Large Acute Care Hospital Research Articles

Nutritional care of the patient: nurses' knowledge and attitudes in an acute care setting.

Concern is growing about the occurrence of malnutrition in hospitals throughout the developed world. Reduced involvement of nurses in patients' nutritional care may be one of the contributing factors. This study explored nurses' attitudes and knowledge about nutrition and food service in hospital. Semi-structured interviews were conducted with seven nurses from the internal medical service of a large Australian acute care hospital. Analysis of the interview transcripts revealed that many nurses lacked the in-depth knowledge needed to give proper nutritional care to their patients. Although nurses considered nutritional care to be important many had difficulty in raising its priority above other nursing activities, as a result of time constraints and multitasking issues. Several problems relating to food service arrangements were also highlighted. The findings suggest a need to raise nurses' awareness of the importance of nutrition in patient outcome. This study provides information which will guide in-service nurse education programs about nutrition, and suggests strategies for practice and organizational change.

Children hospitalized for varicella: A prevaccine review

OBJECTIVES: To describe varicella complications in healthy and previously ill children hospitalized for varicella and to explore trends in group Aβ-hemolytic streptococcus complications of varicella. METHODS: A retrospective record review of children hospitalized for varicella between January 1, 1990, and March 31, 1994, was conducted in nine large acute care hospitals in Los Angeles County, California. RESULTS: We identified 574 children hospitalized for varicella in study hospitals during the 4.25-year study period (estimated risk of hospitalization, approximately 1 in 550 cases of varicella); 53% of the children were healthy before the onset of varicella and 47% were previously ill with underlying cancers or other chronic illnesses. Children were hospitalized for treatment of complications (n = 427, 74%) or for prophylactic antiviral therapy or observation (n = 147, 26%). Systems involved in complications included skin/soft tissue (45%), neurologic (18%), respiratory (14%), gastrointestinal (10%), and hematologic, renal, or hepatic (8% or less). The mean age of children with skin/soft tissue infections was 2.7 years (range <1 to 16 years) compared with 4.7 years (<1 to 18 years) for other complications. Children with skin/soft tissue and neurologic complications were more often previously healthy ( p <0.05), whereas those with respiratory complications were more often previously ill ( p <0.001). Hospitalizations for skin/soft tissue infections increased during the study period. The proportion of complications as a result of group A β-hemolytic streptococcus infection increased from 4.7% before 1993 to 12.2% for the remainder of the study period ( p = 0.02). CONCLUSIONS: Prior health status was predictive of the type of complications experienced by children with varicella requiring hospitalization. Our data suggest a recent increase in skin/soft tissue complications of varicella requiring hospitalization and an increase in the proportion of complications related to group A β-hemolytic streptococcus. Wide-scale vaccine use should reverse this trend and reduce the overall impact of varicella on both healthy and previously ill children.(J P EDIATR 1996;129:529-36)

Balancing Collaboration and Competition: The Kingsport, Tennessee Experience

In 1988, business, health care, and community leaders in Kingsport, Tennessee, initiated the Kingsport Area Health Improvement Project (KAHIP) to improve the health status of local citizens. The community has good conditions for collaboration: (1) a large employer that was a 1993 winner of the Malcolm Baldrige National Quality Award, (2) community structures for the implementation of collaborative efforts, (3) relative stability in community employment and income, (4) adequate medical resources, (5) outside support from foundations and national organization, and (6) the confidence and commitment of its leaders to make quality efforts work. Barriers to improvement have included 1) two large acute care hospitals competing for many of the same physicians and patients, 2) the uncertainties introduced by the restructuring of the community's largest employer, and 3) ongoing moves in the managed care arena by some key players, which have left a degree of anger and mistrust. Realizing that the approach taken in the late 1980s and early 1990s was no longer working in the new competitive environment, KAHIP reconstituted itself in 1994. Providers now have a greater leadership role in community improvement efforts. As a result, improvement efforts in Kingsport include the institution of interventions to reduce injuries to children/adolescents resulting from motor vehicular accidents, the establishment of a primary care health center for the uninsured/underserved, and development of a smoking-cessation program. The keys to continued leadership are 1) explicit faith in the continuous quality improvement approach, 2) commitment to communitywide change, 3) willingness to continue to engage in dialogue, 4) willingness to try new organizational alliances and structures to revitalize the effort, and 5) willingness to address those issues that individuals and institutions can agree to work on and set aside those they cannot agree on.

Reliability of Aggregated Organizational Data: An Evaluation of Five Empirical Indices

Nursing systems research has included many levels of measurement such as individuals, work groups, organizations, and systems of organizations. Variables important to organizational survival often are measured at the individual level, with inferences made to the work group or the organization. This study demonstrated a process for determining the reliability of individual level data aggregated to the work group and organization levels. Data were analyzed on four variables: job enjoyment; manager's leadership style in terms of structuring expectations and consideration; and control over nursing practice. Job enjoyment was assessed over time. Registered staff nurses (n = 632), representing 54 nursing units from 4 large acute care hospitals, comprised the sample. The results indicated the assessment of reliability and validity is important at the level of inference and at each time interval. Aggregated data were deemed reliable when the following criteria were met: Cronbach's alpha > .60; intraclass correlation (1,k) > .60; and a significant F ratio. The interpretation of omega 2 as an indicator of effect size suggested that the validity of inference at the aggregated level is in question when effect size is negligible or small.

Identification of confusion among the elderly in an acute care setting.

An exploratory, descriptive study was conducted in a large acute care hospital to determine: (1) the indicator/descriptors used by staff nurses to arrive at the diagnosis of confusion, and (2) which indicators/descriptors are perceived as most significant in such a diagnosis. In addition, because the literature frequently cites the occurrence of nurses stereotyping patients as confused and thereby treating them as confused (Libow's self-fulfilling prophecy), the third question explored was the type and quantity of information that was given to nurses at intershift report. A self-constructed interview schedule was used on a sample of 25 staff nurses who were primary caregivers of a confused patient on a given day. Content analysis revealed emergent themes of confusion in two domains: cognitive and behavioral. The findings from this study revealed nurses used cognitive descriptors more frequently to diagnose confusion; however, a large majority of nurses used a combination of both cognitive and behavioral descriptors for diagnosis. Nurses also used independent assessment based on their own observations rather than those from the night nurse in arriving at a nursing diagnosis of confusion. This investigation responds to the need to "confirm defining characteristics of the phenomenon of confusion" posited by Foreman. In addition, results from this study will provide a basis for a taxonomy on the phenomenon of confusion. It is hoped that such a taxonomical classification will enable nurses to assess the confused patient more effectively.

Cost Savings by a Pharmacokinetics Service in a Large Acute Care Hospital

Cost Savings by a Pharmacokinetics Service in a Large Acute Care Hospital

Nosocomial Salmonellosis and Shigellosis

In this issue of Infection Control and Hospital Epidemiology, Paton et al1 report the results of a six-month study of the occurrence of Salmonella and Shigella infection determined by routine rectal swab culturing of patients either admitted to a large acute and tertiary care hospital in Nairobi, Kenya, or experiencing a nosocomial episode of acute diarrhea during a six-month period of time at the same institution. The background infection rate for 667 sequentially admitted patients was approximately 3% for both agents. Salmonella infection at the time of admission was seen only in the children under 13 years of age. These infected children were older and were found more

Staff and Patients: Divergent Views of Treatment

A patient-staff survey, focusing on the efficacy of treatment and aftercare, showed inconsistencies in the way staff perceived treatment given patients at a large municipal acute care hospital. Primary therapists, psychiatrists, and psychologists saw treatment in a routine, standardized fashion, whereas nurses, social workers, activity therapists, and others viewed treatment in more elaborate, individualized terms. The survey also showed disparities between what staff intended to do and what patients perceived was happening to them. Implications of these findings and recommendations for coordinating staff efforts and clarifying patient understanding of treatment are presented.

Three-year experience with amikacin sulfate as an exclusive surgical aminoglycoside in a large acute-care Hospital

Aminoglycosides have important roles as perioperative adjunctive antibiotics in the surgical management of peritonitis. In the past, most surgeons have used gentamicin in combination with a drug aimed at intraperitoneal anaerobic pathogens, either clindamycin or metronidazole. Amikacin has been traditionally reserved for culture-proved infections due to gram-negative organisms resistant to gentamicin or other aminoglycosides. At the Minneapolis Veterans Administration Medical Center, a worrisome incidence of gentamicin-resistant hospital isolates led to a decision to make amikacin the exclusive, routine surgical aminoglycoside for all abdominal infections, as well as all hospital-acquired infections in surgical patients involving gram-negative aerobes and requiring parenteral therapy. This report describes the resultant three-year experience with amikacin in surgical patients. Data from four research studies involving these patients suggest that exclusive amikacin use has not led to the emergence of amikacin-resistant organisms or to significant nephrotoxicity. Amikacin use in surgical patients is supported in hospital environments where gentamicin resistance is judged to be a significant clinical risk factor.

Reevaluation of Diagnostic Histoplasma Serologies

There are few quantitative guidelines for the interpretation of serologic tests for histoplasmois. Furthermore, guidelines that have been proposed are not accepted generally. This report reviews experiences with complement fixation and latex agglutination tests performed in a large acute-care hospital in an endemic area, and depicts the relationship between the proportion of false-positive reactions and the titer at which the serologic tests were reactive. We noted a considerable number of false-positive reactions for these widely-used tests. Use of a battery of standard tests for histoplasmosis resulted in a 90% decrease in false-positive reactions. Reliance upon multiple positive results in such a battery of tests would result in failure to detect 50% of cases of disseminated histoplasmosis, but would eliminate most false positives.

Utilization of Within-Hospital Services

This study examined the effect of group affiliation on the use of technical (length of stay, lab tests, etc.) and clinical (rendering and requesting consultations) resources by physicians practicing within a large acute care hospital. Comparisons in use were made between physicians in 1) a prepaid group practice (Colorado Permanente Medical Group [Kaiser]); 2) a fee-for-service group practice; and 3) "unaffiliated" physicians. Patient data were adjusted whenever possible for patient diagnosis and severity. In comparison to other physicians in the hospital, the prepaid group physicians utilized somewhat fewer technical resources, though the results were not statistically significant. Differences in the use of clinical resources were statistically significant, with the fee-for-service group physicians using consulting services the most and prepaid group physicians using them the least. The results indicate that 1) fee-for-service group structures may reinforce the incentives to share in consultation revenues; 2) prepaid group physicians may experience difficulty becoming integrated into the informal structures of physician practice patterns; and 3) the control of groups over the use of technical hospital resources may be substantially weakened when groups do not own or control the hospitals to which they admit their patients.