Vaccines, government misbehavior, and the medical profession

Strategies for Partnering with Health Care Settings to Increase Physical Activity Promotion

Evidence-based nursing practice is essential to the delivery of high-quality care that optimizes patients' outcomes. Studies continue to show improved outcomes when best evidence is used in the delivery of patient care. Despite awareness of the importance of practicing by using best evidence, achieving and sustaining evidence-based practice within practice environments can be challenging, and research suggests that integration of evidence-based practice into daily clinical practice remains inconsistent. This article addresses 4 practice issues that, first, are within the realm of nursing and if changed might improve care of patients and, second, are areas in which the tradition and the evidence do not agree and practice continues to follow tradition. The topics addressed are (1) noninvasive measurement of blood pressure in children, (2) oxygen administration for patients with chronic obstructive pulmonary disease, (3) intravenous catheter size and blood administration, and (4) infection control practices to prevent infections. The related beliefs, current evidence, and recommendations for practice related to each topic are described.

A key limiting factor in the scale up and sustainability of HIV care and treatment programmes is the global shortage of trained health care workers. This paper discusses why it is important to move beyond conceptualising health care workers simply as 'inputs' in the delivery of HIV treatment and care, and to also consider their roles as partners and agents in the process of health care. It suggests a framework for thinking about their roles and responses in HIV care, considers the current evidence base, and concludes by identifying key areas for future research on health care workers' responses in HIV treatment and care in low and middle income settings.

Addressing Shortcomings in Contingency Standards of Care

Medical professionalism in the new millennium: a physician charter.

Annotated Abstracts

Commentary: Standard of Care During a Crisis: What Should a Surgeon Know (and Do)?

ON OCTOBER 23, 2009, PRESIDENT OBAMA DEclared a national emergency in response to the 2009 influenza A(H1N1) pandemic. The president’s declaration followed the US Department of Health and Human Services’ (HHS) prior declaration of a public health emergency in April 2009. Together, these declarations changed the legal landscape for influenza A(H1N1) response efforts domestically. HHS Secretary Kathleen Sebelius, for example, was authorized to waive or conditionally set aside or modify certain federal program requirements and disable federal law requiring hospitals to screen patients seeking emergency services on site. These federal responses and several state-based emergency declarations are intended to help clinicians handle surges of patients with flu symptoms and other conditions. Through what the Institute of Medicine (IOM) has recently framed “crisis standards of care,” health care practitioners (eg, physicians, nurses, counselors) adapt medical standards of care to screen and treat increasing numbers of patients and manage limited resources during severe public health emergencies. Changing medical standards, however, leads to some uncertainty in practice and corresponding unpredictability in how legal decision makers may judge the performance of health care practitioners in crises. Emergency laws provide liability protections for some health care practitioners and many volunteers. Yet, for many clinicians and health care entities lacking immunity during emergencies, questions of liability are pervasive. These clinicians and entities may be unsure about how legal decision makers may judge their actions if patients are harmed stemming from adjustments to the medical standard of care in emergencies. Medical malpractice claims have typically not proliferated in emergencies. However, fears of liability may deter clinicians and hospitals from affirmative responses to protect patients and the public’s health— especially given highly publicized cases such as those involving physicians’ actions during Hurricane Katrina. To assist medical and judicial responders, we propose a new framework for assessing legal standards of care in emergencies that seeks to balance practitioner, patient, and community needs. Existing Legal Standards of Care Nationally, clinicians are obligated to conform to medical standards of care in the provision of health services. Medical standards of care reflect the types and levels of medical care and practices appropriate for each profession. In nonemergencies, these standards are based largely on professional requirements and norms; are established by professional societies, government agencies, accrediting organizations, and other entities; and vary among types of facilities (eg, hospitals, assisted living facilities, clinics). In emergencies, medical standards of care can fluctuate to allow for rapid changes in practices as circumstances evolve. When determining liability, legal decision makers assess a clinician’s practices against the prevalent legal standard of care. As with medical standards, there is no single legal standard of care nationally. Most state courts use the national standard of care as the legal barometer of care that a clinician should provide. At the state level, the legal standard of care is based on what a reasonable and prudent practitioner of the same specialty nationally would do under similar circumstances. Some state courts will also consider a practitioner’s access to available resources (eg, medical equipment, facilities, specialists) in determining whether appropriate care was given under this standard. A minority of states refer to the locality rule, which assesses what a reasonable practitioner in the same or similar locality would do under the circumstances. Under any of these approaches, a practitioner who deviates from the legal standard of care may face medical malpractice liability for resulting patient harms.

EDITOR–The overall aim of the Common Data Elements (CDE) project1 was to standardize data collection and assessment in studies of children and young people with cerebral palsy (CP). Dr Fairhurst's commentary raised the following question: can standardized care coexist with personalized care without losing the flexible art of medicine?2 Standardization promotes the application of evidence-based medicine (or the best available evidence) in a systematic way, to ensure patients receive effective care. We need less variance in clinical practice to achieve more consistent outcomes and improve quality of care and patient safety. On the other hand, personalization of care relies on health professionals knowing their patients well and treating them as unique individuals. Personalization improves the patient experience and increases their engagement and health knowledge. While standardization of clinical care – using universal frameworks, CDEs, toolbox of measures, core sets, care pathways – is valuable to support evidence-based practices, the experience from the child's and his or her family's points of view can still be personalized. It is important to note that with standardized care there are still decisions to be made based on the child's and family's preferences and choices. Setting goals and priorities for intervention, pain management techniques, and type and time of introduction of assistive technologies are examples where clients' decision-making takes place to meet their personalized needs. Hence, we can standardize and personalize care at the same time. The recommended CDEs for children and young adults with CP standardize data collection for this population. In CP, standardization and personalization can complement each other. Most importantly, standardization can enhance personalization by eliminating the unnecessary time and cost of using low quality assessment tools, or ignoring opportunities to obtain relevant clinical information, which in turn minimizes complications or inappropriate treatment that does not adhere to best evidence-informed practices. Health professionals often make assessment and treatment decisions based on their unique clinical education and experiences. Standardization compensates for this variation in history and experience and harmonizes assessment, evaluation, and reporting of outcomes, ultimately facilitating informative comparisons across research studies and therapeutic interventions. Finally, we propose that the essence of good empathic care is based on the personal connection and mutual respect developed between health professionals and the child and family. While standardization of care has the potential to relieve actual workload and to allow for more positive and productive in-person connections. Future CP CDE revisions will incorporate additional information that includes client perspectives, preferences, and choices in a systematic way, to enhance the standardized tools proposed by the current recommendations in CP CDEs version 1.0.

Stress First Aid is an evidence-informed peer-to-peer support intervention to mitigate the effect of the COVID-19 pandemic on the well-being of health care workers (HCWs). To evaluate the effectiveness of a tailored peer-to-peer support intervention compared with usual care to support HCWs' well-being at hospitals and federally qualified health centers (FQHCs) during the COVID-19 pandemic. This cluster randomized clinical trial comprised 3 cohorts of HCWs who were enrolled from March 2021 through July 2022 at 28 hospitals and FQHCs in the US. Participating sites were matched as pairs by type, size, and COVID-19 burden and then randomized to the intervention arm or usual care arm (any programs already in place to support HCW well-being). The HCWs were surveyed before and after peer-to-peer support intervention implementation. Intention-to-treat (ITT) analysis was used to evaluate the intervention's effect on outcomes, including general psychological distress and posttraumatic stress disorder (PTSD). The peer-to-peer support intervention was delivered to HCWs by site champions who received training and subsequently trained the HCWs at their site. Recipients of the intervention were taught to respond to their own and their peers' stress reactions. Primary outcomes were general psychological distress and PTSD. General psychological distress was measured with the Kessler 6 instrument, and PTSD was measured with the PTSD Checklist. A total of 28 hospitals and FQHCs with 2077 HCWs participated. Both preintervention and postintervention surveys were completed by 2077 HCWs, for an overall response rate of 28% (41% at FQHCs and 26% at hospitals). A total of 862 individuals (696 females [80.7%]) were from sites that were randomly assigned to the intervention arm; the baseline mean (SD) psychological distress score was 5.86 (5.70) and the baseline mean (SD) PTSD score was 16.11 (16.07). A total of 1215 individuals (947 females [78.2%]) were from sites assigned to the usual care arm; the baseline mean (SD) psychological distress score was 5.98 (5.62) and the baseline mean (SD) PTSD score was 16.40 (16.43). Adherence to the intervention was 70% for FQHCs and 32% for hospitals. The ITT analyses revealed no overall treatment effect for psychological distress score (0.238 [95% CI, -0.310 to 0.785] points) or PTSD symptom score (0.189 [95% CI, -1.068 to 1.446] points). Post hoc analyses examined the heterogeneity of treatment effect by age group with consistent age effects observed across primary outcomes (psychological distress and PTSD). Among HCWs in FQHCs, there were significant and clinically meaningful treatment effects for HCWs 30 years or younger: a more than 4-point reduction for psychological distress (-4.552 [95% CI, -8.067 to -1.037]) and a nearly 7-point reduction for PTSD symptom scores (-6.771 [95% CI, -13.224 to -0.318]). This trial found that this peer-to-peer support intervention did not improve well-being outcomes for HCWs overall but had a protective effect against general psychological distress and PTSD in HCWs aged 30 years or younger in FQHCs, which had higher intervention adherence. Incorporating this peer-to-peer support intervention into medical training, with ongoing support over time, may yield beneficial results in both standard care and during public health crises. ClinicalTrials.gov Identifier: NCT04723576.

Community-Based Strategies for Blood Pressure Control in Low-Income Countries

Integrating public health research trials into health systems in Africa: individual or cluster randomisation?

4. Oversight of the process by completely independent organizational personnel to ensure compliance. This section discusses this process as it applies to associational and intellectual interests and in the context of educational activities, publications, peer review, research data, technology, and expert testimony. The many other contexts in which an interest can create COIs are beyond the scope of this section. The task force supports the existing relevant policies and guidelines of the ACC and AHA, National Academy of Medicine (NAM), ACGME, AMA, and National Institutes of Health, all of which have been carefully created and vetted, 32 and makes recommendations that merit further consideration in the implementation of this process.

Background: Access to timely, age-appropriate palliative care services and end-of-life communication are two standards of care for adolescents and young adults (AYAs) living with cancer where cure is uncertain or unlikely. Health professionals' capacity to facilitate these standards is critical. This study aimed to understand AYA oncology health professionals' experienced practices in, and barriers to, delivering these standards of care across palliative care and end-of-life communication in Australia, New Zealand, and the United Kingdom (UK). Procedure: We invited health professionals to complete a survey examining access, barriers to, and practices around these standards of care. Tailored to local settings, our survey assessed current delivery of palliative care and end-of-life communication services (including advance care planning [ACP]) and barriers to implementation of these. Results: In total, 148 interdisciplinary health professionals participated (89% female overall; 83% female in Australia, 88% female in New Zealand, and 98% female in the UK). Across countries, participants reported that most institutions had an AYA cancer program (74% overall). Introduction to palliative care services was most often prognosis dependent or "not at any uniform time." ACP was less frequently introduced than palliative care. The most endorsed barrier to palliative care team introduction, as well as ACP, was "some team members not knowing how to introduce the topic." Conclusions: Our results indicate that there are common barriers to AYAs receiving palliative care, end-of-life communication, and ACP. Given that health professionals' confidence in this area can enable facilitation of early, age-appropriate communication, resources and training are urgently needed to bridge these practice gaps.

Collaborative practice agreements: Stimulating increased integration