Hospitals In Estonia Research Articles

Nurses' perceptions of infants’ procedural pain assessment and alleviation with non-pharmacological methods in Estonia

PurposeThe purpose of this study was to describe nurses perceptions of infants' procedural pain assessment and alleviation with non-pharmacological methods including parental guidance in departments of neonatal and infant medicine and Neonatal Intensive Care (NICUs). Design and methodsA descriptive cross-sectional survey was carried out among all nurses (n= 149) who were working in neonatal and infant departments or NICUs in Estonian hospitals. Altogether, 128 questionnaires were returned and 111 respondents were eligible (75% response rate). The data were analysed using statistical methods. ResultsMore than half of the nurses agreed that systematic documentation of the measurement of pain is necessary for nursing care and that it affects pain alleviation in infants. Half of the respondents (51%) confirmed that pain scales are important in the measurement of infants' pain, but 58% claimed they were able to assess pain in a reliable way without using pain assessment scales. Nurses also reported that they were unfamiliar with most pain scales and they were not routinely used in everyday practice. Nurses said that the most useful non-pharmacological pain alleviation methods were touching (83%) and positioning infants (78%), the most rarely used were skin-to-skin care (12%) and encouraging mothers to breastfeed the infant (34%). The majority of respondents (79%) reported that they do not know or do not have written instructions on pain assessment in their workplace, and only a few (10%) reported that they have participated in pain management courses during the last year. ConclusionsThere is a need to increase the use of pain assessment scales and pain documentation in everyday practice in those hospitals in Estonia. The use of scales in pain assessment was valued by few nurses. It seems that there is a lack of knowledge on non-pharmacological methods, and nurses reported using only a few non-pharmacological pain alleviation methods and guided parents on using them. Practice implicationsNurses need pain management guidelines for everyday work, and in addition to nurses, written guidelines for parents are needed.

Care left undone and work organisation: A cross-sectional questionnaire-based study in surgical wards of Estonian hospitals.

Care left undone is a worldwide problem for both the quality of health care and the safety of patients. In surgical nursing, care left undone is a critical issue arising from the intensive pace of work, invasive procedures and the pressure for efficiency. Previous knowledge about care left undone in surgical contexts is missing. To describe care left undone and its relationship to nursing and organisational characteristics in the surgical wards of regional and central hospitals in Estonia. A cross-sectional study with an online questionnaire took place from June to October of 2018. The target population (N=570) consisted of nurses working in the surgical wards of two regional and three central hospitals at the time of the study. The data were analysed using descriptive statistics and Fisher's exact test. The open-ended questions were analysed with deductive content analysis. Nursing care in the surgical wards was reported as having been left undone sometimes or often by 88% of the nurses. Most often, the documentation and evaluation of care plans (33%) were reported as undone and most rarely, disinfection measures were left undone (5%). Nurses with a shorter employment history left care undone more frequently, and when the number of patients per nurse increased, the amount of care left undone increased as well. More than half of the participants (59%) considered work organisation to be the cause of care left undone. Work organisation and staffing in surgical wards require more attention at the management level, as nursing care left undone occurred to a significant degree in the investigated wards, and more than half of the nurses considered work organisation to be the reason for care left undone.

Expectant fathers’ experiences of family-centred births in Estonia: a qualitative study

ObjectiveOne of the aims of family-centred care is to provide expectant fathers with positive experiences during childbirth, so they can support their partners and bond with their new baby. However, research in this area has been limited. This study described men´s experiences with family-centred births in Estonia, Northern Europe. DesignQualitative study with open-ended interviews that were audio taped and analysed by inductive content analysis by Elo and Kyngäs (2008). SettingBirth units at one central and one regional hospital in Estonia. ParticipantsTwelve Estonian fathers aged 22-44, interviewed 4-12 weeks after their baby's birth. Key conclusionsFathers’ experiences of family-centred care during their baby's birth focused on their transition to fatherhood, their experiences of birth as a multifactorial life event and the experiences they shared with other fathers. They discussed supporting their partners during the birth, their involvement in decision making, the attitudes of healthcare professionals and how their role in the family changed. The fathers said that the birth was a private and public event, where their own role, and the roles of healthcare professionals, were confusing. This made family-centred care difficult during the birth. Sharing experiences with other fathers decreased their fears and increased their understanding of becoming fathers. Some fathers were not ready for fatherhood and midwives needed to assess how involved fathers wanted to get during the birth. Implications for practiceFamily-centred care is important during birth, but more research is needed into how fathers see their role. The roles played by medical staff also need to be clearer. Better knowledge about what fathers expect and need, can help midwives to involve and support them at a level they feel comfortable with. Peer support can play a vital role in preparing fathers for birth and fatherhood.

Mortality in young adult patients with acute ischaemic stroke.

This study aimed to determine short- and long-term mortality, clinical determinants and causes of death in young patients with ischaemic stroke. We performed a hospital-based study of 18- to 54-year-old consecutive patients with ischaemic stroke, who were treated in the two largest hospitals in Estonia from 2003 to 2012. All cases were reviewed by the authors. Survival data and causes of death were obtained from the Estonian Population Registry and the Causes of Death Registry, respectively. Logistic regression and Cox proportional hazard models with backwards stepwise analysis were used to identify determinants of mortality. We identified 738 patients, of whom 124 died during the 5-year follow-up. Cumulative mortality rates at 30days and 5years were 4.5% (95% confidence interval [CI], 3.0%-6.0%) and 16.8% (95% CI, 14.1%-19.5%), respectively. The proportion of deaths due to vascular causes was 87.9% at 1month and 54.6% at 5years. Thirty-day mortality was independently associated with severe stroke, with a National Institutes of Health Stroke Scale (NIHSS) score >15, and post-stroke infections. The determinants of 5-year mortality were post-stroke infections, structural cardiac diseases and moderate stroke severity with NIHSS score of 7-15. The mortality rate among young patients with ischaemic stroke in Estonia is higher than that reported in previous studies and is associated with increased stroke severity, post-stroke infections and structural cardiac diseases. These results emphasize the need for more effective preventive strategies in these patient groups.

Surgically treated lung cancer patients: do they all smoke and would they all have been detected with lung cancer screening?

Since publication of the National Lung Cancer Screening Trial (NLST) results early lung cancer detection has been widely studied, targeting individuals based on smoking history and age. However, over recent decades several changes in lung cancer epidemiology, including risk factors, have taken place. The aim of the current study was to explore smoking prevalence among lung cancer patients who had been treated surgically or undergone a diagnostic operation and whether these patients would have met the NLST inclusion criteria.All patients operated on for lung cancer in a university hospital in Estonia between 2009 and 2015 were included. Data were collected from hospital records.426 patients were operated on for lung cancer, with smoking history properly documented in 327 patients (87 females; median age 67 years). 170 (52%) patients were smokers, 97 (30%) patients were ex-smokers and 60 (18%) patients were nonsmokers. The proportion of females among smokers was 15%, among ex-smokers was 9% and among nonsmokers was 87%. 107 of our patients would not have met the NLST age criteria and 128 of our patients would not have met the NLST smoking criteria. In total, 183 patients (56% (79% of females and 48% of males)) would not have met the NLST inclusion criteria.Only half of surgically treated lung cancer patients were current smokers and more than half did not meet the NLST inclusion criteria.

Hospital care in Estonia: thoughts on patient privacy

A student nurse is doing a work placement in a hospital in Estonia. The care techniques are identical to those with which she is familiar. However, the application of concepts of privacy and modesty is somewhat different. A reflexive analysis of the situation ensures no hasty judgements are made and enables her to think about the place of her own representations.

Do Treatment Policies for Proximal Humerus Fractures Differ among Three Nordic Countries and Estonia? Results of a Survey Study.

Proximal humerus fractures are common fragility injuries. The incidence of these fractures has been estimated to be 82-105 per 105 person-years. Treatment of this fracture, especially in the elderly, is controversial. Our study group published a systematic review of the available literature and concluded that non-operative methods are favored over operative methods in three- and four-part fractures. The aim of this multinational study was to compare treatment policies for proximal humerus fractures among the Nordic countries and Estonia. The study was conducted as a questionnaire-based survey, using the Internet-based program, Webropol(®) (webropol.com). The questionnaire link was sent to the surgeons responsible for treating proximal humerus fractures in major public hospitals in Estonia, Finland, Norway, and Sweden. Questionnaire included questions regarding the responder's hospital, patient characteristics, and examinations taken before decision making. Clinical part included eight example patient cases with treatment options. Of the 77 recipients of the questionnaire, 59 responded; consequently, the response rate was 77%. Based on the eight presented displaced fracture examples, in both Estonia and Norway and in Finland, 41% and 38%, respectively, preferred surgical treatment with locking plate. In Sweden, the percentage was 28%. The pre- and post-operative protocols showed a similarity in all participant countries. Our survey revealed a remarkable uniformity in the current practice of operative treatments and rehabilitation for proximal humerus fractures in the participant countries.

Adverse lifestyle and health-related quality of life: gender differences in patients with and without chronic conditions.

The aim was to investigate the relationship between the main lifestyle-related factors and health-related quality of life (HRQoL) in a sample of patients with and without chronic conditions (CCs) with respect to the gender differences in both groups. A cross-sectional study was conducted on 1061 patients (of which 308 had no CCs and 753 of those had one or more CCs) recruited at primary health care centres and the Internal Medicine Clinic at Tartu University Hospital in Estonia. Data were collected during 2012-2014. The patient's age, self-reported smoking status, alcohol consumption (assessed by Alcohol Use Disorders Identification Test) and body mass index were used as independent variables to predict the physical component scores (PCS) and mental component scores (MCS) of HRQoL (assessed by SF-36). Smoking had a negative association with both physical and mental components of HRQoL only in women with CCs. Further, the PCS of chronically ill women was negatively associated with the higher body mass index. Harmful drinking had a negative association with the HRQoL in all patient groups, except with the PCS in women with CC. Light alcohol consumption without symptoms of harmful use or dependency had a positive association with the physical and mental HRQoL in all patient groups, except with the MCS in women without CCs. Adverse lifestyle had the most expressed association with HRQoL in women with CCs. Light alcohol consumption had a positive association, but harmful use of alcohol had an inverse association with HRQoL irrespective of patients' gender or health status.

Work-related psychosocial risk factors and mental health problems amongst nurses at a university hospital in Estonia: a cross-sectional study.

Rapid changes in the Estonian health care system have placed extra pressure on the nursing profession, but the potential impacts of psychosocial changes have not been investigated. We aimed to explore the work-related psychosocial risk factors and their relationships with mental health problems (MHPs) amongst nurses at the university hospital in Estonia. A cross-sectional survey was undertaken amongst registered nurses at Tartu University Hospital (TUH). Psychosocial work factors and MHPs (stress, somatic symptoms, depressive symptoms and burnout) were measured using version two of the Copenhagen Psychosocial Questionnaire (COPSOQ II). Descriptive statistics and Pearson's r correlation with sequential Bonferroni correction were used to analyse the data. The analysis was based on 404 nurses (45% of the full-time working population of nurses). The highest mean scores recorded for the positive work-related psychosocial factors studied were meaning of work, role clarity, social relationships and mutual trust between employees. The highest scores for the negative factors studied were the demands for hiding emotions, work pace, cognitive and emotional demands. Stress and burnout showed the highest mean scores amongst the MHPs. Quantitative and emotional demands were positively related to all of the studied MHPs, while work pace and role conflicts had a positive correlation with stress and burnout. All of the studied negative psychosocial factors were significantly correlated with burnout. work-related psychosocial risk factors such as quantitative demands work load, emotional demands, work pace and role conflicts, had significant positive relationships with MHPS in nurses in Estonia, and may contribute to high levels of stress as well as burnout amongst nurses: .

Impact of fatal cases on the epidemiology of traumatic spinal cord injury in Estonia.

Most epidemiological studies on traumatic spinal cord injury (TSCI) have not included patients who die before hospitalization. The aim of the research was to study the incidence of TSCI by including the individuals who die at the scene of the accident in addition to data retrieved from all hospitals in Estonia. Medical records of patients with TSCI from all hospitals in Estonia from 2005 to 2007 were studied. With collaboration from the Estonian Forensic Science Institute the data of the victims of TSCI who died before hospitalization were included. From 2005 to 2007, 391 TSCI cases were identified: 183 patients were found retrospectively from medical records and 208 cases were detected from autopsy reports. Fifty-three per cent of patients died before hospitalization. The annual incidence rate was 97.0 per million population (95% confidence interval 87.4-106.6). The mean age at injury was 44.4±18.7years. Motor vehicle accidents were the leading cause of TSCI amongst the individuals who died before hospitalization (75%). Falls accounted for the highest number of TSCIs (43%) amongst the patients who reached hospital. Our study shows that, when the cases that die at the scene of the accident are included, the incidence of TSCI in Estonia rises from 39.7 to 97.0 per million population.

Mortality and causes of death after traumatic spinal cord injury in Estonia

Study designRetrospective population-based study with mortality follow-up.ObjectiveTo study mortality, causes and risk factors for death in Estonian patients with traumatic spinal cord injury (TSCI).SettingAll Estonian hospitals.MethodsMedical records of patients with TSCI from all regional, central, general, and rehabilitation hospitals in Estonia from 1997 to 2007, were retrospectively reviewed. Mortality status was ascertained as of 31 December 2011. Causes of death were collected from the Estonian Causes of Death Registry. Standardized mortality ratios (SMRs) were calculated for the entire sample and for causes of death. A Cox proportional hazards modeling was used to identify the risk indicators for death.ResultsDuring the observation period (1997–2011) 162 patients of 595 died. Nearly half of the patients (n = 76) died during the first year after TSCI. The main causes of death were external causes (30%), cardiovascular disease (29%). and suicide (8%). The overall SMR was 2.81 (95% confidence interval 2.40–3.28) and SMR was higher for women than for men (3.80 vs. 2.70). Cause-specific SMRs were markedly elevated for sepsis and suicide. Mortality was significantly affected by the age at the time of injury, neurological level, and extent of the injury as well as the year of TSCI and complications.ConclusionLife expectancy is significantly decreased in patients with TSCI in Estonia compared with the general population. Deaths during the first year after the injury have an important impact on statistics. Treatment of cardiovascular diseases, infections, and prevention of suicide are useful for reducing mortality in patients with TSCI.

Needs of adult patients in intensive care units of Estonian hospitals: a questionnaire survey

To describe the intensive care unit patients' perceptions about the importance of their different needs and how their needs are met in Estonian hospitals, and to determine the correlations between the patients' perceptions and their demographic characteristics and background variables. Meeting needs of patients in intensive care unit is important for avoiding unpleasant experiences and providing patient-centred care. A descriptive questionnaire survey. The study was performed in sixteen intensive care units (ICUs) in six acute care hospitals in Estonia. Data were collected over six months in 2008 using the structured five-point scale questionnaire Needs of Adult Patients in Intensive Care Unit. The Convenience sample consisted of The adult patients discharged from ICUs to hospital wards able to answer the questionnaire (n = 166). Data were analysed using descriptive statistics, correlation analysis and statistical tests. Patients' needs varied and were sometimes unmet. The most important needs were physical comfort and feeling safe. Privacy, involvement of family and friends and being involved in decision-making were less important. The more important a need was perceived to be, the better it was met. The need for physical comfort was met best, involvement in decision-making worst. Patients with lower educational level and unscheduled patients agreed more that their needs were met. The better the patients considered their condition when leaving the ICU, the more they agreed that their needs were met. The findings provide a basis for understanding the needs of critically ill adults in Estonian ICUs to provide them more patient-centred care and improve their psychological well-being and quality of life after discharge. Identifying and acknowledging the personal needs of patients in intensive care unit is important. When meeting the patients' needs, their individual characteristics should be taken into consideration.

High incidence of traumatic spinal cord injury in Estonia

Retrospective population-based cohort study. To provide national data on epidemiology of traumatic spinal cord injury (TSCI) among the population of Estonia from 1997 to 2007. All Estonian hospitals. Medical records of patients with TSCI from all regional, central, general and rehabilitation hospitals in Estonia were retrospectively reviewed. Epidemiological characteristics, etiology, neurological level and severity of injury, concomitant injuries were analyzed. A total of 595 patients with TSCI from 1 January 1997 to 31 December 2007 were identified. The male to female ratio was 5.5:1. The mean age at injury was 39.0 years. The crude incidence rate was 39.7 (95% confidence interval: 36.6-43.0) per million population. The most frequent cause of TSCI was falls (41%), followed by traffic accidents (29%). Alcohol consumption preceded 43% of injuries. The lesion level was cervical in 59.4%, thoracic in 18.3% and lumbar/sacral in 22.3%. Compared to recent studies from Europe, where the incidence of TSCI is between 15 and 30 per million population, the incidence of TSCI in Estonia is among the highest. The rates are significantly higher in men compared with women and especially among the youngest men. The leading cause of TSCI is falls. A significant proportion of injuries are related to alcohol consumption before trauma in Estonia.

Changes in treatment and mortality of acute myocardial infarction in Estonian tertiary and secondary care hospitals in 2001 and 2007

BackgroundHigh quality care for acute myocardial infarction (AMI) improves patient outcomes. Still, AMI patients are treated in hospitals with unequal access to percutaneous coronary intervention. The study compares changes in treatment and 30-day and 3-year mortality of AMI patients hospitalized into tertiary and secondary care hospitals in Estonia in 2001 and 2007.ResultsFinal analysis included 423 cases in 2001 (210 from tertiary and 213 from secondary care hospitals) and 687 cases in 2007 (327 from tertiary and 360 from secondary care hospitals). The study sample in 2007 was older and had twice more often diabetes mellitus. The patients in the tertiary care hospitals underwent reperfusion for ST-elevation myocardial infarction, cardiac catheterization and revascularisation up to twice as often in 2007 as in 2001. In the secondary care, patient transfer for further invasive treatment into tertiary care hospitals increased (P < 0.001). Prescription rates of evidence-based medications for in-hospital and for outpatient use were higher in 2007 in both types of hospitals. However, better treatment did not improve significantly the short- and long-term mortality within a hospital type in crude and baseline-adjusted analysis. Still, in 2007 a mortality gap between the two hospital types was observed (P < 0.010).ConclusionsAMI treatment improved in both types of hospitals, while the improvement was more pronounced in tertiary care. Still, better treatment did not result in a significantly lower mortality. Higher age and cardiovascular risk are posing a challenge for AMI treatment.

Better outcomes for acute myocardial infarction patients first admitted to PCI hospitals in Estonia

Objective – The objective of this study was to compare process of care, in-hospital outcomes, and 1-year mortality of patients with acute myocardial infarction (AMI) first admitted to hospitals with and without percutaneous coronary intervention (PCI) facilities in Estonia in 2007.Methods – We conducted a retrospective cross-sectional study on a random sample of hospitalized AMI patients. Data on process of care and in-hospital outcomes were abstracted from patient records in 16 hospitals according to a standardized study form.Results – Patients first admitted to PCI hospitals (n88=88327) had higher rates of overall use of coronary angiography (78.3% vs. 24.7%; P 88<880.001), revascularization (64.2% vs. 20.6%; P 88<880.001), and echocardiography (85.3% vs. 65.3%, P 88<880.001) than those first admitted to non-PCI hospitals (n88=88360). Among the non-PCI hospital patients those selected for cardiac catheterization were younger, healthier, and had better clinical status on presentation. Patients admitted to PCI hospitals had higher prescription rates of in-hospital and discharge evidence-based medications except for beta-blockers. PCI hospitals’ patients had lower in-hospital mortality (11.3% vs. 19.2%, P 88=880.004) and 1-year mortality (24.5% vs. 34.7%, P 88=880.003), results remained significant after adjustment for baseline characteristics (odds ratio 0.47; 95% confidence interval 0.28-0.78, hazard ratio 0.66; 95% confidence interval 0.48-0.90).Conclusions – There are disparities in process of care, in-hospital and 1-year mortality between patients first admitted to PCI vs. non-PCI hospitals in Estonia. Patients admitted to non-PCI hospitals should undergo more vigorous risk stratification using invasive and non-invasive methods; use of evidence-based medicine should be encouraged even if cardiac revascularization is not done.

Plasma glucose, lactate, sodium, and potassium levels in children hospitalized with acute alcohol intoxication

The aim of our research was to study prevalence of changes in plasma levels of lactate, potassium, glucose, and sodium in relation to alcohol concentration in children hospitalized with acute alcohol intoxication (AAI). Data from 194 under 18-year-old children hospitalized to the two only children's hospital in Estonia over a 2-year period were analyzed. The pediatrician on call filled in a special form on the clinical symptoms of AAI; a blood sample was drawn for biochemical tests, and a urine sample taken to exclude narcotic intoxication. The most common finding was hyperlactinemia occurring in 66% of the patients ( n = 128) followed by hypokalemia (<3.5 mmol/L) in 50% ( n = 97), and glucose above of reference value (>6.1 mmol/L) in 40.2% of the children ( n = 78). Hypernatremia was present in five children. In conclusion, hyperlactinemia, hypokalemia, and glucose levels above of reference value are common biochemical findings in children hospitalized with acute AAI.

Factor V Leiden and prothrombin 21210G&gt;A mutation and paediatric ischaemic stroke: a case–control study and two meta‐analyses

To determine whether factor V Leiden (FVL) and prothrombin (PT) 20210G>A mutation are associated with paediatric ischaemic stroke. The study consisted of two parts. Case-control study included neuroradiologically confirmed paediatric ischaemic stroke patients from two tertiary children's hospitals in Estonia. For control group, DNA was obtained from 400 anonymous screening test cards of newborns born consecutively in all delivery departments of Estonia in January 2005. Meta-analyses was performed to assess the association between paediatric sinovenous thrombosis and FVL and PT 20210G>A. A total of 75 children (45 boys, 30 girls) were included into the case-control study: 19 with childhood arterial ischaemic stroke, 49 with perinatal arterial ischaemic stroke and seven with cerebral venous thrombosis. Both FVL and PT 20210G>A occurred significantly more frequently among patients with sinovenous thrombosis compared with controls (OR = 12.9; 95% CI: 2.3-73.0 and OR = 11.9; 95% CI: 2.1-67.2, respectively). The difference was not significant between childhood/perinatal arterial ischaemic stroke and controls. Meta-analyses (including our study) revealed that both FVL and PT 20210G>A are associated with paediatric sinovenous thrombosis (OR = 3.1; 95% CI: 1.8-5.5 and OR = 3.1; 95% CI: 1.4-6.8, respectively). FVL and PT 20210G>A are associated with paediatric sinovenous thrombosis.

Health-promoting hospitals in Estonia: what are they doing differently?

The health-promoting hospitals (HPH) movement in Estonia was initiated in 1999. This study aimed to compare the implementation of health-promoting and quality-related activities in HPH and those which have not joined the HPH network (non-HPH). In the beginning of 2005, a postal survey was conducted among the top managers of 54 Estonian hospitals. The questionnaire was based on the WHO standards for HPH and on the set of the national quality assurance (QA) requirements for health services. The study demonstrated some significant differences in the uptake of health promotion and QA activities between HPH and non-HPH. For example, regular patient satisfaction studies were conducted in 83% of HPH and 46% of non-HPH (P < 0.03) and 65% of HPH and 46% of non-HPH cooperated with various patient organizations (P < 0.03). Systems for reporting and analysis of complications were implemented in 71% of HPH and 33% of non-HPH (P < 0.03); also, the implementation of various guidelines was more developed in HPH. All HPH have carried out a risk analysis on the workplace and staff job satisfaction studies were conducted in 89% of HPH and 41% non-HPH (P < 0.05). This study indicates that the concepts of HPH and QA are closely related. Making progress in health promotion is accompanied with QA and vice versa. Implementation of health-promoting activities in hospitals will promote the well-being and health of patients and hospital staff, and creates a supportive environment to provide safe and high-quality health services.

Diagnosis and treatment of acute myocardial infarction in tertiary and secondary care hospitals in Estonia

To compare validity of AMI diagnosis and treatment of AMI patients between tertiary and secondary care hospitals in Estonia. Two tertiary and seven secondary care hospitals responsible for the treatment of most AMI patients in Estonia were included in the analysis. A random sample of 520 patients admitted to these hospitals with AMI in 2001 was taken from the Estonian Health Insurance Fund database. Medical records were reviewed by trained experts using a standardized data collection form. Forty cases were excluded due to selection errors by the Health Insurance Fund. Of the remaining cases, a diagnosis of AMI was confirmed in 93.3% of cases in tertiary care hospitals and in 83.5% of cases in secondary care hospitals (p < 0.001). A total of 210 cases from tertiary and 213 cases from secondary care hospitals with confirmed AMI diagnoses were included in subsequent analysis. Utilization of beta-blockers, aspirin, and reperfusion therapy was similar in both types of hospitals. In tertiary care hospitals, ACE inhibitors and statins were more frequently used during hospital stay and recommended at discharge compared with secondary care hospitals. In-hospital mortality was similar in both types of hospitals both before and after adjustment. Tertiary care physicians adhered more strictly to the current definition and guidelines for the management of AMI than did secondary care physicians. However, there is still a need for further improvement in both hospital settings according to international guidelines.

The progress of reforms: job satisfaction in a typical hospital in Estonia.

To evaluate the level of job satisfaction among the staff at an Estonian hospital and to describe factors related to their job satisfaction. Questionnaire survey. Pärnu County Hospital in Estonia. All staff members of the Pärnu County Hospital (n = 673), except 56 staff members who were away from work during the study. Respondents (n = 473) indicated an average job satisfaction level of 3.86 +/- 0.81 on a 5-point scale. The efficiency of hospital management as measured by planning, relationships with supervisors, knowledge and communication regarding hospital goals, plans, quality of services, budgetary situation, and staffing problems was positively correlated with job satisfaction. Stress and unrealistic expectations were negatively correlated with job satisfaction. The feeling of being part of the organization was also correlated with job satisfaction. Recognition from supervisors and discussions with colleagues were found to be weakly correlated with job satisfaction. There were differences between occupational categories. The management of Pärnu County Hospital has been able to create good supervisory relationships with staff by providing sufficient information about the goals of the hospital, the quality of services, the budgetary situation, and staffing problems that arise. Stress levels reported are not excessive and staff are loyal to their hospital.