Natuzzi, Eileen S; Kushner, Adam; Jagilly, Rooney; Pickacha, Douglas; Agiomea, Kaeni; Hou, Levi; Houasia, Patrick; Hendricks, Phillip L; Ba'erodo, Dudley
Access to surgical care and emergency obstetrical care is limited in low-income countries. The Solomon Islands is one of the poorest countries in the Pacific region. Access to surgical care in Solomon Islands is limited and severely affected by a country made up of islands. Surgical care is centralized to the National Referral Hospital (NRH) on Guadalcanal, leaving a void of care in the provinces where more than 80% of the people live. To assess the ability to provide surgical care to the people living on outer islands in the Solomon Islands, the provincial hospitals were evaluated using the World Health Organization's Global Initiative for Emergency and Essential Surgical Care Needs Assessment Tool questionnaire. Data on infrastructure, workforce, and equipment available for treating surgical disease was collected at each provincial hospital visited. Surgical services are centralized to the NRH on Guadalcanal in Solomon Islands. Two provincial hospitals provide surgical care when a surgeon is available. Six of the hospitals evaluated provide only very basic surgical procedures. Infrastructure problems exist at every hospital including lack of running water, electricity, adequate diagnostic equipment, and surgical supplies. The number of surgeons and obstetricians employed by the Ministry of Health is currently inadequate for delivering care at the outer island hospitals. Shortages in the surgical workforce can be resolved in Solomon Islands with focused training of new graduates. Training surgeons locally, in the Pacific region, can minimize the "brain drain." Redistribution of surgeons and obstetricians to the provincial hospitals can be accomplished by creating supportive connections between these hospitals, the NRH, and international medical institutions.
Tyson, Anna F; Msiska, Nelson; Kiser, Michelle; Samuel, Jonathan C; Mclean, Sean; Varela, Carlos; Charles, Anthony G
Specialized pediatric surgeons are unavailable in much of sub-Saharan Africa. Delegating some surgical tasks to non-physician clinical officers can mitigate the dependence of a health system on highly skilled clinicians for specific services. We performed a case-control study examining pediatric surgical cases over a 12 month period. Operating surgeon was categorized as physician or clinical officer. Operative acuity, surgical subspecialty, and outcome were then compared between the two groups, using physicians as the control. A total of 1186 operations were performed on 1004 pediatric patients. Mean age was 6 years (±5) and 64% of patients were male. Clinical officers performed 40% of the cases. Most general surgery, urology and congenital cases were performed by physicians, while most ENT, neurosurgery, and burn surgery cases were performed by clinical officers. Reoperation rate was higher for patients treated by clinical officers (17%) compared to physicians (7.1%), although this was attributable to multiple burn surgical procedures. Physician and clinical officer cohorts had similar complication rates (4.5% and 4.0%, respectively) and mortality rates (2.5% and 2.1%, respectively). Fundamental changes in health policy in Africa are imperative as a significant increase in the number of surgeons available in the near future is unlikely. Task-shifting from surgeons to clinical officers may be useful to provide coverage of basic surgical care. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
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....
Bruno, Emily; White, Michelle C; Baxter, Linden S; Ravelojaona, Vaonandianina Agnès; Rakotoarison, Hasiniaina Narindria; Andriamanjato, Hery Harimanitra; Close, Kristin L; Herbert, Alison; Raykar, Nakul; Saluja, Saurabh; Shrime, Mark G
The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework. Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators. In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135-191 procedures per 100,000 with a perioperative mortality rate of 2.5-3.3%. Patients requiring surgery have a 77.4-86.3 and 78.8-95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate. Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.
Magee, William P
For the past 28 years, Operation Smile has mobilized thousands of volunteers to provide life-changing cleft lip, cleft palate, and other facial deformity surgery to more than 150,000 children in countries all over the world. Our mission is to provide surgical care for children with the goal of developing sustainable health care delivery models for surgical services worldwide. For more than a quarter century, we have learned that good judgment comes from experience and that experience comes from bad judgment. However, it has been woven throughout this sometimes painful, always exhilarating growth process in which we have realized that our mission had so much more power than we initially anticipated that it would. Originally, we focused on the face of a child and our ability to provide a surgery that would change that child's life forever. Today, we still stand in awe of the transformative power of this experience, but we have also realized the great power that lies in educating medical professionals and providing state-of-the-art equipment. For us, action took shape in the form of us establishing a business model at home and in each of our partner countries. This included setting up financial reporting systems and creating program models that organized volunteers to provide care for children outside the reach of where surgery was currently available. Through our journey, we have realized that there is power in the healed face of a child. That moment gives us the opportunity to feel the passion for the service we have the privilege to provide. It is that emotion that leads us to action.
Cotton, Michael; Henry, Jaymie Ang; Hasek, Lauren
.... Surgical care around the world stands much to gain from these innovations. In this paper, we provide a short review of some of these successful innovations and their origins that have had an important impact in healthcare delivery worldwide...
... again after you take off the old dressing. Caring for the Wound You may use a gauze ... Bethesda, MD 20894 U.S. Department of Health and Human Services National Institutes of Health Page last updated: ...
Gesler, Wilbert M.
This article shows how health care delivery is related to cultural or human geography. This is accomplished by describing health care delivery in terms of 12 popular themes of cultural geography. (JDH)
Sharan, Alok D; Schroeder, Gregory D; West, Michael E; Vaccaro, Alexander R
As reimbursement transitions from a volume-based to a value-based system, innovation in health care delivery will be needed. The process of innovation begins with framing the problem that needs to be solved along with the strategic vision that has to be achieved. Similar to scientific testing, a hypothesis is generated for a new solution to a problem. Innovation requires conducting a disciplined form of experimentation and then learning from the process. This manuscript will discuss the different types of innovation, and the key steps necessary for successful innovation in the health care field.
Monica de Boer
Full Text Available BACKGROUND: Surgical patients are at risk for preventable adverse drug events (ADEs during hospitalization. Usually, preventable ADEs are measured as an outcome parameter of quality of pharmaceutical care. However, process measures such as QIs are more efficient to assess the quality of care and provide more information about potential quality improvements. OBJECTIVE: To assess the quality of pharmaceutical care of medication-related processes in surgical wards with quality indicators, in order to detect targets for quality improvements. METHODS: For this observational cohort study, quality indicators were composed, validated, tested, and applied on a surgical cohort. Three surgical wards of an academic hospital in the Netherlands (Academic Medical Centre, Amsterdam participated. Consecutive elective surgical patients with a hospital stay longer than 48 hours were included from April until June 2009. To assess the quality of pharmaceutical care, the set of quality indicators was applied to 252 medical records of surgical patients. RESULTS: Thirty-four quality indicators were composed and tested on acceptability and content- and face-validity. The selected 28 candidate quality indicators were tested for feasibility and 'sensitivity to change'. This resulted in a final set of 27 quality indicators, of which inter-rater agreements were calculated (kappa 0.92 for eligibility, 0.74 for pass-rate. The quality of pharmaceutical care was assessed in 252 surgical patients. Nearly half of the surgical patients passed the quality indicators for pharmaceutical care (overall pass rate 49.8%. Improvements should be predominantly targeted to medication care related processes in surgical patients with gastro-intestinal problems (domain pass rate 29.4%. CONCLUSIONS: This quality indicator set can be used to measure quality of pharmaceutical care and detect targets for quality improvements. With these results medication safety in surgical patients can be enhanced.
to reduce the global burden of disease (GBD), it is ... global players have supported efforts to improve access and safety of surgery ... (i) strengthening surgical services at district hospitals ... of the surrounding community and a model for other.
Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care.
Mosenthal, Anne C; Weissman, David E; Curtis, J Randall; Hays, Ross M; Lustbader, Dana R; Mulkerin, Colleen; Puntillo, Kathleen A; Ray, Daniel E; Bassett, Rick; Boss, Renee D; Brasel, Karen J; Campbell, Margaret; Nelson, Judith E
Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit. We searched the MEDLINE database from inception to May 2011 for all English language articles using the term "surgical palliative care" or the terms "surgical critical care," "surgical ICU," "surgeon," "trauma" or "transplant," and "palliative care" or "end-of- life care" and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report. We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families. Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. "Consultative," "integrative," and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to attitudinal factors and "culture" in the unit and institution. Approaches that emphasize delivery of
Surgical wound infection is an important outcome indicator in the postoperative period. A 3-year prospective cohort epidemiological study of 2202 surgical patients from seven surgical wards across two hospitals was carried out using gold standard surveillance methodology. This involved following patients up as inpatients and postdischarge surveillance to 30 days by an independent observer. The results led to the development of a mathematical model for risk of clean, elective surgical wound infection. Risk of surgical wound infection was increased by smoking, higher body mass index, presence of malignancy, haematoma formation, increasing numbers of people in theatre, adherent dressing usage, and higher times to suture removal (P<0.05). The results show that this type of surveillance is an effective way of collecting accurate data on wound infection rates. It was noted that patient care practices affected the surgical wound infection rate and the surveillance was used to facilitate the adoption of evidence-based practice, through recommendations for clean surgery, to reduce the risk from extrinsic risk factors for wound infection. As a result of the implementation of this evidence-based practice there was a significant reduction (P<0.05) in the clean wound infection rate.
Ford Nathan P
Full Text Available Abstract Background Somalia is one of the most political unstable countries in the world. Ongoing insecurity has forced an inconsistent medical response by the international community, with little data collection. This paper describes the "remote" model of surgical care by Medecins Sans Frontieres, in Guri-El, Somalia. The challenges of providing the necessary prerequisites for safe surgery are discussed as well as the successes and limitations of task shifting in this resource-limited context. Methods In January 2006, MSF opened a project in Guri-El located between Mogadishu and Galcayo. The objectives were to reduce mortality due to complications of pregnancy and childbirth and from violent and non-violent trauma. At the start of the program, expatriate surgeons and anesthesiologists established safe surgical practices and performed surgical procedures. After January 2008, expatriates were evacuated due to insecurity and surgical care has been provided by local Somalian doctors and nurses with periodic supervisory visits from expatriate staff. Results Between October 2006 and December 2009, 2086 operations were performed on 1602 patients. The majority (1049, 65% were male and the median age was 22 (interquartile range, 17-30. 1460 (70% of interventions were emergent. Trauma accounted for 76% (1585 of all surgical pathology; gunshot wounds accounted for 89% (584 of violent injuries. Operative mortality (0.5% of all surgical interventions was not higher when Somalian staff provided care compared to when expatriate surgeons and anesthesiologists. Conclusions The delivery of surgical care in any conflict-settings is difficult, but in situations where international support is limited, the challenges are more extreme. In this model, task shifting, or the provision of services by less trained cadres, was utilized and peri-operative mortality remained low demonstrating that safe surgical practices can be accomplished even without the presence of fully
Kim, Jim Yong; Farmer, Paul; Porter, Michael E
Initiatives to address the unmet needs of those facing both poverty and serious illness have expanded significantly over the past decade. But many of them are designed in an ad-hoc manner to address one health problem among many; they are too rarely assessed; best practices spread slowly. When assessments of delivery do occur, they are often narrow studies of the cost-effectiveness of a single intervention rather than the complex set of them required to deliver value to patients and their families. We propose a framework for global health-care delivery and evaluation by considering efforts to introduce HIV/AIDS care to resource-poor settings. The framework introduces the notion of care delivery value chains that apply a systems-level analysis to the complex processes and interventions that must occur, across a health-care system and over time, to deliver high-value care for patients with HIV/AIDS and cooccurring conditions, from tuberculosis to malnutrition. To deliver value, vertical or stand-alone projects must be integrated into shared delivery infrastructure so that personnel and facilities are used wisely and economies of scale reaped. Two other integrative processes are necessary for delivering and assessing value in global health: one is the alignment of delivery with local context by incorporating knowledge of both barriers to good outcomes (from poor nutrition to a lack of water and sanitation) and broader social and economic determinants of health and wellbeing (jobs, housing, physical infrastructure). The second is the use of effective investments in care delivery to promote equitable economic development, especially for those struggling against poverty and high burdens of disease. We close by reporting our own shared experience of seeking to move towards a science of delivery by harnessing research and training to understand and improve care delivery.
Heather B Neuman
Full Text Available The 2013 Institute of Medicine report investigating cancer care concluded that the cancer care delivery system is in crisis due to an increased demand for care, increasing complexity of treatment, decreasing work force and rising costs. Engaging patients and incorporating evidence-based care into routine clinical practice are essential components of a high quality cancer delivery system. However, a gap currently exists between the identification of beneficial research findings and application in clinical practice. Implementation research strives to address this gap. In this review, we discuss key components of high quality implementation research. We then apply these concepts to a current cancer care delivery challenge in women’s health, specifically the implementation of a surgery decision aid for women newly diagnosed with breast cancer.
Marked regional differences in HIV-related clinical outcomes exist across Europe. Models of outpatient HIV care, including HIV testing, linkage and retention for positive persons, also differ across the continent, including examples of sub-optimal care. Even in settings with reasonably good...... outcomes, existing models are scrutinized for simplification and/or reduced cost. Outpatient HIV care models across Europe may be centralized to specialized clinics only, primarily handled by general practitioners (GP), or a mixture of the two, depending on the setting. Key factors explaining...... this diversity include differences in health policy, health insurance structures, case load and the prevalence of HIV-related morbidity. In clinical stable populations, the current trend is to gradually extend intervals between HIV-specific visits in a shared care model with GPs. A similar shared-model approach...
Mueller, Scarlott K
To generate ideas and explore the future possibilities of patient-centered, transdisciplinary care delivery for individuals with cancer. Journal articles, cancer-related professional resources, and web-based resources. As health care access increases, new strategies for transdisciplinary care need to evolve through education, research, and clinical practice. Application and utilization of palliative care models, survivorship plans, technological advances and other resources will be important components to improve quality of life and the cancer experience. Oncology nurse clinicians (at all levels), educators, researchers, and administrators involved in inpatient and outpatient settings should lead and participate in changes that will drive a more robust approach to transdisciplinary cancer care delivery. Copyright © 2016 Elsevier Inc. All rights reserved.
Inserra, Alessandro; Narciso, Alessandra; Paolantonio, Guglielmo; Messina, Raffaella; Crocoli, Alessandro
Survival rate for childhood cancer has increased in recent years, reaching as high as 70% in developed countries compared with 54% for all cancers diagnosed in the 1980s. In the remaining 30%, progression or metastatic disease leads to death and in this framework palliative care has an outstanding role though not well settled in all its facets. In this landscape, surgery has a supportive actor role integrated with other welfare aspects from which are not severable. The definition of surgical palliation has moved from the ancient definition of noncurative surgery to a group of practices performed not to cure but to alleviate an organ dysfunction offering the best quality of life possible in all the aspects of life (pain, dysfunctions, caregivers, psychosocial, etc.). To emphasize this aspect a more modern definition has been introduced: palliative therapy in whose context is comprised not only the care assistance but also the plans of care since the onset of illness, teaching the matter to surgeons in training and share paths. Literature is very poor regarding surgical aspects specifically dedicated and all researches (PubMed, Google Scholar, and Cochrane) with various meshing terms result in a more oncologic and psychosocial effort. Copyright © 2016 Elsevier Inc. All rights reserved.
Yang, Morgan; Perros, Petros
Most patients with Graves' orbitopathy have mild disease that requires no or minimal intervention. For the minority of patients with moderate or severe disease, multiple medical and surgical treatments may be required at different stages. It is crucial that such patients are monitored closely and treatments applied with care in the right sequence. Medical treatments should be used as early as possible and only during the active phase of the disease. Rehabilitative surgery is indicated in the inactive phase of the disease and should follow the sequence: surgical decompression followed by eye muscle surgery, followed by lid surgery. Delivery of care in a coordinated fashion that makes use of best available expertise is important and best implemented through a Combined Thyroid Eye clinic.
Patterson, C; Sinkewich, M; Short, J; Callas, E
The first step in redesigning the health care delivery process for ambulatory care begins with the patient and the business processes that support the patient. Patient-related business processes include patient access, service documentation, billing, follow-up, collection, and payment. Access is the portal to the clinical delivery and care management process. Service documentation, charge capture, and payment and collection are supporting processes to care delivery. Realigned provider networks now demand realigned patient business services to provide their members/customers/patients with improved service delivery at less cost. Purchaser mandates for cost containment, health maintenance, and enhanced quality of care have created an environment where every aspect of the delivery system, especially ambulatory care, is being judged. Business processes supporting the outpatient are therefore being reexamined for better efficiency and customer satisfaction. Many health care systems have made major investments in their ambulatory care environment, but have pursued traditional supporting business practices--such as multiple access points, lack of integrated patient appointment scheduling and registration, and multiple patient bills. These are areas that are appropriate for redesign efforts--all with the customer's needs and convenience in mind. Similarly, setting unrealistic expectations, underestimating the effort required, and ignoring the human elements of a patient-focused business service redesign effort can sabotage the very sound reasons for executing such an endeavor. Pitfalls can be avoided if a structured methodology, coupled with a change management process, are employed. Deloitte & Touche Consulting Group has been involved in several major efforts, all with ambulatory care settings to assist with the redesign of their business practices to consider the patient as the driver, instead of the institution providing the care.
Wilson, A.; Windak, A.; Oleszczyk, M.; Wilm, S.; Hasvold, T.; Kringos, D.
This chapter will be devoted to the dimensions which have been grouped in the framework as “process” and that focus on essential features of service delivery in primary care. In addition to the breadth of services delivered, a comparative overview will be provided of variation in access to services,
Dembinski, Rolf; Kauczok, Jens; Deisz, Robert; Pallua, Norbert; Marx, Gernot
Critical care medicine in severely burned patients should be adapted to the different pathophysiological phases. Accordingly, surgical and non-surgical therapy must be coordinated adequately. Initial wound care comprises topical treatment of less severely injured skin and surgical debridement of severely burned areas. The first 24 hours of intensive care are focused on calculated fluid delivery to provide stable hemodynamics and avoid progression of local edema formation. In the further course wound treatment with split-thickness skin grafts is the major aim of surgical therapy. Critical care is focused on the avoidance of complications like infections and ventilator associated lung injury. Therefore, lung-protective ventilation strategies, weaning and sedation protocols, and early enteral nutrition are important cornerstones of the treatment.
The delivery of general paediatric surgery is changing in Ireland. Fewer paediatric surgical procedures are being performed by newly appointed consultant general surgeons, resulting in increased referrals to the specialist paediatric surgeons of uncomplicated general paediatric surgical problems. We surveyed current higher surgical trainees about their views on provision of paediatric surgical services.
Faierman, Michelle L; Anderson, Jamie E; Assane, Americo; Bendix, Peter; Vaz, Fernando; Rose, John A; Funzamo, Carlos; Bickler, Stephen W; Noormahomed, Emilia V
Surgical care is increasingly recognised as an important component of global health delivery. However, there are still major gaps in knowledge related to access to surgical care in low-income countries. In this study, we compare distances travelled by surgical patients with patients seeking other medical services at a first-level hospital in rural Mozambique. Data were collected on all inpatients at Hospital Rural de Chókwè in rural Mozambique between 20 June 2012 and 3 August 2012. Euclidean distances travelled by surgical versus non-surgical patients using coordinates of each patient's city of residence were compared. Data were analysed using ArcGIS 10 and STATA. In total, 500 patients were included. Almost one-half (47.6%) lived in the city where the hospital is based. By hospital ward, the majority (62.0%) of maternity patients came from within the hospital's city compared with only 35.2% of surgical patients. The average distance travelled was longest for surgical patients (42 km) compared with an average of 17 km for patients on all other wards. Patients seeking surgical care at this first-level hospital travel farther than patients seeking other services. While other patients may have access to at community clinics, surgical patients depend more heavily on the services available at first-level hospitals. © The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Satisfaction with health facility delivery care services and ssociated factors: The ... of care ranging from 30% reporting to be satisfied with management of labour pains ... women comfortable and satisfied with the process of delivery elsewhere.
Nwanna-Nzewunwa, Obieze C; Ajiko, Mary-Margaret; Kirya, Fred; Epodoi, Joseph; Kabagenyi, Fiona; Batibwe, Emmanuel; Feldhaus, Isabelle; Juillard, Catherine; Dicker, Rochelle
Surgical care delivery is poorly understood in resource-limited settings. To effectively move toward universal health coverage, there is a critical need to understand surgical care delivery in developing countries. This study aims to identify the barriers and facilitators of surgical care delivery at Soroti Regional Referral Hospital in Uganda. In this mixed methods study, we (1) applied the Surgeons OverSeas' Personnel, Infrastructure, Procedures, Equipment, and Supplies tool to assess surgical capacity; (2) retrospectively reviewed inpatient records; (3) conducted four semistructured focus group discussions with 18 purposively sampled providers involved in perioperative care; and (4) observed the perioperative process of care using a time and motion approach. Descriptive statistics were generated from quantitative data. Qualitative data were thematically analyzed. The Personnel, Infrastructure, Procedures, Equipment, and Supplies survey revealed severe deficiencies in workforce (P-score = 14) and infrastructure (I-score = 5). Equipment, supplies, and procedures were generally available. Male and female wards were overbooked 83% and 60% of the time, respectively. Providers identified lack of space, patient overload, and superfluous patients' attendants as barriers to surgical care. Workforce challenges were tackled using teamwork and task sharing. Inadequate equipment and processes were addressed using improvisations. All observed subjects (n = 31) received interventions. The median decision-to-intervention time was 2.5 h (Interquartile Range [IQR], 0.4, 21.4). However, 48% of subjects experienced delays. Median decision-to-intervention delay was 14.8 h (IQR, 0.9, 26.6). Despite severe workforce and physical infrastructural deficiencies at Soroti Regional Referral Hospital, providers are adjusting and innovating to deliver surgical care. Copyright © 2016 Elsevier Inc. All rights reserved.
Toussaint, John; Krueger, David; Shortell, Stephen M; Milstein, Arnold; Cutler, David M
The independent Office of the Actuary for CMS certified that the Pioneer ACO model has met the stringent criteria for expansion to a larger population. Significant savings have accrued and quality targets have been met, so the program as a whole appears to be working. Ironically, 13 of the initial 32 enrollees have left. We attribute this to the design of the ACO models which inadequately support efficient care delivery. Using Bellin-ThedaCare Healthcare Partners as an example, we will focus on correctible flaws in four core elements of the ACO payment model: finance spending and targets, attribution, and quality performance.
Kepros John P
Full Text Available Abstract Background The health care delivery system in the United States is facing cost and quality pressures that will require fundamental changes to remain viable. The optimal structures of the relationships between the hospital, medical school, and physicians have not been determined but are likely to have a large impact on the future of healthcare delivery. Because it is generally agreed that academic medical centers will play a role in the sustainability of this future system, a fundamental understanding of the relative contributions of the stakeholders is important as well as creativity in developing novel strategies to achieve a shared vision. Discussion Core competencies of each of the stakeholders (the hospital, the medical school and the physicians must complement the others and should act synergistically. At the same time, the stakeholders should determine the common core values and should be able to make a meaningful contribution to the delivery of health care. Summary Health care needs to achieve higher quality and lower cost. Therefore, in order for physicians, medical schools, and hospitals to serve the needs of society in a gratifying way, there will need to be change. There needs to be more scientific and social advances. It is obvious that there is a real and urgent need for relationship building among the professionals whose duty it is to provide these services.
Rubin, Susan E; McKee, M Diane; Campos, Giselle; O'Sullivan, Lucia F
Primary care providers' (PCPs') provision of time alone with an adolescent without the parents present (henceforth referred to as "confidential care") has a significant impact on adolescents' disclosure of risk behavior. To inform the development of interventions to improve PCPs' delivery of confidential care, we obtained the perspectives of adolescent males and their mothers about the health care concerns of adolescent males and the provision of confidential care. This focus-group study (5 groups: 2 with adolescent males and 2 with mothers) used standard qualitative methods for analysis. We recruited mother/son dyads who had been seen at urban primary care practices. Adolescents' health concerns focused on pregnancy and sexually transmitted infections; mothers took a broader view. Many adolescents felt that PCPs often delivered safe sex counseling in a superficial, impersonal manner that did not add much value to what they already knew, and that their PCP's principal role was limited to performing sexually transmitted infection testing. Though adolescents cited a number of advantages of confidential care and disclosure, they expressed some general mistrust in PCPs and concerns about limits of confidentiality. Rapport and relationship building with their PCP are key elements to adolescents' comfort and increased disclosure. Overall, mothers viewed confidential care positively, especially in the context of continuity of care, but many felt excluded. To increase adolescents' perception of the relevance of primary care and to foster disclosure during health encounters, our participants described the critical nature of a strong doctor-patient relationship and positive physician demeanor and personalized messages, especially in the context of a continuity relationship. Regular, routine inclusion of confidential care time starting early in adolescence, as well as discussion of the purpose and limitations of confidentiality with parents and adolescents, could lead to
Nguyen, Karissa; Bhattacharya, Syamal D; Maloney, Megan J; Figueroa, Ligia; Taicher, Brad M; Ross, Sherry; Rice, Henry E
Access to pediatric surgical care is limited in low- and middle-income countries. Barriers must be identified before improvements can be made. This pilot study aimed to identify self-reported barriers to pediatric surgical care in Guatemala. We surveyed 78 families of Guatemalan children with surgical conditions who were seen at a pediatric surgical clinic in Guatemala City. Spanish translators were used to complete questionnaires regarding perceived barriers to surgical care. Surgical conditions included hernias, rectal prolapse, anorectal malformations, congenital heart defects, cryptorchidism, soft tissue masses, and vestibulourethral reflux. Average patient age was 8.2 years (range, 1 month to 17 years) with male predominance (62%). Families reported an average symptom duration of 3.7 years before clinic evaluation. Families traveled a variety of distances to obtain surgical care: 36 per cent were local (less than 10 km), 17 per cent traveled 10 to 50 km, and 47 per cent traveled greater than 50 km. Other barriers to surgery included financial (58.9%), excessive wait time in the national healthcare system (10. 2%), distrust of local surgeons (37.2%), and geographic inaccessibility to surgical care (10.2%). The majority of study patients required outpatient procedures, which could improve their quality of life. Many barriers to pediatric surgical care exist in Guatemala. Interventions to remove these obstacles may enhance access to surgery and benefit children in low- and middle-income countries.
Full Text Available Objectives: Anal incontinence is the involuntary loss of flatus and feces and often occurs, as a reason of trauma due to the vaginal delivery in women. In this study, we aimed to evaluate the results of the patients, who underwent surgery, with anal incontinence due to the vaginal delivery.Materials and methods: Between January 2005 and December 2010, 15 patients, who had anal incontinence due to the vaginal delivery and underwent overlapping sphincteroplasty, were analyzed retrospectively.Results: The mean age was 34.7 (range 18-49 years. Sphincter injuries were grade 4 in all patients. The time for the surgery after the formation of vaginal tear varies between the first day after injury and 17 years. Wound infection developed in 2 of the patients. Anal incontinence was revealed in 4 patients in the postoperative period, 3 of them had incontinence of the flatus and 1 of them had flatal and fecal incontinence. Total continence was achieved in 11 patients.Conclusion: The sphincter injuries due to the vaginal delivery traumas can be easily defined with a detailed physical examination and careful questioning of the medical history. Satisfactory results can be achieved with the surgical treatment.
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.
Full Text Available Context: The total time spent in nursing care depends on the type of patient and the patient′s condition. We analysed factors that influenced the time spent in nursing a patient. Aims : To analyse the factors in a patient′s condition that influenced time spent in nursing a patient. Materials and Methods: This study was performed in the Surgical Intensive Care Unit of a tertiary referral centre, over a period of one month. The total time spent on a patient in nursing care for the first 24 hours of admission, was recorded. This time was divided into time for routine nursing care, time for interventions, time for monitoring and time for administering medications. Statistical analysis used: A backward stepwise linear regression analysis using the age, sex, diagnosis, type of admission and ventilatory status as variables, was done. Results: Patients admitted after elective surgery required less time (852.4 ± 234.1 minutes, than those admitted after either emergency surgery (1069.5 ± 187.3 minutes, or directly from the ward or the emergency room (1253.7 ± 42.1 minutes. Patients who were ventilated required more time (1111.5 ± 132.5 minutes, than those brought on a T-piece (732.2 ± 134.8 minutes or extubated (639.5 ± 155.6 minutes. The regression analysis showed that only the type of admission and the ventilatory status significantly affected the time. Conclusions : This study showed that the type of admission and ventilatory status significantly influenced the time spent in nursing care. This will help optimal utilization of nursing resources.
The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts. PMID:25415178
Kajamaa, Anu; Hilli, Angelique
Our aim with this article is to develop a typology for the analysis of client-caregiver encounters in health care. We first observed client-caregiver interactions in the homes of home care clients and during the care processes of surgical patients. We then conducted a data-driven analysis to identify the clients' initiatives and the degree of engagement in the responses they received. The clients shaped their care by commenting on, questioning, ensuring, and enriching their care. The responses from the caregivers consisted of neutral acceptance, disregard, and shared expansive development of the clients' initiatives. The typology developed from these will be a tool to widen our understanding of the complex interactions in care delivery and of the different conceptualizations of care that actors hold. In future studies this typology will help in the analysis of the organizational dynamics of health care delivery.
Sanders, Jay H.
The Interactive Telemedicine Systems (ITS) system was specifically developed to address the ever widening gap between our medical care expertise and our medical care delivery system. The frustrating reality is that as our knowledge of how to diagnose and treat medical conditions has continued to advance, the system to deliver that care has remained in an embryonic stage. This has resulted in millions of people being denied their most basic health care needs. Telemedicine utilizes an interactive video system integrated with biomedical telemetry that allows a physician at a base station specialty medical complex or teaching hospital to examine and treat a patient at multiple satellite locations, such as rural hospitals, ambulatory health centers, correctional institutions, facilities caring for the elderly, community hospital emergency departments, or international health facilities. Based on the interactive nature of the system design, the consulting physician at the base station can do a complete history and physical examination, as if the patient at the satellite site was sitting in the physician's office. This system is described.
Schaum, Kathleen D
Medicare patients' access to surgical dressings and topical wound care products is greatly influenced by the Medicare payment system that exists in each site of care. Qualified healthcare professionals should consider these payment systems, as well as the medical necessity for surgical dressings and topical wound care products. Scientists and manufacturers should also consider these payment systems, in addition to the Food and Drug Administration requirements for clearance or approval, when they are developing new surgical dressings and topical wound care products. Due to the importance of the Medicare payment systems, this article reviews the Medicare payment systems in acute care hospitals, long-term acute care hospitals, skilled nursing facilities, home health agencies, durable medical equipment suppliers, hospital-based outpatient wound care departments, and qualified healthcare professional offices.
Boyd, Jennifer B; McGrath, Mary H; Maa, John
As total health care expenditures are expected to constitute an increasing portion of the US gross domestic product during the coming years, the US health care system is anticipating a historic spike in the need for care. Outsourcing medical and surgical care to other nations has expanded rapidly, and several ethical, legal, and financial considerations require careful evaluation. Ultimately, the balance between cost savings, quality, and patient satisfaction will be the key determinant in the future of medical outsourcing.
American Psychologist, 2013
Psychologists practice in an increasingly diverse range of health care delivery systems. The following guidelines are intended to assist psychologists, other health care providers, administrators in health care delivery systems, and the public to conceptualize the roles and responsibilities of psychologists in these diverse contexts. These…
Sobolev, Boris G; Sanchez, Victor; Vasilakis, Christos
Computer simulation has been employed to evaluate proposed changes in the delivery of health care. However, little is known about the utility of simulation approaches for analysis of changes in the delivery of surgical care. We searched eight bibliographic databases for this comprehensive review of the literature published over the past five decades, and found 34 publications that reported on simulation models for the flow of surgical patients. The majority of these publications presented a description of the simulation approach: 91% outlined the underlying assumptions for modeling, 88% presented the system requirements, and 91% described the input and output data. However, only half of the publications reported that models were constructed to address the needs of policy-makers, and only 26% reported some involvement of health system managers and policy-makers in the simulation study. In addition, we found a wide variation in the presentation of assumptions, system requirements, input and output data, and results of simulation-based policy analysis.
Changes to the surgical workforce and the continued development of health policy have perpetuated the requirement for innovative perioperative roles. The surgical care practitioner is a nurse or allied health professional who works within a surgical team and has advanced perioperative skills, including the ability to undertake surgical interventions.With only limited literature evaluating this role, any benefits of their inclusion to a surgical team are largely anecdotal. This article presents the findings of an autoethnographic inquiry that explored the experiences of surgical team members who worked with the nurse researcher in her role as surgical care practitioner. Surgeons identified the provision of a knowledgeable, competent assistant and operator who enhanced patient care, helped maintain surgical services and supported the training of junior doctors. The professional, ethical and legal obligations of advanced perioperative practice were upheld. Interprofessional collaboration was improved, as was service provision. This further enhanced the patient experience. The traditional viewpoint that nurses who undertake tasks previously associated with medicine should be working to the standard of a doctor is challenged but requires further examination.
Dixon, John B
Indications for bariatric surgery have been clear for some time and many would say that they are conservative. Unfortunately few eligible candidates seek or are referred for bariatric surgery, with less than 1% currently treated annually. In recent years, the evidence base supporting surgical therapy has strengthened with demonstrable improvements in both safety and efficacy. We now have evidence of remarkable improvements in health, quality of life, and increased life expectancy. There is continued frustration with the poor efficacy of non-surgical therapies and no indication that this is about to change. A caring physician should, as best care, refer the seriously ill morbidly obese patient for a surgical opinion. It is no different from their obligation to adequately manage type-2 diabetes, depression or unstable angina. Currently, even discussion of a surgical referral is optional. It is time we articulated and defined a group of patients where referral for a surgical opinion is no longer merely an option but a physician's responsibility as best care for the patient. It is time to provide leadership towards the delivery of better care for these patients.
Mayara Caroline Barbieri
Full Text Available The aim of the study was to analyze the guidelines considering breastfeeding given by health professionals to women during prenatal care, delivery and postpartum care. Quantitative and descriptive work developed at Regional Pinheiros, Maringá-PR, from the registry in SisPreNatal, from May to August 2009. Data were collected through interviews conducted with parents at home, using a structured instrument. Participants were 36 mothers, most of whom received counseling for breastfeeding during prenatal (58.3%, maternity (87.6% and in nursing visits to newborn (84.6%. The prevalence of exclusive breastfeeding was 37.5%, even with the end of maternity leave. The rate is still below the recommended by the World Health Organization for exclusive breastfeeding. The present results may contribute to the monitoring of health actions and development of new strategies in the maintenance of exclusive breastfeeding.
Le Moel, Carole; Mounier, Roman; Ardic-Pulas, Taline
Literature reports a high prevalence of wounds in the hospital environment. A study devoted to wounds encountered in post-surgical intensive care has been carried out in a university hospital. This work highlighted the diversity of acute wounds mainly observed in intensive care and the difficulties nurses have in managing them.
Full Text Available Kathryn Chu and colleagues describe the experiences of Médecins sans Frontières after the 2010 Haiti earthquake, and discuss how to improve delivery of surgery in humanitarian disasters.
Brighton, Brian K
In recent years, the safety, quality, and value of surgical care have become increasingly important to surgeons and hospitals. Quality improvement in surgical care requires the ability to collect, measure, and act upon reliable and clinically relevant data. One example of a large-scale quality effort is the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-Pediatric), the only nationwide, risk-adjusted, outcomes-based program evaluating pediatric surgical care.
Hjort Jakobsen, Dorthe; Rud, Kirsten; Kehlet, Henrik;
guidelines based on the principles of fast-track surgery-i.e. patient information, surgical stress reduction, effective analgesia, early mobilisation and rapid return to normal eating. Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN......-track regimes in all surgical departments in Denmark. We recommend the workshop-practice method for implementation of new procedures in other areas of patient care.......Considerable variations in procedures, hospital stay and rates of recovery have been recorded within specific surgical procedures at Danish hospitals. The aim of this paper is to report on a national initiative in Denmark to improve the quality of surgical care by implementation of clinical...
Miner, Thomas J
Excellence as a surgeon requires not only the technical and intellectual ability to effectively take care of surgical disease but also an ability to respond to the needs and questions of patients. This article provides an overview of the importance of communication skills in optimal surgical palliation and offers suggestions for a multidisciplinary team approach, using the palliative triangle as the ideal model of communication and interpersonal skills. This article also discusses guidelines for advanced surgical decision making and outlines methods to improve communication skills.
Subramaniam, S; Abdul, R
Day-case surgery is preferred for adults, allowing post-operative fast recovery in family environment and support. Myringoplasty using the traditional method of underlay temporalis fascia or tragal perichondrium is usually performed as an in-patient. From 2003 to 2004, 22 myringoplasty procedures were performed in a dedicated day surgery unit at the Hospital Melaka. We report the retrospectively review of the outcome results of these procedures. None of the patients need admission overnight. There were no surgical or anesthetic complications noted and this series suggests that day-case surgery is a safe and desirable practice for patients undergoing myringoplasty. However, there should be the facility for admission if required.
Shirey, Maria R
This article provides a historical overview of nursing models of care for acute and critical care based on currently available literature. Models of care are defined and their advantages and disadvantages presented. The distinctive differences between care delivery models and professional practice models are explained. The historical overview of care delivery models provides a foundation for the introduction of best practice models that will shape the environment for acute and critical care in the future.
Parasyn, Andrew D; Truskett, Philip G; Bennett, Michael; Lum, Sharon; Barry, Jennie; Haghighi, Koroush; Crowe, Philip J
The provision of acute surgical care in the public sector is becoming increasingly difficult because of limitation of resources and the unpredictability of access to theatres during the working day. An acute-care surgical service was developed at the Prince of Wales Hospital to provide acute surgery in a more timely and efficient manner. A roster of eight general surgeons provided on-site service from 08.00 to 18.00 hours Monday to Friday and on-call service in after-hours for a 79-week period. An acute-care ward of four beds and an operating theatre were placed under the control of the rostered acute-care surgeon (ACS). At the end of each ACS roster period all patients whose treatment was undefined or incomplete were handed over to the next rostered ACS. Patient data and theatre utilization data were prospectively collected and compared to the preceding 52-week period. Emergency theatre utilization during the day increased from 57 to 69%. There was a 11% reduction in acute-care operating after hours and 26% fewer emergency cases were handled between midnight and 08.00 hours. There was more efficient use of the entire theatre block, suggesting a significant cultural change. Staff satisfaction was high. On-site consultant-driven surgical leadership has provided significant positive change to the provision of acute surgical care in our institution. The paradigm shift in acute surgical care has improved patient and theatre management and stimulated a cultural change of efficiency.
Samokhvalov, I M; Badalov, V I; Reva, V A; Golovko, K P; Petrov, A N; Kaznacheev, M V; Rozov, A I
A goal of this study is to review perspective technologies of surgical care to the wounded on the basis of an analysis of the experience in medical support in local armed conflicts and a study of the achievements of modern trauma surgery. The study is based on the analysis of personal experience, results of scientific researches being carried out in the Military Medical Academy and a comparison review of available papers and works in the field of our study. Perspective technologies of surgical care to the wounded are strongly dependent on the pre-hospital care: high technologies in personal medical equipment, special disposable devices used in case of life-threatening consequences of injuries and traumas during emergency medical care and advanced trauma management. The main innovation of the last ten years in war surgery is considered to be damage control surgery. Wide application of abbreviated surgical operations (the first phase of damage control surgery) makes the use of remote surgery (telesurgery) for treatment of the wounded more practicable. Increasing effectiveness of military surgeon education is based on the use of all possible achievements in education and information technologies. Feedback in surgical care to the wounded is supplied with analysis of its results in the medical Register of the wounded military.
Brennan, Michael D; Duncan, Alan K; Armbruster, Ryan R; Montori, Victor M; Feyereisn, Wayne L; LaRusso, Nicholas F
Clinical research centers that support hypothesis-driven investigation have long been a feature of academic medical centers but facilities in which clinical care delivery can be systematically assessed and evaluated have heretofore been nonexistent. The Institute of Medicine report "Crossing the Quality Chasm" identified six core attributes of an ideal care delivery system that in turn relied heavily on system redesign. Although manufacturing and service industries have leveraged modern design principles in new product development, healthcare has lagged behind. In this article, we describe a methodology utilized by our facility to study the clinical care delivery system that incorporates modern design principles.
Silva, Denise Conceição; Alvim, Neide Aparecida Titonelli
The purpose of this qualitative research was to characterize the elements that constitute the environment of the Surgical Center and to analyze its implications for dynamic of care and nursing care. Based on the Environmental Theory's principals. Participated twelve nurses from the Surgical Center of a College Hospital in Rio de Janeiro. Data were gathered through the creativity and sensitivity technique "Map-Speaker", semi-structered interviews and participant observation, and were analyzed by thematic categories. The results showed that care can happen directly and indirectly in favor of full client recovery, counting the environment that the integrate in purpose to maintain harmonic and balanced. The nurse interventions aim to maintain the environment in favorable conditions so that a higher standard of care can be promoted.
Zachariah, R.; Kumar, A. M. V.; Trelles, M.; Caluwaerts, S.; van den Boogaard, W.; Manirampa, J.; Tayler-Smith, K.; Manzi, M.; Nanan-N’zeth, K.; Duchenne, B.; Ndelema, B.; Etienne, W.; Alders, P.; Veerman, R.; Van den Bergh, R.
Objectives In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes. Methods A retrospective analysis of EmOC data (2011 and 2012). Results A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by ‘general practitioners with surgical skills’ and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died. Conclusion Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa. PMID:28170398
De Plecker, E; Zachariah, R; Kumar, A M V; Trelles, M; Caluwaerts, S; van den Boogaard, W; Manirampa, J; Tayler-Smith, K; Manzi, M; Nanan-N'zeth, K; Duchenne, B; Ndelema, B; Etienne, W; Alders, P; Veerman, R; Van den Bergh, R
In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes. A retrospective analysis of EmOC data (2011 and 2012). A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by 'general practitioners with surgical skills' and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died. Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.
Chirveches-Pérez, Emilia; Roca-Closa, Josep; Puigoriol-Juvanteny, Emma; Ubeda-Bonet, Inmaculada; Subirana-Casacuberta, Mireia; Moreno-Casbas, María Teresa
To identify the care given by informal caregivers to patients who underwent abdominal surgery in the Consorci Hospitalari of Vic (Barcelona). To compare the responsibility burden for those caregivers in all the different stages of the surgical process. To determine the consequences of the care itself on the caregiver's health and to identify the factors that contribute to the need of providing care and the appearance of consequences for the caregivers in the home. A longitudinal observational study with follow-up at admission, at discharge and 10 days, of 317 non-paid caregivers of patients who suffer underwent surgery. The characteristics of caregivers and surgical patients were studied. The validated questionnaire, ICUB97-R based on the model by Virginia Henderson, was used to measure the care provided by informal caregivers and its impact on patient quality of life. Most of the caregivers were women, with an average age of 52.9±13.7 years without any previous experience as caregivers. The greater intensity of care and impact was observed in the time when they arrived home after hospital discharge (p<0.05). The predictive variables of repercussions were being a dependent patient before the surgical intervention (β=2.93, p=0.007), having a cancer diagnosis (β=2.87, p<.001) and time dedicated to the care process (β=0.07, p=0.018). Caregivers involved in the surgical process provide a great amount of care at home depending on the characteristics of patients they care for, and it affects their quality of life. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.
Thomas, Susan; Beh, LooSee; Nordin, Rusli Bin
Since 1957, there has been major reorganization of health care services in Malaysia. This article assesses the changes and challenges in health care delivery in Malaysia and how the management in health care processes has evolved over the years including equitable health care and health care financing. The health care service in Malaysia is changing towards wellness service as opposed to illness service. The Malaysian Ministry of Health (MOH), being the main provider of health services, may need to manage and mobilize better health care services by providing better health care financing mechanisms. It is recommended that partnership between public and private sectors with the extension of traditional medicine complementing western medicine in medical therapy continues in the delivery of health care.
Full Text Available Since 1957, there has been major reorganization of health care services in Malaysia. This article assesses the changes and challenges in health care delivery in Malaysia and how the management in health care processes has evolved over the years including equitable health care and health care financing. The health care service in Malaysia is changing towards wellness service as opposed to illness service. The Malaysian Ministry of Health (MOH, being the main provider of health services, may need to manage and mobilize better health care services by providing better health care financing mechanisms. It is recommended that partnership between public and private sectors with the extension of traditional medicine complementing western medicine in medical therapy continues in the delivery of health care.
Hazebroek, F.W.J.; Tibboel, D.; Wijnen, R.M.H.
This article places focus on three main subjects that are all related to the ethical aspects of care of newborns undergoing major surgical interventions. The first concerns the communication between the surgeon, as a representative of the treatment team, and the parents. The second is the way to
de Boer, M.
Assessing and improving the quality of pharmaceutical care is a major issue in hospitals nowadays. Medication safety strategies are being developed and widely introduced in hospitals to reduce medication-related harm. Surgical patients are at risk for medication-related harm, also called adverse
of supervised delivery services continues to be low due partly to poor quality of antenatal care (ANC). Aim: The .... At the time of conducting the study, average ... equipment and logistics are nominally available, it offers minimal confidence for ...
Awad, Samir S
Surgical site infection (SSI) is unequivocally morbid and costly. The estimated 300,000 SSIs annually in the United States represent the second most common infection among surgical patients, prolong hospitalization by 7-10 days, and have an estimated annual incremental cost of $1 billion. The mortality rate associated with SSI is 3%, with about three quarters of deaths being attributable directly to the infection. Prevention is possible for the most part, and concerted effort has been made to limit these infections, arguably to little effect. Review of pertinent English-language literature. Numerous risk factors for SSI and tactics for prevention have been described, but efforts to bundle these tactics into an effective, comprehensive prevention program have been disappointing. Numerous studies now demonstrate that the Surgical Care Improvement Program (SCIP), which focused on process improvement rather than outcomes, has been ineffective despite governmental support, financial penalties for non-compliance, and consequent widespread implementation. Required reporting has increased awareness of the problem of SSI, but just as the complexity of SSI risk, pathogenesis, and preventions reflects the complexity of the disease, many other factors must be taken into account, including the skill and knowledge of the surgical team and promulgation of a culture of quality and safety in surgical patient care.
Ferrari, Lynne R; Ziniel, Sonja I; Antonelli, Richard C
The relationship of care coordination activities and outcomes to resource utilization and personnel costs has been evaluated for a number of pediatric medical home practices. One of the first tools designed to evaluate the activities and outcomes for pediatric care coordination is the Care Coordination Measurement Tool (CCMT). It has become widely used as an instrument for health care providers in both primary and subspecialty care settings. This tool enables the user to stratify patients based on acuity and complexity while documenting the activities and outcomes of care coordination. We tested the feasibility of adapting the CCMT to a pediatric surgical population at Boston Children's Hospital. The tool was used to assess the preoperative care coordination activities. Care coordination activities were tracked during the interval from the date the patient was scheduled for a surgical or interventional procedure through the day of the procedure. A care coordination encounter was defined as any task, whether face to face or not, supporting the development or implementation of a plan of care. Data were collected to enable analysis of 5675 care coordination encounters supporting the care provided to 3406 individual surgical cases (patients). The outcomes of care coordination, as documented by the preoperative nursing staff, included the elaboration of the care plan through patient-focused communication among specialist, facilities, perioperative team, and primary care physicians in 80.5% of cases. The average time spent on care coordination activities increased incrementally by 30 minutes with each additional care coordination encounter for a surgical case. Surgical cases with 1 care coordination encounter took an average of 35.7 minutes of preoperative care coordination, whereas those with ≥4 care coordination encounters reported an average of 121.6 minutes. We successfully adapted and implemented the CCMT for a pediatric surgical population and measured nonface
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...
Kam, Jonathan; Ainsworth, Hannah; Handmer, Marcus; Louie-Johnsun, Mark; Winter, Matthew
Continuing education of health professionals is important for delivery of quality health care. Surgical nurses are often required to understand surgical procedures. Nurses need to be aware of the expected outcomes and recognize potential complications of such procedures during their daily work. Traditional educational methods, such as conferences and tutorials or informal education at the bedside, have many drawbacks for delivery of this information in a universal, standardized, and timely manner. The rapid uptake of portable media devices makes portable video media (PVM) a potential alternative to current educational methods. To compare PVM to standard verbal communication (SVC) for surgical information delivery and educational training for nurses and evaluate its impact on knowledge acquisition and participant satisfaction. Prospective, multicenter, randomized controlled crossover trial. Two hospitals: Gosford District Hospital and Wyong Hospital. Seventy-two nursing staff (36 at each site). Information delivery via PVM--7-minute video compared to information delivered via SVC. Knowledge acquisition was measured by a 32-point questionnaire, and satisfaction with the method of education delivery was measured using the validated Client Satisfaction Questionnaire (CSQ-8). Knowledge acquisition was higher via PVM compared to SVC 25.9 (95% confidence interval [CI] 25.2-26.6) versus 24.3 (95% CI 23.5-25.1), p = .004. Participant satisfaction was higher with PVM 29.5 (95% CI 28.3-30.7) versus 26.5 (95% CI 25.1-27.9), p = .003. Following information delivery via SVC, participants had a 6% increase in knowledge scores, 24.3 (95% CI 23.5-25.1) versus 25.7 (95% CI 24.9-26.5) p = .001, and a 13% increase in satisfaction scores, 26.5 (95% CI 25.1-27.9) versus 29.9 (95% CI 28.8-31.0) p information delivery via PVM. PVM provides a novel method for providing education to nurses that improves knowledge retention and satisfaction with the educational process. © 2016 Sigma Theta
Sur, Malini D; Angelos, Peter
A major challenge in the era of shared medical decision making is the navigation of complex relationships between the physicians, patients, and surrogates who guide treatment plans for critically ill patients. This review of ethical issues in adult surgical critical care explores factors influencing interactions among the characters most prominently involved in health care decisions in the surgical intensive care unit: the patient, the surrogate, the surgeon, and the intensivist. Ethical tensions in the surgeon-patient relationship in the elective setting may arise from the preoperative surgical covenant and the development of surgical complications. Unlike that of the surgeon, the intensivist's relationship with the individual patient must be balanced with the need to serve other acutely ill patients. Due to their unique perspectives, surgeons and intensivists may disagree about decisions to pursue life-sustaining therapies for critically ill postoperative patients. Finally, although surrogates are asked to make decisions for patients on the basis of the substituted judgment or best interest standards, these models may underestimate the nuances of postoperative surrogate decision making. Strategies to minimize conflicts regarding treatment decisions are centered on early, honest, and consistent communication between all parties.
Lindquist, Sofie A I; Shah, Neel; Overgaard, Charlotte; Torp-Pedersen, Christian; Glavind, Karin; Larsen, Thomas; Plough, Avery; Galvin, Grace; Knudsen, Aage
In recent decades, the global rates of cesarean delivery have rapidly increased. Nonetheless, the influence of cesarean deliveries on surgical complications later in life has been understudied. To investigate whether previous cesarean delivery increases the risk of reoperation, perioperative and postoperative complications, and blood transfusion when undergoing a hysterectomy later in life. This registry-based cohort study used data from Danish nationwide registers on all women who gave birth for the first time between January 1, 1993, and December 31, 2012, and underwent a benign, nongravid hysterectomy between January 1, 1996, and December 31, 2012. The dates of this analysis were February 1 to June 30, 2016. Cesarean delivery. Reoperation, perioperative and postoperative complications, and blood transfusion within 30 days of a hysterectomy. Of the 7685 women (mean [SD] age, 40.0 [5.3] years) who met the inclusion criteria, 5267 (68.5%) had no previous cesarean delivery, 1694 (22.0%) had 1 cesarean delivery, and 724 (9.4%) had 2 or more cesarean deliveries. Among the 7685 included women, 3714 (48.3%) had an abdominal hysterectomy, 2513 (32.7%) had a vaginal hysterectomy, and 1458 (19.0%) had a laparoscopic hysterectomy. In total, 388 women (5.0%) had a reoperation within 30 days after a hysterectomy. Compared with women having vaginal deliveries, fully adjusted multivariable analysis showed that the adjusted odds ratio of reoperation for women having 1 previous cesarean delivery was 1.31 (95% CI, 1.03-1.68), and the adjusted odds ratio was 1.35 (95% CI, 0.96-1.91) for women having 2 or more cesarean deliveries. Perioperative and postoperative complications were reported in 934 women (12.2%) and were more frequent in women with previous cesarean deliveries, with adjusted odds ratios of 1.16 (95% CI, 0.98-1.37) for 1 cesarean delivery and 1.30 (95% CI, 1.02-1.65) for 2 or more cesarean deliveries. Blood transfusion was administered to 195 women (2.5%). Women having
Sullivan, Debra Henline
Technology is rapidly changing the way nurses deliver patient care. The Health Information Technology for Economic and Clinical Health Act of 2009 encourages health care providers to implement electronic health records for meaningful use of patient information. This development has opened the door to many technologies that use this information to streamline patient care. This article explores current and new technologies that nurses will be working with either now or in the near future.
Luis Rafael Moscote-Salazar
Full Text Available Traumatic brain injury is a leading cause of death in developed countries. It is estimated that only in the United States about 100,000 people die annually in parallel among the survivors there is a significant number of people with disabilities with significant costs for the health system. It has been determined that after moderate and severe traumatic injury, brain parenchyma is affected by more than 55% of cases. Head trauma management is critical is the emergency services worldwide. We present a review of the literature regarding the prehospital care, surgical management and intensive care monitoring of the patients with severe cranioecephalic trauma.
Moore, An'Nita; Fisher, Kathleen
Healthcare information technology in US hospitals and ambulatory care centers continues to expand, and nurses are expected to effectively and efficiently utilize this technology. Researchers suggest that clinical information systems have expanded the realm of nursing to integrate technology as an element as important in nursing practice as the patient or population being served. This study sought to explore how medical surgical nurses make use of healthcare information technology in their current clinical practice and to examine the influence of healthcare information technology on nurses' clinical decision making. A total of eight medical surgical nurses participated in the study, four novice and four experienced. A conventional content analysis was utilized that allowed for a thematic interpretation of participant data. Five themes emerged: (1) healthcare information technology as a care coordination partner, (2) healthcare information technology as a change agent in the care delivery environment, (3) healthcare information technology-unable to meet all the needs, of all the people, all the time, (4) curiosity about healthcare information technology-what other bells and whistles exist, and (5) Big Brother is watching. The results of this study indicate that a new care partnership has emerged as the provision of nursing care is no longer supplied by a single practitioner but rather by a paired team, consisting of nurses and technology, working collaboratively in an interdependent relationship to achieve established goals.
Ramezani, Monir; Ahmadi, Fazlollah; Mohammadi, Eesa; Kazemnejad, Anoshirvan
Despite the paramount importance and direct relationship of spirituality and spiritual care with health and well-being, they are relatively neglected aspects of nursing care. The aim of this study is to explore Iranian nurses' perceptions and experiences of the facilitators of spiritual care delivery. For this qualitative content analysis study, a purposive maximum-variation sample of 17 nurses was recruited from teaching and private hospitals in Tehran, Iran. Data were collected from 19 individual, unstructured interviews. The conventional content-analysis approach was applied in data analysis. The facilitators of spiritual care delivery fall into two main themes: living to achieve cognizance of divinity and adherence to professional ethics. These two main themes are further divided into eight categories: spiritual self-care, active learning, professional belonging, personal and professional competencies, gradual evolution under divine guidance, awareness of the spiritual dimension of human beings, occurrence of awakening flashes and incidents during life, and congruence between patients' and healthcare providers' religious beliefs. The study findings suggest that the facilitators of spiritual care delivery are more personal than organizational. Accordingly, strategies to improve the likelihood and quality of spiritual care delivery should be developed and implemented primarily at the personal level.
Lindquist, Sofie A. I.; Shah, Neel; Overgaard, Charlotte
Importance: In recent decades, the global rates of cesarean delivery have rapidly increased. Nonetheless, the influence of cesarean deliveries on surgical complications later in life has been understudied. Objective: To investigate whether previous cesarean delivery increases the risk...... of reoperation, perioperative and postoperative complications, and blood transfusion when undergoing a hysterectomy later in life. Design, Setting, and Participants: This registry-based cohort study used data from Danish nationwide registers on all women who gave birth for the first time between January 1, 1993......, and December 31, 2012, and underwent a benign, nongravid hysterectomy between January 1, 1996, and December 31, 2012. The dates of this analysis were February 1 to June 30, 2016. Exposure: Cesarean delivery. Main Outcomes and Measures: Reoperation, perioperative and postoperative complications, and blood...
Lumby, J; England, K
This paper describes one arm of a much larger, multi-site study whose hypothesis was that evidence-based nursing practice is more effective than routine nursing care in improving patient outcomes and health gain. This arm of the study investigated patient satisfaction as an outcome measure for those patients undergoing colorectal surgery. The study's relevance for nurses is in the potential feedback for reviewing nursing practice and health care delivery. Patient satisfaction with nursing care was measured through a validated questionnaire, the SERVQUAL, followed by interviews with a percentage of the study population. The results of this arm of the study confirm the importance of measuring patient satisfaction through a triangulated method which investigates thoroughly, providing feedback for continuous quality improvement. The in-depth interviews provided greater insight into the results of the questionnaire, enabling clear feedback to nursing staff at the different sites of the study. Results of the questionnaire revealed age, sex and education levels of patients as major influences on individual perceptions of nursing care. Patients whose surgery resulted in stomas were also less satisfied with health-care delivery.
Shortell, S M; Hull, K E
The U.S. health care system is restructuring at a dizzying pace. In many parts of the country, managed care has moved into third-generation models emphasizing capitated payment for enrolled lives and, in the process, turning most providers and institutions into cost centers to be managed rather than generators of revenue. While the full impact of the new managed care models remains to be seen, most evidence to date suggests that it tends to reduce inpatient use, may be associated with greater use of physician services and preventive care, and appears to result in no net differences either positive or negative with regard to quality or outcomes of care in comparison with fee-for-service plans. Some patients, however, tend to be somewhat less satisfied with scheduling of appointments and the amount of time spent with providers. There is no persuasive evidence that managed care lowers the rate of growth in overall health care costs within a given market. Further, managed care performance varies considerably across the country, and the factors influencing managed care performance are not well understood. Organized delivery systems are a somewhat more recent phenomenon representing various forms of ownership and strategic alliances among hospitals, physicians, and insurers designed to provide more cost-effective care to defined populations by achieving desired levels of functional, physician-system, and clinical integration. Early evidence suggests that organized delivery systems that are more integrated have the potential to provide more accessible coordinated care across the continuum, and appear to be associated with higher levels of inpatient productivity, greater total system revenue, greater total system cash flow, and greater total system operating margin than less integrated delivery forms. Some key success factors for developing organized delivery systems have been identified. Important roles are played by organizational culture, information systems, internal
Rossi, Filippo; Masi, Maurizio
This book offers a state-of-the-art overview of controlled drug delivery systems, covering the most important innovative applications. The principles of controlled drug release and the mechanisms involved in controlled release are clearly explained. The various existing polymeric drug delivery systems are reviewed, and new frontiers in material design are examined in detail, covering a wide range of polymer modification techniques. The concluding chapter is a case study focusing on use of a drug-eluting stent. The book is designed to provide the reader with a complete understanding of the mechanisms and design of controlled drug delivery systems, and to this end includes numerous step-by-step tutorials. It illustrates how chemical engineers can advance medical care by designing polymeric delivery systems that achieve either temporal or spatial control of drug delivery and thus ensure more effective therapy that eliminates the potential for both under-and overdosing.
Zhang, Luyu; Cheng, Gang; Song, Suhang; Yuan, Beibei; Zhu, Weiming; He, Li; Ma, Xiaochen; Meng, Qingyue
Improving efficiency performance of the health care delivery system has been on the agenda for the health system reform that China initiated in 2009. This study examines the changes in efficiency performance and determinants of efficiency after the reform to provide evidence to assess the progress of the reform from the perspective of efficiency. Descriptive analysis, Data Envelopment Analysis, the Malmquist Index, and multilevel regressions are used with data from multiple sources, including the World Bank, the China Health Statistical Yearbook, and routine reports. The results indicate that over the last decade, health outcomes compared with health investment were relatively higher in China than in most other countries worldwide, and the trend was stable. The overall efficiency and total factor productivity increased after the reform, indicating that the reform was likely to have had a positive impact on the efficiency performance of the health care delivery system. However, the health care delivery structure showed low system efficiency, mainly attributed to the weakened primary health care system. Strengthening the primary health care system is central to enhancing the future performance of China's health care delivery system. Copyright © 2017 John Wiley & Sons, Ltd.
Cochran, Maggie F; Berkowitz, Aaron L
The Global Health Delivery (GHD) framework (Farmer, Kim, and Porter, Lancet 2013;382:1060-69) allows for the analysis of health care delivery systems along four axes: a care delivery value chain that incorporates prevention, diagnosis, and treatment of a medical condition; shared delivery infrastructure that integrates care within existing healthcare delivery systems; alignment of care delivery with local context; and generation of economic growth and social development through the health care delivery system. Here, we apply the GHD framework to epilepsy care in rural regions of low- and middle-income countries (LMIC) where there are few or no neurologists.
Twohig, Bridget; Manasia, Anthony; Bassily-Marcus, Adel; Oropello, John; Gayton, Matthew; Gaffney, Christine; Kohli-Seth, Roopa
The experience of critical care is stressful for both patients and their families. This is especially true when patients are not able to make their own care decisions. This article details the creation of a Family Experience Survey in a surgical intensive care unit (SICU) to capture and improve overall experience. Kolcaba's "Enhanced Comfort Theory" provided the theoretical basis for question formation, specifically in regards to the four aspects of comfort: "physical," "psycho-spiritual," "sociocultural" and "environmental." Survey results were analyzed in real-time to identify and implement interventions needed for issues raised. Overall, there was a high level of satisfaction reported especially with quality of care provided to patients, communication and availability of nurses and doctors, explanations from staff, inclusion in decision making, the needs of patients being met, quality of care provided to patients and cleanliness of the unit. It was noted that 'N/A' was indicated for cultural needs and spiritual needs, a chaplain now rounds on all patients daily to ensure these services are more consistently offered. In addition, protocols for doctor communication with families, palliative care consults, daily bleach cleaning of high touch areas in patient rooms and nurse-led progressive mobility have been implemented. Enhanced comfort theory enabled the opportunity to identify and provide a more 'broad' approach to care for patients and families. Copyright © 2015 Elsevier Inc. All rights reserved.
U.S. Department of Health & Human Services — The Affordable Care Act includes tools to improve the quality of health care that can also lower costs for taxpayers and patients. This means avoiding costly...
Hawn, Mary T; Vick, Catherine C; Richman, Joshua; Holman, William; Deierhoi, Rhiannon J; Graham, Laura A; Henderson, William G; Itani, Kamal M F
The objective of this study was to evaluate whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates using national data at the patient level for both SCIP adherence and SSI occurrence. The SCIP was established in 2006 with the goal of reducing surgical complications by 25% in 2010. National Veterans' Affairs (VA) data from 2005 to 2009 on adherence to 5 SCIP SSI prevention measures were linked to Veterans' Affairs Surgical Quality Improvement Program SSI outcome data. Effect of SCIP adherence and year of surgery on SSI outcome were assessed with logistic regression using generalized estimating equations, adjusting for procedure type and variables known to predict SSI. Correlation between hospital SCIP adherence and SSI rate was assessed using linear regression. There were 60,853 surgeries at 112 VA hospitals analyzed. SCIP adherence ranged from 75% for normothermia to 99% for hair removal and all significantly improved over the study period (P Surgical site infection occurred after 6.2% of surgeries (1.6% for orthopedic surgeries to 11.3% for colorectal surgeries). None of the 5 SCIP measures were significantly associated with lower odds of SSI after adjusting for variables known to predict SSI and procedure type. Year was not associated with SSI (P = 0.71). Hospital SCIP performance was not correlated with hospital SSI rates (r = -0.06, P = 0.54). Adherence to SCIP measures improved whereas risk-adjusted SSI rates remained stable. SCIP adherence was neither associated with a lower SSI rate at the patient level, nor associated with hospital SSI rates. Policies regarding continued SCIP measurement and reporting should be reassessed.
Wong, Evan G; Razek, Tarek; Elsharkawi, Hossam; Wren, Sherry M; Kushner, Adam L; Giannou, Christos; Khwaja, Kosar A; Beckett, Andrew; Deckelbaum, Dan L
Recent humanitarian crises have led to a call for professionalization of the humanitarian field, but core competencies for the delivery of surgical care have yet to be established. The objective of this study was to survey surgeons with experience in disaster response to identify surgical competencies required to be effective in these settings. An online survey elucidating demographic information, scope of practice, and previous experience in global health and disaster response was transmitted to surgeons from a variety of surgical societies and nongovernmental organizations. Participants were provided with a list of 111 operative procedures and were asked to identify those deemed essential to the toolset of a frontline surgeon in disaster response via a Likert scale. Responses from personnel with experience in disaster response were contrasted with those from nonexperienced participants. A total of 147 surgeons completed the survey. Participants held citizenship in 22 countries, were licensed in 30 countries, and practiced in >20 countries. Most respondents (56%) had previous experience in humanitarian response. The majority agreed or strongly agreed that formal training (54%), past humanitarian response (94%), and past global health experiences (80%) provided adequate preparation. The most commonly deemed important procedures included control of intraabdominal hemorrhage (99%), abdominal packing for trauma (99%), and wound debridement (99%). Procedures deemed important by experienced personnel spanned multiple specialties. This study addressed specifically surgical competencies in disaster response. We provide a list of operative procedures that should set the stage for further structured education programs. Copyright © 2015 Elsevier Inc. All rights reserved.
Castle, Bryan W; Shapiro, Susan E
Accountable Care Units are a disruptive innovation that has moved care on acute care units from a traditional silo model, in which each discipline works separately from all others, to one in which multiple disciplines work together with patients and their families to move patients safely through their hospital stay. This article describes the "what," "how," and "why" of the Accountable Care Units model as it has evolved in different locations across a single health system and includes the lessons learned as different units and hospitals continue working to implement the model in their complex care environments.
Health care reengineering is a powerful methodology that helps organizations reorder priorities, provide more cost-effective care, and increase value to customers. It should be driven by what the customer wants and what the market needs. Systemwide reengineering integrates three levels of activity: managing community and health plan partnerships; consolidating overlapping delivery system functions among participating providers and vendors; and redesigning administrative functions, clinical services, and caregiving programs to improve health status. Reengineering is not a panacea; it is a critical core competency and requisite skill for health care organizations if they are to succeed under managed care in the future.
Full Text Available Necrotizing fasciitis is a rare disease, potentially limb and life-threatening infection of fascia, subcutaneous tissue with occasionally muscular involvement. Necrotizing faciitis is surgical emergency with high morbidity and mortality. Aim: Aim of this study was to analyze presentation, microbiology, surgical, resuscitative management and outcome of this devastating soft tissue infection. Materials and Methods: The medical records of necrotizing fasciitis patients treated in surgical intensive care unit (SICU of our hospital from Jan 1995 to Feb 2005 were reviewed retrospectively. Results: Ninety-four patients with necrotizing fasciitis were treated in the surgical intensive care unit during the review period. Necrotizing fasciitis accounted for 1.15% of total admissions to our SICU. The mean age of our patients was 48.6 years, 75.5% of the cases were male. Diabetes mellitus was the most common comorbid disease (56.4%, 24.5% patients had hypertension, 14.9% patients had coronary artery disease, 9.6% had renal disease and 6.4% cases were obese. History of operation (11.7% was most common predisposing factor in our patients. All patients had leucocytosis at admission to the hospital. Mean duration of symptoms was 3.4 days. Mean number of surgical debridement was 2.1, mean sequential organ failure assessment (SOFA score at admission to SICU was 8.6, 56.38% cases were type 1 necrotizing fasciitis and 43.61% had type 2 infection. Streptococci were most common bacteria isolated (52.1%, commonest regions of the body affected by necrotizing fasciitis were the leg and the foot. Mean intubated days and intensive care unit (ICU stay were 4.8 and 7.6 days respectively. Mean fluid, blood, fresh frozen plasma and platelets concentrate received in first 24 hours were 4.8 liters, 2.0 units, 3.9 units and 1.6 units respectively. Most commonly used antibiotics were tazocin and clindamycin. Common complication was ventricular tachycardia (6.4. 46.8% patients had
Olawale Ibrahim Olateju
Full Text Available We examine the TQM Strategies and health care delivery in Nigeria, and the various means of measuring service quality. Nigeria continues to suffer outbreaks of various diseases cholera, malaria, cerebrospinal meningitis, measles, yellow fever, Bird flu e.t.c., all these diseases combine to cause high morbidity and mortality in the population. To assess the situation this paper looks at the relevant indicators like Annual Budgets by Government, Individual’s income, the role of Nigerian Medical Association (NMA and various health care agencies vested with the sole responsibility for elaborating standards for products and processes in Health care Delivery.The paper also examines the implication of Government Budget estimates on the Life expectancy of an average Nigerian. The findings necessitated the need for the government to seek support from WHO to assist in strengthening the health care system by advocating and providing technical support to health sector reforms.
Kokhanevych, Ie V; Mitsoda, R M; Konoplianko, T V; Konoplianko, V V
The article addresses issues of comparative characterization of deliveries involving surgery and impact thereof on the health of the mother and her child. Risk factors are identified that the mother and her child run in sectio cesarea, in application of obstetrical forceps, and in vacuum-extraction of the fetus. Cesarean section was found out to be the most acceptable mode of delivery in origination of organic and functional nervous system involvement in children but the most ill-chosen and unpropitious one in the mother, especially so in those groups at risk for bleeding, septic complications, and genital endometriosis. Among those surgical methods of delivery being the least traumatic to the mother are obstetrical forceps and vacuum-extraction of the fetus.
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 (b
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 (b
Full Text Available Abstract Background Delivery by a skilled birth attendant (SBA in a hospital is advocated to improve maternal health; however, hospital expenses for delivery care services are a concern for women and their families, particularly for women who pay out-of-pocket. Although health insurance is now implemented in Lao PDR, it is not universal throughout the country. The objectives of this study are to estimate the total health care expenses for vaginal delivery and caesarean section, to determine the association between health insurance and family income with health care expenditure and assess the effect of health insurance from the perspectives of the women and the skilled birth attendants (SBAs in Lao PDR. Methods A cross-sectional study was carried out in two provincial hospitals in Lao PDR, from June to October 2010. Face to face interviews of 581 women who gave birth in hospital and 27 SBAs was carried out. Both medical and non-medical expenses were considered. A linear regression model was used to assess influencing factors on health care expenditure and trends of medical and non-medical expenditure by monthly family income stratified by mode of delivery were assessed. Results Of 581 women, 25% had health care insurance. Health care expenses for delivery care services were significantly higher for caesarean section (270 USD than for vaginal delivery (59 USD. After adjusting for the effect of hospital, family income was significantly associated with all types of expenditure in caesarean section, while it was associated with non-medical and total expenditures in vaginal delivery. Both delivering women and health providers thought that health insurance increased the utilisation of delivery care. Conclusions Substantially higher delivery care expenses were incurred for caesarean section compared to vaginal delivery. Three-fourths of the women who were not insured needed to be responsible for their own health care payment. Women who had higher family
India's health care system, despite several significant achievements, suffers from some weaknesses and deficiencies. There has been a preoccupation with the promotion of curative and clinical services through city based hospitals which have essentially catered to certain sections of the urban population. The concept of health in its totality, with preventive and promotive health care services in addition to the curative, has yet to be made operational. There has been an overdependence on the states for health care measures and voluntary and local effort has not been able to accept responsibility in any significant way. The involvement of the people in solving their health problems has been almost nonexistent. Health needs to be viewed as part of the strategy of human resources development. Horizontal and vertical linkages must be obtained among all the interrelated programs--protected water supply environmental sanitation and hygiene, nutrition, education, family planning, and maternal and child welfare. Only with such linkages can the benefits of the various programs be optimized. An attack on the problems of diseases cannot be completely successful unless it is accompanied by an attack on poverty. For this reason the 6th plan assigns a high priority to programs of promotion, or gainful employment, eradication of poverty, population control, and meeting the basic human needs of the population. The Alma Alta Declaration of 1977 has become the accepted health policy of India, simplified into the slogan "health for all by 2000." To realize this goaL, the Planning Commission recommends in the 6th 5-Year Plan a restructing and reorientation of the country's health services. The proposed alternative scheme is more decentralized and provides for many more people to be trained at the grassroots level. People would be involved in tackling their health problems and community participation would be encouraged. Finally, the alternative strongly urges the screening of patients
Silver, A D
The rapid changes in the health marketplace have opened the door for entrepreneurs. The author shows how entrepreneurs seek previously unthought of solutions to problems and through a team effort increase corporate value. According to the author, there is a specific profile of the successful entrepreneur. The qualities of the entrepreneur and the managers that work with them, therefore, are discussed in detail. Finally, several examples of problems in health care that present entrepreneurial opportunities are presented. The author includes scenarios for taking advantage of these opportunities.
Fabian, T C
Empiri c therapy of ventilator-associated pneumonia (VAP) in surgical patients should be based on intensive care unit (ICU)-specific surveillance data, because microbial flora patterns vary widely between geographic regions as well as within hospitals. Surgical ICUs have higher VAP rates than other units. Data from the National Nosocomial Infection Surveillance (NNIS) System report Pseudomonas aeruginosa and Staphylococcus aureus to be the most frequent isolates (each 17.4%). Data from the NNIS documents high resistance patterns in ICUs compared with hospitals at large, as well as unit-specific patterns. VAP risk factors for surgical patients include thoracoabdominal surgery, altered level of consciousness, advanced age, diabetes mellitus, malnutrition, chronic obstructive pulmonary disease, and prior antibiotic administration. Promising prevention strategies include restricting ventilator circuit changes, in-line heat moisture exchange filters, semi-recumbant positioning, and continuous subglottic aspiration. Pharmacodynamics should be considered when choosing antibiotic regimens. Postantibiotic effect and time-dependent versus concentration-dependent killing should be studied in clinical trials. Current guidelines for choosing regimens have been well developed by the American Thoracic Society.
J.M. Cramm (Jane); A.P. Nieboer (Anna)
markdownabstract__Abstract__ Objective. Investigate whether high-quality chronic care delivery improved the experiences of patients. Design. This study had a longitudinal design. Setting and Participants. We surveyed professionals and patients in 17 disease management programs targeting patients wi
Campbell, Alex; Restrepo, Carolina; Mackay, Don; Sherman, Randy; Varma, Ajit; Ayala, Ruben; Sarma, Hiteswar; Deshpande, Gaurav; Magee, William
The Guwahati Comprehensive Cleft Care Center (GCCCC) utilizes a high-volume, subspecialized institution to provide safe, quality, and comprehensive and cost-effective surgical care to a highly vulnerable patient population. The GCCCC utilized a diagonal model of surgical care delivery, with vertical inputs of mission-based care transitioning to investments in infrastructure and human capital to create a sustainable, local care delivery system. Over the first 2.5 years of service (May 2011-November 2013), the GCCCC made significant advances in numerous areas. Progress was meticulously documented to evaluate performance and provide transparency to stakeholders including donors, government officials, medical oversight bodies, employees, and patients. During this time period, the GCCCC provided free operations to 7,034 patients, with improved safety, outcomes, and multidisciplinary services while dramatically decreasing costs and increasing investments in the local community. The center has become a regional referral cleft center, and governments of surrounding states have contracted the GCCCC to provide care for their citizens with cleft lip and cleft palate. Additional regional and global impact is anticipated through continued investments into education and training, comprehensive services, and research and outcomes. The success of this public private partnership demonstrates the value of this model of surgical care in the developing world, and offers a blueprint for reproduction. The GCCCC experience has been consistent with previous studies demonstrating a positive volume-outcomes relationship, and provides evidence for the value of the specialty hospital model for surgical delivery in the developing world.
Manuel Molina López
Full Text Available The free flap surgical technique is used to cover extensive skin loss areas and situations where no flap is available, or in axial zones. The great breackthrough in the field of reconstructive surgical techniques and the creation of new units where these complex techniques are used, means that the nursing staff who work in these hospital units are adquiring greater protagonism in caring for, and the subsequent success of this type of surgery in which the problems of collaboration in all the perioperative phases depend entirely on the nursing team.The collaborative nursing problems could be defined as real or potential health problems, where users need nursing staff to follow the treatment and control procedures prescribed by other professional, generally doctors, who control and are responsible for the final outcome.While planning collaborative objectives and activities it should be taken into account that the function of the nursing staff is twofold: on the one hand, the patient must be taken care of as prescribed by other professionals and, on the other hand, it should bring into play cognitive elements (knowledge and know-how and clinical judgment when executing these in controlling the patients evolution.In this article our intention is to give an interesting and comprehensive description of the free flap surgical technique, its pros and cons, and identify the principal collaborative problems which nursing will have to deal with in each one of the perioperative phases, the number and specific nature of such oblige nursing on many occasions, to update and/or acquire new skills.
Mjahed, K; Hamoudi, D; Salmi, S; Barrou, L
The objective of this study was to assess the incidence, prognostic factors and the outcome of obstetric patients admitted in a surgical intensive care unit (SICU) during the ante-partum or postpartum period (within 6 weeks of delivery). Between 1995 and 2002, the patients transferred from the department of obstetrics were retrospectively included into the study. Demographics included: obstetric data, medical and surgical histories, diagnosis, simplified acute physiology score (SAPS II), acute physiology and chronic health evaluation system APACHE II score; and the occurrence of organ failure, therapeutic interventions, length of stay in the SICU and outcome were recorded. During the study period, 364 obstetric patients were admitted to the SICU. Obstetric admissions to the SICU represented 0.6% of all deliveries and the SICU utilisation rate was 14.96%. The main indications for admission were eclampsia (70.6%) and postpartum haemorrhage (16.2%). The overall mortality rate was 16.7% (n = 61). In a logistic regression model, risk factors for death included organ system failure (odds ratio (OR) = 3.95 confidence interval (CI) [1.84 - 8.48], bilirubin >12 mg/l (OR = 1.017 CI [1.00 - 1.03]), and prolonged prothrombin time (OR = 0.97 CI [0.95 - 0.99]). Median length of stay was longer in non- survivors (6.5 +/- 7.3 vs 5.5 +/- 4.6 days). Maternal condition on admission and associated complications are the major determinant of maternal outcome.
Lokich, J J; Silvers, S; Brereton, H; Byfield, J; Bick, R
Free-standing cancer centers (FSCC) represent a growing trend in cancer care delivery within community practice. The critical components to FSCC are multidisciplinary cancer care, a complete menu of direct care and support services, a commitment to clinical trials and clinical investigation, and a comprehensive program for quality assurance. The advantages of FSCC to the community, to hospital programs, to the practicing surgical, medical, and radiation oncologists, and to the third-party carriers, including health maintenance organizations, are detailed. The development of an FSCC depends on the resolution of issues of (a) competition (between hospitals, hospitals and physicians, therapeutic disciplines, regional comprehensive cancer centers and FSCCs) and (b) concerns about conflict of interest. The ideal model of FSCC may well be represented by the joint venture of community hospital(s) and the community oncologists.
Lack of sleep has well established effects on physiological, cognitive and behavioural functionality. Sleep deprivation can adversely affect clinical performance as severely as alcohol according to some sources. Sleep deficiency may be due to loss of one night’s sleep or repeated interruptions of sleep. Chronic sleep degrades the ability to recognise one’s ability to recognise the impairments induced by sleep loss. The problem of sleep deprivation has vexed acute medical practice for decades. Improvement has been painfully slow. The problem is that all 168 hours throughout every week of every year have to be covered and there are a finite number of doctors to shoulder the burden. There are many strongly held views about how best to provide night-time and week-end care. Constructive innovations are thin on the ground. The biggest gap is between administration and doctors with financial considerations being the limiting factor. It is, however, generally accepted on all sides that sleep loss and fatigue can have adverse effects on both patients and doctors.
Full Text Available Background: The aim of this study was to determine the impact of important social and technological trends on health care delivery, in the context of developing “Iran's Health System Reform Plan by 2025”.Methods: A detailed review of the national and international literature was done to identify the main trends affecting health system. To collect the experts’ opinions about important trends and their impact on health care delivery, Focus Group Discussions (FGDs and semi-structured in-depth interviews techniques were used. The study was based on the STEEP model. Final results were approved in an expert’s panel session.Results: The important social and technological trends, affecting health system in Iran in the next 15 years are demographic transition, epidemiologic transition, increasing bio-environmental pollution, increasing slums, increasing private sector partnership in health care delivery, moving toward knowledge-based society, development of information and communication technology, increasing use of high technologies in health system, and development of traditional and alternative medicine. The opportunities and threats resulting from the above mentioned trends were also assessed in this study.Conclusion: Increasing healthcare cost due tosome trends like demographic and epidemiologic transition and uncontrolled increase in using new technologies in health care is one of the most important threats that the health system will be facing. The opportunities that advancement in technology and moving toward knowledge-based society create are important and should not be ignored.
Rajabi, F; Esmailzadeh, H; Rostamigooran, N; Majdzadeh, R; Doshmangir, L
The aim of this study was to determine the impact of important social and technological trends on health care delivery, in the context of developing "Iran's Health System Reform Plan by 2025". A detailed review of the national and international literature was done to identify the main trends affecting health system. To collect the experts' opinions about important trends and their impact on health care delivery, Focus Group Discussions (FGDs) and semi-structured in-depth interviews techniques were used. The study was based on the STEEP model. Final results were approved in an expert's panel session. The important social and technological trends, affecting health system in Iran in the next 15 years are demographic transition, epidemiologic transition, increasing bio-environmental pollution, increasing slums, increasing private sector partnership in health care delivery, moving toward knowledge-based society, development of information and communication technology, increasing use of high technologies in health system, and development of traditional and alternative medicine. The opportunities and threats resulting from the above mentioned trends were also assessed in this study. Increasing healthcare cost due to some trends like demographic and epidemiologic transition and uncontrolled increase in using new technologies in health care is one of the most important threats that the health system will be facing. The opportunities that advancement in technology and moving toward knowledge-based society create are important and should not be ignored.
August, D A; Faubion, W C; Ryan, M L; Haggerty, R H; Wesley, J R
The financial, entrepreneurial, administrative, and legal forces acting within the home care arena make it difficult for clinicians to develop and operate home care initiatives within an academic setting. HomeMed is a clinician-initiated and -directed home care delivery system wholly owned by the University of Michigan. The advantages of a clinician-directed system include: Assurance that clinical and patient-based factors are the primary determinants of strategic and procedural decisions; Responsiveness of the system to clinician needs; Maintenance of an important role for the referring physician in home care; Economical clinical research by facilitation of protocol therapy in ambulatory and home settings; Reduction of lengths of hospital stays through clinician initiatives; Incorporation of outcome analysis and other research programs into the mission of the system; Clinician commitment to success of the system; and Clinician input on revenue use. Potential disadvantages of a clinician-based system include: Entrepreneurial, financial, and legal naivete; Disconnection from institutional administrative and data management resources; and Inadequate clinician interest and commitment. The University of Michigan HomeMed experience demonstrates a model of clinician-initiated and -directed home care delivery that has been innovative, profitable, and clinically excellent, has engendered broad physician, nurse, pharmacist, and social worker enthusiasm, and has supported individual investigator clinical protocols as well as broad outcomes research initiatives. It is concluded that a clinician-initiated and -directed home care program is feasible and effective, and in some settings may be optimal.
Mapara, Sanyat S; Patravale, Vandana B
The advancements in electronics and the progress in nanotechnology have resulted in path breaking development that will transform the way diagnosis and treatment are carried out currently. This development is Medical Capsule Robots, which has emerged from the science fiction idea of robots travelling inside the body to diagnose and cure disorders. The first marketed capsule robot was a capsule endoscope developed to capture images of the gastrointestinal tract. Today, varieties of capsule endoscopes are available in the market. They are slightly larger than regular oral capsules, made up of a biocompatible case and have electronic circuitry and mechanisms to capture and transmit images. In addition, robots with diagnostic features such as in vivo body temperature detection and pH monitoring have also been launched in the market. However, a multi-functional unit that will diagnose and cure diseases inside the body has not yet been realized. A remote controlled capsule that will undertake drug delivery and surgical treatment has not been successfully launched in the market. High cost, inadequate power supply, lack of control over drug release, limited space for drug storage on the capsule, inadequate safety and no mechanisms for active locomotion and anchoring have prevented their entry in the market. The capsule robots can revolutionize the current way of diagnosis and treatment. This paper discusses in detail the applications of medical capsule robots in diagnostics, drug delivery and surgical treatment. In diagnostics, detailed analysis has been presented on wireless capsule endoscopes, issues associated with the marketed versions and their corresponding solutions in literature. Moreover, an assessment has been made of the existing state of remote controlled capsules for targeted drug delivery and surgical treatment and their future impact is predicted. Besides the need for multi-functional capsule robots and the areas for further research have also been
Cataife, Guido; Weinberg, Daniel A; Wong, Hui-Hsing; Kahn, Katherine L
The Surgical Care Improvement Project (SCIP) has developed a set of process compliance measures in an attempt to reduce the incidence of surgical site infections (SSIs). Previous research has been inconclusive on whether compliance with these measures is associated with lower SSI rates. To determine whether hospitals with higher levels of compliance with SCIP measures have lower incidence of SSIs and to identify the measures that are most likely to drive this association. Analysis of linked SCIP compliance rates and SSIs on 295 hospital groups observed annually over the study period 2007-2010. A hospital group comprises all hospitals sharing identical categories for location by state, teaching status, bed size, and urban/rural location. We used a generalized linear model regression with logistic link and binomial family to estimate the association between 3 SCIP measures and SSI rates. Hospital groups with higher compliance rates had significantly lower SSI rates for 2 SCIP measures: antibiotic timing and appropriate antibiotic selection. For a hospital group of median characteristics, a 10% improvement in the measure provision of antibiotic 1 hour before intervention led to a 5.3% decrease in the SSI rates (PSSI rates, supporting the validity of the 2 publicly available healthcare-associated infection metrics.
... 45 Public Welfare 1 2010-10-01 2010-10-01 false Waivers for the delivery of health care service... for the delivery of health care service. In determining whether to request a waiver for an Exchange... the delivery of health care service: (a) The Exchange Visitor must submit a statement that he or...
Shrestha, B; Marhatha, R; Giri, A; Jaisi, S; Maskey, U
Surgical site infection is one of the most common complications following Lower Segment Cesarean Section, which accounts for prolonged hospital stay thereby increasing expense. Prophylactic antibiotics in cesarean section reduces surgical site infection significantly. The best protection is provided when tissue level of antibiotics are adequate before incision, without prejudice to neonatal infectious morbidity. The objective of this study was to compare the incidence of surgical site wound infection with prophylactic antibiotics given before skin incision and after cord clamping following delivery of baby. This was a prospective, hospital based study, in which hundred cases of cesarean deliveries who received antibiotics prophylaxis one hour before the skin incision were compared with another 100 cases where antibiotic was given after cord clamping following delivery of the baby. Surgical site infection occurred in 3% of women who received antibiotics prophylaxis before skin incision as compared to 6% in whom antibiotic was given after cord clamping. It was statistically not significant (p = 0.465).
Stefanis, C N; Madianos, M G
The organizational profile of the mental health care delivery system in Greece is mainly characterized by centralization which is reflected in various functional parts of the system (uneven distribution of psychiatric beds and manpower, absence of psychiatric units in general hospitals serving a certain catchment area, lack of community-based psychiatric services, etc.) As a result of this centralized structure there is a centrifugal flow of the mentally ill patients toward Athens and Thessaloniki and consequently the existing possibilities for community-based care as an alternative to inpatient treatment are rather limited. Future immediate objectives of the national social policy planning should be based on decentralization and reorganization of the psychiatric services in order for the mental health delivery system to respond more effectively to the mental health needs of the Greek population.
Full Text Available Abstract Background Increasingly, women in India attend health facilities for childbirth, partly due to incentives paid under government programs. Increased use of health facilities can alleviate the risks of infections contracted in unhygienic home deliveries, but poor infection control practices in labour and delivery units also cause puerperal sepsis and other infections of childbirth. A needs assessment was conducted to provide information on procedures and practices related to infection control in labour and delivery units in Gujarat state, India. Methods Twenty health care facilities, including private and public primary health centres and referral hospitals, were sampled from two districts in Gujarat state, India. Three pre-tested tools for interviewing and for observation were used. Data collection was based on existing infection control guidelines for clean practices, clean equipment, clean environment and availability of diagnostics and treatment. The study was carried out from April to May 2009. Results Seventy percent of respondents said that standard infection control procedures were followed, but a written procedure was only available in 5% of facilities. Alcohol rubs were not used for hand cleaning and surgical gloves were reused in over 70% of facilities, especially for vaginal examinations in the labour room. Most types of equipment and supplies were available but a third of facilities did not have wash basins with "hands-free" taps. Only 15% of facilities reported that wiping of surfaces was done immediately after each delivery in labour rooms. Blood culture services were available in 25% of facilities and antibiotics are widely given to women after normal delivery. A few facilities had data on infections and reported rates of 3% to 5%. Conclusions This study of current infection control procedures and practices during labour and delivery in health facilities in Gujarat revealed a need for improved information systems
I. V. Mikhno
Full Text Available Objective: to study the impact the impact of surgical delivery on the time course of changes in the concentration of tumor necrosis factor-а (TNF-а, interleukin (IL-1/8, y-interferon, IL-4, IL-6, IL-10, and neopterin in the venous blood of women with severe gestosis and to develop a method for correcting a perioperative systemic inflammatory reaction (SIR.Subjects and methods: 89 females in whom surgical delivery had been performed under spinal anesthesia were examined. A control group comprised 30 females with uncomplicated pregnancy; Group 1 included 29 females with severe gestosis; Group 2 consisted of 30 females with severe gestosis to whom the developed method of perioperative SIR correction with dexametha-sone and pentoxyphylline was applied. Solid-phase enzyme immunoassay was used to determine the peripheral blood level of the cytokines and neopterin. The study was conducted in the following steps: 1 before surgery; 2 during surgery (after aponeurosis suturing, 3, 4, and 5 on days 1, 3, and 5 postoperatively, respectively.Results. In females with uncomplicated pregnancy, surgical delivery was accompanied by increases in the concentrations of IL-1/8 and neopterin. This reaction was limited by the increased synthesis of IL-10. Beginning with the third postoperative day, there was a reduction in the level of proinflammatory cytokines. Significantly elevated venous blood concentrations of y-interferon, IL-1/8, TNF-а, IL-6, and decreased levels of anti-inflammatory cytokines, such as IL-10 and IL-4, were detectable in pregnant females with severe gestosis. Against the above background, surgical delivery caused an increase in the synthesis of proinflammatory cytokines and neopterin with the high level being within 5 postoperative days. The developed method for correction of perioperative SIR in females with severe gestosis lowered the concentrations of y-interferon, IL-1/8, TNF-а, IL-6, and neopterin and promoted the recovery of cytokine
By developing and implementing a method for seeing the healthcare experience from the standpoint of patients and family members, the University of Pittsburgh Medical Center has improved care delivery, lowered costs, and improved patient satisfaction. Cross-functional, multidisciplinary teams use a six-step patient and family-centered care methodology to identify gaps and develop changes that will improve the patient experience and clinical outcomes. Committee members shadow patients and family members to get firsthand knowledge about what they are going through and what goes wrong and what goes right. The teams proposed minor and major changes, but none involve adding more staff and few involve more expenditures.
Nechaev, V S; Krasnov, A V
The high-tech surgical medical care is one of the most effective types of medical care in Russia. However high-tech surgical treatment very often is inaccessible for patients. The development of basics of strategic management of high-tech surgical care makes it possible to enhance availability of this type of care and to shorten the gap between volumes of rendered care and population needs. This approach can be resulted in decrease of disability and mortality of the most prevalent diseases of cardio-vascular diseases, malignant neoplasms, etc. The prerequisites can be developed to enhance life quality and increase longevity of population.
Loughran, John; Puthawala, Tauqir; Sutton, Brad S; Brown, Lorrel E; Pronovost, Peter J; DeFilippis, Andrew P
Prior to the advent of the coronary care unit (CCU), patients having an acute myocardial infarction (AMI) were managed on the general medicine wards with reported mortality rates of greater than 30%. The first CCUs are believed to be responsible for reducing mortality attributed to AMI by as much as 40%. This drastic improvement can be attributed to both advances in medical technology and in the process of health care delivery. Evolving considerably since the 1960s, the CCU is now more appropriately labeled as a cardiac intensive care unit (CICU) and represents a comprehensive system designed for the care of patients with an array of advanced cardiovascular disease, an entity that reaches far beyond its early association with AMI. Grouping of patients by diagnosis to a common physical space, dedicated teams of health care providers, as well as the development and implementation of evidence-based treatment algorithms have resulted in the delivery of safer, more efficient care, and most importantly better patient outcomes. The CICU serves as a platform for an integrated, team-based patient care delivery system that addresses a broad spectrum of patient needs. Lessons learned from this model can be broadly applied to address the urgent need to improve outcomes and efficiency in a variety of health care settings.
Griffiths, Frances; Cave, Jonathan; Boardman, Felicity; Ren, Justin; Pawlikowska, Teresa; Ball, Robin; Clarke, Aileen; Cohen, Alan
With the rapid growth of online social networking for health, health care systems are experiencing an inescapable increase in complexity. This is not necessarily a drawback; self-organising, adaptive networks could become central to future health care delivery. This paper considers whether social networks composed of patients and their social circles can compete with, or complement, professional networks in assembling health-related information of value for improving health and health care. Using the framework of analysis of a two-sided network--patients and providers--with multiple platforms for interaction, we argue that the structure and dynamics of such a network has implications for future health care. Patients are using social networking to access and contribute health information. Among those living with chronic illness and disability and engaging with social networks, there is considerable expertise in assessing, combining and exploiting information. Social networking is providing a new landscape for patients to assemble health information, relatively free from the constraints of traditional health care. However, health information from social networks currently complements traditional sources rather than substituting for them. Networking among health care provider organisations is enabling greater exploitation of health information for health care planning. The platforms of interaction are also changing. Patient-doctor encounters are now more permeable to influence from social networks and professional networks. Diffuse and temporary platforms of interaction enable discourse between patients and professionals, and include platforms controlled by patients. We argue that social networking has the potential to change patterns of health inequalities and access to health care, alter the stability of health care provision and lead to a reformulation of the role of health professionals. Further research is needed to understand how network structure combined with
Gliantsev, S P
The article considers the characteristics of surgical care to warriors of Russian army during 1812 Great Patriotic War. Such conditions are analyzed as damaging action of French weapons, types of combat wounds, organization and forces of military sanitary service of Russian troops, surgeons' support with means of supplying surgical care to the wounded and arsenal of surgical aids. On the basis of given materials analysis a preliminary conclusion is made that surgical care in Russian army in 1812 not only was on the sufficiently high level but it played a specified role in the victory of Russian weapon.
Hsiung, Grace E; Abdullah, Fizan
The role of the healthcare organization is shifting and must overcome the challenges of fragmented, costly care, and lack of evidence in practice, to reduce cost, ensure quality, and deliver high-value care. Notable gaps exist within the expected quality and delivery of pediatric healthcare, necessitating a change in the role of the healthcare organization. To realize these goals, the use of collaborative networks that leverage massive datasets to provide information for the development of learning healthcare systems will become increasingly necessary as efforts are made to narrow the gap in healthcare quality for children. By building upon the lessons learned from early collaborative efforts and other industries, operationalizing new technologies, encouraging clinical-community partnerships, and improving performance through transparent pursuit of meaningful goals, pediatric surgery can increase the adoption of best practices by developing collaborative networks that provide evidence-based clinical decision support and accelerate progress toward a new culture of delivering high-quality, high-value, and evidenced-based pediatric surgical care.
Ritzwoller, Debra P; Goodman, Michael J; Maciosek, Michael V; Elston Lafata, Jennifer; Meenan, Richard; Hornbrook, Mark C; Fishman, Paul A
Economic analyses are increasingly important in medical research. Accuracy often requires that they include large, diverse populations, which requires data from multiple sources. The difficulty is in making the data comparable across different settings. This article focuses on how to create comparable measures of health care resource use and cost using data from seven health plans and delivery systems participating in the Cancer Research Network's HMOs Investigating Tobacco study. We used a data inventory to identify variation in data capture across sites and used data dictionaries to develop algorithms for assigning standardized cost to the three major components of health care use: outpatient, inpatient, and pharmacy. The plans included in this study varied from fully integrated, closed-panel models to plans and delivery systems that include network or independent physician association components. Information derived from the data inventory and data dictionary instruments demonstrated a substantial variation in both the content and capture of data across all sites and across all components of usage. The methods we employed for cost allocation varied by usage component and were based on our ability to leverage the data points available to best reflect actual resource use. The importance of this article is the method of ascertaining, cataloging, and addressing the within- and between-plan differences in health care resource use. Second, the decisions we made to address the differences between health plans provide other researchers a starting point when creating a cost algorithm for multisite retrospective research.
Global trend in quality of health care delivery in the 21 st century. ... health care services without concern for quality is unprofessional and potentially deadly. ... antecedents with emphasis on the most current models of quality health care.
Distance to hospital and utilization of surgical services in Haiti: do children, delivering mothers, and patients with emergent surgical conditions experience greater geographical barriers to surgical care?
Friedman, James M; Hagander, Lars; Hughes, Christopher D; Nash, Katherine A; Linden, Allison F; Blossom, Jeff; Meara, John G
An inverse relationship between healthcare utilization and distance to care has been previously described. The purpose of this study was to evaluate this effect related to emergency and essential surgical care in central Haiti. We conducted a retrospective review of operative logbooks from the Clinique Bon Sauveur in Cange, Haiti, from 2008 to 2010. We used Geographic Information Systems to map the home locations of all patients. Spearman's correlation was used to determine the relationship between surgical utilization and distance, and a multivariate linear regression model identified characteristics associated with differences in distances traveled to care. The highest annual surgical utilization rate was 184 operations/100,000 inhabitants. We found a significant inverse correlation between surgical utilization rate and distance from residence to hospital (rs = -0.68, p = 0.02). The median distance from residence to hospital was 55.9 km. Pediatric patients lived 10.1% closer to the hospital than adults (p Haiti. Children and patients receiving obstetric, gynecologic or emergent surgery lived significantly closer to the hospital, and these groups may need special attention to ensure adequate access to surgical care. Copyright © 2012 John Wiley & Sons, Ltd.
Laker, Lauren F; Torabi, Elham; France, Daniel J; Froehle, Craig M; Goldlust, Eric J; Hoot, Nathan R; Kasaie, Parastu; Lyons, Michael S; Barg-Walkow, Laura H; Ward, Michael J; Wears, Robert L
In 2017, Academic Emergency Medicine convened a consensus conference entitled, "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes." This manuscript, a product of the breakout session on "understanding complex interactions through systems modeling," explores the role that computer simulation modeling can and should play in research and development of emergency care delivery systems. This manuscript discusses areas central to the use of computer simulation modeling in emergency care research. The four central approaches to computer simulation modeling are described (Monte Carlo Simulation, System Dynamics modeling, Discrete-Event Simulation, and Agent Based Simulation), along with problems amenable to their use and relevant examples to emergency care. Also discussed is an introduction to available software modeling platforms and how to explore their use for research, along with a research agenda for computer simulation modeling. Through this manuscript, our goal is to enhance adoption of computer simulation, a set of methods which hold great promise in addressing emergency care organization and design challenges. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Melsen, W.G.; Smet, A.M. de; Kluytmans, J.A.; Bonten, M.J.; Pickkers, P.
BACKGROUND: Selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) are effective in improving survival in patients under intensive care. In this study possible differential effects in surgical and non-surgical patients were investigated. METHODS: This was a post
Castro Maria A
Full Text Available Abstract Background In addition to mortality, Health Related Quality of Life (HRQOL has increasingly been claimed as an important outcome variable. The aim of this study was to assess HRQOL and independence in activities of daily living (ADL six months after discharge from an Intensive Care Unit (ICU, and to study its determinants. Methods All post-operative adult patients admitted to a surgical ICU between October 2004 and July 2005, were eligible for the study. The following variables were recorded on admission: age, gender, American Society of Anesthesiologists physical status (ASA-PS, type and magnitude of surgical procedure, ICU and hospital length of stay (LOS, mortality and Simplified Acute Physiology Score II (SAPS II. Six months after discharge, a Short Form-36 questionnaire (SF-36 and a questionnaire to assess dependency in ADL were sent to all survivors. Descriptive statistics was used to summarize data. Patient groups were compared using non-parametric tests. A logistic regression analysis was performed to identify covariate effects of each variable on dependency in personal and instrumental ADL, and for the change-in-health question of SF-36. Results Out of 333 hospital survivors, 226 completed the questionnaires. Fifty-nine percent reported that their general level of health was better on the day they answered the questionnaire than 12 months earlier. Patients with greater co-morbidities (ASA-PS III/IV, had lower SF-36 scores in all domains and were more frequently dependent in instrumental and personal ADL. Logistic regression showed that SAPS II was associated with changes in general level of health (OR 1.06, 95%CI, 1.01 – 1.11, p = 0,016. Six months after ICU discharge, 60% and 34% of patients, respectively, were dependent in at least one activity in instrumental ADL (ADLI and personal ADL (ADLP. ASA-PS (OR 3.00, 95%CI 1.31 – 6.87, p = 0.009 and age (OR 2.36, 95%CI, 1.04 – 5.34, p = 0.04 were associated with dependency in
Ebben, Steven F; Gieras, Izabella A; Gosbee, Laura Lin
Since the Institute of Medicine's well-publicized 1999 report To Err is Human, the healthcare patient safety movement has grown at an exponential pace. However, much more can be done to advance patient safety from a care process design vantage point-improving safety through effective care processes and technology integration. While progress is being made, the chasm between technology developers and caregivers remains a profound void. Why hasn't more been done to expand our view of patient safety to include technology design? Healthcare organizations have not consolidated their purchasing power to expect improved designs. This article will (1) provide an assessment of the present state of healthcare technology management and (2) provide recommendations for collaborative design of safe healthcare delivery systems.
Velmahos George C
Full Text Available Abstract The era of the acute care surgeon has arrived and this "new" specialty will be expected to provide trauma care, emergency surgery, and surgical critical care to a variety of patients arriving at their institution. With the exception of practicing bariatric surgeons, many general surgeons have limited experience caring for obese patients. Obese patients manifest unique physiology and pathophysiology, which can influence a surgeon's decision-making process. Following trauma, obese patients sustain different injuries than lean patients and have worse outcomes. Emergency surgery diseases may be difficult to diagnose in the obese patient and obesity is associated with increased complications in the postoperative patient. Caring for an obese patient in the surgical ICU presents a distinctive challenge and may require alterations in care. The following review should act as an overview of the pathophysiology of obesity and how obesity modifies the care of trauma, emergency surgery, and surgical critical care patients.
Necrotizing fasciitis is a rare disease, potentially limb and life-threatening infection of fascia, subcutaneous tissue with occasionally muscular involvement. Necrotizing faciitis is surgical emergency with high morbidity and mortality. Aim: Aim of this study was to analyze presentation, microbiology, surgical, resuscitative management and outcome of this devastating soft tissue infection. Materials and Methods: The medical records of necrotizing fasciitis patients treated in surgical in...
Kottmeier, Stephen A; Row, Elliot; Tornetta, Paul; Jones, Clifford B; Lorich, Dean G; Watson, J Tracy
Surgical exposures for the management of extremity fractures continue to evolve. Strategies to achieve satisfactory articular reconstitution require surgeons to have an appreciation and understanding of various conventional and contemporary surgical approaches. The recent literature has witnessed a surge in studies on surgical approaches for the fixation of extremity fractures. This increased interest in surgical exposures resulted from not only a desire to enhance outcomes and minimize complications but also a recognition of the inadequacies of traditionally accepted surgical exposures. Contemporary exposures may be modifications or combinations of existing exposures. All surgical exposures require proper surgical execution and familiarity with regional anatomic structures. Exposures, whether conventional or contemporary, must provide sufficient access for reduction and implant insertion. Proper exposure selection can greatly enhance a surgeon's ability to achieve acceptable reduction and adequate fixation. Unique characteristics of both the patient and his or her fracture pathoanatomy may dictate the surgical approach. Patient positioning, imaging access, and concomitant comorbidities (medical, systemic trauma, and regional extremity related) also must be considered. Minimally invasive methods of reduction and fixation are attractive and have merit; however, adherence to them while failing to achieve satisfactory reduction and fixation will not generate a desirable outcome. Surgeons should be aware of several site-specific anatomic regions in which evolving surgical exposures and strategies for extremity fracture management have had favorable outcomes.
Cramm, Jane Murray; Nieboer, Anna Petra
Empirical evidence on sustainability of programs that improve the quality of care delivery over time is lacking. Therefore, this study aims to identify the predictive role of short and long term improvements in quality of chronic care delivery on program sustainability. In this longitudinal study, professionals [2010 (T0): n=218, 55% response rate; 2011 (T1): n=300, 68% response rate; 2012 (T2): n=265, 63% response rate] from 22 Dutch disease-management programs completed surveys assessing quality of care and program sustainability. Our study findings indicated that quality of chronic care delivery improved significantly in the first 2 years after implementation of the disease-management programs. At T1, overall quality, self-management support, delivery system design, and integration of chronic care components, as well as health care delivery and clinical information systems and decision support, had improved. At T2, overall quality again improved significantly, as did community linkages, delivery system design, clinical information systems, decision support and integration of chronic care components, and self-management support. Multilevel regression analysis revealed that quality of chronic care delivery at T0 (pquality changes in the first (pmanagement programs based on the chronic care model improved the quality of chronic care delivery over time and that short and long term changes in the quality of chronic care delivery predicted the sustainability of the projects.
A contextual review of models for chronic care was doneto develop a context-adapted chronic care model-basedservice delivery model for chronic conditions includingdiabetes. The Philippines was used as the setting ofa low-to-middle-income country. A context-basednarrative review of existing models for chronic carewas conducted. A situational analysis was done at thegrassroots level, involving the leaders and members ofthe community, the patients, the local health system andthe healthcare providers. A second analysis making useof certain organizational theories was done to explore onimproving feasibility and acceptability of organizing carefor chronic conditions. The analyses indicated that carefor chronic conditions may be introduced, consideringthe needs of people with diabetes in particular andthe community in general as recipients of care, andthe issues and factors that may affect the healthcareworkers and the health system as providers of thiscare. The context-adapted chronic care model-basedservice delivery model was constructed accordingly.Key features are incorporation of chronic care in thehealth system＇s services; assimilation of chronic caredelivery with the other responsibilities of the healthcareworkers but with redistribution of certain tasks; andensuring that the recipients of care experience thewhole spectrum of basic chronic care that includes educationand promotion in the general population, riskidentification, screening, counseling including self-caredevelopment, and clinical management of the chroniccondition and any co-morbidities, regardless of level ofcontrol of the condition. This way, low-to-middle incomecountries can introduce and improve care for chronicconditions without entailing much additional demand ontheir limited resources.
Mendias, E P; Clark, M C; Guevara, E B
Mexican American women experience unique health care needs related to integration of Mexican and American cultures. To learn how to better promote self-care practices and service utilization in women of Mexican origin living in Texas, researchers used a qualitative approach to interview a convenience sample of 11 low-income women attending a health clinic. Researchers collected narrative data about the women's perceptions of health, wellness, and self-care. Using the matrix approach described by Miles and Huberman, we organized findings around women's roles, including participants' descriptions of themselves, their health and wellness awareness, self-care practices for health/illness and wellness/nonwellness, barriers to self-care, origin of self-care practices, and perceptions of life control. Implications for health planning and service delivery are presented.
Facility delivery is an important aspect of the strategy to reduce maternal and newborn mortality. Geographic access to care is a strong determinant of facility delivery, but few studies have simultaneously considered the influence of facility quality, with inconsistent findings. In rural Brong Ahafo region in Ghana, we combined surveillance data on 11,274 deliveries with quality of care data from all 64 delivery facilities in the study area. We used multivariable multilevel logistic regressi...
S. Percy Ivy
Full Text Available Understanding the biology of cancer at the cellular and molecular levels, and the application of such knowledge to the patient, has opened new opportunities and uncovered new obstacles to quality cancer care delivery. Benefits include our ability to now understand that many, if not, most cancers are not one-size-fits-all. Cancers are a variety of diseases for which intervention may be very different. This approach is beginning to bear fruit in gynecologic cancers where we are investigating therapeutic optimization at a more focused level, that while not yet precision care, is perhaps much improved. Obstacles to quality care for patients come from many directions. These include incomplete understanding of the role of the mutant proteins in the cancers, the narrow spectrum of agents, and broader mutational profiles in solid tumors, and the sometimes overzealous application of the findings of genetic testing. This has been further compromised by the unbridled use of social media by all stakeholders in cancer care often without scientific qualification, where anecdote sometimes masquerades as fact. The only current remedy is to wave the flag of caution, encourage all patients who undergo genetic testing, either germline or somatic, to do so with the oversight of genetic counselors and physician scientists knowledgeable in the pathways involved. This aspiration is accomplished with well designed clinical trials that inform next steps in this complex and ever evolving process.
Butler, Marilyn W
There are several different models of education and care delivery models in low- and middle-income countries (LMICs), and many endeavors combine more than one of the described models. This article summarizes the burden of pediatric surgical disease and discusses the benefits and shortcomings of the following: faith-based missions; short-term surgical trips; partnerships, twinning, and academic collaborations; teaching workshops, "train the trainer," and pediatric surgery camps; specialty treatment centers; online conferences, telemedicine, and mobile health; specific programs for exchange and education; and training in high-income countries (HICs), fellowships, and observorships. It then addresses ethical concerns common to all humanitarian pediatric surgical efforts. Copyright © 2016 Elsevier Inc. All rights reserved.
Roche, Stephanie; Hall-Clifford, Rachel
Each year, thousands of Guatemalans receive non-emergent surgical care from short-term medical missions (STMMs) hosted by local non-governmental organizations (NGOs) and staffed by foreign visiting medical teams (VMTs). The purpose of this study was to explore the perspectives of individuals based in NGOs involved in the coordination of surgical missions to better understand how these missions articulate with the larger Guatemalan health care system. During the summers of 2011 and 2013, in-depth interviews were conducted with 25 representatives from 11 different Guatemalan NGOs with experience with surgical missions. Transcripts were analysed for major themes using an inductive qualitative data analysis process. NGOs made use of the formal health care system but were limited by several factors, including cost, issues of trust and current ministry of health policy. Participants viewed the government health care system as a potential resource and expressed a desire for more collaboration. The current practices of STMMs are not conducive to health system strengthening. The role of STMMs must be defined and widely understood by all stakeholders in order to improve patient safety and effectively utilise health resources. Priority should be placed on aligning the work of VMTs with that of the larger health care system.
Bhattacharyya, Sanghita; Srivastava, Aradhana; Avan, Bilal Iqbal
Understanding a woman's perspective and her needs during childbirth and addressing them as part of quality-improvement programmes can make delivery care safe, affordable, and respectful. It has been pointed out that the patient's judgement on the quality and goodness of care is indispensible to improving the management of healthcare systems. The objective of the study is to understand the aspects of care that women consider important during childbirth. Individual in-depth interviews (IDIs) and focus-group discussions (FGDs) with women who recently delivered were the techniques used. Seventeen IDIs and four FGDs were conducted in Jharkhand state in east India between January and March 2012. Women who had normal deliveries with live births at home and in primary health centres were included. To minimise recall bias, interviews were conducted within 42 days of childbirth. Using the transcripts of interviews, the data were analysed thematically. Aspects of care most commonly cited by women to be important were: availability of health providers and appropriate medical care (primarily drugs) in case of complications; emotional support; privacy; clean place after delivery; availability of transport to reach the institution; monetary incentives that exceed expenses; and prompt care. Other factors included kind interpersonal behaviour, cognitive support, faith in the provider's competence, and overall cleanliness of the facility and delivery room. Respondents belonging to low socio-economic strata with basic literacy levels might not understand appropriate clinical aspects of care, but they want care that is affordable and accessible, along with privacy and emotional support during delivery. The study highlighted that healthcare quality-improvement programmes in India need to include non-clinical aspects of care as women want to be treated humanely during delivery--they desire respectful treatment, privacy, and emotional support. Further research into maternal satisfaction
MacLean, L D
Most countries have mastered the art of cost containment by global budgeting for public expenditure. It is not as yet clear whether the other option, managed care, or managed competition will accomplish cost control in America. Robert Evans, a Canadian health care expert, remains skeptical. He says, "HMO's are the future, always have been and always will be." With few exceptions, the amount spent on health care is not a function of the system but of the gross domestic product per person. Great Britain is below the line expected for expenditure, which may be due to truly impressive waiting lists. The United States is above the line, which is probably related to the overhead costs to administer the system and the strong demand by patients for prompt and highly sophisticated diagnostic measures and treatments. Canada is on the line, but no other country has subscribed to the Canadian veto on private insurance. Reform or changes are occurring in all countries and will continue to do so. For example, we are as terrified of managed care in Canada as you are of our brand of socialized insurance. We distrust practice by protocol just as you abhor waiting lists. From my perspective as a surgeon, I envision an ideal system that would cover all citizens, would maintain choice of surgeon by patients, would provide mechanisms for cost containment that would have the active and continuous participation of the medical profession, and would provide for research and development. Any alteration in health care delivery in the United States that compromises biomedical research and development will be a retrogressive, expensive step that could adversely affect the health of nations everywhere. Finally, a continuing priority of our training programs must be to ensure that the surgeon participating in this system continues to treat each patient as an individual with concern for his or her own needs.
Bhandari, Tulsi Ram; Kutty, V Raman; Sarma, P Sankara; Dangal, Ganesh
Despite various efforts to increase the utilization of skilled birth attendants (SBA), nearly two-thirds of deliveries take place at home without the assistance of SBAs in Nepal. We hypothesized that the ability of women to take decisions about their own lives-women's autonomy-plays an important part in birth choices. To know this, we conducted a community-based cross-sectional study for assessing women's autonomy and utilization of safe delivery care service in Kapilvastu district of Nepal from June to October 2014. We used multivariate modeling to associate socioeconomic factors and women's autonomy with the utilization of safe delivery care services. Just over one-third of women sought institutional delivery care during the birth of their last child. Out of the total deliveries at health facilities, nearly 58% women visited health facility for self-reported emergency obstructive care. Only 6.2% home deliveries were handled by health workers and 14.7% women used the safe delivery kit for home delivery care. Higher levels of women's education had a strong positive association (odds ratio = 24.11, CI = 9.43-61.64) with institutional delivery care. Stratified analysis showed that when the husband is educated, women's education seems to work partly through their autonomy in decision making. Educational status of women emerged as one of the key predictors of the utilization of delivery care services in Kapilvastu district. Economic status of household and husband's education are other dominant predictors of the utilization of safe delivery care services. Improving the economic and educational status may be the way out for improving the proportion of institutional deliveries. Women's autonomy may be an important mediating factor in this pathway.
Deisz, Robert; Kauczok, Jens; Dembinski, Rolf; Pallua, Norbert; Marx, Gernot
Critical care medicine in severely burned patients should be adapted to the different pathophysiological phases. Accordingly, surgical and non-surgical therapy must be coordinated adequately. Initial stabilization of the burn victim during the first 24 hours (Surgical therapy and critical care medicine in severely burned patients - Part 1: the first 24 ours, AINS 9/12) is followed by a long lasting reconstructive period. During this time calculated fluid replacement to compensate evaporative losses by large bourn wounds is as essential as reconstruction of the integrity of the skin and the modulation of metabolic consequences following severe burn injury. Special attention has to be paid to local and systemic infections.
Smith, Kevin W; Bir, Anupa; Freeman, Nikki L B; Koethe, Benjamin C; Cohen, Julia; Day, Timothy J
Using delivery system innovations to advance health care reform continues to be of widespread interest. However, it is difficult to generalize about the success of specific types of innovations, since they have been examined in only a few studies. To gain a broader perspective, we analyzed the results of forty-three ambulatory care programs funded by the first round of the Center for Medicare and Medicaid Innovation's Health Care Innovations Awards. The innovations' impacts on total cost of care were estimated by independent evaluators using multivariable difference-in-differences models. Through the first two years, most of the innovations did not show a significant effect on total cost of care. Using meta-regression, we assessed the effects on costs of five common components of these innovations. Innovations that used health information technology or community health workers achieved the greatest cost savings. Savings were also relatively large in programs that targeted clinically fragile patients-clinically complex populations at risk for disease progression. While the magnitude of these effects was often substantial, none achieved conventional levels of significance in our analyses. Meta-analyses of a larger number of delivery system innovations are needed to more clearly establish their potential for patient care cost savings. Project HOPE—The People-to-People Health Foundation, Inc.
Gregory, Debbie; Buckner, Martha
The growing complexity of technology, equipment, and devices involved in patient care delivery can be staggering and overwhelming. Technology is intended to be a tool to help clinicians, but it can also be a frustrating hindrance if not thoughtfully planned and strategically aligned. Critical care nurses are key partners in the collaborations needed to improve safety and quality through health information technology (IT). Nurses must advocate for systems that are interoperable and adapted to the context of care experiences. The involvement and collaboration between clinicians, information technology specialists, biomedical engineers, and vendors has never been more relevant and applicable. Working together strategically with a shared vision can effectively provide a seamless clinical workflow, maximize technology investments, and ultimately improve patient care delivery and outcomes. Developing a strategic integrated clinical and IT roadmap is a critical component of today's health care environment. How can technology strategy be aligned from the executive suite to the bedside caregiver? What is the model for using clinical workflows to drive technology adoption? How can the voice of the critical care nurse strengthen this process? How can success be assured from the initial assessment and selection of technology to a sustainable support model? What is the vendor's role as a strategic partner and "co-caregiver"?
Arca, Marjorie J; Goldin, Adam B; Oldham, Keith T
In 2015, the American College of Surgeons (ACS) has begun to verify hospitals and ambulatory centers which meet consensus based optimal resource standards as "Children׳s Surgical Centers." The intent is to identify children-specific resources available within an institution and using a stratification system similar to the ACS Trauma Program match these to the needs of infants and children with surgical problems. This review briefly summarizes the history, supporting data and processes which drove this initiative.
A. Kröner; E. van Iperen; J. Horn; J.M. Binnekade; P.E. Spronk; J. Stoker; M.J. Schultz
Background. The clinical value of postoperative chest radiographs (CXRs) for surgical intensive care unit (ICU) patients is largely unknown. In the present study, we determined the diagnostic and therapeutic efficacy of postoperative CXRs for different surgical subgroups and related their efficacy t
Full Text Available Background: Cesarean delivery is the most common surgical procedure and this prevalence is on the rise. Given these trends, cesarean wound complications, such as disruption or infection, remain an important cause of post-cesarean morbidity. Methods: We conducted a single-center randomized controlled trial that included women with viable pregnancies (≥24 weeks undergoing cesarean delivery at Motahary University Hospital, Urmia, Iran from April to November 2014. All cesarean types were included: scheduled or unscheduled and primary or repeat cesareans. Women were excluded for the following reasons: inability to obtain informed consent, immune compromising disease (e.g. AIDS, chronic steroid use, diabetic mellitus and BMI≥30. Of 266 women, 133 were randomized to staples and 133 women to suture group. Results: The mean±SD age of the staples group was 27.6±5.4 years and mean±SD age of suture was 28.7±5.9 years. Multiparity is the most frequent in both groups that by using Chi-square test, no significant differences were observed between the two groups (P=0.393. The most frequent indication for cesarean section in both groups was history of cesarean section in staple 40 cases (30.1% and suture 32 cases (24.1%. The survey was conducted using the Chi-square test was not significant (P=0.381. Pain at 6 weeks postoperatively was significantly less in the staple group (P=0.001. Operative time was longer with suture closure (4.68±0.67 versus 1.03±0.07 minute, P<0.001. The Vancouver scale score was significantly less in suture closure (6.6±0.8 versus 7.5±0.9, P=0.001. Wound disruption was significantly less in suture closure (3.8% versus 11.3%, P=0.017. Conclusion: The staple group had low pain and operation time but had a significant wound disruption and scar. The patients who have suffered a significant wound disruption were affected by age (P=0.022 and BMI (P=0.001 at compared those who were not affected by factors such as age or high BMI as
Olsen, Ø E; Ndeki, S; Norheim, O F
Our objective was to determine the availability and quality of obstetric care to improve resource allocation in northern Tanzania. We surveyed all facilities providing delivery services (n=129) in six districts in northern Tanzania using the UN Guidelines for monitoring emergency obstetric care (EmOC). The three last questions in this audit outline are examined: Are the right women (those with obstetric complications) using emergency obstetric care facilities (Met Need)? Are sufficient quantities of critical services being provided (cesarean section rate (CSR))? Is the quality of the services adequate (case fatality rate (CFR))? Complications are calculated using Plan 3 of the UN Guidelines to assess the value of routine data for EmOC indicator monitoring. Nearly 60% of the expected complicated deliveries in the study population were conducted at EmOC qualified health facilities. 81.2% of the expected complicated deliveries are conducted in any facility (including facilities not qualifying as EmOC facilities). There is an inadequate level of critical services provided (CSR 4.6). Voluntary agencies provide most of these services in rural settings. All indicators show large variations with the setting (urban/rural location, level and ownership of facilities). Finally, there is large variation in the CFR with only one facility meeting the minimum accepted level. Utilization and quality of critical obstetric services at lower levels and in rural districts must be improved. The potential for improving the resource allocation within lower levels of the health care system is discussed. Given the small number of qualified facilities yet relatively high Met Need, we argue that it is neither the mothers' ignorance nor their lack of ability to get to a facility that is the main barrier to receiving quality care when needed, but rather the lack of quality care at the facility. Little can be concluded using the CFR to describe the quality of services provided.
Full Text Available Background: Congenital surgical anomaly is a major indication for admission of a neonate to an intensive care unit. Profile of surgical conditions is variable by system affecting the neonate and outcomes of the individual conditions depending upon treatment and post surgical facilities. This study was undertaken to highlight the surgical conditions, their burden and their prognosis encountered in our newborn care unit. Methodology: This study is a cross sectional study. All information was collected from the case records of all neonates admitted in newborn care unit of our centre between 1st April, 2011 and 31st October, 2014 with congenital surgical conditions and the following information extracted: surgical condition, age, sex, maturity, birth weight, its treatment and outcome, and other associated features were studied. Result: A total of 9213 neonates were admitted in the study period, of which 328 neonates (3.6% had surgical conditions. Surgery was performed in 225 neonates. Commonest congenital surgical condition was of gastrointestinal tract (GIT. Commonest GIT anomalies were tracheo-oesophageal fistula (28.6%, intestinal obstruction (23.7%, anorectal malformation (17.9%, and omphalocoele (7%. The overall mortality in neonates with congenital surgical condition in this study was 51.2%. Significantly, more deaths occurred in preterm than in term neonates (P = 0.00003 and low birth weight babies more than normal weight (p=0.0002. Conclusion: High mortality is found in neonates suffering from surgical conditions. Commonest anomaly includes conditions of Gastrointestinal tract. Prematurity and low birth weight is a significant factor associated with high mortality. [Natl J Med Res 2016; 6(2.000: 168-170
J.M. Cramm (Jane); A.P. Nieboer (Anna)
markdownabstractEmpirical evidence on sustainability of programs that improve the quality of care delivery over time is lacking. Therefore, this study aims to identify the predictive role of short and long term improvements in quality of chronic care delivery on program sustainability. In this lon
Bassler, Elissa J.; And Others
Upcoming federal and state changes in welfare and social services will have a profound effect on the delivery of early childhood care and education in Illinois. In October, 1995, the Day Care Action Council of Illinois convened a meeting of early childhood experts and advocates. From this retreat, a vision for a new system of the delivery of child…
Anthony, Maureen J
Over 3 million migrant farm workers are employed in the United States. Many factors place them at risk for work-related disease and injury. Knowledge of workers' health issues can prepare medical-surgical nurses to anticipate and meet the needs of this underserved population.
Hjort Jakobsen, Dorthe; Rud, Kirsten; Kehlet, Henrik
guidelines based on the principles of fast-track surgery-i.e. patient information, surgical stress reduction, effective analgesia, early mobilisation and rapid return to normal eating. Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN...
Monahan, Janean Carter
A surgical experience can be stressful for any patient. When the patient is an adolescent, however, the surgical experience can create significant stress, which is related to normal adolescent development. Perioperative nursing care should address what adolescent patients perceive as stressful and should provide a safe environment so that a successful surgical outcome can be achieved. To accomplish this, a nursing model specific to perioperative nursing practice should be developed to guide nurses when providing care to adolescents. The Adolescent Perioperative System Stability Model based on the Neuman Systems Model provides a framework for defining scope of practice and organizing nursing care that is appropriate for the adolescent during a surgical experience. In addition to guiding nursing practice, this model provides direction and guidance for future studies of adolescents in the perioperative setting.
Nesbitt, Robin C; Lohela, Terhi J; Soremekun, Seyi; Vesel, Linda; Manu, Alexander; Okyere, Eunice; Grundy, Chris; Amenga-Etego, Seeba; Owusu-Agyei, Seth; Kirkwood, Betty R; Gabrysch, Sabine
Facility delivery is an important aspect of the strategy to reduce maternal and newborn mortality. Geographic access to care is a strong determinant of facility delivery, but few studies have simultaneously considered the influence of facility quality, with inconsistent findings. In rural Brong Ahafo region in Ghana, we combined surveillance data on 11,274 deliveries with quality of care data from all 64 delivery facilities in the study area. We used multivariable multilevel logistic regression to assess the influence of distance and several quality dimensions on place of delivery. Women lived a median of 3.3 km from the closest delivery facility, and 58% delivered in a facility. The probability of facility delivery ranged from 68% among women living 1 km from their closest facility to 22% among those living 25 km away, adjusted for confounders. Measured quality of care at the closest facility was not associated with use, except that facility delivery was lower when the closest facility provided substandard care on the EmOC dimension. These results do not imply, however, that we should increase geographic accessibility of care without improving facility quality. While this may be successful in increasing facility deliveries, such care cannot be expected to reduce maternal and neonatal mortality.
Nesbitt, Robin C.; Lohela, Terhi J.; Soremekun, Seyi; Vesel, Linda; Manu, Alexander; Okyere, Eunice; Grundy, Chris; Amenga-Etego, Seeba; Owusu-Agyei, Seth; Kirkwood, Betty R.; Gabrysch, Sabine
Facility delivery is an important aspect of the strategy to reduce maternal and newborn mortality. Geographic access to care is a strong determinant of facility delivery, but few studies have simultaneously considered the influence of facility quality, with inconsistent findings. In rural Brong Ahafo region in Ghana, we combined surveillance data on 11,274 deliveries with quality of care data from all 64 delivery facilities in the study area. We used multivariable multilevel logistic regression to assess the influence of distance and several quality dimensions on place of delivery. Women lived a median of 3.3 km from the closest delivery facility, and 58% delivered in a facility. The probability of facility delivery ranged from 68% among women living 1 km from their closest facility to 22% among those living 25 km away, adjusted for confounders. Measured quality of care at the closest facility was not associated with use, except that facility delivery was lower when the closest facility provided substandard care on the EmOC dimension. These results do not imply, however, that we should increase geographic accessibility of care without improving facility quality. While this may be successful in increasing facility deliveries, such care cannot be expected to reduce maternal and neonatal mortality. PMID:27506292
DeKeyser Ganz, Freda; Berkovitz, Keren
To describe surgical nurses' perceived levels of ethical dilemmas, moral distress and perceived quality of care and the associations among them. Nurses are committed to providing quality care. They can experience ethical dilemmas and moral distress while providing patient care. Little research has focused on the effect of moral distress or ethical dilemmas on perceived quality of care. Descriptive, cross-sectional study. After administration and institutional Research Ethics Committee approval, a researcher requested 119 surgical nurses working in two Israeli hospitals to fill out three questionnaires (personal background characteristics; Ethical Dilemmas in Nursing and Quality of Nursing Care). Data collection took place from August 2007 to January 2008. Participant mean age was 39·7 years. The sample consisted mostly of women, Jewish and married staff nurses. The majority of nurses reported low to moderate levels of ethical dilemma frequency but intermediate levels of ethical dilemma intensity. Frequency of ethical dilemmas was negatively correlated with level of nursing skill, meeting patient's needs and total quality of care. No important correlations were found between intensity of ethical dilemmas and quality of care. Levels of ethical dilemma frequency were higher than intensity. Nurses tended to be satisfied with their level of quality of care. Increased frequency of ethical dilemmas was associated with some aspects of perceived quality of care. Quality of care is related to ethical dilemmas and moral distress among surgical nurses. Therefore, efforts should be made to decrease the frequency of these feelings to improve the quality of patient care. © 2011 Blackwell Publishing Ltd.
Full Text Available Objectives: The objective of this study was to describe the care practices of nursing staff caring older people with dementia in a surgical ward. Methods: The data were collected from nursing staff (n = 191 working in surgical wards in one district area in Finland during October to November 2015. Data were collected using a structured questionnaire and analyzed statistically. The instrument consists of a total number of 141 items and four dimensions. The dimensions were as follows: background information (12 of items, specific characteristics of older people with dementia in a surgical ward (24 of items, specific characteristics of their care in a surgical ward (66 of items and use of physical restraints and alternative models for use of restraints for people with dementia (39 of items. Results: The questions which measure the nursing staff’s own assessment of care practices when caring for people with dementia in surgical wards were selected: counseling people with dementia, reaction when a surgical patient with dementia displays challenging behavior and use of alternative approach instead of physical restraints. Most commonly the nursing staff pay attention to patient’s state of alertness before counseling older people with dementia. Instead of using restraints, nursing staff gave painkillers for the patient and tried to draw patients’ attention elsewhere. The nursing staff with longer work experience estimate that they can handle the patients’ challenging behavior. They react by doing nothing more often than others. They pretend not to hear, see or notice anything. Conclusion: The findings of this study can be applied in nursing practice and in future studies focusing on the care practices among older people with dementia in acute care environment. The results can be used while developing patient treatments process in surgical ward to meet future needs.
Jan 25, 2012 ... why a number of cataract blind encountered at homes or communities are not ... eye care worker: A community health worker placed at the primary level of care with short ... The discussion was recorded by digital voice recorder and also ... of the workers in the tertiary, state, and private respectively agree to ...
Kimmel, April D; Martin, Erika G; Galadima, Hadiza; Bono, Rose S; Tehrani, Ali Bonakdar; Cyrus, John W; Henderson, Margaret; Freedberg, Kenneth A; Krist, Alexander H
With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially
Hull, Louise; Athanasiou, Thanos; Russ, Stephanie
The aim of this review was to emphasize the importance of implementation science in understanding why efforts to integrate evidence-based interventions into surgical practice frequently fail to replicate the improvements reported in early research studies. Over the past 2 decades, numerous patient safety initiatives have been developed to improve the quality and safety of surgical care. The surgical community is now faced with translating "promising" initiatives from the research environment into clinical practice-the World Health Organization (WHO) has described this task as one of the greatest challenges facing the global health community and has identified the importance of implementation science in scaling up evidence-based interventions. Using the WHO surgical safety checklist, a prominent example of a rapidly and widely implemented surgical safety intervention of the past decade, a review of literature, spanning surgery, and implementation science, was conducted to identify and describe a broad range of factors affecting implementation success, including contextual factors, implementation strategies, and implementation outcomes. Our current approach to conceptualizing and measuring the "effectiveness" of interventions has resulted in factors critical to implementing surgical safety interventions successfully being neglected. Improvements in the safety and quality of surgical care can be accelerated by drawing more heavily upon implementation science and that until this rapidly evolving field becomes more firmly embedded into surgical research and implementation efforts, our understanding of why interventions such as the checklist "work" in some settings and appear "not to work" in other settings will be limited.
J.M. Hartgerink (Jacqueline); J.M. Cramm (Jane); A.J. de Vos (Annemarie); T.J.E.M. Bakker (Ton); E.W. Steyerberg (Ewout); J.P. Mackenbach (Johan); A.P. Nieboer (Anna)
markdownabstract__Abstract__ Background: It is known that interprofessional collaboration is crucial for integrated care delivery, yet we are still unclear about the underlying mechanisms explaining effectiveness of integrated care delivery to older patients. In addition, we lack research comparing
J.M. Hartgerink (Jacqueline); J.M. Cramm (Jane); A.J. de Vos (Annemarie); T.J.E.M. Bakker (Ton); E.W. Steyerberg (Ewout); J.P. Mackenbach (Johan); A.P. Nieboer (Anna)
markdownabstract__Abstract__ Background: It is known that interprofessional collaboration is crucial for integrated care delivery, yet we are still unclear about the underlying mechanisms explaining effectiveness of integrated care delivery to older patients. In addition, we lack research
J.M. Hartgerink (Jacqueline); J.M. Cramm (Jane); J.B.M. Vos; T.J.E.M. Bakker (Ton); E.W. Steyerberg (Ewout); J.P. Mackenbach (Johan); A.P. Nieboer (Anna)
markdownabstractAbstract Background: It is known that interprofessional collaboration is crucial for integrated care delivery, yet we are still unclear about the underlying mechanisms explaining effectiveness of integrated care delivery to older patients. In addition, we lack research comparing
Neff, Lucas P; Cannon, Jeremy W; Charnock, Kathryn M; Farmer, Diana L; Borgman, Matthew A; Ricca, Robert L
To describe the scope and outcomes of elective pediatric surgical procedures performed during combat operations. The care of patients in Operation Enduring Freedom (OEF) includes elective humanitarian surgery on Afghan children. Unlike military reports of pediatric trauma care, there is little outcome data on elective pediatric surgical care during combat operations to guide treatment decisions. All elective surgical procedures performed on patients≤16years of age from May 2012 through April 2014 were reviewed. Procedures were grouped by surgical specialty and were further classified as single-stage (SINGLE) or multi-stage (MULTI). The primary endpoint was post-operative complications requiring further surgery, and the secondary endpoint was post-operative follow up. A total of 311 elective pediatric surgical procedures were performed on 239 patients. Surgical specialties included general surgery, orthopedics, otolaryngology, ophthalmology, neurosurgery and urology. 178 (57%) were SINGLE while 133 (43%) were MULTI. Fifteen patients required 32 procedures for post-operative complications. Approximately half of all procedures were performed as outpatient surgery. Median length of stay for inpatient was 2.2days, and all patients survived to discharge. The majority of patients returned for outpatient follow-up (207, 87%), and 4 patients (1.7%) died after discharge. Elective pediatric surgical care in a forward deployed setting is feasible; however, limitations in resources for perioperative care and rehabilitation mandate prudent patient selection particularly with respect to procedures that require prolonged post-operative care. Formal guidance on the process of patient selection for elective humanitarian surgery in these settings is needed. Published by Elsevier Inc.
Steele, Joseph Rodgers; Jones, A Kyle; Clarke, Ryan K; Shoemaker, Stowe
The patient experience has moved to the forefront of health care-delivery research. The University of Texas MD Anderson Cancer Center Department of Diagnostic Radiology began collaborating in 2011 with the University of Houston Conrad N. Hilton College of Hotel and Restaurant Management, and in 2013 with the University of Nevada, Las Vegas, William F. Harrah College of Hotel Administration, to explore the application of service science to improving the patient experience. A collaborative pilot study was undertaken by these 3 institutions to identify and rank the specific needs and expectations of patients undergoing imaging procedures in the MD Anderson Department of Diagnostic Radiology. We first conducted interviews with patients, providers, and staff to identify factors perceived to affect the patient experience. Next, to confirm these factors and determine their relative importance, we surveyed more than 6,000 patients by e-mail. All factors considered important in the interviews were confirmed as important in the surveys. The surveys showed that the most important factors were acknowledgment of the patient's concerns, being treated with respect, and being treated like a person, not a "number"; these factors were more important than privacy, short waiting times, being able to meet with a radiologist, and being approached by a staff member versus having one's name called out in the waiting room. Our work shows that it is possible to identify and rank factors affecting patient satisfaction using techniques employed by the hospitality industry. Such factors can be used to measure and improve the patient experience.
Oya, Hisaharu; Matoba, Motohiro; Murakami, Satoshi; Ohshiro, Taihei; Kishino, Takayoshi; Satoh, Yuya; Tsukahara, Tetsuo; Hori, Syutarou; Maeda, Masahiro; Makino, Takashi; Maeda, Takashi
Knowledge concerning palliative care and the associated skills, including effective pain control, is essential for surgeons who treat cancer patients in daily practice. This study focuses on a palliative care training course that has been mandatorily conducted for all surgical residents of our hospital since 2009. We evaluated the effectiveness of our mandatory palliative care training course by conducting a retrospective study of the patients' medical records and participants' questionnaire results and discussed the importance of palliative care education for surgical residents. All 12 surgical residents who participated in the course in 2009 had graduated 4-9 years back. They were assigned to look after a total of 92 cases (average, 7.66 cases per resident) during the course. The purpose of care in most cases (92.3%) was to mitigate pain. Introducing analgesic adjuvants such as gabapentin or amitriptyline accounted for the largest part of initial interventions (23.9%) aimed at controlling cancer pain, followed by changes in route of administration or doses of prior opioid analgesics (21.7%). Interventions with opioid analgesics were conducted most frequently (47.7%). The overall pain improvement rate was 89.1%. We used a questionnaire after the course to evaluate its effectiveness. The surgical residents stated that it was a meaningful course through which they gained practical knowledge on palliative care and that the experience would change their approach to home care.
Full Text Available BACKGROUND: Many sub-Saharan countries, including Ghana, have introduced policies to provide free medical care to pregnant women. The impact of these policies, particularly on access to health services among the poor, has not been evaluated using rigorous methods, and so the empirical basis for defending these policies is weak. In Ghana, a recent report also cast doubt on the current mechanism of delivering free care--the National Health Insurance Scheme. Longitudinal surveillance data from two randomized controlled trials conducted in the Brong Ahafo Region provided a unique opportunity to assess the impact of Ghana's policies. METHODS: We used time-series methods to assess the impact of Ghana's 2005 policy on free delivery care and its 2008 policy on free national health insurance for pregnant women. We estimated their impacts on facility delivery and insurance coverage, and on socioeconomic differentials in these outcomes after controlling for temporal trends and seasonality. RESULTS: Facility delivery has been increasing significantly over time. The 2005 and 2008 policies were associated with significant jumps in coverage of 2.3% (p = 0.015 and 7.5% (p<0.001, respectively after the policies were introduced. Health insurance coverage also jumped significantly (17.5%, p<0.001 after the 2008 policy. The increases in facility delivery and insurance were greatest among the poorest, leading to a decline in socioeconomic inequality in both outcomes. CONCLUSION: Providing free care, particularly through free health insurance, has been effective in increasing facility delivery overall in the Brong Ahafo Region, and especially among the poor. This finding should be considered when evaluating the impact of the National Health Insurance Scheme and in supporting the continuation and expansion of free delivery care.
Full Text Available Background: Understanding a woman's perspective and her needs during childbirth and addressing them as part of quality-improvement programmes can make delivery care safe, affordable, and respectful. It has been pointed out that the patient's judgement on the quality and goodness of care is indispensible to improving the management of healthcare systems. Objective: The objective of the study is to understand the aspects of care that women consider important during childbirth. Design: Individual in-depth interviews (IDIs and focus-group discussions (FGDs with women who recently delivered were the techniques used. Seventeen IDIs and four FGDs were conducted in Jharkhand state in east India between January and March 2012. Women who had normal deliveries with live births at home and in primary health centres were included. To minimise recall bias, interviews were conducted within 42 days of childbirth. Using the transcripts of interviews, the data were analysed thematically. Results: Aspects of care most commonly cited by women to be important were: availability of health providers and appropriate medical care (primarily drugs in case of complications; emotional support; privacy; clean place after delivery; availability of transport to reach the institution; monetary incentives that exceed expenses; and prompt care. Other factors included kind interpersonal behaviour, cognitive support, faith in the provider's competence, and overall cleanliness of the facility and delivery room. Conclusions: Respondents belonging to low socio-economic strata with basic literacy levels might not understand appropriate clinical aspects of care, but they want care that is affordable and accessible, along with privacy and emotional support during delivery. The study highlighted that healthcare quality-improvement programmes in India need to include non-clinical aspects of care as women want to be treated humanely during delivery – they desire respectful treatment
Halaweish, Ihab; Alam, Hasan B
Severe colitis, an umbrella encompassing several entities, is one of the most common acute gastrointestinal disorders resulting in critical illness. Clostridium difficile infection is responsible for the majority of nosocomial diarrhea with fulminant C difficile colitis (CDC) carrying a high mortality. Optimal outcomes can be achieved by early identification and treatment of fulminant CDC, with appropriate surgical intervention when indicated. Ischemic colitis, on the other hand, is uncommon with a range of etiological factors including abdominal aortic surgery, inotropic drugs, rheumatoid diseases, or often no obvious triggering factor. Most cases resolve with nonsurgical management; however, prompt recognition of full-thickness necrosis and gangrene is crucial for good patient outcomes. Fulminant colitis is a severe disease secondary to progressive ulcerative colitis with systemic deterioration. Surgical intervention is indicated for hemorrhage, perforation, or peritonitis and failure of medical therapy to control the disease. Although, failure of medical management is the most common indication, it can be difficult to define objectively and requires a collaborative multidisciplinary approach. This article proposes some simple management algorithms for these clinical entities, with a focus on critically ill patients.
Monroe, C Douglas; Chin, Karen Y
The specialty pharmaceuticals market is expanding more rapidly than the traditional pharmaceuticals market. Specialty pharmacy operations have evolved to deliver selected medications and associated clinical services. The growing role of specialty drugs requires new approaches to managing the use of these drugs. The focus, expectations, and emphasis in specialty drug management in an integrated health care delivery system such as Kaiser Permanente (KP) can vary as compared with more conventional health care systems. The KP Specialty Pharmacy (KP-SP) serves KP members across the United States. This descriptive account addresses the impetus for specialty drug management within KP, the use of tools such as an electronic health record (EHR) system and process management software, the KP-SP approach for specialty pharmacy services, and the emphasis on quality measurement of services provided. Kaiser Permanente's integrated system enables KP-SP pharmacists to coordinate the provision of specialty drugs while monitoring laboratory values, physician visits, and most other relevant elements of the patient's therapy. Process management software facilitates the counseling of patients, promotion of adherence, and interventions to resolve clinical, logistic, or pharmacy benefit issues. The integrated EHR affords KP-SP pharmacists advantages for care management that should become available to more health care systems with broadened adoption of EHRs. The KP-SP experience may help to establish models for clinical pharmacy services as health care systems and information systems become more integrated.
Cole, L; Houston, S
Structured care methodologies are tools that provide a comprehensive approach to patient care delivery. These tools have evolved in their application and purpose over the years. In many situations, multiple tools are needed to obtain the best outcomes for a patient. The presence of a SCM does not preclude clinical judgment. On the contrary, the fundamental purpose of any SCM is to assist practitioners in implementing practice patterns associated with good clinical judgment, research-based interventions, and improved patient outcomes. These tools support smooth operation and appropriate use of resources, establish a means of patient management across the continuum of care, facilitate collaboration among disciplines, reflect patient outcomes, and provide outcomes data. Data from SCMs permit benchmarking, comparison of pre-implementation and post-implementation outcomes, development of action plans for quality enhancement, identification of high-risk patients, identification of issues and problems in the system that require interventions, and the development of research protocols and studies. Structured care methodology development and implementation can be challenging, rewarding, and at times frustrating. When used appropriately, these tools can have a major impact on the standardization of care and the achievement of desired outcomes. However, individual patient needs may supersede adherence to a tool. The challenge then becomes one of balancing the unique needs of each patient and appropriate use of SCMs. Change comes slowly, but persistence pays off.
Fiori, Kevin; Schechter, Jennifer; Dey, Monica; Braganza, Sandra; Rhatigan, Joseph; Houndenou, Spero; Gbeleou, Christophe; Palerbo, Emmanuel; Tchangani, Elfamozo; Lopez, Andrew; Bensen, Emily; Hirschhorn, Lisa R
Providing quality care for all children living with HIV/AIDS remains a global challenge and requires the development of new healthcare delivery strategies. The care delivery value chain (CDVC) is a framework that maps activities required to provide effective and responsive care for a patient with a particular disease across the continuum of care. By mapping activities along a value chain, the CDVC enables managers to better allocate resources, improve communication, and coordinate activities. We report on the successful application of the CDVC as a strategy to optimize care delivery and inform quality improvement (QI) efforts with the overall aim of improving care for Pediatric HIV patients in Togo, West Africa. Over the course of 12 months, 13 distinct QI activities in Pediatric HIV/AIDS care delivery were monitored, and 11 of those activities met or exceeded established targets. Examples included: increase in infants receiving routine polymerase chain reaction testing at 2 months (39-95%), increase in HIV exposed children receiving confirmatory HIV testing at 18 months (67-100%), and increase in patients receiving initial CD4 testing within 3 months of HIV diagnosis (67-100%). The CDVC was an effective approach for evaluating existing systems and prioritizing gaps in delivery for QI over the full cycle of Pediatric HIV/AIDS care in three specific ways: (1) facilitating the first comprehensive mapping of Pediatric HIV/AIDS services, (2) identifying gaps in available services, and (3) catalyzing the creation of a responsive QI plan. The CDVC provided a framework to drive meaningful, strategic action to improve Pediatric HIV care in Togo.
Fatemeh Zahra Karimi
Full Text Available Background The aim of this study was determine the effect of kangaroo mother care (KMC immediately after delivery on mother-infant attachment 3-month after delivery. Materials and Methods: In this RCT study, 72 mother-infant pairs were randomly divided in to kangaroo mother care and routine care groups.The intervention group received kangaroo mother care (KMC in the first two hours post birth. The control group just received routine hospital care. Mothers in the intervention group were encouraged to keep the baby in KMC as much as possible during the day and night throughout the neonatal period. Participants were followed up for three months after birth. The Main outcome measure was mother-infant attachment at 3 months postpartum and maternal anxiety about the baby at the same time. The data was collected by questionnaire (demographic information of parents and neonates and maternal attachment scale. Analysis was performed using SPSS software (version 14. Results: There was no significant difference between two groups regarding their baseline data. Mean maternal attachment score in the KMC group and in the routine care group at three months after delivery was 52.40±3.30 and 49.86±4.18 respectively, which was significantly higher in the KMC group (P
Stover, Angela M; Basch, Ethan M
The American Society of Clinical Oncology (ASCO) palliative care recommendations have been updated into a full guideline. Symptom questionnaires-completed and reviewed with patients during care delivery-are poised to play a large role in this guideline because they provide a more comprehensive understanding of symptoms. This article provides an overview of the guideline and describes how symptom questionnaires can be used to satisfy the guideline. Standardized symptom questionnaires can be used for three purposes in care delivery: symptom management, referral to specialty palliative and supportive care, and to assess high-quality care. Challenges include necessary changes to clinic workflow to collect patient responses and respond to electronic alerts for worsening symptoms. Symptom questionnaires administered as part of routine care delivery are highly informative and worth the time to enhance symptom management in routine care, to increase referrals, and to standardize performance metrics.
Idenburg, Floris J.; Van Dongen, Thijs T C F; Tan, Edward C T H; Hamming, Jaap H.; Leenen, Luke P H; Hoencamp, Rigo
Background From August 2006–August 2010, as part of the ISAF mission, the Armed Forces of the Netherlands deployed a role 2 enhanced Medical Treatment Facility (R2E-MTF) to Uruzgan province, Afghanistan. Although from the principle doctrine not considered a primary task, care was delivered to civi
Foster, L; Moore, P
This article, the last in a series of four, discusses the importance of documenting wound care. Studies have shown that nurses do not document wound care as often, or as accurately, as they should in order to comply with the UKCC's (1998) Guidelines for Records and Record Keeping. Although some wound assessment charts have been published and are in use, there is still concern about the validity or reliability of some of these charts. Studies show that further research is necessary in order to validate the charts that are currently in use. An increase in litigation has placed more emphasis on accurate record keeping which shows, in detail, the wound care that is given to each patient. Patients also want to be more informed about their treatment, and this can be done through the use of clinical pathways or multidisciplinary documents. This article also discusses the factors that have to be considered when putting a wound care chart together and gives some examples of existing charts.
Benefits and myths of breastfeeding may interfere with the breastfeeding relationship during maternal hospitalization. Guidelines for maintaining the breastfeeding relationship and/or protecting the milk supply during contact with the health care system outside of the maternal child area are presented.
Kinder, Karen; Kristensen, Troels; Abrams, Chad
Objectives The aim of this workshop is to provide an insight into how information gained through applications of risk stratification in the primary health care sector, from integrated care networks to primary care clinics and finally at the individual clinician level can improve the delivery of p...
Foss Durant, Anne; McDermott, Shawna; Kinney, Gwendolyn; Triner, Trudy
In early 2010, leaders within Kaiser Permanente (KP) Northern California's Patient Care Services division embarked on a journey to embrace and embed core tenets of Caring Science into the practice, environment, and culture of the organization. Caring Science is based on the philosophy of Human Caring, a theory articulated by Jean Watson, PhD, RN, AHN-BC, FAAN, as a foundational covenant to guide nursing as a discipline and a profession. Since 2010, Caring Science has enabled KP Northern California to demonstrate its commitment to being an authentic person- and family-centric organization that promotes and advocates for total health. This commitment empowers KP caregivers to balance the art and science of clinical judgment by considering the needs of the whole person, honoring the unique perception of health and healing that each member or patient holds, and engaging with them to make decisions that nurture their well-being. The intent of this article is two-fold: 1) to provide context and background on how a professional practice framework was used to transform the ethic of caring-healing practice, environment, and culture across multiple hospitals within an integrated delivery system; and 2) to provide evidence on how integration of Caring Science across administrative, operational, and clinical areas appears to contribute to meaningful patient quality and health outcomes.
Iurkevich, V V; Fidarov, E Z; Bauér, V A
Experience of organization of the surgical care in the military hospital to 438 wounded in extremities during armed conflict in Republic of Chechnya is generalized. Maximum reduction of stages of medical evacuation of the wounded in extremities, approaching of the qualified and urgent specialized surgical care directly to the region of battle actions, use of opportunities for it one-moment rendering corresponded to principles of the modern military-medical doctrine. Due to realization of the requirements of the doctrine life of many wounded ++ was saved, terms of treatment, medical and social rehabilitation are reduced. Besides lethality, treatment cost and numbers of transferring to the reserve from the Armed Forces were reduced.
Goldin, Adam B; Dasgupta, Roshni; Chen, Li Ern; Blakely, Martin L; Islam, Saleem; Downard, Cynthia D; Rangel, Shawn J; St Peter, Shawn D; Calkins, Casey M; Arca, Marjorie J; Barnhart, Douglas C; Saito, Jacqueline M; Oldham, Keith T; Abdullah, Fizan
The United States' healthcare system is facing unprecedented pressures: the healthcare cost curve is not sustainable while the bar of standards and expectations for the quality of care continues to rise. Systems committed to the surgical treatment of children will likely require changes and reorganization. Regardless of these mounting pressures, hospitals must remain focused on providing the best possible care to each child at every encounter. Available clinical expertise and hospital resources should be optimized to match the complexity of the treated condition. Although precise criteria are lacking, there is a growing consensus that the optimal combination of clinical experience and hospital resources must be defined, and efforts toward this goal have been supported by the Regents of the American College of Surgeons, the members of the American Pediatric Surgical Association, and the Society for Pediatric Anesthesia (SPA) Board of Directors. The topic of optimizing outcomes and the discussion of the concepts involved have unfortunately become divisive. Our goals, therefore, are 1) to provide a review of the literature that can provide context for the discussion of regionalization, volume, and optimal resources and promote mutual understanding of these important terms, 2) to review the evidence that has been published to date in pediatric surgery associated with regionalization, volume, and resource, 3) to focus on a specific resource (anesthesia), and the association that this may have with outcomes, and 4) to provide a framework for future research and policy efforts.
studied care pathways. General practitioners/family doctors are responsible for liaising between different teams/services, except in Greece where this is done through pulmonologists. Ireland and the UK are the only countries with services for patients at home to shorten unnecessary hospital stay. HCPs emphasized lack of communication, limited resources, and poor patient engagement as issues in the current pathways. Furthermore, no specified role exists for pharmacists and informal carers.Conclusion: Service and professional integration between care settings using a unified system targeting COPD and comorbidities is a priority. Better communication between health care providers, establishing a clear role for informal carers, and enhancing patients’ engagement could optimize current care pathways resulting in a better integrated system. Keywords: COPD, comorbidities, care delivery pathway, comparative analysis
van Oostveen, Catharina J; Vermeulen, Hester; Nieveen van Dijkum, Els J M; Gouma, Dirk J; Ubbink, Dirk T
Surgeons and nurses sometimes perceive a high workload on the surgical wards, which may influence admission decisions and staffing policy. This study aimed to explore the relative contribution of various patient and care characteristics to the perceived patients' care intensity and whether differences exist in the perception of surgeons and nurses. We invited surgeons and surgical nurses in the Netherlands for a conjoint analysis study through internet and e-mail invitations. They rated 20 virtual clinical scenarios regarding patient care intensity on a 10-point Likert scale. The scenarios described patients with 5 different surgical conditions: cholelithiasis, a colon tumor, a pancreas tumor, critical leg ischemia, and an unstable vertebral fracture. Each scenario presented a mix of 13 different attributes, referring to the patients' condition, physical symptoms, and admission and discharge circumstances. A total of 82 surgeons and 146 surgical nurses completed the questionnaire, resulting in 4560 rated scenarios, 912 per condition. For surgeons, 6 out of the 13 attributes contributed significantly to care intensity: age, polypharmacy, medical diagnosis, complication level, ICU-stay and ASA-classification, but not multidisciplinary care. For nurses, the same six attributes contributed significantly, but also BMI, nutrition status, admission type, patient dependency, anxiety or delirium during hospitalization, and discharge type. Both professionals ranked 'complication level' as having the highest impact. The differences between surgeons and nurses on attributes contributing to care intensity may be explained by differences in professional roles and daily work activities. Surgeons have a medical background, including technical aspects of their work and primary focus on patient curation. However, nurses are focused on direct patient care, i.e., checking vital functions, stimulating self-care and providing woundcare. Surgeons and nurses differ in their perception of
Pelone, F.; Kringos, D.S.; Spreeuwenberg, P.; Belvis, A.G. de; Groenewegen, P.P.
Objective: To measure the relative efficiency of primary care (PC) in turning their structures into services delivery and turning their services delivery into quality outcomes. Design: Cross-sectional study based on the dataset of the Primary Healthcare Activity Monitor for Europe project. Two Data
Pelone, F.; Kringos, D.S.; Spreeuwenberg, P.; de Belvis, A.; Groenewegen, P.P.
OBJECTIVE: To measure the relative efficiency of primary care (PC) in turning their structures into services delivery and turning their services delivery into quality outcomes. DESIGN: Cross-sectional study based on the dataset of the Primary Healthcare Activity Monitor for Europe project. Two Data
Iversen, Tobias Buschmann; Melby, Line; Landmark, Andreas Dypvik; Toussaint, Pieter
In surgical work there is a need for 'continuous planning' among staff to handle the frequently occurring variations from the planned patient treatment. In this paper, we present how three hospital information systems have support for three common patient trajectory variations. Highlight how deviations from a plan cause different information needs and implications for design of awareness supporting computer systems. Participant observations and semi-structured interviews with stakeholders involved in peri-operative work. When trajectories progress according to plan, information needs of staff seem to be minimal, as everything is "running to plan". However, when variations occur the information need increases. In order to provide better support for variations, awareness-support systems need to inform colleagues and other stakeholders about deviations from the plan. Plans and trajectories also need to be connected by projecting estimations of incidental time of ongoing relevant events. Additionally, end-users should have the option to switch between information-sparse and information-rich computer support. Published by Elsevier Ireland Ltd.
Conclusion: The current study shows that use of delivery care services is associated with socioeconomic development and can be enhanced by societies that focus on general issues such as schooling, economic wellbeing, and gender-based discrimination.
Lacchini, Annie Jeanninne Bisso; Noal, Helena Carolina; Padoin, Stela Maris de Mello; Terra, Marlene Gomes
The following study aimed to understand the meanings on the discourse of a Nursing Surgical team regarding the care given to patients with mental disorders submitted to surgical procedures. For such comprehension, a theoretical-philosophical referential by Maurice Merleau-Ponty has been examined. Concerning a methodological approach Paul Ricouer's hermeneutics has been used. Eight nursing caregivers from a public hospital in southern Brazil were interviewed from August to September 2008. The results showed the necessity of stimulating nursing caregivers in the reflective process in acting, thinking, and observing care given to patients with mental disorder; as well as to offer emotional support for them. The caregivers displayed the necessity of understanding the human being receiving care in order to be able to give thorough care as a being-in-the-world.
Conclusions: Neonatal outcome did not depend on mode of delivery though maternal morbidity and cost of care is increased following Caesarean Section. Proper selection of cases and by improving skill and confidence in new generation obstetrician, vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to a woman in a tertiary care centre. [Int J Reprod Contracept Obstet Gynecol 2014; 3(3.000: 562-565
Aarabi, Shahram; Smithers, Charles; Fils, Marie-May Louis; Godson, Jean-Louis; Pierre, Jean-Hamilton; Mukherjee, Joia; Meara, John; Farmer, Paul
Surgical diseases have recently been shown to be a major cause of global morbidity and mortality. Effective methods to decrease the burden of surgical disease and provide care in resource-poor settings are unknown. An opportunity to meet this need exists through collaborative efforts to train local surgeons in specialty care, such as pediatric general surgery. We present a novel model for the provision of surgical care and education in a resource-poor setting via a collaborative Global Surgery Fellowship program. Through Partners in Health in Haiti, this program placed a fully trained pediatric surgeon at an established rural hospital, both to temporarily serve that community and to teach local surgeons pediatric surgical care. The Global Surgery Fellow performed the cases presented here during his term, between July 2009 and June 2010. A total of 147 operative procedures were performed on 131 patients over the course of 12 weeks in Haiti. A total of 134 of the 147 total cases performed (91.2%) were educational cases, in which the Fellow operated with and trained one or more of the following: American medical students, American residents, Haitian residents, or Haitian staff surgeons. The Global Surgery Fellowship model overcomes many of the traditional challenges to providing adequate surgical care in resource-poor countries. Specifically, it meets the challenge of providing a broad educational experience for many levels of local and foreign physicians, while working within an established locally run health care system. We believe that this model is generalizable to many resource-poor hospitals with permanent local staff that are open to collaboration. Copyright © 2015 Elsevier Inc. All rights reserved.
Full Text Available Rostislav Horacek,1 Barbora Krnacova,2 Jan Prasko,2 Klara Latalova2 1Department of Central Intensive Care Unit for Surgery, 2Department of Psychiatry, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University Olomouc, Czech Republic Background: The aim of this study was to examine the impact of somatic illnesses, electrolyte imbalance, red blood cell count, hypotension, and antipsychotic and opioid treatment on the duration of delirium in Central Intensive Care Unit for Surgery.Patients and methods: Patients who were admitted to the Department of Central Intensive Care Unit for Surgery in the University Hospital Olomouc from February 2004 to November 2008 were evaluated using Riker sedation–agitation scale. Their blood pressure, heart rate, respiratory rate, and peripheral blood oxygen saturation were measured continually, and body temperature was monitored once in an hour. The laboratory blood tests including sodium, potassium, chlorides, phosphorus, urea and creatinine, hemoglobin, hematocrit, red and white blood cell count, and C-reactive protein, albumin levels and laboratory markers of renal and liver dysfunction were done every day. All measurements were made at least for ten consecutive days or longer until the delirium resolved.Results: The sample consisted of 140 consecutive delirious patients with a mean age of 68.21±12.07 years. Delirium was diagnosed in 140 of 5,642 patients (2.48% admitted in CICUS in the last 5 years. The median duration of delirium was 48 hours with a range of 12–240 hours. Statistical analysis showed that hyperactive subtype of delirium and treatment with antipsychotics were associated with prolonged delirium duration (hyperactive 76.15±40.53 hours, hypoactive 54.46±28.44 hours, mixed 61.22±37.86 hours; Kruskal–Wallis test: 8.022; P<0.05. The duration of delirium was significantly correlated also with blood potassium levels (Pearson’s r=0.2189, P<0.05, hypotension
Rijsingen, M.C.J. van; Vossen, R.; Huystee, B.E.W.L. van; Gorgels, W.J.; Gerritsen, M.J.P.
BACKGROUND: Due to a rapid increase in the incidence of skin cancer, it seems inevitable that general practitioners (GPs) will play a larger role in skin cancer care. OBJECTIVES: To assess surgical procedures used by GPs in skin tumour management. METHODS: We performed a retrospective study of 1,898
Phipps, Marcy; Bush, Jeffrey A; Buhrow, Dianne; Tittle, Mary B; Singh, Deepak; Harcombe, Julianne; Riddle, Evanthia
Ileus development has been associated with a wide range of complications among hospitalized patients, ranging from increased patient pain and discomfort to malnutrition, aspiration, delayed rehabilitation, and sepsis. This article examines factors that appeared to correlate with an increase in ileus development among patients in a trauma/surgical intensive care unit, with the goal of preventing the condition through nursing practice changes.
Simianu, Vlad V; Morris, Arden M; Varghese, Thomas K; Porter, Michael P; Henderson, Jeffrey A; Buchwald, Dedra S; Flum, David R; Javid, Sara H
American Indian/Alaska Native (AI/AN) patients with cancer have the lowest survival rates of all racial and ethnic groups, possibly because they are less likely to receive "best practice" surgical care than patients of other races. Prospective cohort study comparing adherence with generic and cancer-specific guidelines on processes of surgical care between AI/AN and non-Hispanic white (NHW) patients in Washington State (2010 to 2014) was conducted. A total of 156 AI/AN and 6,030 NHW patients underwent operations for 10 different cancers, and had similar mean adherence to generic surgical guidelines (91.5% vs 91.9%, P = .57). AI/AN patients with breast cancer less frequently received preoperative diagnostic core needle biopsy (81% vs 94%, P = .004). AI/AN patients also less frequently received care adherent to prostate cancer-specific guidelines (74% vs 92%, P = .001). Although AI/ANs undergoing cancer operations in Washington receive similar overall best practice surgical cancer care to NHW patients, there remain important, modifiable disparities that may contribute to their lower survival. Copyright © 2016 Elsevier Inc. All rights reserved.
Gentile, Lori F; Cuenca, Alex G; Efron, Philip A; Ang, Darwin; Bihorac, Azra; McKinley, Bruce A; Moldawer, Lyle L; Moore, Frederick A
Surgical intensive care unit (ICU) stay of longer than 10 days is often described by the experienced intensivist as a "complicated clinical course" and is frequently attributed to persistent immune dysfunction. "Systemic inflammatory response syndrome" (SIRS) followed by "compensatory anti-inflammatory response syndrome" (CARS) is a conceptual framework to explain the immunologic trajectory that ICU patients with severe sepsis, trauma, or emergency surgery for abdominal infection often traverse, but the causes, mechanisms, and reasons for persistent immune dysfunction remain unexplained. Often involving multiple-organ failure (MOF) and death, improvements in surgical intensive care have altered its incidence, phenotype, and frequency and have increased the number of patients who survive initial sepsis or surgical events and progress to a persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Often observed, but rarely reversible, these patients may survive to transfer to a long-term care facility only to return to the ICU, but rarely to self-sufficiency. We propose that PICS is the dominant pathophysiology and phenotype that has replaced late MOF and prolongs surgical ICU stay, usually with poor outcome. This review details the evolving epidemiology of MOF, the clinical presentation of PICS, and our understanding of how persistent inflammation and immunosuppression define the pathobiology of prolonged intensive care. Therapy for PICS will involve innovative interventions for immune system rebalance and nutritional support to regain physical function and well-being. Copyright © 2012 by Lippincott Williams & Wilkins.
Islam, Mohammad T; Yoshimura, Yukie
To assess the rate of cesarean delivery and its indications at public emergency obstetric care (EmOC) hospitals in a district in Bangladesh. In a retrospective, cross-sectional study, data were extracted from the Safe Motherhood Promotion Project database and operation theater registers for cesarean deliveries at three district and three subdistrict EmOC hospitals in Narsingdi between January 1 and December 31, 2008. Information on cesarean deliveries and their indications, and maternal and neonatal outcomes were analyzed descriptively. Among 3329 deliveries, 1075 (32.3%) occurred by cesarean. The frequency of cesarean delivery ranged from 17.8% (147 of 824 deliveries) to 56.3% (174 of 309) among the six hospitals. Information on indications was available for 1043 cesarean deliveries. The main indications were previous cesarean delivery (251 deliveries, 24.1%), fetal distress (228, 21.9%), and prolonged or obstructed labor (214, 20.5%). There were no maternal deaths, but 10 (1.0%) cesarean deliveries resulted in stillbirth. The overall rate of cesarean delivery was high at EmOC hospitals. Interventions to improve decision making and limit possible unnecessary cesarean operations are needed. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Japan is far behind Western nations in emergency care, such as the United States where paramedics are placed under the M-ICU system and France in which the SAMU system is in force. This paper is an attempt to introduce developments in the delivery of emergency care in the Japanese rural setting and the present state of emergency care delivered at our hospitals, while checking them against national policy.
In the last few years world literature examined advantages related to the presence and support of an nonprofessional person (doula) during a delivery. Aside from encouraging the husbands to take an active part in the delivery there was a rise in popularity of doula's help. The results of frequency questionnaire analysis show that in Poland parturients, first and foremost, expect support of a professional personnel (midwife, midwifery students).
Duncombe, Chris; Rosenblum, Scott; Hellmann, Nicholas; Holmes, Charles; Wilkinson, Lynne; Biot, Marc; Bygrave, Helen; Hoos, David; Garnett, Geoff
The delivery of HIV care in the initial rapid scale-up of HIV care and treatment was based on existing clinic-based models, which are common in highly resourced settings and largely undifferentiated for individual needs. A new framework for treatment based on variable intensities of care tailored to the specific needs of different groups of individuals across the cascade of care is proposed here. Service intensity is characterised by four delivery components: (i) types of services delivered, (ii) location of service delivery, (iii) provider of health services and (iv) frequency of health services. How these components are developed into a service delivery framework will vary across countries and populations, with the intention being to improve acceptability and care outcomes. The goal of getting more people on treatment before they become ill will necessitate innovative models of delivering both testing and care. As HIV programmes expand treatment eligibility, many people entering care will not be 'patients' but healthy, active and productive members of society. To take the framework to scale, it will be important to: (i) define which individuals can be served by an alternative delivery framework; (ii) strengthen health systems that support decentralisation, integration and task shifting; (iii) make the supply chain more robust; and (iv) invest in data systems for patient tracking and for programme monitoring and evaluation. © 2015 The Authors. Tropical Medicine & International Health published by John Wiley & Sons Ltd.
Marini, Corrado Paolo; Ritter, Garry; Sharma, Cordelia; McNelis, John; Goldberg, Michael; Barrera, Rafael
Robotic telerounding is effective from the standpoint of patients' satisfaction and patients' care in teaching and community hospitals. However, the impact of robotic telerounding by the intensivist rounding remotely in the surgical intensive care unit (SICU), on patients' outcome and on the education of medical students physician assistants and surgical residents, as well as on nurses' satisfaction has not been studied. Prospective evaluation of robotic telerounding (RT) using a Likert Scale measuring tool to assess whether it can replace conventional rounding (CR) from the standpoint of patients' care and outcome, nursing satisfaction, and educational effectiveness. RT did not have a negative impact on patients' outcome during the study interval: mortality 5/42 (12 %) versus 6/37 (16 %), RT versus CR, respectively, p = 0.747. The intensivists rounding in the SICU were satisfied with their ability to deliver the same patients' care remotely (Likert score 4.4 ± 0.2). The educational experience of medical students, physicia assistants, and surgical residents was not affected by RT (average Likert score 4.5 ± 0.2, 3.9 ± 0.4, and 4.4 ± 0.4 for surgical residents, medical students and PAs, respectively, p > 0.05). However, as shown by a Likert score of 3.5 ± 1.0, RT did not meet nurses' expectations from several standpoints. Intensivists regard robotic telerounding as an effective alternative to conventional rounding from the standpoint of patients' care and teaching. Medical students, physician assistants (PA's), and surgical residents do not believe that RT compromises their education. Despite similar patients' outcome, nurses have a less favorable opinion of RT; they believe that the physical presence of the intensivist is favorable at all times.
Stewart, E E
This article is a checklist for use by health care providers in reviewing proposed managed care contracting agreements. This checklist is not an exhaustive list, but is intended to be used as a framework for review.
Full Text Available Background: Pakistan is one of the most populated countries with a population of 160 million; 67% are rural population but all the tertiary care facilities are concentrated in large cities. The Northern Areas is the most remote region with difficult terrain, harsh weather conditions and the tertiary care hospital at a distance of 600 km with traveling time of 16 h. The Aga Khan Medical Centre, Singul (AKMCS is a secondary healthcare facility in Ghizer district with a population of 132,000. AKMCS was established in 1992 to provide emergency and common elective surgical care. It has strengthened the primary health service through training, education and referral mechanism. It also provided an opportunity for family physicians to be trained in common surgical operations with special emphasis on emergency obstetric care. In addition it offers elective rotations for the residents and medical students to see the spectrum of diseases and to understand the concept of optimal care with limited resources. Methods and Results: The clinical data was collected prospectively using international classification of diseases ICD -9 coding and the database was developed on a desktop computer. Information about the operative procedures and outcome was separately collected on an Excel worksheet. The data from January 1998 to December 2001 were retrieved and descriptive analysis was done on epi info-6. Thirty-one thousand seven hundred and eighty-two patients were seen during this period, 53% were medical, 24% surgical, 16% obstetric and 7% with psychiatric illness. Out of 1990 surgical operations 32% were general surgery, 31% orthopedic, 21% pediatric, 12% obstetric and 4% urological cases; 42% of operations were done under general anesthesia, 22% spinal, 9% intravenous (IV ketamine, 6% IV sedation and 21% under local anesthesia. Six hundred and sixty-two were done in the main operation room including general surgery 337, obstetric 132, urological 67, pediatric 66
markdownabstract__Abstract__ Background: It is known that interprofessional collaboration is crucial for integrated care delivery, yet we are still unclear about the underlying mechanisms explaining effectiveness of integrated care delivery to older patients. In addition, we lack research comparing integrated care delivery between hospitals. Therefore, this study aims to (i) provide insight into the underlying components 'relational coordination' and 'situational awareness' of integrated care...
Horacek, Rostislav; Krnacova, Barbora; Prasko, Jan; Latalova, Klara
Background The aim of this study was to examine the impact of somatic illnesses, electrolyte imbalance, red blood cell count, hypotension, and antipsychotic and opioid treatment on the duration of delirium in Central Intensive Care Unit for Surgery. Patients and methods Patients who were admitted to the Department of Central Intensive Care Unit for Surgery in the University Hospital Olomouc from February 2004 to November 2008 were evaluated using Riker sedation–agitation scale. Their blood pressure, heart rate, respiratory rate, and peripheral blood oxygen saturation were measured continually, and body temperature was monitored once in an hour. The laboratory blood tests including sodium, potassium, chlorides, phosphorus, urea and creatinine, hemoglobin, hematocrit, red and white blood cell count, and C-reactive protein, albumin levels and laboratory markers of renal and liver dysfunction were done every day. All measurements were made at least for ten consecutive days or longer until the delirium resolved. Results The sample consisted of 140 consecutive delirious patients with a mean age of 68.21±12.07 years. Delirium was diagnosed in 140 of 5,642 patients (2.48%) admitted in CICUS in the last 5 years. The median duration of delirium was 48 hours with a range of 12–240 hours. Statistical analysis showed that hyperactive subtype of delirium and treatment with antipsychotics were associated with prolonged delirium duration (hyperactive 76.15±40.53 hours, hypoactive 54.46±28.44 hours, mixed 61.22±37.86 hours; Kruskal–Wallis test: 8.022; Ppiracetam 46.96±18.42 hours; Kruskal–Wallis test: 17.39, P<0.0005), and history of alcohol abuse (with a history of abuse 73.63±45.20 hours, without a history of abuse 59.54±30.61 hours; Mann–Whitney U=1,840; P<0.05). One patient had suffered from complicated postoperative hypostatic pneumonia and died due to respiratory failure (patient with hypoactive subtype). According to the backward stepwise multiple regression
Prætorius, Thim; Chaudhuri, Atanu; Venkataramanaiah, S
impact on patient health. But, there is limited understanding about how coordination takes place across and within the different health care service providers and how this influence hospital transfer time and length of stay. This article addresses this gap in literature by studying trauma care delivery...
Story William T
Full Text Available Abstract Background A primary cause of high maternal mortality in Bangladesh is lack of access to professional delivery care. Examining the role of the family, particularly the husband, during pregnancy and childbirth is important to understanding women's access to and utilization of professional maternal health services that can prevent maternal mortality. This qualitative study examines husbands' involvement during childbirth and professional delivery care utilization in a rural sub-district of Netrokona district, Bangladesh. Methods Using purposive sampling, ten households utilizing a skilled attendant during the birth of the youngest child were selected and matched with ten households utilizing an untrained traditional birth attendant, or dhatri. Households were selected based on a set of inclusion criteria, such as approximate household income, ethnicity, and distance to the nearest hospital. Twenty semi-structured interviews were conducted in Bangla with husbands in these households in June 2010. Interviews were transcribed, translated into English, and analyzed using NVivo 9.0. Results By purposefully selecting households that differed on the type of provider utilized during delivery, common themes--high costs, poor transportation, and long distances to health facilities--were eliminated as sufficient barriers to the utilization of professional delivery care. Divergent themes, namely husbands' social support and perceived social norms, were identified as underlying factors associated with delivery care utilization. We found that husbands whose wives utilized professional delivery care provided emotional, instrumental and informational support to their wives during delivery and believed that medical intervention was necessary. By contrast, husbands whose wives utilized an untrained dhatri at home were uninvolved during delivery and believed childbirth should take place at home according to local traditions. Conclusions This study provides
Nagpal, Kamal; Arora, Sonal; Vats, Amit; Wong, Helen W; Sevdalis, Nick; Vincent, Charles; Moorthy, Krishna
Effective communication is imperative to safe surgical practice. Previous studies have typically focused upon the operating theatre. This study aimed to explore the communication and information transfer failures across the entire surgical care pathway. Using a qualitative approach, semi-structured interviews were conducted with 18 members of the multidisciplinary team (seven surgeons, five anaesthetists and six nurses) in an acute National Health Service trust. Participants' views regarding information transfer and communication failures at each phase of care, their causes, effects and potential interventions were explored. Interviews were recorded, transcribed verbatim, and submitted to emergent theme analysis. Sampling ceased when categorical and theoretical saturation was achieved. Preoperatively, lack of communication between anaesthetists and surgeons was the most common problem (13/18 participants). Incomplete handover from the ward to theatre (12/18) and theatre to recovery (15/18) were other key problems. Work environment, lack of protocols and primitive forms of information transfer were reported as the most common cause of failures. Participants reported that these failures led to increased morbidity and mortality. Healthcare staff were strongly supportive of the view that standardisation and systematisation of communication processes was essential to improve patient safety. This study suggests communication failures occur across the entire continuum of care and the participants opined that it could have a potentially serious impact on patient safety. This data can be used to plan interventions targeted at the entire surgical pathway so as to improve the quality of care at all stages of the patient's journey.
Background Smoking, poor nutrition, risky alcohol use, and physical inactivity are the primary behavioral risks for common causes of mortality and morbidity. Evidence and guidelines support routine clinician delivery of preventive care. Limited evidence describes the level delivered in community health settings. The objective was to determine the: prevalence of preventive care provided by community health clinicians; association between client and service characteristics and receipt of care; ...
Schonberger, Robert B; Barash, Paul G; Lagasse, Robert S
Since 2006, the Surgical Care Improvement Project (SCIP) has promoted 3 perioperative antibiotic recommendations designed to reduce the incidence of surgical site infections. Despite good evidence for the efficacy of these recommendations, the efforts of SCIP have not measurably improved the rates of surgical site infections. We offer 3 arguments as to why SCIP has fallen short of expectations. We then suggest a reorientation of quality improvement efforts to focus less on reporting, and incentivizing adherence to imperfect metrics, and more on creating local and regional quality collaboratives to educate clinicians about how to improve practice. Ultimately, successful quality improvement projects are behavioral interventions that will only succeed to the degree that they motivate individual clinicians, practicing within a particular context, to do the difficult work of identifying failures and iteratively working toward excellence.
Halamka, J D; Hughes, M; Mack, J; Hurwitz, M; Davis, F; Wood, D; Borten, K; Saal, A K
The CareGroup Provider Service Network is a managed care contracting organization which provides central administrative services for over 1800 physicians and 200,000 managed care lives. Services include utilization management, disease management and credentialing for the entire network. The management model of the Provider Service Network empowers local physician groups with information and education. To meet the managed care information needs of the network, we implemented an intranet-based executive information system, PSNWeb, which retrieves data from a managed care data warehouse. The project required the integration of diverse technologies and development of a complex security/confidentiality infrastructure to deliver information to 8 major clinician groups, each with different information needs.
Rantz, Marilyn J; Grando, Victoria; Conn, Vicki; Zwygart-Staffacher, Mary; Hicks, Lanis; Flesner, Marcia; Scott, Jill; Manion, Pam; Minner, Donna; Porter, Rose; Maas, Meridean
In this study, the key exemplar processes of care in facilities with good resident outcomes were described. It follows that with description of these processes, it is feasible to teach facilities about the basics of care and the ways to systematically approach care so they can adopt these care processes and improve resident outcomes. However, for this to happen key organizational commitments must be in place for staff to consistently provide the basics of care. Nursing leadership must have a consistent presence over time, they must be champions of using team and group processes involving staff throughout the facility, and they must actively guide quality improvement processes. Administrative leadership must be present and express the expectation that high quality care is expected for residents, and that workers are expected to contribute to the quality improvement effort. If facilities are struggling with achieving average or poor resident outcomes, they must first make an effort to find nursing and administrative leaders who are willing to stay with the organization. These leaders must be skilled with team and group processes for decision-making and how to implement and use a quality improvement program to improve care. These leaders must be skilled at building employee relations and at retention strategies so residents are cared for by consistent staff who know them. The results of this study illustrate the simplicity of the basics of care that residents in nursing facilities need. The results also illustrate the complexity of the care processes and the organizational systems that must be in place to achieve good outcomes. Achieving these outcomes is the challenge facing those currently working in and leading nursing facilities.
Branco, Bernardino C; Inaba, Kenji; Gausepohl, Andrew; Okoye, Obi; Teixeira, Pedro G; Breed, Wynne; Lam, Lydia; Talving, Peep; Sullivan, Maura; Demetriades, Demetrios
The purpose of this study was to determine the incidence and predictors of nonverifiable research publications among applicants to a trauma and surgical critical care fellowship program. All complete applications submitted to our trauma and surgical critical care fellowship program were prospectively collected for 4 application cycles (2009 to 2012). All publications listed by applicants were tabulated and underwent verification using MEDLINE and direct journal search with verification by a team of professional health sciences librarians. Demographics and academic criteria were compared between applicants with nonverifiable and verifiable publications. A total of 100 applicants reported 301 publications. Of those, 20 applicants (20%) listed 32 papers (11%) that could not be verified. These applicants comprised 30% of those with 1 or more peer-reviewed publications. There were no significant differences in sex (male, 55% nonverifiable vs 60% verifiable, p = 0.684) or age (34.3 ± 6.6 years vs 34.2 ± 5.0 years, p = 0.963). There were no differences with regard to citizenship status (foreign medical graduates, 20% nonverifiable vs 28% verifiable, p = 0.495). Applicants with nonverified publications were less likely to be in the military (0% vs 14%, p = 0.079), more likely to have presented their work at surgical meetings (80% vs 58%, p = 0.064), and to be individuals with 3 or more peer-reviewed publications (55% vs 25%, p = 0.009). In this analysis of academic integrity, one-fifth of all applicants applying to a trauma and surgical critical care fellowship program and 30% of those with 1 or more peer-reviewed publications had nonverifiable publications listed in their curricula vitae. These applicants were less likely to be in the military, more likely to have presented their work at surgical meetings and to have 3 or more peer-reviewed publications. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Udo, Camilla; Danielson, Ella; Melin-Johansson, Christina
To report a qualitative study conducted to gain a deeper understanding of surgical nurses' experiences of existential care situations. Background. Existential issues are common for all humans irrespective of culture or religion and constitute man's ultimate concerns of life. Nurses often lack the strategies to deal with patients' existential issues even if they are aware of them. This is a qualitative study where critical incidents were collected and analysed hermeneutically. During June 2010, ten surgical nurses presented 41 critical incidents, which were collected for the study. The nurses were first asked to describe existential care incidents in writing, including their own emotions, thoughts, and reactions. After 1-2 weeks, individual interviews were conducted with the same nurses, in which they reflected on their written incidents. A hermeneutic analysis was used. The majority of incidents concerned nurses' experiences of caring for patients' dying of cancer. In the analysis, three themes were identified, emphasizing the impact of integration between nurses' personal self and professional role in existential care situations: inner dialogues for meaningful caring, searching for the right path in caring, and barriers in accompanying patients beyond medical care. Findings are interpreted and discussed in the framework of Buber's philosophy of the relationships I-Thou and I-It, emphasizing nurses' different relationships with patients during the process of caring. Some nurses integrate their personal self into caring whereas others do not. The most important finding and new knowledge are that some nurses felt insecure and were caught somewhere in between I-Thou and I-It. © 2012 Blackwell Publishing Ltd.
Adepoju, F G; Adekoya, B J; Ayanniyi, A A; Olatunji, V
Cataract remains a disease of priority being the leading cause of blindness globally. Although surgically curable, cataract surgical output has remained low in Nigeria, Kwara state inclusive. A study was carried out to investigate the perception of eye care workers (ECW) on low surgical output and their adjudged reasons; this has hitherto not being evaluated. A cross-sectional quantitative survey with the aid of pretested structured questionnaire of all ECW and qualitative survey using in-depth interview on selected workers in Kwara State, Nigeria was done. A total of 142 out of the 157 ECWs (90.5%) working in the 14 surgical eye centers in the state were interviewed with a mean age of 40.37 years, SD ± 8.67. There were 94 (66.2%) females, with a female to male ratio of 2:1. 91 (64.1%) participants were of the opinion that the numbers of cataract surgeries in the state were inadequate. Hospital-based and human resource efficiency-related issues such as long clinic waiting time, multiple paying and procedural sites, poor staff mix, and gaps in available human resource were the major reasons given for low cataract output. Others reasons were high cost and fear of surgery, distance of eye clinics from patients. Regular operational researches, proper deployment, and efficient use of human and material resources in addition to subsidized cost and appropriate health education to allay fear of surgery are steps that could enhance cataract surgical output.
determine apgar score , label cord blood, clamp umbilical cord, stabilize neonate’s temperature, and complete identification of neonate. PL-form general...second practical exercise, based on a different written patient scenario, was returned to the nurse researchers. The researchers scored the exercise to...Bolton, L. B. (no date). Determinants of nursing care. Labor and Delivery. An obstetrical acuity scoring system for labor and delivery. Los Angeles, CA
Atinga, RA; Baku, AA; Adongo, PB
Background: In spite of the introduction of free maternal healthcare in Ghana, utilization of supervised delivery services continues to be low due partly to poor quality of antenatal care (ANC). Aim: The study sought to identify the determinants of perceived quality of ANC and uptake of skilled delivery services. Subjects and Methods: A total of 363 expectant mothers were randomly selected in urban health facilities for interview. Logistic regression models were computed to examine the relati...
Melissa L Knothe Tate
Full Text Available PURPOSE: Pluripotent cells residing in the periosteum, a bi-layered membrane enveloping all bones, exhibit a remarkable regenerative capacity to fill in critical sized defects of the ovine femur within two weeks of treatment. Harnessing the regenerative power of the periosteum appears to be limited only by the amount of healthy periosteum available. Here we use a substitute periosteum, a delivery device cum implant, to test the hypothesis that directional delivery of endogenous periosteal factors enhances bone defect healing. METHODS: Newly adapted surgical protocols were used to create critical sized, middiaphyseal femur defects in four groups of five skeletally mature Swiss alpine sheep. Each group was treated using a periosteum substitute for the controlled addition of periosteal factors including the presence of collagen in the periosteum (Group 1, periosteum derived cells (Group 2, and autogenic periosteal strips (Group 3. Control group animals were treated with an isotropic elastomer membrane alone. We hypothesized that periosteal substitute membranes incorporating the most periosteal factors would show superior defect infilling compared to substitute membranes integrating fewer factors (i.e. Group 3>Group 2>Group 1>Control. RESULTS: Based on micro-computed tomography data, bone defects enveloped by substitute periosteum enabling directional delivery of periosteal factors exhibit superior bony bridging compared to those sheathed with isotropic membrane controls (Group 3>Group 2>Group 1, Control. Quantitative histological analysis shows significantly increased de novo tissue generation with delivery of periosteal factors, compared to the substitute periosteum containing a collagen membrane alone (Group 1 as well as compared to the isotropic control membrane. Greatest tissue generation and maximal defect bridging was observed when autologous periosteal transplant strips were included in the periosteum substitute. CONCLUSION: Periosteum
Kristaps Circenis; Liana Deklava
Background: The subject of stress related psychological disorders is considered to be one of the mostcritical problems in the 21st century. Latvia’s social-economic situation is stressful and a lot of nurses stillneed to work more than one shift. There are no complete studies about surgical care nurses and operatingroom nurses burnout, depression, anxiety and compassion fatigue situation in Latvia.Aim and Objectives: Research aim was to find out burnout, depression, compassion fatigue and anx...
Martins, Maria das Graças Teles [UNIFESP; Castro, Odilon; Pereira,Pedro Paulo Gomes
This text seeks to reflect on the concepts of stress among nurses that work in the Surgical and Intensive Care Centers of a teaching hospital in the State of Paraíba. Qualitative ethnographic research allowed us to perceive that when talking about stress, these professionals mentioned their bodies and bodily manifestations. The research undertaken allowed us to understand the intimate relationships between the body, stress and nursing.
Cecile MA Utens
Full Text Available Introduction':' A remarkable difference in care delivery pathways for Chronic Obstructive Pulmonary Disease (COPD is the presence of hospital-at-home for COPD exacerbations in England and its absence in the Netherlands. The objective of this paper is to explain this difference. Methods':' Descriptive COPD statistics and care delivery pathways on all care levels within the institutional context, followed by a comparison of care delivery pathways and an explanation of the difference with regard to hospital-at-home. Results: The Netherlands and England show broad similarities in their care delivery pathways for COPD patients. A major difference is the presence of hospital-at-home for COPD exacerbations in England and its absence in the Netherlands. Three possible explanations for this difference are presented: differences in the urgency for alternatives (higher urgency for alternative treatment models in England, the differences in funding (funding in England facilitated the development of hospital-at-home and the differences in the substitution of tasks to nurses (substitution to nurses has taken place to a larger extent in England. Discussion and Conclusion: The difference between the Netherlands and England regarding hospital-at-home for COPD exacerbations can be explained in three ways. Hospital-at-home has proved to be a safe alternative for hospital care for selected patients, and should be considered as a treatment option for COPD exacerbations in the Netherlands.
Slotkin, Jonathan R; Casale, Alfred S; Steele, Glenn D; Toms, Steven A
Comparative effectiveness research (CER) represents an evolution in clinical decision-making research that allows for the study of heterogeneous groups of patients with complex diseases processes. It has foundations in decision science, reliability science, and health care policy research. Health care finance will increasingly rely on CER for guidance in the coming years. There is increasing awareness of the importance of decreasing unwarranted variation in health care delivery. In the past 7 years, Geisinger Health System has performed broad reengineering of its acute episodic and chronic care delivery models utilizing macrosystem-level application of CER principles. These provider-driven process initiatives have resulted in significant improvement across all segments of care delivery, improved patient outcomes, and notable cost containment. These programs have led to the creation of novel pricing models, and when "hardwired" throughout a care delivery system, they can lead to correct medical decision making by 100% of providers in all patient encounters. Neurosurgery as a specialty faces unique challenges and opportunities with respect to broad adoption and application of CER techniques.
Snihurowych, Roman R; Cornelius, Felix; Amelung, Volker Eric
Despite the widespread use of branding in nearly all other major industries, most health care service delivery organizations have not fully embraced the practices and processes of branding. Facilitating the increased and appropriate use of branding among health care delivery organizations may improve service and technical quality for patients. This article introduces the concepts of branding, as well as making the case that the use of branding may improve the quality and financial performance of organizations. The concepts of branding are reviewed, with examples from the literature used to demonstrate their potential application within health care service delivery. The role of branding for individual organizations is framed by broader implications for health care markets. Branding strategies may have a number of positive effects on health care service delivery, including improved technical and service quality. This may be achieved through more transparent and efficient consumer choice, reduced costs related to improved patient retention, and improved communication and appropriateness of care. Patient satisfaction may be directly increased as a result of branding. More research into branding could result in significant quality improvements for individual organizations, while benefiting patients and the health system as a whole.
Thompson, Steven; Hasham, Salim
The pace and scale of globalization in health care services delivery have accelerated over the past decade. There have been numerous collaborations in health care service delivery between the private sector in North America and Europe with public and private entities in various emerging markets. These partnerships can be extremely fruitful, but also carry significant challenges. Johns Hopkins Medicine International (JHI) has been active for more than a decade in supporting international partners in building capacity and improving delivery systems. In addressing the challenges of globalization we have learned a number of lessons and have come up with several innovations to better help providers in emerging markets respond to the health care needs unique to their regions.
Odhiambo Frank O
Full Text Available Abstract Background Maternal mortality remains high in developing countries and data to monitor indicators of progress in maternal care is needed. We examined the status of maternal care before and after health care worker (HCW training in WHO recommended Focused Antenatal Care. Methods An initial cross-sectional survey was conducted in 2002 in Asembo and Gem in western Kenya among a representative sample of women with a recent birth. HCW training was performed in 2003 in Asembo, and a repeat survey was conducted in 2005 in both areas. Results Antenatal clinic (ANC attendance was similar in both areas (86% in 2005 and not significantly different from 2002 (90%. There was no difference in place of delivery between the areas or over time. However, in 2005, more women in Asembo were delivered by a skilled assistant compared to Gem (30% vs.23%, P = 0.04, and this proportion increased compared to 2002 (17.6% and 16.1%, respectively. Provision of iron (82.4%, folic acid (72.0%, sulfadoxine-pyrimethamine (61.7%, and anthelminths (12.7% had increased in Asembo compared to 2002 (2002: 53.3%, 52.8%, 20.3%, and 4.6%, respectively, and was significantly higher than in Gem in 2005 (Gem 2005: 69.7%, 47.8%, 19.8%, and 4.1%, respectively (P Conclusions We observed improvements in some ANC services in the area where HCWs were trained. However, since our evaluation was carried out 2 years after three-day training, we consider any significant, sustained improvement to be remarkable.
Bonnet, Stéphane; Bertani, Antoine; Savoie, Pierre-Henri; Mathieu, Laurent; Boddaert, Guillaume; Gonzalez, Federico; Poichotte, Antoine; Durand, Xavier; Rongiéras, Frédéric; Balandraud, Paul; Pons, François; Rigal, Sylvain
The aims of this study were as follows: first to quantify and review the types of surgical procedures performed by military surgeons assigned to a Forward Surgical Team (FST) providing medical support to the population (MSP) in the Ivory Coast (IC), and second to analyze how this MSP was achieved. Between 2002 and 2012, all of the local nationals operated on by the different FSTs deployed in the IC were included in the study. The surgical activity was analyzed and divided into surgical specialties, war wounds, nonwar emergency trauma, nontrauma emergencies, and elective surgery. Demographics, circumstances of health care management, wounded organs, and types of surgical procedures were described. Over this period, surgeons operated on 2,315 patients and performed 2,556 procedures. Elective surgery accounted for 78.7% of the surgical activity, nontrauma emergencies accounted for 12.7%, nonwar emergency trauma accounted for 8%, and war wounds accounted for 0.6%. The main surgical activities were visceral (43.8%) and orthopedic (including soft tissues) surgeries (38.5%). The FSTs contributed widely to MSP in the IC. This MSP required limited resources, standardization of the procedures and specific skills beyond the original surgical specialties of military surgeons to fulfill the needs of the local population. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.
Samokhvalov, I M; Kotenko, P K; Severin, V V
There are two triage groups of the walking wounded in a medical company of a brigade/special-purpose medical team: those returning to fighting role and those who have to be evacuated to level 3 echelon of care. The main purposes of surgical care of the walking wounded in the 3rd echelon of care are the following: diagnosis of injury pattern ruling out severe damages and separation of the independent category of the walking wounded. There is medical evacuation of the walking wounded from the 3rd echelon to the 4th echelon deployed in a combat zone. The walking wounded who needs less than 30 days of staying in hospital are evacuated to the garrison military hospitals and medical treatment facilities subordinated to a district military hospital. The wounded with the prolonged period of hospitalization (more than 30 days) are evacuated toward the district military hospital. Treatment of the walking wounded should be accomplished in the military district where the armed conflict goes on.
Ball, Chad G.; Keaney, Marilyn A.; Chun, Rosaleen; Groleau, Michelle; Tyssen, Michelle; Keyte, Jennifer; Broderick, Timothy J.; Kirkpatrick, Andrew W.
BackgroundMultiple nations are actively pursuing manned exploration of space beyond low-earth orbit. The responsibility to improve surgical care for spaceflight is substantial. Although the use of parabolic flight as a terrestrial analogue to study surgery in weightlessness (0 g) is well described, minimal data is available to guide the appropriate delivery of anesthesia. After studying anesthetized pigs in a 0 g parabolic flight environment, our group developed a comprehensive protocol describing prolonged anesthesia in a parabolic flight analogue space surgery study (PFASSS). Novel challenges included a physically remote vivarium, prolonged (>10 h) anesthetic requirements, and the provision of veterinary operating room/intensive care unit (ICU) equivalency on-board an aircraft with physical dimensions of ethical approval, multiple ground laboratory sessions were conducted with combinations of anesthetic, pre-medication, and induction protocols on Yorkshire-cross specific pathogen-free (SPF) pigs. Several constant rate infusion (CRI) intravenous anesthetic combinations were tested. In each regimen, opioids were administered to ensure analgesia. Ventilation was supported mechanically with blended gradients of oxygen. The best performing terrestrial 1 g regime was flight tested in parabolic flight for its effectiveness in sustaining optimal and prolonged anesthesia, analgesia, and maintaining hemodynamic stability. Each flight day, a fully anesthetized, ventilated, and surgically instrumented pig was transported to the Flight Research Laboratory (FRL) in a temperature-controlled animal ambulance. A modular on-board surgical/ICU suite with appropriate anesthesia/ICU and surgical support capabilities was employed. ResultsThe mean duration of anesthesia (per flight day) was 10.28 h over four consecutive days. A barbiturate and ketamine-based CRI anesthetic regimen supplemented with narcotic analgesia by bolus administration offered the greatest prolonged hemodynamic
Hollar, M C
This article presents research findings useful in formulating a Best Practices Model for the delivery of mental health services to underserved minority populations. Aspects of the role of racism in health care delivery and public health planning are explored. An argument is made for inclusion of the legacy of the slavery experience and the history of racism in America in understanding the current health care crisis in the African-American population. The development of an outline in APA DSM IV for the use of cultural formulations in psychiatric diagnosis is discussed.
Polly, David W; Ackerman, Stacey J; Schneider, Karen; Pawelek, Jeff B; Akbarnia, Behrooz A
Purpose Traditional growing rod (TGR) for early-onset scoliosis (EOS) is effective but requires repeated invasive surgical lengthenings under general anesthesia. Magnetically controlled growing rod (MCGR) is lengthened noninvasively using a hand-held magnetic external remote controller in a physician office; however, the MCGR implant is expensive, and the cumulative cost savings have not been well studied. We compared direct medical costs of MCGR and TGR for EOS from the US integrated health care delivery system perspective. We hypothesized that over time, the MCGR implant cost will be offset by eliminating repeated TGR surgical lengthenings. Methods For both TGR and MCGR, the economic model estimated the cumulative costs for initial implantation, lengthenings, revisions due to device failure, surgical-site infections, device exchanges (at 3.8 years), and final fusion, over a 6-year episode of care. Model parameters were estimated from published literature, a multicenter EOS database of US institutions, and interviews. Costs were discounted at 3.0% annually and represent 2015 US dollars. Results Of 1,000 simulated patients over 6 years, MCGR was associated with an estimated 270 fewer deep surgical-site infections and 197 fewer revisions due to device failure compared with TGR. MCGR was projected to cost an additional $61 per patient over the 6-year episode of care compared with TGR. Sensitivity analyses indicated that the results were sensitive to changes in the percentage of MCGR dual rod use, months between TGR lengthenings, percentage of hospital inpatient (vs outpatient) TGR lengthenings, and MCGR implant cost. Conclusion Cost neutrality of MCGR to TGR was achieved over the 6-year episode of care by eliminating repeated TGR surgical lengthenings. To our knowledge, this is the first cost analysis comparing MCGR to TGR – from the US provider perspective – which demonstrates the efficient provision of care with MCGR. PMID:27695352
Lim, Nam Gu; Lee, Jin Yong; Park, Ju Ok; Lee, Jung-A; Oh, Juhwan
The aim of this study was to investigate the whole picture regarding pregnancy, prenatal care, obstetrical complications, and delivery among disabled pregnant women in Korea. Using the data of National Health Insurance Corporation, we extracted the data of women who terminated pregnancy including delivery and abortion from January 1, 2010 to December 31, 2010. Pearson's chi-square test and Student-t test were conducted to examine the difference between disabled women and non-disabled women. Also, to define the factors affecting inadequate prenatal care, logistic regression was performed. The total number of pregnancy were 463,847; disabled women was 2,968 (0.6%) and 460,879 (99.4%) were by non-disabled women. Abortion rates (27.6%), Cesarean section rate (54.5%), and the rate of receiving inadequate prenatal care (17.0%), and the rate of being experienced at least one obstetrical complication (11.3%) among disabled women were higher than those among non-disabled women (P inadequate prenatal care. In conclusion, disabled women are more vulnerable in pregnancy, prenatal care and delivery. Therefore, the government and society should pay more attention to disabled pregnant women to ensure they have a safe pregnancy period up until the delivery.
Begoña San José Ruiz
Full Text Available Objectives: To describe the implementation of a new model face to face and remote pharmaceutical care with home delivery of tyronsine kinase inhibitors medicines for patients with chronic myeloid leukemia. Methods: Patients with chronic myeloid leukemia were selected to start this new model of care. Four characteristics were taken into account for the choice: chronicity of the disease, frequency of doctor visits, pharmaceutical care value and conservation of tyronsine kinase inhibitors medicines at room temperature. Results: Out of 68 patients with chronic myeloid leukemia and treated with tyronsine kinase inhibitors, 42 were selected due to the frequency of their hematologist visits. An introductory letter and a questionnaire about their preferences were sent to these patients.Sixteen of them expressed their desire to participate. The legal department designed a confidentiality contract, as well as a model of informed consent. A logistic distribution model based on defined routes and timetables was established. Prior to inclusion, pharmaceutical care was performed in a face to face consultation and the communication way was established for the followings remote consultations. Home delivery had a monthly cost of 13.2 € (including VAT per patient. All the patients who started this program continue in it. To date, 5 deliveries per patient have been conducted Conclusions: It is possible to establish an alternative model of pharmaceutical care with home delivery of medication, keeping the pharmacist-patient relationship, avoiding travel, ensuring the confidentiality and rationalizing the stocks
Full Text Available Abstract Background About 98% of newborn deaths occur in developing countries, where most newborns deaths occur at home. In Nepal, approximately, 90% of deliveries take place at home. Information about reasons for delivering at home and newborn care practices in urban areas of Nepal is lacking and such information will be useful for policy makers. Methods A cross-sectional survey was carried out in the immunisation clinics of Pokhara city, western Nepal during January and February, 2006. Two trained health workers administered a semi-structured questionnaire to the mothers who had delivered at home. Results A total of 240 mothers were interviewed. Planned home deliveries were 140 (58.3% and 100 (41.7% were unplanned. Only 6.2% of deliveries had a skilled birth attendant present and 38 (15.8% mothers gave birth alone. Only 46 (16.2% women had used a clean home delivery kit and only 92 (38.3% birth attendants had washed their hands. The umbilical cord was cut after expulsion of placenta in 154 (64.2% deliveries and cord was cut using a new/boiled blade in 217 (90.4% deliveries. Mustard oil was applied to the umbilical cord in 53 (22.1% deliveries. Birth place was heated throughout the delivery in 88 (64.2% deliveries. Only 100 (45.8% newborns were wrapped within 10 minutes and 233 (97.1% were wrapped within 30 minutes. Majority (93.8% of the newborns were given a bath soon after birth. Mustard oil massage of the newborns was a common practice (144, 60%. Sixteen (10.8% mothers did not feed colostrum to their babies. Prelacteal feeds were given to 37(15.2% newborns. Initiation rates of breast-feeding were 57.9% within one hour and 85.4% within 24 hours. Main reasons cited for delivering at home were 'preference' (25.7%, 'ease and convenience' (21.4% for planned deliveries while 'precipitate labor' (51%, 'lack of transportation' (18% and 'lack of escort' during labor (11% were cited for the unplanned ones. Conclusion High-risk home delivery and
Lengnick-Hall, C A
Health care enterprises make comprehensive and durable changes in people. This human-centered purpose defines the fundamental nature of quality in health care settings. Traditional perspectives of quality and familiar views of customer satisfaction are inadequate to manage the complex relationships between the health care delivery firm and its patients. Patients play four roles in health care systems that must be reflected when defining and measuring quality in these settings: patient as supplier, patient as product, patient as participant, and patient as recipient. This article presents a conceptual model of quality that incorporates these diverse patient roles. The strategic and managerial implications of the model are also discussed.
Lund, Stine; Boas, Ida Marie; Bedesa, Tariku
Importance: Health apps in low-income countries are emerging tools with the potential to improve quality of health care services, but few apps undergo rigorous scientific evaluation. Objective: To determine the effects of the safe delivery app (SDA) on perinatal survival and on health care workers...... facilities. Analyses were performed based on the intention-to-treat principle. Interventions: Health care workers in intervention facilities received a smartphone with the SDA. The SDA is a training tool in emergency obstetric and neonatal care that uses visual guidance in animated videos with clinical...
Mohammed, Khaled; Nolan, Margaret B; Rajjo, Tamim; Shah, Nilay D; Prokop, Larry J; Varkey, Prathibha; Murad, Mohammad H
Patient experience is one of key domains of value-based purchasing that can serve as a measure of quality and be used to improve the delivery of health services. The aims of this study are to explore patient perceptions of quality of health care and to understand how perceptions may differ by settings and condition. A systematic review of multiple databases was conducted for studies targeting patient perceptions of quality of care. Two reviewers screened and extracted data independently. Data synthesis was performed following a meta-narrative approach. A total of 36 studies were included that identified 10 quality dimensions perceived by patients: communication, access, shared decision making, provider knowledge and skills, physical environment, patient education, electronic medical record, pain control, discharge process, and preventive services. These dimensions can be used in planning and evaluating health care delivery. Future research should evaluate the effect of interventions targeting patient experience on patient outcomes.
Qummry Ali Hindi
Full Text Available Objectives: To determine the cesarean section (CS rate in a consecutive series of pregnant women with Diabetes Mellitus. Material and Methods: This retrospective patients’ files review of deliveries happened to diabetic mothers was carried out from 1st January, 2005 to 31st December, 2006 in the department of Obstetrics and Gynecology of Alnoor Specialist Hospital, Makkah, Saudi Arabia. Results: Among all subjects (118, Saudi national women predominated 101(86%. Majority belonged to the age group of 36-40 years, i.e., 38(32% and 52(44% was diagnosed as gestational diabetes mellitus. However, 89(75% of pregnancies were terminated through CS. Conclusion: Majority were delivered by CS.
Mason, Scott A
By its nature, retail medicine is founded in real estate. That retail medicine has expanded so dramatically in a relatively short period of time has taken people by surprise. This rapid growth of integrating healthcare services into retail real estate begs the question of whether real estate will eventually take on the importance in healthcare delivery that it has in retail. This article advances the view that it will. In the end, what retail and healthcare have in common is that they both reflect the attributes of demanding consumers as part of an experience-based economy, where products and services are sought based on how they fit with their lifestyles and how they make them feel (Pine and Gilmore 1998). Changing the selection process for healthcare services to be more like retail is already expanding how and where healthcare services are delivered.
Kalhor, Rohollah; Keshavarz Mohamadi, Nastaran; Khalesi, Nader; Jafari, Mehdi
Surgery is an essential component of health care, yet it has usually been overlooked in public health across the world. This study aimed to perform a situational analysis of essential surgical care management at district hospitals in Iran. This research was a descriptive and cross-sectional study performed at 42 first-referral district hospitals of Iran in 2013. The World Health Organization (WHO) Tool for the situational analysis of emergency and essential care was used for data collection in four domains of facilities and equipment, human resources, surgical interventions, and infrastructure. Data analysis was conducted using simple descriptive statistical methods. In this study, 100% of the studied hospitals had oxygen cylinders, running water, electricity, anesthesia machines, emergency departments, archives of medical records, and X-ray machines. In 100% of the surveyed hospitals, specialists in surgery, anesthesia, and obstetrics and gynecology were available as full-time staff. Life-saving procedures were performed in the majority of the hospitals. Among urgent procedures, neonatal surgeries were conducted in 14.3% of the hospitals. Regarding non-urgent procedures, acute burn management was conducted in 38.1% of the hospitals. Also, a few other procedures such as cricothyrotomy and foreign body removal were performed in 85.7% of the hospitals. The results indicated that suitable facilities and equipment, human resources, and infrastructure were available in the district hospitals in Iran. These findings showed that there is potential for the district hospitals to provide care in a wider spectrum.
Full Text Available Interprofessional education (IPE is an activity that involves two or more professions who learn interactively together to improve collaboration and the quality of care. Research has continually revealed that health and social care professionals encounter a range of problems with interprofessional coordination and collaboration which impact on the quality and safety of care. This empirical work resulted in policymakers across health care education and practice to invest in IPE to help resolve this collaborative failures. It is anticipated that IPE will provide health and social care professionals with the abilities required to work together effectively in providing safe high quality care to patients. Through a discussion of a range of key professional, educational and organization issues related to IPE, this paper argues that this form of education is an important strategy to improve the delivery of safe and effective care
Brophy, Lisa; Hodges, Craig; Halloran, Kieran; Grigg, Margaret; Swift, Mary
Care coordination models have developed in response to the recognition that Australia's health and welfare service system can be difficult to access, navigate and is often inefficient in caring for people with severe and persistent mental illness (SPMI) and complex care and support needs. This paper explores how the Australian Government's establishment of the Partners in Recovery (PIR) initiative provides an opportunity for the development of more effective and efficient models of coordinated care for the identified people with SPMI and their families and carers. In conceptualising how the impact of the PIR initiative could be maximised, the paper explores care coordination and what is known about current best practice. The key findings are the importance of having care coordinators who are well prepared for the role, can demonstrate competent practice and achieve better systemic responses focused on the needs of the client, thus addressing the barriers to effective care and treatment across complex service delivery systems.
Raykar, Nakul P; Yorlets, Rachel R; Liu, Charles; Greenberg, Sarah L M; Kotagal, Meera; Goldman, Roberta; Roy, Nobhojit; Meara, John G; Gillies, Rowan D
Billions of people worldwide are without access to safe, affordable, and timely surgical care. The Lancet Commission on Global Surgery (LCoGS) conducted a qualitative study to understand the contextual challenges to surgical care provision in low-income and middle-income countries (LMICs), and how providers overcome them. A semi-structured interview was administered to 143 care providers in 21 LMICs using stratified purposive sampling to include both urban and rural areas and reputational case selection to identify individual providers. Interviews were conducted in Argentina (n=5), Botswana (3), Brazil (10), Cape Verde (4), China (14), Colombia (4), Ecuador (6), Ethiopia (10), India (15), Indonesia (1), Mexico (9), Mongolia (4), Namibia (2), Pakistan (13), Peru (5), Philippines (1), Sierra Leone (11), Tanzania (5), Thailand (2), Uganda (9), and Zimbabwe (15). Local collaborators of LCoGS conducted interviews using a standardised implementation manual and interview guide. Questions revolved around challenges or barriers in the area of access to care for patients; challenges or barriers in the area of in-hospital care for patients; and challenges or barriers in the area of governance or health policy. De-identified interviews were coded and interpreted by an independent analyst. Providers across continent and context noted significant geographical, financial, and educational barriers to access. Surgical care provision in the rural hospital setting was hindered by a paucity of trained workforce, and inadequacies in basic infrastructure, equipment, supplies, and access to banked blood. In urban areas, providers face high patient volumes combined with staff shortages, minimal administrative support, and poor interhospital care coordination. At a policy level, providers identified regulations that were inconsistent with the realities of low-resource care provision (eg, a requirement to provide 'free' care to certain populations but without any guarantee for funding
Leem, So Yeon
This study is based on ethnographic fieldwork at a plastic surgery clinic in Seoul, South Korea. Examining the three phases of plastic--consultation, operation and recovery--I show how surgeons work to shape not only patients' bodies but also expectations and satisfaction. Surgeons do so in part to assuage their own anxieties, which arise from the possibility of misaligned beauty standards and unforeseen anatomies, as well as the possible dissatisfaction of the patient. I offer the concept of 'surgical anxiety', which occurs in relation to inherently unruly patient bodies in which worries, fear, frustration, self-pity, cynicism, anger and even loneliness are symptomatic. The unpredictability and uncontrollability of patients' bodies, which generates anxiety for both patients and surgeons, work to constrain the power of plastic surgery and making it inherently vulnerable. This study also pays attention to the invisible work of taking care of surgical anxiety, as practised by female staff members, and surgeons' dependence on these workers. My focus on anxiety is a kind of remedy for the predominant concern with 'ambivalence' in constructivist science and technology studies; rather than continue to highlight the power differentials between experts/practitioners and lay people/patients, this study illuminates surgical anxiety as their shared vulnerability. Thus, this study proposes a new politics of care in technoscience and medicine, which begins with anxiety.
Cuthbertson, B H; Webster, N R
Surgical patients make up 60-70% of the work load of intensive care units in the UK. There is a recognised short fall in the resource allocation for high dependency units (HDUs) and intensive care units (ICUs) in this country, despite repeated national audits urging that this resource be increased. British ICUs admit patients later and with higher severity of illness scores than elsewhere and this leads to higher ICU mortality. How can this situation be improved? Scoring systems that allow selection of appropriate patients for admission to ICU and avoid inappropriate admission are still in development. Pre-operative admission and optimisation in ICU is rare in this country despite increasing evidence to support this practice in high risk surgical patients. Early admission to ICU, with potential improvement in outcomes, could also be achieved using multi-disciplinary medical emergency teams. These teams would be alerted by ward staff in response to set specific conditions and physiological criteria. These proposals are still under trial but may offer benefit by reducing mortality in critically ill surgical patients.
Vuononvirta, Tiina; Timonen, Markku; Keinänen-Kiukaanniemi, Sirkka; Timonen, Olavi; Ylitalo, Kirsti; Kanste, Outi; Taanila, Anja
There is no clear understanding about the concept of technology adoption in the health-care environment. Compatibility is one of the factors affecting telehealth adoption. We investigated the key factors of telehealth's compatibility with health centre activities. Qualitative research was carried out in 2007-2009, with 55 interviews in seven health centres and in one special care hospital. The people interviewed were physicians, nurses and physiotherapists. After analysing the interview material, we concluded that compatibility has three aspects: individual, process and organizational compatibility. Individual compatibility was manifested in four different ways: from the viewpoints of professionals, patients, communication and cooperation. Three aspects of process compatibility were introduced: scheduling, resources and complexity of processes. Modest organizing efforts with telehealth and even a lack of interest can be expressions of organizational compatibility. Functional and user-friendly technology is a basic precondition for telehealth compatibility. With thorough organizing, most of the compatibility challenges can be solved.
Kamath-Rayne, B D; Josyula, S; Rule, A R L; Vasquez, J C
To evaluate changes in neonatal resuscitation and postnatal care following Helping Babies Breathe (HBB) training at a community hospital in rural Honduras. We hypothesized that HBB training would improve resuscitation and essential newborn care interventions. Direct observation and video recording of delivery room care spanned before and after an initial HBB workshop held in August 2013. Rates of essential newborn care interventions were compared in resuscitations performed by individuals who had and had not received HBB training, and run charts recording performance of newborn care practices over time were developed. Ten percent of deliveries (N=250) were observed over the study period, with 156 newborn resuscitations performed by individuals without HBB training, compared to 94 resuscitations performed by HBB trainees. After HBB training, significant improvements were seen in skin-to-skin care, breastfeeding within 60 min of age, and delayed cord clamping after 1 min (all Ptraining that were sustained during the study period, but remained below ideal goals. With improvement in drying/stimulation practices, fewer babies required bag/mask ventilation. In a rural Honduran community hospital, improvements in basic neonatal resuscitation and postnatal essential newborn care practices can be seen after HBB training. Further improvements in newborn care practices may require focused quality improvement initiatives for hospitals to sustain high quality care.Journal of Perinatology advance online publication, 20 July 2017; doi:10.1038/jp.2017.110.
Abstract Introduction: There is more need for pharmacy managers’ development regarding pharmaceutical care after Heath Reform Project. In this study, we designed, delivered and evaluated a virtual one-year short course of pharmaceutical care for pharmacy managers. Methods: We interviewed with five hospital pharmacy managers for educational need assessment. Then we developed the curriculum and performed a systematic instructional design for its blended delivery. Faculty members participa...
Frey, Rosemary; Gott, Merryn; Raphael, Deborah; O'Callaghan, Anne; Robinson, Jackie; Boyd, Michal; Laking, George; Manson, Leigh; Snow, Barry
Central to appropriate palliative care management in hospital settings is ensuring an adequately trained workforce. In order to achieve optimum palliative care delivery, it is first necessary to create a baseline understanding of the level of palliative care education and support needs among all clinical staff (not just palliative care specialists) within the acute hospital setting. The objectives of the study were to explore clinical staff: perceptions concerning the quality of palliative care delivery and support service accessibility, previous experience and education in palliative care delivery, perceptions of their own need for formal palliative care education, confidence in palliative care delivery and the impact of formal palliative care training on perceived confidence. A purposive sample of clinical staff members (598) in a 710-bed hospital were surveyed regarding their experiences of palliative care delivery and their education needs. On average, the clinical staff rated the quality of care provided to people who die in the hospital as 'good' (x̄=4.17, SD=0.91). Respondents also reported that 19.3% of their time was spent caring for end-of-life patients. However, only 19% of the 598 respondents reported having received formal palliative care training. In contrast, 73.7% answered that they would like formal training. Perceived confidence in palliative care delivery was significantly greater for those clinical staff with formal palliative care training. Formal training in palliative care increases clinical staff perceptions of confidence, which evidence suggests impacts on the quality of palliative care provided to patients. The results of the study should be used to shape the design and delivery of palliative care education programmes within the acute hospital setting to successfully meet the needs of all clinical staff. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Chung, Hui-Ting; Shu, Ling-Hui; Pan, Chao-Chun; Yang, Shu-Yen; Chen, Wan-I
Pressure ulcers were an increasingly significant problem among patients in the authors' ward. The eight patients diagnosed with pressure ulcers (0.42% of all inpatients) during the first half of 2009 represented a 140% increase over the first half of 2008 (0.28% of all inpatients). This project was designed to reduce pressure ulcer incidence in the surgical intensive care unit (ICU) to 0.05%. Intervention measures included: 1) holding professional training on preventing pressure ulcers; 2) specifying appropriate patient turnover tools; 3) creating and distributing to nurses a proper turnover technique and positioning manual; 4) creating and distributing to nurses a comprehensive patient skin inspection checklist; and 5) organizing a permanent pressure ulcer care quality and audit committee. Pressure ulcer incidence fell from 0.42% to 0.04% following implementation of the methods. Results demonstrate the effectiveness of using the proposed methods to reduce pressure ulcer incidence and enhance nursing care quality.
Wahass, Saeed H
Advances in the biomedical and the behavioral sciences have paved the way for the integration of medical practice towards the biopsychosocial approach. Therefore, dealing with health and illness overtakes looking for the presence or absence of the disease and infirmity (the biomedical paradigm) to the biopsychosocial paradigm in which health means a state of complete physical, psychological and social well-being. Psychology as a behavioral health discipline is the key to the biopsychosocial practice, and plays a major role in understanding the concept of health and illness. The clinical role of psychologists as health providers is diverse with the varying areas of care giving (primary, secondary and tertiary care) and a variety of subspecialties. Overall, psychologists assess, diagnose, and treat the psychological problems and the behavioral dysfunctions resulting from, or related to physical and mental health. In addition, they play a major role in the promotion of healthy behavior, preventing diseases and improving patients' quality of life. They perform their clinical roles according to rigorous ethical principles and code of conduct. This article describes and discusses the significant role of clinical health psychology in the provision of health care, following a biopsychosocial perspective of health and illness. Professional and educational issues have also been discussed.
Full Text Available Abstract Background Disparities in perinatal health care occur worldwide. If the UN Millennium Development Goals in maternal and child health are to be met, this needs to be addressed. This study was conducted to facilitate our understanding of the changing use of maternity care services in a semi-urban community in Entebbe Uganda and to examine the range of antenatal and delivery services received in health care facilities and at home. Methods We conducted a retrospective community survey among women using structured questionnaires to describe the use of antenatal services and delivery care. Results In total 413 women reported on their most recent pregnancy. Antenatal care attendance was high with 96% attending once, and 69% the recommended four times. Blood pressure monitoring (95% and tetanus vaccination (91% were the services most frequently reported and HIV testing (47%, haematinics (58% and presumptive treatment for malaria (66% least frequently. Hospital clinics significantly outperformed public clinics in the quality of antenatal service. A significant improvement in the reported quality of antenatal services received was observed by year (p Conclusion Although antenatal services were well utilised, the quality of services varied. Women were able and willing to travel to a facility providing a good service. Access to essential skilled birth attendants remains difficult especially for less educated, poorer women, commonly mediated by financial and transport difficulties and several simple post delivery practices were commonly neglected. These factors need to be addressed to ensure that high quality care reaches the most vulnerable women and infants.
Dalal, Koustuv; Shabnam, Jahan; Andrews-Chavez, Johanna
OBJECTIVE: Maternal mortality is a major public health problem in low-income countries, such as Bangladesh. Women's empowerment in relation to enhanced utilization of delivery care is underexplored. This study investigates the associations between women's economic empowerment and their utilization...... for the analyses. Economic empowerment, neighborhood socioeconomic status, household economic status, and demographic factors were considered as explanatory variables. The chi square test and unadjusted and adjusted logistic regression analyses were applied at the collected data. RESULTS: In the adjusted model......, respondent's and husband's education, household economic status, and residency emerged as important predictors for utilization of delivery care services. In the unadjusted model, economically empowered working and microfinanced women displayed more home delivery. CONCLUSION: The current study shows that use...
Niemeijer, G.C.; Does, R.J.M.M.; de Mast, J.; Trip, A.; van den Heuvel, J.
Background: The purpose of this article is to create actionable knowledge, making the definition of process improvement projects in health care delivery more effective. Methods: This study is a retrospective analysis of process improvement projects in hospitals, facilitating a case-based reasoning a
Groot, M.M.; Vernooij-Dassen, M.J.F.J.; Verhagen, C.A.H.H.V.; Crul, B.J.P.; Grol, R.P.T.M.
INTRODUCTION: In order to facilitate GPs in their work and increase the possibilities for patients to remain at home, it is important to identify the obstacles which hinder the delivery of primary palliative care. From previous research we learned about some of the problems experienced by GPs. In th
Niemeijer, G.C.; Does, R.J.M.M.; de Mast, J.; Trip, A.; van den Heuvel, J.
Background: The purpose of this article is to create actionable knowledge, making the definition of process improvement projects in health care delivery more effective. Methods: This study is a retrospective analysis of process improvement projects in hospitals, facilitating a case-based reasoning a
Full Text Available Abstract Background The provision of surgical assistance in conflict is often associated with care for victims of violence. However, there is an increasing appreciation that surgical care is needed for non-traumatic morbidities. In this paper we report on surgical interventions carried out by Médecins sans Frontières in Masisi, North Kivu, Democratic Republic of Congo to contribute to the scarce evidence base on surgical needs in conflict. Methods We analysed data on all surgical interventions done at Masisi district hospital between September 2007 and December 2009. Types of interventions are described, and logistic regression used to model associations with violence-related injury. Results 2869 operations were performed on 2441 patients. Obstetric emergencies accounted for over half (675, 57% of all surgical pathology and infections for another quarter (160, 14%. Trauma-related injuries accounted for only one quarter (681, 24% of all interventions; among these, 363 (13% were violence-related. Male gender (adjusted odds ratio (AOR = 20.0, p Conclusions In this study, most surgical interventions were unrelated to violent trauma and rather reflected the general surgical needs of a low-income tropical country. Programs in conflict zones in low-income countries need to be prepared to treat both the war-wounded and non-trauma related life-threatening surgical needs of the general population. Given the limited surgical workforce in these areas, training of local staff and task shifting is recommended to support broad availability of essential surgical care. Further studies into the surgical needs of the population are warranted, including population-based surveys, to improve program planning and resource allocation and the effectiveness of the humanitarian response.
Farhan, Hassan; Moreno-Duarte, Ingrid; Latronico, Nicola; Zafonte, Ross; Eikermann, Matthias
Muscle weakness is common in the surgical intensive care unit (ICU). Low muscle mass at ICU admission is a significant predictor of adverse outcomes. The consequences of ICU-acquired muscle weakness depend on the underlying mechanism. Temporary drug-induced weakness when properly managed may not affect outcome. Severe perioperative acquired weakness that is associated with adverse outcomes (prolonged mechanical ventilation, increases in ICU length of stay, and mortality) occurs with persistent (time frame: days) activation of protein degradation pathways, decreases in the drive to the skeletal muscle, and impaired muscular homeostasis. ICU-acquired muscle weakness can be prevented by early treatment of the underlying disease, goal-directed therapy, restrictive use of immobilizing medications, optimal nutrition, activating ventilatory modes, early rehabilitation, and preventive drug therapy. In this article, the authors review the nosology, epidemiology, diagnosis, and prevention of ICU-acquired weakness in surgical ICU patients.
Bjerså, Kristofer; Forsberg, Anna; Fagevik Olsén, Monika
There is increasing interest in complementary and alternative medicine (CAM) among healthcare professions. However, no studies have been conducted in Sweden or in a surgical context. The aim of this study is to describe different perceptions of complementary therapies among registered healthcare professions in Swedish surgical care. Sixteen interviews were conducted with registered physicians, nurses, physiotherapists and clinical dieticians at a Swedish university hospital. Analysis was made with a phenomenographic research approach. The findings showed variations in perceptions of the definition of complementary therapies. A constructive approach toward use was observed, but there was a conflict in matters of indications and contraindications, and also criticism over a lack of knowledge. There was seen to be a need for education to be able to act professionally. Scepticism over high costs of treatment was highlighted. In conclusion, a need for policies on management, education and research in the field of CAM should be addressed.
Godil, Saniya S; Parker, Scott L; Zuckerman, Scott L; Mendenhall, Stephen K; Devin, Clinton J; Asher, Anthony L; McGirt, Matthew J
Given the unsustainable costs of the US health-care system, health-care purchasers, payers, and hospital systems are adopting the concept of value-based purchasing by shifting care away from low-quality providers or hospitals. Legislation now allows public reporting of these quality rankings. True measures of quality, such as surgical morbidity and validated questionnaires of effectiveness, are burdensome and costly to collect. Hence, patients' satisfaction with care has emerged as a commonly used metric as a proxy for quality because of its feasibility of collection. However, patient satisfaction metrics have yet to be validated as a measure of overall quality of surgical spine care. We set out to determine whether patient satisfaction is a valid measure of safety and effectiveness of care in a prospective longitudinal spine registry. Prospective longitudinal cohort study. All patients undergoing elective spine surgery for degenerative conditions over a 6-month period at a single medical center. Patient-reported outcome instruments (numeric rating scale [NRS], Oswestry disability index [ODI], neck disability index [NDI], short-form 12-item survey [SF-12], Euro-Qol-5D [EQ-5D], Zung depression scale, and Modified Somatic Perception Questionnaire [MSPQ] anxiety scale), return to work, patient satisfaction with outcome, and patient satisfaction with provider care. All patients undergoing elective spine surgery for degenerative conditions over a 6-month period at a single medical center were enrolled into a prospective longitudinal registry. Data collected on all patients included demographics, disease characteristics, treatment variables, readmissions/reoperations, and all 90-day surgical morbidity. Patient-reported outcome instruments (NRS, ODI, NDI, SF-12, EQ-5D, Zung depression scale, and MSPQ anxiety scale), return to work, patient satisfaction with outcome, and patient satisfaction with provider care were recorded at baseline and 3 months after treatment
Full Text Available Abstract Background In low-resource settings, where abortion is highly restricted and self-induced abortions are common, access to post-abortion care (PAC services, especially treatment of incomplete terminations, is a priority. Standard post-abortion care has involved surgical intervention but can be hard to access in these areas. Misoprostol provides an alternative to surgical intervention that could increase access to abortion care. We sought to gather additional evidence regarding the efficacy of 400 mcg of sublingual misoprostol vs. standard surgical care for treatment of incomplete abortion in the environments where need for economical non-surgical treatments may be most useful. Methods A total of 860 women received either sublingual misoprostol or standard surgical care for treatment of incomplete abortion in a multi-site randomized trial. Women with confirmed incomplete abortion, defined as past or present history of vaginal bleeding during pregnancy and an open cervical os, were eligible to participate. Participants returned for follow-up one week later to confirm clinical status. If abortion was incomplete at that time, women were offered an additional follow-up visit or immediate surgical evacuation. Results Both misoprostol and surgical evacuation are highly effective treatments for incomplete abortion (misoprostol: 94.4%, surgical: 100.0%. Misoprostol treatment resulted in a somewhat lower chance of success than standard surgical practice (RR = 0.90; 95% CI: 0.89-0.92. Both tolerability of side effects and women’s satisfaction were similar in the two study arms. Conclusion Misoprostol, much easier to provide than surgery in low-resource environments, can be used safely, successfully, and satisfactorily for treatment of incomplete abortion. Focus should shift to program implementation, including task-shifting the provision of post-abortion care to mid- and low- level providers, training and assurance of drug availability. Trial
Desebbe, Olivier; Lanz, Thomas; Kain, Zeev; Cannesson, Maxime
Contrary to the intraoperative period, the current perioperative environment is known to be fragmented and expensive. One of the potential solutions to this problem is the newly proposed perioperative surgical home (PSH) model of care. The PSH is a patient-centred micro healthcare system, which begins at the time the decision for surgery is made, is continuous through the perioperative period and concludes 30 days after discharge from the hospital. The model is based on multidisciplinary involvement: coordination of care, consistent application of best evidence/best practice protocols, full transparency with continuous monitoring and reporting of safety, quality, and cost data to optimize and decrease variation in care practices. To reduce said variation in care, the entire continuum of the perioperative process must evolve into a unique care environment handled by one perioperative team and coordinated by a leader. Anaesthesiologists are ideally positioned to lead this new model and thus significantly contribute to the highest standards in transitional medicine. The unique characteristics that place Anaesthesiologists in this framework include their systematic role in hospitals (as coordinators between patients/medical staff and institutions), the culture of safety and health care metrics innate to the specialty, and a significant role in the preoperative evaluation and counselling process, making them ideal leaders in perioperative medicine.
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J.M. Hartgerink (Jacqueline); J.M. Cramm (Jane); J.B.M. Vos; T.J.E.M. Bakker (Ton); E.W. Steyerberg (Ewout); J.P. Mackenbach (Johan); A.P. Nieboer (Anna)
markdownabstractAbstract Background: It is known that interprofessional collaboration is crucial for integrated care delivery, yet we are still unclear about the underlying mechanisms explaining effectiveness of integrated care delivery to older patients. In addition, we lack research comparing in
Full Text Available Today, hospitals offer surgical treatment within a short hospital admission. This brief interaction may challenge the well-being of old patients. The aim of this study was to explore how the well-being of old hospitalized patients was affected by the interaction with staff during a fast-track surgical treatment and hospital admission for colon cancer. We used an ethnographic methodology with field observations and unstructured interviews focusing on one patient at a time (n=9 during a full day; the hours ranging from 7:45 a.m. to 8 p.m. Participants were between 74 and 85 years of age and of both sexes. The study was reported to the Danish Data Protection Agency with reference number (2007-58-0010. The encounter between old patients and the staff was a main theme in our findings elucidating a number of care challenges. The identified care challenges illustrated “well-being as a matter of different perspectives,” “vulnerability in contrast to well-being,” and “staff mix influencing the care encounter.” The experience of well-being in old cancer patients during hospital admission was absent or challenged when staff did not acknowledge their individual vulnerability and needs.
Davis, B; Sullivan, S; Levine, A; Dallara, J
To determine what patient characteristics are associated with prolonged emergency department (ED) length-of-stay (LOS) for surgical critical care patients, the charts of 169 patients admitted from the ED directly to the operating room (OR) or intensive care unit (ICU) during a 6-week period in 1993 were reviewed. The ED record was reviewed for documentation of factors that might be associated with prolonged ED LOS, such as use of computed tomographic (CT), radiology special procedures, and the number of plain radiographs and consultants. ED LOS was considered to be the time from triage until a decision was made to admit the patient. Using a Cox proportional hazards model, use of CT and special procedures were the strongest independent predictors of prolonged ED length-of-stay. The number of plain radiographs and consultants had only a minimal effect. Use of a protocol-driven trauma evaluation system was associated with a shorter ED LOS. In addition to external factors that affect ED overcrowding, ED patient management decisions may also be associated with prolonged ED length-of-stay. Such ED-based factors may be more important in surgical critical care patients, whose overall ED LOS is affected more by the length of the ED work-up rather than the time spent waiting for a ICU bed or operating suite.
Kamo, Norifumi; Williams, Barbara L; Smith, Donna L; Blackmore, C Craig
To determine the effectiveness of a multifaceted quality improvement intervention in outpatient clinics at an integrated healthcare delivery system on capture rate of advance directives (ADs) in the electronic medical record (EMR). Interrupted time series analysis with control groups between January 2010 and June 2015. Oncology, nephrology, and primary care outpatient clinics in an integrated healthcare delivery system. All individuals aged 65 and older with at least one office visit in any outpatient clinic in the care delivery system (n = 77,350 with 502,446 office visits). A series of quality improvement interventions to improve rates of advance care planning discussions and capture of those discussions in the EMR between 2010 and 2014. Capture rate of ADs in the EMR. Visits in the intervention primary care clinic were twice as likely to mention ADs in the EMR (53.4%) than visits in nonintervention primary care clinics (26.5%). Visits in the intervention oncology clinic were more than eight times as likely to mention ADs in the EMR (49.3% vs 6.0%), and visits in the intervention nephrology clinic were 2.5 times as likely to mention ADs (15.4% vs 6.0%) than visits in other specialty clinics. A series of quality improvement interventions to increase discussions about advance care planning and capture of advance care directives in the EMR significantly increased the rate of capture in primary care and specialty care outpatient settings. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.
Macleod Jana B
Full Text Available Abstract Background The hierarchical nature of medical education has been thought necessary for the safe care of patients. In this setting, medical students in particular have limited opportunities for experiential learning. We report on a student-faculty collaboration that has successfully operated an annual, short-term surgical intervention in Haiti for the last three years. Medical students were responsible for logistics and were overseen by faculty members for patient care. Substantial planning with local partners ensured that trip activities supplemented existing surgical services. A case review was performed hypothesizing that such trips could provide effective surgical care while also providing a suitable educational experience. Findings Over three week-long trips, 64 cases were performed without any reported complications, and no immediate perioperative morbidity or mortality. A plurality of cases were complex urological procedures that required surgical skills that were locally unavailable (43%. Surgical productivity was twice that of comparable peer institutions in the region. Student roles in patient care were greatly expanded in comparison to those at U.S. academic medical centers and appropriate supervision was maintained. Discussion This demonstration project suggests that a properly designed surgical trip model can effectively balance the surgical needs of the community with an opportunity to expose young trainees to a clinical and cross-cultural experience rarely provided at this early stage of medical education. Few formalized programs currently exist although the experience above suggests the rewarding potential for broad-based adoption.
Nicolás, Ana; Aizpitarte, Eva; Iruarrizaga, Angélica; Vázquez, Mónica; Margall, Angeles; Asiain, Carmen
The night-time sleep of patients hospitalized in intensive care is a very important feature within the health or disease process, as it has a direct repercussion on their adequate recovery. (1) To describe how surgical patients perceive their sleep in the intensive care unit; (2) to compare the subjective perception of patients with the nursing records and analyse these for the degree of agreement. Descriptive research. One hundred and four surgical patients were recruited to the study. Patients completed the Richards-Campbell Sleep Questionnaire, a five-item visual analogue scale, to subjectively measure their perceived level of sleep (range 0-100 mm). The observation of patient sleep by nurses, demographic data, nursing care during the night and use of specific pharmacological treatments were also collected from the nursing records. The total mean score of sleep on the first post-operative night was 51.42 mm, 28% of patients had a good sleep, 46% a regular sleep and 26% a bad sleep. The sleep profile of these patients has been characterized by the patients having a light sleep, with frequent awakening and generally little difficulty to go back to sleep after the awakenings. The agreement between the nurses' perceptions of patients' sleep and the patients' perception of their sleep was tested by means of one-factor analysis of variance (p nurse-patient perception, we obtained 44% of total agreement and 56% of disagreement. When discrepancy was found, the nurse generally overestimated the patients' perception. Surgical patients' perceptions of their sleep in the ICU suggest that this is inadequate. Nurses' perceptions of patients' sleep partially coincides with the latter's perception, but we have also found that the former frequently overestimate patients' sleep.
Leroux, Eric J; Morton, John M; Rivas, Homero
To calculate the public health impact and economic benefit of using ancillary health care professionals for routine postoperative care. The need for specialty surgical care far exceeds its supply, particularly in weight loss surgery. Bariatric surgery is cost-effective and the only effective long-term weight loss strategy for morbidly obese patients. Without clinically appropriate task shifting, surgeons, hospitals, and untreated patients incur a high opportunity cost. Visit schedules, time per visit, and revenues were obtained from bariatric centers of excellence. Case-specific surgeon fees were derived from published Current Procedural Terminology data. The novel Microsoft Excel model was allowed to run until a steady state was evident (status quo). This model was compared with one in which the surgeon participates in follow-up visits beyond 3 months only if there is a complication (task shifting). Changes in operative capacity and national quality-adjusted life years (QALYs) were calculated. In the status quo model, per capita surgical volume capacity equilibrates at 7 surgical procedures per week, with 27% of the surgeon's time dedicated to routine long-term follow-up visits. Task shifting increases operative capacity by 38%, resulting in 143,000 to 882,000 QALYs gained annually. Per surgeon, task shifting achieves an annual increase of 95 to 588 QALYs, $5 million in facility revenue, 48 cases of cure of obstructive sleep apnea, 44 cases of remission of type 2 diabetes mellitus, and 35 cases of cure of hypertension. Optimal resource allocation through task shifting is economically appealing and can achieve dramatic public health benefit by increasing access to specialty surgery.
Iannuzzi, James C; Kahn, Steven A; Zhang, Linlin; Gestring, Mark L; Noyes, Katia; Monson, John R T
Hospital consumer assessment of health care providers and systems (HCAHPS) survey scores formally recognize that patients are central to health care, shifting quality metrics from the physician to patient perspective. This study describes clinical predictors of patient satisfaction in surgical patients. Analysis of a single institution's Surgical Department HCAHPS responses was performed from March 2011-October 2012. The end points were top box satisfaction on two global domains. Multivariable regression was used to determine satisfaction predictors including HCAHPS domains, demographics, and clinical variables such as comorbidities, intensive care unit stay, emergency case, discharge day, floor transfers, complications, and ancillary procedures. In total, 978 surveys were evaluated representing admissions to Acute care and/or Trauma (n = 177, 18.1%), Thoracic (n = 169, 17.3%), Colorectal (n = 107, 10.9%), Transplant (n = 95, 9.7%), Vascular (n = 92, 9.4%), Oncology (n = 88, 9.0%), Plastic (n = 49, 5.0%), and Cardiac (n = 201, 20.6%) divisions. Overall, 658 patients (67.3%) had high satisfaction and 733 (74.9%) gave definite hospital recommendations. Hospital satisfaction was positively associated with an intensive care unit admission (odds ratio [OR] = 1.64, confidence interval [CI]: 1.20-2.23, P = 0.002) and satisfaction with provider and pain domains. Factors associated with decreased satisfaction were race (non-black minority compared with whites; OR = 0.41, CI: 0.21-0.83, P = 0.012), self-reported poor health (OR = 0.43, CI: 0.27-0.68, P nurse-patient interactions. These results help inform future quality improvement and resource allocation. Copyright © 2015 Elsevier Inc. All rights reserved.
Full Text Available BACKGROUND: As part of the mid-term evaluation of a Women's Health Care Project, a study was conducted to compare the utilization of maternal and neonatal health (MNH services in two areas with different levels of service in Punjab, Pakistan. METHODS: A cross-sectional survey was conducted to interview Married Women of Reproductive Age (MWRA. Information was collected on MWRA knowledge regarding danger signs during pregnancy, delivery, postnatal periods, and MNH care seeking behavior. After comparing MNH service utilization, the two areas were compared using a logistic regression model, to identify the association of different factors with the intervention after controlling for socio-demographic, economic factors and distance of the MWRA residence to a health care facility. RESULTS: The demographic characteristics of women in the two areas were similar, although socioeconomic status as indicated by level of education and better household amenities, was higher in the intervention area. Consequently, on univariate analysis, utilization of MNH services: antenatal care, TT vaccination, institutional delivery and use of modern contraceptives were higher in the intervention than control area. Nonetheless, multivariable analysis controlling for confounders such as socioeconomic status revealed that utilization of antenatal care services at health centers and TT vaccination during pregnancy are significantly associated with the intervention. CONCLUSIONS: Our findings suggest positive changes in health care seeking behavior of women and families with respect to MNH. Some aspects of care still require attention, such as knowledge about danger signs and neonatal care, especially umbilical cord care. Despite overall success achieved so far in response to the Millennium Development Goals, over the past two decades decreases in maternal mortality are far from the 2015 target. This report identifies some of the key factors to improving MNH and serves as an
Kumar, Sameer; Breuing, Richard; Chahal, Rajneet
This study highlights some of the inefficiencies in the U.S. health care system and determines what effect medical tourism has had on the U.S. and global health care supply chains. This study also calls attention to insufficient health communication efforts to inform uninsured or underinsured medical tourists about the benefits and risks and determines the managerial and cost implications of various surgical procedures on the global health care system into the future. This study evaluated 3 years (2005, 2007, and 2011) of actual and projected surgical cost data. The authors selected 3 countries for analysis: the United States, India, and Thailand. The surgeries chosen for evaluation were total knee replacement (knee arthroplasty), hip replacement (hip arthroplasty), and heart bypass (coronary artery bypass graft). Comparisons of costs were made using Monte Carlo simulation with variability encapsulated by triangular distributions. The results are staggering. In 2005, the amount of money lost to India and Thailand on just these 3 surgeries because of cost inefficiencies in the U.S. health care system was between 1.3 to 2 billion dollars. In 2011, because many more Americans are expected to travel overseas for health care, this amount is anticipated to rise to between 20 and 30.2 billion dollars. Therefore, more attention should be paid to health communication efforts that truly illustrate the benefits/risks of medical travel. The challenge of finding reliable data for surgeries performed and associated surgical cost estimates was mitigated by the use of a Monte Carlo simulation of triangular distributions. The implications from this study are clear: If the U.S. health care industry is unable to eliminate waste and inefficiency and thus curb rising costs, it will continue to lose surgical revenue to foreign health providers. Copyright © Taylor & Francis Group, LLC
Hwang, Jason; Christensen, Clayton M
Disruptive innovation has brought affordability and convenience to customers in a variety of industries. However, health care remains expensive and inaccessible to many because of the lack of business-model innovation. This paper explains the theory of disruptive innovation and describes how disruptive technologies must be matched with innovative business models. The authors present a framework for categorizing and developing business models in health care, followed by a discussion of some of the reasons why disruptive innovation in health care delivery has been slow.
Full Text Available Health and social care systems are implementing fundamental changes to organizational structures and work practices in an effort to achieve integrated care. While some integration initiatives have produced positive outcomes, many have not. We reframe the concept of integration as a learning process fueled by knowledge exchange across diverse professional and organizational communities. We thus focus on the cognitive and social dynamics of learning in complex adaptive systems, and on learning behaviours and conditions that foster collective learning and improved collaboration. We suggest that the capacity to learn how to learn shapes the extent to which diverse professional groups effectively exchange knowledge and self-organize for integrated care delivery.
This paper outlines the role of quality audit within the framework of quality assurance, presenting the concurrent and retrospective approaches available. The literature survey provides a review of the limited audit tools available and their application to continence services and care delivery, as well as attempts to produce tools from national and local standard setting. Audit is part of a process; it can involve staff, patients and their relatives and the team of professionals providing care, as well as focusing on organizational and management levels. In an era of market delivery of services there is a need to justify why audit is important to continence advisors and managers. Effectiveness, efficiency and economics may drive the National Health Service, but quality assurance, which includes standards and audit tools, offers the means to ensure the quality of continence services and care to patients and auditing is also required in the purchaser/provider contracts for patient services. An overview and progress to date of published and other a projects in auditing continence care and service is presented. By outlining and highlighting the audit of continence service delivery and care as a basis on which to build quality assurance programmes, it is hoped that this knowledge will be shared through the setting up of a central auditing clearing project.
Tanbakuchi, Anthony A.; Rouse, Andrew R.; Udovich, Josh A.; Gmitro, Arthur F.
We present a laparoscope for fluorescence confocal microendoscopy specifically designed for microscopic imaging during diagnostic laparoscopic surgery. The catheter consists of a disposable rigid distal tip which houses a flexible microendoscope and dye channel. The laparoscopic tip is a small disposable polycarbonate sheath containing two inner lumens with a glass window on the distal end. The sheath outer diameter suitable for use in a 5mm trocar. The smaller inner lumen provides a channel for delivering fluorescent contrast agents to the tissue through a 200um hole in the glass window. On the proximal end, the smaller lumen is coupled to a computer controlled fluid delivery system that controls the amount of contrast agent dispensed onto the tissue down to a fraction of a micro liter. The main lumen houses the microendoscope. The microendoscope incorporates a computer-controlled focus mechanism that can quickly and accurately focus while correcting for hysteresis. This fluorescence confocal micro-laparoscope will be tested in a small-scale clinical trial on women undergoing oophorectomy in the near future.
Kaml, Gary J; Davis, Kimberly A
Sepsis and multiple organ dysfunction syndrome (MODS) is common in the surgical intensive care unit. Sepsis involves infection and the patient's immune response. Timely recognition of sepsis and swift application of evidence-based interventions is critical to the success of therapy. This article reviews the nature of the septic process, existing definitions of sepsis, and current evidence-based treatment strategies for sepsis and MODS. An improved understanding of the process of sepsis and its relation to MODS has resulted in clinical definitions and scoring systems that allow for the quantification of disease severity and guidelines for treatment. Copyright © 2016 Elsevier Inc. All rights reserved.
Pucher, Philip H; Aggarwal, Rajesh; Singh, Pritam; Darzi, Ara
Recent evidence has demonstrated the variability in quality of postoperative care, as measured by rates of failure to rescue (FTR). The identification of structure- and process-related factors affecting the quality of postoperative care is the first step towards understanding and improving outcomes. The aim of this review is to review current evidence for structure and process factors affecting postoperative care. A systematic review was conducted. Studies were selected that examined structure or process variables affecting FTR rates and postoperative outcomes. Quality analysis with Jadad and Newcastle-Ottawa scales was conducted and poor-quality studies were excluded. Thirty-seven studies were included in final analysis. Of these, 23 were related to enhanced recovery protocols in seven surgical specialties. Twenty-one of these 23 studies reported decreases in length of stay. Six studies also reported decreases in morbidity. No studies reported increases in stay duration or morbidity. Of the 16 studies that examined other structural and process factors, the strongest evidence was for the association between nursing ratios and FTR rates. The effects of hospital size, resources, and subspecialist care processes were less clear. Process-led care represents a clear, evidence-based approach that can be integrated on a local scale, without necessitating major structural or organisational change, to improve outcomes and may also be cost effective. To foster success, process improvement must be driven on a local level and backed up by appropriate understanding, education, and multidisciplinary involvement.
Dare, Anna J.; Lee, Katherine C.; Bleicher, Josh; Elobu, Alex E.; Kamara, Thaim B.; Liko, Osborne; Luboga, Samuel; Danlop, Akule; Kune, Gabriel; Hagander, Lars; Leather, Andrew J. M.; Yamey, Gavin
Background Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs. Methods and Findings We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable. Conclusions National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political
Pelone, Ferruccio; Kringos, Dionne S; Spreeuwenberg, Peter; De Belvis, Antonio G; Groenewegen, Peter P
To measure the relative efficiency of primary care (PC) in turning their structures into services delivery and turning their services delivery into quality outcomes. Cross-sectional study based on the dataset of the Primary Healthcare Activity Monitor for Europe project. Two Data Envelopment models were run to compare the relative technical efficiency. A sensitivity analysis of the resulting efficiency scores was performed. PC systems in 22 European countries in 2009/2010. Model 1 included data on PC governance, workforce development and economic conditions as inputs and access, coordination, continuity and comprehensiveness of care as outputs. Model 2 included the previous process dimensions as inputs and quality indicators as outputs. There is relatively reasonable efficiency in all countries at delivering as many as possible PC processes at a given level of PC structure. It is particularly important to invest in economic conditions to achieve an efficient structure-process balance. Only five countries have fully efficient PC systems in turning their services delivery into high quality outcomes, using a similar combination of access, continuity and comprehensiveness, although they differ on the adoption of coordination of services. There is a large variation in efficiency levels obtained by countries with inefficient PC in turning their services delivery into quality outcomes. Maximizing the individual functions of PC without taking into account the coherence within the health-care system is not sufficient from a policymaker's point of view when aiming to achieve efficiency.
Gebrehiwot, Tesfay; Goicolea, Isabel; Edin, Kerstin; San Sebastian, Miguel
In 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP), which was intended to increase access to reproductive health care. Despite enormous effort, utilization of maternal health services remains limited, and the reasons for the low utilization of the services offered through the HEP previously have not been explored in depth.This study explores women's experiences and perceptions regarding delivery care in Tigray, a northern region of Ethiopia, and enables us to make suggestions for better implementation of maternal health care services in this setting. We used six focus group discussions with 51 women to explore perceptions and experiences regarding delivery care. The data were analysed by means of grounded theory. One core category emerged, 'making pragmatic choices', which connected the categories 'aiming for safer deliveries', 'embedded in tradition', and 'medical knowledge under constrained circumstances'. In this setting, women - aiming for safer deliveries - made choices pragmatically between the two available models of childbirth. On the one hand, choice of home delivery, represented by the category 'embedded in tradition', was related to their faith, the ascendancy of elderly women, the advantages of staying at home and the custom of traditional birth attendants (TBAs). On the other, institutional delivery, represented by the category 'medical knowledge under constrained circumstances', and linked to how women appreciated medical resources and the support of health extension workers (HEWs) but were uncertain about the quality of care, emphasized the barriers to transportation.In Tigray women made choices pragmatically and seemed to not feel any conflict between the two available models, being supported by traditional birth attendants, HEWs and husbands in their decision-making. Representatives of the two models were not as open to collaboration as the women themselves, however. Although women did not see any conflict
Full Text Available Abstract Background There is still debate as to which features, types or components of primary care interventions are associated with improved depression outcomes. Previous reviews have focused on components of collaborative care models in general practice settings. This paper aims to determine the effective components of depression care in primary care through a systematic examination of both general practice and community based intervention trials. Methods Fifty five randomised and controlled research trials which focused on adults and contained depression outcome measures were identified through PubMed, PsycInfo and the Cochrane Central Register of Controlled Trials databases. Trials were classified according to the components involved in the delivery of treatment, the type of treatment, the primary focus or setting of the study, detailed features of delivery, and the discipline of the professional providing the treatment. The primary outcome measure was significant improvement on the key depression measure. Results Components which were found to significantly predict improvement were the revision of professional roles, the provision of a case manager who provided direct feedback and delivered a psychological therapy, and an intervention that incorporated patient preferences into care. Nurse, psychologist and psychiatrist delivered care were effective, but pharmacist delivery was not. Training directed to general practitioners was significantly less successful than interventions that did not have training as the most important intervention. Community interventions were effective. Conclusion Case management is important in the provision of care in general practice. Certain community models of care (education programs have potential while others are not successful in their current form (pharmacist monitoring.
Steinmetz, O K; Meakins, J L
The traditional approach to the care of the gastrointestinal tract in the intensive care unit has been one of neglect. However, recent evidence has linked enteric flora to the generation of clinical sepsis in the absence of other infectious foci. The role of the bowel as an efficient barrier to the invasion of its own flora is addressed in this paper. A variety of insults disrupt the integrity of the barrier function of the gut, allowing the entry of bowel organisms or endotoxins, or both, into the portal and systemic circulatory systems. In animal and early clinical studies, a number of interventions, aimed at altering the enteric flora and enhancing the bowel's barrier function, have been shown to modulate the host's resistance to different insults and may even improve clinical outcome. Such interventions include maintenance of enteral feeding, glutamine supplementation of hyperalimentation solutions and selective bacterial decontamination of the bowel.
Full Text Available Abstract The United States pediatric population with chronic health conditions is expanding. Currently, this demographic comprises 12-18% of the American child and youth population. Affected children often receive fragmented, uncoordinated care. Overall, the American health care delivery system produces modest outcomes for this population. Poor, uninsured and minority children may be at increased risk for inferior coordination of services. Further, the United States health care delivery system is primarily organized for the diagnosis and treatment of acute conditions. For pediatric patients with chronic health conditions, the typical acute problem-oriented visit actually serves as a barrier to care. The biomedical model of patient education prevails, characterized by unilateral transfer of medical information. However, the evidence basis for improvement in disease outcomes supports the use of the chronic care model, initially proposed by Dr. Edward Wagner. Six inter-related elements distinguish the success of the chronic care model, which include self-management support and care coordination by a prepared, proactive team. United States health care lacks a coherent policy direction for the management of high cost chronic conditions, including rheumatic diseases. A fundamental restructure of United States health care delivery must urgently occur which places the patient at the center of care. For the pediatric rheumatology workforce, reimbursement policies and the actions of health plans and insurers are consistent barriers to chronic disease improvement. United States reimbursement policy and overall fragmentation of health care services pose specific challenges for widespread implementation of the chronic care model. Team-based multidisciplinary care, care coordination and self-management are integral to improve outcomes. Pediatric rheumatology demand in the United States far exceeds available workforce supply. This article reviews the career
Brunkhorst, Jessica; Weiner, Julie; Lantos, John
For more than half a century neonatologists and ethicists alike have struggled with ethical dilemmas surrounding infants born at the limits of viability. Both doctors and parents face difficult decisions. Do we try to save these babies, knowing that such efforts are likely to be unsuccessful? Or do we provide only comfort care, knowing that, in doing so, you will inevitably allow some babies to die who might have been saved? In this paper, we review the outcome data on these babies and offer ten suggestions for doctors: (1) accept that there is a 'gray zone' during which decisions are not black and white; (2) do not place too much emphasis on gestational age; (3) dying is generally not in an infant's best interest; (4) impairment does not necessarily equal poor quality of life; (5) just because the train has left the station doesn't mean you can't get off; (6) respect powerful emotions; (7) be aware of the self-fulfilling prophecies; (8) time lag likely skews all outcome data; (9) statistics can be both confused and confusing; (10) never abandon parents.
Martinez, Enid E; Ariagno, Katelyn A; Stenquist, Nicole; Anderson, Daniela; Muñoz, Eliana; Mehta, Nilesh M
Early and optimal energy and protein delivery have been associated with improved clinical outcomes in the pediatric intensive care unit (PICU). Overweight and obese children in the PICU may be at risk for suboptimal macronutrient delivery; we aimed to describe macronutrient delivery in this cohort. We performed a retrospective study of PICU patients ages 2-21 years, with body mass index (BMI) ≥85th percentile and >48 hours stay. Nutrition variables were extracted regarding nutrition screening and assessment, energy and protein prescription, and delivery. Data from 83 patient encounters for 52 eligible patients (52% male; median age 9.6 [5-15] years) were included. The study cohort had a longer median PICU length of stay (8 vs 5 days, P Energy expenditure was estimated primarily by predictive equations. Stress factor >1.0 was applied in 44% (22/50). Median energy delivered as a percentage of estimated requirements by the Schofield equation was 34.6% on day 3. Median protein delivered as a percentage of recommended intake was 22.1% on day 3. The study cohort had suboptimal nutrition assessments and macronutrient delivery during their PICU course. Mortality and duration of PICU stay were greater when compared with the general PICU population. Nutrition assessment, indirect calorimetry-guided energy prescriptions, and optimizing the delivery of energy and protein must be emphasized in this cohort. The impact of these practices on clinical outcomes must be investigated.
Akhter, M Siddique J; Verma, R; Madhukar, K Premjeet; Vaishampayan, A Rajiv; Unadkat, P C
A prospective observational was carried out to calculate the incidence of surgical site infections (SSI) along with the main risk factors and causative organisms in postoperative patients at a tertiary care setting in Mumbai. A total number of 1196 patients between June 2011 to March 2013 admitted to the general surgical ward or surgical ICU of our hospital were included in the study. Post laproscopy patients and organ space SSIs were excluded. Patient data were collected using a preformed pro forma and a wound Southampton score tabulated and checked repeatedly until suture removal of patient. Regular follow-up was maintained until at least 30 days postoperatively. The study showed a SSI rate of 11%. Risk factors associated with a higher incidence of SSI were found to be age (>55 years), diabetes mellitus (especially uncontrolled sugar in the perioperative period), immunocompromised patients (mainly HIV and immunosuppressive therapy patients), surgeon skill (higher in senior professors compared with junior residents), nature of the cases, (emergency surgeries), placement of drains, wound class (highest in dirty wounds), type of closure (multilayer closure), prolonged duration of hospital stay, longer duration of surgery (>2 hours), type of surgery (highest in cholecystectomy). The highest rates of causative organisms for SSIs found were Staphylococcus aureus, Escherichia coli and Klebsiella ssp. Prevention of SSIs requires a multipronged approach with particular emphasis on optimising preoperative issues, adhering religiously to strict protocols during the intraoperative period and addressing and optimising metabolic and nutritional status in postoperative period.
Warner, Echo L; Wu, Yelena P; Hacking, Claire C; Wright, Jennifer; Spraker-Perlman, Holly L; Gardner, Emmie; Kirchhoff, Anne C
Current guidelines recommend all pediatric cancer survivors receive a survivor care plan (SCP) for optimal health management, yet clinical delivery of SCPs varies. We evaluated oncology providers' familiarity with and preferences for delivering SCPs to inform the implementation of a future SCP program at our institution. From November 2013 to April 2014, oncology providers from the Primary Children's Hospital in Salt Lake City, UT, completed a survey (n=41) and a 45-min focus group (n=18). Participants reported their familiarity with and training in SCP guidelines, opinions on SCPs, and barriers to delivering SCPs. As a secondary analysis, we examined differences in survey responses between physicians and nurses with Fisher's exact tests. Focus group transcripts and open-ended survey responses were content analyzed. Participants reported high familiarity with late effects of cancer treatment (87.8%) and follow-up care that cancer survivors should receive (82.5%). Few providers had delivered an SCP (oncologists 35.3% and nurses 5.0%; p=0.03). Barriers to providing SCPs included lack of knowledge (66.7%), SCP delivery is not expected in their clinic (53.9%), and no champion (48.7%). In qualitative comments, providers expressed that patient age variation complicated SCP delivery. Participants supported testing an SCP intervention program (95.1%) and felt this should be a team-based approach. Strategies for optimal delivery of SCPs are needed. Participants supported testing an SCP program to improve the quality of patient care. Team-based approaches, including nurses and physicians, that incorporate provider training on and support for SCP delivery are needed to improve pediatric cancer care.
Bachrach, Deborah; du Pont, Lammot; Lipson, Mindy
As states' Medicaid programs continue to evolve from traditional fee-for-service to value-based health care delivery, there is growing recognition that systemwide multipayer approaches provide the market power needed to address the triple aim of improved patient care, improved health of populations, and reduced costs. Federal initiatives, such as the State Innovation Model grant program, make significant funds available for states seeking to transform their health care systems. In crafting their reform strategies, states can learn from early innovators. This issue brief focuses on one such state: Arkansas. Insights and lessons from the Arkansas Health Care Payment Improvement Initiative (AHCPII) suggest that progress is best gained through an inclusive, deliberative process facilitated by committed leadership, a shared agreement on root problems and opportunities for improvement, and a strategy grounded in the state's particular health care landscape.
Kessler, D M
Through strategic clinical diversification, political activism, and bold expansion, Wills Eye Hospital, a teaching specialty surgical hospital, survives ravages of sudden onslaughts of managed care payment reductions while maintaining autonomy. Slack inpatient resources were re-utilized to create unique programs attractive to regional managed care organizations. Advocacy and lobbying for short-term favorable treatment from Medicare bought the Hospital valuable time and positioning. Building out a regional network of ambulatory surgical centers assures the growth and access to market required for Wills to maintain its autonomy in a managed care contracting environment.
Shaza A Fadel
Full Text Available Clinical studies demonstrate the efficacy of interventions to reduce neonatal deaths, but there are fewer studies of their real-life effectiveness. In India, women often seek facility delivery after complications arise, rather than to avoid complications. Our objective was to quantify the association of facility delivery and postnatal checkups with neonatal mortality while examining the "reverse causality" in which the mothers deliver at a health facility due to adverse perinatal events.We conducted nationally representative case-control studies of about 300,000 live births and 4,000 neonatal deaths to examine the effect of, place of delivery and postnatal checkup on neonatal mortality. We compared neonatal deaths to all live births and to a subset of live births reporting excessive bleeding or obstructed labour that were more comparable to cases in seeking care.In the larger study of 2004-8 births, facility delivery without postnatal checkup was associated with an increased odds of neonatal death (Odds ratio = 2.5; 99% CI 2.2-2.9, especially for early versus late neonatal deaths. However, use of more comparable controls showed marked attenuation (Odds ratio = 0.5; 0.4-0.5. Facility delivery with postnatal checkup was associated with reduced odds of neonatal death. Excess risks were attenuated in the earlier study of 2001-4 births.The combined effect of facility deliveries with postnatal checks ups is substantially higher than just facility delivery alone. Evaluation of the real-life effectiveness of interventions to reduce child and maternal deaths need to consider reverse causality. If these associations are causal, facility delivery with postnatal check up could avoid about 1/3 of all neonatal deaths in India (~100,000/year.
Howell, Elizabeth A; Padrón, Norma A; Beane, Susan J; Stone, Joanne; Walther, Virginia; Balbierz, Amy; Kumar, Rashi; Pagán, José A
Purpose This paper describes the implementation of an innovative program that aims to improve postpartum care through a set of coordinated delivery and payment system changes designed to use postpartum care as an opportunity to impact the current and future health of vulnerable women and reduce disparities in health outcomes among minority women. Description A large health care system, a Medicaid managed care organization, and a multidisciplinary team of experts in obstetrics, health economics, and health disparities designed an intervention to improve postpartum care for women identified as high-risk. The program includes a social work/care management component and a payment system redesign with a cost-sharing arrangement between the health system and the Medicaid managed care plan to cover the cost of staff, clinician education, performance feedback, and clinic/clinician financial incentives. The goal is to enroll 510 high-risk postpartum mothers. Assessment The primary outcome of interest is a timely postpartum visit in accordance with NCQA healthcare effectiveness data and information set guidelines. Secondary outcomes include care process measures for women with specific high-risk conditions, emergency room visits, postpartum readmissions, depression screens, and health care costs. Conclusion Our evidence-based program focuses on an important area of maternal health, targets racial/ethnic disparities in postpartum care, utilizes an innovative payment reform strategy, and brings together insurers, researchers, clinicians, and policy experts to work together to foster health and wellness for postpartum women and reduce disparities.
2016 CAPS ethics session/Ein debate: 1. Regionalization of pediatric surgical care 2. Ethical introduction of surgical innovation 3. Addressing stress in a surgical practice: resiliency, well-being, and burnout.
Bagwell, Charles E; Chiu, Priscilla; Fecteau, Annie; Gow, Kenneth W; Mueller, Claudia M; Price, David; Zigman, Andrew F
The following is the conference proceeding of the Second Ein Debate from the 48th Annual Meeting of the Canadian Association of Paediatric Surgeons held in Vancouver, BC, from September 22 to 24, 2016. The three main topics for debate, as prepared by the members of the CAPS Ethics Committee, are: 1. Regionalization of care: pros and cons, 2. Innovation in clinical care: ethical considerations, and 3. Surgeon well-being: caring for the caregiver. The authors of this paper, as participants in the debate, were assigned their positions at random. Therefore, the opinions they express within this summary might not reflect their own viewpoints. In the first discussion, arguments for and against the regionalization of pediatric surgical care are discussed, primarily in the context of a case of BA. In the pro argument, the evidence and lessons learned from different European countries are explored as well as different models to provide the best BA care outside of large teaching centers. In the counterargument, the author explains how regionalization of care could be detrimental for the patient, the family, the regional center, and for the health care system in general. In the debate on surgical innovation the authors define surgical innovation. They review the pertinent ethical principles, explore a model for its implementation, and the role of the institution at which the innovation is proposed. In the third section, surgeon well-being is examined, and recent literature on surgeon resiliency and burnout both at the attending and resident level is reviewed.
Rozin, Yu A; Ivanenko, A A
The authors share their experience gained in rendering early specialized surgical care during combat operations in Donbas, having operated on a total of 139 wounded with lesions of large vessels, of these, 21 (15.1%) presenting with concomitant lesions of vessels. Reconstructive operations were carried out in 122 (87.8%) wounded, ligating operations - in 12 (8.6%), and primary amputations - in 5 (3.6%). Two (1.4%) patients died. Blood flow was restored in 117 (84.2%) patients, with six amputations performed after primary operations. The limb was saved in 116 (83.4%) wounded. Peculiarities of a vascular injury in Donbas comprise a large proportion of severe concomitant vascular wounds and lack of intermediate stages of evacuation. The prognosis of life and limb salvage largely depends on correctly chosen method of temporary arrest of bleeding at first stages of medical evacuation and shortening the terms of rendering first specialized surgical care. The variant of operation (reconstruction, ligation or primary amputation) in severe concomitant vascular wounds should be determined proceeding from the degree of ischaemia and severity of the condition of the wounded person, assessed by means of the Military Surgery - Mangled Extremity Severity Score.
Ireland, Sandra E; Arthur, Heather M; Gunn, Elizabeth A; Oczkowski, Wieslaw
Internationally, the development and implementation of stroke care guidelines have resulted in the evolution of stroke prevention outpatient clinics designed to accelerate patient access to treatment and behavioral risk reduction following transient ischemic attack or stroke. To examine the extent to which selected demographic, social-psychological, physiological, and adherence characteristics predicted achievement of blood pressure and glucose targets in a group of patients referred to a Canadian stroke prevention clinic with confirmed transient ischemic attack (TIA) or stroke and hypertension and/or diabetes. A total of 313, English speaking, adult patients who were referred from family or emergency department physicians to a stroke prevention clinic provided demographic data and received social-psychological screening testing at intake. Of these, 93 participants who met criteria of confirmed TIA or stroke plus hypertension and/or diabetes were identified as the study group. Seventy-seven of study group participants completed a 6-month follow-up. Admission screening tests included the Modified and Mini-Mental State Examinations, Trail Making Test, Clock Drawing Test, a medication self-efficacy scale, the Lubben Social Network Scale and the Geriatric Depression Scale. Family physician follow-up was ascertained 4-8 weeks after intake. At approximately 6 months after the initial screening measures, 77 study group participants completed additional measures of adherence, blood pressure and/or glycated hemoglobin. Transient ischemic attack was confirmed in 58% and stroke in 42% of the study group. Mean age was 69 years (SD=11); 53% were male; 97% had hypertension; and 25% were diabetic; some had both. Twenty-three percent were not followed-up by family practitioners. At 6-month follow-up, 97% reported ≥80% adherence to medication; only 57% met treatment targets. A logistic regression analysis identified three independent predictors of achieving blood pressure and
Gerlach, Anthony T; Stawicki, Stanislaw P; Cook, Charles H; Murphy, Claire
Background: Aminoglycosides are commonly used antibiotics in the intensive care unit (ICU), but are associated with nephrotoxicity. This study evaluated the development of aminoglycoside-associated nephrotoxicity (AAN) in a single surgical intensive care unit. Materials and Methods: Adult patients in our surgical ICU who received more than two doses of aminoglycosides were retrospectively reviewed for demographics, serum creatinine, receipt of nephrotoxins [angiotensin converting enzyme (ACE) inhibitors, angiotensin-II receptor blockers, diuretics, non-steroidal anti-inflammatory drugs, cyclosporine, tacrolimus, vasopressors, vancomycin and intravenous iodinated contrast] and the need for dialysis. AAN was defined as an increase in serum creatinine >0.5 mg/dL on at least 2 consecutive days. Univariate and multiple regression analyses were performed. Results: Sixty-one patients (43 males) receiving aminoglycoside were evaluated. Mean age, weight, initial serum creatinine, and duration of aminoglycoside therapy were 58.7 (±15) years, 83.3 (±24.4) kg, 0.9 (±0.5) mg/dL, and 4 (±2.3) days, respectively. Thirty-one (51%) aminoglycoside recipients also received additional nephrotoxins. Seven aminoglycoside recipients (11.5%) developed AAN, four of whom required dialysis and all had received additional nephrotoxins. Only concurrent use of vasopressors (P = 0.041) and vancomycin (P = 0.002) were statistically associated with AAN. Receipt of vasopressors or vancomycin were independent predictors of acute kidney insufficiency (AKI) with odds ratios of 19.9 (95% CI: 1.6–245, P = 0.019) and 49.8 (95% CI: 4.1–602, P = 0.002), respectively. Four patients (6.6%) required dialysis. Conclusions: In critically ill surgical patients receiving aminoglycosides, AAN occurred in 11.5% of the patients. Concurrent use of aminoglycosides with other nephrotoxins increased the risk of AAN. PMID:22096769
Rogier M P H Crolla
Full Text Available BACKGROUND: Surgical Site Infections (SSI are relatively frequent complications after colorectal surgery and are associated with substantial morbidity and mortality. OBJECTIVE: Implementing a bundle of care and measuring the effects on the SSI rate. DESIGN: Prospective quasi experimental cohort study. METHODS: A prospective surveillance for SSI after colorectal surgery was performed in the Amphia Hospital, Breda, from January 1, 2008 until January 1, 2012. As part of a National patient safety initiative, a bundle of care consisting of 4 elements covering the surgical process was introduced in 2009. The elements of the bundle were perioperative antibiotic prophylaxis, hair removal before surgery, perioperative normothermia and discipline in the operating room. Bundle compliance was measured every 3 months in a random sample of surgical procedures. RESULTS: Bundle compliance improved significantly from an average of 10% in 2009 to 60% in 2011. 1537 colorectal procedures were performed during the study period and 300 SSI (19.5% occurred. SSI were associated with a prolonged length of stay (mean additional length of stay 18 days and a significantly higher 6 months mortality (Adjusted OR: 2.71, 95% confidence interval 1.76-4.18. Logistic regression showed a significant decrease of the SSI rate that paralleled the introduction of the bundle. The adjusted Odds ratio of the SSI rate was 36% lower in 2011 compared to 2008. CONCLUSION: The implementation of the bundle was associated with improved compliance over time and a 36% reduction of the SSI rate after adjustment for confounders. This makes the bundle an important tool to improve patient safety.
Svetlana A. Mukhortova
Full Text Available Improving the quality of medical care is a priority in countries with developed and developing health care system. There are various approaches to improve the quality and safety of patient’s care, as well as various strategies to encourage hospitals to achieve this goal. The purpose of the presented literature review was to analyze existing experience of the implementation of technology of supportive supervision in health care facilities to improve the quality of hospital care delivery. The data sources for publication were obtained from the following medical databases: PubMed, Cochrane Library, Medscape, e-library, and books on the topic of the review written by experts. The article discusses the results of the research studies demonstrating the successes and failures of supportive supervision technology application. Implementation of supportive supervision in medical facilities based on generalized experience of different countries is a promising direction in improving the quality of medical care delivery. This technology opens up opportunities to improve skills and work quality of the staff at pediatric hospitals in the Russian Federation.
Tabrizi, Jafar S; Askari, Samira; Fardiazar, Zahra; Koshavar, Hossein; Gholipour, Kamal
Our aim was to determine the service quality of delivered care for people with Caesarean Section and Normal Delivery. A cross-sectional study was conducted among 200 people who had caesarean section and normal delivery in Al-Zahra Teaching Hospital in Tabriz, north western Iran. Service quality was calculated using: Service Quality = 10 - (Importance × Performance) based on importance and performance of service quality aspects from the postpartum women's perspective.A hierarchical regression analysis was applied in two steps using the enter method to examine the associations between demographics and SQ scores. Data were analysed using the SPSS-17 software. "Confidentiality", "autonomy", "choice of care provider" and "communication" achieved scores at the highest level of quality; and "support group", "prompt attention", "prevention and early detection", "continuity of care", "dignity", "safety", "accessibility and "basic amenities" got service quality score less than eight. Statistically significant relationship was found between service quality score and continuity of care (P=0.008). A notable gap between the participants‟ expectations and what they have actually received in most aspects of provided care. So, there is an opportunityto improve the quality of delivered care.
Nicolás, A; Aizpitarte, E; Iruarrizaga, A; Vázquez, M; Margall, M A; Asiain, M C
Night-time rest of the patients hospitalized in Intensive Care is a very important feature within the health/disease process since it has a direct repercussion on their adequate recovery. The objectives of this investigation are: 1) describe how the surgical patients perceive their night-time sleep in the Polyvalent Intensive Care Unit: 2) compare the subjective perception of the patients with the nursing record in the care plan and analyze the degree of agreement between both assessments. Night-time sleep has been studied in 104 patients; surgery patients from emergencies, patients who are intubated, with previous psychiatric treatment, sleep apnea, drinking habit or impossibility of adequate communication were not included. To measure the patient's perception, the five item sleep questionnaire of Richards-Campbell and the assessment of sleep by the nurse, as well as the remaining variables included in a computerized care plan, were used. The total mean score of the sleep on the first post-operative night was 51.42 mm. When the scores obtained in each one of the questionnaire items are analyzed, it is seen that the sleep profile of these patients has been characterized by being light sleep, with frequent wakenings and generally with little difficulty to go back to sleep when woke op or were awakened. The assessment of the night-time sleep performed by the nurse coincides with the perception of the patients on many occasions, and when there is discrepancy, the nurse has overestimated the patient's sleep.
Full Text Available Abstract Background Several studies have reported higher rates of antimicrobial resistance among isolates from intensive care units than among isolates from general patient-care areas. The aims of this study were to review the pathogens associated with nosocomial infections in a surgical intensive care unit of a university hospital in Turkey and to summarize rates of antimicrobial resistance in the most common pathogens. The survey was conducted over a period of twelve months in a tertiary-care teaching hospital located in the south-eastern part of Turkey, Gaziantep. A total of 871 clinical specimens from 615 adult patients were collected. From 871 clinical specimens 771 bacterial and fungal isolates were identified. Results Most commonly isolated microorganisms were: Pseudomonas aeruginosa (20.3%, Candida species (15% and Staphylococcus aureus (12.9%. Among the Gram-negative microorganisms P. aeruginosa were mostly resistant to third-generation cephalosporins (71.3–98.1%, while Acinetobacter baumannii were resistant in all cases to piperacillin, ceftazidime and ceftriaxone. Isolates of S. aureus were mostly resistant to penicillin, ampicillin, and methicillin (82–95%, whereas coagulase-negative staphylococci were 98.6% resistant to methicillin and in all cases resistant to ampicillin and tetracycline. Conclusion In order to reduce the emergence and spread of antimicrobial-resistant pathogens in ICUs, monitoring and optimization of antimicrobial use in hospitals are strictly recommended. Therefore local resistance surveillance programs are of most value in developing appropriate therapeutic guidelines for specific infections and patient types.
Full Text Available Abstract Background In 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP, which was intended to increase access to reproductive health care. Despite enormous effort, utilization of maternal health services remains limited, and the reasons for the low utilization of the services offered through the HEP previously have not been explored in depth. This study explores women’s experiences and perceptions regarding delivery care in Tigray, a northern region of Ethiopia, and enables us to make suggestions for better implementation of maternal health care services in this setting. Methods We used six focus group discussions with 51 women to explore perceptions and experiences regarding delivery care. The data were analysed by means of grounded theory. Results One core category emerged, ‘making pragmatic choices’, which connected the categories ‘aiming for safer deliveries’, ‘embedded in tradition’, and ‘medical knowledge under constrained circumstances’. In this setting, women – aiming for safer deliveries – made choices pragmatically between the two available models of childbirth. On the one hand, choice of home delivery, represented by the category ‘embedded in tradition’, was related to their faith, the ascendancy of elderly women, the advantages of staying at home and the custom of traditional birth attendants (TBAs. On the other, institutional delivery, represented by the category ‘medical knowledge under constrained circumstances’, and linked to how women appreciated medical resources and the support of health extension workers (HEWs but were uncertain about the quality of care, emphasized the barriers to transportation. In Tigray women made choices pragmatically and seemed to not feel any conflict between the two available models, being supported by traditional birth attendants, HEWs and husbands in their decision-making. Representatives of the two models were not as open to
Bauer, Amy M.; Thielke, Stephen M.; Katon, Wayne; Unützer, Jürgen; Areán, Patricia
Objective Healthcare reforms in the United States, including the Affordable Care and HITECH Acts, and the NCQA criteria for the Patient Centered Medical Home have promoted health information technology (HIT) and the integration of general medical and mental health services. These developments, which aim to improve chronic disease care have largely occurred in parallel, with little attention to the need for coordination. In this article, the fundamental connections between HIT and improvements in chronic disease management are explored. We use the evidence-based collaborative care model as an example, with attention to health literacy improvement for supporting patient engagement in care. Method A review of the literature was conducted to identify how HIT and collaborative care, an evidence-based model of chronic disease care, support each other. Results Five key principles of effective collaborative care are outlined: care is patient-centered, evidence-based, measurement-based, population-based, and accountable. The potential role of HIT in implementing each principle is discussed. Key features of the mobile health paradigm are described, including how they can extend evidence-based treatment beyond traditional clinical settings. Conclusion HIT, and particularly mobile health, can enhance collaborative care interventions, and thus improve the health of individuals and populations when deployed in integrated delivery systems. PMID:24963895
Sands, D Z; Wald, J S
Address current topics in consumer health informatics. Literature review. Current health care delivery systems need to be more effective in the management of chronic conditions as the population turns older and experiences escalating chronic illness that threatens to consume more health care resources than countries can afford. Most health care systems are positioned poorly to accommodate this. Meanwhile, the availability of ever more powerful and cheaper information and communication technology, both for professionals and consumers, has raised the capacity to gather and process information, communicate more effectively, and monitor the quality of care processes. Adapting health care systems to serve current and future needs requires new streams of data to enable better self-management, improve shared decision making, and provide more virtual care. Changes in reimbursement for health care services, increased adoption of relevant technologies, patient engagement, and calls for data transparency raise the importance of patient-generated health information, remote monitoring, non-visit based care, and other innovative care approaches that foster more frequent contact with patients and better management of chronic conditions.
... the security, care and handling, and delivery of gifts and decorations to GSA, and all costs... security, care and handling, and delivery of gifts and decorations to GSA, and all costs associated with... Disposition § 102-42.30 Who is responsible for the security, care and handling, and delivery of gifts...
Virginia T LeBaron
Full Text Available Context: Nurses in India often practice in resource-constrained settings and care for cancer patients with high symptom burden yet receive little oncology or palliative care training. Aim: The aim of this study is to explore challenges encountered by nurses in India and offer recommendations to improve the delivery of oncology and palliative care. Methods: Qualitative ethnography. Setting: The study was conducted at a government cancer hospital in urban South India. Sample: Thirty-seven oncology/palliative care nurses and 22 others (physicians, social workers, pharmacists, patients/family members who interact closely with nurses were included in the study. Data Collection: Data were collected over 9 months (September 2011– June 2012. Key data sources included over 400 hours of participant observation and 54 audio-recorded semi-structured interviews. Analysis: Systematic qualitative analysis of field notes and interview transcripts identified key themes and patterns. Results: Key concerns of nurses included safety related to chemotherapy administration, workload and clerical responsibilities, patients who died on the wards, monitoring family attendants, and lack of supplies. Many participants verbalized distress that they received no formal oncology training. Conclusions: Recommendations to support nurses in India include: prioritize safety, optimize role of the nurse and explore innovative models of care delivery, empower staff nurses, strengthen nurse leadership, offer relevant educational programs, enhance teamwork, improve cancer pain management, and engage in research and quality improvement projects. Strong institutional commitment and leadership are required to implement interventions to support nurses. Successful interventions must account for existing cultural and professional norms and first address safety needs of nurses. Positive aspects from existing models of care delivery can be adapted and integrated into general nursing
Full Text Available Purpose: To propose an integration index of home care delivery to older persons, to study its validity and to apply it to home care services of European cities. Theory: Home care delivery integration was based on two dimensions referring to process-centred integration and organisational structure approach. Method: Items considered as part of both dimensions according to an expert consensus (face validity were extracted from a standardised questionnaire used in “Aged in Home care” (AdHoc study to capture basic characteristics of home care services. Their summation leads to a services' delivery integration index. This index was applied to AdHoc services. A factor analysis was computed in order to empirically test the validity of the theoretical constructs. The plot of the settings was performed. Results: Application of the index ranks home care services in four groups according to their score. Factor analysis identifies a first factor which opposes working arrangement within service to organisational structure bringing together provisions for social care. A second factor corresponds to basic nursing care and therapies. Internal consistency for those three domains ranges from 0.78 to 0.93. When plotting the different settings different models of service delivery appear. Conclusion: The proposed index shows that behind a total score several models of care delivery are hidden. Comparison of service delivery integration should take into account this heterogeneity.
Full Text Available Purpose: To propose an integration index of home care delivery to older persons, to study its validity and to apply it to home care services of European cities. Theory: Home care delivery integration was based on two dimensions referring to process-centred integration and organisational structure approach. Method: Items considered as part of both dimensions according to an expert consensus (face validity were extracted from a standardised questionnaire used in “Aged in Home care” (AdHoc study to capture basic characteristics of home care services. Their summation leads to a services' delivery integration index. This index was applied to AdHoc services. A factor analysis was computed in order to empirically test the validity of the theoretical constructs. The plot of the settings was performed. Results: Application of the index ranks home care services in four groups according to their score. Factor analysis identifies a first factor which opposes working arrangement within service to organisational structure bringing together provisions for social care. A second factor corresponds to basic nursing care and therapies. Internal consistency for those three domains ranges from 0.78 to 0.93. When plotting the different settings different models of service delivery appear. Conclusion: The proposed index shows that behind a total score several models of care delivery are hidden. Comparison of service delivery integration should take into account this heterogeneity.
Paa Kobina Turkson
The study used logistic regression modelling to determine predictors of satisfaction with delivery of animal health care services for 889 clients (livestock and poultry keepers) in periurban Ghana. Of the 15 indicators tested as predictors of satisfaction in this study, 8 were included in the best fit model. These were accessibility, availability of services, service charge, effectiveness, efficiency, quality of services, meeting client needs, and getting help. Efficiency and effectiveness we...
Brownbridge, G; Evans, A.; Wall, T
The effects of the use of a computer on the delivery of care in consultations in general practice were examined. In this trial a computer system provided for the review and update of patients' medical histories, notes on doctor-patient contacts, and information on repeat prescribing. Thirty consultations in which the computer system was used and 30 consultations in which no computer was used were matched individually for the doctor consulted, the sex and age of the patient, and the presenting...
Abdullah, Fizan; Troedsson, Hans; Cherian, Meena
This special article provides an introduction to the World Health Organization (WHO) Emergency and Essential Surgical Care (EESC) program. The program was launched by the WHO in December of 2005 to address the lack of adequate surgical capacity as a global public health issue. The overall objective is to reduce death and disability from trauma, burns, pregnancy-related complications, domestic violence, disasters, and other surgically treatable conditions. The program and materials have spread to over 35 countries and focus on providing (1) basic education and training materials; (2) enhancement of surgical infrastructure at the governmental and health facility level; and (3) resources for monitoring and evaluating surgical, obstetrical, and anesthetic capacity. Additionally, a global forum for program members was established that collaborates with ministries of health, WHO country offices, nongovernmental organizations, and academia. The results of the third biennial meeting of global EESC members in Mongolia are outlined as well as future challenges.
Silver, Julie K; Raj, Vishwa S; Fu, Jack B; Wisotzky, Eric M; Smith, Sean Robinson; Kirch, Rebecca A
Palliative care and rehabilitation practitioners are important collaborative referral sources for each other who can work together to improve the lives of cancer patients, survivors, and caregivers by improving both quality of care and quality of life. Cancer rehabilitation and palliative care involve the delivery of important but underutilized medical services to oncology patients by interdisciplinary teams. These subspecialties are similar in many respects, including their focus on improving cancer-related symptoms or cancer treatment-related side effects, improving health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision-making. They also aim to improve healthcare efficiencies and minimize costs by means such as reducing hospital lengths of stay and unanticipated readmissions. Although their goals are often aligned, different specialized skills and approaches are used in the delivery of care. For example, while each specialty prioritizes goal-concordant care through identification of patient and family preferences and values, palliative care teams typically focus extensively on using patient and family communication to determine their goals of care, while also tending to comfort issues such as symptom management and spiritual concerns. Rehabilitation clinicians may tend to focus more specifically on functional issues such as identifying and treating deficits in physical, psychological, or cognitive impairments and any resulting disability and negative impact on quality of life. Additionally, although palliative care and rehabilitation practitioners are trained to diagnose and treat medically complex patients, rehabilitation clinicians also treat many patients with a single impairment and a low symptom burden. In these cases, the goal is often cure of the underlying neurologic or musculoskeletal condition. This report defines and describes cancer rehabilitation and palliative care, delineates their
Titaley Christiana R; Hunter Cynthia L; Dibley Michael J; Heywood Peter
Abstract Background Trained birth attendants at delivery are important for preventing both maternal and newborn deaths. West Java is one of the provinces on Java Island, Indonesia, where many women still deliver at home and without the assistance of trained birth attendants. This study aims to explore the perspectives of community members and health workers about the use of delivery care services in six villages of West Java Province. Methods A qualitative study using focus group discussions ...
Wiler, Jennifer L; Bookman, Kelly; Birznieks, Derek B; Leeret, Robert; Koehler, April; Planck, Shauna; Zane, Richard
Health care systems have utilized various process redesign methodologies to improve care delivery. This article describes the creation of a novel process improvement methodology, Rapid Process Optimization (RPO). This system was used to redesign emergency care delivery within a large academic health care system, which resulted in a decrease: (1) door-to-physician time (Department A: 54 minutes pre vs 12 minutes 1 year post; Department B: 20 minutes pre vs 8 minutes 3 months post), (2) overall length of stay (Department A: 228 vs 184; Department B: 202 vs 192), (3) discharge length of stay (Department A: 216 vs 140; Department B: 179 vs 169), and (4) left without being seen rates (Department A: 5.5% vs 0.0%; Department B: 4.1% vs 0.5%) despite a 47% increased census at Department A (34 391 vs 50 691) and a 4% increase at Department B (8404 vs 8753). The novel RPO process improvement methodology can inform and guide successful care redesign.
Jafar S. Tabrizi
Full Text Available Background: Our aim was to determine the service quality of delivered care for people with Caesarean Section and Normal Delivery. Methods: A cross-sectional study was conducted among 200 people who had caesarean section and normal delivery in Al-Zahra Teaching Hospital in Tabriz, north western Iran. Service quality was calculated using: Service Quality = 10 – (Importance × Performance based on importance and performance of service quality aspects from the postpartum women‟s perspective.A hierarchical regression analysis was applied in two steps using the enter method to examine the associations between demographics and SQ scores. Data were analysed using the SPSS-17 software. Results: “Confidentiality”, “autonomy”, “choice of care provider” and “communication” achieved scores at the highest level of quality; and “support group”, “prompt attention”, “prevention and early detection”, “continuity of care”, “dignity”, “safety”, “accessibility and “basic amenities” got service quality score less than eight. Statistically significant relationship was found between service quality score and continuity of care (P=0.008. Conclusion: A notable gap between the participants‟ expectations and what they have actually received in most aspects of provided care. So, there is an opportunityto improve the quality of delivered care.
Cochella, Susan; Liaw, Winston; Binienda, Juliann; Hustedde, Carol
The Society of Teachers of Family Medicine's (STFM) National Clerkship Curriculum (NCC) was created to standardize and improve teaching of a minimum core curriculum in family medicine clerkships, promoting the Triple Aim of better care and population health at lower cost. It includes competencies all clerkships should teach and tools to support clerkship directors (CDs). This 2014 CERA survey of clerkship directors is one of several needs assessments that guide STFM's NCC Editorial Board in targeting improvements and peer-review processes. CERA's 2014 survey of CDs was sent to all 137 CDs at US and Canadian allopathic medical schools. Primary aims included: (1) Identify curricular topics of greatest need, (2) Inventory the percent of family medicine clerkships teaching each NCC topic, and (3) Determine if longitudinal or blended clerkship have unique needs. This survey also assessed use of NCC to advocate for teaching resources and collaborate with colleagues at other institutions. Ninety-one percent of CDs completed the survey. Sixty-four percent reported their clerkship covers all of the NCC minimum core, but on detailed analysis, only 1% teach all topics. CDs need curricula on care delivery topics (cost-effective approach to acute care, role of family medicine in the health care system, quality/safety, and comorbid substance abuse). Single-question assessments overestimate the percentage of clerkships teaching all of the NCC minimum core. Clerkships need national curricula on care delivery topics and tools to help them find their curricular gaps.
Collinsworth, Ashley; Vulimiri, Madhulika; Snead, Christine; Walton, James
New, comprehensive, approaches for chronic disease management are needed to ensure that patients, particularly those more likely to experience health disparities, have access to the clinical care, self-management resources, and support necessary for the prevention and control of diabetes. Community health workers (CHWs) have worked in community settings to reduce health care disparities and are currently being deployed in some clinical settings as a means of improving access to and quality of care. Guided by the chronic care model, Baylor Health Care System embedded CHWs within clinical teams in community clinics with the goal of reducing observed disparities in diabetes care and outcomes. This study examines findings from interviews with patients, CHWs, and primary care providers (PCPs) to understand how health care delivery systems can be redesigned to effectively incorporate CHWs and how embedding CHWs in primary care teams can produce informed, activated patients and prepared, proactive practice teams who can work together to achieve improved patient outcomes. Respondents indicated that the PCPs continued to provide clinical exams and manage patient care, but the roles of diabetes education, nutritional counseling, and patient activation were shifted to the CHWs. CHWs also provided patients with social support and connection to community resources. Integration of CHWs into clinical care teams improved patient knowledge and activation levels, the ability of PCPs to identify and proactively address specific patient needs, and patient outcomes.
Diana, Mark L
The purpose of this study is to explore the factors associated with outsourcing of information systems (IS) in hospital-based health care delivery systems, and to determine if there is a difference in IS outsourcing activity based on the strategic value of the outsourced functions. IS sourcing behavior is conceptualized as a case of vertical integration. A synthesis of strategic management theory (SMT) and transaction cost economics (TCE) serves as the theoretical framework. The sample consists of 1,365 hospital-based health care delivery systems that own 3,452 hospitals operating in 2004. The findings indicate that neither TCE nor SMT predicted outsourcing better than the other did. The findings also suggest that health care delivery system managers may not be considering significant factors when making sourcing decisions, including the relative strategic value of the functions they are outsourcing. It is consistent with previous literature to suggest that the high cost of IS may be the main factor driving the outsourcing decision.
Kaggal, Vinod C; Elayavilli, Ravikumar Komandur; Mehrabi, Saeed; Pankratz, Joshua J; Sohn, Sunghwan; Wang, Yanshan; Li, Dingcheng; Rastegar, Majid Mojarad; Murphy, Sean P; Ross, Jason L; Chaudhry, Rajeev; Buntrock, James D; Liu, Hongfang
The concept of optimizing health care by understanding and generating knowledge from previous evidence, ie, the Learning Health-care System (LHS), has gained momentum and now has national prominence. Meanwhile, the rapid adoption of electronic health records (EHRs) enables the data collection required to form the basis for facilitating LHS. A prerequisite for using EHR data within the LHS is an infrastructure that enables access to EHR data longitudinally for health-care analytics and real time for knowledge delivery. Additionally, significant clinical information is embedded in the free text, making natural language processing (NLP) an essential component in implementing an LHS. Herein, we share our institutional implementation of a big data-empowered clinical NLP infrastructure, which not only enables health-care analytics but also has real-time NLP processing capability. The infrastructure has been utilized for multiple institutional projects including the MayoExpertAdvisor, an individualized care recommendation solution for clinical care. We compared the advantages of big data over two other environments. Big data infrastructure significantly outperformed other infrastructure in terms of computing speed, demonstrating its value in making the LHS a possibility in the near future.
McWilliams, J. Michael; Chernew, Michael E.; Zaslavsky, Alan M.; Hamed, Pasha; Landon, Bruce E.
Background The Medicare accountable care organization (ACO) programs rely on delivery system integration and provider risk sharing to lower spending while improving quality of care. Methods Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5,000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We compared spending and quality of care between larger and smaller provider groups and examined how size-related differences varied by 2 factors considered central to ACO performance: group primary care orientation (measured by the primary care share of large groups’ specialty mix) and provider risk sharing (measured by county health maintenance organization penetration and its relationship to financial risk accepted by different group types for managed care patients). Spending and quality of care measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. Results Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference: +$849), higher 30-day readmission rates (+1.3% percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (−$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. Conclusions Spending
Flatow, V H; Ibragimova, N; Divino, C M; Eshak, D S A; Twohig, B C; Bassily-Marcus, A M; Kohli-Seth, R
The electronic health record (EHR) is increasingly viewed as a means to provide more coordinated, patient-centered care. Few studies consider the impact of EHRs on quality of care in the intensive care unit (ICU) setting. To evaluate key quality measures of a surgical intensive care unit (SICU) following implementation of the Epic EHR system in a tertiary hospital. A retrospective chart review was undertaken to record quality indicators for all patients admitted to the SICU two years before and two years after EHR implementation. Data from the twelve-month period of transition to EHR was excluded. We collected length of stay, mortality, central line associated blood stream infection (CLABSI) rates, Clostridium difficile (C. diff.) colitis rates, readmission rates, and number of coded diagnoses. To control for variation in the patient population over time, the case mix indexes (CMIs) and APACHE II scores were also analyzed. There was no significant difference in length of stay, C. diff. colitis, readmission rates, or case mix index before and after EHR. After EHR implementation, the rate of central line blood stream infection (CLABSI) per 1 000 catheter days was 85% lower (2.16 vs 0.39; RR, 0.18; 95% CI, 0.05 to 0.61, p < .005), and SICU mortality was 28% lower (12.2 vs 8.8; RR, 1.35; 95% CI, 1.06 to 1.71, p < .01). Moreover, after EHR there was a significant increase in the average number of coded diagnoses from 17.8 to 20.8 (p < .000). EHR implementation was statistically associated with reductions in CLABSI rates and SICU mortality. The EHR had an integral role in ongoing quality improvement endeavors which may explain the changes in CLABSI and mortality, and this invites further study of the impact of EHRs on quality of care in the ICU.
Full Text Available Abstract Background Tight glucose control by intensive insulin therapy has become a key part of critical care and is an important field of study in acute coronary care. A balance has to be found between frequency of measurements and the risk of hypoglycemia. Current nurse-driven protocols are paper-based and, therefore, rely on simple rules. For safety and efficiency a computer decision support system that employs complex logic may be superior to paper protocols. Methods We designed and implemented GRIP, a stand-alone Java computer program. Our implementation of GRIP will be released as free software. Blood glucose values measured by a point-of-care analyzer were automatically retrieved from the central laboratory database. Additional clinical information was asked from the nurse and the program subsequently advised a new insulin pump rate and glucose sampling interval. Results Implementation of the computer program was uneventful and successful. GRIP treated 179 patients for a total of 957 patient-days. Severe hypoglycemia ( Conclusion A computer driven protocol is a safe and effective means of glucose control at a surgical ICU. Future improvements in the recommendation algorithm may further improve safety and efficiency.
Morgan, David J R; Ho, Kwok Ming; Ong, Yang Jian; Kolybaba, Marlene L
The 'weekend' effect is a controversial theory that links reduced staffing levels, staffing seniority and supportive services at hospitals during 'out-of-office hours' time periods with worsening patient outcomes. It is uncertain whether admitting elective surgery patients to intensive care units (ICU) during 'out-of-office hours' time periods mitigates this affect through higher staffing ratios and seniority. Over a 3-year period in Western Australia's largest private hospital, this retrospective nested-cohort study compared all elective surgical patients admitted to the ICU based on whether their admission occurred 'in-office hours' (Monday-Friday 08.00-18.00 hours) or 'out-of-office hours' (all other times). The main outcomes were surgical complications using the Dindo-Clavien classification and length-of-stay data. Of the total 4363 ICU admissions, 3584 ICU admissions were planned following elective surgery resulting in 2515 (70.2%) in-office hours and 1069 (29.8%) out-of-office hours elective ICU surgical admissions. Out-of-office hours ICU admissions following elective surgery were associated with an increased risk of infection (P = 0.029), blood transfusion (P = 0.020), total parental nutrition (P office hours ICU admissions were also associated with an increased hospital length-of-stay, with (1.74 days longer, P office hours ICU admissions following elective surgery is common and associated with serious post-operative complications culminating in significantly longer hospital length-of-stays and greater transfers with important patient and health economic implications. © 2017 Royal Australasian College of Surgeons.
Liqin Xu; Junlian Tan
Purpose:To explore the nursing care following surgical treat-ment of fungal endophthalmitis in children. Methods:Thirty two children (32 eyes) with fungal endoph-thalmitis were enrolled in this study. After receiving antifungal medication,.the children underwent either intravitreal injec-tion,.intravitreal injection of medicine combined with vitrecto-my,.or intravitreal injection in combination with vitrectomy and intraocular C3F8 tamponade. Prior to surgery, psycholog-ical and quarantine nursing,.and medication use was properly prepared..After the surgery,.the changes in the severity of diseases were strictly observed..A suitable body posture was selected and the eyes were protected from infection. Results:.Among 32 patients with fungal endophthalmitis,.8 (25%).cases presented with alleviated inflammation and no changes in visual acuity. The visual acuity of 18 cases (56.25%). was improved to different extents postoperatively. The inflam-mation in 6 children (18.75%) was properly controlled and the visual acuity declined. No cross-infection was noted in any pa-tient. Conclusion: Prior to surgery, quarantine nursing and drug administration should be properly prepared. Postoperatively, the changes in the severity of diseases should be tightly moni-tored. The patients should be treated with effective therapies in a proper position,.aiming to enhance the surgical efficacy.
Kwedza Ru K
Full Text Available Abstract Background Australia's Aboriginal and Torres Strait Islander (Indigenous populations have disproportionately high rates of adverse perinatal outcomes relative to other Australians. Poorer access to good quality maternal health care is a key driver of this disparity. The aim of this study was to describe patterns of delivery of maternity care and service gaps in primary care services in Australian Indigenous communities. Methods We undertook a cross-sectional baseline audit for a quality improvement intervention. Medical records of 535 women from 34 Indigenous community health centres in five regions (Top End of Northern Territory 13, Central Australia 2, Far West New South Wales 6, Western Australia 9, and North Queensland 4 were audited. The main outcome measures included: adherence to recommended protocols and procedures in the antenatal and postnatal periods including: clinical, laboratory and ultrasound investigations; screening for gestational diabetes and Group B Streptococcus; brief intervention/advice on health-related behaviours and risks; and follow up of identified health problems. Results The proportion of women presenting for their first antenatal visit in the first trimester ranged from 34% to 49% between regions; consequently, documentation of care early in pregnancy was poor. Overall, documentation of routine antenatal investigations and brief interventions/advice regarding health behaviours varied, and generally indicated that these services were underutilised. For example, 46% of known smokers received smoking cessation advice/counselling; 52% of all women received antenatal education and 51% had investigation for gestational diabetes. Overall, there was relatively good documentation of follow up of identified problems related to hypertension or diabetes, with over 70% of identified women being referred to a GP/Obstetrician. Conclusion Participating services had both strengths and weaknesses in the delivery of maternal
Akyüz, Elif; Erdemir, Firdevs
The purpose of this study was to determine the opinions and expectations of patients and nurses about privacy during a hospital admission for surgery. The study explored what enables and maintains privacy from the perspective of Turkish surgical patients and nurses. The study included 102 adult patients having surgery and 47 nurses caring for them. Data were collected via semistructured questionnaire by face-to-face interviews. The results showed that patients were mostly satisfied by the respect shown to their privacy by the nurses but were less confident of the confidentiality of their personal data. It was found that patients have expectations regarding nursing approaches and attitudes about acknowledging and respecting patient autonomy and confidentiality. It is remarkable that while nurses focused on the physical dimension of privacy, patients focused on informational and psychosocial dimensions of privacy, as well as its physical dimension.
Collins, Jennifer L
The purpose of this integrative review is to summarize evidence describing delivery of healthcare services to adolescents while in foster care and to young adults after they exit foster care. The long-term, deleterious effect of abuse and/or neglect by caregivers among youth who have been placed in foster care is grounded in empirical evidence demonstrating the relationship between long-term health needs and exposure to trauma in childhood. Evidence is needed to provide culturally-specific care and also to identify knowledge gaps in the care of adolescents and young adults who have been in the foster care system. Peer-reviewed research studies published between 2004 and 2014 that include samples of youth 12 to 30 years of age are included in the review. Eighteen studies met inclusion criteria for the review. Physical and behavioral healthcare needs among youth with foster care experience are significant. The ability to adequately meet health needs are inextricable from the ability to negotiate resources and to successfully interact with adults. Challenges that youth with foster care histories experience when transitioning into young adulthood are comparable to other populations of vulnerable youth not in foster care. Nurses must use each healthcare encounter to assess how the social determinants of health facilitate or impede optimal health among youth with foster care experience. The development of integrated intervention strategies to inform best practice models is a priority for current and former foster care youth as they transition into young adulthood. Copyright Â© 2016 Elsevier Inc. All rights reserved.
Wylie, Kevan; Knudson, Gail; Khan, Sharful Islam; Bonierbale, Mireille; Watanyusakul, Suporn; Baral, Stefan
The World Professional Association for Transgender Health (WPATH) standards of care for transsexual, transgender, and gender non-conforming people (version 7) represent international normative standards for clinical care for these populations. Standards for optimal individual clinical care are consistent around the world, although the implementation of services for transgender populations will depend on health system infrastructure and sociocultural contexts. Some clinical services for transgender people, including gender-affirming surgery, are best delivered in the context of more specialised facilities; however, the majority of health-care needs can be delivered by a primary care practitioner. Across high-income and low-income settings alike, there often remains a dearth of educational programming for health-care professionals in transgender health, although the best evidence supports introducing modules on transgender health early during clinical education of clinicians and allied health professionals. While these challenges remain, we review the increasing evidence and examples of the defined roles of the mental health professional in transgender health-care decisions, effective models of health service provision, and available surgical interventions for transgender people.
... 42 Public Health 4 2010-10-01 2010-10-01 false Delivery of benchmark and benchmark-equivalent...: GENERAL PROVISIONS Benchmark Benefit and Benchmark-Equivalent Coverage § 440.385 Delivery of benchmark and benchmark-equivalent coverage through managed care entities. In implementing benchmark or...
Description of situation concerning care of pregnancy, childbirth and childbed in Wageningen, the Netherlands. Diagnosis of pregnancy / supervision of pregnancy ( zwangerschapsbegeleiding ) / place of delivery / maternity home / controls of pregnancy / gymnastics course for parents / evaluation of
Description of situation concerning care of pregnancy, childbirth and childbed in Wageningen, the Netherlands. Diagnosis of pregnancy / supervision of pregnancy ( zwangerschapsbegeleiding ) / place of delivery / maternity home / controls of pregnancy / gymnastics course for parents / evaluation of p
Anderson, Cheryl I; Nelson, Catherine S; Graham, Corey F; Mosher, Benjamin D; Gohil, Kartik N; Morrison, Chet A; Schneider, Paul D; Kepros, John P
Performance improvement driven by the review of surgical morbidity and mortality is often limited to critiques of individual cases with a focus on individual errors. Little attention has been given to an analysis of why a decision seemed right at the time or to lower-level root causes. The application of scientific performance improvement has the potential to bring to light deeper levels of understanding of surgical decision-making, care processes, and physician psychology. A comprehensive retrospective chart review of previously discussed morbidity and mortality cases was performed with an attempt to identify areas where we could better understand or influence behavior or systems. We avoided focusing on traditional sources of human error such as lapses of vigilance or memory. An iterative process was used to refine the practical areas for possible intervention. Definitions were then created for the major categories and subcategories. Of a sample of 152 presented cases, the root cause for 96 (63%) patient-related events was identified as uni-factorial in origin, with 51 (34%) cases strictly related to patient disease with no other contributing causes. Fifty-six cases (37%) had multiple causes. The remaining 101 cases (66%) were categorized into two areas where the ability to influence outcomes appeared possible. Technical issues were found in 27 (18%) of these cases and 74 (74%) were related to disorganized care problems. Of the 74 cases identified with disorganized care, 42 (42%) were related to failures in critical thinking, 18 (18%) to undisciplined treatment strategies, 8 (8%) to structural failures, and 6 (6%) were related to failures in situational awareness. On a comprehensive review of cases presented at the morbidity and mortality conference, disorganized care played a large role in the cases presented and may have implications for future curriculum changes. The failure to think critically, to deliver disciplined treatment strategies, to recognize
Duffy, Malia; Ojikutu, Bisola; Andrian, Soa; Sohng, Elaine; Minior, Thomas; Hirschhorn, Lisa R
Non-communicable diseases (NCD) are a growing cause of morbidity in low-income countries including in people living with human immunodeficiency virus (HIV). Integration of NCD and HIV services can build upon experience with chronic care models from HIV programmes. We describe models of NCD and HIV integration, challenges and lessons learned. A literature review of published articles on integrated NCD and HIV programs in low-income countries and key informant interviews were conducted with leaders of identified integrated NCD and HIV programs. Information was synthesised to identify models of NCD and HIV service delivery integration. Three models of integration were identified as follows: NCD services integrated into centres originally providing HIV care; HIV care integrated into primary health care (PHC) already offering NCD services; and simultaneous introduction of integrated HIV and NCD services. Major challenges identified included NCD supply chain, human resources, referral systems, patient education, stigma, patient records and monitoring and evaluation. The range of HIV and NCD services varied widely within and across models. Regardless of model of integration, leveraging experience from HIV care models and adapting existing systems and tools is a feasible method to provide efficient care and treatment for the growing numbers of patients with NCDs. Operational research should be conducted to further study how successful models of HIV and NCD integration can be expanded in scope and scaled-up by managers and policymakers seeking to address all the chronic care needs of their patients. © 2017 John Wiley & Sons Ltd.
This article will examine the Catholic concept of global justice within a health care framework as it relates to women's needs for delivery doctors in the developing world and women's demands for assisted reproduction in the developed world. I will first discuss justice as a theory, situating it within Catholic social teachings. The Catholic perspective on global justice in health care demands that everyone have access to basic needs before elective treatments are offered to the wealthy. After exploring specific discrepancies in global health care justice, I will point to the need for delivery doctors in the developing world to provide basic assistance to women who hazard many pregnancies as a priority before offering assisted reproduction to women in the developed world. The wide disparities between maternal health in the developing world and elective fertility treatments in the developed world are clearly unjust within Catholic social teachings. I conclude this article by offering policy suggestions for moving closer to health care justice via doctor distribution.
Gunn, I P
Problems in health care delivery relative to access, costs, and quality have been debated for more than a quarter of a century. Health care costs have significantly increased since the implementation of the Medicare/Medicaid legislation. Cost containment has been high on the agendas of government officials, legislators, health policy decision makers, business leaders, and economists since the 1980s. There has been a shift toward market medicine and managed care as a means for cost containment. Although some costs were contained for a short period, they are once again rising significantly, and there is growing dissatisfaction with this shift. The United States is not alone in this dilemma. Mark Lema, MD, PHD, editor of the ASA Newsletter, wrote a thought-provoking editorial in the July 1999 issue, raising concerns about change, relationships, reimbursement, and demise relative to anesthesia personnel. In response, this article primarily raises the issue of health manpower mix as a major factor in the cost of health care delivery regarding these systems. Whereas change is inevitable, it is difficult for state and federal governments in the United States to force change because of the number of special interests involved in campaign financing involving elected government officials. It is nevertheless important for health professionals to be involved in the changes that come about, or change will be made for them. It is essential to renew society, institutions, and individuals in order to prevent decay and obsolescence. If we don't make the future, the future will make us.
Sarwar, Ammar; Boland, Giles; Monks, Annamarie; Kruskal, Jonathan B
Accelerated by the Patient Protection and Affordable Care Act of 2010, health care delivery in the United States is poised to move from a model that rewards the volume of services provided to one that rewards the value provided by such services. Radiology department operations are currently managed by an array of metrics that assess various departmental missions, but many of these metrics do not measure value. Regulators and other stakeholders also influence what metrics are used to assess medical imaging. Metrics such as the Physician Quality Reporting System are increasingly being linked to financial penalties. In addition, metrics assessing radiology's contribution to cost or outcomes are currently lacking. In fact, radiology is widely viewed as a contributor to health care costs without an adequate understanding of its contribution to downstream cost savings or improvement in patient outcomes. The new value-based system of health care delivery and reimbursement will measure a provider's contribution to reducing costs and improving patient outcomes with the intention of making reimbursement commensurate with adherence to these metrics. The authors describe existing metrics and their application to the practice of radiology, discuss the so-called value equation, and suggest possible metrics that will be useful for demonstrating the value of radiologists' services to their patients.
Frohman, Larry P
In contradiction to fundamental laws of supply and demand, 2 decades of payment policies have led to some medical specialties experiencing declines in both manpower and reimbursement. This paradox has resulted in increasingly long wait times to see some specialists, some specialties becoming less attractive to potential trainees, and a dearth of new trainees entering these fields. Evolving models of health care delivery hold the promise of increasing patient access to most providers and may diminish costs and improve outcomes for most patients/conditions. However, patients who need care in understaffed fields may, in the future, be unable to quickly access a specialist with the requisite expertise. Impeding the sickest and most complex patients from seeing physicians with appropriate expertise may lead to increased costs and deleterious outcomes-consequences contrary to the goals of health care reform. To ensure appropriate access for these patients requires 2 conditions: 1. Compensation models that do not discourage trainees from pursuing nonprocedural specialties, and 2. A care delivery model that expediently identifies and routes these patients to the appropriate specialist.
Henke, Peter K; Kubus, Jim; Englesbe, Michael J; Harbaugh, Calista; Campbell, Darrell A
Regional surgical quality improvement consortiums are becoming more common. Herein we have reported the effectiveness of a statewide consortium focusing on open vascular operative procedures. The statewide Michigan Surgical Quality Consortium was established in 2005 with 16 hospitals that report cases of vascular open operative intervention, in a sampling manner consistent with the private sector National Surgical Quality Improvement Program. Data are abstracted by onsite trained nurses using defined and validated pre-, peri-, and postoperative variables with 30-day follow-up. Outpatient and emergent cases were excluded. We compared outcomes over the course of the consortium (era I, April 2005-March 2007; era II, April 2007-March 2008) via univariate and multivariate techniques. Era I (n = 2,453) and era II (n = 3,409) cases were similar in age (mean, 68 years), gender (61% male), relative value units (mean, 21), and distribution of Current Procedural Terminology codes. Duration of stay and operative time decreased by 15% and 11%, respectively, when comparing era I with era II (P cardiac or renal, complications. When evaluating both eras, modifiable variables (able to be altered by the surgeon) for morbidity included increased length of operation (odds ratio [OR], 1.004; 95% confidence interval [CI], 1.003-1.005; P < .0001), hypertension (OR, 1.46; 95% CI, 1.03-2.1; P = .03), and blood transfusion (OR, 2.8; 95% CI, 2.04-3.88; P < .0001). However, anemic patients (11%; hematocrit <30) who were transfused were less likely to suffer morbidity (OR, 56; 95% CI, 0.47-0.67; P < .0001) than those transfused who were not anemic. The absolute 2% reduction in complications led to a $172 cost savings for the payers per patient in era II compared with era I. A statewide quality-of-care consortium with timely feedback of data was associated with decreased morbidity over a relatively short follow-up period in vascular patients. Focusing on best processes in real-world practice
Browne, Joyce L.; Kayode, Gbenga A; Arhinful, Daniel; Fidder, Samuel A J; Grobbee, Diederick E; Klipstein-Grobusch, Kerstin
OBJECTIVE: This study aims to evaluate the effect of maternal health insurance status on the utilisation of antenatal, skilled delivery and postnatal care. DESIGN: A population-based cross-sectional study. SETTING AND PARTICIPANTS: We utilised the 2008 Demographic and Health Survey data of Ghana, which included 2987 women who provided information on maternal health insurance status. PRIMARY OUTCOMES: Utilisation of antenatal, skilled delivery and postnatal care. STATISTICAL ANALYSES: Multivar...
Kayyali, Reem; Odeh, Bassel; Frerichs, Inéz; Davies, Nikki; Perantoni, Eleni; D’arcy, Shona; Vaes, Anouk W; Chang, John; Spruit, Martijn A; Deering, Brenda; Philip, Nada; Siva, Roshan; Kaimakamis, Evangelos; Chouvarda, Ioanna; Pierscionek, Barbara; Weiler, Norbert; Wouters, Emiel FM; Raptopoulos, Andreas; Nabhani-Gebara, Shereen
Background COPD is among the leading causes of chronic morbidity and mortality in the European Union with an estimated annual economic burden of €25.1 billion. Various care pathways for COPD exist across Europe leading to different responses to similar problems. Determining these differences and the similarities may improve health and the functioning of health services. Objective The aim of this study was to compare COPD patients’ care pathway in five European Union countries including England, Ireland, the Netherlands, Greece, and Germany and to explore health care professionals’ (HCPs) perceptions about the current pathways. Methods HCPs were interviewed in two stages using a qualitative, semistructured email interview and a face-to-face semistructured interview. Results Lack of communication among different health care providers managing COPD and comorbidities was a common feature of the studied care pathways. General practitioners/family doctors are responsible for liaising between different teams/services, except in Greece where this is done through pulmonologists. Ireland and the UK are the only countries with services for patients at home to shorten unnecessary hospital stay. HCPs emphasized lack of communication, limited resources, and poor patient engagement as issues in the current pathways. Furthermore, no specified role exists for pharmacists and informal carers. Conclusion Service and professional integration between care settings using a unified system targeting COPD and comorbidities is a priority. Better communication between health care providers, establishing a clear role for informal carers, and enhancing patients’ engagement could optimize current care pathways resulting in a better integrated system. PMID:27881915
Gipson, Jessica D; Gyaltsen, Kunchok; Gyal, Lhusham; Kyi, Tsering; Hicks, Andrew L; Pebley, Anne R
To identify sociodemographic characteristics and factors involved in Tibetan women's decisions to deliver at the Tibetan Birth and Training Center (TBTC) in rural western China. In the present mixed-methods study, a random sample of married women who delivered at the TBTC between June 2011 and June 2012 were surveyed. Additionally, four focus group discussions were conducted among married women living in the TBTC catchment area. Descriptive analyses were conducted, and dominant themes were identified. In focus group discussions, women (n=33) reported that improved roads and transportation meant that access to health facilities was easier than in the past. Although some of the 114 survey participants voiced negative perceptions of healthcare facilities and providers, 99 (86.8%) indicated that they chose to deliver at the TBTC because they preferred to have a doctor present. Most women (75 [65.8%]) said their mother/mother-in-law made the final decision about delivery location. Women valued logistic and cultural aspects of the TBTC, and 108 (94.7%) said that they would recommend the TBTC to a friend. Study participants preferred delivery care that combines safety and comfort. The findings highlight avenues for further promotion of facility delivery among populations with lower rates of skilled deliveries. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Full Text Available Objectives. To describe the application of teleophthalmology in rural and underserved areas of India. Study Design. This paper describes the major teleophthalmology projects in India and its benefits. Results. Teleophthalmology is the use of telecommunication for electronic transfer of health-related data from rural and underserved areas of India to specialities in urban cities. The MDRF/WDF Rural Diabetes Project has proved to be very beneficial for improvement of quality health care in Tamilnadu and can be replicated at the national level. This community outreach programme using telemedicine facilities has increased awareness of eye diseases, improved access to specialized health care, helped in local community empowerment, and provided employment opportunities. Early detection of sight threatening disorders by teleophthalmology and prompt treatment can help decrease visual impairment. Conclusion. Teleophthalmology can be a very effective model for improving eye care delivery system in rural and underserved areas of India.
Turkson, P K
I assessed the satisfaction in July-August 2005 of 889 livestock and poultry owners with animal health-care services delivery in peri-urban Ghana and determined factors associated with that satisfaction (and with being the owner of poultry versus of other livestock with or without poultry). Overall, 48% of the respondents were satisfied or very satisfied with service delivery, with only 8% in the very satisfied category. Of the 401 owners of poultry and 488 owners of other livestock, 52% and 45%, respectively, reported being satisfied or very satisfied with veterinary services delivery. I found significant differences between poultry and livestock owners in 11 of 15 indicators of quality of animal health-care services; significantly higher proportions of poultry owners gave positive assessments in nine of the indicators. All but one of the 15 indicators tested was significantly and positively associated with satisfaction among all owners, overall. The indicators are proposed as a checklist for Qualitative Rapid Appraisal of Veterinary Services.
van der Eijk, Martijn; Faber, Marjan J; Post, Bart; Okun, Michael S; Schmidt, Peter; Munneke, Marten; Bloem, Bastiaan R
Capturing patients' perspectives has become an essential part of a quality of care assessment. The patient centeredness questionnaire for PD (PCQ-PD) has been validated in The Netherlands as an instrument to measure patients' experiences. This study aims to assess the level of patient centeredness in North American Parkinson centers and to demonstrate the PCQ-PD's potential as a quality improvement instrument. 20 Parkinson Centers of Excellence participated in a multicenter study. Each center asked 50 consecutive patients to complete the questionnaire. Data analyses included calculating case mix-adjusted scores for overall patient centeredness (scoring range 0-3), six subscales (0-3), and quality improvement (0-9). Each center received a feedback report on their performance. The PCQ-PD was completed by 972 PD patients (median 50 per center, range 37-58). Significant differences between centers were found for all subscales, except for emotional support (p < 0.05). The information subscale (mean 1.62 SD 0.62) and collaboration subscale (mean 2.03 SD 0.58) received the lowest experience ratings. 14 centers (88 %) who returned the evaluation survey claimed that patient experience scores could help to improve the quality of care. Nine centers (56 %) utilized the feedback to change specific elements of their care delivery process. PD patients are under-informed about critical care issues and experience a lack of collaboration between healthcare professionals. Feedback on patients' experiences facilitated Parkinson centers to improve their delivery of care. These findings create a basis for collecting patients' experiences in a repetitive fashion, intertwined with existing quality of care registries.
The American Academy of Pediatrics (AAP) believes that optimal pediatric health care depends on a team-based approach with supervision by a physician leader, preferably a pediatrician. The pediatrician, here defined to include not only pediatric generalists but all pediatric medical subspecialists, all surgical specialists, and internal medicine/pediatric physicians, is uniquely qualified to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment, in all practice settings. The AAP recognizes the valuable contributions of nonphysician clinicians, including nurse practitioners and physician assistants, in delivering optimal pediatric care. However, the expansion of the scope of practice of nonphysician pediatric clinicians raises critical public policy and child health advocacy concerns. Pediatricians should serve as advocates for optimal pediatric care in state legislatures, public policy forums, and the media and should pursue opportunities to resolve scope of practice conflicts outside state legislatures. The AAP affirms the importance of appropriate documentation and standards in pediatric education, training, skills, clinical competencies, examination, regulation, and patient care to ensure safety and quality health care for all infants, children, adolescents, and young adults.
Hasanin, Ahmed; Eladawy, Akram; Mohamed, Hossam; Salah, Yasmin; Lotfy, Ahmed; Mostafa, Hanan; Ghaith, Doaa; Mukhtar, Ahmed
The prevalence of extensively drug resistant gram negative bacilli (XDR-GNB) is rapidly progressing; however in Egypt data are sparse. We conducted the present study to quantify the incidence, risk factors and outcome of patients harboring XDR-GNB. A one year prospective study was done by collecting all the bacteriological reports for cultures sent from the surgical intensive care unit, Cairo university teaching hospital. XDR-GNB were defined as any gram negative bacilli resistant to three or more classes of antimicrobial agents. Patients with XDR-GNB compared with those sustaining non extensively drug-resistant infection. A multivariate logistic regression model was created to identify independent predictors of multi-resistance. During one-year study period, a total of 152 samples (65%) out of 234 gram negative bacilli samples developed extensively drug resistant infection. XDR strains were significantly higher in Acinetobacterspp (86%), followed by Pseudomonas (63%), then Proteus (61%), Klebsiella (52%), and E coli (47%). Fourth generation cephalosporine (Cefipime) had the lowest susceptibility (10%) followed by third generation cephalosporines (11%), Quinolones (31%), Amikacin (42%), Tazobactam (52%), Carbapinems (52%), and colistin (90%). Relaparotomy was the only significant risk factor for acquisition of XDR infection. Extensively drug-resistant gram negative infections are frequent in our ICU. This is an alarming health care issue in Egypt which emphasizes the need to rigorously implement infection control practices.
Williams, Mallory; Alban, Rodrigo F; Hardy, James P; Oxman, David A; Garcia, Edward R; Hevelone, Nathanael; Frendl, Gyorgy; Rogers, Selwyn O
Staff coverage strategies of intensive care units (ICUs) impact clinical outcomes. High-intensity staff coverage strategies are associated with lower morbidity and mortality. Accessible clinical expertise, team work, and effective communication have all been attributed to the success of this coverage strategy. We evaluate the impact of in-hospital fellow coverage (IHFC) on improving communication of cardiorespiratory events. A prospective observational study performed in an academic tertiary care center with high-intensity staff coverage. The main outcome measure was resident to fellow communication of cardiorespiratory events during IHFC vs home coverage (HC) periods. Three hundred twelve cardiorespiratory events were collected in 114 surgical ICU patients in 134 study days. Complete data were available for 306 events. One hundred three communication errors occurred. IHFC was associated with significantly better communication of events compared to HC (Pcommunicated 89% of events during IHFC vs 51% of events during HC (PCommunication patterns of junior and midlevel residents were similar. Midlevel residents communicated 68% of all on-call events (87% IHFC vs 50% HC, Pcommunicated 66% of events (94% IHFC vs 52% HC, PCommunication errors were lower in all ICUs during IHFC (Pcommunication errors. Copyright © 2014 Elsevier Inc. All rights reserved.
Huang, Wei-Chen; Chang, Shiow-Ru; Tang, Chi-Min
Our unit recorded 21 cases of pressure sores from January 2011 to June 2011. The resulting pressure-sore incidence density of 0.74% exceeded the Taiwan Clinical Performance Indicator (TCPI) for medical centers (0.62%) as well as the mean incidence density for our unit (0.55%) during the same period in 2010. We developed this project to decrease the incidence density of pressure sores at our pediatric-surgical-intensive-care unit from 0.74% to 0.31%. Strategies implemented included: 1. providing on-the-job education; 2. providing bedside teaching; 3. developing a series of pictures to illustrate proper sitting, lying, and changing positions and the proper fixation of catheters; 4. implementing a reminder mechanism; 5. introducing pressure-preventing devices; 6. and establishing an audit team. Incidence density decreased from 0.74% (Jan. to Jun. 2011) to 0.18% (Mar. to Jul. 2012). We demonstrated that the developed improvement program effectively reduced the incidence density of pressure sores and increased the quality of nursing care.
Simonaitis, Linas; Belsito, Anne; Cravens, Gary; Shen, Changyu; Overhage, J Marc
The goal of the Enhanced Medication History (EMH) project is to provide medication histories to ambulatory primary care practices in the Indiana Network for Patient Care. Medications were aggregated from three different sources of pharmacy data (Medicaid, SureScripts, and the county health system of Indianapolis). Dispensing events were assembled into the Continuity of Care Document (CCD), and presented to clinicians as RxNorm Clinical Drugs. The EMH project completed 46 weeks of operation in a community health center in Indianapolis. Medication Histories were generated for 10498 office visits for 4449 distinct patients. Seven (of nine) attending physicians responded to a written survey and found the Medication Histories useful (3.9±0.4 on a scale of 1 to 5). Implementation of the EMH project demonstrated the successful use (as well as the challenging aspects) of the CCD and the RxNorm terminology in the outpatient clinical setting.
Full Text Available The demand for new healthcare services is growing rapidly. Improving accessibility of the African population to diabetes care seems to be a big challenge in most countries where the number of care centers and medical staff is reduced. Information and communication technologies (ICT have great potential to address some of these challenges faced by several countries in providing accessible, cost-effective, and high-quality health care services. This paper presents the Mobil Diab system which is a telemedical approach proposed for the management of long-term diseases. The system applies modern mobile and web technologies which overcome geographical barriers, and increase access to health care services. The idea of the system is to involve patients in the therapy process and motivate them for an active participation. For validation of the system in African context, a trial was conducted in the Democratic Republic of Congo. 40 Subjects with diabetes divided randomly into control and intervention groups were included in the test. Results show that Mobil Diab is suitable for African countries and presents a number of benefits for the population and public health care system. It improves clinical management and delivery of diabetes care services by enhancing access, quality, motivation, reassurance, efficiency, and cost-effectiveness.
Upenieks, Valda V; Akhavan, Jaleh; Kotlerman, Jenny
Spiraling costs in health care have placed hospitals in a constant state of transition. As a result, nursing practice is now influenced by numerous factors and has remained in a continuous state of flux. Multiple changes within the last 2 decades in nurse/patient ratio and blend of front-line nurses are examples of this transition. To reframe the nursing practice into an economic equation that captures the cost, quality, and service, a paradigm shift in thinking is needed in order to assess work redesign. Nursing productivity must be evaluated in terms of value-added care, a vision that goes beyond direct care activities and includes team collaboration, physician rounding, increased RN-to-aide communication, and patient centeredness; all of which are crucial to the nurse's role and the patient's well-being. The science of appropriating staffing depends on assessment and implementation of systematic changes best illustrated through a "systems theory" framework. A throughput transformation is required to create process changes with input elements (number of front-line nurses) in order to increase time spent in value-added care and to decrease waste activities with an improvement in efficiency, quality, and service. The purpose of this pilot study was two-fold: (a) to gain an understanding of how much time RNs spent in value-added care, and (b) whether increasing the combined level of RNs and unlicensed assistive personnel increased the amount of time spent in value-added care compared to time spent in necessary tasks and waste.
Titaley Christiana R
Full Text Available Abstract Background Trained birth attendants at delivery are important for preventing both maternal and newborn deaths. West Java is one of the provinces on Java Island, Indonesia, where many women still deliver at home and without the assistance of trained birth attendants. This study aims to explore the perspectives of community members and health workers about the use of delivery care services in six villages of West Java Province. Methods A qualitative study using focus group discussions (FGDs and in-depth interviews was conducted in six villages of three districts in West Java Province from March to July 2009. Twenty FGDs and 165 in-depth interviews were conducted involving a total of 295 participants representing mothers, fathers, health care providers, traditional birth attendants and community leaders. The FGD and in-depth interview guidelines included reasons for using a trained or a traditional birth attendant and reasons for having a home or an institutional delivery. Results The use of traditional birth attendants and home delivery were preferable for some community members despite the availability of the village midwife in the village. Physical distance and financial limitations were two major constraints that prevented community members from accessing and using trained attendants and institutional deliveries. A number of respondents reported that trained delivery attendants or an institutional delivery were only aimed at women who experienced obstetric complications. The limited availability of health care providers was reported by residents in remote areas. In these settings the village midwife, who was sometimes the only health care provider, frequently travelled out of the village. The community perceived the role of both village midwives and traditional birth attendants as essential for providing maternal and health care services. Conclusions A comprehensive strategy to increase the availability, accessibility, and
Titaley, Christiana R; Hunter, Cynthia L; Dibley, Michael J; Heywood, Peter
Trained birth attendants at delivery are important for preventing both maternal and newborn deaths. West Java is one of the provinces on Java Island, Indonesia, where many women still deliver at home and without the assistance of trained birth attendants. This study aims to explore the perspectives of community members and health workers about the use of delivery care services in six villages of West Java Province. A qualitative study using focus group discussions (FGDs) and in-depth interviews was conducted in six villages of three districts in West Java Province from March to July 2009. Twenty FGDs and 165 in-depth interviews were conducted involving a total of 295 participants representing mothers, fathers, health care providers, traditional birth attendants and community leaders. The FGD and in-depth interview guidelines included reasons for using a trained or a traditional birth attendant and reasons for having a home or an institutional delivery. The use of traditional birth attendants and home delivery were preferable for some community members despite the availability of the village midwife in the village. Physical distance and financial limitations were two major constraints that prevented community members from accessing and using trained attendants and institutional deliveries. A number of respondents reported that trained delivery attendants or an institutional delivery were only aimed at women who experienced obstetric complications. The limited availability of health care providers was reported by residents in remote areas. In these settings the village midwife, who was sometimes the only health care provider, frequently travelled out of the village. The community perceived the role of both village midwives and traditional birth attendants as essential for providing maternal and health care services. A comprehensive strategy to increase the availability, accessibility, and affordability of delivery care services should be considered in these West Java
Hamm, L Lee; Hostetter, Thomas H; Shaffer, Rachel N
In 2012, 27 organizations will initiate participation in the Medicare Shared Savings Program as Accountable Care Organizations. This level of participation reflects the response of Centers for Medicare and Medicaid Services to criticism that the program as outlined in the proposed rule was overly burdensome, prescriptive, and too risky. Centers for Medicare and Medicaid Service made significant changes in the final rule, making the Accountable Care Organization program more attractive to these participants. However, none of these changes addressed the serious concerns raised by subspecialty societies-including the American Society of Nephrology-regarding care of patients with multiple chronic comorbidities and complex and end stage conditions. Virtually all of these concerns remain unaddressed, and consequently, Accountable Care Organizations will require guidance and partnership from the nephrology community to ensure that these patients are identified and receive the individualized care that they require. Although the final rule fell short of addressing the needs of patients with kidney disease, the Centers for Medicare and Medicaid Innovation presents an opportunity to test the potentially beneficial concepts of the Accountable Care Organization program within this patient population. The American Society of Nephrology Accountable Care Organization Task Force developed a set of principles that must be reflected in a possible pilot program or demonstration project of an integrated nephrology care delivery model. These principles include preserving a leadership role for nephrologists, encompassing care for patients with later-stage CKD and kidney transplants as well as ESRD, enabling the participation of a diversity of dialysis provider sizes and types, facilitating research, and establishing monitoring systems to identify and address preferential patient selection or changes in outcomes.
Walk, Ryan M; Donahue, Timothy F; Sharpe, Richard P; Safford, Shawn D
On January 12, 2010, Haiti experienced the western hemisphere's worst-ever natural disaster. Within 24 hours, the United States Naval Ship Comfort received orders to respond, and a group of more than 500 physicians, nurses, and staff undertook the largest and most rapid triage and treatment since the inception of hospital ships. These data represent pediatric surgical patients treated aboard the United States Naval Ship Comfort between January 19 and February 27, 2010. Prospective databases managed by patient administration, radiology, blood bank, laboratory services, and surgical services were combined to create an overall patient care database that was retrospectively reviewed for this analysis. Two hundred thirty-seven pediatric surgical patients were treated, representing 27% of the total patient population. These patients underwent a total of 213 operations composed of 243 unique procedures. Orthopedic procedures represented 71% of the total caseload. Patients returned to the operating room up to 11 times and required up to 28 days for completion of surgical management. This represents the largest cohort of pediatric surgical patients in an earthquake response. Our analysis provides a model for anticipating surgical caseload, injury patterns, and duration of surgical course in preparing for future disaster response missions. Moreover, we propose a 3-phased response to disaster medicine that has not been previously described. Published by Elsevier Inc.
Psek, Wayne; Davis, F. Daniel; Gerrity, Gloria; Stametz, Rebecca; Bailey-Davis, Lisa; Henninger, Debra; Sellers, Dorothy; Darer, Jonathan
Introduction: Healthcare leaders need operational strategies that support organizational learning for continued improvement and value generation. The learning health system (LHS) model may provide leaders with such strategies; however, little is known about leaders’ perspectives on the value and application of system-wide operationalization of the LHS model. The objective of this project was to solicit and analyze senior health system leaders’ perspectives on the LHS and learning activities in an integrated delivery system. Methods: A series of interviews were conducted with 41 system leaders from a broad range of clinical and administrative areas across an integrated delivery system. Leaders’ responses were categorized into themes. Findings: Ten major themes emerged from our conversations with leaders. While leaders generally expressed support for the concept of the LHS and enhanced system-wide learning, their concerns and suggestions for operationalization where strongly aligned with their functional area and strategic goals. Discussion: Our findings suggests that leaders tend to adopt a very pragmatic approach to learning. Leaders expressed a dichotomy between the operational imperative to execute operational objectives efficiently and the need for rigorous evaluation. Alignment of learning activities with system-wide strategic and operational priorities is important to gain leadership support and resources. Practical approaches to addressing opportunities and challenges identified in the themes are discussed. Conclusion: Continuous learning is an ongoing, multi-disciplinary function of a health care delivery system. Findings from this and other research may be used to inform and prioritize system-wide learning objectives and strategies which support reliable, high value care delivery. PMID:27683668
Steinthorsdottir, Kristin J; Kehlet, Henrik; Aasvang, Eske K
The immediate postoperative course in the post-anaesthesia care unit (PACU) remains a challenge across surgical procedures. Postoperative pain, sedation/cognitive dysfunction, nausea and vomiting (PONV), circulatory and respiratory problems and orthostatic intolerance constitute the bulk of the d...
Houdenhoven, van Mark; Oostrum, van Jeroen M.; Wullink, Gerhard; Hans, Erwin; Hurink, Johann L.; Bakker, Jan; Kazemier, Geert
Purpose: Mounting health care costs force hospital managers to maximize utilization of scarce resources and simultaneously improve access to hospital services. This article assesses the benefits of a cyclic case scheduling approach that exploits a master surgical schedule (MSS). An MSS maximizes ope
D. Talon; C. Rouget; V. Cailleaux; P. Bailly; M. Thouverez; F. Barale; Y. Michel-Briand
textabstractA six month prospective study was carried out in a surgical intensive care unit (SICU) of a university hospital to assess the incidence and routes of exogenous colonization by Staphylococcus aureus. A total of 157 patients were included in the study. One thousand one hundred and eleven s
Exarchopoulos, Themistocles; Charitidou, Efstratia; Dedeilias, Panagiotis; Charitos, Christos; Routsi, Christina
Most scoring systems used to predict clinical outcome in critical care were not designed for application in cardiac surgery patients. To compare the predictive ability of the most widely used scoring systems (Acute Physiology and Chronic Health Evaluation [APACHE] II, Simplified Acute Physiology Score [SAPS] II, and Sequential Organ Failure Assessment [SOFA]) and of 2 specialized systems (European System for Cardiac Operative Risk Evaluation [EuroSCORE] II and the cardiac surgery score [CASUS]) for clinical outcome in patients after cardiac surgery. Consecutive patients admitted to a cardiac surgical intensive care unit (CSICU) were prospectively studied. Data on the preoperative condition, intraoperative parameters, and postoperative course were collected. EuroSCORE II, CASUS, and scores from 3 general severity-scoring systems (APACHE II, SAPS II, and SOFA) were calculated on the first postoperative day. Clinical outcome was defined as 30-day mortality and in-hospital morbidity. A total of 150 patients were included. Thirty-day mortality was 6%. CASUS was superior in outcome prediction, both in relation to discrimination (area under curve, 0.89) and calibration (Brier score = 0.043, χ(2) = 2.2, P = .89), followed by EuroSCORE II for 30-day mortality (area under curve, 0.87) and SOFA for morbidity (Spearman ρ= 0.37 and 0.35 for the CSICU length of stay and duration of mechanical ventilation, respectively; Wilcoxon W = 367.5, P = .03 for probability of readmission to CSICU). CASUS can be recommended as the most reliable and beneficial option for benchmarking and risk stratification in cardiac surgery patients. ©2015 American Association of Critical-Care Nurses.
Niemeijer, Gerard C; Does, Ronald J M M; de Mast, Jeroen; Trip, Albert; van den Heuvel, Jaap
The purpose of this article is to create actionable knowledge, making the definition of process improvement projects in health care delivery more effective. This study is a retrospective analysis of process improvement projects in hospitals, facilitating a case-based reasoning approach to project definition. Data sources were project documentation and hospital-performance statistics of 271 Lean Six Sigma health care projects from 2002 to 2009 of general, teaching, and academic hospitals in the Netherlands and Belgium. Objectives and operational definitions of improvement projects in the sample, analyzed and structured in a uniform format and terminology. Extraction of reusable elements of earlier project definitions, presented in the form of 9 templates called generic project definitions. These templates function as exemplars for future process improvement projects, making the selection, definition, and operationalization of similar projects more efficient. Each template includes an explicated rationale, an operationalization in the form of metrics, and a prototypical example. Thus, a process of incremental and sustained learning based on case-based reasoning is facilitated. The quality of project definitions is a crucial success factor in pursuits to improve health care delivery. We offer 9 tried and tested improvement themes related to patient safety, patient satisfaction, and business-economic performance of hospitals.
D.F. de Korne (Dirk); J.C.A. Sol (Kees); T. Custers (Thomas); E. van Sprundel (Esther); B.M. van Ineveld (Martin); H.G. Lemij (Hans); N.S. Klazinga (Niek)
textabstractPurpose: The purpose of this paper is to explore in a specific hospital care process the applicability in practice of the theories of quality costing and value chains. Design/methodology/approach: In a retrospective case study an in-depth evaluation of the use of a quality cost model (QC
D.F. de Korne (Dirk); J.C.A. Sol (Kees); T. Custers (Thomas); E. van Sprundel (Esther); B.M. van Ineveld (Martin); H.G. Lemij (Hans); N.S. Klazinga (Niek)
textabstractPurpose: The purpose of this paper is to explore in a specific hospital care process the applicability in practice of the theories of quality costing and value chains. Design/methodology/approach: In a retrospective case study an in-depth evaluation of the use of a quality cost model
Armstrong, Melissa J; Mullins, C Daniel
Incorporation of patient values is a key element of patient-centered care, but consistent incorporation of patient values at the point of care is lacking. Shared decision making encourages incorporation of patient values in decision making, but associated tools often lack guidance on value assessment. In addition, focusing on patient values relating only to specific decisions misses an opportunity for a more holistic approach to value assessment that could impact other aspects of clinical encounters, including health care planning, communication, and stakeholder involvement. In this commentary, we propose a taxonomy of values underlying patient decision making and provide examples of how these impact provision of health care. The taxonomy describes four categories of patient values: global, decisional, situational, and external. Global values are personal values impacting decision making at a universal level and can include value traits and life priorities. Decisional values are the values traditionally conceptualized in decision making, including considerations such as efficacy, toxicity, quality of life, convenience, and cost. Situational values are values tied to a specific moment in time that modify patients' existing global and decisional values. Finally, discussion of external values acknowledges that many patients consider values other than their own when making decisions. Recognizing the breadth of values impacting patient decision making has implications for both overall health care delivery and shared decision making because value assessments focusing only on decisional values may miss important patient considerations. This draft taxonomy highlights different values impacting decision making and facilitates a more complete value assessment at the point of care. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.
Bachoura, Abdo; Guitton, Thierry G; Smith, R Malcolm; Vrahas, Mark S; Zurakowski, David; Ring, David
Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization rates, and increase healthcare costs. Additionally, patients with orthopaedic surgical-site infections (SSI) have substantially greater physical limitations and reductions in their health-related quality of life. However, the risk factors for SSI after operative fracture care are unclear. We determined the incidence and quantified modifiable and nonmodifiable risk factors for SSIs in patients with orthopaedic trauma undergoing surgery. We retrospectively indentified, from our prospective trauma database and billing records, 1611 patients who underwent 1783 trauma-related procedures between 2006 and 2008. Medical records were reviewed and demographics, surgery-specific data, and whether the patients had an SSI were recorded. We determined which if any variables predicted SSI. Six factors independently predicted SSI: (1) the use of a drain, OR 2.3, 95% CI (1.3-3.8); (2) number of operations OR 3.4, 95% CI (2.0-6.0); (3) diabetes, OR 2.1, 95% CI (1.2-3.8); (4) congestive heart failure (CHF), OR 2.8, 95% CI (1.3-6.5); (5) site of injury tibial shaft/plateau, OR 2.3, 95% CI (1.3-4.2); and (6) site of injury, elbow, OR 2.2, 95% CI (1.1-4.7). The risk factors for SSIs after skeletal trauma are most strongly determined by nonmodifiable factors: patient infirmity (diabetes and heart failure) and injury complexity (site of injury, number of operations, use of a drain). Level II, prognostic study. See the Guideline for Authors for a complete description of levels of evidence.
ROLANDO R. CRUZADA, JR.
Full Text Available This study focused on the determination of the delivery of services of day care workers in the municipality of Sta. Maria, Province of Laguna during the first semester of school year 2012-2013. Descriptive research was used in this study. Among the key findings were that Day Care Workers with respect to interactional relationship accomplished the functions with outstanding adequacy such as constantly giving feedback and praises on the performance of children, along with workers and parents coordination and cooperation, with verbal interpretation of Always Observe. In terms of instructional quality both group of respondents perceived that day care workers in-charge had adequate abilities and competencies concerning their education and trainings in connection with teaching small children with verbal interpretation of Always Observe. The parents had confidence to the day care workers in-charge of their children aside from regularly consulting the day care workers about their children’s progress with verbal interpretation of Always Observe. There were only 871 households who availed of the services of day care centers in which 27 workers were employed and each of them assigned to handle an average of 33 children. Notable along with other findings was the day care workers and parents had the same perception as to the extent of services provided by the Day Care Center with respect to interactional relationship, instructional quality and parental participation. Subsequently the study ensued with these five factual remarks: Children’s interactions with parents in the centers were the direct mechanisms through which children learn. The educational qualification and the capability of the day care workers to handle small children were the primary essentials in children’s learning. Parents’ participation in the day care centers premises brought harmonious relationship between the Day Care Workers and children as well. The capacity of day care worker
Noble, Anita; Rom, Miriam; Newsome-Wicks, Mona; Engelhardt, Kay; Woloski-Wruble, Anna
Many communities throughout the world, especially in the United States and Israel, contain large populations of religiously observant Jews. The purpose of this article is to provide a comprehensive, descriptive guide to specific laws, customs, and practices of traditionally, religious observant Jews for the culturally sensitive management of labor, delivery, and postpartum. Discussion includes intimacy issues between husband and wife, dietary laws, Sabbath observance, as well as practices concerning prayer, communication trends, modesty issues, and labor and birth customs. Health care professionals can tailor their practice by integrating their knowledge of specific cultures into their management plan.
tubal ligation , and myringotomy (Staff, 1984, July). Surgical Patients 25 This list was submitted to the Chiefs of the Department of Surgery and...capacity Surgical Patients 46 restricted to minimal care patients such as those with Acute Respiratory Disease Syndrome (ARDS). These wards were...the surgery and post -surgical healing is aided. And yet, in the military, lasers are seldom-used (there are none Surgical Patients 83 at RACR), and are
Frey, Rosemary; Boyd, Michal; Foster, Sue; Robinson, Jackie; Gott, Merryn
Organisational culture has been shown to impact on resident outcomes in residential aged care (RAC). This is particularly important given the growing number of residents with high palliative care needs. The study described herein (conducted from January 2013 to March 2014) examined survey results from a convenience sample of 46 managers, alongside interviews with a purposively selected sample of 23 bereaved family members in order to explore the perceptions of organisational culture within New Zealand RAC facilities in one large urban District Health Board. Results of the Organisational Culture Assessment Instrument (OCAI) completed by managers indicated a preference for a 'Clan' and the structured 'Hierarchy' culture. Bereaved family interviews emphasised both positive and negative aspects of communication, leadership and teamwork, and relationship with residents. Study results from both managers' OCAI survey scores and next of kin interviews indicate that while the RAC facilities are culturally oriented towards providing quality care for residents, they may face barriers to adopting organisational processes supportive of this goal.
J.M. Hartgerink (Jacqueline); J.M. Cramm (Jane); T.J.E.M. Bakker (Ton); J.P. Mackenbach (Johan); A.P. Nieboer (Anna)
markdownabstractAbstract Background:Older patients’experiences with care delivery may be important for their quality of life over time.Evidence is however lacking. Therefore, this study aims to identify the longitudinal relationship between older patients’experiences with hospital care, perceived
Jasper van der Slegt
Full Text Available BACKGROUND: Surgical site infections (SSI's are associated with severe morbidity, mortality and increased health care costs in vascular surgery. OBJECTIVE: To implement a bundle of care in vascular surgery and measure the effects on the overall and deep-SSI's rates. DESIGN: Prospective, quasi-experimental, cohort study. METHODS: A prospective surveillance for SSI's after vascular surgery was performed in the Amphia hospital in Breda, from 2009 through 2011. A bundle developed by the Dutch hospital patient safety program (DHPSP was introduced in 2009. The elements of the bundle were (1 perioperative normothermia, (2 hair removal before surgery, (3 the use of perioperative antibiotic prophylaxis and (4 discipline in the operating room. Bundle compliance was measured every 3 months in a random sample of surgical procedures and this was used for feedback. RESULTS: Bundle compliance improved significantly from an average of 10% in 2009 to 60% in 2011. In total, 720 vascular procedures were performed during the study period and 75 (10.4% SSI were observed. Deep SSI occurred in 25 (3.5% patients. Patients with SSI's (28,5±29.3 vs 10.8±11.3, p<0.001 and deep-SSI's (48.3±39.4 vs 11.4±11.8, p<0.001 had a significantly longer length of hospital stay after surgery than patients without an infection. A significantly higher mortality was observed in patients who developed a deep SSI (Adjusted OR: 2.96, 95% confidence interval 1.32-6.63. Multivariate analysis showed a significant and independent decrease of the SSI-rate over time that paralleled the introduction of the bundle. The SSI-rate was 51% lower in 2011 compared to 2009. CONCLUSION: The implementation of the bundle was associated with improved compliance over time and a 51% reduction of the SSI-rate in vascular procedures. The bundle did not require expensive or potentially harmful interventions and is therefore an important tool to improve patient safety and reduce SSI's in patients undergoing
Jørgensen, L; Garne, J P; Søgaard, M; Laursen, B S
A diagnosis of breast cancer is a key turning point in a woman's life that may lead to her experiencing severe and persistent distress and potentially presaging a psychiatric disorder, such as major depression. In Denmark an increased standardization of care and a short hospital stay policy minimize the time of medical and nursing surveillance. Consequently, there is the potential risk that distress goes unnoticed, and therefore, untreated. Therefore, the purpose of this study was to explore the experience of distress in Danish women taking part in surgical continuity of care for breast cancer. A phenomenological-hermeneutic approach inspired by the French philosopher Paul Ricoeur was conducted to explore the experience of distress in relation to surgical treatment and care for breast cancer. Semi-structured interviews were conducted with 12 women who recently had surgery for breast cancer at six departments of breast surgery in Denmark from May 2013 to November 2013. The understanding of the experience of distress in the period of surgical continuity of care for breast cancer is augmented and improved through a discussion related to four identified themes: A time of anxiety, loss of identities, being treated as a person and being part of a system, drawing on theory and other research findings. Distress experienced by women in the period following diagnosis arises from multiple sources. Support and care must be based on the woman's individual experience of distress. Copyright © 2015 Elsevier Ltd. All rights reserved.
Edoh, Thierry Oscar; Teege, Gunnar
One of the problems in health care in developing countries is the bad accessibility of medicine in pharmacies for patients. Since this is mainly due to a lack of organization and information, it should be possible to improve the situation by introducing information and communication technology. However, for several reasons, standard solutions are not applicable here. In this paper, we describe a case study in Benin, a West African developing country. We identify the problem and the existing obstacles for applying standard ECommerce solutions. We develop an adapted system approach and describe a practical test which has shown that the approach has the potential of actually improving the pharmaceutical care delivery. Finally, we consider the security aspects of the system and propose an organizational solution for some specific security problems.
For years, commentators have debated how to most appropriately allocate scarce medical resources over large populations. In this paper, I abstract the major rationing schema into three general approaches: rationing by price, quantity, and prioritization. Each has both normative appeal and considerable weakness. After exploring them, I present what some commentators have termed the "moral paradigm" as an alternative to broader philosophies designed to encapsulate the universe of options available to allocators (often termed the market, professional, and political paradigms). While not itself an abstraction of any specific viable rationing scheme, it provides a strong basis for the development of a new scheme that offers considerable moral and political appeal often absent from traditionally employed rationing schema. As I explain, the moral paradigm, in its strong, absolute, and uncompromising version, is economically untenable. This paper articulates a modified version of the moral paradigm that is pluralist in nature rather than absolute. It appeals to the moral, emotional, and irrational sensibilities of each individual person. The moral paradigm, so articulated, can complement any health care delivery system that policy-makers adopt. It functions by granting individuals the ability to appeal to an administrative adjudicatory board designated for this purpose. The adjudicatory board would have the expertise and power to act in response to the complaints of individual aggrieved patients, including those complaints that stem from the moral, religious, ethical, emotional, irrational, or other subjective positions of the patient, and would have plenary power to affirm the denial of access to medical care or to mandate the provision of such care. The board must be designed to facilitate its intended function while creating structural limitations on abuse of power and other excess. I make some specific suggestions on matters of structure and function in the hope of
Wood, Leanne; Buczkowski, Andrzej; Panton, Ormond M.N.; Sidhu, Ravi S.; Hameed, S. Morad
Background In July 2007, a large Canadian teaching hospital realigned its general surgery services into elective general surgery subspecialty-based services (SUBS) and a new urgent surgical care (USC) service (also know in the literature as an acute care surgery service). The residents on SUBS had their number of on-call days reduced to enable them to focus on activities related to SUBS. Our aim was to examine the effect of the creation of the USC service on the educational experiences of SUBS residents. Methods We enrolled residents who were on SUBS for the 6 months before and after the introduction of the USC service. We collected data by use of a survey, WEB eVAL and recorded attendance at academic half days. Our 2 primary outcomes were residents’ attendance at ambulatory clinics and compliance with the reduction in the number of on-call days. Our secondary outcomes included residents’ time for independent study, attendance at academic half days, operative experience, attendance at multidisciplinary rounds and overall satisfaction with SUBS. Results Residents on SUBS had a decrease in the mean number of on-call days per resident per month from 6.28 to 1.84 (p = 0.006), an increase in mean attendance at academic half days from 65% to 87% (p = 0.028), at multidisciplinary rounds (p = 0.002) and at ambulatory clinics and an increase in independent reading time (p = 0.015), and they reported an improvement in their work environment. There was no change in the amount of time residents spent in the operating room or in their overall satisfaction with SUBS. Conclusion Residents’ education in the SUBS structure was positively affected by the creation of a USC service. Compliance with the readjustment of on-call duties was high and was identified as the single most significant factor in enabling residents to take full advantage of the unique educational opportunities available only while on SUBS. PMID:20334744
Kuo Christina L
Full Text Available Abstract Background While physicians are key to primary preventive care, their delivery rate is sub-optimal. Assessment of physician beliefs is integral to understanding current behavior and the conceptualization of strategies to increase delivery. Methods A focus group with regional primary care physician (PCP Opinion Leaders was conducted as a formative step towards regional assessment of attitudes and barriers regarding preventive care delivery in primary care. Following the PRECEDE-PROCEED model, the focus group aim was to identify conceptual themes that characterize PCP beliefs and practices regarding preventive care. Seven male and five female PCPs (family medicine, internal medicine participated in the audiotaped discussion of their perceptions and behaviors in delivery of primary preventive care. The transcribed audiotape was qualitatively analyzed using grounded theory methodology. Results The PCPs' own perceived role in daily practice was a significant barrier to primary preventive care. The prevailing PCP model was the "one-stop-shop" physician who could provide anything from primary to tertiary care, but whose provision was dominated by the delivery of immediate diagnoses and treatments, namely secondary care. Conclusions The secondary-tertiary prevention PCP model sustained the expectation of immediacy of corrective action, cure, and satisfaction sought by patients and physicians alike, and, thereby, de-prioritized primary prevention in practice. Multiple barriers beyond the immediate control of PCP must be surmounted for the full integration of primary prevention in primary care practice. However, independent of other barriers, physician cognitive value of primary prevention in practice, a base mediator of physician behavior, will need to be increased to frame the likelihood of such integration.
Full Text Available Health related quality of life (HRQoL and the effect of selected socio-demographic and clinical intensive care variables on HRQoL of patients 12 months following adult surgical intensive care unit discharge in the Western Cape was evaluated. A prospective observational study was conducted. The sample comprised 46 patients who had survived 12 months following discharge. Structured telephonic interviews were conducted using a self-developed and SF-36v2 HRQoL questionnaire. Data was analyzed using Stastica 7 and values were accepted as significant at the 5% level. Low mean HRQoL domain scores (43% - 53% were found implying a poor HRQoL outcome. Physical functioning [43.5%], Role Play [44.5%] and Role Emotion [43.1%] scores were specifically lower than the other HRQoL domain scores. Age and severity of illness scores (APACHE II were significantly associated with the social functioning (p=0.01 and physical functioning (p=0.02 scores respectively. APACHE II may be a useful contributor in predicting long-term physical functioning outcomes in patients following surgical ICU discharge. The HRQoL outcomes are slightly lower than that found for inter-national ICU populations however responses in the domains affected are comparable. Low physical functioning, role play and role emotion scores indicate a need for further physical and emotional rehabilitation following surgical ICU discharge.
Full Text Available Background: Surgical site infections (SSIs still cause significant morbidity and mortality despite advances in trauma care. We have studied in this paper the rate of SSIs, their outcomes in patients undergoing interventions for trauma and SSI trends in developing countries. Materials and Methods: A 16-month study (May, 2011- August, 2012 was carried out. Patients undergoing interventions for orthopedic trauma were followed and assessed for SSIs and their outcomes and antimicrobial sensitivity patterns of the micro-organisms isolated were noted and correlated. Results: A total of 40 (4.4% confirmed cases of SSIs were identified among 852 patients of orthopedic trauma. Based on the new CDC criteria, after ruling out cellulitis, only 24 (2.6% were found to have SSIs. A total of 12.5% of the SSIs were detected during follow-up. Acinetobacter baumannii was the predominant organism as also Staphylococcus aureus. Outcomes observed included changes in antibiotic regime, revision surgery, readmission to hospital and deaths. Conclusion: SSI is prevalent in orthopaedic trauma patients and an active surveillance program will help in early management and prevention.
Imogie, A O; Agwubike, E O; Aluko, K
This study was conducted to assess the role of traditional birth attendants (TBAs) in modern health care delivery in Edo State, Nigeria. A total of 391 respondents comprising 48 TBAs, 309 childbearing mothers and 34 medical and para-medical professionals constituted the study sample. In-depth interviews and focus group discussions as well as validated questionnaires were the tools used for data collection. The results reveal that respondents believe that TBAs can play meaningful roles in family planning, screening of high-risk pregnant mothers, fertility/infertility treatment and maternal and child care services. Rural dwellers prefer to use the services of TBAs, as compared to their urban counterparts. Reasons for the preference included TBAs, availability, accessibility, cheap services and rural dwellers' faith in the efficacy of their services. There is, therefore, the need to restructure the training of TBAs as well as to fully integrate their services into the Nigerian orthodox healthcare delivery system especially as they affect rural settings.
Essary, Alison C; Wade, Nathaniel L
According to the most recent statistics from the National Center for Education Statistics, disparities in enrollment in undergraduate and graduate education are significant and not improving commensurate with the national population. Similarly, only 12% of graduating medical students and 13% of graduating physician assistant students are from underrepresented racial and ethnic groups. Established in 2012 to promote health care transformation at the organization and system levels, the School for the Science of Health Care Delivery is aligned with the university and college missions to create innovative, interdisciplinary curricula that meet the needs of our diverse patient and community populations. Three-year enrollment trends in the program exceed most national benchmarks, particularly among students who identify as Hispanic and American Indian/Alaska Native. The Science of Health Care Delivery program provides students a seamless learning experience that prepares them to be solutions-oriented leaders proficient in the business of health care, change management, innovation, and data-driven decision making. Defined as the study and design of systems, processes, leadership and management used to optimize health care delivery and health for all, the Science of Health Care Delivery will prepare the next generation of creative, diverse, pioneering leaders in health care.
Anthea M Burnett
Full Text Available Background: Routine eye and vision assessments are vital for the detection and subsequent management of vision loss, which is particularly important for Aboriginal and Torres Strait Islander people, who face higher rates of vision loss than other Australians. In order to guide improvements, this paper will describe patterns, variations and gaps in these eye and vision assessments for Aboriginal and Torres Strait Islander people. Methods: Clinical audits from 124 primary health care centres (sample size 15,175 from five Australian States and Territories were conducted during 2005-2012. Main outcome measure was adherence to current guidelines for delivery of eye and vision assessments to adults with diabetes, those without a diagnosed major chronic disease and children attending primary health care centres. Results: Overall delivery of recommended eye and vision assessments varied widely between health centres. Of the adults with diabetes, 45% had a visual acuity assessment recorded within the previous 12 months (health centre range 0-88%, and 33% had a retinal examination recorded (health centre range 0-73%. Of the adults with no diagnosed major chronic disease, 31% had a visual acuity assessment recorded within the previous two years (health centre range 0-30%, and 13% had received an examination for trichiasis (health centre range 0-40%. In children, 49% had a record of a vision assessment (health centre range 0-97%, and 25% had a record of an examination for trachoma within the previous 12 months (health centre range 0-63%. Conclusions: There was considerable range, and variation in the recorded delivery of scheduled eye and vision assessments across health centres. Sharing the successful strategies of the better-performing health centres to support focused improvements in key areas of need may increase overall rates of eye examinations – important for the timely detection, referral and treatment of eye conditions affecting Aboriginal and
Urich, A; Maier, R R J; Yu, Fei; Knight, J C; Hand, D P; Shephard, J D
We present the delivery of high energy microsecond pulses through a hollow-core negative-curvature fiber at 2.94 µm. The energy densities delivered far exceed those required for biological tissue manipulation and are of the order of 2300 J/cm(2). Tissue ablation was demonstrated on hard and soft tissue in dry and aqueous conditions with no detrimental effects to the fiber or catastrophic damage to the end facets. The energy is guided in a well confined single mode allowing for a small and controllable focused spot delivered flexibly to the point of operation. Hence, a mechanically and chemically robust alternative to the existing Er:YAG delivery systems is proposed which paves the way for new routes for minimally invasive surgical laser procedures.
Haider, Adil H; Schneider, Eric B; Sriram, N; Dossick, Deborah S; Scott, Valerie K; Swoboda, Sandra M; Losonczy, Lia; Haut, Elliott R; Efron, David T; Pronovost, Peter J; Lipsett, Pamela A; Cornwell, Edward E; MacKenzie, Ellen J; Cooper, Lisa A; Freischlag, Julie A
, 0.66 [95% CI, 0.57-0.75]) relative to men (mean IAT D scores, 0.44 [95% CI, 0.37-0.52] and 0.82 [95% CI, 0.75-0.89], respectively). In univariate analyses, we found an association between race/social class bias and 3 of 27 possible patient-care decisions. Multivariable analyses revealed no association between the IAT D scores and vignette-based clinical assessments. Unconscious social class and race biases were not significantly associated with clinical decision making among acute care surgical clinicians. Further studies involving real physician-patient interactions may be warranted.
Cloyes, Kristin G.; Rosenkranz, Susan J.; Supiano, Katherine P.; Berry, Patricia H.; Routt, Meghan; Llanque, Sarah M.; Shannon-Dorcy, Kathleen
The increasing numbers of aging and chronically ill prisoners incarcerated in Western nations is well documented, as is the growing need for prison-based palliative and end-of-life care. Less often discussed is specifically how end-of-life care can and should be provided, by whom, and with what resources. One strategy incorporates prisoner volunteers into end-of-life services within a peer care program. This article reports on one such program based on focused ethnographic study including in-depth interviews with inmate hospice volunteers, nursing staff, and corrections officers working in the hospice program. We describe how inmate volunteers learn hospice care through formal education and training, supervised practice, guidance from more experienced inmates, and support from correctional staff. We discuss how emergent values of mentorship and stewardship are seen by volunteers and staff as integral to prison hospice sustainability and discuss implications of this volunteer-centric model for response-ability for the end-of-life care of prisoners. PMID:28100141
Trujillo, Juan C; Carrillo, Bladimir; Iglesias, Wilman J
The determinants of maternal and child health have been the recurrent topics of study in developing countries. Using the Demographic and Health Survey (2010) of Colombia, this study aimed to identify the determinants for professional antenatal care and institutional delivery, taking into account the interdependence of these two decisions, which we consider using a bivariate probit model. This study found that when certain factors affecting both the decision to seek prenatal care and giving birth in a hospital are neglected, the results of the estimates are inefficient. Estimates show that the effects of education, parity, regional location and economic status on institutional delivery tend to be underestimated in a univariate probit model. The results indicate that economic status, level of education, parity and medical-insurance affiliation influenced the joint likelihood of accessing professional antenatal care and delivering in a health facility. An important finding is that mothers with a higher level of education are 9 percentage points more likely to access these two health services compared with mothers who are illiterate. Another observed finding is the regional disparities. The evidence indicates that mothers in the Pacific Region, the poorest region of Colombia, are 6 percentage points less likely to access such services. Thus, the results indicate that the Colombian health policy should emphasize increasing the level of schooling of mothers and establish health facilities in the poorest regions of the country to ensure that women in need are provided with social health insurance. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2013; all rights reserved.
Full Text Available The Tamil Nadu model of public health is renowned for its success in providing quality health services at an affordable cost especially to the rural people. Tamil Nadu is the only state with a distinctive public health cadre in the district level and also the first state to enact a Public Health Act in 1939. Tamil Nadu has gained significant ground in the various aspects of health in the last few decades largely because of the significant reforms in its health sector which dates back to 1980s which saw rigorous expansion of rural health infrastructure in the state besides deployment of thousands of multipurpose health workers as village health nurses in rural areas. Effective implementation of Universal Immunization Programme, formation of Tamil Nadu Medical Services Corporation for regulating the drug procurement and promoting generic drugs, early incorporation of indigenous system of medicine into health care service, formulation of a health policy in 2003 by the state with special emphasis on low-income, disadvantaged communities alongside efficient implementation of The Tamil Nadu Health Systems Project (TNHSP are the major factors which contributed for the success of the state. The importance of good political commitment and leadership in the health gains of the state warrants special mention. Moreover, the economic growth of the state, improved literacy rate, gender equality, and lowered fertility rate in the last few decades and contributions from the private sector have their share in the public health success of the state. In spite of some flaws and challenges, the Tamil Nadu Model remains the prototype health care delivery system in resource-limited settings which can be emulated by other states also toward a better health care delivery system.
Parthasarathi, R; Sinha, S P
The Tamil Nadu model of public health is renowned for its success in providing quality health services at an affordable cost especially to the rural people. Tamil Nadu is the only state with a distinctive public health cadre in the district level and also the first state to enact a Public Health Act in 1939. Tamil Nadu has gained significant ground in the various aspects of health in the last few decades largely because of the significant reforms in its health sector which dates back to 1980s which saw rigorous expansion of rural health infrastructure in the state besides deployment of thousands of multipurpose health workers as village health nurses in rural areas. Effective implementation of Universal Immunization Programme, formation of Tamil Nadu Medical Services Corporation for regulating the drug procurement and promoting generic drugs, early incorporation of indigenous system of medicine into health care service, formulation of a health policy in 2003 by the state with special emphasis on low-income, disadvantaged communities alongside efficient implementation of The Tamil Nadu Health Systems Project (TNHSP) are the major factors which contributed for the success of the state. The importance of good political commitment and leadership in the health gains of the state warrants special mention. Moreover, the economic growth of the state, improved literacy rate, gender equality, and lowered fertility rate in the last few decades and contributions from the private sector have their share in the public health success of the state. In spite of some flaws and challenges, the Tamil Nadu Model remains the prototype health care delivery system in resource-limited settings which can be emulated by other states also toward a better health care delivery system.
Full Text Available Background: Health system should be organized to meet the needs of entire population of the nation. This means that the state has the direct responsibility for the health of its population and improving the quality of life through research, education, and provision of health services. The present study was conducted to evaluate the government oral health care delivery system in Haryana, India. Materials and Methods: The present cross-sectional study was conducted among 135 dental care units (DCUs of various primary health centers (PHCs, community health centers (CHCs, and general hospitals (GHs existing in the state by employing a cluster random sampling technique. Data regarding the provision of water and electricity supply, dental man power and their qualification, number and type of instruments in the dental operatory unit, etc., were collected on a structured format. Statistical analysis was done using number and percentages (SPSS package version 16. Results: Alternative source of electricity (generator existed in only a few of health centers. About 93.4% (155 of the staff were graduates (BDS and 6.6% (11 were postgraduates (MDS. Ultrasonic scaler was available at dental units of 83.1% (64 of PHCs, 73.1% (19 of CHCs, and 93.8% (30 of GHs. Patient drapes were provided in 48.1% (65 of the DCUs, doctor′s aprons were provided in 74.1% (100 of the places. Conclusion: There is a shortfall in infrastructure and significant problem with the adequacy of working facilities. A great deal of effort is required to harmonize the oral health care delivery system.
Paul A Bourne
Full Text Available Paul A Bourne1, Chloe Morris1, Christopher AD Charles2, Maureen D Kerr-Campbell3, Denise Eldemire-Shearer11Department of Community Health and Psychiatry and 2King Graduate School, Monroe College, Bronx, and Center for Victim Support, Harlem Hospital Center, New York; 3Systems Development Unit, Main Library, Faculty of Humanities and Education, The University of the West Indies, Mona, JamaicaAbstract: Patient satisfaction and quality of life are becoming increasingly important among the more traditional clinical outcomes in the monitoring and evaluation of health care delivery. This study explored patient’s self-rated health and patient satisfaction with health care providers, and examined whether health care providers are a barrier to patient care. The sample consisted of 2000 men aged 55 years and older in the parish of St Catherine, Jamaica. A 132-item questionnaire was used to collect the data. Descriptive statistics was used to provide information about their satisfaction with the health care system. Seventy-four percent of the sample indicated good self-rated health status (excellent, 19.0%. Forty-seven percent of the sample had sought advice from a health care provider in the last 12 months; 14.1% understood the advice of the clinician, community health aide (19.9%, pharmacist (15.4%, nurse (2.1% and nurse aide (4.6%. The respondents indicated that community health aides contributed more to improving their health (43.4% when compared with nurses (34.8%, clinicians (17.5%, and herbalists (3.7%. Furthermore, 31.7% indicated that their medical doctors were hospitable and 4.2% were knowledgeable. Negative self-rated health, perceived lack of knowledge among doctors, lack of understanding of advice from health care providers, are just some of the factors associated with dissatisfaction of patients with chronic conditions. These findings provide a framework and foundation from which further studies on effective intervention aimed at
Background Many western countries have policies of dispersal and direct provision accommodation (state-funded accommodation in an institutional centre) for asylum seekers. Most research focuses on its effect on the asylum seeking population. Little is known about the impact of direct provision accommodation on organisation and delivery of local primary care and social care services in the community. The aim of this research is to explore this issue. Methods In 2005 a direct provision accommodation centre was opened in a rural area in Ireland. A retrospective qualitative case study was designed comprising in-depth interviews with 37 relevant stakeholders. Thematic analysis following the principles of framework analysis was applied. Results There was lack of advance notification to primary care and social care professionals and the community about the new accommodation centre. This caused anxiety and stress among relevant stakeholders. There was insufficient time to plan and prepare appropriate primary care and social care for the residents, causing a significant strain on service delivery. There was lack of clarity about how primary care and social care needs of the incoming residents were to be addressed. Interdisciplinary support systems developed informally between healthcare professionals. This ensured that residents of the accommodation centre were appropriately cared for. Conclusions Direct provision accommodation impacts on the organisation and delivery of local primary care and social care services. There needs to be sufficient advance notification and inter-agency, inter-professional dialogue to manage this. Primary care and social care professionals working with asylum seekers should have access to training to enhance their skills for working in cross-cultural consultations. PMID:21575159
Abstract Background Many western countries have policies of dispersal and direct provision accommodation (state-funded accommodation in an institutional centre) for asylum seekers. Most research focuses on its effect on the asylum seeking population. Little is known about the impact of direct provision accommodation on organisation and delivery of local primary care and social care services in the community. The aim of this research is to explore this issue. Methods In 2005 a direct provision accommodation centre was opened in a rural area in Ireland. A retrospective qualitative case study was designed comprising in-depth interviews with 37 relevant stakeholders. Thematic analysis following the principles of framework analysis was applied. Results There was lack of advance notification to primary care and social care professionals and the community about the new accommodation centre. This caused anxiety and stress among relevant stakeholders. There was insufficient time to plan and prepare appropriate primary care and social care for the residents, causing a significant strain on service delivery. There was lack of clarity about how primary care and social care needs of the incoming residents were to be addressed. Interdisciplinary support systems developed informally between healthcare professionals. This ensured that residents of the accommodation centre were appropriately cared for. Conclusions Direct provision accommodation impacts on the organisation and delivery of local primary care and social care services. There needs to be sufficient advance notification and inter-agency, inter-professional dialogue to manage this. Primary care and social care professionals working with asylum seekers should have access to training to enhance their skills for working in cross-cultural consultations.
Otolorin, Emmanuel; Gomez, Patricia; Currie, Sheena; Thapa, Kusum; Dao, Blami
Approximately 15% of expected births worldwide will result in life-threatening complications during pregnancy, delivery, or the postpartum period. Providers skilled in emergency obstetric and newborn care (EmONC) services are essential, particularly in countries with a high burden of maternal and newborn mortality. Jhpiego and its consortia partners have implemented three global programs to build provider capacity to provide comprehensive EmONC services to women and newborns in these resource-poor settings. Providers have been educated to deliver high-impact maternal and newborn health interventions, such as prevention and treatment of postpartum hemorrhage and pre-eclampsia/eclampsia and management of birth asphyxia, within the broader context of quality health services. This article describes Jhpiego's programming efforts within the framework of the basic and expanded signal functions that serve as indicators of high-quality basic and emergency care services. Lessons learned include the importance of health facility strengthening, competency-based provider education, global leadership, and strong government ownership and coordination as essential precursors to scale-up of high impact evidence-based maternal and newborn interventions in low-resource settings.
Most poor countries have a large and growing private medical sector. Evidence suggests that a large proportion of tuberculosis patients in many high TB- burden countries first approach a private health care provider. Further, private providers manage a significant proportion of tuberculosis cases. Surprisingly though, there is virtually no published evidence on linking private providers to tuberculosis programmes. As a part of global efforts to control tuberculosis through effective DOTS implementation, the World Health Organization has recently begun addressing the issue of private providers in TB control through an evolving global strategy. As a first step, a global assessment of private providers' participation in tuberculosis programmes was undertaken. The findings of the assessment were discussed and debated in a consultation involving private practitioners, TB programme managers and policy makers. Their recommendations have contributed to the evolving global strategy called Public-Private Mix for DOTS implementation (PPM DOTS). This paper presents the guiding principles of PPM DOTS and major elements of the global strategy. These include: informed advocacy; setting-up "learning projects"; scaling-up successful projects and formulation of regional, national and local strategies; developing practical tools to facilitate PPM DOTS and pursuing an operational research agenda to help better design and shape PPM DOTS strategies. Encouraging results from some ongoing project sites are discussed. The paper concludes that concerted global efforts and local input are required for a sustained period to help achieve productive engagement of private practitioners in DOTS implementation. Such efforts have to be targeted as much towards national tuberculosis programmes as towards private providers and their associations. Continued apathy in this area could not only potentially delay achieving global targets for TB control but also undo, in the long run, the hard
... in place to control the advance of your baby's head. Forceps deliveries aren't always successful. If your health care ... com. Accessed June 12, 2015. You and your baby: Prenatal care, labor and delivery, and postpartum care. Washington, D.C.: The American ...
Sosa-Rubí, Sandra G; Walker, Dilys; Serván, Edson; Bautista-Arredondo, Sergio
BACKGROUND The Mexican programme Oportunidades/Progresa conditionally transfers money to beneficiary families. Over the past 10 years, poor rural women have been obliged to attend antenatal care (ANC) visits and reproductive health talks. We propose that the length of time in the programme influences women's preferences, thus increasing their use not only of services directly linked to the cash transfers, but also of other services, such as clinic-based delivery, whose utilization is not obligatory. OBJECTIVE To analyse the long-term effect of Oportunidades on women's use of antenatal and delivery care. METHODOLOGY 5051 women aged between 15 and 49 years old with at least one child aged less than 24 months living in rural localities were analysed. Multilevel probit and logit models were used to analyse ANC visits and physician/nurse attended delivery, respectively. Models were adjusted with individual and socio-economic variables and the locality's exposure time to Oportunidades. Findings On average women living in localities with longer exposure to Oportunidades report 2.1% more ANC visits than women living in localities with less exposure. Young women aged 15-19 and 20-24 years and living in localities with longer exposure to Oportunidades (since 1998) have 88% and 41% greater likelihood of choosing a physician/nurse vs. traditional midwife for childbirth, respectively. Women of indigenous origin are 68.9% less likely to choose a physician/nurse for delivery care than non-indigenous women. CONCLUSIONS An increase in the average number of ANC visits has been achieved among Oportunidades beneficiaries. An indirect effect is the increased selection of a physician/nurse for delivery care among young women living in localities with greater exposure time to Oportunidades. Disadvantaged women in Mexico (indigenous women) continue to have less access to skilled delivery care. Developing countries must develop strategies to increase access and use of skilled obstetric
Full Text Available Background: In Tanzania, a country of 42 million, access to oral morphine is rare.Aim: To demonstrate the effectiveness of palliative care teams in reducing patients’ pain and in increasing other positive life qualities in the absence of morphine; and to document the psychological burden experienced by their clinical providers, trained in morphine delivery, as they observed their patients suffering and in extreme pain.Setting: One hundred and forty-fie cancer patients were included from 13 rural hospitals spread across Tanzania.Method: A mixed method study beginning with a retrospective quantitative analysis of cancer patients who were administered the APCA African POS tool four times. Bivariate analyses of the scores at time one and four were compared across the domains. The qualitative arm included an analysis of interviews with six nurses, each with more than fie years’ palliative care experience and no access to strong opioids.Results: Patients and their family caregivers identifid statistically signifiant (p < 0.001 improvements in all of the domains. Thematic analysis of nurse interviews described the patient and family benefis from palliative care but also their great distress when ‘bad cases’ arose who would likely benefi only from oral morphine.Conclusion: People living with chronic cancer-related pain who receive palliative care experience profound physical, spiritual and emotional benefis even without oral morphine. These results demonstrate the need for continued advocacy to increase the availability of oral morphine in these settings in addition to palliative care services.
Full Text Available AIM OF THE STUDY To identify infection rates and risk factors associated with Surgical Site Infection (SSI following Caesarean Section. DESIGN OF THE STUDY Case control study. PLACE OF STUDY Academic Tertiary Care Obstetrics and Gynaecology Centre with 60 Beds. PATIENTS All women who delivered by caesarean section in Govt. Medical College, Thrissur, during 1st June 2010 to 30th September 2011. METHODS Wound infections were identified during hospital stay using the criteria of the Centres for Disease Control and Prevention, National Nosocomial Infections Surveillance System. A case control study of 50 patients with wound infection after Lower Segment Caesarean Section (LSCS was undertaken between 1st June 2010 and 30th September 2011. The control group comprised of 50 patients selected randomly from among those who had LSCS during the study period with no wound infection. The CDC definition describes three levels of SSI (Superficial incisional, Deep incisional and Organ or Space infection. Comparisons for categorical variables were performed using the X2 or Fisher exact test. Continuous variables were compared using the 2-tailed Student ‘t’ test and p 0.05 was considered significant. RESULTS The overall wound infection rate in the study was 3.5%, (50 among 1410 Lower Transverse CS. Obesity, Hypertension and Poorly Controlled Diabetes are associated with significant risk for development of SSI. The commonest presentation of SSI in LSCS was fever 40 (80% followed by local pain and induration 25 (50%. SSI was detected on 6±3 days. Average duration of hospital stay among SSI was 22.78±10.2 days. Staphylococcus aureus was the commonest pathogen for SSI in our series. The increase in the presence of (Methicillin Resistant Staphylococcus Aureus MRSA (20.83% might alter the pattern of prophylactic antibiotic given preoperatively in the near future. CONCLUSIONS Increased incidence of drug resistant organisms needs proper attention and strategies for
Taufiq, Intikhab; Najjad, Muhammad Kazim Raheem; Khan, Naveed; Zia, Osama Bin
Purpose Acetabular fractures are mainly caused by trauma and the incidence is rising in developing countries. Initially these fractures were managed conservatively, due to lack of specialized and dedicated acetabulum surgery centres. Our aim is to study the radiological and functional outcomes of surgical management of acetabular fractures in tertiary care hospital. Materials and Methods Total 50 patients were enrolled. The patients with acetabular fractures were enrolled between the years 2012 to 2014. Patients were evaluated clinically with Harris hip score (HHS) and radiologically with Matta outcome grading. The factors examined include age, gender, fracture pattern, time between injury and surgery, initial displacement and quality of reduction on the final outcome. Results There were 34 males and 16 females. Mean age was 44.20±11.65 years while mean duration of stay was 9.28±2.36 days. Duration of follow-up was 24 months. Most common mechanism of injury was motor vehicle accident (n=37, 74.0%). Open reduction and internal fixation of fractures were performed using reconstruction plates. Mean HHS at 24 months was 82.36±8.55. The clinical outcome was acceptable (excellent or good) in 35 (70.0%) cases and not acceptable (fair or poor) in 15 (30.0%) cases. The radiological outcome was anatomical in 39 (78.0%) cases, congruent in 5 (10.0%) cases, incongruent in 6 (12.0%) cases. Conclusion Study results indicated that mechanism of injury, time between injury and surgery, initial degree of displacement and quality of reduction had significant effect on functional as well as radiological outcome. PMID:28097111
Chavira, Denise A; Drahota, Amy; Garland, Ann F; Roesch, Scott; Garcia, Maritza; Stein, Murray B
In this study, we examine the feasibility of cognitive behavior therapy (CBT) for children with anxiety in primary care, using two modes of treatment delivery. A total of 48 parents and youth (8-13) with anxiety disorders were randomly assigned to receive 10-sessions of CBT either delivered by a child anxiety specialist in the primary care clinic or implemented by the parent with therapist support by telephone (i.e., face-to-face or therapist-supported bibliotherapy). Feasibility outcomes including satisfaction, barriers to treatment participation, safety, and dropout were assessed. Independent evaluators, blind to treatment condition, administered the Anxiety Disorders Interview Schedule for Children (ADIS) and the Clinical Global Impression of Improvement (CGI-I) at baseline, post-treatment and 3-month follow-up; clinical self-report questionnaires were also administered. Findings revealed high satisfaction, low endorsement of barriers, low drop out rates, and no adverse events across the two modalities. According to the CGI-I, 58.3%-75% of participants were considered responders (i.e., much or very much improved) at the various time points. Similar patterns were found for remission from "primary anxiety disorder" and "all anxiety disorders" as defined by the ADIS. Clinically significant improvement was seen on the various parent and child self-report measures of anxiety. Findings suggest that both therapy modalities are feasible and associated with significant treatment gains in the primary care setting. (clinicaltrials.gov unique identifier: NCT00769925).
de Matos Deslandes, Anna Karina; Aguiar, Simone; Neto, Mercedes; Porto, Fernando Rocha
to analyze the images of Public Health Nurses in care delivery to society, disseminated by the Revista da Semana, in 1929. historical-semiotic study. The documents used were images, to which an analysis matrix was applied, including fashion and body language literature, besides others to address the study object. The data were interpreted in the light of the sociologist Pierre Bourdieu's notions of object representations and body hexis. the distinctive use of uniforms for the Public Health Nurses' activities was a non-verbal communication strategy to gain visibility and credibility during home visits . Public Health Nurses were particularly responsible for patient care and guidance to prevent illnesses, with a view to the qualitative development of Public Health. The intent in this study was to produce knowledge on image records about nurses' care practice at the National Public Health Department's School of Nurses, as well as to strengthen Public Health Nursing History research in Brazil, thus contributing to a better understanding about the construction process of nurses' image.
Sobolewski, S; Marren, J
The strategy undertaken by the VNSNY for its survival has been to create a new service delivery model. The design of the SDM is based on a study of organizations, within and outside of health care, that face common challenges in the home health industry today: increased competition, declining reimbursement with escalating costs, and demands for improved outcomes and customer satisfaction. The model that emerged contained several important strategies in its design, including the alignment of team goals with organizational strategic objectives, restructuring teams as multidisciplinary units, redefining the work of teams to include practice improvement and supporting team learning, increasing members' accountability for team not individual performance. The SDM continues to evolve and improve during the process of implementation as lessons emerge from our experience with teams. Preliminary results indicate that the efforts have begun to show improvements in outcomes.
MacPherson, Peter; Munthali, Chigomezgo; Ferguson, Jane; Armstrong, Alice; Kranzer, Katharina; Ferrand, Rashida A; Ross, David A
Adolescents living with HIV face substantial difficulties in accessing HIV care services and have worse treatment outcomes than other age groups. The objective of this review was to evaluate the effectiveness of service delivery interventions to improve adolescents' linkage from HIV diagnosis to antiretroviral therapy (ART) initiation, retention in HIV care and adherence to ART. We systematically searched the Medline, SCOPUS and Web of Sciences databases and conference abstracts from the International AIDS Conference and International Conference on AIDS and STIs in Africa (ICASA). Studies published in English between 1st January 2001 and 9th June 2014 were included. Two authors independently evaluated reports for eligibility, extracted data and assessed methodological quality using the Cochrane risk of bias tool and Newcastle-Ottawa Scale. Eleven studies from nine countries were eligible for review. Three studies were randomised controlled trials. Interventions assessed included individual and group counselling and education; peer support; directly observed therapy; financial incentives; and interventions to improve the adolescent-friendliness of clinics. Most studies were of low to moderate methodological quality. This review identified limited evidence on the effectiveness of service delivery interventions to support adolescents' linkage from HIV diagnosis to ART initiation, retention on ART and adherence to ART. Although recommendations are qualified because of the small numbers of studies and limited methodological quality, offering individual and group education and counselling, financial incentives, increasing clinic accessibility and provision of specific adolescent-tailored services appear promising interventions and warrant further investigation. © 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
Ellner, Andrew L; Stout, Somava; Sullivan, Erin E; Griffiths, Elizabeth P; Mountjoy, Ashlin; Phillips, Russell S
Challenged by demands to reduce costs and improve service delivery, the U.S. health care system requires transformational change. Health systems innovation is defined broadly as novel ideas, products, services, and processes-including new ways to promote healthy behaviors and better integrate health services with public health and other social services-which achieve better health outcomes and/or patient experience at equal or lower cost. Academic health centers (AHCs) have an opportunity to focus their considerable influence and expertise on health systems innovation to create new approaches to service delivery and to nurture leaders of transformation. AHCs have traditionally used their promotions criteria to signal their values; creating a health systems innovator promotion track could be a critical step towards creating opportunities for innovators in academic medicine. In this Perspective, the authors review publicly available promotions materials at top-ranked medical schools and find that while criteria for advancement increasingly recognize systems innovation, there is a lack of specificity on metrics beyond the traditional yardstick of peer-reviewed publications. In addition to new promotions pathways and alternative evidence for the impact of scholarship, other approaches to fostering health systems innovation at AHCs include more robust funding for career development in health systems innovation, new curricula to enable trainees to develop skills in health systems innovation, and new ways for innovators to disseminate their work. AHCs that foster health systems innovation could meet a critical need to contribute both to the sustainability of our health care system and to AHCs' continued leadership role within it.
Calisti, Alessandro; Belay, Kibreab; Mazzoni, Guglielmo; Fiocca, Guido; Retrosi, Giuseppe; Olivieri, Claudio
Access to pediatric surgical care in many sub-Saharan African countries is strongly limited by lack of medical facilities, adequate transport system, and trained medical and nursing manpower. The mortality rate for major congenital abnormalities remains extremely elevated in this area of the world. Strong efforts have been spent during the past decades to elevate the level of pediatric surgery standards in these countries through cooperation programs acting through periodical medical missions or supporting local medical teaching institutions. This is a report of a partnership between an Italian Medical Institution and the Eritrean Ministry of Health with the goal to improve pediatric surgical standard of care in the country. During the past 4 years, teams composed of two pediatric surgeons, a pediatric anesthetist, and a pediatric nurse regularly visited the Orotta Medical and Surgical Referral Hospital of Asmara (Eritrea) to offer modern surgical treatment to children with major congenital abnormalities and to offer academic training to local medical and nursing staff. The team worked in local health structures. A total of 714 patients have been visited and 430 surgical procedures have been performed during 35 weeks of clinical work. Among them were 32 anorectal malformations, 11 Hirschsprung's disease cases, 8 bladder extrophies, and many other major surgical problems, such as congenital intestinal obstructions, obstructive uropathies, and solid tumors. The standard of care has been based on the principle of researching sustainable solutions. Surgical options and timing of each procedure have been decided to reduce hospitalization and the recourse to temporary stomas, indwelling catheterization, and prolonged intravenous feeding. Posterior sagittal anorectoplasties (PSARP) and posterior vagino-anorectoplasty (PSVARP) were performed for anorectal malformations, introducing minimal technical variants to reduce the need for postoperative nursing. Endorectal pull
Landry, Craig M; Jackson, Aurora P; Tang, Lingqi; Miranda, Jeanne; Chung, Bowen; Jones, Felica; Ong, Michael K; Wells, Kenneth
This study examined the effects of a depression care quality improvement (QI) intervention implemented by using Community Engagement and Planning (CEP), which supports collaboration across health and community-based agencies, or Resources for Services (RS), which provides technical assistance, on training participation and service delivery by primarily unlicensed, racially and ethnically diverse case managers in two low-income communities in Los Angeles. The study was a cluster-randomized trial with program-level assignment to CEP or RS for implementation of a QI initiative for providing training for depression care. Staff with patient contact in 84 health and community-based programs that were eligible for the provider outcomes substudy were invited to participate in training and to complete baseline and one-year follow-up surveys; 117 case managers (N=59, RS; N=58, CEP) from 52 programs completed follow-up. Primary outcomes were time spent providing services in community settings and use of depression case management and problem-solving practices. Secondary outcomes were depression knowledge and attitudes and perceived system barriers. CEP case managers had greater participation in depression training, spent more time providing services in community settings, and used more problem-solving therapeutic approaches compared with RS case managers (pTraining participation, time spent providing services in community settings, and use of problem-solving skills among primarily unlicensed, racially and ethnically diverse case managers were greater in programs that used CEP rather than RS to implement depression care QI, suggesting that CEP offers a model for including case managers in communitywide depression care improvement efforts.
Rowe, Fiona; Walker, Marion; Rockliffe, Janet; Pollock, Alex; Noonan, Carmel; Howard, Claire; Currie, Jim
We sought to identify exemplars of high quality care provision from established stroke vision services. We identified areas of high quality services across the UK, judged as having integrated stroke/vision care provision for stroke survivors. Healthcare professionals were selected to participate in 1:1 interviews or focus groups. A strengths-weaknesses-opportunities-threats (SWOT) framework was used to lead the discussion in a semi-structured format. Thematic analysis was undertaken. Interviewees (n = 24) from 14 NHS Trusts included eye clinic managers, nurses, orthoptists, occupational therapists and physiotherapists. Identified strengths of their services included established communication, training provision for stroke team staff, "open access" for referrals, use of standardised screening/referral forms, provision of lay summaries and information sheets, patients assessed on the stroke unit with continued follow-up and initial visual assessments made within 1 week of stroke onset. Weaknesses included lack of funding, insufficient orthoptic cover, and time consuming retraining of stroke staff because of staff rotation and changes. Opportunities included increasing the number (or length) of orthoptic sessions and training of stroke staff. Perceived threats related to funding and increased appointment waiting times. Practical elements for improved stroke and vision care provision are highlighted which can be implemented with relatively little financial inputs. Implications for Rehabilitation Integrated vision services within stroke units can improve the detection of visual problems in stroke survivors leading to earlier visual rehabilitation. Orthoptists within core stroke teams are beneficial to the delivery of a high quality service. This study illustrates clear practical elements to support the provision of high quality integrated stroke and vision services. Relatively little financial inputs are required to fund such services but with larger potential to
Menger, Richard P; Thakur, Jai Deep; Jain, Gary; Nanda, Anil
OBJECTIVE Insurance preauthorization is used as a third-party tool to reduce health care costs. Given the expansion of managed care, the impact of the insurance preauthorization process in delaying health care delivery warrants investigation through a diversified neurosurgery practice. METHODS Data for 1985 patients were prospectively gathered over a 12-month period from July 1, 2014, until June 30, 2015. Information regarding attending, procedure, procedure type, insurance type, need for insurance approval, number of days for authorization, or insurance denial was obtained. Delay in authorization was defined as any wait period greater than 7 days. Some of the parameters were added retrospectively to enhance this study; hence, the total number of subjects may vary for different variables. RESULTS The most common procedure was back surgery with instrumentation (28%). Most of the patients had commercial insurance (57%) while Medicaid was the least common (1%). Across all neurosurgery procedures, insurance authorization, on average, was delayed 9 days with commercial insurance, 10.7 days with Tricare insurance, 8.5 days with Medicare insurance, 11.5 days with Medicaid, and 14.4 days with workers' compensation. Two percent of all patients were denied insurance preauthorization without any statistical trend or association. Of the 1985 patients, 1045 (52.6%) patients had instrumentation procedures. Independent of insurance type, instrumentation procedures were more likely to have delays in authorization (p = 0.001). Independent of procedure type, patients with Tricare (military) insurance were more likely to have a delay in approval for surgery (p = 0.02). Predictably, Medicare insurance was protective against a delay in surgery (p = 0.001). CONCLUSIONS Choice of insurance provider and instrumentation procedures were independent risk factors for a delay in insurance preauthorization. Neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and
Hückstädt, M; Hofmann, G O; Mendel, T; Stuttmann, R; Hilbert-Carius, P
investigated parameters. Significant differences were found between surviving and deceased patients regarding to their age as well as the timeframe from the beginning of impaired oxygenation to the onset of the effect of the administered antibiotics. These two parameters (age, time to sufficient antibiotic therapy) were confirmed by regression analysis and showing similar effect coefficients, age 1.09 and time to sufficient antibiotic therapy 1.04 respectively. An urgent worsening of pulmonary function in patients in intensive care requires immediate differential diagnostics due to substantial therapeutic consequences. Our results confirm that impairment of pulmonary oxygenation is the first prognostic symptom of severe onset of sepsis. Consequently, we recommend that this parameter be considered in diagnostic staging. After exclusion of a few differential diagnoses impairment of oxygenation can be the very first symptom of severe sepsis. The patient's age and time to sufficient antibiotic therapy are two very important prognostic factors with respect to mortality. Early and sufficient antibiotic therapy, and in a few cases surgical intervention are of utmost importance.
Melaku, Yohannes Adama; Weldearegawi, Berhe; Tesfay, Fisaha Haile; Abera, Semaw Ferede; Abraham, Loko; Aregay, Alemseged; Ashebir, Yemane; Eshetu, Friehiwot; Haile, Ashenafi; Lakew, Yihunie; Kinsman, John
Progress towards attaining the maternal mortality and maternal health targets set by Millennium Development Goal 5 has been slow in most African countries. Assessing antenatal care and institutional delivery service utilization and their determinants is an important step towards improving maternal health care services. Data were drawn from the longitudinal database of Kilite-Awlaelo Health and Demographic Surveillance System. A total of 2361 mothers who were pregnant and who gave birth between September 2009 and August 2013 were included in the analysis. Potential variables to explain antenatal care and institutional delivery service utilization were extracted, and descriptive statistics and logistic regression were used to determine the magnitude of maternal health care service utilization and associated factors, respectively. More than three-quarters, 76% [95% CI: 74.8%-78.2%] (n = 1806), of mothers had undergone at least one antenatal care visit during their previous pregnancy. However, only 27% [95% CI: 25.3%-28.9%] (n = 639) of mothers gave birth at a health institution. Older mothers, urban residents, mothers with higher education attainment, and farmer mothers were more likely to use antenatal care. Institutional delivery services were more likely to be used among older mothers, urban residents, women with secondary education, mothers who visited antenatal care, and mothers with lower parity. Despite a relatively high proportion of mothers attending antenatal care services at least once, we found low levels of institutional delivery service utilization. Health service providers in Kilite-Awlaelo should be particularly vigilant regarding the additional maternal health needs of rural and less educated women with high parity.
Duncombe, Chris; Rosenblum, Scott; Hellmann, Nicholas; Holmes, Charles; Wilkinson, Lynne; Biot, Marc; Bygrave, Helen; Hoos, David; Garnett, Geoff
The delivery of HIV care in the initial rapid scale-up of HIV care and treatment was based on existing clinic-based models, which are common in highly resourced settings and largely undifferentiated for individual needs. A new framework for treatment based on variable intensities of care tailored to the specific needs of different groups of individuals across the cascade of care is proposed here. Service intensity is characterised by four delivery components: (i) types of services delivered, (ii) location of service delivery, (iii) provider of health services and (iv) frequency of health services. How these components are developed into a service delivery framework will vary across countries and populations, with the intention being to improve acceptability and care outcomes. The goal of getting more people on treatment before they become ill will necessitate innovative models of delivering both testing and care. As HIV programmes expand treatment eligibility, many people entering care will not be ‘patients’ but healthy, active and productive members of society 1. To take the framework to scale, it will be important to: (i) define which individuals can be served by an alternative delivery framework; (ii) strengthen health systems that support decentralisation, integration and task shifting; (iii) make the supply chain more robust; and (iv) invest in data systems for patient tracking and for programme monitoring and evaluation. La délivrance des soins du VIH dans le déploiement initial rapide des soins et du traitement du VIH a été basée sur des modèles existants dans les cliniques, qui sont courants dans les régions bénéficiant d’importantes ressources et largement indifférenciées pour les besoins individuels. Un nouveau cadre est proposé ici pour le traitement basé selon les intensités variables de soins, adaptés aux besoins spécifiques des différents groupes de personnes à travers la cascade de soins. L’intensité des services est caract
Milić, Morena; Goranović, Tatjana; Holjevac, Jadranka Katancić
The aim of this study was to evaluate the usefulness of using Acute Physiology and Chronic Health Evaluation (APACHE) II score and Sequential Organ Failure Assessment (SOFA) score as the predictors of length of stay (LOS) in various surgical intensive care units (ICUs) and to test the hypothesis that the significance of scoring for predicting LOS is greater in specialized surgical ICUs. We scored patients in a non-specialized general surgical ICU (n = 328) and in a specialized cardiosurgical ICU (n = 158) consecutively on admission (APACHE II-1st day; SOFA-1st day) and on third day of stay (APACHE II-3rd day; SOFA-3rd day) in a 4-month period. LOS and APACHE II/SOFA scores were significantly correlated both on admission and on third day of stay in the general surgical ICU (APACHE II-1st day r = 0.289; SOFA-1st day r = 0.306; APACHE II-3rd day r = 0.728; SOFA-3rd day r = 0.725). LOS and APACHE II on admission were not significantly correlated in the cardiosurgical ICU (APACHE II-1st day r = 0.092), while SOFA on admission and APACHE II and SOFA on third day were significantly correlated (SOFA-1st day r = 0.258; APACHE II-3rd day r = 0.716; SOFA-3rd day r = 0.719). Usefulness of scoring for predicting LOS in ICU varied between different surgical ICUs. Contrary to our hypothesis, scoring had greater value for predicting LOS in the non-specialized general surgical ICU. APACHE II score on admission had no value for predicting LOS in the cardiosurgical ICU.
Full Text Available Mikaela L Jorgensen,1 Jane M Young,1,2 Michael J Solomon2,3 1Cancer Epidemiology and Services Research (CESR, Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; 2Surgical Outcomes Research Centre (SOuRCe, Sydney Local Health District and University of Sydney, Sydney, NSW, Australia; 3Discipline of Surgery, University of Sydney, Sydney, NSW, Australia Abstract: Colorectal cancer (CRC is the third most commonly diagnosed cancer worldwide. With population aging and increases in survival, the number of CRC survivors is projected to rise dramatically. The time following initial treatment is often described as a period of transition from intensive hospital-based care back into “regular life.” This review provides an overview of recommended follow-up care for people with CRC who have been treated with curative intent, as well as exploring the current state of the research that underpins these guidelines. For patients, key concerns following treatment include the development of recurrent and new cancers, late and long-term effects of cancer and treatment, and the interplay of these factors with daily function and general health. For physicians, survivorship care plans can be a tool for coordinating the surveillance, intervention, and prevention of these key patient concerns. Though much of the research in cancer survivorship to date has focused on surveillance for recurrent disease, many national guidelines differ in their conclusions about the frequency and timing of follow-up tests. Most CRC guidelines refer only briefly to the management of side effects, despite reports that many patients have a range of ongoing physiological, psychosocial, and functional needs. Guidance for surveillance and intervention is often limited by a small number of heterogeneous trials conducted in this patient group. However, recently released survivorship guidelines emphasize the potential for the effectiveness of
Witter, Sophie; Adjei, Sam; Armar-Klemesu, Margaret; Graham, Wendy
Background: There is a growing movement, globally and in the Africa region, to reduce financial barriers to health care generally, but with particular emphasis on high priority services and vulnerable groups. Objective: This article reports on the experience of implementing a national policy to exempt women from paying for delivery care in public, mission and private health facilities in Ghana. Design: Using data from a complex evaluation which was carried out in 2005-2006, lessons are drawn ...
Full Text Available Abstract Background Previous studies show an increased interest and usage of complementary and alternative medicine (CAM in the general population and among health care workers both internationally and nationally. CAM usage is also reported to be common among surgical patients. Earlier international studies have reported that a large amount of surgical patients use it prior to and after surgery. Recent publications indicate a weak knowledge about CAM among health care workers. However the current situation in Sweden is unknown. The aim of this study was therefore to explore perceived knowledge about CAM among registered healthcare professions in surgical departments at Swedish university hospitals. Method A questionnaire was distributed to 1757 registered physicians, nurses and physiotherapists in surgical wards at the seven university hospitals in Sweden from spring 2010 to spring 2011. The questionnaire included classification of 21 therapies into conventional, complementary, alternative and integrative, and whether patients were recommended these therapies. Questions concerning knowledge, research, and patient communication about CAM were also included. Result A total of 737 (42.0% questionnaires were returned. Therapies classified as complementary; were massage, manual therapies, yoga and acupuncture. Alternative therapies; were herbal medicine, dietary supplements, homeopathy and healing. Classification to integrative therapy was low, and unfamiliar therapies were Bowen therapy, iridology and Rosen method. Therapies recommended by > 40% off the participants were massage and acupuncture. Knowledge and research about CAM was valued as minor or none at all by 95.7% respectively 99.2%. Importance of possessing knowledge about it was valued as important by 80.9%. It was believed by 61.2% that more research funding should be addressed to CAM research, 72.8% were interested in reading CAM-research results, and 27.8% would consider taking part in
Stout, N L; Weiss, R; Feldman, J L; Stewart, B R; Armer, J M; Cormier, J N; Shih, Y-C T
A project of the American Lymphedema Framework Project (ALFP), this review seeks to examine the policy and economic impact of caring for patients with lymphedema, a common side effect of cancer treatment. This review is the first of its kind undertaken to investigate, coordinate, and streamline lymphedema policy initiatives in the United States with potential applicability worldwide. As part of a large scale literature review aiming to systematically evaluate the level of evidence of contemporary peer-reviewed lymphedema literature (2004 to 2011), publications on care delivery models, health policy, and economic impact were retrieved, summarized, and evaluated by a team of investigators and clinical experts. The review substantiates lymphedema education models and clinical models implemented at the community, health care provider, and individual level that improve delivery of care. The review exposes the lack of economic analysis related to lymphedema. Despite a dearth of evidence, efforts towards policy initiatives at the federal and state level are underway. These initiatives and the evidence to support them are examined and recommendations for translating these findings into clinical practice are made. Medical and community-based disease management interventions, taking on a public approach, are effective delivery models for lymphedema care and demonstrate great potential to improve cancer survivorship care. Efforts to create policy at the federal, state, and local level should target implementation of these models. More research is needed to identify costs associated with the treatment of lymphedema and to model the cost outlays and potential cost savings associated with comprehensive management of chronic lymphedema.
Full Text Available BACKGROUND Surgical site infections are the infections that occur within thirty days after the operative procedure (Except in case of added implants. Surgical site infections are the 3rd most commonly reported nosocomial infections accounting for a quarter of all such infections. A wide range of organisms are known to infect wounds like gram positive cocci, gram negative bacilli, spore formers, aerobes and anaerobes. Despite the advances in operative technique and better understanding of the pathogenesis of wound infections and wound healing, surgical site infections still remain a major source of morbidity and mortality. Hence, this study was done to identify the aetiological bacterial agents and their antibiogram pattern and the risk factors associated with surgical site infections. METHODS Wounds were examined for signs and symptoms of infection in postoperative ward. All the pus swabs were processed and identified as per standard methods of identification. Antibiogram was performed as per CLSI guidelines. The isolates were screened and confirmed with double disc diffusion method using CLSI guidelines. RESULTS The rate of surgical site infections in our study was 8.3%. The rate of surgical site infections was higher (73.3% in emergency surgeries than the elective surgeries. E. coli was the commonest isolate among gram negative bacilli; 33.3% isolates of E. coli were ESBL procedures. E. coli were sensitive to cefepime and ciprofloxacin and showed maximum resistance to ampicillin and ceftazidime. All the E. coli were sensitive to imipenem.
Shew, Matthew; Carlisle, Michael P; Lu, Guanning Nina; Humphrey, Clinton; Kriet, J David
Orbital fractures are a common result of facial trauma. Sequelae and indications for repair include enophthalmos and/or diplopia from extraocular muscle entrapment. Alloplastic implant placement with careful release of periorbital fat and extraocular muscles can effectively restore extraocular movements, orbital integrity, and anatomic volume. However, rare but devastating complications such as retrobulbar hematoma (RBH) can occur after repair, which pose a risk of permanent vision loss if not addressed emergently. For this reason, some surgeons take the precaution of admitting patients for 24-hour postoperative vision checks, while others do not. The incidence of postoperative RBH has not been previously reported and existing data are limited to case reports. Our aim was to examine national trends in postoperative management and to report the incidence of immediate postoperative complications at our institution following orbital repair. A retrospective assessment of orbital blowout fractures was undertaken to assess immediate postoperative complications including RBH. Only patients treated by a senior surgeon in the Department of Otolaryngology were included in the review. In addition, we surveyed AO North America (AONA) Craniomaxillofacial faculty to assess current trends in postoperative management. There were 80 patients treated surgically for orbital blowout fractures over a 9.5-year period. Nearly all patients were observed overnight (74%) or longer (25%) due to other trauma. Average length of stay was 17 hours for those observed overnight. There was one (1.3%) patient with RBH, who was treated and recovered without sequelae. Results of the survey indicated that a majority (64%) of responders observe postoperative patients overnight. Twenty-nine percent of responders indicated that they send patients home the same day of surgery. Performance of more than 20 orbital repairs annually significantly increased the likelihood that faculty would manage patients on
Craske, Michelle G; Rose, Raphael D; Lang, Ariel; Welch, Stacy Shaw; Campbell-Sills, Laura; Sullivan, Greer; Sherbourne, Cathy; Bystritsky, Alexander; Stein, Murray B; Roy-Byrne, Peter P
This article describes a computer-assisted cognitive behavioral therapy (CBT) program designed to support the delivery of evidenced-based CBT for the four most commonly occurring anxiety disorders (panic disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder) in primary-care settings. The purpose of the current report is to (1) present the structure and format of the computer-assisted CBT program, and (2) to present evidence for acceptance of the program by clinicians and the effectiveness of the program for patients. Thirteen clinicians using the computer-assisted CBT program with patients in our ongoing Coordinated Anxiety Learning and Management study provided Likert-scale ratings and open-ended responses about the program. Rating scale data from 261 patients who completed at least one CBT session were also collected. Overall, the program was highly rated and modally described as very helpful. Results indicate that the patients fully participated (i.e., attendance and homework compliance), understood the program material, and acquired CBT skills. In addition, significant and substantial improvements occurred to the same degree in randomly audited subsets of each of the four primary anxiety disorders (N=74), in terms of self ratings of anxiety, depression, and expectations for improvement. Computer-assisted CBT programs provide a practice-based system for disseminating evidence-based mental health treatment in primary-care settings while maintaining treatment fidelity, even in the hands of novice clinicians. (c) 2009 Wiley-Liss, Inc.
The public sector is facing turbulent times and this challenges nurses, who are expected to serve both patient interests and the efficiency drives of their organisations. In the context of implementing person-centred health policy, this paper explores the evolving role of front-line nurses as leaders and champions of change. Nurses can be seen to have some autonomy in health-care delivery. However, they are subject to systems of social control. In implementing person-centred policy, nurses can be seen to be doing the best they can within a constrained environment. A survey of nursing practice in person-centred health-policy implementation is presented. Despite much being written about managing health-professional resistance to policy implementation, there is a gap between what is being asked of nurses and the resources made available to them to deliver. In this milieu, nurses are utilising their discretion and leading from the front-line in championing change. Empowering nurses who seek to lead patient involvement could be the key to unlocking health-care improvement. Health services tend to be over-managed and under-led and there is a need to harness the potential of front-line nurses by facilitating leadership development through appropriate organisational support. © 2015 John Wiley & Sons Ltd.
Furin, Jennifer; Shutts, Mike; Keshavjee, Salmaan
In many regions of the world plagued by high burdens of disease, there is difficulty in accessing basic medical care. This is often due to logistical constraints and a lack of infrastructure such as roads. Medical aviation can play a major role in addressing some of these crucial issues as it allows for the rapid transport of patients, personnel, and medications to remote-and sometimes otherwise inaccessible-areas. Lesotho is a mountainous nation of 2 million people that provides a good example of medical aviation as a cornerstone in the delivery of health care. The population has a reported HIV seroprevalence of 25%, and many patients live in rural areas that are inaccessible by road. Mission Aviation Fellowship has joined forces with a medical team from the nongovernmental organization Partners In Health in an effort to launch a comprehensive program to address HIV and related problems in rural Lesotho. This medical aviation partnership has allowed for the provision of HIV prevention and treatment services to thousands of people living in the mountains. This commentary describes how medical aviation has been crucial in developing models to address complex, serious health problems in remote settings.
Mason, Virginia M; Leslie, Gail; Clark, Kathleen; Lyons, Pat; Walke, Erica; Butler, Christina; Griffin, Martha
Preparation for replacing the large proportion of staff nurses reaching retirement age in the next few decades in the United States is essential to continue delivering high-quality nursing care and improving patient outcomes. Retaining experienced critical care nurses is imperative to successfully implementing the orientation of new inexperienced critical care nurses. It is important to understand factors that affect work engagement to develop strategies that enhance nurse retention and improve the quality of patient care. Nurses' experience of moral distress has been measured in medical intensive care units but not in surgical trauma care units, where nurses are exposed to patients and families faced with sudden life-threatening, life-changing patient consequences.This pilot study is a nonexperimental, descriptive, correlational design to examine the effect of compassion satisfaction, compassion fatigue, moral distress, and level of nursing education on critical care nurses' work engagement. This is a partial replication of Lawrence's dissertation. The study also asked nurses to describe sources of moral distress and self-care strategies for coping with stress. This was used to identify qualitative themes about the nurse experiences. Jean Watson's theory of human caring serves as a framework to bring meaning and focus to the nursing-patient caring relationship.A convenience sample of 26 of 34 eligible experienced surgical intensive care unit trauma nurses responded to this survey, indicating a 77% response rate. Twenty-seven percent of the nurses scored high, and 73% scored average on compassion satisfaction. On compassion fatigue, 58% scored average on burnout and 42% scored low. On the secondary traumatic stress subscale, 38% scored average, and 62% scored low. The mean moral distress situations subscale score was 3.4, which is elevated. The mean 9-item Utrecht Work Engagement Scale total score, measuring work engagement, was 3.8, which is considered low
Leana S. Wen
Conclusion: Despite ongoing challenges, the infrastructure for the delivery of emergency care is much improved since 1994, and Rwanda’s continuing progress can serve as a model for EM development in other developing and/or post-conflict countries in Africa.
Browne, Joyce L; Kayode, Gbenga A; Arhinful, Daniel; Fidder, Samuel A J; Grobbee, Diederick E; Klipstein-Grobusch, Kerstin
OBJECTIVE: This study aims to evaluate the effect of maternal health insurance status on the utilisation of antenatal, skilled delivery and postnatal care. DESIGN: A population-based cross-sectional study. SETTING AND PARTICIPANTS: We utilised the 2008 Demographic and Health Survey data of Ghana, wh
P. Moons (Philip); P.M. Engelfriet (Peter); H. Kaemmerer (Harald); F.J. Meijboom (Folkert); E.N. Oechslin (Erwin); B.J.M. Mulder (Barbara)
textabstractAims: The increasing number of adults with congenital heart disease (CHD) has prompted the development of recommendations for the management of these patients and for the organization of their healthcare. The aim of this report is to describe the delivery of care in Europe for adults wit
Background: Systems of care is a family centered, strengths-based service delivery model for treating youth experiencing a serious emotional disturbance. Wraparound is the most common method of service delivery adopted by states and communities as a way to adhere to systems of care philosophy. Objective: The purpose of this study was to evaluate…
Marshall, Deborah A.; Burgos-Liz, Lina; IJzerman, Maarten Joost; Crown, William; Padula, William V.; Wong, Peter K.; Pasupathy, Kalyan S.; Higashi, Mitchell K.; Osgood, Nathaniel D.
In a previous report, the ISPOR Task Force on Dynamic Simulation Modeling Applications in Health Care Delivery Research Emerging Good Practices introduced the fundamentals of dynamic simulation modeling and identified the types of health care delivery problems for which dynamic simulation modeling
Marshall, Deborah A.; Burgos-Liz, Lina; IJzerman, Maarten Joost; Crown, William; Padula, William V.; Wong, Peter K.; Pasupathy, Kalyan S.; Higashi, Mitchell K.; Osgood, Nathaniel D.
In a previous report, the ISPOR Task Force on Dynamic Simulation Modeling Applications in Health Care Delivery Research Emerging Good Practices introduced the fundamentals of dynamic simulation modeling and identified the types of health care delivery problems for which dynamic simulation modeling c
Noonan, Vanessa K.; Soril, Lesley; Atkins, Derek; Lewis, Rachel; Santos, Argelio; Fehlings, Michael G.; Burns, Anthony S.; Singh, Anoushka
Abstract The long-term impact of spinal cord injury (SCI) on the health care system imposes a need for greater efficiency in the use of resources and the management of care. The Access to Care and Timing (ACT) project was developed to model the health care delivery system in Canada for patients with traumatic SCI. Techniques from Operations Research, such as simulation modeling, were used to predict the impact of best practices and policy initiatives on outcomes related to both the system and patients. These methods have been used to solve similar problems in business and engineering and may offer a unique solution to the complexities encountered in SCI care delivery. Findings from various simulated scenarios, from the patients' point of injury to community re-integration, can be used to inform decisions on optimizing practice across the care continuum. This article describes specifically the methodology and implications of producing such simulations for the care of traumatic SCI in Canada. Future publications will report on specific practices pertaining to the access to specialized services and the timing of interventions evaluated using the ACT model. Results from this type of research will provide the evidence required to support clinical decision making, inform standards of care, and provide an opportunity to engage policymakers. PMID:22800432
Noonan, Vanessa K; Soril, Lesley; Atkins, Derek; Lewis, Rachel; Santos, Argelio; Fehlings, Michael G; Burns, Anthony S; Singh, Anoushka; Dvorak, Marcel F
The long-term impact of spinal cord injury (SCI) on the health care system imposes a need for greater efficiency in the use of resources and the management of care. The Access to Care and Timing (ACT) project was developed to model the health care delivery system in Canada for patients with traumatic SCI. Techniques from Operations Research, such as simulation modeling, were used to predict the impact of best practices and policy initiatives on outcomes related to both the system and patients. These methods have been used to solve similar problems in business and engineering and may offer a unique solution to the complexities encountered in SCI care delivery. Findings from various simulated scenarios, from the patients' point of injury to community re-integration, can be used to inform decisions on optimizing practice across the care continuum. This article describes specifically the methodology and implications of producing such simulations for the care of traumatic SCI in Canada. Future publications will report on specific practices pertaining to the access to specialized services and the timing of interventions evaluated using the ACT model. Results from this type of research will provide the evidence required to support clinical decision making, inform standards of care, and provide an opportunity to engage policymakers.
A K Alotaibi
Full Text Available Introduction: Ventilator-associated pneumonia is a major morbid outcome among intensive care unit (ICU patients. Providing oral care for intubated patients is an important task by the ICU nursing staff in reducing the mortality and morbidity. The objectives of this study were to evaluate the attitudes and knowledge of ICU nurses regarding oral care delivery to critically ill patients in Saudi Arabian ICUs. The findings were further correlated to the presence of healthcare quality accreditation of the institution. Materials and Methods: The nurses′ knowledge, attitudes, and healthcare quality accreditation status of the hospital were recorded. Two hundred fifteen nurses conveniently selected from 10 random hospitals were included in this study from Riyadh city, Saudi Arabia. This is a cross-sectional study in the form of a questionnaire. Results: When comparing the knowledge of the participants to their level of education, there was no statistically significant difference between the two groups of nurses. The majority of the nurses agreed that the oral cavity is difficult to clean and that oral care delivery is a high priority for mechanically ventilated patients. Furthermore, there was no statistically significant difference in the attitudes between nurses working in accredited and nonaccredited hospitals. Conclusion: The presence of healthcare quality accreditation did not reflect any significance in attitudes or knowledge of the ICU nurses in regard to mechanically ventilated patients. Factors affecting oral care delivery should be evaluated on the personal and institutional level to achieve better understanding of them.
Piva, Simone; Dora, Giancarlo; Minelli, Cosetta; Michelini, Mariachiara; Turla, Fabio; Mazza, Stefania; D'Ottavi, Patrizia; Moreno-Duarte, Ingrid; Sottini, Caterina; Eikermann, Matthias; Latronico, Nicola
We validated the Italian version of Surgical Optimal Mobility Score (SOMS) and evaluated its ability to predict intensive care unit (ICU) and hospital length of stay (LOS), and hospital mortality in a mixed population of ICU patients. We applied the Italian version of SOMS in a consecutive series of prospectively enrolled, adult ICU patients. Surgical Optimal Mobility Score level was assessed twice a day by ICU nurses and twice a week by an expert mobility team. Zero-truncated Poisson regression was used to identify predictors for ICU and hospital LOS, and logistic regression for hospital mortality. All models were adjusted for potential confounders. Of 98 patients recruited, 19 (19.4%) died in hospital, of whom 17 without and 2 with improved mobility level achieved during the ICU stay. SOMS improvement was independently associated with lower hospital mortality (odds ratio, 0.07; 95% confidence interval [CI], 0.01-0.42) but increased hospital LOS (odds ratio, 1.21; 95% CI: 1.10-1.33). A higher first-morning SOMS on ICU admission, indicating better mobility, was associated with lower ICU and hospital LOS (rate ratios, 0.89 [95% CI, 0.80-0.99] and 0.84 [95% CI, 0.79-0.89], respectively). The first-morning SOMS on ICU admission predicted ICU and hospital LOS in a mixed population of ICU patients. SOMS improvement was associated with reduced hospital mortality but increased hospital LOS, suggesting the need of optimizing hospital trajectories after ICU discharge. Copyright © 2015 Elsevier Inc. All rights reserved.
Dzakpasu, S; Soremekun, S; Manu, A; ten Asbroek, G.; Tawiah, C.; Hurt, L.; Fenty, J; Owusu-Agyei, S; Hill, Z; Campbell, OM; Kirkwood, BR
BACKGROUND: Many sub-Saharan countries, including Ghana, have introduced policies to provide free medical care to pregnant women. The impact of these policies, particularly on access to health services among the poor, has not been evaluated using rigorous methods, and so the empirical basis for defending these policies is weak. In Ghana, a recent report also cast doubt on the current mechanism of delivering free care--the National Health Insurance Scheme. Longitudinal surveillance data from t...
Geary, M S
Active in the United States for the past 25 years, the women's health movement was originally an outgrowth of the larger feminist movement and shares many of the same assumptions. The women's health movement has been successful in increasing public awareness of the problems involved in the delivery of health care to women and effecting changes in that health care. This article seeks to identify societal contributions and specific events that resulted in the occurrence of this social reform movement, enumerate some of the accomplishments, and suggest why health care providers would benefit by understanding this phenomenon.
Rossdale, Michael; Clark, Carol; James, John
The delivery of health care has been improved in an inner-city well-baby clinic by staffing the clinic with members of a primary health care team and by offering a therapeutic service together with a preventive service. Over a three-year period attendance at the clinic has doubled and the uptake of immunization has increased. Of children registered with the practice supplying the health care team, 95% are up to date with diphtheria, tetanus and polio immunizations and 93% have been immunized ...
T B Singh
Full Text Available Acute kidney injury (AKI is a common complication in hospitalized patients. There are few comparative studies on hospital-acquired AKI (HAAKI in medical, surgical, and ICU patients. This study was conducted to compare the epidemiological characteristics, clinical profiles, and outcomes of HAAKI among these three units. All adult patients (>18 years of either gender who developed AKI based on RIFLE criteria (using serum creatinine, 48 h after hospitalization were included in the study. Patients of acute on chronic renal failure and AKI in pregnancy were excluded. Incidence of HAAKI in medical, surgical, and ICU wards were 0.54%, 0.72%, and 2.2% respectively ( P < 0.0001. There was no difference in age distribution among the groups, but onset of HAAKI was earliest in the medical ward ( P = 0.001. RIFLE-R was the most common AKI in medical (39.2% and ICU (50% wards but in the surgical ward, it was RIFLE-F that was most common (52.6%. Acute tubular necrosis was more common in ICU ( P = 0.043. Most common etiology of HAAKI in medical unit was drug induced (39.2%, whereas in surgical and ICU, it was sepsis (34% and 35.2% respectively. Mortality in ICU, surgical and medical units were 73.5%, 43.42%, and 37.2%, respectively ( P = 0.003. Length of hospital stay in surgical, ICU and medical units were different ( P = 0.007. This study highlights that the characters of HAAKI are different in some aspects among different hospital settings.
Oliveira, Rosana Rosseto de; Melo, Emiliana Cristina; Novaes, Elisiane Soares; Ferracioli, Patrícia Louise Rodrigues Varela; Mathias, Thais Aidar de Freitas
Identifying factors associated to Caesarean sections among the residents of Maringá-PR, according to the financing source for delivery. A cross-sectional study with data from 920 postpartum women interviewed between October 2013 and February 2014. Association analysis was performed by logistic regression. Caesarean section rates were 55.5% in the Unified Healthcare System (SUS) and 93.8% in the private system. Factors associated with Caesarean section in the SUS were: previous Caesarean section (OR=8.9; CI=4.6-16.9), desire for Caesarean section early in pregnancy (OR=2.0; CI=1.1-3.6), pregestational overweight/obesity (OR=1.8; CI=1.1-2.8), and per capita family income higher than one minimum wage (OR=2.1; CI=1.3-3.4). In the private system, desire for Caesarean section early in pregnancy (OR=25.3) and a previous Caesarean section (OR=11.3) were strongly associated to its performance. It is necessary to properly orientate all pregnant women who desire a Caesarean delivery, from both the SUS and the private system, about the inherent risks of the surgical procedure without indication. In the public health sector, guidelines should be focused on pregnant women with previous Caesarean delivery, with a per capita income higher than one minimum wage and those who are overweight or obese, as these women are more likely to have a Caesarean section. Identificar fatores associados à cesárea entre residentes de Maringá-PR, segundo a fonte de financiamento do parto. Estudo transversal com dados de 920 puérperas entrevistadas entre outubro de 2013 e fevereiro de 2014. A análise de associação foi feita por regressão logística. A taxa de cesariana foi de 55,5% e 93,8% no Sistema Único de Saúde (SUS) e no sistema privado, respectivamente. Associou-se à cesárea no SUS: realização de cesárea anterior (OR=8,9; IC=4,6-16,9), desejo pela cesárea no início da gestação (OR=2,0; IC=1,1-3,6), sobrepeso/obesidade pré-gestacional (OR=1,8; IC=1,1-2,8), e renda familiar
Martinez, Enid E; Bechard, Lori J; Mehta, Nilesh M
Enteral nutrition (EN) delivery is associated with improved outcomes in critically ill patients. We aimed to describe EN practices, including details of algorithms and individual bedside practices, in pediatric intensive care units (PICUs). Available EN algorithm details from 31 international PICUs were obtained. Daily nutrient intake data from 524 mechanically ventilated patients, 1 month to 18 years old, were prospectively documented, including EN delivery, adjunct therapies, and energy prescription. Practices associated with higher percentage adequacy of EN delivery were determined by regression analysis. Nine EN algorithms were available. All algorithms defined advancement and EN intolerance; 7 of 9 defined intolerance by gastric residual volume; 3 of 9 recommended nutrition screening and fasting guidelines. Few elements were in agreement with the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition guidelines. Of the 341 patients who received EN exclusively 32.9% received ≥66.6% of prescribed energy on day 7. Percentage adequacy of EN delivered was inversely associated with days to EN initiation (-8.92; P algorithms, promotility agents, or postpyloric feeding. A minority of PICUs employ EN algorithms; recommendations were variable and not in agreement with national guidelines. Optimal EN delivery was achieved in less than one-third of our cohort. EN adjunct therapies were not associated with increased EN delivery. Studies aimed at promoting early EN and decreasing interruptions may optimize energy delivery in the PICU.
Indrapal Ishwarji Meshram
Full Text Available Background: Maternal and infant mortality rates and prevalence of under nutrition are high in the State Madhya Pradesh. Regular ante-natal check-ups (ANC, delivery by trained health personnel, delivery practices and optimal infant feeding practices are important to reduce maternal and infant mortality. Objectives: The aim was to assess antenatal care, delivery and infant feeding practices of mothers of <1-year-old children in Madhya Pradesh. Materials and Methods: This was community-based cross-sectional study carried out in the rural areas of Madhya Pradesh by adopting systematic random sampling procedure. Data were collected from 5324 mothers having <1-year-old children. Information on household (HH socioeconomic and demographic particulars was collected from the mothers. Bivariate and multivariate analysis was performed to study the association between dependent and independent variables. Results and Interpretations: About 36% mothers had undergone at least three ante-natal check-ups and 73% delivered either at government or private hospitals. Only 26% mothers initiated breastfeeding within 1-h of birth and 92% fed colostrum. Step-wise regression analysis showed that ante-natal care for <3 times was significantly (P < 0.01 higher among women with high parity (≥5, illiterate women, and among lower socioeconomic group,s while home delivery was higher among women with high parity (≥5 (odds ratio [OR]: 2.3, among Scheduled Caste and Tribe women (OR: 1.5, illiteracy of head of HH (OR: 2, and among lower socioeconomic groups (OR: 1.3. Discarding colostrum was higher among illiterate women (OR: 1.6, belonging to lower socioeconomic groups (OR: 1.4 and delivery conducted by untrained person (OR: 3.9, while initiation of breastfeeding after 1-h of childbirth was higher among ≥30 years women (OR: 1.9, illiterate women (OR: 1.4, and delivery by untrained person (OR: 2.9. Conclusions: It was observed that antenatal care, delivery and infant and
Semel, Marcus E; Resch, Stephen; Haynes, Alex B; Funk, Luke M; Bader, Angela; Berry, William R; Weiser, Thomas G; Gawande, Atul A
Use of the World Health Organization's Surgical Safety Checklist has been associated with a significant reduction in major postoperative complications after inpatient surgery. We hypothesized that implementing the checklist in the United States would generate cost savings for hospitals. We performed a decision analysis comparing implementation of the checklist to existing practice in U.S. hospitals. In a hospital with a baseline major complication rate after surgery of at least 3 percent, the checklist generates cost savings once it prevents at least five major complications. Using the checklist would both save money and improve the quality of care in hospitals throughout the United States.
Utter, Garth H; Schuster, Kevin M; Miller, Preston R; Mowery, Nathan T; Agarwal, Suresh K; Winchell, Robert J; Crandall, Marie L
The International Classification of Diseases, 10th edition, Clinical Modification and Procedure Coding System (ICD-10-CM/PCS) have been in effect since October 1, 2015 and offer much greater capacity than previous classifications to characterize the nature and treatment of surgical conditions. However, the diagnosis codes of ICD-10-CM are unevenly specific across the spectrum of surgical conditions and currently do not adequately allow description of important distinctions in disease severity for many common surgical conditions. Through our work on the Patient Assessment Committee of the American Association for the Surgery of Trauma, we sought changes to ICD-10-CM to allow for better characterization of the severity of several common emergency general surgical conditions, such as acute appendicitis and acute pancreatitis. The ICD Coordination and Maintenance Committee periodically entertains requests to improve ICD-10-CM/PCS through a formal process with public input; the Centers for Medicare and Medicaid services, in coordination with other agencies and organizations, issue annual updates to these classifications. We describe some potential improvements to ICD-10-CM/PCS as well as how individuals and organizations can propose and effect such changes. With the next parent classification for mortality reporting (ICD-11) currently in development by the World Health Organization, now is also an opportune time to request changes that eventually would be incorporated into the future U.S. version of ICD-11 for morbidity reporting.
N. A. Azeez
Full Text Available Cloud services permit healthcare providers to ensure information handling and allow different service resources such as Software as a Service (SaaS, Platform as a Service (PaaS and Infrastructure as a Service (IaaS on the Internet, given that security and information proprietorship concerns are attended to. Health Care Providers (HCPs in Nigeria however, have been confronted with various issues because of their method of operations. Amongst the issues are ill-advised methods of data storage and unreliable nature of patient medical records. Apart from these challenges, trouble in accessing quality healthcare services, high cost of medical services, and wrong analysis and treatment methodology are not left out. Cloud Computing has relatively possessed the capacity to give proficient and reliable method for securing medical information and the need for data mining tools in this form of distributed system will go a long way in achieving the objective set out for this project. The aim of this research therefore is to implement a cloud-based architecture that is suitable to integrate Healthcare Delivery into the cloud to provide a productive mode of operation. The proposed architecture consists of four phases (4-Tier; a User Authentication and Access Control Engine (UAACE which prevents unauthorized access to patient medical records and also utilizes standard encryption/decoding techniques to ensure privacy of such records. The architecture likewise contains a Data Analysis and Pattern Prediction Unit (DAPPU which gives valuable data that guides decision making through standard Data mining procedures as well as Cloud Service Provider (CSP and Health Care Providers (HCPs. The architecture which has been implemented on CloudSim has proved to be efficient and reliable base on the results obtained when compared with previous work.
Full Text Available Background: Efforts have been made to measure integration in health care delivery, but few existing instruments have adopted a patient perspective, and none is sufficiently generic and brief for administration at scale. We sought to develop a brief and generic patient-reported measure of integration in health care delivery.Methods: Drawing on both existing conceptualisations of integrated care and research on patients’ perspectives, we chose to focus on four distinct domains of integration: information sharing,consistent advice, mutual respect and role clarity. We formulated candidate items and conducted cognitive interviews with end users to further develop and refine the items. We then pilot-tested the measure.Results: Four rounds of cognitive interviews were conducted (n = 14 and resulted in a four-item measure that was both relevant and understandable to end users. The pilot administration of the measure (n = 15 further confirmed the relevance and interpretability of items and demonstrated that the measure could be completed in less than one minute.Conclusions: This new measure, IntegRATE, represents a patient-reported measure of integration in health care delivery that is conducive to use in both routine performance monitoring and research. The psychometric properties of the measure will be assessed in the next stage of development.
Nicaise, Pablo; Dubois, Vincent; Lorant, Vincent
Most mental health care delivery systems in welfare states currently face two major issues: deinstitutionalisation and fragmentation of care. Belgium is in the process of reforming its mental health care delivery system with the aim of simultaneously strengthening community care and improving integration of care. The new policy model attempts to strike a balance between hospitals and community services, and is based on networks of services. We carried out a content analysis of the policy blueprint for the reform and performed an ex-ante evaluation of its plan of operation, based on the current knowledge of mental health service networks. When we examined the policy's multiple aims, intermediate goals, suggested tools, and their articulation, we found that it was unclear how the new policy could achieve its goals. Indeed, deinstitutionalisation and integration of care require different network structures, and different modes of governance. Furthermore, most of the mechanisms contained within the new policy were not sufficiently detailed. Consequently, three major threats to the effectiveness of the reform were identified. These were: issues concerning the relationship between network structure and purpose, the continued influence of hospitals despite the goal of deinstitutionalisation, and the heterogeneity in the actual implementation of the new policy. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Zachary M. Bauman
Full Text Available Background. Lung injury prediction score (LIPS is valuable for early recognition of ventilated patients at high risk for developing acute respiratory distress syndrome (ARDS. This study analyzes the value of LIPS in predicting ARDS and mortality among ventilated surgical patients. Methods. IRB approved, prospective observational study including all ventilated patients admitted to the surgical intensive care unit at a single tertiary center over 6 months. ARDS was defined using the Berlin criteria. LIPS were calculated for all patients and analyzed. Logistic regression models evaluated the ability of LIPS to predict development of ARDS and mortality. A receiver operator characteristic (ROC curve demonstrated the optimal LIPS value to statistically predict development of ARDS. Results. 268 ventilated patients were observed; 141 developed ARDS and 127 did not. The average LIPS for patients who developed ARDS was 8.8±2.8 versus 5.4±2.8 for those who did not (p<0.001. An ROC area under the curve of 0.79 demonstrates LIPS is statistically powerful for predicting ARDS development. Furthermore, for every 1-unit increase in LIPS, the odds of developing ARDS increase by 1.50 (p<0.001 and odds of ICU mortality increase by 1.22 (p<0.001. Conclusion. LIPS is reliable for predicting development of ARDS and predicting mortality in critically ill surgical patients.
Meyer, Zainna C; Schreinemakers, Jennifer M J; de Waal, Ruud A L; van der Laan, Lijckle
We reviewed the use of the levels of C-reactive protein, lactate and procalcitonin and/or the Sequential Organ Failure Assessment score to determine their diagnostic accuracy for predicting surgical complications in critically ill general post-surgery patients. Included were all studies published in PubMed from inception to July 2013 that met the following inclusion criteria: evaluation of the above parameters, describing their diagnostic accuracy and the risk stratification for surgical complications in surgical patients admitted to an intensive care unit. No difference in the Sequential Organ Failure Assessment scores was seen between patients with or without complications. The D-lactate levels were significantly higher in those who developed colonic ischemic complications after a ruptured abdominal aortic aneurysm. After gastro-intestinal surgery, contradictory data were reported, with both positive and negative use of C-reactive protein and procalcitonin in the diagnosis of septic complications. However, in trauma patients, the C-reactive protein levels may help to discriminate between those with and without infectious causes. We conclude that the Sequential Organ Failure Assessment score, lactate concentration and C-reactive protein level have no significant predictive value for early postoperative complications in critically ill post-surgery patients. However, procalcitonin seems to be a useful parameter for diagnosing complications in specific patient populations after surgery and/or after trauma.
Breast cancer is the most common cancer among women worldwide. In Denmark, one in every 9 women will be diagnosed with breast cancer during her life. The initial treatment is removal of the tumour and the surrounding tissue, or removal of the breast. The axillary is examined to stage spread...... of cancer and if metastases are detected, an axillary clearance is performed. Consequences of breast cancer are manifold and vary within individuals, but the most cited are anxiety, depression, pain, sleep disturbance, fatigue, and/or altered body image. These consequences may cause distress at some point...... during breast cancer trajectory. Overall, distress has been linked to suffering, and lower quality of life, increased admission rates, and greater health care costs. This thesis uses mixed methods to investigate the prevalence of distress among women taking part in surgical continuity of care at time...
Thirukumaran, Caroline Pinto; Dolan, James G; Reagan Webster, Patricia; Panzer, Robert J; Friedman, Bruce
To examine the impact of electronic health record (EHR) deployment on Surgical Care Improvement Project (SCIP) measures in a tertiary-care teaching hospital. SCIP Core Measure dataset from the CMS Hospital Inpatient Quality Reporting Program (March 2010 to February 2012). One-group pre- and post-EHR logistic regression and difference-in-differences analyses. Statistically significant short-term declines in scores were observed for the composite, postoperative removal of urinary catheter and post-cardiac surgery glucose control measures. A statistically insignificant improvement in scores for these measures was noted 3 months after EHR deployment. The transition to an EHR appears to be associated with a short-term decline in quality. Implementation strategies should be developed to preempt or minimize this initial decline. © Health Research and Educational Trust.
Surgical education continues to evolve from the master-apprentice model. Newer methods of the process need to be used to manage the dual challenges of educating while providing safe surgical care. This requires integrating adult learning concepts into delivery of practical training and education in busy clinical environments. A narrative review aimed at outlining and integrating adult learning and surgical education theory was undertaken. Additionally, this information was used to relate the practical delivery of surgical training and education in day-to-day surgical practice. Concepts were sourced from reference material. Additional material was found using a PubMed search of the words: 'surgical education theory' and 'adult learning theory medical'. This yielded 1351 abstracts, of which 43 articles with a focus on key concepts in adult education theory were used. Key papers were used to formulate structure and additional cross-referenced papers were included where appropriate. Current concepts within adult learning have a lot to offer when considering how to better deliver surgical education and training. Better integration of adult learning theory can be fruitful. Individual teaching surgical units need to rethink their paradigms and consider how each individual can contribute to the education experience. Up skilling courses for trainers can do much to improve the delivery of surgical education. Understanding adult learning concepts and integrating these into day-to-day teaching can be valuable.
Surgical education continues to evolve from the master-apprentice model. Newer methods of the process need to be used to manage the dual challenges of educating while providing safe surgical care. This requires integrating adult learning concepts into delivery of practical training and education in busy clinical environments. A narrative review aimed at outlining and integrating adult learning and surgical education theory was undertaken. Additionally, this information was used to relate the practical delivery of surgical training and education in day-to-day surgical practice. Concepts were sourced from reference material. Additional material was found using a PubMed search of the words: ‘surgical education theory’ and ‘adult learning theory medical’. This yielded 1351 abstracts, of which 43 articles with a focus on key concepts in adult education theory were used. Key papers were used to formulate structure and additional cross-referenced papers were included where appropriate. Current concepts within adult learning have a lot to offer when considering how to better deliver surgical education and training. Better integration of adult learning theory can be fruitful. Individual teaching surgical units need to rethink their paradigms and consider how each individual can contribute to the education experience. Up skilling courses for trainers can do much to improve the delivery of surgical education. Understanding adult learning concepts and integrating these into day-to-day teaching can be valuable.
Full Text Available Musculoskeletal pain syndromes are one of the most common causes of disability and referral to a medical specialist. Seven million consultations for lumbosacral pain are annually carried out in the United Kingdom.Examination of patients with back pain. Three levels of health care delivered to patients with back pain in the United Kingdom may be arbitrarily identified. Level 1 is outpatient: a general practitioner jointly with a manipulative therapist, a physiotherapist, a rehabilitation specialist, and mid-level health workers render care to patients with insignificant and mild pain syndrome; Level 2 is also outpatient, which involves the participation of a hospital or multidisciplinary team consultant, for example, in a musculoskeletal pain service or a specialized pain center; Level 3 is to deliver care at neurosurgical or orthopedic hospital, by applying invasive interventions. Acute back pain is a benign condition in the vast majority of cases; there is no need for additional instrumental and laboratory studies; but spinal X-ray study, computed tomography (СT scan, or magnetic resonance imaging (MRI, general blood and urine tests are required when marked neurological and somatic disorders are present.Management of patients with acute lumbosacral pain is to inform a patient about the benign nature of the disease; to exclude bed rest; to explain the need to maintain normal activity; to train how to correctly lift weights and to maintain normal posture; to refer for manual and exercise therapy in order to return to normal motor activity; to use proven effective medication. In most cases, acute back pain goes away spontaneously for a short period of time; an active treatment approach is considered to be optimal. Nonsteroidal anti-inflammatory drugs (NSAIDs and acetaminophen are used for analgesia if required. Patients who show no improvement after 4 weeks of treatment need rescreening for markers of potentially dangerous spinal diseases, as
Visser, Anita; Stellingsma, Cornelis; Raghoebar, Gerry M.; Meijer, Henny J. A.; Vissink, Arjan
BackgroundDifferent treatment strategies for the atrophied mandible are described in literature. The need for long term care and aftercare for these strategies is sparsely described, however. PurposeTo prospectively assess the need for prosthetic and surgical care and aftercare of two implant
Møller, M H; Larsson, H J; 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...
Plummer, Joseph Martin; Roberts, Patrick Oral; Leake, Pierre Anthony; Mitchell, Derek Ian
In an era of technology-dependent surgery, Jamaica and other developing countries must deal with the wide disparity between their surgical practices and those of developed nations. Although there is still a place for the well-trained surgeon, the current emphasis in developed nations is less on the individual surgeon and more on the surgery team and system, with increasing costs despite diminishing government support. At the University of the West Indies, we are challenged to continue providi...
Restrepo, Paula; Jameson, Deborah L; Carroll, Diane L
Deep vein thrombosis remains a source of adverse outcomes in surgical patients. Deep vein thrombosis is preventable with prophylactic intervention. The success of noninvasive mechanical modalities for prophylaxis relies on compliance with correct application. The goals of this project were to create a guideline that reflected current evidence and expert thinking about mechanical modalities use, assess compliance with mechanical modalities, and develop strategies to disseminate an evidence-based guideline for deep vein thrombosis prophylaxis.
Doerflinger, Deirdre M Carolan
All health care professionals will at some point come into contact with elderly patients. The older population is increasing in numbers never seen before. Older patients present uniquely in the health care setting. Their bodies have specific changes as a result of aging that impact all facets of their health care. Pain, debility, loss of function, and many other symptoms are expected by the older person and their family and accepted as a fact associated with aging. Every system in the human body undergoes changes related to aging. Recognition of normal changes of aging will allow the health care provider to identify atypical presentations of illness owing to changes in aging, allowing earlier and more effective treatment. It is incumbent upon all nurses to learn to differentiate normal changes of aging from pathology and to use evidence-based geriatrics practices to improve care of seniors.
Esposito, T J; Kuby, A M; Unfred, C; Young, H L; Gamelli, R L
A national sample of 2500 surgeons was surveyed. Thirteen variables were analyzed to ascertain perceived differences between trauma care and other surgical emergencies, as well as to identify factors contributing to a preferential reluctance to treat trauma. The response rate was 60%. Trauma was perceived as most likely to occur at inconvenient times by 67% of respondents, more often complex (44%), and more demanding of specialized knowledge (39%). Trauma was viewed as less likely to be reimbursed by 35% and most often litigious by 30%. Fewer respondents perceived differences for risk of exposure to lethal pathogens and violence (26% and 9%) and personal or professional rewards (25%). Surgeons who prefer to treat trauma view it as more often demanding of specialized knowledge and more complex than other surgical emergencies. Surgeons who prefer not to treat trauma or take trauma call perceive it as never personally or professionally rewarding, more often disruptive to personal life, emotionally taxing, litigious, and inconvenient compared with other emergencies. Perception of dissimilar reimbursement and personal health risk are less often associated factors. Perceived differences in the litigious nature of cases are not based on fact. We conclude that the individual degree of reluctance or enthusiasm for trauma care in comparison with other emergencies is influenced by perception, personality, and myth rather than by logic and facts.
Jangland, Eva; Yngman Uhlin, Pia; Arakelian, Erebouni
The position of Nurse Practitioner is a new role in Nordic countries. The transition from a registered nurse to the Nurse Practitioner role has been reported to be a personal challenge. This study, guided by the Nordic theoretical model for use in the education of advanced practice nurses, represents a unique opportunity to describe this transition for newly graduated Nurse Practitioners in an interprofessional surgical care team in Sweden. The aim was to explore how the first Nurse Practitioners in surgical care experienced the transition into a new role and what competences they used in the team. Eight new Nurse Practitioners with parallel work in clinical practice were interviewed twice around the time of their graduation. The qualitative analyses show that the participants integrated several central competences, but the focus in this early stage in their new role was on direct clinical praxis, consultation, cooperation, case management, and coaching. Transition from the role of clinical nurse specialist to nurse practitioner was a challenging process in which the positive response from patients was a driving force for the new Nurse Practitioners. The participants felt prepared for and determined to solve the challenging situations they approached working in the interprofessional team.
Pasquali, S; Sommariva, A; Spillane, A J; Bilimoria, K Y; Rossi, C R
In an attempt to ensure high standards of cancer care, there is increasing interest in determining and monitoring the quality of interventions in surgical oncology. In recent years, this has been particularly the case for melanoma surgery. The vast majority of patients with melanoma undergo surgery. Usually, this is with combinations of wide excision, sentinel lymph node biopsy and lymphadenectomy. The indications for these procedures evolved during a time when no effective systemic adjuvant therapy was available, and whilst the rationale has been sound, the justification for differences in extent and thoroughness has generally been supported by inadequate or low-level evidence. This has led to a substantial variation among melanoma centres or even among surgeons within a centre in how these procedures are done. With recent rapid progress in the efficacy of systemic treatments that are impacting on overall survival, the prospect of long-term survival in these previously high risk patients means that more than ever long-term locoregional control of melanoma is imperative. Furthermore, the understanding of effects of systemic therapy on locoregional disease will only be interpretable if surgeons use standardized, high quality techniques. This article focuses on standardization and evolution of quality indicators for melanoma surgery and how these might have a positive impact on patient care. Copyright © 2016 Elsevier Ltd, BASO ~ the Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.
Udo, C; Melin-Johansson, C; Henoch, I; Axelsson, B; Danielson, E
This is a randomised controlled pilot study using a mixed methods design. The overall aim was to test an educational intervention on existential issues and to describe surgical nurses' perceived attitudes towards caring for patients dying of cancer. Specific aims were to examine whether the educational intervention consisting of lectures and reflective discussions, affects nurses' perceived confidence in communication and to explore nurses' experiences and reflections on existential issues after participating in the intervention. Forty-two nurses from three surgical wards at one hospital were randomly assigned to an intervention or control group. Nurses in both groups completed a questionnaire at equivalent time intervals: at baseline before the educational intervention, directly after the intervention, and 3 and 6 months later. Eleven face-to-face interviews were conducted with nurses directly after the intervention and 6 months later. Significant short-term and long-term changes were reported. Main results concerned the significant long-term effects regarding nurses' increased confidence and decreased powerlessness in communication, and their increased feelings of value when caring for a dying patient. In addition, nurses described enhanced awareness and increased reflection. Results indicate that an understanding of the patient's situation, derived from enhanced awareness and increased reflection, precedes changes in attitudes towards communication. © 2014 John Wiley & Sons Ltd.
Munger, Mark A; Walsh, Michael; Godin, Jon; Feehan, Michael
The US population continues to expand providing the need for primary health care services. Community pharmacies integrated with medicine may provide greater access while providing high quality care. To gauge pharmacists' demand for primary health care services delivered through community pharmacies. An online survey was administered to determine community pharmacists' preferences for varying primary care services that could be offered in the community pharmacy setting. A Discrete Choice Experiment was employed to show pharmacists competing scenarios with varied primary care service offerings in the community pharmacy setting. Attributes evaluated were operation hours, service provider, medical records, service logistics, physical examinations, point-of-care diagnostic testing, preventative care, and drug prescribing. Respondents chose the scenario most likely to induce switching employment from base pharmacy to one providing advanced services. The optimal service delivery model from 291 community pharmacists comprised: inclusion of patient prescriptions and health information into the patient's medical record; provision of point of care testing and vital sign, including blood pressure, heart rate and breathing rate, and blood sugar and cholesterol measurement; and pharmacists prescribing (under physician oversight). Pharmacists were 4 times more likely to switch employment from their current pharmacy to their choice for advanced pharmacy services. Pharmacist demand was highest among those with a PharmD, less experience, working >40 hours per week, and in rural areas. This study provides empirical support for the model of pharmacists playing a greater role in the provision of primary care health services through community pharmacy settings.
Kirkley, Catherine; Bamford, Claire; Poole, Marie; Arksey, Hilary; Hughes, Julian; Bond, John
Ensuring the development and delivery of person-centred care in services providing respite care and short breaks for people with dementia and their carers has a number of challenges for health and social service providers. This article explores the role of organisational culture in barriers and facilitators to person-centred dementia care. As part of a mixed-methods study of respite care and short breaks for people with dementia and their carers, 49 telephone semi-structured interviews, two focus groups (N= 16) and five face-to-face in-depth interviews involving front-line staff and operational and strategic managers were completed in 2006-2007. Qualitative thematic analysis of transcripts identified five themes on aspects of organisational culture that are perceived to influence person-centred care: understandings of person-centred care, attitudes to service development, service priorities, valuing staff and solution-focused approaches. Views of person-centred care expressed by participants, although generally positive, highlight a range of understandings about person-centred care. Some organisations describe their service as being person-centred without the necessary cultural shift to make this a reality. Participants highlighted resource constraints and the knowledge, attitudes and personal qualities of staff as a barrier to implementing person-centred care. Leadership style, the way that managers' support and value staff and the management of risk were considered important influences. Person-centred dementia care is strongly advocated by professional opinion leaders and is prescribed in policy documents. This analysis suggests that person-centred dementia care is not strongly embedded in the organisational cultures of all local providers of respite-care and short-break services. Provider organisations should be encouraged further to develop a shared culture at all levels of the organisation to ensure person-centred dementia care.
Gordon, Chad R; Axelrad, Alex; Alexander, James B; Dellinger, R Phillip; Ross, Steven E
As a result of the recently mandated work-hour restrictions, it has become more difficult to provide 24-hour intensive care unit (ICU) in-house coverage by the general surgical residents. To assess the current state of providing appropriate continuous care to surgical critical care patients during the era of resident work-hour constraints, a national survey was conducted by the Association of Program Directors of Surgery. The results revealed that 37 per cent of programs surveyed have residents other than general surgery housestaff providing cross-coverage and writing orders for surgical ICU patients. Residents in emergency medicine, anesthesia, family medicine, otorhinolaryngology, obstetrics/gynecology, internal medicine, urology, and orthopedic surgery have provided this cross-coverage. Some found it necessary to use physician extenders (i.e., nurse practitioners or physician assistants), thereby decreasing the burden of surgical housestaff coverage. The results indicated that 30 per cent use physician extenders to help cover the ICU during daytime hours and 11 per cent used them during nighttime hours. In addition, 24 per cent used a "night-float" system in an attempt to maintain continuous care, yet still adhere to the mandated guidelines. In conclusion, our survey found multiple strategies, including the use of physician extenders, a "night-float" system, and the use of nongeneral surgical residents in an attempt to provide continuous coverage for surgical ICU patients. The overall outcome of these new strategies still needs to be assessed before any beneficial results can be demonstrated.
Vedula S. Swaroop
assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future.
Vedula, S Swaroop; Hager, Gregory D
-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future.
Egharevba, Johnbull; Pharr, Jennifer; van Wyk, Brian; Ezeanolue, Echezona
In Nigeria, most deliveries take place at home or with traditional birth attendants (TBAs). This study examined the factors that influenced or determined utilization of healthcare facility delivery services among women who attended antenatal care (ANC) services. A cross-sectional survey was conducted with 220 women who registered for ANC at a hospital and delivered within 18 months. Associations between independent variables and choice of healthcare facility delivery were analyzed. Multiple logistic regression was also used to identify the predictors of choice of delivery among women. Of the 220 women who registered for ANC, 75% delivered at a healthcare facility while 15% delivered with a TBA or at home. In the final model, number of children, having planned to deliver at a hospital, labor occurring at night, and labor allowing time for transportation were significant predictors of child delivery location among the women. Utilization of the health facilities for childbirth may increase if pregnant women are encouraged to book early for ANC and if during ANC, pregnant women were counseled to detect labor signs early. In addition to focused and intensified counseling for women with more children, support should be provided that includes financial provisions for transportation to the healthcare facility.
Mohd Nasiq Sambo
Full Text Available Background: Maternal mortality remains a leading cause of death among women of reproductive age. While Nigeria has only two percent of the global population, it contributes 10% to the global maternal mortality burden. Antenatal care (ANC reduces the incidence of maternal mortality. However, financial capability affects access to antenatal care. Thus, the rural poor are at a higher risk of maternal mortality. Materials and Methods: A cross-sectional descriptive study involving 135 women (pregnant women and those who are 6 weeks postpartum. Structured interviewer-administered questionnaires were used for data collection. Data analysis was carried out using statistical package for social sciences software (version 17. Results: The average amount spent on booking and initial laboratory investigations were N77 (half a dollar and N316 ($2, respectively. Per ANC visit, average amount spent on drugs and transportation were N229 ($1.5 and N139 ($0.9 respectively. For delivery, the average amount spent was N1500 ($9.6. On an average, ANC plus delivery cost about N3,365.00 ($22. There was a statistically significant association between husband′s income and ANC attendance (X 2 = 2.451, df = 2, P = 0.048. Conclusion: Cost of Antenatal care and delivery services were not catastrophic but were a barrier to accessing antenatal care and facility-based delivery services in the study area. ANC attendance was associated with the income of household heads. Pro-poor policies and actions are needed to address this problem, as it will go a long way in reducing maternal mortality in this part of the country.
Shrivastava, Saurabh RamBihariLal; Shrivastava, Prateek Saurabh; Ramasamy, Jegadeesh
India has a population of 1.21 billion people and there is a high degree of socio-cultural, linguistic, and demographic heterogeneity. There is a limited number of health care professionals, especially doctors, per head of population. The National Rural Health Mission has decided to mainstream the Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) system of indigenous medicine to help meet the challenge of this shortage of health care professionals and to strengthen the delivery system of the health care service. Multiple interventions have been implemented to ensure a systematic merger; however, the anticipated results have not been achieved as a result of multiple challenges and barriers. To ensure the accessibility and availability of health care services to all, policy-makers need to implement strategies to facilitate the mainstreaming of the AYUSH system and to support this system with stringent monitoring mechanisms. PMID:26151021
Saurabh RamBihariLal Shrivastava
Full Text Available India has a population of 1.21 billion people and there is a high degree of socio-cultural, linguistic, and demographic heterogeneity. There is a limited number of health care professionals, especially doctors, per head of population. The National Rural Health Mission has decided to mainstream the Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy (AYUSH system of indigenous medicine to help meet the challenge of this shortage of health care professionals and to strengthen the delivery system of the health care service. Multiple interventions have been implemented to ensure a systematic merger; however, the anticipated results have not been achieved as a result of multiple challenges and barriers. To ensure the accessibility and availability of health care services to all, policy-makers need to implement strategies to facilitate the mainstreaming of the AYUSH system and to support this system with stringent monitoring mechanisms.
Full Text Available Background: The organizational environment and its existing context may deeply affect on empowerment of individuals. In educational institutions as well as other organizations, students are going to be powerful when opportunities for growth and achievement of power are provided for them in learning and educational environments. This study has been carried out to explain the facilitators and impediment factors of midwifery student′s empowerment in pregnancy and delivery care. Materials and Methods: The current qualitative study has been conducted with participation of 15 midwifery senior students, 10 midwifery academic teachers, and 2 employed midwives in educational hospitals. The given data were collected through individual and group semi-structured interviews, and there were analyzed using directed content analysis method. Results: Three main categories of opportunity for acquisition of knowledge, opportunity for acquisition of clinical skills and opportunity for acquisition of clinical experiences formed structure of access to opportunity in the course of an explanation of facilitators and impediment factors for midwifery student′s empowerment in pregnancy and delivery care. Conclusion: To prepare and train the skilled midwives for giving care services to mothers during pregnancy and on delivery and after this period, the academic teachers and clinical instructors should pay due attention to providing the needed opportunities to acquire the applied knowledge and proficiency in the required skills for clinical work and the necessary clinical experiences in these individuals during college period.
Background: Intravenous (IV) fluid administration is an integral component of clinical care. Errors in administration can cause detrimental patient outcomes and increase healthcare costs, although little is known about medication administration errors associated with continuous IV infusions.
Carli, Francesco; Kehlet, Henrik; Baldini, Gabriele
Fast-track programs have been developed with the aim to reduce perioperative surgical stress and facilitate patient's recovery after surgery. Potentially, regional anesthesia and analgesia techniques may offer physiological advantages to support fast-track methodologies in different type of surge......Fast-track programs have been developed with the aim to reduce perioperative surgical stress and facilitate patient's recovery after surgery. Potentially, regional anesthesia and analgesia techniques may offer physiological advantages to support fast-track methodologies in different type...... of surgeries. The aim of this article was to identify and discuss potential advantages offerred by regional anesthesia and analgesia techniques to fast-track programs. In the first section, the impact of regional anesthesia on the main elements of fast-track surgery is addressed. In the second section......, procedure-specific fast-track programs for colorectal, hernia, esophageal, cardiac, vascular, and orthopedic surgeries are presented. For each, regional anesthesia and analgesia techniques more frequently used are discussed. Furthermore, clinical studies, which included regional techniques as elements...
Pesenti, S; Ciceron, C; Toledano, E; Niddam, J; Tournebise, H
Pressure sores are a frequent complication in spinal injured people. Their treatment is often long and complex. We report the case of a 60-year-old man affected with complete paraplegia who developed a right trochanteric pressure ulcer complicated with osteoarthritis of the coxofemoral joint. The treatment was done in three steps. First, a large excision of necrotic tissues and a femoral head-neck resection is performed. Then, the defect is partly covered with a Gluteus Maximus and a Biceps Femoris myocutaneous flaps. Finally, the residual defect is covered with a cutaneous pedicled groin flap called McGregor's flap. Later, the patient showed a right para-scrotal pressure sore on a heterotopic ossification of the ischial tuberosity. McGregor's flap is rarely employed for treating trochanteric pressure sores. It was here the only pedicled flap available. It was necessary to autonomize it in order to get enough length and to place a hip external fixation. The para-scrotal pressure sore illustrates the fact that bone resection surgery lifts the weight-bearing zones and can lead to pressure sores in unusual locations. The surgical treatment of these "giant" pressure sores requires a perfect collaboration between teams of rehabilitation and several surgical areas. Without a good adherence of the patient, the treatment is doomed to fail. Copyright Â© 2016 Elsevier Masson SAS. All rights reserved.
Full Text Available Abstract Background Antenatal Care (ANC during pregnancy can play an important role in the uptake of evidence-based services vital to the health of women and their infants. Studies report positive effects of ANC on use of facility-based delivery and perinatal mortality. However, most existing studies are limited to cross-sectional surveys with long recall periods, and generally do not include population-based samples. Methods This study was conducted within the Health and Demographic Surveillance System (HDSS of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b in Matlab, Bangladesh. The HDSS area is divided into an icddr,b service area (SA where women and children receive care from icddr,b health facilities, and a government SA where people receive care from government facilities. In 2007, a new Maternal, Neonatal, and Child Health (MNCH program was initiated in the icddr,b SA that strengthened the ongoing maternal and child health services including ANC. We estimated the association of ANC with facility delivery and perinatal mortality using prospectively collected data from 2005 to 2009. Using a before-after study design, we also determined the role of ANC services on reduction of perinatal mortality between the periods before (2005 – 2006 and after (2008–2009 implementation of the MNCH program. Results Antenatal care visits were associated with increased facility-based delivery in the icddr,b and government SAs. In the icddr,b SA, the adjusted odds of perinatal mortality was about 2-times higher (odds ratio (OR 1.91; 95% confidence intervals (CI: 1.50, 2.42 among women who received ≤1 ANC compared to women who received ≥3 ANC visits. No such association was observed in the government SA. Controlling for ANC visits substantially reduced the observed effect of the intervention on perinatal mortality (OR 0.64; 95% CI: 0.52, 0.78 to non-significance (OR 0.81; 95% CI: 0.65, 1.01, when comparing cohorts before
Hignett, Sue; Edmunds Otter, Mary; Keen, Christine
To explore the safety risks associated with physical interactions between patients and caregivers during treatment and care delivery in Home Care settings. Seven-stage framework from the PRISMA statement for research question, eligibility (definition), search, identification of relevant papers from title and abstract, selection and retrieval of papers, appraisal and synthesis. British Nursing Index (BNI), Allied and Complementary Medicine Database (AMED), Applied Social Sciences Index and Abstracts (ASSIA), Cinahl, Cochrane Library, Embase, Ergonomics Abstracts, Health Business Elite, Health Management Information Consortium (HMIC), Medline, PsycInfo, Scopus, Social Care online, Social Science Citation Index. The included references (n=42) were critically appraised using a modified version of Downs and Black checklist and the Mixed Methods Appraisal Tool. The risk factors are reported using the modified model of human factors of health care in the home to represent the roles of both patients and caregivers in the system. The results are grouped as environment (health policy, physical and social), artefacts (equipment and technology), tasks (procedures and work schedules) and care recipient/provider. These include permanent and temporary building design and access, communication and lone working, provision of equipment and consumables, and clinical tasks. The topics with strong evidence from at least 2 papers relate to risks associated with awkward working positions, social environment issues (additional tasks and distractions), abuse and violence, inadequate team (peer) support, problems with workload planning, needle stick injuries and physical workload (moving and handling patients). As home care increases, there is a need to ensure the safety of both patients and caregivers with an understanding of the physical interactions and tasks to manage safety risks and plan safer care delivery systems. Copyright © 2016 Elsevier Ltd. All rights reserved.
Kehlet, H.; Wilmore, D.W.
, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However......BACKGROUND: Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program. OBJECTIVE: To assess, synthesize, and discuss implementation of "fast-track" recovery programs. DATA SOURCES: Medline MBASE...... (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational...
Pawlik, Timothy M; Curley, Steven A
Recent medical advances have complicated decisions regarding terminal care. Surgeons should be familiar with the ethical issues that contribute to end-of-life decision-making. Four clusters of ethical principles (autonomy, nonmaleficence, beneficence, and justice)are used commonly in ethical deliberations. Artificial ethical distinctions between withholding versus withdrawing care or ordinary versus extraordinary treatments can confuse clinical decision-making at the end of life. An ethics of death and dying requires that the intent and the action of the moral agent be considered.
Full Text Available Objective: The most efficient and most cost effective method for preventing health care associated infections is hand hygiene. Although hand hygiene is the most effective and simple method, compliance rates are very low among health care workers. It was aimed to evaluate the rates of compliance of healthcare workers in a state hospital. Material and Method: In this study, totally 112 healthcare workers (31 doctors and 81 nurses were evaluated with the 5-indication observation method in a period between January and July 2013. Results: A total of 754 (65.9% out of 1.144 cases were resulted in accurate hand washing and hand-rubbing. When the intensive care unit and surgical clinics were evaluated together, it was found that hand hygiene compliance rates were 51.26% in 199 cases and 66.85% in 591 cases for doctors and nurses, respectively. Conclusion: Consequently, we think that pre-informed observations are important training instruments for hand hygiene compliance.
Full Text Available High quality care is crucial in ensuring that women and newborns receive interventions that may prevent and treat birth-related complications. As facility deliveries increase in developing countries, there are concerns about service quality. Observation is the gold standard for clinical quality assessment, but existing observation-based measures of obstetric quality of care are lengthy and difficult to administer. There is a lack of consensus on quality indicators for routine intrapartum and immediate postpartum care, including essential newborn care. This study identified key dimensions of the quality of the process of intrapartum and immediate postpartum care (QoPIIPC in facility deliveries and developed a quality assessment measure representing these dimensions.Global maternal and neonatal care experts identified key dimensions of QoPIIPC through a modified Delphi process. Experts also rated indicators of these dimensions from a comprehensive delivery observation checklist used in quality surveys in sub-Saharan African countries. Potential QoPIIPC indices were developed from combinations of highly-rated indicators. Face, content, and criterion validation of these indices was conducted using data from observations of 1,145 deliveries in Kenya, Madagascar, and Tanzania (including Zanzibar. A best-performing index was selected, composed of 20 indicators of intrapartum/immediate postpartum care, including essential newborn care. This index represented most dimensions of QoPIIPC and effectively discriminated between poorly and well-performed deliveries.As facility deliveries increase and the global community pays greater attention to the role of care quality in achieving further maternal and newborn mortality reduction, the QoPIIPC index may be a valuable measure. This index complements and addresses gaps in currently used quality assessment tools. Further evaluation of index usability and reliability is needed. The availability of a streamlined