Daily Care Practice Research Articles

Sensor-floors: Changing Work and Values in Care for Frail Older Persons

Based on an ethnographic study in a Danish residential care center, this article shows how the interplay of a sensor-floor technology and currently influential values of person-centeredness, privacy, and security in care transforms care work and care interactions between residents and care workers. Based on an understanding of care as realized in a heterogeneous collective of human and nonhuman actors, this article illustrates how new modes of monitoring and interpreting residents’ care needs at a distance arise, and how a new organization of work focusing on quick and responsive care is established. These new care practices lead to conflicts between the values of privacy and security, to ambivalent experiences among care workers of simultaneously increased security and insecurity in work, and, paradoxically, also often to a decentering rather than person-centering of care. Instead of accommodating simultaneous compliance to the values of privacy, security, and person-centeredness, the use of the sensor-floors makes the tensions between these values continuously and loudly present in daily care practices.

Understanding Technology in Birth Care from the Experiences of Taiwanese Obstetricians

Childbirth in Taiwan is characterized by the use of intensive technological and surgical interventions. Taiwanese cesarean rates are among the highest in the world, fetal monitoring is standard, and interventions such as episiotomy and labor augmentation are routinized practices during childbirth. In this Research Note, I describe the sociopolitical context that has given rise to this situation. More specifically, based on ethnographic research concerning birth care, I explore the ways obstetricians navigate this context and highlight the values and considerations that produce and shape “care” on the ground. I argue that understanding how interventionist birth care has come about, and how it is sustained as obstetricians manage care in daily practice, is vital to inform ongoing feminist activism for women’s self-determination and the de-medicalization of childbirth in Taiwan.

STERILIZATION AND DISINFECTANTS USED IN A DENTAL OFFICE- A REVIEW

As dentists, we must disinfect and clean all equipment’s and countertops between patients with a recommended hospital-grade bactericidal product. Non visible blood and saliva does not mean it is absent on environmental surfaces. Blood and saliva are present throughout dental treatment. If a patient becomes ill as a result of an exposure to a pathogen or a bacterium that is later found in our dental office surfaces, the employer and/or dentist is at risk of being responsible for the patient's illness and associated compensatory damages. Understanding and recognizing the risk of disease will drastically reduce patient illness, practice liability and employee illnesses. Dentists cannot pretend that this is only a theoretical problem. Therefore the dental community needs to stay updated of the rapidly evolving standard of care and do its best to comply with the standard of care in daily practice.
 Key Words: Sterilization, Chemical Disinfection, Fumigation, Pathogens.

Abstract NS1: Implementation Science Study Suggests That Key Concepts of Systems of Stroke Care Are Missing or Not Fully Implemented

Background and Purpose: The timely integration of high quality scientific evidence into daily patient care practices is an issue that has been around for decades. Newer research says it may take even longer for practitioners to stop unnecessary practices. What is evident is that there is a need to shorten the time from discovery to practice with an expectation of improved outcomes and control of heath care spending. Understanding the extent to which concepts (research) of stroke systems have been implemented (practice) within a region, can result in meaningful system improvement. We sought to evaluate the current state of systems in the southeastern United States to inform the development of a large-scale implementation science system of care improvement program. Methods: An 85 question, internet-based survey was developed to obtain information on current practices in sites located in the southeastern US. Data was collected in October, 2017. A total of 13 stroke centers from 3 states participated. We used the Research Electronic Data Capture (REDCap) data base; simple calculations were used where appropriate. Results 911: 50% of sites knew that 911 used a stroke screening tool. EMS: 69% allowed EMS bypass of Emergency Department (ED) to the Computerized Tomography (CT) scanner, 67% of EMS have destination plans, and 33% have stroke severity scales. ED: 50-86 % of victims arrive by EMS, 62% allowed the Register Nurse (RN) to activate the code, and 62% have CT scanners in ED. Reversal Agents: 20% of sites have available in ED. Transfer: 24% of transfer patients go directly to Interventional Radiology (IR) lab for Suspected LVO, 33% track door in door out at the referral center, 31% transport time, and 31% first hospital to groin. QI: 83% collect pre-hospital metrics manually, 42% have data immediately available, and 67% have regional meetings. Conclusions: The American Heart Association outlines key concepts for Systems of Stroke Care for adoption but few have been able to fully implement the recommendations. The survey results demonstrate application of key components are still missing or not fully implemented. Implementation science programs have the tools to mentor sites into full application of the systems recommendations which will ultimately improve outcomes.

The safety of punch biopsies on hard-to-heal wounds: a large multicentre clinical trial

Objective: Punch biopsy is a simple and effective diagnostic technique used in hard-to-heal wound management. Histologic examination can rule out cancer in the wound bed or diagnose vasculitis in a hard-to-heal or suspicious ulcer. A biopsy can determine the level of bacteria in an ulcer when infection is suspected. Despite its use, health professionals practicing in wound clinics hesitate to perform punch biopsies. The reasons vary from the invasive nature of the procedure to a fear of complications. Methods: A multicentre clinical trial evaluated the addition of fluorescence imaging to clinical examination in determining bacterial burden in hard-to-heal wounds. The protocol required a 6mm punch biopsy of any area (up to three) suspected of having moderate-to-high bacteria levels either on clinical examination or fluorescence image. If clinical examination and fluorescence imaging both did not indicate bacteria, the health professional took a biopsy of the centre of the ulcer. The biopsies were performed under local anaesthesia after cleansing the ulcer bed with sterile normal saline. Haemostasis was achieved with direct pressure and the occasional topical clotting agent. All of the patients were followed for 30 days to monitor for adverse events. Results: A total of 350 patientis with wounds (diabetic foot ulcer n=138; venous leg ulcer n=106; pressure ulcer n=22; surgical site infection n=60; other n=24), enrolled by 20 investigators at 14 sites in the US, underwent a total of 412 punch biopsies. Haemostasis was achieved in all 412 biopsies. No biopsy sites required cautery or suture ligation to control bleeding. No subjects returned to the clinic secondary to bleeding. A patient developed an infection three days post-biopsy that could have been due to the punch biopsy. However, the patient was HIV-positive and the quantitative biopsy was positive for infection, biopsy bacterial load of 106 colony forming units (CFU)/g. Conclusion: This trial used a 6mm punch to obtain tissue for culture, histology and additional biomarker research. In daily wound care practice, a smaller 3mm punch suffices. Adverse events were rare despite the larger biopsy. Punch biopsies are a safe procedure for obtaining tissue for histologic or microbiologic analysis.

Self-reported attitudes, knowledge and skills of using evidence-based medicine in daily health care practice: A national survey among students of medicine and health sciences in Hungary.

In order to map attitudes, knowledge and skills related to evidence-based medicine (EBM) in students of medical and health sciences faculties, we performed an online survey during the spring semester 2019 in all medical and health sciences faculties in Hungary. In total, 1080 students of medicine and 911 students of health sciences completed the online questionnaire. The attitude towards EBM was generally positive; however, only a small minority of students rated their EBM-related skills as advanced. There were large differences in the understanding of different EBM-related terms, with 'sample size' as the term with the highest (65%) and 'intention-to-treat analysis' with the lowest (7%) proportion of medical students being able to properly explain the meaning of the expression. Medical students who already participated in some EBM training rated their skills in searching and evaluating medical literature and their knowledge of EBM-related terms significantly better and had a more positive attitude towards using EBM in the practice than students without previous EBM training. EBM trained medical students were more likely to choose online journals (17.5% compared to 23.9%, p<0.05) and professional guidelines (15.4% compared to 6.1%, p<0.001) instead of printed books (33.6% compared to 52.6, p<0.001) as the main source of healthcare information retrieval and used Pubmed/Medline, Medscape and the Cochrane Library to a significant higher rate than students without any previous EBM training. Healthcare work experience (OR = 1.59; 95% CI = 1.01-2.52), conducting student research (OR = 2.02; 95% CI = 1.45-2.82) and upper year university students (OR = 1.65; 95% CI = 1.37-1.98) were other factors significantly influencing EBM-related knowledge. We conclude that the majority of students of medical and health sciences faculties are keen to acquire EBM-related knowledge and skills during their university studies. Significantly higher EBM-related knowledge and skills among EBM trained students underline the importance of targeted EBM education, while parallel increase of knowledge and skills with increasing number of education years highlight the importance of integrating EBM terminology and concepts also into the thematic of other courses.

A context analysis on how oral care is delivered in hospitalised patients: A mixed‐methods study

To analyse oral care delivery in one hospital through exploring experiences from both nurses' and patients' perspectives and examining patients' oral health. Oral health problems are associated with undernutrition and other general health outcomes. Although oral care belongs to the essentials of nursing, it is often neglected. Improving oral health may require behaviour change of both nurses and patients. Defining tailored strategies need a clear view on the context. A context analysis in one hospital using a convergent parallel mixed-methods design was reported following the EQUATOR guidelines using two checklists: COnsolidated criteria for REporting Qualitative research (qualitative research) and STROBE (observational research). Semi-structured interviews were conducted with 19 nurses and 11 patients. The topic list was based on the Integrated Change Model. Prospective oral examination was performed among 91 surgical patients using the Oral Health Assessment Tool (OHAT). Nurses acknowledged that they did not prioritise oral care in daily practice. Furthermore, they lacked knowledge and skills to identify and provide care for oral problems. Nurses mentioned helpful resources to perform oral care, like standardised language and instruments. However, they had no access to or were unaware of them. Patients admitted that they did not prioritise oral care due to their sickness during hospitalisation, were unaware of the importance of oral care, but felt responsible for their oral care. The most prominent oral problems identified with the OHAT were unclean mouths (n=75, 82%), unhealthy gum and tissues (n=55, 60%) and dry mouth (n=42, 46%). This context analysis identified inadequate oral care due to lack of positive attitude and knowledge in both nurses and patients, skills for nurses, and resources. The behavioural factors indicate strategies for development of a multicomponent intervention to improve oral care in this hospital, nutritional status and general health outcomes.

Psychiatric and behavioral problems and well-being in gerontopsychiatric nursing home residents

Objectives Gerontopsychiatric nursing home residents are residents with a chronic mental condition (not dementia), in combination with one or more physical disorders. Psychiatric and behavioral problems are common within this population. The objective of this study is to examine these behaviors and their relationship to the level of both observed and self-rated well-being in the gerontopsychiatric population. Method Both gerontopsychiatric residents, and their primary formal caregiver in several nursing homes in The Netherlands were asked to participate in a structured interview concerning psychiatric and behavioral problems and resident well-being. Psychiatric and behavioral problems were measured with the Neuropsychiatric Inventory Questionnaire (NPI-Q) and the Cohen Mansfield Agitation Index (CMAI). Well-being was measured through the self-rated Laurens Well-being Inventory for Gerontopsychiatry (LWIG), and the observer rated Laurens Well-being Observations for Gerontopsychiatry (LWOG). Results A total of 126 residents participated in the study with ages varying from 42 to 90. Different types of chronic mental disorders such as schizophrenia spectrum disorder, bipolar disorders and personality disorders were prevalent in the population. Most psychiatric and behavioral problems are associated with lower observed and self-rated well-being. For irritability and affective problem behaviors the relationship with well-being was the most evident Conclusion In daily care practice the relationship between well-being and psychiatric and behavioral problems should be taken into account in care planning and treatment. To further explore the direction and details of this relationship, more research is needed.

Analgesic use in contemporary burn practice: Applications to burn mass casualty incident planning

BackgroundDetermining the amount of analgesics required will help burn centers improve their ability to plan for a burn mass casualty incident (BMCI). We sought to quantify the amount of analgesics needed in an inpatient burn population. We hoped that assessing the analgesic use in daily burn care practice will potentially help estimate opioid needs in a burn mass casualty incident (BMCI). MethodsWe included patients with burns covering equal to or less than 30% total body surface area (TBSA), admitted from spring 2013 to spring 2015. Patient records were reviewed for analgesics and adjuncts, pain scores, age and TBSA. The doses of the different opioids administered were converted into morphine equivalent doses (MED). ResultsWe enrolled 141 acute burn survivors with a mean TBSA of 8.2±0.6%. The lowest daily average MED per person was 24.6±2.0mg MED, recorded on the day of injury. The daily average MED per person increased until it peaked at 52.5±5.6mg MED at day 8 post-burn. Then, it declined to 24.6±3.4mg MED by day 14. Bivariate regression analysis of average MED by TBSA showed a significant positive correlation (p<0.001). The analysis of average MED by age showed a significant negative correlation (p<0001). ConclusionOur study quantified opioid requirements in an inpatient burn population and identified TBSA (positively) and age (negatively) as significant predictors.

Natural history of growth and anaemia in children with epidermolysis bullosa: a retrospective cohort study.

Impaired growth and anaemia are major extracutaneous complications of epidermolysis bullosa (EB), but data on their development are lacking. To determine the clinical course of growth and anaemia in children with EB and clarify the impact of nutritional compromise, inflammation and genetic factors. A retrospective study was conducted of 200 children, 157 with recessive dystrophic EB (RDEB) and 43 with junctional EB (JEB)-generalized intermediate, followed at the main referral centre in Germany. Growth charts were calculated using the modified LMS method and were correlated with parameters of anaemia, nutrition, inflammation and the molecular defect in a linear model. In our cohort of patients with RDEB, weight impairment started at 12-18 months old; by the age of 10 years, 50% showed wasting. The predicted median weight at age 20 years was 35·2 kg for men and 40·1 kg for women. In JEB, growth resembled that of healthy children. Anaemia was present from the second year of life onwards in RDEB and JEB. Low levels of haemoglobin, iron, vitamin D, zinc and albumin, high levels of C-reactive protein, and absence of collagen VII correlated significantly with low weight in RDEB. No correlation was observed in JEB. The results highlight that nutritional compromise occurs early in children with RDEB and therefore may require interventions as of the first year or two of life. What's already known about this topic? Children with epidermolysis bullosa (EB) suffer from failure to thrive and anaemia as major extracutaneous complications. The course of growth and the development of anaemia in EB are poorly characterized. What does this study add? A molecularly well characterized cohort of 200 children with EB was followed with regard to anthropometrics, anaemia and inflammation. We demonstrate early onset of growth failure and anaemia, most pronounced in the subset of recessive dystrophic EB. Awareness of early growth delay and nutritional deficiencies will improve EB care in daily practice.

GECAT - German Evaluation of Cancer Associated Thrombosis: A Prospective Register Trial for Patients with Active Cancer and Venous Thromboembolism (VTE) in Berlin

Background: National and international guidelines for the diagnosis and treatment of cancer associated venous thromboembolism (CAT) recommend anticoagulation treatment for 3 to 6 months and a re-evaluation for resumption depending on the individual risk of every patient. In CAT low molecular weight heparin (LMWH) was estimated to be the most effective and safest treatment option in 2015. However, it remains unclear how cancer patients with VTE were (treated in clinical daily care in Germany. In former register trials, the specific characteristics of individual cancer patients were insufficiently characterized and inadequately discussed. Special aspects of daily care are lacking in most publications. Methods: The GECAT register was set up for Berlin´s two main hospital companies Charité-Universitaetsmedizin Berlin and Vivantes, (both covering about 50 % of the hospital beds in Berlin) to document prospectively patients with a newly diagnosed VTE . Patients with the diagnosis of cancer within 2 years prior to the VTE got basis documentation by a physician after informed consent. A follow up of these patients was scheduled after 3 and 6 months per telephone interview. Points of interest were: kind and location of the VTE event, diagnostic procedures, drug and dosage of initial and follow-up anti-coagulation treatment, relapse of VTE or bleeding complications, serious adverse events, mortality, and date and reason for determination of anticoagulation. Primary objective was to evaluate the treatment reality of patients with cancer associated VTE in clinical daily practice. Results: Between May 2015 and May 2017, 382 patients (pts) with active cancer within the last 2 years and newly diagnosed VTE gave consent to this register trial. 193 (50.5%) were female, median age was 65 years (range 19-89). For 133 pts (34.8%), VTE was the primary reason for admission at hospital, 34.3% were referred by their oncologist, 13,6% by their general practitioner, 15,5% by other treating physicians and 36.6% directly via the emergency department. 182 pts (47.6%) had pulmonary embolism, 268 pts (70.2%) had venous thrombosis and 18,6%71 pts (18.6%) had both. The most common cancer sites were lung (n=57, 14,9%), gynecological (n=44, 11,5%), colorectal (n=40, 10,5%) and pancreatic cancer (n=33 8,6%); 204 pts (56%) with solid tumors presented with stage IV diseases; 60 pts (15.7%) had hematological malignancies. 279 pts (73%) received anticancer treatments at the time of diagnosis of VTE. 148 (38.7%) pts died in the 6 months study period (20 pts died in hospital after admission, 90 pts within the first 3 months and 38 pts within the 6 months follow up). Initially, the majority of pts (n=350; 91.6%) was treated with LMWH. After discharge from hospital 78.7% remained on LMWH and 12.7% were treated with direct oral anticoagulants (DOACs). After 3 months 64.9% of pts received LMWH and 26.1% DOACs; after 6 months 48.4% LMWH and 44% DOACs. Responsible for the anticoagulation treatment decisions was mostly the oncologist (58%), followed by the general practitioner (26.3%) and other physicians (15,7%) . During the initial hospital stay, 2.6% of pts had a bleeding complication and 0.8% were diagnosed with a progress of VTE. At 6 months follow up, 6.4% reported bleeding complications and 2.4% recurrent VTE. Conclusion: The GECAT register trial gives new and clinically relevant information about the clinical daily care practice of cancer patients with newly diagnosed VTE in Berlin, Germany. The treating oncologist is in most cases responsible for the treatment. Disclosures Sinn: LEO: Research Funding; Bayer Healthcare AG: Research Funding; Servier: Honoraria, Research Funding; Astra Zeneca: Honoraria, Research Funding; Amgen: Honoraria; Sanofi: Honoraria. Scholz:Celgene: Consultancy; GILEAD: Consultancy, Speakers Bureau; Roche: Consultancy; Janssen-Cilag: Consultancy; Hexal: Consultancy; Novartis: Consultancy; Pfizer: Speakers Bureau; Takeda: Consultancy; Daiichi Sankio: Consultancy. Klamroth:Bayer, Biomarin, CSL Behring, Novo Nordisk, Octapharma, Pfizer, Roche, SOBI, Takeda: Consultancy; Bayer, Novo Nordisk, SOBI: Research Funding.

Social Processes Affecting the Workforce Integration of First-Generation Immigrant Health Care Professionals in Aging Citizens in the Netherlands.

Introduction: Within a Dutch nursing home, the prevailing workforce culture was challenged by new personnel, which caused institutional change, which in turn, affected workforce integration. The purpose of this study was to examine social processes affecting workforce integration of first-generation immigrant health care professionals in aging citizens in a Dutch health institution in the Netherlands. Method: A purposive sample of 10 immigrants and 10 established nurses was recruited. Ethnography was used to guide this study. 105 hours of participant observation, 8 semistructured interviews with 4 immigrants and 4 established nurses, and 2 focus-group discussions with 8 immigrants and 6 established nurses. Results: The study identified various processes that affect culturally congruent care in the nursing home, like the imposing professional norms, the use of "weapons of the weak," mutual suspicions of indifference, and collective images of "us" versus "them." Both groups conceived the "others" as the source of their discomfort, however, both had pain of not mattering. Discussion: When recruiting international educated nurses "all nursing staff" face difficulties when going through the precarious process of mutual integration in daily care practices. We recommend that nurse leaders facilitate positive intergroup interactions that promotes reciprocity for all groups of nurses for better health care outcomes for all.

Explanations for medically unexplained symptoms: a qualitative study on GPs in daily practice consultations

General practice is the centre of care for patients with medically unexplained symptoms (MUS). Providing explanations for MUS, i.e. making sense of symptoms, is considered to be an important part of care for MUS patients. However, little is known how general practitioners (GPs) do this in daily practice. This study aimed to explore how GPs explain MUS to their patients during daily general practice consultations. A thematic content analysis was performed of how GPs explained MUS to their patients based on 39 general practice consultations involving patients with MUS. GP provided explanations in nearly all consultations with MUS patients. Seven categories of explanation components emerged from the data: defining symptoms, stating causality, mentioning contributing factors, describing mechanisms, excluding explanations, discussing the severity of symptoms and normalizing symptoms. No pattern of how GPs constructed explanations with the various categories was observed. In general, explanations were communicated as a possibility and in a patient-specific way; however, they were not very detailed. Although explanations for MUS are provided in most MUS consultations, there seems room for improving the explanations given in these consultations. Further studies on the effectiveness of explanations and on the interaction between patients and GP in constructing these explanations are required in order to make MUS explanations more suitable in daily primary care practice.

Understanding Determinants of Health Care Professionals' Perspectives on Mobile Health Continuance and Performance.

BackgroundWith the widespread use of mobile technologies, mobile information systems have become crucial tools in health care operations. Although the appropriate use of mobile health (mHealth) may result in major advances in expanding health care coverage (increasing decision-making speeds, managing chronic conditions, and providing suitable health care in emergencies), previous studies have argued that current mHealth research does not adequately evaluate mHealth interventions, and it does not provide sufficient evidence regarding the effects on health.ObjectiveThe aim of this study was to facilitate the widespread use of mHealth systems; an accurate evaluation of the systems from the users’ perspective is essential after the implementation and use of the system in daily health care practices. This study extends the expectation-confirmation model by using characteristics of individuals, technology, and tasks to identify critical factors affecting mHealth continuance and performance from the perspective of health care professionals (HCPs).MethodsA questionnaire survey was used to collect data from HCPs who were experienced in using mHealth systems of a Taiwanese teaching hospital. In total, 282 questionnaires were distributed, and 201 complete and valid questionnaires were returned, thus indicating a valid response rate of 71.3% (201/282). The collected data were analyzed using WarpPLS version 5.0 (ScriptWarp Systems).ResultsThe results revealed that mHealth continuance (R2=0.522) was mainly affected by perceived usefulness, technology maturity, individual habits, task mobility, and user satisfaction, whereas individual performance (R2=0.492) was affected by mHealth continuance. In addition, user satisfaction (R2=0.548) was affected by confirmation and perceived usefulness of mHealth, whereas perceived usefulness (R2=0.521) was affected by confirmation. This implied that confirmation played a key role in affecting perceived usefulness and user satisfaction. Furthermore, the results showed that mHealth continuance positively affected individual performance.ConclusionsThe identified critical factors influencing mHealth continuance and performance can be used as a useful assessment tool by hospitals that have implemented mHealth systems to facilitate the use and infusion of the systems. Furthermore, the results can help health care institutions that intend to introduce or develop mHealth applications to identify critical issues and effectively allocate limited resources to mHealth systems.

Implementing a Scientifically Valid, Cost-Effective, and Scalable Data Collection System at Point of Care: The Cleveland Clinic OME Cohort.

Improving outcomes after surgical procedures and determining the value of health care can be facilitated by a scientifically valid, cost-effective, and scalable data outcome collection system. We hypothesized that such a system could be constructed in orthopaedic surgery to (1) capture >95% of baseline validated patient-reported outcome measures (PROMs) for patients undergoing elective surgery, (2) capture >95% of surgeon-entered data on disease severity and treatment, and (3) be implemented as standard clinical care in daily practice. A modified Research Electronic Data Capture (REDCap) system was developed and was implemented at the time of surgery in a prospective cohort to collect demographic data, general health PROMs, joint-specific PROMs, and disease severity and treatments from patients and surgeons. All elective knee, hip, and shoulder orthopaedic surgical procedures performed in the Cleveland Clinic system at 7 hospitals were included. Of 16,021 consecutive eligible patients (February 18, 2015, to July 31, 2017), 2% (320) were excluded because of language or physical barriers, and 0.6% (91) of the remaining 15,701 patients refused to participate. Of the remaining 15,610 patients, 97.4% (15,202) completed PROMs, and surgeons provided details on the disease severity and treatment for 99.9% (15,592) of the 15,610 patients. Overall, 97.3% (15,185) of the 15,610 patients had complete patient-reported and surgeon-reported baseline enrollment. The median completion time was 11.5 minutes for the patients and 1.6 minutes for the surgeons. The overall complete 1-year follow-up rate was 72.5% (9,354 of 12,896). A data collection system with validated measures with >97% baseline completion of PROMs and surgeon forms regarding disease severity and treatments, across elective knee, hip, and shoulder orthopaedic surgical procedures, was successfully implemented at 7 hospitals. The system is potentially scalable to the entire orthopaedic community and could serve as a template for all procedural-based specialties during routine patient care.

The Dutch Hip Fracture Audit: evaluation of the quality of multidisciplinary hip fracture care in the Netherlands

SummaryThe nationwide Dutch Hip Fracture Audit (DHFA) is initiated to improve the quality of hip fracture care by providing insight into the actual quality of hip fracture care in daily practice. The baseline results demonstrate variance in practice, providing potential starting points to improve the quality of care.PurposeThe aim of this study is to describe the development and initiation of the DHFA. The secondary aim is to describe the hip fracture care in the Netherlands at the start of the audit and to assess whether there are differences in processes at baseline between hospitals.MethodsEighty-one hospitals were asked to register their consecutive hip fracture patients since April 2016. In 2017, the first full calendar year, the case ascertainment was determined at audit level. Three quality indicators were used to describe and assess the care process at audit and hospital level: the proportion of completed variables at discharge and at 3 months after operation, time to surgery and orthogeriatric management.ResultsSixty (74%) hospitals documented 14,274 patients in the DHFA by December 2017. In 2017, the case ascertainment was 58% and the average proportion of completed variables was 77%: 91% at discharge and 30% at 3 months. The median time to operation was 18 h (IQR 7–23) for American Society of Anesthesiologists score (ASA) 1–2 patients and 21 h (IQR 13–27) for ASA 3–4 patients. Of patients aged 70 years and older, 78% received orthogeriatric management. At hospital level, all three indicators showed significant practice variance.ConclusionNot all hospitals participate in the DHFA, and the data gathering process needs to be further optimized. However, the baseline results demonstrate an apparent variance in hip fracture practice between hospitals in the Netherlands, providing potential starting points to improve the quality of hip fracture care.

Systematic Symptom Reporting by Pediatric Palliative Care Patients with Cancer: A Preliminary Report.

Background: Systematic symptom assessment is not a standard of care in children with cancer. Many well-known symptom assessment tools are lengthy or difficult to integrate into a daily pediatric palliative care practice. We created a series of brief and simple questions to be systematically given to children and their caregivers. Objective: The primary objective was to determine the percentage of eligible children and caregivers exposed to the questions that were able to complete the assessment. Secondary objectives included documenting the symptom burden at the time of consultation, evaluating the level of agreement in symptom reporting between children and caregivers, as well as between children/caregivers and the referring medical team. Design: A series of systematic questions were presented to all caregivers (if present) and children who were seven years of age or older at the time of initial consultation with pediatric palliative care. Results: One hundred twenty-two consecutive children/caregiver dyads were given the survey. One hundred seven of 108 (99%) eligible caregivers and 83 of 97 (86%) eligible children completed the survey. Lack of appetite (child-72/83, 87%; caregiver-89/107, 83%) and pain (child-71/83, 86%; caregiver-86/107, 80%) were the most commonly reported symptoms. Caregivers reported irritability (p = 0.005) and nervousness (p < 0.001) more frequently than children. Referring medical teams significantly underdiagnosed psychological and other less clinically evident symptoms such as lack of appetite, fatigue, and sleep disturbance (p < 0.001). Conclusions: Our series of questions is easy to complete by children and caregivers. Systematic symptom assessment of children with cancer referred to palliative care should become a true standard of care.

“An innovative new technique of paediatric vaccination: Take both hands and hold the needle to avoid damage of nociceptors and capillaries”

Pediatric vaccination is an important field in the daily pediatric care practice of pediatricians in Germany. According to the STIKO recommendations, children were vaccinated up to 20 times till the age of 17. A new technique of vaccination will be presented vaccinate a child taking both hands, one makes the injections, the other one holds the needle in the skin due to relieve pain and not to damage nociceptors. The importance of this technique is to avoid movement of the needle inside the skin after injection to avoid damage of nociceptors in the skin.

Transforming End-of-Life Care by Implementing a Patient-Centered Care Model: Findings From an Action Research Project.

Patient-centered care is valued by health care professionals working in palliative care settings. However, studies have revealed the difficulty of adopting patient-centered care in daily practice and of sharing its meaning within the interdisciplinary team. The aim of this study was to report the process of transforming end-of-life care by implementing a patient-centered model of care in an Italian hospice. An action research process was conducted between June 2012 and June 2014. The following phases were performed: (a) "looking" phase: the diagnosis was established by collecting data through semistructured interviews in the field study and through the administration of the Frommelt Attitude Toward the Care of the Dying Scale Form B-Italian Version; (b) "thinking" phase: staff members, guided by a research team, redesigned practice by identifying priorities in improvements and actions through multiprofessional focus groups; (c) "acting" phase: actions identified in the previous phase were implemented; and (d) "relooking" phase: the same data collection processes used in the looking phase were applied to evaluate the outcomes achieved. Three areas of improvement have been established: (1) symptoms were intensively audited through patient self-reports by using validated tools; (2) patients' family needs were also regularly collected, documented in clinical records, and addressed; (3) patients' family members were involved in the plan of care through support and education. Inpatient hospice health carers in this study were aware of the concept of patient-centered care. However, its actual implementation was lacking. An action research approach helped them to implement expected changes.

A simple system for symptom assessment in pediatric palliative care patients with cancer: A preliminary report.

81 Background: Systematic symptom assessment is not a standard of care in children with cancer. Many well-known symptom assessment tools are lengthy or difficult to integrate into a daily pediatric palliative care practice. We created a series of brief and simple questions to be systematically given to children and their caregivers. The primary objective was to determine the percentage of eligible children and caregivers exposed to the questions that were able to complete the assessment. Secondary objectives included documenting the symptom burden at time of consultation, evaluating the level of agreement in symptom reporting between children and caregivers, as well as between children/caregivers and the referring medical team. Methods: A series of systematic questions were presented to all caregivers (if present) and children who were 7 years of age or older at time of initial consultation with pediatric palliative care. Results: 122 consecutive children and caregivers were given the survey. 107/108 (99%) of eligible caregivers and 83/97 (86%) of eligible children successfully completed the survey. Lack of appetite (child – 72/83, 87%; caregiver – 89/107, 83%) and pain (child – 71/83, 86%; caregiver – 86/107, 80%) were the most commonly reported symptoms. Caregivers reported irritability (p = 0.005) and nervousness (p &lt; 0.0001) more frequently than children. Referring medical teams significantly under-diagnosed psychological and other less clinically evident symptoms such as anorexia, fatigue, and insomnia (p &lt; 0.0001). Conclusions: Our series of questions is easy to complete by children and caregivers. Systematic symptom assessment of children with cancer needs to become a true standard of care.