High-technology Care Research Articles

Outpatient and home parenteral antibiotic therapy (OHPAT) in the UK: a consensus statement by a working party

Outpatient and home parenteral antibiotic therapy (OHPAT) in the UK: a consensus statement by a working party

Persistent vegetative state: clinical and ethical issues.

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. The patient outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family.

Do community hospitals reduce the use of district general hospital inpatient beds?

Community hospitals have been supported by the general public and by professionals as one means of increasing choice between local, low technology, care and high technology care at the district general hospital. However, there is no information on the impact of community hospitals on district general hospital use subsequent to NHS and community care reforms. Examination of routinely gathered activity data in the Bath Health District revealed that availability of community hospital beds was associated with reduced use of central inpatient services in the city of Bath. The reduction was most apparent for medical and geriatric beds. Decrease in the use of surgical beds was small. However, total inpatient bed use (including central and community hospital beds) was higher in the population with access to community hospital beds. We conclude that community hospitals offer one option for accessible health care and, as such merit systematic evaluation of costs and benefits. This study presents some evidence that savings could be achieved through improved efficiency.

Current Intra-aortic Balloon Pump Practice Issues: Survey Results

Patient care delivery has changed or has at least begun to change throughout institutions nationwide. Those who once regarded theory as a formulation for patient outcome have rendered it inefficient; as the practice of balloon pumping has expanded, many important questions have been raised surrounding the basis for procedures involving IABP. Nursing guidelines for correct IABP procedures are theoretically based procedures. Although it is influential, theory-based practice has proven to be an inefficient means for formulating current practice standards. The Ahern Gould and Stark Current Practice Survey exemplifies the uncertainties that surround the practice of IABP. The nationwide search for scientifically based IABP methods is realized as those surveyed present numerous questions, giving rise to clinical research directions for IABP practitioners.

The SUPPORT Project: Lessons for Action

One of greatest living scholars of quality, Professor Noriaki Kano of Tokyo University, and his American colleague, Tom Nolan, suggest that system improvements can come in three categories: 1. Reductions of defects experienced by customers; 2. Reductions of cost, while maintaining or improving experiences of customers; and 3. Creating and satisfying a new need, or satisfying an old need to an unprecedented degree.[1] Kano and Nolan suggest further that, at any specific time, improvements in one of these three categories are strategically most important. A modem computer manufacturer, for example, must be focusing on improvements of Type 3, or it will be shortly out of business. In computer industry, production costs are already low and computer purchasers simply will not tolerate noticeable defects. By contrast, most Americans, asked what improvements ought to occur in U.S. postal system, will immediately cite as key issue. Few will mention cost of stamps, and even fewer will request some new, delightful, unexpected service or product. The postal service needs Type 1 improvement most. For American medicine today, improvements that matter--the ones that contain strongest seeds of organizational survival--are Type 2 improvements: reduction in cost while maintaining or improving experiences of those who depend on these improvements today: payers, governments, patients, and families. This is one of reasons that report from SUPPORT project is so important, and, at this stage, so teasingly disappointing. Many, many opportunities exist in health care to reduce costs while maintaining or improving quality, but few are as direct and consequential as opportunity to stay our hand from delivering invasive, painful, undignified, and wasteful high-technology care to patients who neither want nor can benefit from that care. At best, such care is profligate; at worst, it is abusive. Despite opportunity, interventions of SUPPORT project came up dry. Aside from a few, marginally significant gains, patients offered voice, participation, and new communication channels experienced as much costly, painful, and unwanted care as did patients in usual system. What happened? Are potential gains from more appropriate use of technology at end of life out of our reach? Not at all. The SUPPORT study shows in this phase only that systems of care are complex, nonlinear, and difficult to manipulate in simple, cause-and-effect experimental modes. Here are some clues worth investigating further. In first place, one of crucial findings of study is that only half of doctors allegedly given information about patient preferences acknowledged that they had ever seen such information. Furthermore, only one-sixth of those who did recognize existence of SUPPORT information said that it affected their decisions regarding treatment. These results suggest that issues in communication may be crucial to success of future efforts to mold care at end of life--not efferent communication of desires from patients (which this study confirms is possible), but afferent communication of information to medical decisionmakers in receptive postures. The doctors in this study were poor receptors. How could we improve transfer and use of this crucial information? First, psychology of adult learning may help us to shape better effects next time. We know, for example, that adults learn better when they initiate questions, not when they receive answers never asked for. (When student is ready, says Zen aphorism, the teacher appears.) The SUPPORT intervention system appears to have lacked element of curiosity among doctors, who, like most adults, rejected or ignored answers to questions they never asked. Second, we know that leaders can help to create a context for learning, and yet there is little evidence of such a context in design of SUPPORT system. …

Helping the relatives of patients with cancer

THE DIAGNOSIS and treatment of cancer inevitably affects not only patients but also their relatives. Few people inhabit a social vacuum, so the primary sources of social support for patients are likely to be family members. Furthermore, changes in the delivery of cancer services, as well as cost containment issues, mean that a considerable burden of complex physical treatment, after-care and terminal-care may also become part of the families’ responsibilities. McCorkle and associates [l] have pointed out that, with patients being discharged from acute care settings so much earlier than in the past,, there has been a dramatic shift in the role of care-giving from “lone of promoting convalescence to actively providing high technology care in the home”. It is not that unusual for patients to be receiving chemotherapy through intravenous lines at home and seriously ill patients with cancer having parenteral nutrition. Although some families become adept at administering treatments, many find it an intolerable strain [2]. It is gratifying that, in contrast to the situation which existed in the past, much more emphasis is now placed on helping patients with cancer deal with their many psychosocial concerns. However, if counsellors and others focus too narrowly on the patients’ feelings, thoughts and concerns, it is too easy to overlook the major needs of the family. A failure to acknowledge and then help alleviate the families’ predominant emotional needs, will ultimately deprive patients of the comfort, love, support and companionship Ithat they will need throughout the course of their disease. As many studies have reported the importance of appropriate social support in mediating the effects of a serious stressor such as cancer, e.g. [3,4] and others have shown that the psychological status and coping styles of patients with their closest family care-giver are closely matched [S], assessment of both patients and their carers may be crucial for long-term adaptation. The article by Harrison and colleagues in this issue (pages 1736-1740) identifies the aigniftcant levels of psychological distress and major concerns experienced by the key relatives of patients with newly diagnosed cancer. Using a standardised psychiatric screening tool, Hhrrison and colleagues found that almost half the relatives had scores above threshold, which suggests that rates of anxiety and depression were probably

Enhancing Ethical Thinking: the Role of a National Nurses' Association

In democratic Switzerland, each of its 26 cantons (states) has its own government and its own laws. Thus there are 26 ministries of health and as many different laws regulating medical and health care practice. The Swiss Nurses' Association likewise has 13 regional chapters and a central organization that works on the national level. Medicine is private and practically all of the Swiss population is privately insured. High technology has led to high specialization with, among other results, a reduced number of premature deaths, longer life span but also rising costs of health. Health professionals are also becoming much more aware of ethical issues such as cost versus quality, high technology versus compassionate care, etc. A multilingual (four national languages) and multicultural country, Switzerland's health care system relies heavily on foreign nurses, many of whom come from neighbouring France and Germany but also from England, Yugoslavia, Canada and other countries. Regulation of nursing practice is still poor. Nursing or nurses are hardly mentioned in the state laws and, when mentioned, are often put in a dependent relation to the physician. Basic nurse training is regulated nationally by cantonal delegations to the Swiss Red Cross. Although there is a good postbasic training scheme, nurses are still striving for access to the university. Meanwhile, they go abroad to acquire degrees. Research in nursing is being developed mainly by the efforts of individuals and the Swiss Nurses' Association.

Synchronous connections: nursing's little secret.

As nurses prepare for their place in health care reform, it is becoming more important than ever to be clear about the unique contribution nurses make to health care outcomes. In our technology-driven society, however, some of nursing's most powerful contributions go unacknowledged. An unexpected finding of a study on nurse experts' perceptions of synchrony revealed that nurses themselves frequently do not document or even dialog about important contributions if they cannot be captured within the dominant paradigm of high-technology care. The article describes nurses "little secret" that must be exposed.

The intelligent pediatric cardiologist's guide to resource allocation between high technology and primary care

Health care costs are increasing at an unsustainable rate, largely due to changes in technology that raise rather than lower costs. As a result, policymakers are examining options and methods for changing the mix of high technology and primary care. This paper reviews four methods of allocating resources between these two types of care and finds flaws with each. The first method, the status quo, allocates resources largely based on the patient's insurance status, an approach that is highly inequitable. A second approach, used in Canada and Europe, is to substantially shift the balance of care toward primary care, largely through constraining the availability of high-technology resources. The third method, cost-effectiveness analysis, fails to address the fact that most persons find ‘saving a life’ more worthy than providing a small benefit to a large number of people. The final method, allocation by community values, cannot adequately overcome the deep differences in values that exist in society.

On Viability, Ethics, and Outcomes: The View from Neonatal Follow-Up

This paper examines some of the difficult dilemmas facing us in the care of pregnancies that are likely to lead to the birth of an infant of extremely low gestational age. Recent publications have provided better information regarding outcomes for these babies and a framework of guidelines to assist in decision making. From the neonatal follow-up perspective, the concept of viability has to include more than independent survival; impairments are common in tiny baby survivors, particularly as they grow to school age and face competition for scarce resources for rehabilitation and education with their term born peers. Some of the ethical issues surrounding the long term consequences of a treatment or non-treatment decision are discussed. With budget restrictions inevitably coming, our biggest challenge as perinatal health-care workers is to provide compassionate, supportive care for those mothers and infants who can benefit most from high technology care, while realizing the limitations of what is possible. Short term decisions have long term consequences for the child, the family, and society.

US Teaching Hospitals in the Evolving Health Care System

AMONG the surprises in the last 2 years' health care debate was the extensive controversy engendered by proposals related to teaching hospitals and their associated academic health centers. Of more than 6500 hospitals nationwide, only some 300 nonfederal hospitals are generally considered to be "major teaching hospitals" (hospitals whose ratio of the number of interns and residents to the number of beds is ≥0.25)¹and fewer than 1250 participate in graduate medical education.²Nevertheless, the importance of these institutions and their medical school partners in the national dialogue soon became clear. They play a central role in workforce training, research, and patient care, especially for disadvantaged populations. As centers of excellence, they epitomize the high-technology care that many US citizens associate with worldwide leadership in the quality of their medical care. Most of the policy interest and controversy centered on two key issues: the financial viability of teaching

Health promotion in France. Toward a new way of giving medical care.

Health promotion is not a concept often encountered in France, especially in university teaching hospitals. In fact, the spontaneous orientation of healthcare services tends to emphasize high-technology care, rather than preventive care. This article describes the main characteristics of the French healthcare system, some new elements of its health policy, and a specific experiment of health promotion in a new geriatric hospital.

High imaging technology and health care expenditures

Health care expenditures constitute a large part of the gross domestic product of the industrialized world and are growing at an alarming rate in some countries, particularly in the United States. Although the expenditures of radiology represented only 3.5% of the total health-care bill in the United States in 1990, the high price of certain high-technology instruments, such as magnetic resonance imagers, attracts attention. Yet, high imaging technology properly used reduces the cost of health care as can be seen from many examples. High imaging technology is non-invasive and often replaces procedures that would require hospitalization. Ethical considerations, such as large expenditures during the last year of life and some inappropriate uses, presently counterbalance the savings that the use of high technology could otherwise offer. By controlling its proper uses, high imaging technology can be a very useful tool.

Workload of an inpatient cardiac rehabilitation service in Edinburgh: a five year survey

When the cardiac rehabilitation programme at Astley Ainslie Hospital, Edinburgh, UK, was instituted in 1976, it served predominantly patients under 65 years of age who had suffered a recent myocardial infarction. We describe a detailed survey of the medical records of all cardiac admissions to the Rehabilitation Medicine Unit of the hospital during 1986-1990. This survey stresses the changing face of cardiac rehabilitation which has now developed fundamentally into a post cardiac surgical rehabilitation service, catering to an increasingly elderly group of patients. Perhaps this is a logical development as cardiologists and general physicians become more aware of the rehabilitation needs of patients post myocardial infarction and these are instituted both in the acute setting and as an outpatient service. In contrast, cardiothoracic surgical units with the need for high technology and specialist intensive care skills are perhaps environments less suited to the institution of rehabilitation services.

Eye care delivery in developing nations: paradigms, paradoxes, and progress.

Only 5% of the world's population is found in the United States, yet we as a nation consume 40% of the world's resources. In stark contrast, two thirds of the world's population live in developing countries where 90% of all blindness occurs and where even the most basic resources for eye care delivery are scarce or absent. Using U.S. criteria defining blindness (less than 20/200 [6/60]), the World Health Organization estimated in 1984 that 42-52 million people were blind from all causes, an increase of more than 10% since 1978. High population growth rates in most developing countries coupled with the failure of governments to develop health services commensurate with needs are responsible for this trend. On economic grounds alone, the U.S. eye care delivery paradigm cannot be broadly replicated in the developing world. Instead, cost-effective creative strategies, many already in place, such as mass surgery camps in Asia and delivery of eye care by non-ophthalmologists in Africa, can be expanded and streamlined. The upgrading of sight restoration and preservation care depends upon mobilization of political will within the international health community; governments must prioritize eye care as a public health problem; health planners must mobilize financial resources and work closely with technical assistance organizations, and ministries of health must cease to emulate expensive high-technology eye care models.

The influence of high technology care on patients, their relatives and nurses.

This article focuses on the potentially dichotomous relationship of caring for critically ill patients in a high technology environment. Does technology enhance or hinder the quality of patient care delivered by nurses in such an environment? The discussion within this article is initially at a societal level before focusing at an interpersonal level within a specific care setting. The author argues for finding a balance between high technology and humanity within the intensive care environment by highlighting the psychological impact that this may have on patients, relatives and nurses. Guidance as to how a balance may be achieved is also provided. Technology is an explicit theme within the text, whilst the concept of power that technology holds is discussed in an implicit manner.

From equal access to health care to equitable access to health: a review of Canadian provincial health commissions and reports.

Having achieved equality of access to health care, Canadian policymakers are setting new policy goals, within resource constraints, primarily to achieve equity of access to health. Across the country, provincial royal commissions have explored a number of policy options to achieve this goal. These options are reviewed and critically analyzed within the context of such challenges in health policy as insufficient access to high-technology care and the limits of medical care, and such external challenges as economic and demographic trends, federal-provincial disputes, and ideological beliefs. Particular attention is given to the implications of a broader definition of health and the concept of regional health authorities. Based on the provincial reviews, the authors conclude that Canada wants to achieve equitable access to health. With the shift of health policy away from the formerly protected arena of medical care, achieving equitable access to health will require both an alteration of priorities and values and considerable political will. Canada will be forced to meet these new challenges to maintain current achievements and to make its system even more successful.

Can Medical Rationing Be Made Rational?

The truth is beginning to leak out: not only are our national resources less than infinite, but even in the United States in 1992 we have a medical care system that is already involved in rationing, sometimes overtly and sometimes covertly. While fiscal redistribution could alleviate part of the problem—whether by less spending on health care administration, unnecessary procedures, military hardware, or cashmere sweaters for household pets — many now believe it unlikely that we will be able to provide unrestricted, high-technology care on (patient, physician, and lawyer) demand for everyone in every circumstance forever. If this is in fact true, then it is only reasonable, although frightening, to deal with this honestly and upfront. Can rationing be made rational? Singer and Lowy, in this issue, suggest that one ethically compelling approach to rationing is to have the individual patient's preferences solely guide the agenda. The underlying assumption is that

National Health Policy Without Rationing?

To the Editor. — The editorial by Bone and Elpern 1 points up the conflict between patients' expectations of care and their willingness to pay for this. It is unquestioned that the explosion in health care costs has been, at least in part, consumer driven. Equally, the liability situation makes physicians ever more eager to accede to the patient's every demand. Bone and Elpern make the statement that explicitly rationing medical services may become the norm unless a national health care policy is developed. However, what is a health care policy if not a de facto way of rationing health care? Is it not in truth rationing health care to deny a terminally ill patient the benefit of intensive or high-technology care by fiat? In addition, the authors seem discomfited by the fact that high technology health care could become an option only for those who are able to pay

High Technology and Psychiatric Care of the Elderly

The dramatic explosion of scientific information, as well as the development of computerized devices in medicine, will continue to change both the diagnosis and treatment of the elderly as it changes our entire culture. There are many technological forces now combining to push the frontiers of knowledge about the brain to new levels. This article outlines these new scientific and technological frontiers in psychiatric diagnosis including: diagnostic imaging, computer EEG, and psychiatric evaluation; treatment including health-related computerized aids, computerized psychopharmacology, neuropsychiatric training for handicapped and brain-injured, and chronic care; and medical education. This article discusses some of the issues that arise due to these new developments. Computers have multiplied the kinds of questions that can be meaningfully asked. In this way, the advent of the computer has opened the minds of many researchers to new frontiers. An important question is, "What will the psychiatric 'state of the art' be in a technological age?" Other issues include confidentiality with new devices, use of high technology to define malpractice liability, the lack of professional standards in software, the resistance of medical profession to computers, and the increased ability to misuse statistics. Geriatric psychiatrists must take an active role in planning the future impact of high technology in our field.