic: Transitional Care.We propose a double session. The first one will address different interventions in Transitional Care to be compared following a similar presentation pattern that will allow to identify the lessons learns in three key as...
Mitchell, Shannon H; Overman, Pamela; Forrest, Jane L
Health care providers can enhance their critical thinking skills, essential to providing patient centered care, by use of motivational interviewing and evidence-based decision making techniques. The need for critical thinking skills to foster optimal patient centered care is being emphasized in educational curricula for health care professions. The theme of this paper is that evidence-based decision making (EBDM) and motivational interviewing (MI) are tools that when taught in health professions educational programs can aid in the development of critical thinking skills. This paper reviews the MI and EBDM literature for evidence regarding these patient-centered care techniques as they relate to improved oral health outcomes. Comparisons between critical thinking and EBDM skills are presented and the EBDM model and the MI technique are briefly described followed by a discussion of the research to date. The evidence suggests that EBDM and MI are valuable tools; however, further studies are needed regarding the effectiveness of EBDM and MI and the ways that health care providers can best develop critical thinking skills to facilitate improved patient care outcomes. Copyright © 2014 Elsevier Inc. All rights reserved.
Martinez, Noelle G; Niznik, Charlotte M; Yee, Lynn M
Gestational diabetes mellitus poses well-established risks to both the mother and infant. As >50% of women with gestational diabetes mellitus will develop type 2 diabetes mellitus in their lifetime, performing postpartum oral glucose tolerance testing is paramount to initiation of appropriate lifestyle interventions and pharmacologic therapy. Nonetheless, test completion among women with gestational diabetes mellitus is estimated to be diabetes mellitus. Based on existing evidence, we propose best practices for the postpartum care of women with gestational diabetes mellitus: (1) enhanced patient support for identifying long-term health care providers, (2) patient-centered medical home utilization when possible, (3) patient and provider test reminders, and (4) formalized obstetrician-primary care provider hand offs using the Situation Background Assessment Recommendation (SBAR) mnemonic. These strategies deserve future investigation to solidify a multilevel approach for identifying and preventing the continuum of diabetes. Copyright © 2017 Elsevier Inc. All rights reserved.
Candlin, Josie; Stark, Sheila
To identify factors that influence nurses' practice in apron use during direct patient care. A small-scale documentary analysis of a purposive sample of 15 journal articles relating to nurses' apron use during patient care was undertaken. The analysis sought to address what factors affect nurses' decisions in relation to apron use. Nurses' decisions regarding apron use during patient care tend to be ritualistic rather than evidence-based. Their knowledge of infection control is limited. Although there is current literature available on infection control, as well as health and safety regulations, if local policy regarding apron use in nursing care is scant this can result in inconsistent and, perhaps, less desirable practices.
O'Sullivan, Rory; Mailo, Kevin; Angeles, Ricardo; Agarwal, Gina
To establish the prevalence of patients with advance directives in a family practice, and to describe patients' perspectives on a family doctor's role in initiating discussions about advance directives. A self-administered patient questionnaire. A busy urban family medicine teaching clinic in Hamilton, Ont. A convenience sample of adult patients attending the clinic over the course of a typical business week. The prevalence of advance directives in the patient population was determined, and the patients' expectations regarding the role of their family doctors were elucidated. The survey population consisted of 800 participants (a response rate of 72.5%) well distributed across age groups; 19.7% had written advance directives and 43.8% had previously discussed the topic of advance directives, but only 4.3% of these discussions had occurred with family doctors. In 5.7% of cases, a family physician had raised the issue; 72.3% of respondents believed patients should initiate the discussion. Patients who considered advance directives extremely important were significantly more likely to want their family doctors to start the conversation (odds ratio 3.98; P < .05). Advance directives were not routinely addressed in the family practice. Most patients preferred to initiate the discussion of advance directives. However, patients who considered the subject extremely important wanted their family doctors to initiate the discussion. Copyright© the College of Family Physicians of Canada.
External radiation therapy, or teletherapy, is the use of ionizing radiation to destroy cancer cells. Clinical use of ionizing radiation as treatment for cancer began with the discovery of x-rays in 1895, the identification of natural radioactivity (radium) in 1896, and the first reported cure of cancer, a basal cell epithelioma, induced by radiation in 1899. Initially, radiation was administered as a single large dose and produced severe, life-threatening side effects. The basis for the use of ionizing radiation in daily increments for a period of weeks was provided by Regaud in 1922; ten years later, Coutard clinically developed the method of dose fractionation, which remains in use today. Although the use of ionizing radiation as a treatment is over eighty years old, only in recent years have advancements in its clinical application been based on research related to the biologic effect of radiation on human cells. To effectively care for the patient prior to, during, and at the completion of external radiation therapy, the nurse must know the physical and biologic basis of external radiation therapy and its clinical application.
External radiation therapy, or teletherapy, is the use of ionizing radiation to destroy cancer cells. Clinical use of ionizing radiation as treatment for cancer began with the discovery of x-rays in 1895, the identification of natural radioactivity (radium) in 1896, and the first reported cure of cancer, a basal cell epithelioma, induced by radiation in 1899. Initially, radiation was administered as a single large dose and produced severe, life-threatening side effects. The basis for the use of ionizing radiation in daily increments for a period of weeks was provided by Regaud in 1922; ten years later, Coutard clinically developed the method of dose fractionation, which remains in use today. Although the use of ionizing radiation as a treatment is over eighty years old, only in recent years have advancements in its clinical application been based on research related to the biologic effect of radiation on human cells. To effectively care for the patient prior to, during, and at the completion of external radiation therapy, the nurse must know the physical and biologic basis of external radiation therapy and its clinical application
van Rijsbergen, M.; Boucherie, Richardus J.; van Houdenhoven, M.; Litvak, Nelli
Many hospitals in the Netherlands are confronted with capacity problems at their Intensive Care Units (ICUs) resulting in cancelling operations, overloading the staff with extra patients, or rejecting emergency patients. In practice, the last option is a common choice because juridically, as well as
Egerod, Ingrid; Bagger, Christine
The aim of the study was to explore patients' experiences and perceptions of receiving intensive care diaries. A focus group and intensive care diaries for four former ICU patients were analysed to understand what works and what needs further development for patients who receive a diary. The stud......-ICU patients to gradually construct or reconstruct their own illness narrative, which is pieced together by their fragmented memory, the diary, the pictures, the hospital chart and the accounts from family and friends.......The aim of the study was to explore patients' experiences and perceptions of receiving intensive care diaries. A focus group and intensive care diaries for four former ICU patients were analysed to understand what works and what needs further development for patients who receive a diary. The study...... that the diary alone provided incomplete information and reading the diary did not necessarily bring back memories, but helped complete their story. The patients needed to know what they had gone through in ICU and wished to share their story with their family. We conclude that diaries might help post...
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)
Wysham, Nicholas G; Mularski, Richard A; Schmidt, David M; Nord, Shirley C; Louis, Deborah L; Shuster, Elizabeth; Curtis, J Randall; Mosen, David M
Communication in the intensive care unit (ICU) is an important component of quality ICU care. In this report, we evaluate the long-term effects of a quality improvement (QI) initiative, based on the VALUE communication strategy, designed to improve communication with family members of critically ill patients. We implemented a multifaceted intervention to improve communication in the ICU and measured processes of care. Quality improvement components included posted VALUE placards, templated progress note inclusive of communication documentation, and a daily rounding checklist prompt. We evaluated care for all patients cared for by the intensivists during three separate 3 week periods, pre, post, and 3 years following the initial intervention. Care delivery was assessed in 38 patients and their families in the pre-intervention sample, 27 in the post-intervention period, and 41 in follow-up. Process measures of communication showed improvement across the evaluation periods, for example, daily updates increased from pre 62% to post 76% to current 84% of opportunities. Our evaluation of this quality improvement project suggests persistence and continued improvements in the delivery of measured aspects of ICU family communication. Maintenance with point-of-care-tools may account for some of the persistence and continued improvements. Copyright © 2014 Elsevier Inc. All rights reserved.
Common sense dictates that one should choose tried and tested drugs with proven, concrete benefits that outweigh their adverse effects. Many new drugs are approved each year, often despite a lack of solid evidence that they are any better than existing treatments. Worse, some are approved despite being less effective or more harmful than current options. Massive promotion is used to ensure that such drugs achieve a positive image in the eyes of healthcare professionals and patients. Renowned "opinion leaders" intervene in their favour at conferences and in specialist media, and their opinions are further propagated by specialists in the field. Finally, campaigns in the lay media are used to highlight the target illness, encouraging patients to request a prescription. New data sometimes show that older, initially promising drugs are less effective or more harmful than first thought. For all these reasons, many drugs that are now present on the market are more harmful than beneficial and should be avoided. Unfortunately, negative assessment data and warnings are often drowned in the flood of promotion and advertising. Front-line healthcare professionals who are determined to act in their patients' best interests can find themselves swimming against a tide of specialist opinion, marketing authorisation, and reimbursement decisions. By leaving drugs that are more harmful than beneficial on the market and contenting themselves with simple half-measures, healthcare authorities are failing in their duty to protect patients. Prescrire, a journal funded solely by its subscribers, does not seek to do the work of health authorities, and does not have the means to do so. Prescrire's goal is simply to help healthcare professionals provide better care. The following text lists the principal drugs that we consider more harmful than beneficial, based on our reviews published between 2010 and 2012 in our French edition. These drugs should not be used. Patients and healthcare
Carey, Irene; Shouls, Susanna; Bristowe, Katherine; Morris, Michelle; Briant, Linda; Robinson, Carole; Caulkin, Ruth; Griffiths, Mathew; Clark, Kieron; Koffman, Jonathan; Hopper, Adrian
Despite preferences to the contrary, 53% of deaths in England occur in hospital. Difficulties in managing clinical uncertainty can result in delayed recognition that a person may be approaching the end of life, and a failure to address his/her preferences. Planning and shared decision-making for hospital patients need to improve where an underlying condition responds poorly to acute medical treatment and there is a risk of dying in the next 1-2 months. This paper suggests an approach to improve this care. A care bundle (the AMBER care bundle) was designed by a multiprofessional development team, which included service users, utilising the model for improvement following an initial scoping exercise. The care bundle includes two identification questions, four subsequent time restricted actions and systematic daily follow-up. This paper describes the development and implementation of a care bundle. From August 2011 to July 2012, 638 patients received care supported by the AMBER care bundle. In total 42.8% died in hospital and a further 14.5% were readmitted as emergencies within 30 days of discharge. Clinical outcome measures are in development. It has been possible to develop a care bundle addressing a complex area of care which can be a lever for cultural change. The implementation of the AMBER care bundle has the potential to improve care of clinically uncertain hospital patients who may be approaching the end of life by supporting their recognition and prompting discussion of their preferences. Outcomes associated with its use are currently being formally evaluated. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Kozhimannil, Katy B; Sommerness, Samantha A; Rauk, Phillip; Gams, Rebecca; Hirt, Charles; Davis, Stanley; Miller, Kristi K; Landers, Daniel V
Although costs of providing care may decrease with hospital initiatives to improve obstetric and neonatal outcomes, the accompanying reduced adverse outcomes may negatively affect hospital revenues. In 2008 a Minnesota-based hospital system (Fairview Health Services) launched the Zero Birth Injury (ZBI) initiative, which used evidence-based care bundles to guide management of obstetric services. A pre-post analysis of financial impacts of ZBI was conducted by using hospital administrative records to measure costs and revenues associated with changes in maternal and neonatal birth injuries before (2008) and after (2009-2011) the initiative. For the Fairview Health Services hospitals, after adjusting for relevant covariates, implementation of ZBI was associated with a mean 11% decrease in the rate of maternal and neonatal adverse outcomes between 2008 and 2011 (adjusted odds ratio [AOR] = 0.89, p = .076). As a result of the adverse events avoided, the hospital system saved $284,985 in costs but earned $324,333 less revenue, which produced a net financial decrease of $39,348 (or a $305 net financial loss per adverse event avoided) in 2011, compared with 2008. Adoption of a perinatal quality and safety initiative that reduced birth injuries had little net financial impact on the hospital. ZBI produced better clinical results at a lower cost, which represents potential savings for payers, but the hospital system offering improved quality reaped no clear financial rewards. These results highlight the important role for shared-savings collaborations (among patients, providers, government and third-party payers, and employers) to incentivize QI. Widespread adoption of perinatal safety initiatives combined with innovative payment models may contribute to better health at reduced cost.
blood diseases and conditions; parasitic infections; rheumatic and inflammatory diseases; and rare and neglected diseases. CMRP’s collaborative approach to clinical research and the expertise and dedication of staff to the continuation and success of the program’s mission has contributed to improving the overall standards of public health on a global scale. The Clinical Monitoring Research Program (CMRP) provides comprehensive, dedicated clinical research, study coordination, and administrative support to the National Cancer Institute’s (NCI’s), Center for Cancer Research (CCR), Urologic Oncology Branch (UOB) located at the National Institutes of Health (NIH) in Bethesda, Maryland. KEY ROLES/RESPONSIBILITIES - THIS POSITION IS CONTINGENT UPON FUNDING APPROVAL The Patient Care Coordinator III (PCC III) provides administrative services, as well as patient care coordination. Responsibilities will include: Communicates with various clinical administrative support offices/clinics/diagnostic centers concerning scheduling of patient appointments, new and existing work scopes and clinical protocols (Surgery, X-ray, etc.). Consults with the patient, chooses the appropriate appointment, and enters ID and demographic data supplied by patient to secure an appointment in order to update clinic and physician schedules. Composes correspondence on various administrative issues including patient letters and notices to the patient’s home and physicians. Provides patients with information about their appointments, including medical materials the patient will need to bring, dates and times, clinic information, hospital maps and appropriate travel and hotel information. Arranges Admission Travel Voucher (ATV) travel, including lodging, meals and direct bill requests and enters data in the ATV system daily. Obtains up-to-date patient records and other pertinent information prior to patient appointments or admission. Maintains a roster of all patients and tracks their appointments
Full Text Available Introduction: Despite the importance of continuity of care and patient engagement, few studies have captured patients’ views on integrated care. This study assesses patient experience in the Integrated Care Pilot in North West London with the aim to help clinicians and policy makers understand patients’ acceptability of integrated care and design future initiatives. Methods: A survey was developed, validated and distributed to 2029 randomly selected practice patients identified as having a care plan. Results: A total of 405 questionnaires were included for analysis. Respondents identified a number of benefits associated with the pilot, including increased patient involvement in decision-making, improved patient-provider relationship, better organisation and access to care, and enhanced inter-professional communication. However, only 22.4% were aware of having a care plan, and of these only 37.9% had a copy of the care plan. Knowledge of care plans was significantly associated with a more positive experience. Conclusions: This study reinforces the view that integrated care can improve quality of care and patient experience. However, care planning was a complex and technically challenging process that occurred more slowly than planned with wide variation in quality and time of recruitment to the pilot, making it difficult to assess the sustainability of benefits.
Loeb, Danielle F; Bayliss, Elizabeth A; Candrian, Carey; deGruy, Frank V; Binswanger, Ingrid A
Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care. Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion. PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients. Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of
Institutional psychotherapy was developed in the specific context of the "assassination" of the Spanish revolution. There are two distinct movements or two periods. The first, based around Georges Daumézon and Henri Ey gave birth to the sector. The second, around FrançoisTosquelles and Jean Oury emphasised the asylum as the place of care. The function of institutional psychotherapy is to care not only for the patients but also the place of treatment. To fulfil this function, it has a tool box: transfer, the fight against the overvaluation of hierarchy as well as the function of the therapeutic club.
Abdurrouf, Muh; Nursalam, Nursalam; Purwaningsih, Purwaningsih
Introduction: Patient satisfaction was important aspect that must be considered by health service providers, patients who were not satisfied will leave the hospital and be a competitor's customers so be able caused a decrease in sales of products/services and in turn could reduce and even loss of profit, therefore, the hospital must provided the best service so that it could increase patient satisfaction. The purpose of this study was to exams the effect of Islamic caring model on increase pa...
Bhatt, Surya P; Wells, J Michael; Iyer, Anand S; Kirkpatrick, deNay P; Parekh, Trisha M; Leach, Lauren T; Anderson, Erica M; Sanders, J Greg; Nichols, Jessica K; Blackburn, Cindy C; Dransfield, Mark T
Approximately 20% of Medicare beneficiaries hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) are readmitted within 30 days of discharge. In addition to implementing penalties for excess readmissions, the U.S. Centers for Medicare and Medicaid Services has developed Bundled Payments for Care Improvement (BPCI) initiatives to improve outcomes and control costs. To evaluate whether a comprehensive COPD multidisciplinary intervention focusing on inpatient, transitional, and outpatient care as part of our institution's BPCI participation would reduce 30-day all-cause readmission rates for COPD exacerbations and reduce overall costs. We performed a pre-postintervention study comparing all-cause readmissions and costs after index hospitalization for Medicare-only patients with acute exacerbation of COPD. The primary outcome was the difference in 30-day all-cause readmission rate compared with historical control subjects; secondary outcomes included the 90-day all-cause readmission rate and also health care costs compared with BPCI target prices. Seventy-eight consecutive Medicare patients were prospectively enrolled in the BPCI intervention in 2014 and compared with 109 patients in the historical group from 2012. Patients in BPCI were more likely to receive regular follow-up phone calls, pneumococcal and influenza vaccines, home health care, durable medical equipment, and pulmonary rehabilitation, and to attend pulmonary clinic. There was no difference in all-cause readmission rates at 30 days (BPCI, 12 events [15.4%] vs. non-BPCI, 19 events [17.4%]; P = 0.711), and 90 days (21 [26.9%] vs. 37 [33.9%]; P = 0.306). Compared with BPCI target prices, we incurred 4.3% lower 90-day costs before accounting for significant investment from the health system. A Medicare BPCI intervention did not reduce 30-day all-cause readmission rates or overall costs after hospitalization for acute exacerbation of COPD. Although additional studies
Sep 9, 2003 ... Objective: To describe the emergency care of injuries at a main city hospital. Design: A prospective study. Setting: Data were collected between February 1st, 1999 and 30th April, 1999 from the records of the 2000 bed Kenyatta National Hospital (KNH) in Nairobi, Kenya. Subjects: Two hundred and forty ...
... Duty member. Additionally, with respect to care that is related to a non-covered initial surgery or... interest; namely, protecting former active duty members who have received private sector care pursuant to a... incorporated by reference for the benefits provided in the civilian health care sector to active duty family...
Barrett, Nina; Wholihan, Dorothy
Nurses should be familiar with and equipped to address the challenges that arise when caring for lesbian, gay, bisexual, transgender, or queer-identified (LGBTQ) patients. LGBTQ individuals have increased rates of certain physical diseases and are at greater risk of suffering from stress-sensitive mental health issues. Negative social attitudes, widespread discrimination and stigma, physical and psychological victimization, and less social support with aging contribute to the complexity of care for these individuals. Open communication, welcoming and accepting attitudes and environments, and sensitivity to unique multidimensional issues improve care to LGBTQ patients with serious advanced illness. Nursing can reach this vulnerable minority and positively impact the quality of care. Copyright © 2016 Elsevier Inc. All rights reserved.
Ozbolt, Judy; Ozdas, Asli; Waitman, Lemuel R; Smith, Janis B; Brennan, Grace V; Miller, Randolph A
The application of principles and methods of cybernetics permits clinicians and managers to use feedback about care effectiveness and resource expenditure to improve quality and to control costs. Keys to the process are the specification of therapeutic goals and the creation of an organizational culture that supports the use of feedback to improve care. Daily feedback on the achievement of each patient's therapeutic goals provides tactical decision support, enabling clinicians to adjust care as needed. Monthly or quarterly feedback on aggregated goal achievement for all patients on a clinical pathway provides strategic decision support, enabling clinicians and managers to identify problems with supposed "best practices" and to test hypotheses about solutions. Work is underway at Vanderbilt University Medical Center to implement feedback loops in care and management processes and to evaluate the effects.
Rohde, C; Polcwiartek, C; Kragholm, K
OBJECTIVE: Using national Danish registers, we estimated rates of clozapine-associated cardiac adverse events. Rates of undiagnosed myocarditis were estimated by exploring causes of death after clozapine initiation. METHOD: Through nationwide health registers, we identified all out-patients initi......OBJECTIVE: Using national Danish registers, we estimated rates of clozapine-associated cardiac adverse events. Rates of undiagnosed myocarditis were estimated by exploring causes of death after clozapine initiation. METHOD: Through nationwide health registers, we identified all out...... the maximum rate of clozapine-associated fatal myocarditis to 0.28%. CONCLUSION: Cardiac adverse effects in Danish out-patients initiating clozapine treatment are extremely rare and these rates appear to be comparable to those observed for other antipsychotic drugs....
Het instellen op insuline van patiënten met diabetes mellitus type 2: In een transmurale organisatievorm minstens even effectief als poliklinisch; een retrospectief onderzoek met 4 jaar follow-up [Initiating insulin therapy in patients with diabetes mellitus type 2: In a transmural form of care at least as effective as an outpatients form; a retrospective study with a 4-year follow-up
Rosendal, H.; Vondeling, H.; Witte, L.P. de; Hutubessy, R.C.W.; Beekum, W.T. van; Heine, R.J.
Objective. Assessing whether the initiation of insulin therapy in patients with diabetes mellitus type 2 can be delivered as effectively in a structured transmural care model as in the more usual outpatients structure. Design. Retrospective comparative cohort study. Method. In 1997 data were
David, Guy; Saynisch, Philip A; Smith-McLallen, Aaron
The Patient-Centered Medical Home (PCMH) is a widely-implemented model for improving primary care, emphasizing care coordination, information technology, and process improvements. However, its treatment as an undifferentiated intervention in policy evaluation obscures meaningful variation in implementation. This heterogeneity leads to contracting inefficiencies between insurers and practices and may account for mixed evidence on its success. Using a novel dataset we group practices into meaningful implementation clusters and then link these clusters with detailed patient claims data. We find implementation choice affects performance, suggesting that generally-unobserved features of primary care reorganization influence patient outcomes. Reporting these features may be valuable to insurers and their members. Copyright © 2018 Elsevier B.V. All rights reserved.
Hincapie, Ana L; Slack, Marion; Malone, Daniel C; MacKinnon, Neil J; Warholak, Terri L
Patients may be the most reliable reporters of some aspects of the health care process; their perspectives should be considered when pursuing changes to improve patient safety. The authors evaluated the association between patients' perceived health care quality and self-reported medical, medication, and laboratory errors in a multinational sample. The analysis was conducted using the 2010 Commonwealth Fund International Health Policy Survey, a multinational consumer survey conducted in 11 countries. Quality of care was measured by a multifaceted construct developed using Rasch techniques. After adjusting for potentially important confounding variables, an increase in respondents' perceptions of care coordination decreased the odds of self-reporting medical errors, medication errors, and laboratory errors (P < .001). As health care stakeholders continue to search for initiatives that improve care experiences and outcomes, this study's results emphasize the importance of guaranteeing integrated care.
Epplen, Kelly T
This article discusses how to plan and implement an ambulatory care pharmacist service, how to integrate a hospital- or health-system-based service with the mission and operations of the institution, and how to help the institution meet its challenges related to quality improvement, continuity of care, and financial sustainability. The steps in implementing an ambulatory care pharmacist service include (1) conducting a needs assessment, (2) aligning plans for the service with the mission and goals of the parent institution, (3) collaborating with patients and physicians, (4) standardizing the patient care process, (5) proposing the service, (6) attaining the necessary resources, (7) identifying stakeholders, (8) identifying applicable quality standards, (9) defining competency standards, (10) planning for service payment, and (11) monitoring outcomes. Ambulatory care pharmacists have current opportunities to become engaged with patient-centered medical homes, accountable care organizations, preventive and wellness programs, and continuity of care initiatives. Common barriers to the advancement of ambulatory care pharmacist services include lack of complete access to patient information, inadequate information technology, and lack of payment. Ambulatory care pharmacy practitioners must assertively promote appropriate medication use, provide patient-centered care, pursue integration with the patient care team, and seek appropriate recognition and compensation for the services they provide. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
Panattoni, Laura; Stone, Ashley; Chung, Sukyung; Tai-Seale, Ming
The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient's experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes. We aimed to examine the relationships between a physicians' clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician. We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010. The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688). Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0-100 % scale, were measured. Access to care was measured as days to the third next-available appointment. Physician FTE was directly associated with better continuity of care received (0.172% per FTE, p part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.
Van Severen, Evie; Willemsen, Robert; Vandervoort, Pieter; Sabbe, Marc; Dinant, Geert-Jan; Buntinx, Frank
It is important that patients with symptoms of acute coronary syndrome receive appropriate medical care as soon as possible. Little is known about the preadmission actions that patients with chest pain take before arrival at the Emergency Department (ED). This study aimed to describe the actions of patients with chest pain or pressure after onset of symptoms. What is the first action following onset of symptoms? Who is the first lay or professional person to be contacted? Which steps are taken first? How is the patient transported to the hospital? Consecutive patients, arriving at the ED of two large hospitals in Belgium, were asked additional questions during the initial assessment. Overall, 35% of 412 consecutive patients with chest pain admitted to the ED were diagnosed with acute coronary syndrome. A total of 57% contacted a GP between symptom onset and arrival at the ED. Only 32% of the patients were transported to the ED by ambulance, 16% drove themselves and 52% arrived by other means of transport (by family, neighbour, GP, public transport). In Belgium, the GP is still the first professional to be contacted for most patients. Other patients initially rely on their partner, family or friends when symptoms emerge. Too often, patients with chest pain rely on other transport to get to the ED instead of calling the Emergency Medical Services. This study included only patients who ultimately attended the ED.
Many of the radiation reactions which may occur in patients following radiotherapy and the care of these reactions are described. These include the systemic reaction, reactions of the blood and skin, reactions occurring after treatment of the breast and chest wall, reactions after irradiation of the mouth and throat, intrathoracic tumours, the abdominal alimentary tract and pelvis, bone, the CNS and the eye. Patient care during the treatment of children and also during treatment using small sealed sources is also described. (U.K.)
The anxiety and associated depression suffered by most patients undergoing radiotherapy is discussed and the possibilities open to the nurse to encourage and reassure patients thus facilitating physical care are considered. The general symptoms of anorexia, nausea, tiredness, skin problems, alopecia, bonemarrow depresssion and rapid tumour destruction are described and nursing care prescribed. The side-effects which may occur following radiation of the brain, head and neck region, eyes, oesophagus, lung, abdomen, pelvis, bones, skin, spine, and spinal cord are considered from the nursing standpoint. The specialised subject of radiotherapy in children is discussed briefly. (U.K.)
Pediatric supportive care is an important aspect of cancer care as children and adolescents face unique challenges compared to adult patients. Learn more about supportive care for pediatric patients during and after treatment in this expert-reviewed summary.
Lillibridge, Nichole; Botti, Mari; Wood, Beverley; Redley, Bernice
To identify patient care outcome indicators sensitive to the quality of interprofessional handover between the anaesthetist and the Post-Anaesthetic Care Unit nurse. The relationship between interprofessional clinical handover when patients are transferred from the operating theatre to the Post-Anaesthetic Care Unit and patient outcomes of subsequent patient care delivery is not well understood. Naturalistic, exploratory descriptive design using observation. Observations of 31 patient journeys through Post-Anaesthetic Care Units across three public and private hospitals. Characteristics of interprofessional handover on arrival in the Post-Anaesthetic Care Unit, the trajectory of patient care activities in Post-Anaesthetic Care Unit and patient outcomes were observed. Of the 821 care activities observed across 31 "patient journeys" in the Post-Anaesthetic Care Unit, observations (assessments and vital signs) (52.5 %), communication (15.8 %) and pain management (assessment of pain and analgesic administration) (10.3%) were most common. Examination of patterns in handover communications and subsequent trajectories of patient care activities revealed three patient trajectory typologies and two patient outcome indicators expected to be sensitive to the quality of interprofessional handover communication in the Post-Anaesthetic Care Unit: pain on discharge from the Post-Anaesthetic Care Unit and timely response to clinical deterioration. An additional process indicator, seeking missing information, was also identified. Patient's pain on discharge from Post-Anaesthetic Care Unit, escalation of care in response to early signs of deterioration and the need for nurses to seek out missing information to deliver care are indicators expected to be sensitive to the quality of interprofessional handover communication in the Post-Anaesthetic Care Unit. Future research should test these indicators. Patient outcomes sensitive to the quality of interprofessional handover on patient
Afione, Cristina; Binda, Maria del C.
Purpose: To determine the role of imaging diagnostic methods in the location of infection causes of unknown origin in the critical care patient. Material and methods: A comprehensive medical literature search has been done. Recommendations for the diagnostic imaging of septic focus in intensive care patients are presented for each case, with analysis based on evidence. The degree of evidence utilized has been that of Oxford Center for Evidence-based Medicine. Results: Nosocomial infection is the most frequent complication in the intensive care unit (25 to 33%) with high sepsis incidence rate. In order to locate the infection focus, imaging methods play an important role, as a diagnostic tool and to guide therapeutic procedures. The most frequent causes of infection are: ventilation associated pneumonia, sinusitis, intra-abdominal infections and an acute acalculous cholecystitis. This paper analyses the diagnostic imaging of hospital infection, with the evaluation of choice methods for each one and proposes an algorithm to assess the septic patient. Conclusion: There are evidences, with different degrees of recommendation, for the use of diagnostic imaging methods for infectious focuses in critical care patients. The studies have been selected based on their diagnostic precision, on the capacity of the medical team and on the availability of resources, considering the risk-benefit balance for the best safety of the patient. (author)
Silvestre, Maria Asuncion A; Mannava, Priya; Corsino, Marie Ann; Capili, Donna S; Calibo, Anthony P; Tan, Cynthia Fernandez; Murray, John C S; Kitong, Jacqueline; Sobel, Howard L
To determine whether intrapartum and newborn care practices improved in 11 large hospitals between 2008 and 2015. Secondary data analysis of observational assessments conducted in 11 hospitals in 2008 and 2015. Eleven large government hospitals from five regions in the Philippines. One hundred and seven randomly sampled postpartum mother-baby pairs in 2008 and 106 randomly sampled postpartum mothers prior to discharge from hospitals after delivery. A national initiative to improve quality of newborn care starting in 2009 through development of a standard package of intrapartum and newborn care services, practice-based training, formation of multidisciplinary hospital working groups, and regular assessments and meetings in hospitals to identify actions to improve practices, policies and environments. Quality improvement was supported by policy development, health financing packages, health facility standards, capacity building and health communication. Sixteen intrapartum and newborn care practices. Between 2008 and 2015, initiation of drying within 5 s of birth, delayed cord clamping, dry cord care, uninterrupted skin-to-skin contact, timing and duration of the initial breastfeed, and bathing deferred until 6 h after birth all vastly improved (P<0.001). The proportion of newborns receiving hygienic cord handling and the hepatitis B birth dose decreased by 11-12%. Except for reduced induction of labor, inappropriate maternal care practices persisted. Newborn care practices have vastly improved through an approach focused on improving hospital policies, environments and health worker practices. Maternal care practices remain outdated largely due to the ineffective didactic training approaches adopted for maternal care.
Xie, Zhonghui; Li, Jing; Chen, Yuhua; Cui, Kaijun
Patient initiated aggression is common among Chinese health-care workers, reaching over 10,000 incidents annually (Jinyang web. http://6d.dxy.cn/article/55497 . 2013), and the tense doctor-patient relationship generates stress among medical students. Because of the paucity of data (few surveys pay attention to the effects of violence perpetrated by patients on medical students), this study aimed to characterize patient initiated aggression against medical students. In this cross-sectional survey conducted at a medical school in West China in 2015, 157 medical students completed a self-administered questionnaire and the Short Form-36, which assesses quality of life. The associations between patient initiated aggression exposure and medical students' career planning or quality of life were assessed using a chi-square test. Of the 157 medical students, 48 (30.6%) reported having suffered patient initiated aggression at least once during the previous year in the form of mental abuse (20.4%), offensive threat (14.6%), physical violence (8.3%), sexual harassment (verbal: 8.3% or physical: 1.6%), and extreme violence (physical violence leading to surgical treatment or hospitalization) (0.6%). Insufficient communication was the primary reason cited (27.2%). Emotional attack (mental abuse and offensive threat) occurrence differed among age groups (χ 2 = 9.786, P = 0.020) and was ubiquitous among those aged >30 years old. Women were more likely than men to suffer physical violence (χ 2 = 6.796, P = 0.009). Patient initiated aggression was not significantly associated with medical students' career planning or quality of life. In this study, patient initiated aggression, albeit common, as in the rest of China, did not appear to be associated with medical students' career planning or quality of life. However, the characteristics described can inform policymaking and the design of programs to minimize patient initiated aggression occurrence.
Taylor, Charles Grafton; Taylor, Gordon; Atherley, Anique; Hambleton, Ian; Unwin, Nigel; Adams, Oswald Peter
With regards to insulin initiation in Barbados we explored primary care doctor (PCD) perception, healthcare system factors and predictors of PCD reluctance to initiate insulin. PCDs completed a questionnaire based on the theory of planned behaviour (TPB) and a reluctance to initiate insulin scale. Using linear regression, we explored the association between TPB domains and the reluctance to initiate insulin scale. Of 161 PCDs, 70% responded (75 private and 37 public sector). The majority felt initiating insulin was uncomplicated (68%) and there was benefit if used before complications developed (68%), but would not use it until absolutely necessary (58%). More private than public sector PCDs (p<0.05) thought that the healthcare system allowed enough flexibility of time for education (68 vs 38%) and initiating insulin was easy (63 vs 35%), but less thought system changes would help initiating insulin (42 vs 70%). Reasons for reluctance to initiate insulin included patient nonadherence (83%) and reluctance (63%). Only the attitudes and belief domain of the TPB was associated with the reluctance to initiate insulin scale (p<0.001). Interventions focusing on PCD attitudes and beliefs and restructuring services inclusive of the use of diabetes specialist nurses are required. Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Full Text Available Abstract Background This study explores with patients, carers and health care professionals if, when and how Advance Care Planning conversations about patients’ preferences for place of care (and death were facilitated and documented. Methods The study adopted an exploratory case study design using qualitative interviews, across five services delivering palliative care to cancer and non-cancer patients within an urban and rural English region. The study recruited 18 cases made up of patients (N = 18; 10 men; 8 women; median age 75; nominated relatives (N = 11; 7 women; 4 men; median age 65 and healthcare professionals (N = 15 caring for the patient. Data collection included: 18 initial interviews (nine separate interviews with patients and 9 joint interviews with patients and relatives and follow up interviews in 6 cases (involving a total of 5 patients and 5 relatives within one year of the first interview. Five group interviews were conducted with 15 healthcare professionals; 8 of whom also participated in follow up interviews to review their involvement with patients in our study. Results Patients demonstrated varying degrees of reticence, evasion or reluctance to initiate any conversations about end of life care preferences. Most assumed that staff would initiate such conversations, while staff were often hesitant to do so. Staff-identified barriers included the perceived risks of taking away hope and issues of timing. Staff were often guided by cues from the patient or by intuition about when to initiate these discussions. Conclusions This study provides insights into the complexities surrounding the initiation of Advance Care Planning involving conversations about end of life care preferences with patients who are identified as having palliative care needs, in particular in relation to the risks inherent in the process of having conversations where mortality must be acknowledged. Future research is needed to examine how to
Happ, Mary Beth; Garrett, Kathryn; Thomas, Dana DiVirgilio; Tate, Judith; George, Elisabeth; Houze, Martin; Radtke, Jill; Sereika, Susan
Background The inability to speak during critical illness is a source of distress for patients, yet nurse-patient communication in the intensive care unit has not been systematically studied or measured. Objectives To describe communication interactions, methods, and assistive techniques between nurses and nonspeaking critically ill patients in the intensive care unit. Methods Descriptive observational study of the nonintervention/usual care cohort from a larger clinical trial of nurse-patient communication in a medical and a cardiothoracic surgical intensive care unit. Videorecorded interactions between 10 randomly selected nurses (5 per unit) and a convenience sample of 30 critically ill adults (15 per unit) who were awake, responsive, and unable to speak because of respiratory tract intubation were rated for frequency, success, quality, communication methods, and assistive communication techniques. Patients self-rated ease of communication. Results Nurses initiated most (86.2%) of the communication exchanges. Mean rate of completed communication exchange was 2.62 exchanges per minute. The most common positive nurse act was making eye contact with the patient. Although communication exchanges were generally (>70%) successful, more than one-third (37.7%) of communications about pain were unsuccessful. Patients rated 40% of the communication sessions with nurses as somewhat difficult to extremely difficult. Assistive communication strategies were uncommon, with little to no use of assistive communication materials (eg, writing supplies, alphabet or word boards). Conclusions Study results highlight specific areas for improvement in communication between nurses and nonspeaking patients in the intensive care unit, particularly in communication about pain and in the use of assistive communication strategies and communication materials. PMID:21362711
Sugarman, Jonathan R; Phillips, Kathryn E; Wagner, Edward H; Coleman, Katie; Abrams, Melinda K
Despite findings that medical homes may reduce or eliminate health care disparities among underserved and minority populations, most previous medical home pilot and demonstration projects have focused on health care delivery systems serving commercially insured patients and Medicare beneficiaries. To develop a replicable approach to support medical home transformation among diverse practices serving vulnerable and underserved populations. Facilitated by a national program team, convening organizations in 5 states provided coaching and learning community support to safety net practices over a 4-year period. To guide transformation, we developed a framework of change concepts aligned with supporting tools including implementation guides, activity checklists, and measurement instruments. Sixty-five health centers, homeless clinics, private practices, residency training centers, and other safety net practices in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. We evaluated implementation of the change concepts using the Patient-Centered Medical Home-Assessment, and conducted a survey of participating practices to assess perceptions of the impact of the technical assistance. All practices implemented key features of the medical home model, and nearly half (47.6%) implemented the 33 identified key changes to a substantial degree as evidenced by level A Patient-Centered Medical Home-Assessment scores. Two thirds of practices that achieved substantial implementation did so only after participating in the initiative for >2 years. By the end of the initiative, 83.1% of sites achieved external recognition as medical homes. Despite resource constraints and high-need populations, safety net clinics made considerable progress toward medical home implementation when provided robust, multimodal support over a 4-year period.
Full Text Available South Africa bears the greatest burden of HIV infection globally with the most infected people living in KwaZulu-Natal (KZN. Decentralised medical care for HIV positive patients and antiretroviral therapy (ART delivery to primary health care facilities were proposed nationally to achieve adequate ART coverage for patients in need of treatment. This study described the HIV positive patients who accessed medical care and were initiated on ART at two existing government Primary Health Care (PHC clinics with no added donor support, in Ilembe, KZN. This was an observational descriptive study of ART initiation from 01 April 2008 to 30 April 2009. Data were collected from clinical records kept on site. HIV Testing and the pre-ART programmes which consisted of medical care prior to ART initiation are briefly described. Socio-economic, demographic and clinical characteristics of patients who were initiated on ART were sampled and described. A minority (2.95% of the study population tested for HIV of which 36.0% tested positive. Majority (60.0% of patients who joined the pre-ART programme care did not return. The ART sample consisted of 375 patients of whom 65.0% were women, 85.9% were unmarried, 61.6% were unemployed and 50.4% had a secondary level of education. Tuberculosis (TB prevalence and incidence at ART initiation were 22.1% and 14.7% respectively. The prevalence of Syphilis and Hepatitis B co-infections were 13.1% and 8.6 % respectively. Two thirds of female patients (66.4% received a Pap smear result of which the majority (62.3% were abnormal. Uptake for HIV testing followed by relevant CD4 testing was poor. High TB, Hepatitis B and Syphilis co-infection was noted amongst patients initiated on ART. Cervical cancer screening must be intensified. Although ART initiation with no added external resources was successful, record keeping was suboptimal. Suid-Afrika dra die grootste las van MIV-infeksie ter wêreld met die meeste besmette mense in Kwa
Dencker, Annemarie; Kristiansen, Maria; Andreassen Rix, Bo
. In this qualitative comparative study, we explore the influence of medical contexts in three Danish hospital wards, haematology, oncological gynaecology and neuro-intensive care, on communication with patients about their children. In exploring the degree to which the inclusion of children in clinical encounters......Patients' family relations play an important part in the provision of patient-centred cancer care, not least when healthcare professionals encounter seriously ill patients with dependent children. Little is known about how children are perceived and dealt with in clinical encounters....... The thematic analysis was based on Bateson's conceptualisation of communication. We found that healthcare professionals' approach to children in clinical encounters and the ways in which children were positioned on each ward were influenced by aspects specific to the ward, including the diagnosis...
Yedidia, Michael J
Palliative care was studied for its potential to yield lessons for transforming doctor-patient relationships to promote patient-centered care. Examination of patient and provider experiences of the transition from curative to palliative care promises valuable insights about establishing and maintaining trust as the goals of care shift and about addressing a broad spectrum of patient needs. The study was guided by a conceptual framework grounded in existing models to address five dimensions of doctor-patient relationships: range of needs addressed, source of authority, maintenance of trust, emotional involvement, and expression of authenticity. Data collection included observation of the care of 40 patients in the inpatient hospice unit and at home, interviews with patients and family members, and in-depth interviews with 22 physicians and two nurses providing end-of-life care. Standard qualitative procedures were used to analyze the data, incorporating techniques for maximizing the validity of the results and broadening their relevance to other contexts. Findings provide evidence for challenging prominent assumptions about possibilities for doctor-patient relationships: questioning the merits of the prohibition on emotional involvement, dependence on protocols for handling difficult communication issues, unqualified reliance on consumer empowerment to assure that care is responsive to patients' needs, and adoption of narrowly defined boundaries between medical and social service systems in caring for patients. Medical education can play a role in preparing doctors to assume new roles by openly addressing management of emotions in routine clinical work, incorporating personal awareness training, facilitating reflection on interactions with patients through use of standardized patients and videotapes, and expanding capacity to effectively address a broad range of needs through teamwork training.
Boykin, Amanda; Wright, Danielle; Stevens, Lydia; Gardner, Lauren
An innovative collaborative care model to improve transitions of care (TOC) for patients with heart failure (HF) is described. As part of a broad effort by New Hanover Regional Medical Center (NHRMC) to reduce avoidable 30-day hospital readmissions and decrease associated healthcare costs through a team-centered, value-based approach to patient care, an interprofessional team was formed to help reduce hospital readmissions among discharged patients with HF. The team consists of 5 TOC pharmacists, 4 community paramedics, and 4 advanced care practitioners (ACPs) who collaborate to coordinate care and prevent 30-day readmissions among patients with HF transitioning from the hospital to the community setting. Each team member plays an integral role in providing high-quality postdischarge care. The TOC pharmacist ensures that patients have access to all needed medications, provides in-home medication reconciliation services, makes medication recommendations, and alerts the team of potential medication-related issues. Community paramedics conduct home visits consisting of physical and mental health assessments, diet and disease state education, reviews of medication bottles and education on proper medication use, and administration of i.v. diuretics to correct volume status under provider orders. The ACPs offer close clinic follow-up (typically initiated within 7 days of discharge) as well as long-term HF management and education. At NHRMC, collaboration among healthcare professionals, including a TOC pharmacist, community paramedics, and ACPs, has assisted in the growth and expansion of services provided to patients with HF. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
Gelblum, Daphna Y.; Amols, Howard
Purpose: To review the experience of a large cancer center with radiotherapy (RT) patients bearing implantable cardiac defibrillators (ICDs) to propose some preliminary care guidelines as we learn more about the devices and their interaction with the therapeutic radiation environment. Methods and Materials: We collected data on patients with implanted ICDs treated with RT during a 2.5-year period at any of the five Memorial Sloan-Kettering clinical campuses. Information regarding the model, location, and dose detected from the device, as well as the treatment fields, fraction size, and treatment energy was collected. During this time, a new management policy for these patients had been implemented requiring treatment with low-energy beams (6 MV) and close surveillance of the patients in partnership with their electrophysiologist, as they received RT. Results: During the study period, 33 patients were treated with an ICD in place. One patient experienced a default of the device to its initial factory setting that was detected by the patient hearing an auditory signal from the device. This patient had initially been treated with a 15-MV beam. After this episode, his treatment was replanned to be completed with 6-MV photons, and he experienced no further events. Conclusion: Patients with ICDs and other implanted computer-controlled devices will be encountered more frequently in the RT department, and proper management is important. We present a policy for the safe treatment of these patients in the radiation oncology environment.
de Oliveira Riboldi, Caren; Macedo, Andrea Barcellos Teixeira; Mergen, Thiane; Dias, Vera Lúcia Mendes; da Costa, Diovane Ghignatti; Malvezzi, Maria Luiza Falsarella; Magalhães, Ana Maria Muller; Silveira, Denise Tolfo
Presentation of the computerized structure to implement, in a university hospital in the South of Brazil, the Patients Classification System of Perroca, which categorizes patients according to the care complexity. This solution also aims to corroborate a recent study at the hospital, which evidenced that the increasing workload presents a direct relation with the institutional quality indicators. The tools used were the Google applications with high productivity interconnecting the topic knowledge on behalf of the nursing professionals and information technology professionals.
a history of oral candidiasis (HR 2.58, 95% CI 1.37 - 4.88) remained significant in multivariate analysis. A history of tuberculosis was not a significant predictor of mortality. Conclusions. Simple clinical and laboratory data independently predict mortality and allow for risk stratification in patients initiating ART in South Africa.
Moreo, Kathleen; Lattimer, Cheri; Lett, James E; Heggen-Peay, Cherilyn L; Simone, Laura
Many continuing education (CE) resources are available to support case management professionals in developing competencies in transitions of care (TOC) that apply generally across disease areas. However, CE programs and tools are lacking for advanced TOC competencies in specific disease areas. This article describes 2 projects in which leading TOC, case management, and CE organizations collaborated to develop CE-accredited interdisciplinary pathways for promoting safe and effective TOC for patients with rare pulmonary diseases, including pulmonary arterial hypertension (PAH) and idiopathic pulmonary fibrosis (IPF). The interdisciplinary pathways apply to PAH and IPF case management practice and TOC across settings that include community-based primary care and specialty care, PAH or IPF centers of expertise, acute care and post-acute settings, long-term care, rehabilitation and skilled nursing facilities, and patients' homes. Both PAH and IPF are chronic, progressive respiratory diseases that are associated with severe morbidity and mortality, along with high health care costs. Because they are relatively rare diseases with nonspecific symptoms and many comorbidities, PAH and IPF are difficult to diagnose. Early diagnosis, referral to centers of expertise, and aggressive treatment initiation are essential for slowing disease progression and maintaining quality of life and function. Both the rarity and complexity of PAH and IPF pose unique challenges to ensuring effective and safe TOC. Expert consensus and evidence-based approaches to meeting these challenges, and thereby improving PAH and IPF patient outcomes, are presented in the 2 interdisciplinary TOC pathways that are described in this article. In coordinating care for patients with complex pulmonary diseases such as PAH and IPF, case managers across practice settings can play key roles in improving workflow processes and communication, transition planning, coordinating TOC with centers of expertise
Bao, Yuhua; Casalino, Lawrence P.; Pincus, Harold Alan
Discussions of health care delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient Centered Medical Home, the H...
Eden, Elizabeth L; Rack, Laurie L; Chen, Ling-Wan; Bump, Gregory M
Rapid response teams (RRTs) help in delivering safe, timely care. Typically they are activated by clinicians using specific parameters. Allowing patients and families to activate RRTs is a novel intervention. The University of Pittsburgh Medical Center developed and implemented a patient- and family-initiated rapid response system called Condition Help (CH). When the CH system is activated, a patient care liaison or an on-duty administrator meets bedside with the unit charge nurse to address the patient's concerns. In this study, we collected demographic data, call reasons, call designations (safety or nonsafety), and outcome information for all CH calls made during the period January 2012 through June 2015. Two hundred forty patients/family members made 367 CH calls during the study period. Most calls were made by patients (76.8%) rather than family members (21.8%). Of the 240 patients, 43 (18%) made multiple calls; their calls accounted for 46.3% of all calls (170/367). Inadequate pain control was the reason for the call in most cases (48.2%), followed by dissatisfaction with staff (12.5%). The majority of calls involved nonsafety issues (83.4%) rather than safety issues (11.4%). In 41.4% of cases, a change in care was made. Patient- and family-initiated RRTs are designed to engage patients and families in providing safer care. In the CH system, safety issues are identified, but the majority of calls involve nonsafety issues. Journal of Hospital Medicine 2017;12:157-161. © 2017 Society of Hospital Medicine
Stevens, Wendy S; Gous, Natasha M; MacLeod, William B; Long, Lawrence C; Variava, Ebrahim; Martinson, Neil A; Sanne, Ian; Osih, Regina; Scott, Lesley E
Lack of accessible laboratory infrastructure limits HIV antiretroviral therapy (ART) initiation, monitoring, and retention in many resource-limited settings. Point-of-care testing (POCT) is advocated as a mechanism to overcome these limitations. We executed a pragmatic, prospective, randomized, controlled trial comparing the impact of POCT vs. standard of care (SOC) on treatment initiation and retention in care. Selected POC technologies were embedded at 3 primary health clinics in South Africa. Confirmed HIV-positive participants were randomized to either SOC or POC: SOC participants were venesected and specimens referred to the laboratory with patient follow-up as per algorithm (∼3 visits); POC participants had phlebotomy and POCT immediately on-site using Pima CD4 to assess ART eligibility followed by hematology, chemistry, and tuberculosis screening with the goal of receiving same-day adherence counseling and treatment initiation. Participant outcomes measured at recruitment 6 and 12 months after initiation. Four hundred thirty-two of 717 treatment eligible participants enrolled between May 2012 and September 2013: 198 (56.7%) SOC; 234 (63.6%) POC. Mean age was 37.4 years; 60.5% were female. Significantly more participants were initiated using POC [adjusted prevalence ratio (aPR) 0.83; 95% confidence interval (CI): 0.74 to 0.93; P ART was similar for both arms at 6 months (47 vs. 50%) (aPR 0.96; 95% CI: 0.79 to 1.16) and 12 months (32 vs. 32%) (aPR 1.05; 95% CI: 0.80 to 1.38), with similar mortality rates. Loss to follow-up at 12 months was higher for POC (36% vs. 51%) (aPR 0.82; 95% CI: 0.65 to 1.04). Adoption of POCT accelerated ART initiation but once on treatment, there was unexpectedly higher loss to follow-up on POC and no improvement in outcomes at 12 months over SOC.
Kirchgessner, J; Perera-Chang, M; Klinkner, G; Soley, I; Marcelli, D; Arkossy, O; Stopper, A; Kimmel, P L
Patient satisfaction is an important aspect of dialysis care, only recently evaluated in clinical studies. We developed a tool to assess peritoneal dialysis (PD) customer satisfaction, and sought to evaluate and validate the Customer Satisfaction Questionnaire (CSQ), quantifying PD patient satisfaction. The CSQ included questions regarding administrative issues, Delivery Service, PD Training, Handling Requests, and transportation. The study was performed using interviews in all Hungarian Fresenius Medical Care dialysis centers offering PD. CSQ results were compared with psychosocial measures to identify if patient satisfaction was associated with perception of social support and illness burden, or depression. We assessed CSQ internal consistency and validity. Factor analysis explored potential underlying dimensions of the CSQ. One hundred and thirty-three patients treated with PD for end-stage renal disease for more than 3 months were interviewed. The CSQ had high internal consistency. There was high patient satisfaction with customer service. PD patient satisfaction scores correlated with quality of life (QOL) and social support measures, but not with medical or demographic factors, or depressive affect. The CSQ is a reliable tool to assess PD customer satisfaction. PD patient satisfaction is associated with perception of QOL. Efforts to improve customer satisfaction may improve PD patients' quantity as well as QOL.
PURPOSE: The purpose of this paper is to investigate different types of patient involvement in Denmark, and to discuss the potential implications of pursuing several strategies for patient involvement simultaneously. DESIGN/METHODOLOGY/APPROACH: The paper presents a preliminary framework for anal......PURPOSE: The purpose of this paper is to investigate different types of patient involvement in Denmark, and to discuss the potential implications of pursuing several strategies for patient involvement simultaneously. DESIGN/METHODOLOGY/APPROACH: The paper presents a preliminary framework...... for analysis of patient involvement in health care. This framework is used to analyze key governance features of patient involvement in Denmark based on previous research papers and reports describing patient involvement in Danish health care. FINDINGS: Patient involvement is important in Denmark...... be identified when pursuing the strategies at the same time. RESEARCH LIMITATIONS/IMPLICATIONS: Because of the chosen research approach, the research results may lack generalizability. Therefore, researchers are encouraged to test the proposed framework further. PRACTICAL IMPLICATIONS: The paper includes...
Edwards, Samuel T; Bitton, Asaf; Hong, Johan; Landon, Bruce E
Patient-centered medical home initiatives are central to many efforts to reform the US health care delivery system. To better understand the extent and nature of these initiatives, in 2013 we performed a nationwide cross-sectional survey of initiatives that included payment reform incentives in their models, and we compared the results to those of a similar survey we conducted in 2009. We found that the number of initiatives featuring payment reform incentives had increased from 26 in 2009 to 114 in 2013. The number of patients covered by these initiatives had increased from nearly five million to almost twenty-one million. We also found that the proportion of time-limited initiatives--those with a planned end date--was 20 percent in 2013, a decrease from 77 percent in 2009. Finally, we found that the dominant payment model for patient-centered medical homes remained fee-for-service payments augmented by per member per month payments and pay-for-performance bonuses. However, those payments and bonuses were higher in 2013 than they were in 2009, and the use of shared-savings models was greater. The patient-centered medical home model is likely to continue both to become more common and to play an important role in delivery system reform. Project HOPE—The People-to-People Health Foundation, Inc.
Tan, A M; Muthusamy, L; Ng, C C; Phoon, K Y; Ow, J H; Tan, N C
Type 2 diabetes mellitus is a progressive condition in which the pancreatic beta-cell function deteriorates with increasing duration of the disease. When good glycaemic control is not achieved despite adherence to oral hypoglycaemic drugs, healthy diet and lifestyle, insulin should be initiated. However, this is often delayed due to various reasons. We aimed to determine the issues relating to insulin initiation for diabetic patients managed in primary care polyclinics in Singapore. Qualitative data was obtained during four focus group discussions, with participation from healthcare professionals (HCPs), including physicians and nurses, and type 2 diabetes mellitus patients. The data was transcribed into text, coded and grouped into themes. Launching the topic and doctor-patient communication on insulin therapy were key issues in insulin initiation. Patient barriers to insulin commencement included: refusal to acknowledge the need for insulin therapy; its perception as a social stigma, an inconvenient mode of treatment or punishment for failure; and fear of needles, side-effects and complications. The HCP's attitude and experience with insulin therapy were also possible barriers. Our findings highlight that insulin initiation is affected by the complex interaction between the patients and HCPs, and other system factors. Patients may harbour misconceptions about insulin due to the late introduction of insulin therapy by HCPs or the way the therapy is being communicated to them. The key issues to address are the disparity in perceptions of diabetic control between HCPs and patients, and education regarding the need for insulin therapy.
Full Text Available Purpose: Analyzing the influence of nursing students’ learning initiative in the course reform of aged caring. Discuss the way of the aged care reform. Method: To reform the course of aged care in our school level 2013 88 nursing undergraduate. The specific content: learning aged care theory, learning Japanese care technology basic knowledge, adding Japanese and Taiwan’s nursing concepts to the traditional aged care teaching, performing sitcoms about old people’s disease and nursing way , reporting the plan of aged care by PowerPoint, organizing student volunteers to visit the nursing home and so on. The specific content lasted four months. Adopting the learning initiative (ALS scale developed by Zang Yuli and others after course reform. Measure the students’ learning initiative before and after the teaching. Result: Nursing student’s self-study ability was in the middle and lower level before the course reform(59.26±7.38; After the course reform, nursing student gain higher score than before learning on the three aspects contain “Learning motivation”,“Learning goals” and “Solid study”. The difference has statistically significant.(P<0.05.Conclusion: Through the aged care course reform, nursing students strengthen the study enthusiasm and initiative; enhance nursing student’s self-study ability. It is conducive to improve the learning interest of aged care course for nursing students.
Several diseases and operations may necessitate the formation of a stoma. Patients may be concerned about the effect of the stoma on their ability to carry out activities of daily living, as well as quality of life. Nurses who may be involved in the care of patients with a stoma should have an understanding of the reasons for stoma formation, and the types of stoma and appliances available, to educate and support patients, and allay any concerns. Issues related to diet, sexual relationships and self-image are also discussed briefly.
Thonon, Frédérique; Watson, Jonathan; Saghatchian, Mahasti
We performed a literature review of existing benchmarking projects of health facilities to explore (1) the rationales for those projects, (2) the motivation for health facilities to participate, (3) the indicators used and (4) the success and threat factors linked to those projects. We studied both peer-reviewed and grey literature. We examined 23 benchmarking projects of different medical specialities. The majority of projects used a mix of structure, process and outcome indicators. For some projects, participants had a direct or indirect financial incentive to participate (such as reimbursement by Medicaid/Medicare or litigation costs related to quality of care). A positive impact was reported for most projects, mainly in terms of improvement of practice and adoption of guidelines and, to a lesser extent, improvement in communication. Only 1 project reported positive impact in terms of clinical outcomes. Success factors and threats are linked to both the benchmarking process (such as organisation of meetings, link with existing projects) and indicators used (such as adjustment for diagnostic-related groups). The results of this review will help coordinators of a benchmarking project to set it up successfully. PMID:26770800
Lomborg, Kirsten; Nielsen, Else Skånning; Jensen, Annesofie Lunde
Aim: To document the efficacy of a training programme in patient-centred care in which the nursing staff was trained to involve chronic obstructive pulmonary patients in assisted personal body care (APBC). The objectives were to describe the programme and uncover the outcomes. Background: Chronic....... In order to achieve such competences in nursing staff, we developed, implemented and evaluated a training programme. Design: A qualitative outcome analysis was conducted in order to explore the dynamics of the training programme process and the outcome. patients to be more active, as was common practice...... prior to the training. According to the staff, there was no actual change in the patients’ level of activity. The training was time-consuming. Methods: Seven nurses and six nursing assistants from three hospital units were divided into two groups in which training and evaluation took place. The content...
Full Text Available This is a qualitative descriptive study examining nurses’ attitudes about caring for patients with intractable neurological diseases, with a focus on dedication and conflicts. Semistructured interviews were conducted on 11 nurses with more than 5 years of clinical experience in addition to more than 3 years of experience in neurology wards. Senior nursing officers from each hospital selected the participants. In general, these nurses expressed distress over the inevitable progression of disease. Nurses talked about the “basis of dedication,” “conflicts with dedication,” “reorganization for maintaining dedication,” and “the reason for the change from conflict to commitment.” “Reorganization for maintaining dedication” meant that nurses were able to handle the prospect of rededicating themselves to their patients. Furthermore, “the reason for the change from conflict to commitment” referred to events that changed nurses’ outlooks on nursing care, their pride as nurses, or their learning experiences. They felt dedicated and conflicted both simultaneously and separately. While committing to their patients’ physical care, nurses were empowered to think positively and treat patients with dignity in spite of the care taking much time and effort, as well as entailing considerable risk.
Tapp, Hazel; Phillips, Shay E; Waxman, Dael; Alexander, Matthew; Brown, Rhett; Hall, Mary
Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.
Mazanec, Susan; Antunez, Antonio; Novak, Louis; Vinkler, Robert; Stark, Bonita; Mangosh, Linda; Pillai, Kunjan; Jackson, Celeste; Wilkenfeld, Bruce
Purpose/Objective: The goals of a carepath are to provide a framework for quality patient care, enhance collaborative practice, improve resource utilization, and increase patient satisfaction. Carepaths are designed to move the patient toward specific clinical outcomes, which have been defined by a multidisciplinary team. Carepaths enhance the quality improvement process by tracking clinical outcomes and patient satisfaction. The purpose of this report is to share the 1996 results of our breast cancer carepath. Methods: In 1994 the multidisciplinary Quality Improvement Committee of the Division of Radiation Oncology constructed a carepath for women with breast cancer receiving breast or chest wall radiation. Eleven clinical outcomes were defined which reflected the educational and selfcare focus of the carepath. Recording on the carepath of patient attainment of the outcomes was done by the RN, RTT and MD. Patient satisfaction tools were designed by the quality improvement committee in conjunction with the Department of Marketing Support. Each patient was given a written survey at two points along the carepath: post simulation and post treatment. Results: Ninety-five women were placed on the breast carepath in 1996. Outcomes were reviewed for 40 of these carepaths. The return rate of patient satisfaction surveys post simulation and post treatment approached 99%. Overall satisfaction was high with 76% of patients feeling 'very satisfied' with the simulation process and 93% 'very satisfied' with the treatment experience. Common themes noted in anecdotes related to comfort and privacy issues. Conclusions: Based on our experience, carepaths facilitated the structuring of a comprehensive and collaborative approach to patient care. Strategies for process improvement were guided by the ongoing surveillance of clinical outcomes and patient satisfaction
van, Claire; McInerney, Patricia; Cooke, Richard
Over the last 20 years, quality improvement in health has become an important strategy in health services in many countries. With the emphasis on quality health care, there has been a shift in social paradigms towards including service users in their own health on different levels. There is growing evidence in literature on the positive impact on health outcomes where patients are active participants in their personal care. There is however less information available on the broader influence of users on improvement in systems. The objective of this review was to identify the barriers and enablers to patients being involved in quality improvement efforts directed towards their own health care. This review considered studies that included adults and children of any age experiencing any health problem.The review considered studies that explored patient or user participation in quality improvement and the factors enabling and hindering this processThe qualitative component of this review considered studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Other texts such as opinion papers and reports were also considered. The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. The searches using all identified keywords and index terms included the databases PubMed, PsycINFO, Medline, Scopus, EBSCOhost and CINAHL.Qualitative, text and opinion papers were considered for inclusion in this review.Closely related concepts like community involvement, family involvement, patients' involvement in their own care (for example, in the case of shared decision making), and patient centeredness in the context of a consultation were excluded. Qualitative and textual papers selected for retrieval were assessed by two independent reviewers for authenticity prior to inclusion in the review using
Full Text Available Jehovah's Witnesses is a religious association, who refuses blood transfusions even in life-threatening conditions. There are several alternative methods, implemented for use with patients that religion, whose task is to reduce the risk of bleeding and hemorrhage in the perioperative period. Good cooperation of the therapeutic team, the selection of appropriate treatment, the use of recommended methods of anesthesia, surgical techniques and proper nursing care with careful monitoring of post-operative complications and quick response if they leave, they contribute to the improvement of health.
Blackberry, Irene D; Furler, John S; Ginnivan, Louise E; Manski-Nankervis, Jo-Anne; Jenkins, Alicia; Cohen, Neale; Best, James D; Young, Doris; Liew, Danny; Ward, Glenn; O'Neal, David N
To evaluate basal and prandial insulin initiation and titration in people with type 2 diabetes mellitus (T2DM) in primary care and to explore the feasibility of retrospective-continuous glucose monitoring (r-CGM) in guiding insulin dosing. The new model of care features General Practitioners (GPs) and Practice Nurses (PNs) working in an expanded role, with Credentialed Diabetes Educator - Registered Nurse (CDE-RN) support. Insulin-naïve T2DM patients (HbA1c >7.5% [>58 mmol/mol] despite maximal oral therapy) from 22 general practices in Victoria, Australia commenced insulin glargine, with glulisine added as required. Each was randomised to receive r-CGM or self-monitoring of blood glucose (SMBG). Glycaemic control (HbA1c) was benchmarked against specialist ambulatory patients referred for insulin initiation. Ninety-two patients mean age (range) 59 (28-77) years; 40% female; mean (SD) diabetes duration 10.5 (6.1) years participated. HbA1c decreased from (median (IQR)) 9.9 (8.8, 11.2)%; 85 (73, 99) mmol/mol to 7.3 (6.9, 7.8)%; 56 (52, 62) mmol/mol at 24 weeks (p < 0.0001). Comparing r-CGM (n = 46) with SMBG (n = 42), there were no differences in major hypoglycaemia (p=0.17) or ΔHbA1c (p = 0.31). More r-CGM than SMBG participants commenced glulisine (26/48 vs. 7/44; p < 0.001). Results were comparable to 82 benchmark patients, with similar low rates of major hypoglycaemia (2/89 vs. 0/82; p = 0.17) and less loss to follow up in the INITIATION group (3/92 vs. 14/82; p = 0.002). Insulin initiation and titration for T2DM patients in primary care was safe and improved HbA1c with low rates of major hypoglycaemia. CDE-RNs were effective in a new consultant role. r-CGM use in primary care was feasible and enhanced post-prandial hyperglycaemia recognition. Trial registration ACTRN12610000797077. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Brown, Jack E; Fominaya, Cory; Christensen, Keith J; McConnell, Scott A; Lamp, Kenneth C
Vancomycin is often the drug of choice in critically ill patients with gram-positive infections, although circumstances often prevent its use. In these situations, clinicians are frequently left with limited data regarding alternative agents. To describe patients with reported sepsis receiving daptomycin in a critical care unit. This multicenter, noncomparative, noninterventional study identified patients in critical care units, using the Cubicin Outcomes Registry and Experience (CORE) 2005-2009 registry. A descriptive account of patient characteristics, infectious etiology, outcomes at the end of daptomycin therapy, and 30-day mortality is reported. Nonevaluable patients were excluded from the efficacy analysis but included in the safety analysis. We identified 128 patients, 98 (77%) of whom were evaluable for efficacy. Patient characteristics for the efficacy population were 55 (56%) males, 30 (31%) aged 66 years or older, 38 (39%) had creatinine clearance less than 30 mL/min, and 27 (28%) were on dialysis. Common underlying diseases included acute or chronic renal failure 44 (45%), hypertension 40 (41%), and diabetes 27 (28%). Seventy-two (73%) patients were bacteremic. The most common pathogens found were methicillin-resistant Staphylococcus aureus (32%), vancomycin-resistant Enterococcus faecium (21%), and coagulase-negative staphylococci (20%). Prior to daptomycin, antibiotics were used in 84 (86%) patients, most commonly vancomycin (65/84; 77%). The median (range) initial daptomycin dose was 6 mg/kg (3-10) and duration of 10 days (1-58). Overall success rate was 70% (31% cured; 39% improved). Twelve adverse events possibly related to daptomycin were reported in 9 of 128 (7%) patients in the safety population; 4 of these in 4 (3%) patients were serious. The mortality rate within 30 days of completing daptomycin was 42 of 128 (33%) patients. These data provide preliminary results on the use of daptomycin in critically ill patients with complicated conditions
Zulman, Donna M.; Asch, Steven M.; Martins, Susana B.; Kerr, Eve A.; Hoffman, Brian B.; Goldstein, Mary K.
Multimorbidity—the presence of multiple chronic conditions in a patient—has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient’s number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relation...
Bao, Yuhua; Casalino, Lawrence P; Pincus, Harold Alan
Discussions of health care delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient-Centered Medical Home, the Health Home initiative within Medicaid, and the Accountable Care Organization. To incorporate behavioral health into health reform, policymakers and practitioners may consider embedding in the reform efforts explicit tools-accountability measures and payment designs-to improve access to and quality of care for patients with behavioral health needs.
Bagger, Bettan; Poulsen, Dorthe Varning; Hørdam, Britta
with partners from hospitals of Naestved and Slagelse, Denmark and University Hospital of Lund, Sweden. Target group: Hip surgery patients, family and network Aim: - Optimizing quality in patients outcomes using an e-health concept - Making patients aware of possibilities for using healthcare across national...... borders - Developing new health technology information to hip surgery patients and their relatives - Innovating an interactive media directed to the target group (ex. age and competencies) Methodology: Identifying the field - Literature study - Interviews for identifying needs for the target groups......Political and cultural visions for health care necessitate the need for transnational resources and services optimizing and supporting patients and their families. The project has its approach in an Interregional Project named Pro-hip. Lead partner is University College Zealand collaborating...
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.
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...
Isabel Cristina Ramos Vieira Santos
Full Text Available This study aimed to describe the treatment of patients with wounds in the Primary Health Care. A descriptive research with quantitative approach. Ninety-three Family Health Units of the city of Recife-PE, Brazil, were selected, and 112 nurses were interviewed from July to December 2011. The record book of bandages and procedures and the dressing form were used as an additional source of data. Frequencies, measures of central tendency and dispersion, prevalence and, for continuous variables, the analysis of variance were estimated. The prevalence of patients with wounds was 1.9% of the estimated covered population. Vascular ulcers accounted for 74.1% of the treated wounds. The dressing was predominantly performed by Nursing technicians, and the products available for this procedure did not match the current technological development.
The Procalcitonin And Survival Study (PASS) - a randomised multi-center investigator-initiated trial to investigate whether daily measurements biomarker Procalcitonin and pro-active diagnostic and therapeutic responses to abnormal Procalcitonin levels, can improve survival in intensive care unit patients. Calculated sample size (target population): 1000 patients
Jensen, Jens-Ulrik; Lundgren, Bettina; Hein, Lars
. Complies with, "Good Clinical Practice" (ICH-GCP Guideline (CPMP/ICH/135/95, Directive 2001/20/EC)). Inclusion: 1) Age > or = 18 years of age, 2) Admitted to the participating intensive care units, 3) Signed written informed consent.Exclusion: 1) Known hyper-bilirubinaemia. or hypertriglyceridaemia, 2...... daily Procalcitonin measurements and immediate diagnostic and therapeutic response on day-to-day changes in procalcitonin can reduce the mortality of critically ill patients. DISCUSSION: For the first time ever, a mortality-endpoint, large scale randomized controlled trial with a biomarker......-guided strategy compared to the best standard of care, is conducted in an Intensive care setting. Results will, with a high statistical power answer the question: Can the survival of critically ill patients be improved by actively using biomarker procalcitonin in the treatment of infections? 700 critically ill...
Soderberg, Karen; Rajamani, Sripriya; Wholey, Douglas; LaVenture, Martin
Minnesota enacted legislation in 2007 that requires all health care providers in the state to implement an interoperable electronic health record (EHR) system by 2015. 100% of hospitals and 98% of clinics had adopted EHR systems by end of 2015. Minnesota's 2008 health reform included a health care home (HCH) program, Minnesota's patient centered medical home. By end of 2014, 43% of HCH eligible clinics were certified with 335 certified HCHs and 430 eligible but not certified clinics. To study the association between adoption and use of EHRs in primary care clinics and HCH certification, including use of clinical decision support tools, patient registries, electronic exchange of patient information, and availability of patient portals. Study utilized data from the 2015 Minnesota Health Information Technology Clinic Survey conducted annually by the Minnesota Department of Health. The response rate was 80% with 1,181 of 1,473 Minnesota clinics, including 662 HCH eligible primary care clinics. The comparative analysis focused on certified HCHs (311) and eligible but not certified clinics (351). HCH clinics utilized the various tools of EHR technology at a higher rate than non-HCH clinics. This greater utilization was noted across a range of functionalities: clinical decision support, patient disease registries, EHR to support quality improvement, electronic exchange of summary care records and availability of patient portals. HCH certification was significant for clinical decision support tools, registries and quality improvement. HCH requirements of care management, care coordination and quality improvement can be better supported with EHR technology, which underscores the higher rate of utilization of EHR tools by HCH clinics. Optimizing electronic exchange of health information remains a challenge for all clinics, including HCH certified clinics. This research presents the synergy between complementary initiatives supporting EHR adoption and HCH certification
Klein, Dawn M; Pham, Kassi; Samy, Leila; Bluth, Adam; Nazi, Kim M; Witry, Matthew; Klutts, J Stacey; Grant, Kathleen M; Gundlapalli, Adi V; Kochersberger, Gary; Pfeiffer, Laurie; Romero, Sergio; Vetter, Brian; Turvey, Carolyn L
Information continuity is critical to person-centered care when patients receive care from multiple healthcare systems. Patients can access their electronic health record data through patient portals to facilitate information exchange. This pilot was developed to improve care continuity for rural Veterans by (1) promoting the use of the Department of Veterans Affairs (VA) patient portal to share health information with non-VA providers, and (2) evaluating the impact of health information sharing at a community appointment. Veterans from nine VA healthcare systems were trained to access and share their VA Continuity of Care Document (CCD) with their non-VA providers. Patients and non-VA providers completed surveys on their experiences. Participants (n = 620) were primarily older, white, and Vietnam era Veterans. After training, 78% reported the CCD would help them be more involved in their healthcare and 86% planned to share it regularly with non-VA providers. Veterans (n = 256) then attended 277 community appointments. Provider responses from these appointments (n = 133) indicated they were confident in the accuracy of the information (97%) and wanted to continue to receive the CCD (96%). Ninety percent of providers reported the CCD improved their ability to have an accurate medication list and helped them make medication treatment decisions. Fifty percent reported they did not order a laboratory test or another procedure because of information available in the CCD. This pilot demonstrates feasibility and value of patient access to a CCD to facilitate information sharing between VA and non-VA providers. Outreach and targeted education are needed to promote consumer-mediated health information exchange.
Dundon, John M; Bosco, Joseph; Slover, James; Yu, Stephen; Sayeed, Yousuf; Iorio, Richard
In January 2013, a large, tertiary, urban academic medical center began participation in the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty, a program implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011. Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 were included. We participated in BPCI Model 2, by which an episode of care includes the inpatient and all post-acute care costs through 90 days following discharge. The goal for this initiative is to improve patient care and quality through a patient-centered approach with increased care coordination supported through payment innovation. Length of stay (LOS), readmissions, discharge disposition, and cost per episode of care were analyzed for year 3 compared with year 1 of the initiative. Multiple programs were implemented after the first year to improve performance metrics: a surgeon-directed preoperative risk-factor optimization program, enhanced care coordination and home services, a change in venous thromboembolic disease (VTED) prophylaxis to a risk-stratified protocol, infection-prevention measures, a continued emphasis on discharge to home rather than to an inpatient facility, and a quality-dependent gain-sharing program among surgeons. There were 721 Medicare primary total joint arthroplasty patients in year 1 and 785 in year 3; their data were compared. The average hospital LOS decreased from 3.58 to 2.96 days. The rate of discharge to an inpatient facility decreased from 44% to 28%. The 30-day all-cause readmission rate decreased from 7% to 5%; the 60-day all-cause readmission rate decreased from 11% to 6%; and the 90-day all-cause readmission rate decreased from 13% to 8%. The average 90-day cost per episode decreased by 20%. Mid-term results from the implementation of Medicare BPCI Model 2 for primary total joint arthroplasty demonstrated decreased LOS, decreased discharges to inpatient facilities, decreased readmissions, and
Vaag, Allan; Lund, Søren
This review addresses the apparent disconnect between international guideline recommendations, real-life clinical practice and the results of clinical trials, with regard to the initiation of insulin using basal (long-acting) or premixed insulin analogues in patients with type 2 diabetes (T2D...... and monitoring regimens. Enforced intensification of unrealistic complex treatment regimens and glycaemic targets may theoretically worsen the psychological well-being in some patients. More simple and sustainable treatment regimens and guidelines are urgently needed. As for the use of insulin in T2D...
Faeda, Marília Silveira; Perroca, Márcia Galan
analyze agreement between nursing prescriptions recorded in medical files and patients' care needs; investigate the correlation between the nurses' professional background and agreement of prescriptions. descriptive study with quantitative and documentary approach conducted in the medical clinic, surgical, and specialized units of a university hospital in the interior of São Paulo, Brazil. The new validated version of a Patient Classification Instrument was used and 380 nursing prescriptions written at the times of hospital admission and discharge were assessed. 75% of the nursing prescriptions items were compatible with the patients' care needs. Only low correlation between nursing prescription agreement and professional background was found. the nursing prescriptions did not fully meet the care needs of patients. The care context and work process should be analyzed to enable more effective prescriptions, while strategies to assess the care needs of patients are recommended. analisar a concordância entre prescrições de enfermagem, registradas nos prontuários, e as necessidades de cuidados dos pacientes; investigar a correlação entre o perfil profissional dos enfermeiros e a concordância das prescrições. estudo descritivo com abordagem quantitativa e documental, realizado em unidades de clínica médica, cirúrgica e especializada de um hospital de ensino, no interior do Estado de São Paulo. Foi aplicada a nova versão validada do Instrumento de Classificação de Pacientes e, posteriormente, investigadas 380 prescrições de enfermagem no momento da admissão e alta hospitalar. foi identificado que 75% dos itens das prescrições de enfermagem estavam compatíveis com as necessidades cuidativas dos pacientes. Encontrou-se baixa correlação entre a concordância da prescrição de enfermagem e o perfil profissional. as prescrições de enfermagem não estão sendo realizadas, em sua totalidade, em consonância com as necessidades dos pacientes. Para
Transgender and gender-nonconforming individuals experience significant health disparities. They are more likely to use drugs and alcohol, smoke, be diagnosed with HIV infection or other sexually transmitted infections, and experience depression or attempt suicide. Many also experience discrimination within the health care system. Office-level strategies to create a safe and affirming space for gender-expansive patients include posting of a nondiscrimination statement, use of intake forms that ask about current gender identity and birth-assigned sex, provision of gender-neutral restrooms, and staff training in use of appropriate language. Hormone or surgical therapy can be initiated for patients with persistent gender dysphoria who are of age and have the capacity to make informed decisions, and have reasonable control of coexisting medical and psychiatric conditions. Estrogens, antiandrogens, and progestins are used for feminization, and testosterone for masculinization. Hormone treatment should be followed by careful monitoring for potential adverse effects. Surgical options include male-to-female and female-to-male procedures. The family physician may need to provide a referral letter, preoperative and postoperative examinations and care, and advocacy with health insurance providers. Preventive care for transgender patients includes counseling for cardiovascular health, cancer screening, provision of appropriate contraception, and screening for sexually transmitted infections. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.
Full Text Available Regulation of the Minister of Health dated 20/12/2012 on medical standards of conduct in the field of Anaesthesiology and intensive therapy, for carrying out the activities of healing in section § 2.2 intense therapy defines as: "any proceedings to maintain vital functions, and treatment of patients in life-threatening States, caused by potentially reversible renal failure one or more basic body systems, in particular the respiration, cardiovascular, central nervous system". However, in point § 12.1. We read that "Treatment of patients under intensive care in the hospital is an interdisciplinary". Annex 1 to this regulation refers to the work of physiotherapist in the ICU (INTENSIVE CARE UNITS and reads as follows: "the equivalent of at least 0.5 FTE-physical therapist-up to a range of benefits to be performed (the third reference level". [6
Simon, Harold; Mykolow, Grégory; Guyodo, Josselin
The management of a suicidal crisis falls within the scope of nursing care. There is a high rate of recurrence in the months following an attempted suicide. The nurse monitoring strategy, based on the principle of the 'recontacting' of patients, has been tested by the team of a post-emergency psychiatric unit of a university hospital. Copyright © 2017. Published by Elsevier Masson SAS.
Edward R Cachay
Full Text Available The aims were to investigate the hepatitis C (HCV cascade of care among HIV-infected patients and to identify reasons for not referring for and not initiating HCV therapy after completion of HCV treatment staging.Retrospective cohort analysis of HIV-infected patients under care at the University of California, San Diego (UCSD. We identified patients screened for and diagnosed with active HCV infection. Logistic regression analyses were used to identify factors associated with lack of referral for HCV therapy. Electronic medical records were reviewed to ascertain reasons for not initiating HCV therapy.Between 2008 and 2012, 4725 HIV-infected patients received care at the UCSD Owen clinic. Most patients [4534 (96%] were screened for HCV, 748 (16% patients had reactive serum HCV antibodies but only 542 patients had active HCV infection. Lack of engagement in care was the most important predictor of non-referral for HCV therapy [odds ratio (OR: 5.08, 95% confidence interval 3.24-6.97, p<0.00001]. Other significant predictors included unstable housing (OR: 2.26, AIDS (OR: 1.83, having a detectable HIV viral load (OR: 1.98 and being non-white (OR: 1.67. The most common reason (40% for not initiating or deferring HCV therapy was the presence of ongoing barriers to care.Screening for HCV in HIV-infected patients linked to care is high but almost half of patients diagnosed with HCV are not referred for HCV therapy. Despite improvements in HCV therapy the benefits will not be realized unless effective measures for dealing with barriers to care are implemented.
Basavatia, Amar; Fret, Jose; Lukaj, Alex; Kuo, Hsiang; Yaparpalvi, Ravindra; Tome, Wolfgang A; Kalnicki, Shalom
To implement a biometric patient identification system in the field of radiation oncology. A biometric system using palm vein scanning technology has been implemented to ensure the delivery of treatment to the correct patient each and every time. By interfacing a palm vein biometrics system (PVBS) (PatientSecure®, Imprivata, Lexington, Massachusetts) with the radiation oncology patient management system (ROPMS) (ARIA®, Varian Medical Systems, Palo Alto, California) one can integrate patient check-in at the front desk and identify and open the correct treatment record of the patient at the point of care prior to the initiation of the radiation therapy treatment. The learning time for the use of the software and palm scanner was extremely short. The staff at the front desk and treatment machines learned the procedures to use, clean, and care for the device in one hour's time. The first key to the success of the system is to have a policy and procedure in place; such a procedure was created and put in place in the department from the first day. The second key to the success is the actual hand placement on the scanner. Learning the proper placement and gently reminding patients from time to time was found to be efficient and to work well. The use of a biometric patient identification system employing palm vein technology allows one to ensure that the right care is delivered to the right patient each and every time. Documentation through the PVBS database now exists to show that this has taken place.
Vivó, C; Galeiras, R; del Caz, Ma D P
The major improvement in burn therapy is likely to focus on the early management of hemodynamic and respiratory failures in combination with an aggressive and early surgical excision and skin grafting for full-thickness burns. Immediate burn care by first care providers is important and can vastly alter outcomes, and it can significantly limit burn progression and depth. The goal of prehospital care should be to cease the burning process as well as prevent future complications and secondary injuries for burn shock. Identifying burn patients appropriate for immediate or subacute transfer is an important step in reducing morbidity and mortality. Delays in transport to Burn Unit should be minimized. The emergency management follows the principles of the Advanced Trauma Life Support Guidelines for assessment and stabilization of airway, breathing, circulation, disability, exposure and environment control. All patients with suspected inhalation injury must be removed from the enclosure as soon as possible, and immediately administer high-flow oxygen. Any patient with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in the oral cavity, and history of being in a fire in an enclosed space should be strongly considered for early intubation. Fibroscopy may also be useful if airway damage is suspected and to assess known lung damage. Secondary evaluation following admission to the Burn Unit of a burned patient suffering a severe thermal injury includes continuation of respiratory support and management and treatment of inhalation injury, fluid resuscitation and cardiovascular stabilization, pain control and management of burn wound. Copyright © 2015 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.
In 2005, two physicians, former NASA astronauts, created LifeWings Partners LLC in Memphis, Tennessee and began using Crew Resource Management (CRM) techniques developed at Ames Research Center in the 1970s to help improve safety and efficiency at hospitals. According to the company, when hospitals follow LifeWings? training, they can see major improvements in a number of areas, including efficiency, employee satisfaction, operating room turnaround, patient advocacy, and overall patient outcomes. LifeWings has brought its CRM training to over 90 health care organizations and annual sales have remained close to $3 million since 2007.
Aakre, Kenneth T; Valley, Timothy B; O'Connor, Michael K
Lean Six Sigma process improvement methodologies have been used in manufacturing for some time. However, Lean Six Sigma process improvement methodologies also are applicable to radiology as a way to identify opportunities for improvement in patient care delivery settings. A multidisciplinary team of physicians and staff conducted a 100-day quality improvement project with the guidance of a quality advisor. By using the framework of DMAIC (define, measure, analyze, improve, and control), time studies were performed for all aspects of patient and technologist involvement. From these studies, value stream maps for the current state and for the future were developed, and tests of change were implemented. Comprehensive value stream maps showed that before implementation of process changes, an average time of 20.95 minutes was required for completion of a bone densitometry study. Two process changes (ie, tests of change) were undertaken. First, the location for completion of a patient assessment form was moved from inside the imaging room to the waiting area, enabling patients to complete the form while waiting for the technologist. Second, the patient was instructed to sit in a waiting area immediately outside the imaging rooms, rather than in the main reception area, which is far removed from the imaging area. Realignment of these process steps, with reduced technologist travel distances, resulted in a 3-minute average decrease in the patient cycle time. This represented a 15% reduction in the initial patient cycle time with no change in staff or costs. Radiology process improvement projects can yield positive results despite small incremental changes.
Yelena V. Skryabina
Full Text Available Recently, akanthamoeba keratitis (AK is seen more and more often in ophthalmological practice. However, today there are no standard guidelines concerning diagnosis and treatment of patients with AK. In the article, the experience in care for such patients is presented. Purpose: to estimate the efficiency of diagnosis and treatment of patients with AK. Materials and methods. Case histories of patients, who received treatment for akanthamoeba keratitis in the Eye Microsurgery Department No. 4, City Ophthalmologic Center of the City Hospital No. 2, from 2011 to 2016, were analyzed. Under observation, there were 25 patients (26 eyes with akanthamoeba keratitis aged from 18 to 77 years; there were 15 men and 10 women. Patients were observed during 1 year. Full ophthalmologic examination was conducted in all patients. Additional diagnostic methods included microbiological investigation of corneal scrapes and washings, culturing them on innutritious agar (with E. сoli covering, confocal corneal microscopy (HRT 3 with cornea module, Heidelberg Retina Tomograph Rostock Cornea Module. A superficial punctate keratits (AK stage 2 was found in one patient. All other patients were divided into two groups. Stromal ring-shaped keratitis was diagnosed in patients of the first group (7 patients, AK stage 3. The 2nd group consisted of 17 patients with corneal ulcer (AK stage 4. All patients received medicamentous treatment. However patients of the 2nd group required different kinds of surgical treatment. Results. In AK diagnosis, corneal confocal microscopy is the most informative method. In patients with AK stages 2 and 3, there was an improvement in visual functions as a result of medicamentous therapy. As a result of treatment at the discharge from the hospital, the best corrected visual acuity was 0.5-1.0 for most patients. In the 2nd group patients, who were subjects to different types of surgical treatment visual functions stabilized. However non
Wüller, Johannes; Küttner, Stefanie; Foldenauer, Ann Christina; Rolke, Roman; Pastrana, Tania
Our aim was to examine the accuracy of the German version of the Distress Thermometer (DT) compared with the Hospital Anxiety and Depression Scale (HADS) in patients with palliative care needs living at home. Ours was a 15-month cross-sectional study beginning in September of 2013 in Germany with consecutive patients cared for by a palliative home care service. The survey was implemented during the initial visit by a home care team. Patients were excluded if they were under 18 years of age, mentally or physically unable to complete the assessment questionnaires as judged by their healthcare worker, or unable to understand the German language. During the first encounter, the DT and HADS were applied, and sociodemographic and medical data were collected. A total of 89 persons completed both the HADS and DT questionnaires (response rate = 59.7%; mean age = 67 years; female = 55.1%; married = 65.2%; living home with relatives = 73.0%; oncological condition = 92.1%; Karnofsky Performance Scale [KPS] score: 0-40 = 30.3%, 50-70 = 57.3%, >80 = 6.7%). The mean DT score was 6.3 (±2.3), with 84.3% of participants scoring above the DT cutoff (≥4). The mean HADStotal score was 17.9 (±7.8), where 64% of participants had a total HADS score (HADStotal) ≥15, 51.7% reported anxiety (HADSanxiety ≥ 8), and 73% reported depression (HADSdepression ≥ 8). Using the HADS as a gold standard, a DT cutoff score ≥5 was optimal for identifying severe distress in patients with palliative care needs, with a sensitivity of 93.0%, a specificity of 34.4%, a positive predictive value (PPV) of 73.3%, and likelihood ratios LR+ = 1.42 (home with palliative care needs in order to offer adequate support.
Bede, Peter; Oliver, David; Stodart, James; van den Berg, Leonard; Simmons, Zachary; O Brannagáin, Doiminic; Borasio, Gian Domenico; Hardiman, Orla
Amyotrophic lateral sclerosis (ALS) is a relentlessly progressive neurodegenerative condition. Optimal management requires a palliative approach from diagnosis with emphasis on patient autonomy, dignity and quality of life. To conduct a systematic analysis of the type, level and timing of specialist palliative care intervention in ALS. Despite an international consensus that ALS management should adopt a multidisciplinary approach, integration of palliative care into ALS management varies considerably across health care systems. Late referral to palliative services in ALS is not uncommon and may impact negatively on the quality of life of ALS patients and their caregivers. However, common themes and principles of engagement can be identified across different jurisdictions, and measurement systems have been established that can assess the impact of palliative care intervention. There is considerable evidence that palliative care intervention improves quality of life in patients and carers. International consensus guidelines would assist in the development of a framework for active palliative care engagement in ALS and other neurodegenerative diseases.
Full Text Available Parkinson's disease (PD is a neurodegenerative disease that affects the motor system and cognitive and behavioral functions. Due to these impairments, PD patients also have problems in using the computer. However, using computers and the Internet could help these patients to overcome social isolation and enhance information search. Specifically, avatars (defined as virtual representations of humans are increasingly used in online environments to enhance human-computer interaction by simulating face-to-face interaction. Our laboratory experiment investigated how PD patients behave in a trust game played with human and avatar counterparts, and we compared this behavior to the behavior of age, income, education and gender matched healthy controls. The results of our study show that PD patients trust avatar faces significantly more than human faces. Moreover, there was no significant difference between initial trust of PD patients and healthy controls in avatar faces, while PD patients trusted human faces significantly less than healthy controls. Our data suggests that PD patients' interaction with avatars may constitute an effective way of communication in situations in which trust is required (e.g., a physician recommends intake of medication. We discuss the implications of these results for several areas of human-computer interaction and neurological research.
Simoens, Steven; Kutten, Betty; Keirse, Emmanuel; Berghe, Paul Vanden; Beguin, Claire; Desmedt, Marianne; Deveugele, Myriam; Léonard, Christian; Paulus, Dominique; Menten, Johan
In addition to the effectiveness of hospital care models for terminal patients, policy makers and health care payers are concerned about their costs. This study aims to measure the hospital costs of treating terminal patients in Belgium from the health care payer perspective. Also, this study compares the costs of palliative and usual care in different types of hospital wards. A multicenter, retrospective cohort study compared costs of palliative care with usual care in acute hospital wards and with care in palliative care units. The study enrolled terminal patients from a representative sample of hospitals. Health care costs included fixed hospital costs and charges relating to medical fees, pharmacy and other charges. Data sources consisted of hospital accountancy data and invoice data. Six hospitals participated in the study, generating a total of 146 patients. The findings showed that palliative care in a palliative care unit was more expensive than palliative care in an acute ward due to higher staffing levels in palliative care units. Palliative care in an acute ward is cheaper than usual care in an acute ward. This study suggests that palliative care models in acute wards need to be supported because such care models appear to be less expensive than usual care and because such care models are likely to better reflect the needs of terminal patients. This finding emphasizes the importance of the timely recognition of the need for palliative care in terminal patients treated in acute wards.
Uijen, Annemarie A.; Schers, Henk J.; Schene, Aart H.; Schellevis, Francois G.; Lucassen, Peter; van den Bosch, Wil J. H. M.
Existing studies about continuity of care focus on patients with a severe mental illness. Explore the level of experienced continuity of care of patients at risk for depression in primary care, and compare these to those of patients with heart failure. Explorative study comparing patients at risk
Weiss, Daniel J; Turner, Leigh; Levine, Aaron D; Ikonomou, Laertis
Businesses marketing unproven stem cell interventions proliferate within the U.S. and in the larger global marketplace. There have been global efforts by scientists, patient advocacy groups, bioethicists, and public policy experts to counteract the uncontrolled and premature commercialization of stem cell interventions. In this commentary, we posit that medical societies and associations of health care professionals have a particular responsibility to be an active partner in such efforts. We review the role medical societies can and should play in this area through patient advocacy and awareness initiatives. Copyright © 2017 International Society for Cellular Therapy. Published by Elsevier Inc. All rights reserved.
The Procalcitonin And Survival Study (PASS) – A Randomised multi-center investigator-initiated trial to investigate whether daily measurements biomarker Procalcitonin and pro-active diagnostic and therapeutic responses to abnormal Procalcitonin levels, can improve survival in intensive care unit patients. Calculated sample size (target population): 1000 patients
Jensen, Jens-Ulrik; Lundgren, Bettina; Hein, Lars; Mohr, Thomas; Petersen, Pernille L; Andersen, Lasse H; Lauritsen, Anne Ø; Hougaard, Sine; Mantoni, Teit; Bømler, Bonnie; Thornberg, Klaus J; Thormar, Katrin; Løken, Jesper; Steensen, Morten; Carl, Peder; Petersen, J Asger; Tousi, Hamid; Søe-Jensen, Peter; Bestle, Morten; Hestad, Søren; Andersen, Mads H; Fjeldborg, Paul; Larsen, Kim M; Rossau, Charlotte; Thomsen, Carsten B; Østergaard, Christian; Kjær, Jesper; Grarup, Jesper; Lundgren, Jens D
Background Sepsis and complications to sepsis are major causes of mortality in critically ill patients. Rapid treatment of sepsis is of crucial importance for survival of patients. The infectious status of the critically ill patient is often difficult to assess because symptoms cannot be expressed and signs may present atypically. The established biological markers of inflammation (leucocytes, C-reactive protein) may often be influenced by other parameters than infection, and may be unacceptably slowly released after progression of an infection. At the same time, lack of a relevant antimicrobial therapy in an early course of infection may be fatal for the patient. Specific and rapid markers of bacterial infection have been sought for use in these patients. Methods Multi-centre randomized controlled interventional trial. Powered for superiority and non-inferiority on all measured end points. Complies with, "Good Clinical Practice" (ICH-GCP Guideline (CPMP/ICH/135/95, Directive 2001/20/EC)). Inclusion: 1) Age ≥ 18 years of age, 2) Admitted to the participating intensive care units, 3) Signed written informed consent. Exclusion: 1) Known hyper-bilirubinaemia. or hypertriglyceridaemia, 2) Likely that safety is compromised by blood sampling, 3) Pregnant or breast feeding. Computerized Randomisation: Two arms (1:1), n = 500 per arm: Arm 1: standard of care. Arm 2: standard of care and Procalcitonin guided diagnostics and treatment of infection. Primary Trial Objective: To address whether daily Procalcitonin measurements and immediate diagnostic and therapeutic response on day-to-day changes in procalcitonin can reduce the mortality of critically ill patients. Discussion For the first time ever, a mortality-endpoint, large scale randomized controlled trial with a biomarker-guided strategy compared to the best standard of care, is conducted in an Intensive care setting. Results will, with a high statistical power answer the question: Can the survival of critically ill
The Procalcitonin And Survival Study (PASS – A Randomised multi-center investigator-initiated trial to investigate whether daily measurements biomarker Procalcitonin and pro-active diagnostic and therapeutic responses to abnormal Procalcitonin levels, can improve survival in intensive care unit patients. Calculated sample size (target population: 1000 patients
Full Text Available Abstract Background Sepsis and complications to sepsis are major causes of mortality in critically ill patients. Rapid treatment of sepsis is of crucial importance for survival of patients. The infectious status of the critically ill patient is often difficult to assess because symptoms cannot be expressed and signs may present atypically. The established biological markers of inflammation (leucocytes, C-reactive protein may often be influenced by other parameters than infection, and may be unacceptably slowly released after progression of an infection. At the same time, lack of a relevant antimicrobial therapy in an early course of infection may be fatal for the patient. Specific and rapid markers of bacterial infection have been sought for use in these patients. Methods Multi-centre randomized controlled interventional trial. Powered for superiority and non-inferiority on all measured end points. Complies with, "Good Clinical Practice" (ICH-GCP Guideline (CPMP/ICH/135/95, Directive 2001/20/EC. Inclusion: 1 Age ≥ 18 years of age, 2 Admitted to the participating intensive care units, 3 Signed written informed consent. Exclusion: 1 Known hyper-bilirubinaemia. or hypertriglyceridaemia, 2 Likely that safety is compromised by blood sampling, 3 Pregnant or breast feeding. Computerized Randomisation: Two arms (1:1, n = 500 per arm: Arm 1: standard of care. Arm 2: standard of care and Procalcitonin guided diagnostics and treatment of infection. Primary Trial Objective: To address whether daily Procalcitonin measurements and immediate diagnostic and therapeutic response on day-to-day changes in procalcitonin can reduce the mortality of critically ill patients. Discussion For the first time ever, a mortality-endpoint, large scale randomized controlled trial with a biomarker-guided strategy compared to the best standard of care, is conducted in an Intensive care setting. Results will, with a high statistical power answer the question: Can the survival
Lu, Yueh-An; Lee, Shen-Yang; Lin, Hui-Yi; Liu, Yen-Chun; Kao, Huang-Kai; Chen, Yung-Chang; Tian, Ya-Chung; Hung, Cheng-Chieh; Yang, Chih-Wei; Hsu, Hsiang-Hao
Reconsidering when to initiate renal replacement therapy (RRT) in patients with chronic kidney disease (CKD) has been emphasized recently. With evolving modern aged and diabetes-prone populations, conventional markers of uremia are not sufficient for determining the optimal timing for dialysis initiation. This retrospective cohort study examined the association between hyperphosphatemia and uremic patients who need RRT registration. All patients from the department of nephrology in one tertiary medical center in northern Taiwan who had advanced CKD and estimated glomerular filtration rates regression models were used to identify factors associated with hemodialysis initiation decision making. During the study period, 209 of 292 patients with advanced CKD were enrolled in hemodialysis program and 83 patients (controls) were not. Univariable analysis indicated that male sex, current smoking, diabetes mellitus, hypertension, coronary artery disease, high serum creatinine level, and high serum phosphate level were associated with initiation of hemodialysis. Multivariable analysis indicated that those with higher serum phosphate level (odds ratio [OR] = 2.4, 95% confidence interval [CI] = 1.6-3.5, p = 1.4 × 10(-5)) and being in nephrology care for <12 months (OR = 0.4, 95% CI = 0.2-0.8, p = 0.016) tended to be significant markers for hemodialysis initiation. Hyperphosphatemia, in addition to conventional laboratory markers and uremic symptoms, may be a useful marker to determine timing of hemodialysis initiation in patients with advanced CKD. Copyright © 2016 Chang Gung University. Published by Elsevier B.V. All rights reserved.
Ganz, Patricia A; Yip, Cheng Har; Gralow, Julie R; Distelhorst, Sandra R; Albain, Kathy S; Andersen, Barbara L; Bevilacqua, Jose Luiz B; de Azambuja, Evandro; El Saghir, Nagi S; Kaur, Ranjit; McTiernan, Anne; Partridge, Ann H; Rowland, Julia H; Singh-Carlson, Savitri; Vargo, Mary M; Thompson, Beti; Anderson, Benjamin O
Breast cancer survivors may experience long-term treatment complications, must live with the risk of cancer recurrence, and often experience psychosocial complications that require supportive care services. In low- and middle-income settings, supportive care services are frequently limited, and program development for survivorship care and long-term follow-up has not been well addressed. As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert panel identified nine key resources recommended for appropriate survivorship care, and developed resource-stratified recommendations to illustrate how health systems can provide supportive care services for breast cancer survivors after curative treatment, using available resources. Key recommendations include health professional education that focuses on the management of physical and psychosocial long-term treatment complications. Patient education can help survivors transition from a provider-intense cancer treatment program to a post-treatment provider partnership and self-management program, and should include: education on recognizing disease recurrence or metastases; management of treatment-related sequelae, and psychosocial complications; and the importance of maintaining a healthy lifestyle. Increasing community awareness of survivorship issues was also identified as an important part of supportive care programs. Other recommendations include screening and management of psychosocial distress; management of long-term treatment-related complications including lymphedema, fatigue, insomnia, pain, and women's health issues; and monitoring survivors for recurrences or development of second primary malignancies. Where possible, breast cancer survivors should implement healthy lifestyle modifications, including physical activity, and maintain a healthy weight. Health professionals should provide well-documented patient care records that can follow a patient as they transition from active treatment
Kjørstad, Odd Jarle; Haugen, Dagny Faksvåg
The criteria for refraining from cardiopulmonary resuscitation in palliative care cancer patients are based on patients' right to refuse treatment and the duty of the treating personnel not to exacerbate their suffering and not to administer futile treatment. When is cardiopulmonary resuscitation futile in these patients? Systematic literature searches were conducted in PubMed for the period 1989-2010 on the results of in-hospital cardiopulmonary resuscitation in advanced cancer patients and on factors that affected the results of CPR when special mention was made of cancer. The searches yielded 333 hits and 18 included articles: four meta-analyses, eight retrospective clinical studies, and six review articles. Cancer patients had a poorer post-CPR survival than non-cancer patients. Survival declined with increasing extent of the cancer disease. Widespread and therapy-resistant cancer disease coupled with a performance status lower than WHO 2 or a PAM score (Pre-Arrest Morbidity Index) of above 8 was regarded as inconsistent with survival after cardiopulmonary resuscitation. Cardiopulmonary resuscitation is futile for in-hospital cancer patients with widespread incurable disease and poor performance status.
Full Text Available Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a “human face” to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.
Thomsen, Thordis; Vester-Andersen, Morten; Nielsen, Martin Vedel
AIMS AND OBJECTIVES: To elicit knowledge of patient experiences of postoperative intermediate care in an intensive care unit and standard postoperative care in a surgical ward after emergency abdominal surgery. BACKGROUND: Emergency abdominal surgery is common, but little is known about how patie......, intermediate care patients felt hindered in doing so by continuous monitoring of vital signs. RELEVANCE TO CLINICAL PRACTICE: Intermediate care may increase patient perceptions of quality and safety of care.......AIMS AND OBJECTIVES: To elicit knowledge of patient experiences of postoperative intermediate care in an intensive care unit and standard postoperative care in a surgical ward after emergency abdominal surgery. BACKGROUND: Emergency abdominal surgery is common, but little is known about how...... patients experience postoperative care. The patient population is generally older with multiple comorbidities, and the short-term postoperative mortality rate is 15-20%. Thus, vigilant surgeon and nursing attention is essential. The present study is a qualitative sub-study of a randomised trial evaluating...
Borel, Anne-Laure; Schwebel, Carole; Planquette, Benjamin; Vésin, Aurélien; Garrouste-Orgeas, Maité; Adrie, Christophe; Clec'h, Christophe; Azoulay, Elie; Souweine, Bertrand; Allaouchiche, Bernard; Goldgran-Toledano, Dany; Jamali, Samir; Darmon, Michael; Timsit, Jean-François
A high catabolic rate characterizes the acute phase of critical illness. Guidelines recommend an early nutritional support, regardless of the previous nutritional status. We aimed to assess whether the nutritional status of patients, which was defined by the body mass index (BMI) at admission in an intensive care unit (ICU), affected the time of nutritional support initiation. We conducted a cohort study that reported a retrospective analysis of a multicenter ICU database (OUTCOMEREA) by using data prospectively entered from January 1997 to October 2012. Patients who needed orotracheal intubation within the first 72 h and >3 d were included. Data from 3257 ICU stays were analyzed. The delay before feeding was different according to BMI groups (P = 0.035). The delay was longer in obese patients [BMI (in kg/m²) ≥30; n = 663] than in other patients with either low weight (BMI nutritional status and a delay in nutrition initiation was independent of potential confounding factors such as age, sex, and diabetes or other chronic diseases. In comparison with normal weight, the adjusted RR (95% CI) associated with a delayed nutrition initiation was 0.92 (0.86, 0.98) for patients with low weight, 1.00 (0.94, 1.05) for overweight patients, and 1.06 (1.00, 1.12) for obese patients (P = 0.004). The initiation of nutritional support was delayed in obese ICU patients. Randomized controlled trials that address consequences of early compared with delayed beginnings of nutritional support in critically ill obese patients are needed. © 2014 American Society for Nutrition.
Main goal of the thesis was to map out the specifics of nursing care for a patient with a nutritious stoma. Three research questions have been identified in connection to this goal. First research question was focused on mapping out the nursing care for a patient prior applying the nutritious stoma. Second research question was focusing on nursing care for a patient while the nutritious stoma is being applied, and the last third question researches the nursing care for a patient after applyin...
Wickson-Griffiths, Abigail; Kaasalainen, Sharon; Brazil, Kevin; McAiney, Carrie; Crawshaw, Diane; Turner, Mickey; Kelley, Mary Lou
This article reports a pilot evaluation of Comfort Care Rounds (CCRs)--a strategy for addressing long-term care home staff's palliative and end-of-life care educational and support needs. Using a qualitative descriptive design, semistructured individual and focus group interviews were conducted to understand staff members' perspectives and feedback on the implementation and application of CCRs. Study participants identified that effective advertising, interest, and assigning staff to attend CCRs facilitated their participation. The key barriers to their attendance included difficulty in balancing heavy workloads and scheduling logistics. Interprofessional team member representation was sought but was not consistent. Study participants recognized the benefits of attending; however, they provided feedback on how the scheduling, content, and focus could be improved. Overall, study participants found CCRs to be beneficial to their palliative and end-of-life care knowledge, practice, and confidence. However, they identified barriers and recommendations, which warrant ongoing evaluation. Copyright 2015, SLACK Incorporated.
Wong, Sabrina T; Lynam, M Judith; Khan, Koushambhi B; Scott, Lorine; Loock, Christine
The Responsive Interdisciplinary Child-Community Health Education and Research (RICHER) initiative is an intersectoral and interdisciplinary community outreach primary health care (PHC) model. It is being undertaken in partnership with community based organizations in order to address identified gaps in the continuum of health services delivery for 'at risk' children and their families. As part of a larger study, this paper reports on whether the RICHER initiative is associated with increased: 1) access to health care for children and families with multiple forms of disadvantage and 2) patient-reported empowerment. This study provides the first examination of a model of delivering PHC, using a Social Paediatrics approach. This was a mixed-methods study, using quantitative and qualitative approaches; it was undertaken in partnership with the community, both organizations and individual providers. Descriptive statistics, including logistic regression of patient survey data (n=86) and thematic analyses of patient interview data (n=7) were analyzed to examine the association between patient experiences with the RICHER initiative and parent-reported empowerment. Respondents found communication with the provider clear, that the provider explained any test results in a way they could understand, and that the provider was compassionate and respectful. Analysis of the survey and in-depth interview data provide evidence that interpersonal communication, particularly the provider's interpersonal style (e.g., being treated as an equal), was very important. Even after controlling for parents' education and ethnicity, the provider's interpersonal style remained positively associated with parent-reported empowerment (p<0.01). This model of PHC delivery is unique in its purposeful and required partnerships between health care providers and community members. This study provides beginning evidence that RICHER can better meet the health and health care needs of people, especially
Slort, W; Schweitzer, B P M; Blankenstein, A H; Abarshi, E A; Riphagen, I I; Echteld, M A; Aaronson, N K; van der Horst, He; Deliens, L
While effective general practitioner (GP)-patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed to identify barriers and facilitators for GP-patient communication in palliative care. In a systematic review seven computerized databases were searched to find empirical studies on GP-patient communication in palliative care. Fifteen qualitative studies and seven quantitative questionnaire studies were included. The main perceived barriers were GPs' lack of availability, and patients' and GPs' ambivalence to discuss 'bad prognosis'. Main perceived facilitators were GPs being available, initiating discussion about several end-of-life issues and anticipating various scenarios. Lack of availability and failure to discuss former mistakes appear to be blind spots of GPs. GPs should be more forthcoming to initiate discussions with palliative care patients about prognosis and end-of-life issues. Empirical studies are needed to investigate the effectiveness of the perceived barriers and facilitators.
The field of critical care has changed markedly in recent years to accommodate a growing population of chronically critically ill patients. New administrative structures have evolved to include divisions, departments, and sections devoted exclusively to the practice of critical care medicine. On an individual level, the ability to manage complex multisystem critical illnesses and to introduce invasive monitoring devices defines the intensivist. On a systems level, critical care services managed by an intensivist-led multidisciplinary team are now recognized by their ability to efficiently utilize hospital resources and improve patient outcomes. Due to the numerous cost and quality issues related to the delivery of critical care medicine, intensive care unit physician staffing (IPS) has become a charged subject in recent years. Although the federal government has played a large role in regulating best practices by physicians, other third parties have entered the arena. Perhaps the most influential of these has been The Leapfrog Group, a consortium representing 130 employers and 65 Fortune 500 companies that purchase health care for their employees. This group has proposed specific regulatory guidelines for IPS that are purported to result in substantial cost containment and improved quality of care. This narrative review examines the impact of The Leapfrog Group's recommendations on critical care delivery in the United States. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Bloom, Chloe I; Slaich, Bhavan; Morales, Daniel R; Smeeth, Liam; Stone, Patrick; Quint, Jennifer K
Mortality and symptom burden from chronic obstructive pulmonary disease (COPD) and lung cancer are similar but there is thought to be an inequality in palliative care support (PCS) between diseases. This nationally representative study assessed PCS for COPD patients within primary care in the UK.This was a cohort study using electronic healthcare records (2004-2015). Factors associated with receiving PCS were assessed using logistic regression for the whole cohort and deceased patients.There were 92 365 eligible COPD patients, of which 26 135 died. Only 7.8% of the whole cohort and 21.4% of deceased patients received PCS. Lung cancer had a strong association with PCS compared with other patient characteristics, including Global Initiative for Chronic Obstructive Lung Disease stage and Medical Research Council Dyspnoea score (whole cohort, lung cancer: OR 14.1, 95% CI 13.1-15; deceased patients, lung cancer: OR 6.5, 95% CI 6-7). Only 16.7% of deceased COPD patients without lung cancer received PCS compared with 56.5% of deceased patients with lung cancer. In patients that received PCS, lung cancer co-diagnosis significantly increased the chances of receiving PCS before the last month of life (1-6 versus ≤1 month pre-death: risk ratio 1.4, 95% CI 1.3-1.7).Provision of PCS for COPD patients in the UK is inadequate. Lung cancer, not COPD, was the dominant driver for COPD patients to receive PCS. Copyright ©ERS 2018.
Danz, B.; Biehl, C.; Baehren, W.
To determine the value of supine chest radiography in comparison to orientating chest CT in the initial diagnostic evaluation of severely polytraumatised patients. 303 patients with primary indication for a cranial CT following trauma were investigated between 1988 and 1993. After performing the cranial CT all patients underwent a chest CT with an average of 6 CT slices without changing the position of the patient and with a median scan time of 4 minutes. The results of the chest CT were correlated with the findings of the supine chest radiography in regard to therapeutically relevant pathological changes. The sensitivity in detection of pneumothorax in supine chest radiography was 53% versus 97% in CT, atelectasis 20% versus 94%, lung contusion 79% versus 99%, haemotothorax 62% versus 97%. More fractures were found conventionally (sensitivity 94%) than by chest CT (sensitivity 44%). Supine chest radiography of polytraumatised patients is clearly inferior to orientating chest CT in demonstrating posttraumatic lesions; obtaining therapeutically relevant information justifies the additionally needed small amount of time. (orig.) [de
Lebovics, Edward; Torres, Richard; Porter, Lucinda K
Enormous progress has been made in recent years toward effectively treating and curing patients with chronic hepatitis C (CHC). However, at least half of the possible 7 million individuals infected with hepatitis C virus (HCV) in the US remain undiagnosed. The formidable task of increasing the number of patients diagnosed, and subsequently linked to appropriate care has fallen to primary care clinicians, who are mandated by some US States to offer screening to individuals born between 1945 and 1965 (the Baby Boomer Generation). This peer-reviewed video roundtable discussion http://hepcresource.amjmed.com/Content/jplayer/video_roundtable.html#video0 addresses the challenges encountered by primary care clinicians faced with the increasing societal need to screen for HCV, make appropriate diagnoses, and subsequently link infected patients to appropriate care. Discussion in this roundtable initially focuses on the offering of HCV screening to patients in primary care settings. Roundtable participants discuss the need for primary care clinicians to ask appropriate risk factor-based questions of their patients, especially if the ongoing HCV epidemic is to be curtailed. The participants note, however, that the majority of patients currently infected with HCV in the US are Baby Boomers, and USPTF guidelines require this population to be tested for HCV regardless of any past risk-taking behaviors. So while asking the right questions is important, the failure of a Baby Boomer to recall risk-taking behavior does not preclude HCV screening. In fact, clinicians should proactively screen all persons in this birth cohort, and be more sensitive and open to screening requests from these individuals. Roundtable participants also discuss how HCV screening results should be communicated to patients, and how physicians can keep patients engaged and not lost to follow-up after an initial positive HCV antibody test. Patients screened and found to be HCV antibody positive require a follow
Latorraca, Carolina de Oliveira Cruz; Martimbianco, Ana Luiza Cabrera; Pachito, Daniela Vianna; Pacheco, Rafael Leite; Riera, Rachel
Nineteen million adults worldwide are in need of palliative care. Of those who have access to it, 80% fail to receive an efficient management of symptoms. To assess the effectiveness and safety of mindfulness meditation for palliative care patients. We searched CENTRAL, MEDLINE, Embase, LILACS, PEDro, CINAHL, PsycINFO, Opengrey, ClinicalTrials.gov and WHO-ICTRP. No restriction of language, status or date of publication was applied. We considered randomised clinical trials (RCTs) comparing any mindfulness meditation scheme vs any comparator for palliative care. Cochrane Risk of Bias (Rob) Table was used for assessing methodological quality of RCTs. Screening, data extraction and methodological assessments were performed by two reviewers. Mean differences (MD) (confidence intervals of 95% (CI 95%)) were considered for estimating effect size. Quality of evidence was appraised by GRADE. Four RCTs, 234 participants, were included. All studies presented high risk of bias in at least one RoB table criteria. We assessed 4 comparisons, but only 2 studies showed statistically significant difference for at least one outcome. 1. Mindfulness meditation (eight weeks, one session/week, daily individual practice) vs control: statistically significant difference in favour of control for quality of life - physical aspects. 2. Mindfulness meditation (single 5-minute session) vs control: benefit in favour of mindfulness for stress outcome in both time-points. None of the included studies analysed safety and harms outcomes. Although two studies have showed statistically significant difference, only one showed effectiveness of mindfulness meditation in improving perceived stress. This study focused on one single session of mindfulness of 5 minutes for adult cancer patients in palliative care, but it was considered as possessing high risk of bias. Other schemes of mindfulness meditation did not show benefit in any outcome evaluated (low and very low quality evidence). © 2017 John Wiley
Elwyn, Glyn; Lloyd, Amy; May, Carl; van der Weijden, Trudy; Stiggelbout, Anne; Edwards, Adrian; Frosch, Dominick L; Rapley, Tim; Barr, Paul; Walsh, Thom; Grande, Stuart W; Montori, Victor; Epstein, Ronald
Existing theoretical work in decision making and behavior change has focused on how individuals arrive at decisions or form intentions. Less attention has been given to theorizing the requirements that might be necessary for individuals to work collaboratively to address difficult decisions, consider new alternatives, or change behaviors. The goal of this work was to develop, as a forerunner to a middle range theory, a conceptual model that considers the process of supporting patients to consider alternative health care options, in collaboration with clinicians, and others. Theory building among researchers with experience and expertise in clinician-patient communication, using an iterative cycle of discussions. We developed a model composed of five inter-related propositions that serve as a foundation for clinical communication processes that honor the ethical principles of respecting individual agency, autonomy, and an empathic approach to practice. We named the model 'collaborative deliberation.' The propositions describe: (1) constructive interpersonal engagement, (2) recognition of alternative actions, (3) comparative learning, (4) preference construction and elicitation, and (5) preference integration. We believe the model underpins multiple suggested approaches to clinical practice that take the form of patient centered care, motivational interviewing, goal setting, action planning, and shared decision making. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Smith, Francis Duval
Body piercing, a type of body modification that is practiced in many cultures, creates an unnatural tract through tissue that is then held open by artificial means. Today, professional body piercing is often performed in piercing establishments that are subject to dissimilar forms of regulation. The most frequently reported medical complication of body piercing and similar body modifications, such as dermal implantation, is infection. Patients with piercings who undergo surgery may have additional risks for infection, electrical burns, trauma, or airway obstruction. The published research literature on piercing prevalence, complications, regulations, education, and nursing care is outdated. The purpose of this article is to educate nurses on topics related to nursing care for patients with piercings and similar body modifications, including the history, prevalence, motivations for, and perceptions of body piercings as well as possible complications, devices used, locations, healing times, regulations, patient education, and other health concerns. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Llewellin, Peter; Arendts, Glenn; Weeden, Jacqueline; Pethebridge, Andrew
To identify any significant differences in the population of patients brought in to a hospital ED under involuntary mental health orders, based on whether the orders are initiated by police or health professionals. A retrospective analysis of consecutive presentations to a tertiary hospital ED with a co-located psychiatric emergency care centre over a 12 month period, with univariate and multivariate statistical comparisons. Two hundred and eighty-two patients (making 378 ED presentations) met the case definition and were analysed. Compared with patients on medical orders, patients on police orders had significantly more presentations related to violence, longer stays in ED and lower rates of admission to an inpatient bed, but were no more likely to require restraint or security intervention within the ED. Patients on police and medical orders differ considerably, but the impact of these differences on ED workload is small. © 2011 The Authors. EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.
Houben, Carmen H M; Spruit, Martijn A; Schols, Jos M G A; Wouters, Emiel F M; Janssen, Daisy J A
Patient-clinician communication is an important prerequisite to delivering high-quality end-of-life care. However, discussions about end-of-life care are uncommon in patients with advanced chronic organ failure. The aim was to examine the quality of end-of-life care communication during one year follow-up of patients with advanced chronic organ failure. In addition, we aimed to explore whether and to what extent quality of communication about end-of-life care changes toward the end of life and whether end-of-life care communication is related to patient-perceived quality of medical care. Clinically stable outpatients (n = 265) with advanced chronic obstructive pulmonary disease, chronic heart failure, or chronic renal failure were visited at home at baseline and four, eight, and 12 months after baseline to assess quality of end-of-life care communication (Quality of Communication questionnaire). Two years after baseline, survival status was assessed, and if patients died during the study period, a bereavement interview was done with the closest relative. One year follow-up was completed by 77.7% of the patients. Quality of end-of-life care communication was rated low at baseline and did not change over one year. Quality of end-of-life care communication was comparable for patients who completed two year follow-up and patients who died during the study. The correlation between quality of end-of-life care communication and satisfaction with medical treatment was weak. End-of-life care communication is poor in patients with chronic organ failure and does not change toward the end of life. Future studies should develop an intervention aiming at initiating high-quality end-of-life care communication between patients with advanced chronic organ failure and their clinicians. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Chung, Kevin C; Shauver, Melissa J
The quality of health care is important to American consumers, and discussion on quality will be a driving force toward improving the delivery of health care in America. Funding agencies are proposing a variety of quality measures, such as centers of excellence, pay-for-participation, and pay-for-performance initiatives, to overhaul the health care delivery system in this country. It is quite uncertain, however, whether these quality initiatives will succeed in curbing the unchecked growth in health care spending in this country, and physicians understandably are concerned about more intrusion into the practice of medicine. This article outlines the genesis of the quality movement and discusses its effect on the surgical community.
The primary aim of the present study was to consider health care service quality from the patients' perspective, specifically through the patient's eyes. A narrative analysis was performed on 300 patient stories. This rigorous analysis of patient stories is designed to identify and describe health care service quality through patients' eyes in an authentic and accurate, experiential manner. The findings show that there are variant and complex ways that patients experience health care service quality. Patient stories offer an authentic view of the complex ways that patients experience health care service quality. Narrative analysis is a useful tool to identify and describe how patients experience health care service quality. Patients experience health care service quality in complex and varying ways.
Rodiek, S.; Neu, I.
The first 100 computed tomographic (CT) examinations of the patients on the neurological intensive care ward are discussed and reported on the basis of selected typical findings. Characteristic patterns of the CT findings in determined cerebral diseases are explained. The possibility and necessity of CT observations of the development of inflammatory and cerebrovascular processes in particular are emphasized. A comparison of our experience with CT and other neuroradiological methods, is made. The clinical diagnoses, including the respective number of cases and the pertinent CT findings, are presented in a Table. (orig.) [de
Singer, Sara J; Burgers, Jako; Friedberg, Mark; Rosenthal, Meredith B; Leape, Lucian; Schneider, Eric
Integration of care is emerging as a central challenge of health care delivery, particularly for patients with multiple, complex chronic conditions. The authors argue that the concept of "integrated patient care" would benefit from further clarification regarding (a) the object of integration and (b) its essential components, particularly when constructing measures.To address these issues, the authors propose a definition of integrated patient care that distinguishes it from integrated delivery organizations, acknowledging that integrated organizational structures and processes may fail to produce integrated patient care. The definition emphasizes patients' central role as active participants in managing their own health by including patient centeredness as a key element of integrated patient care. Measures based on the proposed definition will enable empirical assessment of the potential relationships between the integration of organizations, the integration of patient care, and patient outcomes, providing valuable guidance to health systems reformers.
Subhani, Muhammad T; Kanwal, Ifrah
In this article, we describe a digital photo scrapbooking project as a standard of care for the parents of infants admitted in a neonatal intensive care unit (NICU). Photographs were taken from birth until discharge or expiry at special moments during the infant's hospitalization and used to create a digital scrapbook with daily notes by the parents. The scrapbook and original photos were provided on a CD at discharge or at expiry. Parents and their families unanimously appreciated the photos and the opportunity to record their thoughts, and considered the CDs as a lifetime treasure. Digital photo journaling could be implemented as a standard of care at other institutions with a commitment from the nursing and ancillary staff of the NICU and labor and delivery department, with possible support from volunteers.
Di Bona, Laura; Kennedy, Sheila; Mountain, Gail
Dementia friendly communities, in which people living with dementia actively participate and those around them are educated about dementia, may improve the wellbeing of those living with dementia and reduce the associated stigma. The Adopt a Care Home scheme aims to contribute towards this by teaching schoolchildren about dementia and linking them with people living with dementia in a local care home. Forty-one children, 10 people living with dementia and 8 school/care home staff participated in a mixed methods (questionnaires, observations, interviews and focus groups) evaluation to assess the scheme's feasibility and impact. Data were analysed statistically and thematically. The scheme was successfully implemented, increased children's dementia awareness and appeared enjoyable for most participants. Findings, therefore, demonstrate the scheme's potential to contribute towards dementia friendly communities by increasing children's knowledge and understanding of dementia and engaging people living with dementia in an enjoyable activity, increasing their social inclusion.
Risco, Ester; Zabalegui, Adelaida; Miguel, Susana; Farré, Marta; Alvira, Carme; Cabrera, Esther
To describe the implementation of the Balance of Care model in decision-making regarding the best care for patients with dementia in Spain. The Balance of Care model was used, which consists of (1) describing the profile of the typical cases of people with dementia and their caregivers, (2) identifying the most suitable care setting for each of the cases (home-care or long-term care institution), (3) designing specific care plans for each case, and (4) evaluating the cost of the proposed care plans. A total of 1,641 people with dementia and their caregivers from eight European countries were used in the case design. The evaluation of cases was conducted by 20 experts in different medical fields of dementia. In Spain, the results indicated that initially the most suitable placement to take care of people with dementia was the home, however in cases with higher dependency in activities of daily living, the long-term care setting was the best option. For the best care plan, the following resources were chosen: professional help to perform basic activities; day center; multidisciplinary home care team; financial support; community nurse; and social worker. The Balance of Care method allows us to assess the most appropriate place of care for people with dementia systematically, objectively and with a multidisciplinary team. Other cost-effective interventions should be integrated in patients with dementia care in order to improve home care. Copyright © 2016 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.
Uijen, A.A.; Schers, H.J.; Schene, A.H.; Schellevis, F.G.; Lucassen, P.; Bosch, W.J.H.M. van den
Background: Existing studies about continuity of care focus on patients with a severe mental illness. Objectives: Explore the level of experienced continuity of care of patients at risk for depression in primary care, and compare these to those of patients with heart failure. Methods: Explorative
Cheraghi, Mohammad Ali; Esmaeili, Maryam; Salsali, Mahvash
Patient-centered care is both a goal in itself and a tool for enhancing health outcomes. The application of patient-centered care in health care services globally however is diverse. This article reports on a study that sought to introduce patient-centered care. The aim of this study is to explore the process of providing patient-centered care in critical care units. The study used a grounded theory method. Data were collected on 5 critical care units in Tehran University of Medical Sciences. Purposive and theoretical sampling directed the collection of data using 29 semistructured interviews with 27 participants (nurses, patients, and physician). Data obtained were analyzed according to the analysis stages of grounded theory and constant comparison to identify the concepts, context, and process of the study. The core category of this grounded theory is "humanizing care," which consisted of 4 interrelated phases, including patient acceptance, purposeful patient assessment and identification, understanding patients, and patient empowerment. A core category of humanizing care integrated the theory. Humanizing care was an outcome and process. Patient-centered care is a dynamic and multifaceted process provided according to the nurses' understanding of the concept. Patient-centered care does not involve repeating routine tasks; rather, it requires an all-embracing understanding of the patients and showing respect for their values, needs, and preferences.
Montejo Fernández, Marta; Benito Manrique, Iñaki; Montiel Eguía, Arantza; Benito Fernández, Javier
Although evidence-based guidelines for acute bronchiolitis recommend primarily supportive care unnecessary treatments remain well documented. The objective of this study was to analyse a quality improvement initiative to reduce overuse of unnecessary treatments in infants with acute bronchiolitis in primary care settings. To determine the number of unnecessary treatments we reviewed the charts corresponding to infants aged initiative may be applied to the settings where the majority of infants with acute bronchiolitis are attended in western countries. Copyright © 2018. Publicado por Elsevier España, S.L.U.
Gonçalves, Marta; Cook, Benjamin; Mulvaney-Day, Norah; Alegría, Margarita; Kinrys, Gustavo
We compared service outcomes of dedicated language and cultural competency services in adequacy of care, ER, and inpatient care among Portuguese-speaking patients in ethnic- and non-ethnic-specific behavioral health clinics. We assessed adequacy of mental health care, and use of inpatient emergency department among Portuguese-speaking patients, comparing individuals receiving care from a culturally and linguistically competent mental health care setting (the Portuguese Mental Health Program [PMHP]) with usual mental health care in a community health care system in the USA. Propensity score matching was used to balance patients in treatment and control groups on gender, marital status, age, diagnosis of mental disorder, and insurance status. We used de-identified, longitudinal, administrative data of 854 Portuguese-speaking patients receiving care from the PMHP and 541 Portuguese-speaking patients receiving usual care from 2005–2008. Adequate treatment was defined as receipt of at least eight outpatient psychotherapy visits, or at least four outpatient visits of which one was a psychopharmacological visit. PMHP patients were more likely to receive adequate care. No differences were found in rates of ER use or inpatient mental health care. The present study suggests increased quality of care for patients that have contact with a clinic that dedicates resources specifically to a minority/immigrant group. Advantages of this setting include greater linguistic and cultural concordance among providers and patients. Further research is warranted to better understand the mechanisms by which culturally appropriate mental health care settings benefit minority/immigrant patients. PMID:23427258
Freund, Tobias; Peters-Klimm, Frank; Boyd, Cynthia M.
Background: Patients with multiple chronic conditions are at high risk of potentially avoidable hospital admissions, which may be reduced by care coordination and self-management support. Medical assistants are an increasingly available resource for patient care in primary care practices. Objective......: To determine whether protocol-based care management delivered by medical assistants improves patient care in patients at high risk of future hospitalization in primary care. Design: Two-year cluster randomized clinical trial. Setting: 115 primary care practices in Germany. Patients: 2,076 patients with type 2......, and monitoring delivered by medical assistants with usual care. Measurements: All-cause hospitalizations at 12 months (primary outcome) and quality of life scores (Short Form 12 Health Questionnaire [SF-12] and the Euroqol instrument [EQ-5D]). Results: Included patients had, on average, four co-occurring chronic...
Full Text Available Patients with heart failure have a significant symptom burden and other palliative care needs often over a longer period than patients with cancer. It is acknowledged that this need may be unmet but by how much has not been quantified in primary care data at the population level.This was the first use of Clinical Practice Research Datalink, the world's largest primary care database to explore recognition of the need for palliative care. Heart failure and cancer patients who had died in 2009 aged 18 or over and had at least one year of primary care records were identified. A palliative approach to care among patients with heart failure was compared to that among patients with cancer using entry onto a palliative care register as a marker for a palliative approach to care.Among patients with heart failure, 7% (234/3 122 were entered on the palliative care register compared to 48% (3 669/7 608 of cancer patients. Of heart failure patients on the palliative care register, 29% (69/234 were entered onto the register within a week of their death.This confirms that the stark inequity in recognition of palliative care needs for people with heart failure in a large primary care dataset. We recommend a move away from prognosis based criteria for palliative care towards a patient centred approach, with assessment of and attention to palliative needs including advance care planning throughout the disease trajectory.
Chanin Johann C
Full Text Available Abstract Background Few individuals with depression treated in the primary care setting receive care consistent with clinical treatment guidelines. Interventions based on the chronic care model (CCM have been promoted to address barriers and improve the quality of care. A current understanding of barriers to depression care and an awareness of whether physicians believe interventions effectively address those barriers is needed to enhance the success of future implementation. Methods We conducted semi-structured interviews with 23 primary care physicians across the US regarding their experience treating patients with depression, barriers to care, and commonly promoted CCM-based interventions. Themes were identified from interview transcripts using a grounded theory approach. Results Six barriers emerged from the interviews: difficulty diagnosing depression, patient resistance, fragmented mental health system, insurance coverage, lack of expertise, and competing demands and other responsibilities as a primary care provider. A number of interventions were seen as helpful in addressing these barriers – including care managers, mental health integration, and education – while others received mixed reviews. Mental health consultation models received the least endorsement. Two systems-related barriers, the fragmented mental health system and insurance coverage limitations, appeared incompletely addressed by the interventions. Conclusion CCM-based interventions, which include care managers, mental health integration, and patient education, are most likely to be implemented successfully because they effectively address several important barriers to care and are endorsed by physicians. Practices considering the adoption of interventions that received less support should educate physicians about the benefit of the interventions and attend to physician concerns prior to implementation. A focus on interventions that address systems-related barriers is
Lawrason, J.N.; Novelline, R.A.; Rhea, J.T.; DeLuca, S.A.; Sacknoff, R.
In the unconscious, multiple-trauma patient, thoracic spine fractures may be initially overlooked due to a combination of immediate concern given to more obvious injuries and a failure to carefully scrutinize the initial, often anteroposterior (AP) and portable chest radiograph. In a recent review of their cases the authors retrospectively identified primary or secondary signs of thoracic spine fracture in 80% of the initial chest radiographs of multiple-trauma patients with this injury. This paper reviews these obvious and subtle, bony and soft-tissue AP chest radiograph signs of thoracic spine fracture and compare them with matching spine radiographs, tomography, and CT
Lucarelli, Jennifer; Welchons, Leah; Sideridis, Georgios; Sullivan, Nancy R; Chan, Eugenia; Weissman, Laura
To evaluate the effectiveness of a multimodal educational curriculum on increasing hospital personnel's awareness of successful strategies and comfort in caring for children with autism spectrum disorder (ASD). We developed a 3-part training for front-line staff (i.e., front desk, clinical assistants, and phlebotomists) in 8 outpatient hospital departments frequented by patients with ASD. Following a needs assessment, participants completed an online educational module and then attended an in-person seminar tailored to each department. To evaluate training effectiveness, we administered pre-, immediate post-, and 1 month post-training surveys assessing personnel attitudes, comfort, perceived knowledge, and behaviors around caring for patients with ASD. We trained 168 staff members from 8 departments. On the needs assessment, participants (N = 129) reported a mean 2.5 behavioral incidents involving patients with ASD over the previous 3 months; 92% believed that the training would be helpful for their work. Across pre-, immediate- and 1-month post-training surveys, scores improved on all questions related to personnel attitudes about the importance of ASD-friendly care, comfort interacting with patients with ASD, perceived knowledge about ASD, and self-reported frequency of behaviors intended to help children with ASD adjust to the hospital setting (p initiative led to improvement in attitudes, comfort level, perceived knowledge, and self-reported behaviors of hospital personnel working with patients with ASD, which was maintained over 1 month.
Full Text Available A full understanding of and a competent approach to dying patients may lead to a more qualitative service delivery, an enhanced quality of life paradigms, and the patients’ wellbeing, all of which remain the ultimate goal of health care practice. The modern world has developed in parallel with secularism and religious diversity. This paper aims to illustrate the secularization process in Britain (with indications of generalized meanings and juxtaposes it with a description of the needs of dying patients regarding the meanings of religion and nonreligion. Although this paper draws on and provides a review of selected theoretical literature, it also addresses a significant challenge: the lack of scientifi c research on the subject. Hence, this paper aims to give an overview of the issues, but not synthesise them. The arguments that are elaborated in the paper are also supported by the author’s current research project in the city of London. The approach here is client oriented, and concerns social and health care. Practitioners ought to become competent, and maintain their competence throughout their professional career. Religious competence seems to have not been at the centre of discussions, regardless of the historical pathway that religious discourse has drawn since the beginnings of humanity. The paper concludes with certain suggestions for future research and inclusive approaches regarding religious matters.
Sandsdalen, Tuva; Rystedt, Ingrid; Grøndahl, Vigdis Abrahamsen; Hov, Reidun; Høye, Sevald; Wilde-Larsson, Bodil
Instruments specific to palliative care tend to measure care quality from relative perspectives or have insufficient theoretical foundation. The instrument Quality from the Patient's Perspective (QPP) is based on a model for care quality derived from patients' perceptions of care, although it has not been psychometrically evaluated for use in palliative care. The aim of this study was to adapt the QPP for use in palliative care contexts, and to describe patients' perceptions of the care quality in terms of the subjective importance of the care aspects and the perceptions of the care received. A cross-sectional study was conducted between November 2013 and December 2014 which included 191 patients (73% response rate) in late palliative phase at hospice inpatient units, hospice day-care units, wards in nursing homes that specialized in palliative care and homecare districts, all in Norway. An explorative factor analysis using principal component analysis, including data from 184 patients, was performed for psychometric evaluation. Internal consistency was assessed by Cronbach's alpha and paired t-tests were used to describe patients' perceptions of their care. The QPP instrument was adapted for palliative care in four steps: (1) selecting items from the QPP, (2) modifying items and (3) constructing new items to the palliative care setting, and (4) a pilot evaluation. QPP instrument specific to palliative care (QPP-PC) consists of 51 items and 12 factors with an eigenvalue ≥1.0, and showed a stable factor solution that explained 68.25% of the total variance. The reliability coefficients were acceptable for most factors (0.79-0.96). Patients scored most aspects of care related to both subjective importance and actual care received as high. Areas for improvement were symptom relief, participation, continuity, and planning and cooperation. The QPP-PC is based on a theoretical model of quality of care, and has its roots in patients' perspectives. The instrument was
Kheng Hock Lee
Full Text Available Background: Interventions to prevent readmissions of patients at highest risk have not been rigorously evaluated. We conducted a randomised controlled trial to determine if a post-discharge transitional care programme can reduce readmissions of such patients in Singapore. Methods: We randomised 840 patients with two or more unscheduled readmissions in the prior 90 days and Length of stay, Acuity of admission, Comorbidity of patient, Emergency department utilisation score ≥10 to the intervention programme (n = 419 or control (n = 421. Patients allocated to the intervention group received post-discharge surveillance by a multidisciplinary integrated care team and early review in the clinic. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge. Results: We found no statistically significant reduction in readmissions or emergency department visits in patients on the intervention group compared to usual care. However, patients in the intervention group reported greater patient satisfaction (p < 0.001. Conclusion: Any beneficial effect of interventions initiated after discharge is small for high-risk patients with multiple comorbidity and complex care needs. Future transitional care interventions should focus on providing the entire cycle of care for such patients starting from time of admission to final transition to the primary care setting. Trial Registration: Clinicaltrials.gov, no NCT02325752
Kheng Hock Lee
Full Text Available Background: Interventions to prevent readmissions of patients at highest risk have not been rigorously evaluated. We conducted a randomised controlled trial to determine if a post-discharge transitional care programme can reduce readmissions of such patients in Singapore.Methods: We randomised 840 patients with two or more unscheduled readmissions in the prior 90 days and Length of stay, Acuity of admission, Comorbidity of patient, Emergency department utilisation score ≥10 to the intervention programme (n = 419 or control (n = 421. Patients allocated to the intervention group received post-discharge surveillance by a multidisciplinary integrated care team and early review in the clinic. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge.Results: We found no statistically significant reduction in readmissions or emergency department visits in patients on the intervention group compared to usual care. However, patients in the intervention group reported greater patient satisfaction (p < 0.001.Conclusion: Any beneficial effect of interventions initiated after discharge is small for high-risk patients with multiple comorbidity and complex care needs. Future transitional care interventions should focus on providing the entire cycle of care for such patients starting from time of admission to final transition to the primary care setting.Trial Registration: Clinicaltrials.gov, no NCT02325752
Maa, April Y; Wojciechowski, Barbara; Hunt, Kelly J; Dismuke, Clara; Shyu, Jason; Janjua, Rabeea; Lu, Xiaoqin; Medert, Charles M; Lynch, Mary G
The aging population is at risk of common eye diseases, and routine eye examinations are recommended to prevent visual impairment. Unfortunately, patients are less likely to seek care as they age, which may be the result of significant travel and time burdens associated with going to an eye clinic in person. A new method of eye-care delivery that mitigates distance barriers and improves access was developed to improve screening for potentially blinding conditions. We present the quality data from the early experience (first 13 months) of Technology-Based Eye Care Services (TECS), a novel ophthalmologic telemedicine program. With TECS, a trained ophthalmology technician is stationed in a primary care clinic away from the main hospital. The ophthalmology technician follows a detailed protocol that collects information about the patient's eyes. The information then is interpreted remotely. Patients with possible abnormal findings are scheduled for a face-to-face examination in the eye clinic. Any patient with no known ocular disease who desires a routine eye screening examination is eligible. Technology-Based Eye Care Services was established in 5 primary care clinics in Georgia surrounding the Atlanta Veterans Affairs hospital. Four program operation metrics (patient satisfaction, eyeglass remakes, disease detection, and visit length) and 2 access-to-care metrics (appointment wait time and no-show rate) were tracked. Care was rendered to 2690 patients over the first 13 months of TECS. The program has been met with high patient satisfaction (4.95 of 5). Eyeglass remake rate was 0.59%. Abnormal findings were noted in 36.8% of patients and there was >90% agreement between the TECS reading and the face-to-face findings of the physician. TECS saved both patient (25% less) and physician time (50% less), and access to care substantially improved with 99% of patients seen within 14 days of contacting the eye clinic, with a TECS no-show rate of 5.2%. The early experience with
Mamdouh M. Shubair
Full Text Available Background: Men in rural and northern areas of Canada experience considerable challenges in health care access for chronic conditions such as obesity, type 2 diabetes (T2D, and cancer. Obese men (body mass index/BMI ≥ 30 kg/m2 in rural/remote northern British Columbia (BC experience poorer health outcomes due to cancer risk compared to other men elsewhere in urban Canada. Context: Challenges faced by men who develop cancer as a complication of being obese are paramount in terms of primary care treatment of their cancers. Oftentimes cancer treatment is multi-modal and complex. Models of shared care have been proposed to provide coordinated survivorship care to the growing population of rural male cancer patients suffering from obesity and the Metabolic Syndrome (MetS. Methods: Objectives: The main objective of the study was to examine the type of cancer care programs that may have focused on men with cancer in northern British Columbia (BC. A secondary objective is to identify challenges in care experienced by men with cancer during their transition from in-hospital care back to their home communities. Population: We conducted a comprehensive literature review and a qualitative focus group interview with primary care physicians (PCPs, oncologists (n=8, and a convenience sample of male cancer patients (n=6 who have underlying obesity and Metabolic Syndrome (MetS. We examined the types of cancer care programs that may have targeted such men. We further identified challenges experienced by male cancer patients while transitioning back to their home communities. Results: The focus group results outlined themes speaking to a comprehensive shared care model that goes beyond surveillance of cancer recurrence in men with obesity. Conclusion: A shared survivorship care plan or model integrates collaboration among specialists in clinical decision making and best practice for treatment of cancer in obese men.
Minton, Mary E; Isaacson, Mary; Banik, Deborah
To explore nurse comfort with patient-initiated prayer request scenarios. Spiritual care is fundamental to patient care evidenced by Joint Commission requirement of a spiritual assessment on a patient's hospital admission. Prayer is an assessment component. Patients may seek solace and support by requesting prayer from the bedside nurse, the nurse may lack confidence in responding. Absent in the literature are reports specific to nurses' comfort when patients initiate prayer requests. Cross-sectional mixed methods study. Data were collected in early 2014 from 134 nurses in the USA via an online survey using QuestionPro. The qualitative results reported here were collated by scenario and analysed using thematic analysis. The scenario responses revealed patterns of ease and dis-ease in response to patient requests for prayer. The pattern of ease of prayer with patients revealed three themes: open to voice of calm or silence; physical or spiritual; can I call the chaplain. For these nurses, prayer is a natural component of nursing care, as the majority of responses to all scenarios demonstrated an overwhelming ease in response and capacity to pray with patients on request. The pattern of dis-ease of prayer with patients distinguished two themes: cautious hesitancy and whose God. These nurses experienced dis-ease with the patient's request no matter the situation. Educators and administrators must nurture opportunities for students and nurses to learn about and engage in the reflective preparation needed to respond to patient prayer requests. © 2016 John Wiley & Sons Ltd.
Attwell, David; Rogers-Warnock, Leslie; Nemis-White, Joanna
Healthcare gaps, the difference between usual care and best care, are evident in Canada, particularly with respect to our aging, ailing population. Primary care practitioners are challenged to identify, prevent and close care gaps in their practice environment given the competing demands of informed, litigious patients with complex medical needs, ever-evolving scientific evidence with new treatment recommendations across many disciplines and an enhanced emphasis on quality and accountability in healthcare. Patient-centred health and disease management partnerships using measurement, feedback and communication of practice patterns and outcomes have been shown to narrow care gaps. Practice management strategies such as the use of patient registries and recall systems have also been used to help practitioners better understand, follow and proactively manage populations of patients in their practice. The Enhancing Practice to Improve Care project was initiated to determine the impact of a patient-centred health and disease management partnership using practice management strategies to improve patient care and outcomes for patients with chronic kidney disease (CKD). Forty-four general practices from four regions of British Columbia participated and, indeed, demonstrated that care and outcomes for patients with CKD could be improved via the implementation of practice management strategies in a patient-centred partnership measurement model of health and disease management.
Beauvais, Audrey; Frost, Lenore
Predicted work-related injuries for nurses and home healthcare workers are on the rise given the many risk factors in the home environment and the escalating demands for home healthcare workers in the United States. Fortunately, safe patient handling and mobility programs can dramatically decrease injuries. Despite strides being made to promote safe patient handling and mobility programs in acute care, more can be done to establish such initiatives in the home care setting.
Thompson, Debra N; Wolf, Gail A; Spear, Steven J
Nurses today are attempting to do more with less while grappling with faulty error-prone systems that do not focus on patients at the point of care. This struggle occurs against a backdrop of rising national concern over the incidence of medical errors in healthcare. In an effort to create greater value with scarce resources and fix broken systems that compromise quality care, UPMC Health System is beginning to master and implement the Toyota Production System (TPS)--a method of managing people engaged in work that emphasizes frequent rapid problem solving and work redesign that has become the global archetype for productivity and performance. The authors discuss the rationale for applying TPS to healthcare and implementation of the system through the development of "learning unit" model lines and initial outcomes, such as dramatic reductions in the number of missing medications and thousands of hours and dollars saved as a result of TPS-driven changes. Tracking data further suggest that TPS, with sufficient staff preparation and involvement, has the potential for continuous, lasting, and accelerated improvement in patient care.
... organizations to participate in one or more of the initial four models under the Bundled Payments for Care... organizations must submit a nonbinding letter of intent by September 22, 2011 for Model 1 and November 4, 2011... environments that stimulate rapid development of new evidence-based knowledge. The models to be tested based on...
Wichita Initiative to Renew the Environment is a recipient of a CARE Level II Cooperative agreement to reduce the risk of mobile air emissions, reduce the risk of storm water run-off, reduce the risk of solid waste pollution/greenhouse gas emissions
Ricciardi, Benjamin F; Waddell, Brad S; Nodzo, Scott R; Lange, Jeffrey; Nocon, Allina A; Amundsen, Spencer; Tarity, T David; McLawhorn, Alexander S
Recently, providers have begun to publicly report the results of patient satisfaction surveys from their practices. However, these outcomes have never been compared with the findings of commercial online physician rating websites. The goals of the current study were to (1) compare overall patient satisfaction ratings for orthopedic surgeons derived from provider-based third-party surveys with existing commercial physician rating websites and (2) determine the association between patient ratings and provider characteristics. The authors identified 12 institutions that provided publicly available patient satisfaction outcomes derived from third-party surveys for their orthopedic surgeons as of August 2016. Orthopedic surgeons at these institutions were eligible for inclusion (N=340 surgeons). Provider characteristics were recorded from publicly available data. Four high-traffic commercial online physician rating websites were identified: Healthgrades.com, UCompareHealthCare.com, Vitals.com, and RateMDs.com. For each surgeon, overall ratings (on a scale of 1-5), total number of ratings, and percentage of negative ratings were compared between provider-initiated internal ratings and each commercial online website. Associations between baseline factors and overall physician ratings and negative ratings were assessed. Provider-initiated internal patient satisfaction ratings showed a greater number of overall patient ratings, higher overall patient satisfaction ratings, and a lower percentage of negative comments compared with commercial online physician rating websites. A greater number of years in practice had a weak association with lower internal ratings, and an academic practice setting and a location in the Northeast were protective factors for negative physician ratings. Compared with commercial online physician rating websites, provider-initiated patient satisfaction ratings of orthopedic surgeons appear to be more favorable, with greater numbers of responses
DeJesus, Ramona S; Howell, Lisa; Williams, Mark; Hathaway, Julie; Vickers, Kristin S
Chronic disease management in the primary care setting increasingly involves self-management support from a nurse care manager. Prior research had shown patient acceptance and willingness to work with care managers. This survey study evaluated patient-perceived satisfaction with care management and patient opinions on the effectiveness of care management in promoting self-management. Qualitative and quantitative survey responses were collected from 125 patients (79% female; average age 46; 94% Caucasian) enrolled in care management for depression. Qualitative responses were coded with methods of content analysis by 2 independent analysts. Patients were satisfied with depression care management. Patients felt that care management improved their treatment above and beyond other aspects of their depression treatment (mean score, 6.7 [SD, 2]; 10 = Very much), increased their understanding of depression self-management (mean score, 7.2 [SD, 2]; 10 = Very much), and increased the frequency of self-management goal setting (mean score, 6.9 [SD, 3]; 10 = Very much). Predominant qualitative themes emphasized that patients value emotional, motivational, and relational aspects of the care manager relationship. Patients viewed care managers as caring and supportive, helpful in creating accountability for patients and knowledgeable in the area of depression care. Care managers empower patients to take on an active role in depression self-management. Some logistical challenges associated with a telephonic intervention are described. Care manager training should include communication and motivation strategies, specifically self-management education, as these strategies are valued by patients. Barriers to care management, such as scheduling telephone calls, should be addressed in future care management implementation and study.
Van Vorst, Rebecca F.; Crane, Lori A.; Barton, Phoebe Lindsey; Kutner, Jean S.; Kallail, K. James; Westfall, John M.
Context: Barriers to providing optimal palliative care in rural communities are not well understood. Purpose: To identify health care personnel's perceptions of the care provided to dying patients in rural Kansas and Colorado and to identify barriers to providing optimal care. Methods: An anonymous self-administered survey was sent to health care…
Lenzini, Petra A; Grice, Gloria R; Milligan, Paul E; Gatchel, Susan K; Deych, Elena; Eby, Charles S; Burnett, R Stephen J; Clohisy, John C; Barrack, Robert L; Gage, Brian F
Warfarin sodium is commonly prescribed for the prophylaxis and treatment of venous thromboembolism. Dosing algorithms have not been widely adopted because they require a fixed initial warfarin dose (eg, 5 mg) and are not tailored to other factors that may affect the international normalized ratio (INR). To develop an algorithm that could predict a therapeutic warfarin dose based on drug interactions, INR response after the initial warfarin doses, and other clinical factors. We used stepwise regression to quantify the relationship between these factors in patients beginning prophylactic warfarin therapy immediately prior to joint replacement. In the derivation cohort (n = 271), we separately modeled the therapeutic dose after 2 and 3 initial doses. We prospectively validated these 2 models in an independent cohort (n = 105). About half of the therapeutic dose variability was predictable after 3 days of therapy: R2 was 53% in the derivation cohort and 42% in the validation cohort. INR response after 3 warfarin doses (INR3) inversely correlated with therapeutic dose (p < 0.001). Intraoperative blood loss transiently, but significantly, elevated the postoperative INR values. Other significant (p < 0.03) predictors were the first and second warfarin doses (+7% and +6%, respectively, per 1 mg), and statin use (-15.0%). The model derived after 2 warfarin doses explained 32% of the variability in therapeutic dose. We developed and validated algorithms that estimate therapeutic warfarin doses based on clinical factors and INR response available after 2-3 days of warfarin therapy. The algorithms are implemented online at www.WarfarinDosing.org.
Kimerling, Rachel; Pavao, Joanne; Wong, Ava
We utilized a nationally representative survey of women veteran primary care users to examine associations between patient activation and mental health care experiences. A dose-response relationship was observed, with odds of high quality ratings significantly greater at each successive level of patient activation. Higher activation levels were also significantly associated with preference concordant care for gender-related preferences (use of female providers, women-only settings, and women-only groups as often as desired). Results add to the growing literature documenting better health care experiences among more activated patients, and suggest that patient activation may play an important role in promoting engagement with mental health care.
Jansen, Daphne L; Heijmans, Monique; Rijken, Mieke
To examine the use of individual care plans (ICPs) within primary chronic illness care in the Netherlands, and to explore the relationships between ICP use, patient characteristics, and patient-perceived quality of care. Cross-sectional study using survey data from a panel of chronically ill patients and medical registration data provided by their general practices. A sample of 1377 patients with somatic chronic disease(s) randomly selected in general practices throughout the Netherlands, supplemented with a sample of 225 COPD patients, also recruited from general practices. (i) Percentage of ICP use based on self-report by chronically ill patients, and (ii) patient-perceived quality of care as assessed using the Patient Assessment of Chronic Illness Care (PACIC). ICP use among the total generic sample was low (9%), but slightly higher (13%) among patients diagnosed with diabetes or COPD, diseases for which disease management programmes have been set up in the Netherlands. Patients with a low educational level and patients with poor(er) self-rated health were more likely to have an ICP. Compared with patients without an ICP, patients with an ICP more often reported that the care they received was patient-centred, proactive, planned, and included collaborative goal setting, problem-solving, and follow-up support. Findings reveal a discrepancy between practice and policy aspirations regarding ICP use in primary chronic illness care. More research is needed to gain insight into the effectiveness of ICPs to improve the quality of chronic illness care in various patient populations.
Full Text Available High rates of patient attrition from care between HIV testing and antiretroviral therapy (ART initiation have been documented in sub-Saharan Africa, contributing to persistently low CD4 cell counts at treatment initiation. One reason for this is that starting ART in many countries is a lengthy and burdensome process, imposing long waits and multiple clinic visits on patients. We estimated the effect on uptake of ART and viral suppression of an accelerated initiation algorithm that allowed treatment-eligible patients to be dispensed their first supply of antiretroviral medications on the day of their first HIV-related clinic visit.RapIT (Rapid Initiation of Treatment was an unblinded randomized controlled trial of single-visit ART initiation in two public sector clinics in South Africa, a primary health clinic (PHC and a hospital-based HIV clinic. Adult (≥18 y old, non-pregnant patients receiving a positive HIV test or first treatment-eligible CD4 count were randomized to standard or rapid initiation. Patients in the rapid-initiation arm of the study ("rapid arm" received a point-of-care (POC CD4 count if needed; those who were ART-eligible received a POC tuberculosis (TB test if symptomatic, POC blood tests, physical exam, education, counseling, and antiretroviral (ARV dispensing. Patients in the standard-initiation arm of the study ("standard arm" followed standard clinic procedures (three to five additional clinic visits over 2-4 wk prior to ARV dispensing. Follow up was by record review only. The primary outcome was viral suppression, defined as initiated, retained in care, and suppressed (≤400 copies/ml within 10 mo of study enrollment. Secondary outcomes included initiation of ART ≤90 d of study enrollment, retention in care, time to ART initiation, patient-level predictors of primary outcomes, prevalence of TB symptoms, and the feasibility and acceptability of the intervention. A survival analysis was conducted comparing attrition
Fábryová, Viera; Božek, Peter; Drakulová, Monika; Kollárová, Andrea; Striežencová, Zuzana Laluhová; Macichová, Michaela; Sakalová, Adriena
The paper presents the results od 22-year study of screening and follow-up of haemoglobinopathies in Slovakia, an overview of genetic mutations, the coincidence with hereditary haemochromatosis mutations, and the procedure in genetic councelling. Between 1993-2015, in three centres in Bratislava and in one centre in Kosice, carriers of beta-thalassaemic genes or other haemoglobinopathies were searched for. Diagnosis was performed by haematologists, whereby the family history was evaluated, together with the overall clinical condition, blood count and blood smear, iron and haemolysis parameters, mutations of hereditary haemochromatosis, and haemoglobin electrophoresis testing. In the last years the haemoglobin division also examined by high performance liquid chromatography (HPLC). A clinical suspicion of the heterozygous form of beta-thalassaemia or other haemoglobinopathies was documented in 554 patients. Of them 32 (5.8%) were foreigners. 213 (38.45%) patients were genetically examined. In 190 (33.93%) of them heterozygote beta-thalassaemia was confirmed. The most frequent mutations were IVS 1.110 (33.15%), IVS 2.1 (33.15%), and IVS 1.6 (14.7%). Evidence of haemoglobin S (heterozygote sickle cell anaemia) was also notable in two non-relative children, whose fathers were of African origin, and one patient from Ghana. One female patient was followed up for haemoglobin Santa Ana (non-stabile haemoglobin previously diagnosed as mutation de novo). In our group, we took care of pregnant patients with haemoglobinopathies. The study showed that there is a higher number of heterozygotes for beta-thalassaemia and rarely haemoglobinopathies in Slovakia. Over the past years, we have recorded an increase number of foreigners coming to our country. It is necessary to continue in search of pathological gene carriers to avoid serious forms of haemoglobinopathies. Copyright© by the National Institute of Public Health, Prague 2017
Iorio, Richard; Clair, Andrew J; Inneh, Ifeoma A; Slover, James D; Bosco, Joseph A; Zuckerman, Joseph D
In 2011 Medicare initiated a Bundled Payment for Care Improvement (BPCI) program with the goal of introducing a payment model that would "lead to higher quality, more coordinated care at a lower cost to Medicare." A Model 2 bundled payment initiative for Total Joint Replacement (TJR) was implemented at a large, tertiary, urban academic medical center. The episode of care includes all costs through 90 days following discharge. After one year, data on 721 Medicare primary TJR patients were available for analysis. Average length of stay (LOS) was decreased from 4.27 days to 3.58 days (Median LOS 3 days). Discharges to inpatient facilities decreased from 71% to 44%. Readmissions occurred in 80 patients (11%), which is slightly lower than before implementation. The hospital has seen cost reduction in the inpatient component over baseline. Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings. IV economic and decision analyses-developing an economic or decision model. Copyright © 2016 Elsevier Inc. All rights reserved.
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.
Hoffman, Susie; Tymejczyk, Olga; Kulkarni, Sarah; Lahuerta, Maria; Gadisa, Tsigereda; Remien, Robert H; Melaku, Zenebe; Nash, Denis; Elul, Batya
Stigma harms the mental health of HIV-positive individuals and reduces adherence to antiretroviral therapy (ART), but less is known about stigma and other outcomes across the HIV care continuum. Among 1180 Ethiopian adults initiating ART at 6 urban HIV clinics, we examined the relationship of internalized, anticipated, and enacted stigma to HIV care-related outcomes ascertained by interview (repeat HIV-positive testing, provider vs. self-referred testing, missed clinic visit before ART initiation, eagerness to begin ART), and by abstraction of routinely collected clinical data (late ART initiation, 3-month gap in care following ART initiation). Logistic regression was used to assess the association of each type of stigma with each outcome, adjusting for potential confounders. Scoring higher on each stigma domain was associated with 50%-90% higher odds of repeat HIV-positive testing. High internalized stigma was associated with higher odds of provider vs. self-referred test [adjusted odds ratio (aOR)high vs. low: 1.7; 95% confidence interval (CI): 1.3 to 2.2]. Higher anticipated stigma was associated with lower eagerness to begin ART (aORhigh vs. low: 0.55; 0.35-0.87; aORmedium vs. low: 0.45; 95% CI: 0.30 to 0.69). Any enacted stigma was associated with higher odds of a missed visit (aORany vs. none 1.8; 1.2-2.8). Stigma was not associated with late ART-initiation or with a subsequent gap in care. These findings provide further evidence of the importance of measuring and addressing stigma across the entire care continuum. Future work should test hypotheses about specific stigma domains and outcomes in prospective intervention or observational studies.
Renedo, Alicia; Marston, Cicely
heart of policy and services may discourage consumers from claiming rights to quality care by contributing to public unwillingness to challenge the status quo in service provision. If the democratic potential of patient and public involvement initiatives is to be realised, it will be crucial to help citizens to engage critically with how neoliberal rationalities can undermine their abilities to demand quality care.
Odhiambo, J; Kizito, W; Njoroge, A; Wambua, N; Nganga, L; Mburu, M; Mansoer, J; Marum, L; Phillips, E; Chakaya, J; De Cock, K M
Integrated tuberculosis (TB) and human immunodeficiency virus (HIV) services in a resource-constrained setting. Pilot provider-initiated HIV testing and counselling (PITC) for TB patients and suspects. Through partnerships, resources were mobilised to establish and support services. After community sensitisation and staff training, PITC was introduced to TB patients and then to TB suspects from December 2003 to December 2005. Of 5457 TB suspects who received PITC, 89% underwent HIV testing. Although not statistically significant, TB suspects with TB disease had an HIV prevalence of 61% compared to 63% for those without. Of the 614 suspects who declined HIV testing, 402 (65%) had TB disease. Of 2283 patients referred for cotrimoxazole prophylaxis, 1951 (86%) were enrolled, and of 1727 patients assessed for antiretroviral treatment (ART), 1618 (94%) were eligible and 1441 (83%) started treatment. PITC represents a paradigm shift and is feasible and acceptable to TB patients and TB suspects. Clear directives are nevertheless required to change practice. When offered to TB suspects, PITC identifies large numbers of persons requiring HIV care. Community sensitisation, staff training, multitasking and access to HIV care contributed to a high acceptance of HIV testing. Kenya is using this experience to inform national response and advocate wide PITC implementation in settings faced with the TB-HIV epidemic.
Death, an unavoidable event in the human experience, causes physical as well as mental and spiritual suffering. This paper reports on a nursing experience giving spiritual care to a terminal liver cancer patient between January 17 and February 9, 2009. Eleven nursing logs were used as the source of data for daily information. During the care period, patient religious needs featured prominently, including his desire to become a Christian and his eagerness to know about and help in the arrangement of his funeral. Taking the initiative, the nurse helped link him with religious resources, arranged a minister for his baptism ceremony, had the priest explain funeral proceedings, and assisted with the completion of his entrusted plans. The function of this nursing care intervention was to provide a personal touch to a patient who was in desperate need of warm spiritual care. It is hoped that this report can help caregivers increase their sensitivity toward patient spiritual needs and enhance routine nursing care quality.
Veterans Health Administration Office of Nursing Services exploration of positive patient care synergies fueled by consumer demand: care coordination, advanced clinic access, and patient self-management.
Wertenberger, Sydney; Yerardi, Ruth; Drake, Audrey C; Parlier, Renee
The consumers who utilize the Veterans Health Administration healthcare system are older, and most are learning to live with chronic diseases. Their desires and needs have driven changes within the Veterans Health Administration. Through patient satisfaction initiatives and other feedback sources, consumers have made it clear that they do not want to wait for their care, they want a say in what care is provided to them, and they want to remain as independent as possible. Two interdisciplinary processes/models of healthcare are being implemented on the national level to address these issues: advanced clinic access and care coordination. These programs have a synergistic relationship and are integrated with patient self-management initiatives. Positive outcomes of these programs also meet the needs of our staff. As these new processes and programs are implemented nationwide, skills of both patients and nursing staff who provide their care need to be enhanced to meet the challenges of providing nursing care now and into the 21st century. Veterans Health Administration Office of Nursing Services Strategic Planning Work Group is defining and implementing processes/programs to ensure nurses have the knowledge, information, and skills to meet these patient care demands at all levels within the organization.
Conclusion: Oncologists, oncology nurses, and patients felt that integration of early specialist palliative care in cancer improves symptom control, end-of-life care, health-related communication, and continuity of care. The perceptions of benefit of the palliative care intervention in the components surveyed, differed among the three groups.
Caris-Verhallen, W.M.C.M.; Kerkstra, A.
The aim of this study was to examine patients' satisfaction with continuity of care while on a waiting list for residential care or nursing home care. Two hundred and seventy-eight patients participated in the study, all living in the community setting of two cities in the Netherlands. These
Singer, S.J.; Burgers, J.S.; Friedberg, M.; Rosenthal, M.B.; Leape, L.; Schneider, E.
Integration of care is emerging as a central challenge of health care delivery, particularly for patients with multiple, complex chronic conditions. The authors argue that the concept of "integrated patient care" would benefit from further clarification regarding (a) the object of integration and
Zhu, Lei; Schroevers, Maya J.; van der Lee, Marije; Garssen, Bert; Stewart, Roy E.; Sanderman, Robbert; Ranchor, Adelita V.
Objective: This study aimed to (1) identify subgroups of cancer patients with distinct personal control trajectories during psychological care, (2) examine whether socio-demographic, clinical, and psychological care characteristics could distinguish trajectories, and (3) examine differential
Patients\\' Perception of the Benefits of Pharmaceutical Care Services in the Management of Hypertension in a Tertiary Health Care Facility in Benin City. ... effects, exercises, weight and blood pressure control were rated as “not beneficial”.
Murugasu, G Dr.
Under the Quality and Continuing Care Directorate (QCCD) in stroke care Cavan General Hospital was identified as a hospital that received a large number of stroke and TIA patients. A programme was established to improve services to this population.
Zhu, Lei; Schroevers, Maya J.; van der Lee, Marije; Garssen, Bert; Stewart, Roy E.; Sanderman, Robbert; Ranchor, A.V.
Objective This study aimed to (1) identify subgroups of cancer patients with distinct personal control trajectories during psychological care, (2) examine whether socio-demographic, clinical, and psychological care characteristics could distinguish trajectories, and (3) examine differential patterns
Lorenza Nogueira Campos
Full Text Available INTRODUCTION: Despite improvement in clinical treatment for HIV-infected patients, the impact of antiretroviral therapy on the overall quality of life has become a major concern. OBJECTIVE: To identify factors associated with increased levels of self-reported quality of life among HIV-infected patients after four months of antiretroviral therapy. METHODS: Patients were recruited at two public health referral centers for AIDS, Belo Horizonte, Brazil, for a prospective adherence study. Patients were interviewed before initiating treatment (baseline and after one and four months. Quality of life was assessed using a psychometric instrument, and factors associated with good/very good quality of life four months after the initiation of antiretroviral therapy were assessed using a cross-sectional approach. Logistic regression was used for analysis. RESULTS: Overall quality of life was classified as 'very good/good' by 66.4% of the participants four months after initiating treatment, while 33.6% classified it as 'neither poor nor good/poor/very poor'. Logistic regression indicated that >8 years of education, none/mild symptoms of anxiety and depression, no antiretroviral switch, lower number of adverse reactions and better quality of life at baseline were independently associated with good/very good quality of life over four months of treatment. CONCLUSIONS: Our results highlight the importance of modifiable factors such as psychiatric symptoms and treatment-related variables that may contribute to a better quality of life among patients initiating treatment. Considering that poor quality of life is related to non-adherence to antiretroviral therapy, careful clinical monitoring of these factors may contribute to ensuring the long-term effectiveness of antiretroviral regimens.
Melaku, Zenebe; Lulseged, Sileshi; Wang, Chunhui; Lamb, Matthew R; Gutema, Yoseph; Teasdale, Chloe A; Ahmed, Solomon; Gadisa, Tsigereda; Habtamu, Zelalem; Bedri, Abubaker; Fayorsey, Ruby; Abrams, Elaine J
To describe pediatric ART scale-up in Ethiopia, one of the 21 global priority countries for elimination of pediatric HIV infection. A descriptive analysis of routinely collected HIV care and treatment data on HIV-infected children (<15 years) enrolled at 70 health facilities in four regions in Ethiopia, January 2006-September 2013. Characteristics at enrollment and ART initiation are described along with outcomes at 1 year after enrollment. Among children who initiated ART, cumulative incidence of death and loss to follow-up (LTF) were estimated using survival analysis. 11 695 children 0-14 years were enrolled in HIV care and 6815 (58.3%) initiated ART. At enrollment, 31.2% were WHO stage III and 6.3% stage IV. The majority (87.9%) were enrolled in secondary or tertiary facilities. At 1 year after enrollment, 17.9% of children were LTF prior to ART initiation. Among children initiating ART, cumulative incidence of death was 3.4%, 4.1% and 4.8%, and cumulative incidence of LTF was 7.7%, 11.8% and 16.6% at 6, 12 and 24 months, respectively. Children <2 years had higher risk of LTF and death than older children (P < 0.0001). Children with more advanced disease and those enrolled in rural settings were more likely to die. Children enrolled in more recent years were less likely to die but more likely to be LTF. Over the last decade large numbers of HIV-infected children have been successfully enrolled in HIV care and initiated on ART in Ethiopia. Retention prior to and after ART initiation remains a major challenge. © 2017 John Wiley & Sons Ltd.
Dahlem, Chin Hwa Y; Villarruel, Antonia M; Ronis, David L
Poor patient-provider interaction among racial/ethnic minorities is associated with disparities in health care. In this descriptive, cross-sectional study, we examine African American women's perspectives and experiences of patient-provider interaction (communication and perceived discrimination) during their initial prenatal visit and their influences on perceptions of care received and prenatal health behaviors. Pregnant African American women (n = 204) and their providers (n = 21) completed a pre- and postvisit questionnaire at the initial prenatal visit. Women were also interviewed face to face at the subsequent return visit. Women perceived high quality patient-provider communication (PPC) and perceived low discrimination in their interaction with providers. Multiple regression analyses showed that PPC had a positive effect on trust in provider (p prenatal care satisfaction (p prenatal health behaviors. Findings suggest that quality PPC improves the prenatal care experience for African American women. © The Author(s) 2014.
Full Text Available Patients with rare and complex diseases such as congenital adrenal hyperplasia (CAH often receive fragmented and inadequate care unless efforts are coordinated among providers. Translating the concepts of the medical home and comprehensive health care for individuals with CAH offers many benefits for the affected individuals and their families. This manuscript represents the recommendations of a 1.5 day meeting held in September 2009 to discuss the ideal goals for comprehensive care centers for newborns, infants, children, adolescents, and adults with CAH. Participants included pediatric endocrinologists, internal medicine and reproductive endocrinologists, pediatric urologists, pediatric surgeons, psychologists, and pediatric endocrine nurse educators. One unique aspect of this meeting was the active participation of individuals personally affected by CAH as patients or parents of patients. Representatives of Health Research and Services Administration (HRSA, New York-Mid-Atlantic Consortium for Genetics and Newborn Screening Services (NYMAC, and National Newborn Screening and Genetics Resource Center (NNSGRC also participated. Thus, this document should serve as a "roadmap" for the development phases of comprehensive care centers (CCC for individuals and families affected by CAH.
Lovett, Marlina E; Moore-Clingenpeel, Melissa; Ayad, Onsy; O'Brien, Nicole
OBJECTIVE Severe traumatic brain injury remains a leading cause of morbidity and mortality in the pediatric population. Providers focus on reducing secondary brain injury by avoiding hypoxemia, avoiding hypotension, providing normoventilation, treating intracranial hypertension, and reducing cerebral metabolic demand. Hyperthermia is frequently present in patients with severe traumatic brain injury, contributes to cerebral metabolic demand, and is associated with prolonged hospital admission as well as impaired neurological outcome. The objective of this quality improvement initiative was to reduce the duration of hyperthermia for pediatric patients with severe traumatic brain injury during the initial 72 hours of admission to the pediatric intensive care unit. METHODS A retrospective chart review was performed to evaluate the incidence and duration of hyperthermia within a preintervention cohort. The retrospective phase was followed by three 6-month intervention periods (intervention Phase 1, the maintenance phase, and intervention Phase 2). Intervention Phase 1 entailed placement of a cooling blanket on the bed prior to patient arrival and turning it on once the patient's temperature rose above normothermia. The maintenance phase focused on sustaining the results of Phase 1. Intervention Phase 2 focused on total prevention of hyperthermia by initiating cooling blanket use immediately upon patient arrival to the intensive care unit. RESULTS The median hyperthermia duration in the preintervention cohort (n = 47) was 135 minutes. This was reduced in the Phase 1 cohort (n = 9) to 45 minutes, increased in the maintenance phase cohort (n = 6) to 88.5 minutes, and decreased again in the Phase 2 cohort (n = 9) to a median value of 0 minutes. Eight percent of patients in the intervention cohorts required additional sedation to tolerate the cooling blanket. Eight percent of patients in the intervention cohorts became briefly hypothermic while on the cooling blanket. No
Chan, Kitty S; Bird, Chloe E; Weiss, Robert; Duan, Naihua; Meredith, Lisa S; Sherbourne, Cathy D
We sought to determine whether patient-provider gender concordance influences the detection and care of depression and comorbid anxiety and substance use in patients with major depression Cross-sectional analyses of baseline patient survey data linked with provider data were performed. Data based on routine primary care visits in clinics from a variety of health systems serving diverse patient populations across the United States. Participants all had major depression. Depression care was examined in the Quality Improvement for Depression (QID) Collaboration sample (n patients = 1,428, n providers = 389). In a subanalysis of data solely from 714 patients and 157 providers from Partners-In-Care, one of the projects participating in QID, we also examined detection of anxiety disorder and alcohol or drug problems. Rates of detection and care of mental health problems in primary care were low even among patients with major depression. Except for anxiety counseling in female patients, patient-provider gender concordance did not improve care as hypothesized. However, female providers were more likely to counsel on anxiety and less likely to counsel on alcohol or drug use than male providers. Female patients were less likely to be counseled on alcohol or drug use compared with male patients. Detection and care of mental health and substance use problems for patients with major depression is not influenced by patient-provider gender concordance. However, depressed female patients may have greater unmet needs for alcohol and drug use counseling than their male counterparts.
Heins, Marianne; Hofstede, Jolien; Rijken, Mieke; Korevaar, Joke; Donker, Gé; Francke, Anneke
In many countries, GPs and home care nurses are involved in care for patients with advanced cancer. Given the varied and complex needs of these patients, providing satisfactory care is a major challenge for them. We therefore aimed to study which aspects of care patients, GPs and home care nurses consider important and whether patients receive these aspects. Seventy-two Dutch patients with advanced cancer, 87 GPs and 26 home care nurses rated the importance of support when experiencing symptoms, respect for patients' autonomy and information provision. Patients also rated whether they received these aspects. Questionnaires were based on the CQ index palliative care. Almost all patients rated information provision and respect for their autonomy as important. The majority also rated support when suffering from specific symptoms as important, especially support when in pain. In general, patients received the care they considered important. However, 49% of those who considered it important to receive support when suffering from fatigue and 23% of those who wanted to receive information on the expected course of their illness did not receive this or only did so sometimes. For most patients with advanced cancer, the palliative care that they receive matches what they consider important. Support for patients experiencing fatigue may need more attention. When symptoms are difficult to control, GPs and nurses may still provide emotional support and practical advice. Furthermore, we recommend that GPs discuss patients' need for information about the expected course of their illness.
Ekblad, Solvig; Mollica, Richard F; Fors, Uno; Pantziaras, Ioannis; Lavelle, James
Virtual Patients (VPs) have been used in undergraduate healthcare education for many years. This project is focused on using VPs for training professionals to care for highly vulnerable patient populations. The aim of the study was to evaluate if Refugee Trauma VPs was perceived as an effective and engaging learning tool by primary care professionals (PCPs) in a Primary Health Care Centre (PHC). A VP system was designed to create realistic and engaging VP cases for Refugee Trauma for training refugee patient interview, use of established trauma and mental health instruments as well as to give feedback to the learners. The patient interview section was based on video clips with a Bosnian actor with a trauma story and mental health problems. The video clips were recorded in Bosnian language to further increase the realism, but also subtitled in English. The system was evaluated by 11 volunteering primary health clinicians at the Lynn Community Health Centre, Lynn, Massachusetts, USA. The participants were invited to provide insights/feedback about the system's usefulness and educational value. A mixed methodological approach was used, generating both quantitative and qualitative data. Self-reported dimensions of clinical care, pre and post questionnaire questions on the PCPs clinical worldview, motivation to use the VP, and IT Proficiency. Construct items used in these questionnaires had previously demonstrated high face and construct validity. The participants ranked the mental status examination more positively after the simulation exercise compared to before the simulation. Follow up interviews supported the results. Even though virtual clinical encounters are quite a new paradigm in PHC, the participants in the present study considered our VP case to be a relevant and promising educational tool. Next phase of our project will be a RCT study including comparison with specially prepared paper-cases and determinative input on improving clinical diagnosis and
Background Virtual Patients (VPs) have been used in undergraduate healthcare education for many years. This project is focused on using VPs for training professionals to care for highly vulnerable patient populations. The aim of the study was to evaluate if Refugee Trauma VPs was perceived as an effective and engaging learning tool by primary care professionals (PCPs) in a Primary Health Care Centre (PHC). Methods A VP system was designed to create realistic and engaging VP cases for Refugee Trauma for training refugee patient interview, use of established trauma and mental health instruments as well as to give feedback to the learners. The patient interview section was based on video clips with a Bosnian actor with a trauma story and mental health problems. The video clips were recorded in Bosnian language to further increase the realism, but also subtitled in English. The system was evaluated by 11 volunteering primary health clinicians at the Lynn Community Health Centre, Lynn, Massachusetts, USA. The participants were invited to provide insights/feedback about the system’s usefulness and educational value. A mixed methodological approach was used, generating both quantitative and qualitative data. Results Self-reported dimensions of clinical care, pre and post questionnaire questions on the PCPs clinical worldview, motivation to use the VP, and IT Proficiency. Construct items used in these questionnaires had previously demonstrated high face and construct validity. The participants ranked the mental status examination more positively after the simulation exercise compared to before the simulation. Follow up interviews supported the results. Conclusions Even though virtual clinical encounters are quite a new paradigm in PHC, the participants in the present study considered our VP case to be a relevant and promising educational tool. Next phase of our project will be a RCT study including comparison with specially prepared paper-cases and determinative input on
Meesters, P.D.; Comijs, H.C.; Dröes, R.M.; de Haan, L.; Smit, J.H.; Eikelenboom, P.; Beekman, A.T.F.; Stek, M.L.
Objective: Elderly patients constitute the fastest growing segment of the schizophrenia population. Still, their needs for care are poorly understood. This study aimed to gain insight into the care needs of older patients with schizophrenia spectrum disorders. Setting and Participants: Patients,
Wiborg, J.F.; Gieseler, D.; Fabisch, A.B.; Voigt, K.; Lautenbach, A.; Lowe, B.
Objective To examine rates of suicidality in primary care patients with somatoform disorders and to identify factors that might help to understand and manage active suicidal ideation in these patients. Methods We conducted a cross-sectional study screening 1645 primary care patients. In total, 142
Matsui, Miho; Kanai, Emi; Kitagawa, Akiko; Hattori, Keiko
Care managers (CMs) have an important role in coordinating care for cancer patients who are in the end-of-life stage; however, little is known about their views of death and their experiences while caring for older cancer patients. This study was conducted to examine CMs' views of death and caring for older cancer patients in a home care setting in Japan. Convenience sampling was undertaken, and 35 offices from 43 approached services agreed to participate. The final valid sample included responses from 136 CMs (90.7%). Most CMs, including nurses, care workers, home helpers, and social workers in home care settings, experienced difficulty in managing the care of cancer patients in the end-of-life stage. Respondents reported a wide array of experiences with end-of-life care, care management, and seminar attendance, and their ages and Frommelt Attitude Toward Care of the Dying (FATCOD) scores were associated factors. Moreover, multiple regression analysis indicated that better attitudes toward caring for the dying were positively associated with seminar attendance. These results suggest that CMs need education about palliative and end-of-life care in order to promote good home care for cancer patients.
Lorincz, Ilona S.; Lawson, Brittany C. T.
Incentive programs directed at both providers and patients have become increasingly widespread. Pay-for-performance (P4P) where providers receive financial incentives to carry out specific care or improve clinical outcomes has been widely implemented. The existing literature indicates they probably spur initial gains which then level off or partially revert if incentives are withdrawn. The literature also indicates that process measures are easier to influence through P4P programs but that intermediate outcomes such as glucose, blood pressure, and cholesterol control are harder to influence, and the long term impact of P4P programs on health is largely unknown. Programs directed at patients show greater promise as a means to influence patient behavior and intermediate outcomes such as weight loss; however, the evidence for long term effects are lacking. In combination, both patient and provider incentives are potentially powerful tools but whether they are cost-effective has yet to be determined. PMID:23225214
Esmaeili, Maryam; Cheraghi, Mohammad A; Salsali, Mahvash
The aim of this study was to explore cardiac patients' perception of patient-centred care. Despite patient's importance in the process of care, less attention has been paid to experiences and expectations of patients in definitions of patient-centred care. As patients are an important element in process of patient-centred care, organizing care programs according to their perceptions and expectations will lead to enhanced quality of care and greater patient satisfaction. This study is a descriptive qualitative study. Content analysis approach was performed for data analysis. Participants were 18 cardiac patients (10 women and 8 men) hospitalized in coronary care units of teaching hospitals affiliated to Tehran University of Medical Sciences. We collected the study data through conducting personal face-to-face semi-structured interviews. The participants' perceptions of patient-centred care fell into three main themes including managing patients uncertainty, providing care with more flexibility and establishing a therapeutic communication. The second theme consisted of two sub-themes: empathizing with patients and having the right to make independent decisions. Receiving patient-centred care is essential for cardiac patients. Attention to priorities and preferences of cardiac patients and making decisions accordingly is among effective strategies for achieving patient-centred care. Cardiac care unit nurses ought to be aware that in spite of technological developments and advances, it is still important to pay attention to patients' needs and expectations in order to achieve patient satisfaction. In planning care programs, they should consider accountability towards patients' needs, flexibility in process of care and establishing medical interactions as an effective strategy for improving quality of care. © 2014 British Association of Critical Care Nurses.
Background: Sleep disorders are frequent in patients with advanced cancer receiving palliative-care, especially in elderly patients (1). Sleep disorders during palliative-care may be related with anxiety, opioids related central-sleep apnoea or corticoids therapy between others (2). Our aim was to quantify the effectiveness of hypnotic medication in the sleep quality in advanced cancer receiving palliative-care elderly patients. Material and methods: A descriptive cross-sectional study was...
Ates, Elif; Set, Turan; Saglam, Zuhal; Tekin, Nil; Karatas Eray, Irep; Yavuz, Erdinc; Sahin, Mustafa Kursat; Selcuk, Engin Burak; Cadirci, Dursun; Cubukcu, Mahcube
Our aim was to evaluate the insulin initiation status, barriers to insulin initiation and knowledge levels about treatment administered by primary care physicians (PCP). We conducted our study in accordance with a multicenter, cross-sectional design in Turkey, between July 2015 and July 2016. A questionnaire inquiring demographic features, status of insulin initiation, obstacles to insulin initiation and knowledge about therapy of the PCPs was administered during face-to-face interviews. 84 PCPs (19%) (n=446, mean age=41.5±8.4years, 62.9% male and 90.0% ministry certified family physicians) initiated insulin therapy in the past. Most of the stated primary barriers (51.9%, n=230) were due to the physicians. The most relevant barrier was "lack of clinical experience" with a rate of 19% (n=84 of the total). The average total knowledge score was 5.7±2.0 for the family medicine specialist, and 3.8±2.1 for the ministry certified family physicians (p=0.000, maximum knowledge score could be 10). The status of insulin initiation in Turkey by the primary care physicians is inadequate. Medical education programs and health care systems may require restructuring to facilitate insulin initiation in primary care. Copyright © 2017 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Waits and delays for healthcare are legendary. These delays are not only frustrating and potentially hazardous for patients and providers but also represent significant cost to office practices. The traditional medical model that defines urgent care versus routine care is a vain and futile attempt to sort demand. This approach is at constant odds with patients' definition of urgency. Trusting patients to determine when and how they want to access care makes sense from a customer service perspective. If approached systematically using the principles of Advanced Access, patient demand patterns can be tracked to forecast demand. These demand patterns become the template for deploying the resources necessary to meet patients' needs. Although not a simple journey, the transformation to Advanced Access provides an entree to patient-centered care where patients can say, "I get exactly the care I want and need, when I want and need it."
... Pillbox Patient-Safety Initiative ACTION: Notice. SUMMARY: The National Library of Medicine (NLM) invites..., production version of Pillbox. This initiative is an important element of ongoing efforts to enhance patient.... SUPPLEMENTARY INFORMATION: NLM has established Pillbox, an initiative to enhance patient safety, by making...
Torres, Rosamar; Kehoe, Priscilla; Heilemann, MarySue V
Little is known of late adolescent Texas Latinas' prenatal care perceptions or how these perceptions predict timely prenatal care initiation or adequate utilization. Hence, the purpose of this study is to describe and compare these perceptions between participants with timely versus late prenatal care initiation and adequate, intermediate, and inadequate prenatal care utilization; and to determine predictors of timely prenatal care initiation and adequate utilization. Fifty-four postpartum Latinas were recruited through social media. Eligibility criteria were 18 to 21 years old, Texas-born, primiparous, uncomplicated pregnancy/delivery, and English literate. Prenatal care perceptions were measured with the Revised Better Babies Survey and Access Barriers to Care Index. Participants had favorable views of prenatal care benefits; however, not living with the baby's father predicted inadequate prenatal care, Wald χ 2 (1) = 4.93, p = .026. Perceived benefits of timely and adequate prenatal care predicted timely prenatal care initiation, χ 2 (1) = 7.47, p = .006. Self-reported depression during pregnancy predicted timely entry into prenatal care, χ 2 (1) = 4.73, p = .03. Participants' positive prenatal care perceptions did not predict adequate prenatal care utilization, indicating that barriers serve as powerful obstacles in late adolescent Texas Latinas.
Al-Busaidi, Ibrahim S.; Abdulhadi, Nadia N.; Coppell, Kirsten J.
Diabetes mellitus is a major public health challenge and causes substantial morbidity and mortality worldwide. Diabetic foot disease is one of the most debilitating and costly complications of diabetes. While simple preventative foot care measures can reduce the risk of lower limb ulcerations and subsequent amputations by up to 85%, they are not always implemented. In Oman, foot care for patients with diabetes is mainly provided in primary and secondary care settings. Among all lower limb amputations performed in public hospitals in Oman between 2002–2013, 47.3% were performed on patients with diabetes. The quality of foot care among patients with diabetes in Oman has not been evaluated and unidentified gaps in care may exist. This article highlights challenges in the provision of adequate foot care to Omani patients with diabetes. It concludes with suggested strategies for an integrated national diabetic foot care programme in Oman. PMID:27606104
Full Text Available Introduction: Many of the patients with Alzheimer disease are taken care of in nursing homes. However the literature on the experiences of Iranian formal caregivers of older adults with Alzheimer disease is scarce. This qualitative study explored the caring experiences of formal caregivers in nursing homes that can improve the quality of care and patient’s quality of life. Methods: This qualitative study used the principles of descriptive content analysis to analyze these data. Our participants included 11 female and 3 male caregivers aged 25 to 38 years who were selected for interviewing based on a purposive sampling method. The data were analyzed with a content analysis method. Results: Nearly 900 initial codes were extracted and categorized into 6 main themes including "managing difficult behaviors", "dependence on familial care", "continuum of different feelings", "care for a child", "living with the patients" and "not understanding the patients", which was further analyzed in the two subcategories "caring without enough information" and " a dead man moving". Conclusion: The care provided by our informants was mainly influenced by attitudes, culture and religious beliefs of caregivers about family attachment and ample driven reward of helping and caring frail or old people in Islam. These cultural and religious beliefs could facilitate provision of care and confrontation with patients’ child-like behaviors. It is suggested that employment of trained staff and plans for their continued education can improve the quality of care and the quality of the patient's life.
Tseng, Eric K; Hicks, Lisa K
Two distinct but overlapping care philosophies have emerged in cancer care: patient-centered care (PCC) and value-based care (VBC). Value in healthcare has been defined as the quality of care (measured typically by healthcare outcomes) modified by cost. In this conception of value, patient-centeredness is one important but not necessarily dominant quality measure. In contrast, PCC includes multiple domains of patient-centeredness and places the patient and family central to all decisions and evaluations of quality. The alignment of PCC and VBC is complicated by several tensions, including a relative lack of patient experience and preference measures, and conceptions of cost that are payer-focused instead of patient-focused. Several strategies may help to align these two philosophies, including the use of patient-reported outcomes in clinical trials and value determinations, and the purposeful integration of patient preference in clinical decisions and guidelines. Innovative models of care, including accountable care organizations and oncology patient-centered medical homes, may also facilitate alignment through improved care coordination and quality-based payment incentives. Ultimately, VBC and PCC will only be aligned if patient-centered outcomes, perspectives, and preferences are explicitly incorporated into the definitions and metrics of quality, cost, and value that will increasingly influence the delivery of cancer care.
Frühwald, Stefan; Karner, Angelika; Seyringer, Michaela-Elena; Skribe, Teresa; Frottier, Patrick; Entenfellner, Anna
Community mental health teams (CMHT) provide support for severely disabled, chronic mentally ill patients. In this study, referrals to CMHT by a psychiatric hospital in Lower Austria were analysed, as were the first few weeks of care for referred patients. Referrals to CMHT of a catchment area (pop 250.000) were analysed for 2002- 2006. In the first 6 months of each year, 124 to 189 patients were referred to CMHT. Between 2002 and 2006, the percentage of affective disorders (ICD-10: F3: 40.0 %), and substance use disorders (F1: 38.9 %) within the referrals diminished, as compared to patients suffering from schizophrenia (F2 initially 25.4 % of referrals vs. 49.7 %) and personality disorders (F6 initially 6.4 % of referrals vs. 22.4 %). In 30.7 % vs. 56.6 % of patients, CMHT workers managed to establish contact to patients after discharge from hospital. They actively sought contact with 39.9 to 74.6 % of referred patients (by means of telephone calls, letters, home visits, etc.). In 26.5 to 46.9 % of the referrals, continuous care was planned. This study emphasizes the advantage of specific referrals to CMHT, if care for severely disabled individuals is needed and should be provided. Furthermore, a description of outreach activities, which are intended to maintain contact with patients characterized by poor compliance, is presented. These activities are not yet part of routine care in German speaking countries.
To report an analysis of the concept of patient engagement in prenatal care. Engagement in health care has been widely discussed but vaguely defined. Patients benefit more from their health care when they are fully engaged in their care. Patient engagement in prenatal care is an important element of prenatal care utilization that has not been analyzed, standardized as a concept, or measured. Concept analysis. CINAHL, MEDLINE, PsycINFO databases, and the internet were searched for literature published in English with a focus on peer-reviewed journals from disciplines of business, allied health sciences, health administration, psychology, and nursing, focusing on the period of 2010-2015. Hybrid version of the Walker and Avant concept analysis method (2011). This concept analysis provides 4 defining attributes of patient engagement in prenatal care and a table of related empirical referents of engagement. These elements offer a foundation for further nursing scholarship toward measurement and evaluation of patient engagement in prenatal care. Patient engagement in prenatal care represents a human response to a health condition. Efforts to increase patient engagement in health care are best addressed by the nursing profession through continued research and intervention development. © 2017 Wiley Periodicals, Inc.
Full Text Available Abstract Background Negative events are abusive, potentially dangerous or life-threatening health care events, as perceived by the patient. Patients' perceptions of negative events are regarded as a potentially important source of information about the quality of health care. We explored negative events in hospital care as perceived by immigrant patients. Methods Semi-structured individual and group interviews were conducted with respondents about negative experiences of health care. Interviews were transcribed and analyzed using a framework method. A total of 22 respondents representing 7 non-Dutch ethnic origins were interviewed; each respondent reported a negative event in hospital care or treatment. Results Respondents reported negative events in relation to: 1 inadequate information exchange with care providers; 2 different expectations between respondents and care providers about medical procedures; 3 experienced prejudicial behavior on the part of care providers. Conclusions We identified three key situations in which negative events were experienced by immigrant patients. Exploring negative events from the immigrant patient perspective offers important information to help improve health care. Our results indicate that care providers need to be trained in adequately exchanging information with the immigrant patient and finding out specific patient needs and perspectives on illness and treatment.
Musheke, Maurice; Bond, Virginia; Merten, Sonja
Some people living with HIV (PLHIV) refuse to initiate antiretroviral therapy (ART) despite availability. Between March 2010 and September 2011, using a social ecological framework, we investigated barriers to ART initiation in Lusaka, Zambia. In-depth interviews were conducted with PLHIV who were offered treatment but declined (n=37), ART staff (n=5), faith healers (n=5), herbal medicine providers (n=5), and home-based care providers (n=5). One focus group discussion with lay HIV counselors and observations in the community and at an ART clinic were conducted. Interviews were audio-recorded, transcribed, and translated, coded using Atlas ti, and analyzed using latent content analysis. Lack of self-efficacy, negative perceptions of medication, desire for normalcy, and fear of treatment-induced physical body changes, all modulated by feeling healthy, undermined treatment initiation. Social relationships generated and perpetuated these health and treatment beliefs. Long waiting times at ART clinics, concerns about long-term availability of treatment, and taking strong medication amidst livelihood insecurity also dissuaded PLHIV from initiating treatment. PLHIV opted for herbal remedies and faith healing as alternatives to ART, with the former being regarded as effective as ART, while the latter contributed to restoring normalcy through the promise of being healed. Barriers to treatment initiation were not mutually exclusive. Some coalesced to undermine treatment initiation. Ensuring patients initiate ART requires interventions at different levels, addressing, in particular, people's health and treatment beliefs, changing perceptions about effectiveness of herbal remedies and faith healing, improving ART delivery to attenuate social and economic costs and allaying concerns about future non-availability of treatment.
This thesis describes an example of optimization of the traditional multidisciplinary team care model and evolving arthritis care models with emphasis on the question how theoretical models of the system theory and communication can be used to analyse, evaluate, and optimize care delivery. With
Boulet, Louis-Philippe; FitzGerald, J Mark; Levy, Mark L
In 1995, the Global Initiative for Asthma (GINA) published an evidence-based workshop report as a guide to clinicians managing asthma patients, and has updated it annually to ensure that recommendations remain current. Although the report has been widely disseminated and influenced clinical...... practice and research, its major objective, of forming the basis for local and national initiatives to improve services for asthma patients, remains to be achieved. Over recent years, the science of guideline implementation has progressed, and encouraging examples of successful asthma programmes have been...... published. This report is intended to draw on this experience and assist with the translation of asthma guideline recommendations into quality programmes for patients with asthma using current knowledge translation principles. It also provides examples of successful initiatives in various socioeconomic...
Harrod, Molly; Manojlovich, Milisa; Kowalski, Christine P; Saint, Sanjay; Krein, Sarah L
Health care-associated infection (HAI) is costly to hospitals and potentially life-threatening to patients. Numerous infection prevention programs have been implemented in hospitals across the United States. Yet, little is known about infection prevention practices and implementation in rural hospitals. The purpose of this study was to understand the infection prevention practices used by rural Veterans' Affairs (VA) hospitals and the unique factors they face in implementing these practices. This study used a sequential, mixed methods approach. Survey data to identify the HAI prevention practices used by rural VA hospitals were collected, analyzed, and used to inform the development of a semistructured interview guide. Phone interviews were conducted followed by site visits to rural VA hospitals. We found that most rural VA hospitals were using key recommended infection prevention practices. Nonetheless, a number of challenges with practice implementation were identified. The 3 most prominent themes were: (1) lack of human capital including staff with HAI expertise; (2) having to cultivate needed resources; and (3) operating as a system within a system. Rural VA hospitals are providing key infection prevention services to ensure a safe environment for the veterans they serve. However, certain factors, such as staff expertise, limited resources, and local context impacted how and when these practices were used. The creative use of more accessible alternative resources as well as greater flexibility in implementing HAI-related initiatives may be important strategies to further improve delivery of these important services by rural VA hospitals. Published 2013. This article is a U.S. Government work and is in the public domain in the USA.
Kindy, Justin; Roer, David; Wanovich, Robert; McMurray, Stephen
Patients with end-stage renal disease (ESRD) are clinically complex, requiring intensive and costly care. Coordinated care may improve outcomes and reduce costs. The objective of this study was to determine the impact of a payer-provider care partnership on key clinical and economic outcomes in enrolled patients with ESRD. Retrospective observational study. Data on patient demographics and clinical outcomes were abstracted from the electronic health records of the dialysis provider. Data on healthcare costs were collected from payer claims. Data were collected for a baseline period prior to initiation of the partnership (July 2011-June 2012) and for two 12-month periods following initiation (April 2013-March 2014 and April 2014-March 2015). Among both Medicare Advantage and commercial insurance program members, the rate of central venous catheter use for vascular access was lower following initiation of the partnership compared with the baseline period. Likewise, hospital admission rates, emergency department visit rates, and readmission rates were lower following partnership initiation. Rates of influenza and pneumococcal vaccination were higher than 95% throughout all 3 time periods. Total medical costs were lower for both cohorts of members in the second 12-month period following partnership initiation compared with the baseline period. Promising trends were observed among members participating in this payer-provider care partnership with respect to both clinical and economic outcomes. This suggests that collaborations with shared incentives may be a valuable approach for patients with ESRD.
Hales, Caz; de Vries, Kay; Coombs, Maureen
Critically ill morbidly obese patients pose considerable healthcare delivery and resource utilisation challenges in the intensive care setting. These are resultant from specific physiological responses to critical illness in this population and the nature of the interventional therapies used in the intensive care environment. An additional challenge arises for this population when considering the social stigma that is attached to being obese. Intensive care staff therefore not only attend to the physical and care needs of the critically ill morbidly obese patient but also navigate, both personally and professionally, the social terrain of stigma when providing care. To explore the culture and influences on doctors and nurses within the intensive care setting when caring for critically ill morbidly obese patients. A focused ethnographic approach was adopted to elicit the 'situated' experiences of caring for critically ill morbidly obese patients from the perspectives of intensive care staff. Participant observation of care practices and interviews with intensive care staff were undertaken over a four month period. Analysis was conducted using constant comparison technique to compare incidents applicable to each theme. An 18 bedded tertiary intensive care unit in New Zealand. Sixty-seven intensive care nurses and 13 intensive care doctors involved with the care and management of seven critically ill patients with a body mass index ≥40kg/m(2). Interactions between intensive care staff and morbidly obese patients were challenging due to the social stigma surrounding obesity. Social awkwardness and managing socially awkward moments were evident when caring for morbidly obese patients. Intensive care staff used strategies of face-work and mutual pretence to alleviate feelings of discomfort when engaged in aspects of care and caring. This was a strategy used to prevent embarrassment and distress for both the patients and staff. This study has brought new understandings
Wong Sabrina T
Full Text Available Abstract Background The Responsive Interdisciplinary Child-Community Health Education and Research (RICHER initiative is an intersectoral and interdisciplinary community outreach primary health care (PHC model. It is being undertaken in partnership with community based organizations in order to address identified gaps in the continuum of health services delivery for ‘at risk’ children and their families. As part of a larger study, this paper reports on whether the RICHER initiative is associated with increased: 1 access to health care for children and families with multiple forms of disadvantage and 2 patient-reported empowerment. This study provides the first examination of a model of delivering PHC, using a Social Paediatrics approach. Methods This was a mixed-methods study, using quantitative and qualitative approaches; it was undertaken in partnership with the community, both organizations and individual providers. Descriptive statistics, including logistic regression of patient survey data (n=86 and thematic analyses of patient interview data (n=7 were analyzed to examine the association between patient experiences with the RICHER initiative and parent-reported empowerment. Results Respondents found communication with the provider clear, that the provider explained any test results in a way they could understand, and that the provider was compassionate and respectful. Analysis of the survey and in-depth interview data provide evidence that interpersonal communication, particularly the provider’s interpersonal style (e.g., being treated as an equal, was very important. Even after controlling for parents’ education and ethnicity, the provider’s interpersonal style remained positively associated with parent-reported empowerment (p Conclusions This model of PHC delivery is unique in its purposeful and required partnerships between health care providers and community members. This study provides beginning evidence that RICHER can
Wu, Li-Fen; Koo, Malcolm; Liao, Yu-Chen; Chen, Yuh-Min; Yeh, Dah-Cherng
Spiritual care is increasingly being recognized as an integral aspect of nursing practice. The aim of this study was to develop a new instrument, Spiritual Care Needs Inventory (SCNI), for measuring spiritual care needs in acute care hospital patients with different religious beliefs. The 21-item instrument was completed by 1,351 adult acute care patients recruited from a medical center in Taiwan. Principal components analysis of the SCNI revealed two components, (a) meaning and hope and (b) caring and respect, which together accounted for 66.2% of the total variance. The internal consistency measures for the two components were 0.96 and 0.91, respectively. Furthermore, younger age, female sex, Christian religion, and regularly attending religious activities had significantly higher mean total scores in both components. The SCNI was found to be a simple instrument with excellent internal consistency for measuring the spiritual care needs in acute care hospital patients. © The Author(s) 2015.
Solimeo, Samantha L; Ono, Sarah S; Stewart, Kenda R; Lampman, Michelle A; Rosenthal, Gary E; Stewart, Greg L
International implementation of the patient-centered medical home (PCMH) model for delivering primary care has dramatically increased in the last decade. A majority of research on PCMH's impact has emphasized the care provided by clinically trained staff. In this article, we report our ethnographic analysis of data collected from Department of Veterans Affairs staff implementing PACT, the VA version of PCMH. Teams were trained to use within-team delegation, largely accomplished through attention to clinical licensure, to differentiate staff in providing efficient, patient-centered care. In doing so, PACT may reinforce a clinically defined culture of care that countermands PCMH ideals. Such competing rubrics for care are brought into relief through a focus on the care work performed by clerks. Ethnographic analysis identifies clerks' care as a kind of emotional dirty work, signaling important areas for future anthropological study of the relationships among patient-centered care, stigma, and clinical authority. © 2016 by the American Anthropological Association.
King, Heidi B; Kesling, Kimberly; Birk, Carmen; Walker, Theodore; Taylor, Heather; Datena, Michael; Burgess, Brittany; Bower, Lyndsay
Partnership for Patients (PfP) was a national initiative sponsored by the Department of Health and Human Services, Centers for Medicare and Medicaid Services, to reduce preventable hospital acquired conditions (HACs) by 40% and readmissions (within 30 days) by 20%, by the end of 2013 (as compared to the baseline of CY2010). Along with partners across the nation, the Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, pledged to support PfP in June 2011. Participation of the Military Health System (MHS) in PfP marked the implementation of the first enterprise-wide patient safety initiative. Three phases of the MHS initiative were developed to meet the aims of the national PfP initiative: (1) Planning and Design, (2) Implementation, and (3) Monitoring and Sustainment. The Planning and Design phase focused on the identification of evidence-based practices (Table III); the development of implementation guides; the implementation of various communication, education, and improvement strategies; and the development of methods by which to track progress and share successes. The implementation phase focused on identifying roles and responsibilities across all levels of care; creating, disseminating, and implementing evidence-based practices at participating military treatment facilities; and establishing a structured learning action network. Finally, during the monitoring and sustainment phase, per the guidance of the Agency for Healthcare Research and Quality, an overall HAC rate was developed for quarterly analysis. The HAC rate per 1,000 dispositions (i.e., discharges) was an aggregate of all PfP HACs. Using the HAC rate, the improvement rate was calculated by comparing the current quarter's HAC rate to the baseline (CY2010). This allowed the MHS to track the overall progress across the enterprise. The MHS achieved a number of accomplishments, including a 15.8% cumulative reduction in HACs by the end of 2013, an 11.1% reduction in readmissions
Field, John; Pearson, Alan
Beyond the initial 'shock-horror' reaction in the mass media, little attention is paid by nurses or the public to nurses who murder patients. This study used discursive inquiry to uncover social constructions of this phenomenon and their implications for the definition and treatment of such murders. The mass media and professional literature were searched for commentary on cases of nurses who had been convicted of murder between 1980 and 2006. The retrieved texts were subjected to discursive analysis. Discursive constructions included the profile of murderous nurses; types of murders; contexts in which murder occurs; factors that aid detection and apprehension; legal processes and punishment; and reactions of the public, profession, regulators and families. The findings imply that murder of a patient by a nurse might occur in any setting in which nurses care for vulnerable patients--the old, the young, the sick and the disabled. Trust in nurses assists a nurse to murder. Nurses have a responsibility to understand how their workplaces can form crucibles in which murder can take place. The profession needs to acknowledge the possibility of nurses who murder patients and to commence a discussion about what might be done to limit the harm they do.
Full Text Available Abstract Background Many Finnish emergency departments (ED serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland. Methods The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital. A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care, B (to be examined within 10 min, C (to be examined within 1 h, D (to be examined within 2 h and E (no need for immediate treatment for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse. The introduction of this triage system was combined with information to the public on the "correct" use of emergency services. Results After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month as compared to the three previous years in the EDs
Neergaard, Mette Asbjørn; Jensen, Anders Bonde; Olesen, Frede
BACKGROUND. Palliative care for cancer patients is an important part of a GP's work. Although every GP is frequently involved in care for terminally ill cancer patients, only little is known about how these palliative efforts are perceived by the patients and their families, a knowledge...... that is vital to further improve palliative care in the primary sector.AIM. The aim of the study was to analyse the quality of palliative home care with focus on the GP's role based on evaluations by relatives of recently deceased cancer patients and professionals from both the primary and secondary health care...... approach.RESULTS. The analyses revealed several key areas, e.g.: 1) How to take, give and maintain professional responsibility for palliative home care. 2) A need for transparent communication both among primary care professionals and among professionals across the primary/secondary interface. 3...
Wiest, G H; Harsch, I A; Fuchs, F S; Kitzbichler, S; Bogner, K; Brueckl, W M; Hahn, E G; Ficker, J H
Heated humidifiers (HH) enable effective treatment of upper airway dryness during nasal continuous positive airway pressure (nCPAP) therapy for obstructive sleep apnoea (OSA), but the role of prophylactic use of HH during the initiation of nCPAP treatment has not been studied so far. The aim of the present study was to investigate whether prophylactic HH during the initiation of CPAP would result in improved initial patient comfort and acceptance. In 44 consecutive, previously untreated OSA patients with no history of upper airway dryness, CPAP titration with and without HH was performed on two consecutive nights in a randomised order. The patients were interviewed after each treatment night in order to establish the comfort of the treatment, and, after the second treatment, they were asked which of the two nights they considered more pleasant, and which treatment they would prefer for long-term use. Following CPAP titration with HH, 32 patients (73%) claimed to have had a better night's sleep than usual (i.e. without CPAP treatment) compared with 33 patients (75%) saying the same following CPAP treatment without HH. For 21 patients (47.7%) treatment with HH was more pleasant, 23 (52.3%) saw no difference or said that treatment without HH was more pleasant. Nineteen patients (43.2%) gave preference to treatment with HH for long-term use, while 25 patients (56.8%) had no preference or said they would prefer treatment without HH. The use of HH during the initiation phase of CPAP treatment was associated neither with an initial improvement in comfort nor with greater initial treatment acceptance. Copyright 2002 S. Karger AG, Basel
Lin, Yea-Pyng; Tsai, Yun-Fang
This article is a report of a study undertaken to understand how nurses maintain patients' dignity in clinical practice. Dignity is a core concept in nursing care and maintaining patients' dignity is critical to their recovery. In Western countries, measures to maintain dignity in patients' care include maintaining privacy of the body, providing spatial privacy, giving sufficient time, treating patients as a whole person and allowing patients to have autonomy. However, this is an under-studied topic in Asian countries. For this qualitative descriptive study, data were collected in Taiwan in 2009 using in-depth interviews with a purposive sample of 30 nurses from a teaching hospital in eastern Taiwan. The audiotaped interviews were transcribed verbatim and analysed using content analysis. Nurses' measures to maintain dignity in patient care were captured in five themes: respect, protecting privacy, emotional support, treating all patients alike and maintaining body image. Participants did not mention beneficence, a crucial element achieved through the professional care of nurses that can enhance the recovery of patients. In-service education to help nurses enhance dignity in patient care should emphasize emotional support, maintaining body image and treating all patients alike. Our model for maintaining dignity in patient care could be used to develop a clinical care protocol for nurses to use in clinical practice. © 2010 Blackwell Publishing Ltd.
Untas, Aurélie; Rascle, Nicole; Idier, Laetitia; Lasseur, Catherine; Combe, Christian
This study investigated the effect of family relations on patients' adjustment to dialysis. The two main aims were to develop a family typology, and to explore the influence of family profile on the patient's anxiety, depression and adherence to nutritional guidelines. The sample consisted of 120 patients (mean age 63 years; 67.5% of men). They completed several measures 1, 6 and 12 months after dialysis initiation. The scales used were the Family Relationship Index and the Hospital Anxiety and Depression Scale. Perceived adherence to nutritional guidelines was assessed using two visual analogical scales. Results showed that family relations remained stable over time. Cluster analysis yielded three family profiles, which were named conflict, communicative and supportive families. Patients belonging to conflict families perceived themselves as less adhering to nutritional guidelines. For these patients, anxiety and depressive moods increased significantly over time, whereas mental health remained stable over time for communicative and supportive families. This research underlines that family relations are essential in global consideration of the care of patients treated by dialysis. Conflict families seem especially at risk. They should be identified early to help them adapt to this stressful treatment.
Kawai, Yu; Weatherhead, Jeffrey R; Traube, Chani; Owens, Tonie A; Shaw, Brenda E; Fraser, Erin J; Scott, Annette M; Wojczynski, Melody R; Slaman, Kristen L; Cassidy, Patty M; Baker, Laura A; Shellhaas, Renee A; Dahmer, Mary K; Shever, Leah L; Malas, Nasuh M; Niedner, Matthew F
Noise pollution in pediatric intensive care units (PICU) contributes to poor sleep and may increase risk of developing delirium. The Environmental Protection Agency (EPA) recommends noise pollution, to develop a delirium bundle targeted at reducing noise, and to assess the effect of the bundle on nocturnal noise pollution. This is a QI initiative at an academic PICU. Thirty-five sound sensors were installed in patient bed spaces, hallways, and common areas. The pediatric delirium bundle was implemented in 8 pilot patients (40 patient ICU days) while 108 non-pilot patients received usual care over a 28-day period. A total of 20,609 hourly dB readings were collected. Hourly minimum, average, and maximum dB of all occupied bed spaces demonstrated medians [interquartile range] of 48.0 [39.0-53.0], 52.8 [48.1-56.2] and 67.0 [63.5-70.5] dB, respectively. Bed spaces were louder during the day (10AM to 4PM) than at night (11PM to 5AM) (53.5 [49.0-56.8] vs. 51.3 [46.0-55.3] dB, P noise pollution exists in our PICU, and utilizing the pediatric delirium bundle led to a significant noise reduction that can be perceived as half the loudness with hourly nighttime average dB meeting the EPA standards when compliant with the bundle.
Scardina, S A
Rising health care costs and competition among hospital facilities have resulted in the need to recognize patient satisfaction as an important indicator of quality care. Nurses provide the primary service to patients; therefore, their role is influential in overall satisfaction. Several instruments have been developed to measure patient satisfaction with nursing care; however, most of them focus only on patient perceptions. One such approach to evaluating patient satisfaction with nursing care involves an instrument, SERVQUAL, derived from a marketing service perspective. Adapting SERVQUAL for use in evaluating nursing care is the focus of this article. SERVQUAL assesses both patient perceptions and expectations of quality service and permits managers and clinicians to view the gaps between the two; thus, the overall areas of improvement in nursing services can be determined.
Surya, Asik; Setyaningsih, Budiarti; Suryani Nasution, Helmi; Gita Parwati, Cicilia; Yuzwar, Yullita E; Osberg, Mike; Hanson, Christy L; Hymoff, Aaron; Mingkwan, Pia; Makayova, Julia; Gebhard, Agnes; Waworuntu, Wiendra
Tuberculosis (TB) is the fourth leading cause of death in Indonesia. In 2015, the World Health Organization estimated that nearly two-thirds of the TB patients in Indonesia had not been notified, and the status of their care remained unknown. As such, Indonesia is home to nearly 20% of the world's "missing" TB patients. Understanding where patients go for care may enable strategic planning of services to better reach them. A patient pathway analysis (PPA) was conducted to assess the alignment between patient care seeking and the availability of TB diagnostic and treatment services at the national and subnational level in Indonesia. The PPA results revealed that only 20% of patients encountered diagnostic capacity at the location where they first sought care. Most initial care seeking occurred in the private sector and case notification lagged behind diagnostic confirmation in the public sector. The PPA results emphasize the role that the private sector plays in TB patient care seeking and suggested a need for differentiated approaches, by province, to respond to variances in care-seeking patterns and the capacities of public and private providers. © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.
Miranda, David J; Zeller, Paula K; Lee, Rosemary; Koepke, Christopher P; Holland, Howard E; Englert, Farah; Swift, Elaine K
... patients reduce health care system errors and improve the safety of their care. The basis for the fact sheet was a larger set of messages drawn from a review of the health care literature by the Agency for Healthcare Research and Quality...
Self care activities among patients with diabetes attending a tertiary care hospital in Mangalore Karnataka, India. ... Conclusions: Self‑care practices were found to be unsatisfactory in almost all aspects except for blood sugar monitoring and treatment adherence. As these practices are essential for prevention of ...
Cabana, Michael D.; Slish, Kathryn K.; Evans, David; Mellins, Robert B.; Brown, Randall W.; Lin, Xihong; Kaciroti, Niko; Clark, Noreen M.
Objective: We evaluated the effectiveness of a continuing medical education program, Physician Asthma Care Education, in improving pediatricians' asthma therapeutic and communication skills and patients' health care utilization for asthma. Methods: We conducted a randomized trial in 10 regions in the United States. Primary care providers were…
LeBlanc, Allana; Bourbonnais, Frances Fothergill; Harrison, Denise; Tousignant, Kelly
The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) To examine intensive care nurses' experiences of caring for adult patients with delirium; 2) To identify factors that facilitate or hinder intensive care nurses caring for these patients. This study utilised an interpretive phenomenological approach as described by van Manen. Individual conversational interviews were conducted with eight intensive care nurses working in a tertiary level, university-affiliated hospital in Canada. The essence of the experience of nurses caring for patients with delirium in intensive care was revealed to be finding a way to help them come through it. Six main themes emerged: It's Exhausting; Making a Picture of the Patient's Mental Status; Keeping Patients Safe: It's aReally Big Job; Everyone Is Unique; Riding It Out With Families and Taking Every Experience With You. The findings contribute to an understanding of how intensive care nurses help patients and their families through this complex and distressing experience. Copyright © 2017 Elsevier Ltd. All rights reserved.
Loeb, Danielle F; Binswanger, Ingrid A; Candrian, Carey; Bayliss, Elizabeth A
Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor-a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)-that complicated care for chronic medical illnesses. This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. © 2015 Annals of Family Medicine, Inc.
Lilley, Lisa; Lodrigues, William; Dreadin-Pulliam, Julie; Xie, Xian-Jin; Mathur, Sakshi; Rao, Madhu; Harvey, Valorie; Leitch, Ann Marilyn; Rao, Roshni
Background Cancer is one of the most common diseases that patients research on the Internet. The Commission on Cancer (CoC) recommended that Parkland Memorial Hospital (PMH) improve the oncology services website. PMH is Dallas County’s public health care facility, serving a largely uninsured, minority population. Most research regarding patient Internet use has been conducted in insured, Caucasian populations, raising concerns that the needs of PMH patients may not be extrapolated from available data. The PMH Cancer Committee, therefore, adopted a quality improvement initiative to understand patients’ Internet usage. Objective The objective of the study was to obtain and analyze data regarding patients’ Internet usage in order to make targeted improvements to the oncology services section of the institutional website. Methods A task force developed an 11-question survey to ascertain what proportion of our patients have Internet access and use the Internet to obtain medical information as well as determine the specific information sought. Between April 2011 and August 2011, 300 surveys were administered to newly diagnosed cancer patients. Multivariate analyses were performed. Results Of 300 surveys, 291 were included. Minorities, primarily African-American and Hispanic, represented 78.0% (227/291) of patients. Only 37.1% (108/291) of patients had Internet access, most (256/291, 87.9%) having access at home. Younger patients more commonly had Internet access, with a mean age of 47 versus 58 years for those without (PInternet research was to develop questions for discussion with one’s physician. Patients most frequently sought information regarding cancer treatment options, outcomes, and side effects. Conclusions Less than one-half of PMH oncology patients have Internet access. This is influenced by age, educational level, and ethnicity. Those with access use it to obtain information related to their cancer diagnosis. The most effective way of addressing our
Wiese, C H R; Vagts, D A; Kampa, U; Pfeiffer, G; Grom, I-U; Gerth, M A; Graf, B M; Zausig, Y A
At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients. For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources. As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment. Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive
Raphael, Bram P; Schumann, Caitlin; Garrity-Gentille, Sara; McClelland, Jennifer; Rosa, Carolyn; Tascione, Christina; Gallotto, Mary; Takvorian-Bené, Melissa; Carey, Alexandra N; McCarthy, Patrick; Duggan, Christopher; Ozonoff, Al
Despite being less costly than prolonged hospitalization, home parenteral nutrition (HPN) is associated with high rates of post-discharge complications, including frequent readmissions and central line-associated bloodstream infections (CLABSIs). Telemedicine has been associated with improved outcomes and reduced healthcare utilization in other high-risk populations, but no studies to date have supported effectiveness of telemedicine in pediatric HPN. We prospectively collected data on pediatric patients managed at a single HPN program who participated in postdischarge telemedicine visits from March 1, 2014 to March 30, 2016. We excluded patients with a history of HPN and strictly palliative care goals. Univariate analysis was performed for primary outcomes: Community-acquired CLABSI and 30-day readmission rate. Twenty-six families participated in the pilot initiative with median (interquartile range) patient age 1.5 (5.7) years old, diagnosis of short bowel syndrome in 16 (62%), and in-state residence in 17 (55%). Ishikawa (fishbone) diagram identified causes of post-discharge HPN complications. Areas of focus during telemedicine visit included central venous catheter care methods, materials, clinical concerns, and equipment. Compared to historical comparison group, the telemedicine group experienced CLABSI rates of 1.0 versus 2.7 per 1,000 line days and readmission rates of 38% versus 17% (p = 0.03, 0.02, respectively). Telemedicine visits identified opportunities for improvement for families newly discharged on HPN. In a small cohort of patients who experienced telemedicine visits, we found lower CLABSI rates alongside higher readmission rates compared with a historical comparison group. Further studies are needed to optimize telemedicine in delivering care to this high-risk population.
Czakert, Judith; Lehmann, Yvonne; Ewers, Michael
In recent years there has been a growing trend towards nursing care at home in general as well as towards intensive home care being provided by specialized home care services in Germany. However, resulting challenges for patient safety have rarely been considered. Against this background we aimed to explore whether international recommendations for patient safety in home care in general and in intensive home care in particular already exist and how they can stimulate further practice development in Germany. A review of online English documents containing recommendations for patient safety in intensive home care was conducted. Available documents were analyzed and compared in terms of their form and content. Overall, a small number of relevant documents could be identified. None of these documents exclusively refer to the intensive home care sector. Despite their differences, however, the analysis of four selected documents showed similarities, e. g., regarding specific topics of patient safety (communication, involvement of patients and their relatives, risk assessment, medication management, qualification). Furthermore, strengths and weaknesses of the documents became apparent: e. g., an explicit understanding of patient safety, a literature-based introduction to safety topics or an adaptation of the recommendations to the specific features of home care were occasionally lacking. This document analysis provides interesting input to the formal and content-related development of specific recommendations and to practice development in Germany to improve patient safety in home care. Copyright © 2018. Published by Elsevier GmbH.
Psychiatric nurses are expert care providers for individuals with mental health needs. The art of caring spans across multiple species, is important to understand, and is universal whether intentions are toward individuals or animals. Pets are often cared for and viewed as family members. The current research examined psychiatric nurses' views on the similarities and differences of caring for patients and their pet dogs. Twenty-five nurses were interviewed. Similarities of caring for patients and canines included trusting relationships, companionship, daily basic needs, and improved communication through monitored body language. Differences in caring included personal expectations, unconditional love, and professional boundaries. Understanding the concepts of caring for patients and pet dogs will provide the opportunity for insight into familial versus professional relationships, improve communication with others, and strengthen the human-animal bond. [Journal of Psychosocial Nursing and Mental Health Services, 55(3), 46-52.]. Copyright 2017, SLACK Incorporated.
Dyrstad, Dagrunn Nåden; Storm, Marianne
Educating and training healthcare professionals is known to improve the quality of transitional care for older adults. Arranging interprofessional meetings for healthcare professionals might be useful to improve patient participation skills in transitional care. To describe the learning activities used in The Meeting Point programme, focusing on patient participation in transitional care, and assess whether they increase healthcare professionals' awareness of and competencies relating to patient participation in the transitional care of older patients. Data were collected as part of an educational intervention programme, The Meeting Point, including three seminars on 'Patient participation in the transitional care of older patients' and four follow-up meetings. Participants were nurses, care assistants, doctors, physiotherapists, patient coordinators and administrative personnel from hospital, nursing homes and home-based care services. The Meeting Point was organised around four pillars: introduction, teaching session, group work activity and plenary discussion. Qualitative data included log reports, summaries of meetings, notes from group work activities, and reports from participants and from follow-up meetings. Feedback from participants shows that they were satisfied with meeting healthcare professionals from other units of care. A film scenario was perceived relevant for group work activity and useful in focusing participants' attention to patient participation. Follow-up meetings show that some nursing home wards, the emergency department and one medical ward at the hospital continued with ongoing work to improve quality of care. Efforts included implementation of an observational waiting room with comfortable chairs, planning for discharge in hospital admission, a daily patient flow registration system and motivational interviewing during admission to nursing home. The description of the learning activities used at The Meeting Point seminars shows that they
Tisherman, Samuel A; Kaplan, Lewis; Gracias, Vicente H; Beilman, Gregory J; Toevs, Christine; Byrnes, Matthew C; Coopersmith, Craig M
Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few. Recommendations are made for broadening the multidisciplinary training and practice opportunities in surgical critical care for intensivists from all base specialties and for maintaining the intensivist model within acute care surgery practice. Support from academic and administrative leadership, as well as national organizations, will be needed.
Thomas, Kristin; Krevers, Barbro; Bendtsen, Preben
Non-communicable diseases are a leading cause of death and can largely be prevented by healthy lifestyles. Health care organizations are encouraged to integrate healthy lifestyle promotion in routine care. This study evaluates the impact of a team initiative on healthy lifestyle promotion in primary care. A quasi-experimental, cross-sectional design compared three intervention centres that had implemented lifestyle teams with three control centres that used a traditional model of care. Outcomes were defined using the RE-AIM framework: reach, the proportion of patients receiving lifestyle promotion; effectiveness, self-reported attitudes and competency among staff; adoption, proportion of staff reporting regular practice of lifestyle promotion; implementation, fidelity to the original lifestyle team protocol. Data collection methods included a patient questionnaire (n = 888), a staff questionnaire (n = 120) and structured interviews with all practice managers and, where applicable, team managers (n = 8). The chi square test and problem-driven content analysis was used to analyse the questionnaire and interview data, respectively. Reach: patients at control centres (48%, n = 211) received lifestyle promotion significantly more often compared with patients at intervention centres (41%, n = 169). Effectiveness: intervention staff was significantly more positive towards the effectiveness of lifestyle promotion, shared competency and how lifestyle promotion was prioritized at their centre. Adoption: 47% of staff at intervention centres and 58% at control centres reported that they asked patients about their lifestyle on a daily basis. all intervention centres had implemented multi-professional teams and team managers and held regular meetings but struggled to implement in-house referral structures for lifestyle promotion, which was used consistently among staff. Intervention centres did not show higher rates than control centres on reach of patients
Cristiane A. Menezes de Pádua
Full Text Available A cross-sectional analysis was carried out to describe adverse reactions to antiretroviral therapy (ART reported by HIV-infected patients initiating treatment at two public health AIDS referral centers in Belo Horizonte, Brazil, 2001-2003 and to verify their association with selected variables. Adverse reactions were obtained through interview at the first follow-up visit (first month after the antiretroviral prescription. Socio-demographic and behavioral variables related to ART were obtained from baseline and follow-up interviews and clinical variables from medical charts. Patients with four or more reactions were compared to those with less than four. Odds ratio with 95% confidence interval were estimated using logistic regression model for both univariate and multivariate analyses. At least one adverse reaction was reported by 92.2% of the participants while 56.2% reported four or more different reactions. Antiretroviral regimens including indinavir/ritonavir, irregular use of antiretrovirals and switch in regimens were independently associated with four or more adverse reactions (OR=7.92, 5.73 and 2.03, respectively. The initial period of ARV treatment is crucial and patients´ perception of adverse reactions should be carefully taken into account. Strategies for monitoring and management of adverse reactions including the choice of regimens and the prevention of irregular ART should be developed in AIDS/HIV referral centers in Brazil to promote better adherence to antiretroviral therapy.
Suurmond, J.; Uiters, E.; de Bruijne, M.C.; Stronks, K.; Essink-Bot, M.L.
ABSTRACT: BACKGROUND: Negative events are abusive, potentially dangerous or life-threatening health care events, as perceived by the patient. Patients' perceptions of negative events are regarded as a potentially important source of information about the quality of health care. We explored negative
Verbakel, Natasha J.; Langelaan, Maaike; Verheij, Theo J. M.; Wagner, Cordula; Zwart, Dorien L. M.
Background: Patient safety culture, described as shared values, attitudes and behavior of staff in a health-care organization, gained attention as a subject of study as it is believed to be related to the impact of patient safety improvements. However, in primary care, it is yet unknown, which
Campbell, Suzann K.
The purpose of this special issue of Physical & Occupational Therapy in Pediatrics is to present an evidence-based system to guide the physical therapy management of patients in the Neonatal Intensive Care Unit (NICU). Two systematic guides to patient management will be presented. The first is a care path intended primarily for use by physical…
Poulsen, Erik; Overgaard, Søren; Vestergaard, Jacob T
BACKGROUND: Hip osteoarthritis (OA) is the most common diagnosis in primary care adult patients presenting with hip pain but pain location and pain distribution in primary care patients with hip OA have been reported inadequately. OBJECTIVE: To describe pain location and pain distribution...
Halpern, Michael T.; Teixeira-Poit, Stephanie M.; Kane, Heather; Frost, Corey; Keating, Michael; Olmsted, Murrey
Neurologists are central to providing quality care for individuals with MS. However, neurologist shortages may restrict access to care for MS patients. To examine factors influencing neurologists' provision of MS care, we surveyed 1,700 US neurologists to assess demographic/practice characteristics, training, and attitudes toward MS care. The study population consisted of 573 respondents: 87 (15.2%) MS subspecialists and 486 (84.8%) “other neurologists,” including subspecialists in other neurology areas (i.e., non-MS) and general neurologists. MS subspecialists indicating they “enjoy interacting with MS patients” had a significantly greater rate of MS patients seen per week. In separate analyses of the “other neurologists” group, the rate of MS patients seen was lower among neurologists in university-based groups or those practicing in major cities; female neurologists; and neurologists who indicated lack of sufficient knowledge regarding MS patient care. Rates of MS patients seen were significantly greater for other neurologists who agreed that MS care involved “ability to improve patient outcomes and quality of life”; “dynamic area with evolving treatment options”; and “enjoy interacting with MS patients.” Understanding factors influencing MS patient care by neurologists and developing policies for appropriate access to care is critical for optimal outcomes among this population. PMID:24949203
Michael T. Halpern
Full Text Available Neurologists are central to providing quality care for individuals with MS. However, neurologist shortages may restrict access to care for MS patients. To examine factors influencing neurologists’ provision of MS care, we surveyed 1,700 US neurologists to assess demographic/practice characteristics, training, and attitudes toward MS care. The study population consisted of 573 respondents: 87 (15.2% MS subspecialists and 486 (84.8% “other neurologists,” including subspecialists in other neurology areas (i.e., non-MS and general neurologists. MS subspecialists indicating they “enjoy interacting with MS patients” had a significantly greater rate of MS patients seen per week. In separate analyses of the “other neurologists” group, the rate of MS patients seen was lower among neurologists in university-based groups or those practicing in major cities; female neurologists; and neurologists who indicated lack of sufficient knowledge regarding MS patient care. Rates of MS patients seen were significantly greater for other neurologists who agreed that MS care involved “ability to improve patient outcomes and quality of life”; “dynamic area with evolving treatment options”; and “enjoy interacting with MS patients.” Understanding factors influencing MS patient care by neurologists and developing policies for appropriate access to care is critical for optimal outcomes among this population.
The study shows that there are wide variations within and between professional health groups in the classification of errors in patient care. The implications of the absence of a classificatory scheme for errors in patient care for service improvement and organisational learning in the hospital environment are discussed.
Conclusions Patients and HCPs welcomed the introduction of agent technology to the delivery of health care. Widespread use will depend more on the trust patients place in their own GP than on technological issues.
Stuurman-Bieze, A.GG; Kokenberg, M.E.A.P.; Tobi, H; de Boer, W.O.; van Doormaal, Jasperien E.; de Jong-van den Berg, Lolkje Theodora Wilhelmina; Tromp, Th.F.J.
Objective: The IPMP study (Interventions on the principle of Pulmonary Medication Profiles) investigates and describes the results of complex pharmaceutical care interventions provided to selected pulmonary patients to improve their drug use. This paper describes the patients' opinions about the
Martinez-Litago, E; Martínez-Velasco, M C; Muniesa-Zaragozano, M P
Patients with advanced chronic diseases receive fragmented care, which entails high resource consumption and a poor quality of life. Uncertainty in the prognosis and scarce investigation into the importance of symptomatic control in this patient group hinders a proper therapeutic approach. Palliative care teams optimise the use of resources through comprehensive patient care, the optimization of the patient's environment, communication, the preparation of early care plans and the creation of coordinated healthcare circuits, which improve the quality of the patient's care in advanced stages of the disease. In the end-of-life phase, the therapeutic approach is focused on symptomatic control, selecting treatments according to the cause, comorbidities and the patient's wishes. To control refractory symptoms, palliative sedation is considered an indispensable option. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.
Selix, Nancy W; Rowniak, Stefan
Transgender individuals have unique health care needs and experience health disparities. There is an increased need for transgender health care services and primary care for this underserved population. However, provision of appropriate health care services for transgender persons requires cultural competency and skill on the part of the health care provider, and providers need specific skills to address the needs of this population. A review of the literature was performed by accessing CINAHL, PsycINFO, and PubMed databases. Pertinent research was extracted and reviewed for relevance. References in these publications were reviewed to identify additional publications that address primary prevention, secondary prevention, and tertiary care of transgender individuals. Articles that include prevention, screening, and treatment of health problems of transgender persons were identified. Research on the health needs of the transgender population is limited. Whenever available, research findings that address this unique population should be incorporated into clinical practice. When research evidence is not available to address the unique needs of transgender individuals, research and clinical care guidelines from the general population may be applied for health screening and maintenance. This article provides information about primary care services for transgender individuals and seeks to improve awareness of the health disparities this underserved population experiences. Simple solutions to modify clinical settings to enhance care are provided. © 2016 by the American College of Nurse-Midwives.
Fox, Brent I; Felkey, Bill G
In our earliest thoughts of how to engage patients in self-care management, we found online banking and finance to be the best model for health care to follow. This model is still right for today. Although no digital approach will apply to 100% of any population, there is evidence that older patient populations see the benefit of being able to access their health care providers online and on mobile devices. It's all about the data, the systems, and the people.
Managers in health care organizations today are expected to achieve higher-quality patient care at a lower cost. Developing and maintaining a positive organizational climate can help improve motivation and foster higher employee performance. In turn, this will help the organization deliver better patient care at a lower cost. This article offers metrics for assessing organizational climate, analyzes barriers to a positive climate, and explores strategies that managers can use to build the type of climate that fosters high performance.
Lee, Ping Yein; Khoo, Ee Ming; Low, Wah Yun; Lee, Yew Kong; Abdullah, Khatijah Lim; Azmi, Syahidatul Akmal; Ng, Chirk Jenn
Malaysia is an Asian country with population of diverse culture and health perceptions. Patient decision aid (PDA) is a new tool in Malaysia. Patients' and health-care professionals' (HCPs) expectation of a PDA is unknown. We aimed to explore patients' and health-care professionals'(HCPs) views on the information needed in a patient decision aid (PDA) on insulin initiation developed for patients with type 2 diabetes mellitus (T2DM). We used a qualitative design and thematic approach. Three main primary health-care settings in Malaysia: public university-based primary care clinics, public health-care clinics and private general practices. We conducted focus groups and one-to-one interviews with a purposive sample of health professionals and patients with type 2 diabetes. We interviewed 18 patients and 13 HCPs. Patients viewed the content of the PDA as simple and clear. However, HCPs felt the PDA might be difficult for patients with low literacy to understand. HCPs thought the PDA was too lengthy. Nevertheless, patients would prefer more information. HCPs tended to focus on benefits of insulin, while patients wanted to know the impact of insulin on their quality of life and practical issues regarding insulin and its side-effects. Patients preferred numbers to weigh the risks and benefits of treatment options. HCPs' views that presenting numbers in a PDA would be too complex for patients to understand. It is important to consider including issues related to psycho-social impact of treatment to patients when developing a patient decision aid. © 2015 John Wiley & Sons Ltd.
Elizabeth M. Borycki
Full Text Available This special issue of the Knowledge Management & E-Learning: An International Journal is dedicated to describing “Advances in Healthcare Provider and Patient Training to Improve the Quality and Safety of Patient Care.” Patient safety is an important and fundamental requirement of ensuring the quality of patient care. Training and education has been identified as a key to improving healthcare provider patient safety competencies especially when working with new technologies such as electronic health records and mobile health applications. Such technologies can be harnessed to improve patient safety; however, if not used properly they can negatively impact on patient safety. In this issue we focus on advances in training that can improve patient safety and the optimal use of new technologies in healthcare. For example, use of clinical simulations and online computer based training can be employed both to facilitate learning about new clinical discoveries as well as to integrate technology into day to day healthcare practices. In this issue we are publishing papers that describe advances in healthcare provider and patient training to improve patient safety as it relates to the use of educational technologies, health information technology and on-line health resources. In addition, in the special issue we describe new approaches to training and patient safety including, online communities, clinical simulations, on-the-job training, computer based training and health information systems that educate about and support safer patient care in real-time (i.e. when health professionals are providing care to patients. These educational and technological initiatives can be aimed at health professionals (i.e. students and those who are currently working in the field. The outcomes of this work are significant as they lead to safer care for patients and their family members. The issue has both theoretical and applied papers that describe advances in patient
To describe the critical care nurses' experiences in caring for patients of Muslim denomination in Saudi Arabia. Caring is known to be the essence of nursing but many health-care settings have become more culturally diverse. Caring has been examined mainly in the context of Western cultures. Muslims form one of the largest ethnic minority communities in Britain but to date, empirical studies relating to caring from an Islamic perspective is not well documented. Research conducted within the home of Islam would provide essential truths about the reality of caring for Muslim patients. Phenomenological descriptive. Methods. Six critical care nurses were interviewed from a hospital in Saudi Arabia. The narratives were analysed using Colaizzi's framework. The meaning of the nurses' experiences emerged as three themes: family and kinship ties, cultural and religious influences and nurse-patient relationship. The results indicated the importance of the role of the family and religion in providing care. In the process of caring, the participants felt stressed and frustrated and they all experienced emotional labour. Communicating with the patients and the families was a constant battle and this acted as a further stressor in meeting the needs of their patients. The concept of the family and the importance and meaning of religion and culture were central in the provision of caring. The beliefs and practices of patients who follow Islam, as perceived by expatriate nurses, may have an effect on the patient's health care in ways that are not apparent to many health-care professionals and policy makers internationally. Readers should be prompted to reflect on their clinical practice and to understand the impact of religious and cultural differences in their encounters with patients of Islam denomination. Policy and all actions, decisions and judgments should be culturally derived.
O'Donnell, Alison J; Bogner, Hillary R; Cronholm, Peter F; Kellom, Katherine; Miller-Day, Michelle; McClintock, Heather F de Vries; Kaye, Elise M; Gabbay, Robert
Hypertension is a major modifiable risk factor for cardiovascular and kidney disease, yet the proportion of adults whose hypertension is controlled is low. The patient-centered medical home (PCMH) is a model for care delivery that emphasizes patient-centered and team-based care and focuses on quality and safety. Our goal was to investigate changes in hypertension care under PCMH implementation in a large multipayer PCMH demonstration project that may have led to improvements in hypertension control. The PCMH transformation initiative conducted 118 semistructured interviews at 17 primary care practices in southeastern Pennsylvania between January 2011 and January 2012. Clinicians (n = 47), medical assistants (n = 26), office administrators (n = 12), care managers (n = 11), front office staff (n = 7), patient educators (n = 4), nurses (n = 4), social workers (n = 4), and other administrators (n = 3) participated in interviews. Study personnel used thematic analysis to identify themes related to hypertension care. Clinicians described difficulties in expanding services under PCMH to meet the needs of the growing number of patients with hypertension as well as how perceptions of hypertension control differed from actual performance. Staff and office administrators discussed achieving patient-centered hypertension care through patient education and self-management support with personalized care plans. They indicated that patient report cards were helpful tools. Participants across all groups discussed a team- and systems-based approach to hypertension care. Practices undergoing PCMH transformation may consider stakeholder perspectives about patient-centered, team-based, and systems-based approaches as they work to optimize hypertension care.
Sadigh, Gelareh; Carlos, Ruth C; Krupinski, Elizabeth A; Meltzer, Carolyn C; Duszak, Richard
The purpose of this article is to review the literature on communicating transparency in health care pricing, both overall and specifically for medical imaging. Focus is also placed on the imperatives and initiatives that will increasingly impact radiologists and their patients. Most Americans seek transparency in health care pricing, yet such discussions occur in fewer than half of patient encounters. Although price transparency tools can help decrease health care spending, most are used infrequently and most lack information about quality. Given the high costs associated with many imaging services, radiologists should be aware of such initiatives to optimize patient engagement and informed shared decision making.
Maria do Céu Mendes Pinto Marques
Full Text Available Objectives: To adapt the Self-Care of Heart Failure Index V6.2 to Portuguese and analyze self-care capability in maintenance, management and self-confidence in patients with heart failure attending nursing care services at two Portuguese hospitals. Method: Exploratory study, sample of 110 patients who attended the nursing care service for patients with heart failure at two Portuguese hospitals, carried out over a six-month period. Descriptive statistics and psychometric tests were used. Results: Internal consistency similar to the original scale. The patients consisted mostly of older adults with low self-care literacy, low values associated with physical activity and salt control in meals taken outside the home, and inadequate control of signs and symptoms. Conclusion: Patients present difficulties in maintenance and management of the disease, and are self-confident regarding it. This instrument enables individualized assessment leading to decision-making and adjusted action.
Serena P Koenig
Full Text Available High attrition during the period from HIV testing to antiretroviral therapy (ART initiation is widely reported. Though treatment guidelines have changed to broaden ART eligibility and services have been widely expanded over the past decade, data on the temporal trends in pre-ART outcomes are limited; such data would be useful to guide future policy decisions.We evaluated temporal trends and predictors of retention for each step from HIV testing to ART initiation over the past decade at the GHESKIO clinic in Port-au-Prince Haiti. The 24,925 patients >17 years of age who received a positive HIV test at GHESKIO from March 1, 2003 to February 28, 2013 were included. Patients were followed until they remained in pre-ART care for one year or initiated ART.24,925 patients (61% female, median age 35 years were included, and 15,008 (60% had blood drawn for CD4 count within 12 months of HIV testing; the trend increased over time from 36% in Year 1 to 78% in Year 10 (p500 cells/mm3, respectively. The trend increased over time for each CD4 strata, and in Year 10, 94%, 95%, 79%, and 74% were retained in pre-ART care or initiated ART for each CD4 strata. Predictors of pre-ART attrition included male gender, low income, and low educational status. Older age and tuberculosis (TB at HIV testing were associated with retention in care.The proportion of patients completing assessments for ART eligibility, remaining in pre-ART care, and initiating ART have increased over the last decade across all CD4 count strata, particularly among patients with CD4 count ≤350 cells/mm3. However, additional retention efforts are needed for patients with higher CD4 counts.
Babiker, Amir; El Husseini, Maha; Al Nemri, Abdurrahman; Al Frayh, Abdurrahman; Al Juryyan, Nasir; Faki, Mohamed O; Assiri, Asaad; Al Saadi, Muslim; Shaikh, Farheen; Al Zamil, Fahad
In delivering health care, an effective teamwork can immediately and positively affect patient safety and outcome. The need for effective teams is increasing due to increasing co-morbidities and increasing complexity of specialization of care. Time has gone when a doctor or a dentist or any other health practitioner in whatsoever health organization would be able to solely deliver a quality care that satisfies his or her patients. The evolution in health care and a global demand for quality patient care necessitate a parallel health care professional development with a great focus on patient centred teamwork approach. This can only be achieved by placing the patient in the centre of care and through sharing a wide based culture of values and principles. This will help forming and developing an effective team able to deliver exceptional