Minimum Standard Of Care Research Articles

Implementation and Enforcement of Quality and Safety in Long-Term Care

Long before the new coronavirus struck, nursing homes and other long-term care facilities have had declining quality care that coincides with inadequate staffing and rampant infections. These pre-pandemic conditions increased the vulnerability of these facilities to an infectious disease outbreak. As the elderly death toll rises into the tens of thousands, an overdue national discussion on how to prioritize long-term care in the US has emerged, revealing an opportunity to better link quality care metrics with sufficient reimbursement and meaningful regulatory oversight. However, the opposite approach has also surfaced, which would allow the status quo to continue and may erode the minimum standards of care that currently exist. This concerning trend is on the rise with efforts to relax the Centers for Medicare and Medicaid Services (CMS) regulatory authority over nursing homes by waiving requirements and reducing enforcement penalties. In addition, states are passing measures to limit liability exposure for nursing homes during COVID-19 and similar protections are under consideration at the federal level, even as infection rates climb and there is no evidence of frivolous lawsuits. While political will is uncertain, public outcry is ready for legislative reform that will lead to better later-in-life care. The stakes have never been higher — act now and pass laws that connect funding with regulation to support quality care in nursing homes during and after the COVID-19 pandemic — or continue to condone practices that allow infection to spread and take many lives before their time. This paper was prepared as part of Assessing Legal Responses to COVID-19, a comprehensive report published by Public Health Law Watch in partnership with the de Beaumont Foundation and the American Public Health Association.

Achieving equitable management of allergic disorders and primary immunodeficiency in a Black, Asian and Minority Ethnic population

Achieving equitable management of allergic disorders and primary immunodeficiency in a Black, Asian and Minority Ethnic population

Provision of services in primary care for type 2 diabetes: a qualitative study with patients, GPs, and nurses in the East of England.

BackgroundThere is little evidence on the impact of national pressures on primary care provision for type 2 diabetes from the perspectives of patients, their GPs, and nurses.AimTo explore experiences of primary care provision for people with type 2 diabetes and their respective GPs and nurses.Design and settingA qualitative primary care interview study in the East of England.MethodSemi-structured interviews were conducted, between August 2017 and August 2018, with people who have type 2 diabetes along with their respective GPs and nurses. Purposive sampling was used to select for heterogeneity in glycaemic control and previous healthcare experiences. Interviews were audio-recorded and analysed thematically. The consolidated criteria for reporting qualitative research were followed.ResultsThe authors interviewed 24 patients and 15 GPs and nurses, identifying a changing landscape of diabetes provision owing to burgeoning pressures that were presented repeatedly. Patient responders wanted GP-delivered care with continuity. They saw GPs as experts best placed to support them in managing diabetes, but were increasingly receiving nurse-led care. Nurses reported providing most of the in-person care, while GPs remained accountable but increasingly distanced from face-to-face diabetes care provision. A reluctant acknowledgement surfaced among GPs, nurses, and their patients that only minimum care standards could be maintained, with aspirations for high-quality provision unlikely to be met.ConclusionType 2 diabetes is a tracer condition that reflects many aspects of primary care. Efforts to manage pressures have not been perceived favourably by patients and providers, despite some benefits. Reframing expectations of care, by communicating solutions to both patients and providers so that they are understood, managed, and realistic, may be one way forward.

World Small Animal Veterinary Association Global Dental Guidelines

Dental, oral, and maxillofacial diseases are some of the most common problems in small animal veterinary practice. These conditions create significant pain as well as localized and potentially systemic infection. As such, the World Small Animal Veterinary Association (WSAVA) believes that un- and under treated oral and dental diseases pose a significant animal welfare concern. Dentistry is an area of veterinary medicine which is still widely ignored and is subject to many myths and misconceptions. Effective teaching of veterinary dentistry in the veterinary school is the key to progression in this field of veterinary medicine, and to the improvement of welfare for all our patients globally. These guidelines were developed to provide veterinarians with the information required to understand best practices for dental therapy and create realistic minimum standards of care. Using the three-tiered continuing education system of WSAVA, the guidelines make global equipment and therapeutic recommendations and highlight the anaesthetic and welfare requirements for small animal patients. This document contains information on common oral and dental pathologies, diagnostic procedures (an easily implementable and repeatable scoring system for dental health, dental radiography and radiology) and treatments (periodontal therapy, extractions). Further, there are sections on anaesthesia and pain management for dental procedures, home dental care, nutritional information, and recommendations on the role of the universities in improving veterinary dentistry. A discussion of the deleterious effects of anaesthesia free dentistry (AFD) is included, as this procedure is ineffective at best and damaging at worst. Throughout the document the negative effects of undiagnosed and/or treated dental disease on the health and well-being of our patients, and how this equates to an animal welfare issue, is discussed.

Physical distancing, face masks, and eye protection for prevention of COVID-19

Physical distancing, face masks, and eye protection for prevention of COVID-19

Standards for the provision of antenatal care for patients with inflammatory bowel disease: guidance endorsed by the British Society of Gastroenterology and the British Maternal and Fetal Medicine Society

BackgroundPregnant women with inflammatory bowel disease (IBD) are at increased risk of adverse pregnancy outcomes. Comprehensive guidelines on medical management have been published; yet, there is limited guidance on service...

Guidance Statement for the Management of Febrile Neutropenia in Pediatric Patients Receiving Cancer-Directed Therapy in Central America and the Caribbean.

PURPOSEOur objective was to provide regionally appropriate, resource-conscious recommendations for the diagnosis and treatment of pediatric patients with febrile neutropenia.METHODSA multinational panel of Central American and Caribbean clinicians who deliver pediatric oncology care prioritized clinically important questions and then used the Grading of Recommendations Assessment, Development and Evaluation methodology to provide recommendations on the selected topics.RESULTSTwenty-two questions and 2 definitions were included in the guideline, which was intended to establish minimum care standards for pediatric patients treated in regional centers. Of all the included studies, 6.9% were conducted in low- and middle-income countries, and no studies were performed in countries represented on the panel.CONCLUSIONThe panel made recommendations on the basis of existing evidence but identified important gaps in knowledge from the region and from resource-limited settings that may affect the clinical applicability of these recommendations. These deficiencies suggest a research agenda that will enable future guidelines to be more responsive to the local context.

The evaluation of medical malpractice claims: Creating a Standard Approach Model Using the Delphi Method

Complaints about alleged medical malpractice have increased over time in Turkey, as well as other countries around the world. And it is often the subject of debate in health law and medical law.It can be seen that discussions are underway on “standard of care” which is highlighted in the finalization of claims for medical malpractice. In this case, the expert opinion offered to be the key point for the cases. In the expert opinion, there seems to be differences in approach and procedure. However, the period of determination of whether health professionals provide the expected minimum standard of care needs to be analyzed in a standard way. In addition to standard, objective and scientific evaluation of the evidence of liability for the medical malpractice claims by the experts, it is aimed to create an algorithm that will facilitate the evaluation by the judicial authorities.The aim of this research is to provide minimum common denominator which will be the standard approach model for the experts in the evaluation of medical malpractice claims.The Delphi method was used as a tool for the panelists to express their opinions freely without being under the influence of each other and to reveal different ideas. The research conducted with 11 panelists consist of forensic medicine experts, clinicians, and a lawyer between January 2017 and September 2017.This research will impact the forensic science and law community by serving the evaluations of the experts in medical malpractice claims whether evaluations are based on methodological and logical considerations and the scientific validity of the evaluations is objective or not.

A text message intervention for quitting cigarette smoking among young adults experiencing homelessness: study protocol for a pilot randomized controlled trial

BackgroundCigarette smoking is much more prevalent among young people experiencing homelessness than in the general population of adolescents and young adults. Although many young homeless smokers are motivated to quit, there are no empirically-evaluated smoking cessation programs for this population. It is important that any such program address the factors known to be associated with quitting-related outcomes among homeless young people, to provide ongoing support in a way that accommodates the mobility of this population, and does not rely on scarce service provider resources for its delivery. The objective of this project is to develop and pilot test a text messaging-based intervention (TMI), as an adjunct to brief cessation counseling and provision of nicotine patches, to help homeless young people who want to quit smoking.Methods/designThis pilot study will utilize a cluster cross-over randomized controlled design with up to 80 current smokers who desire to quit and are recruited from three drop-in centers serving young people experiencing homelessness in the Los Angeles area. All participants will be provided with a minimum standard of care: a 30-min group-based smoking cessation counseling session and free nicotine replacement. Half of these smokers will then also receive the TMI, as an adjunct to this standard care, which will provide 6 weeks of ongoing support for quitting. This support includes continued and more intensive education regarding nicotine dependence, quitting smoking, and relapse; does not require additional agency resources; can be available “on demand” to users; and includes features to personalize the quitting experience. This study will investigate whether receiving the TMI adjunct to standard smoking cessation care results in greater reductions in cigarette smoking compared to standard care alone over a 3-month period.DiscussionThis study has the potential to address an important gap in the clinical research literature on cigarette smoking cessation and provide empirical support for using a TMI to provide ongoing assistance and support for quitting among young smokers experiencing homelessness.Trial registration ClinicalTrials.gov Identifier NCT03874585. Registered March 14, 2019, https://clinicaltrials.gov/ct2/show/record/NCT03874585.

Provisions for Health Sector Response to Substance Use Disorders in the Indian Policy: A Critique of the National Policy on Narcotic Drugs and Psychotropic Substances

ABSTRACTThis article reviews the provisions of Indian national policy on narcotic drugs and psychotropic substances in context of the health sector services for (illicit) psychoactive substances and substance use disorders (SUD). For the the current review, a checklist was developed based on recommendations from various agencies and organizations. The document on Indian national policy on narcotic drugs and psychotropic substances was reviewed based on the checklist. Themes such as identification in the aims/objectives/vision of the policy, including those highlighting treatment-related needs for SUD; establishment of minimum standards of care for treatment; evaluation of treatment programs for SUD; government regulation of public and private drug treatment services; capacity building for treatment services; and harm reduction services to reduce bloodborne infections were documented in the policy. Others such as transparency of the policy making process; situation analysis; implementation of substance abuse prevention and treatment programs that target key populations; impetus on evidence-based programs and practices were inadequately documented. Finally, integration of treatment into existing health care systems; services for co-occurring disorders (medical and psychiatric); monitoring and performance evaluation of prevention programs; harm reduction services to reduce overdose; budget allocations and provisions for implementation were not documented in the current policy.

A Care Bundle Approach: Quality Nursing Care

A Care bundle is a group of three to five evidence-based interventions which, when performed together, have a better outcome than if performed individually. Care bundles can be used to ensure the delivery of the minimum standard of care. It is a set of interventions that, when used together, significantly improve patient outcomes. Multidisciplinary teams work together to deliver the best possible care supported by evidence-based research and practices, with the ultimate outcome of improving patient care. The steps of the care bundle are carefully selected, well-established practices that are packaged together and scientifically supported. The focus of the bundle is on how to deliver the best care using a clear-cut method to provide the best possible outcome for patient.

161 The Impact of Statewide Emergency Department Opioid Overdose Treatment Standards on Naloxone Distribution, Behavioral Counseling, and Referral to Treatment

Determine the impact of Rhode Island (RI)’s emergency department (ED) opioid use disorder (OUD) treatment standards, the Levels of Care for Rhode Island EDs and Hospitals for Treating Overdose and OUD (Levels of Care), on ED provision of take-home naloxone, behavioral counseling, and referral to treatment after certification of level of care policy implementation. Data from the Rhode Island Department of Health’s 48-hour ED opioid overdose reporting system were analyzed from 2016 to 2018 to determine changes in services provision after hospital level of care certification for patients 18 years of age and older discharged from a RI ED after being treated for a non-fatal opioid overdose. The primary outcomes were offering and provision of: 1) take-home naloxone; 2) ED behavioral counseling; 3) referral to OUD treatment. Changes in services provision before and after hospital certification were compared using a chi-square test and using predicted probabilities from a multivariable GEE model with a binomial outcome, logit link, and variance clustered within hospitals. Sub-analyses were conducted looking at changes after certification at facilities certified as Level 3, the minimum standard of care, and those certified as Level 1, which provide the minimum standard of care as well as access to comprehensive addiction treatment services and medication for addiction treatment. There were 2,049 ED opioid overdose visits before hospital level of care certification and 1,338 after. Six hospitals were certified as Level 1; four were certified as Level 3. The majority of patients were male (71%), 25-44 years old (61%), and white (78%). After hospital certification, patients were more likely to be offered (60% vs 82%, p<0.001) and given (41% vs 51%, p<0.001) take-home naloxone. Overall, counseling offers increased (58% vs 85%, p<0.001), but receipt of counseling did not change (35% vs 33%, p=0.137). After adjusting for age, sex, naloxone administration prior to ED arrival, previous overdose ED visit in the past year, calendar time, season, and within-hospital clustering, there was no significant change in offering or receipt of take-home naloxone after hospital certification. In adjusted estimates, more patients were offered counseling after certification at Level 3 (24% vs. 77%, p<0.001) hospitals, but there was no significant change at Level 1 hospitals (42% vs. 72%, p=0.139). There was no significant change in receiving counseling; however, there was an increase in referral to treatment for both Level 1 (15% vs. 21%, p=0.044) and Level 3 (27% vs. 43%, p=0.004) hospitals after certification. The RI Levels of Care are the first state-wide adopted treatment standards for opioid overdose and OUD. Hospital certification is associated with increased provision of take-home naloxone, offering of counseling at Level 3 hospitals, and referral to treatment at all hospitals. Future investigations are needed to better characterize implementation barriers and evaluate policy impact on patient outcomes.

P4.48: Evaluating psychological support services available for intestinal failure patients nationally

Introduction: New Zealand (NZ) has a population of 4.9 million with a publicly funded health system. The NZ Health Strategy 2016 requires care to be delivered close to home. A multidisciplinary team approach for patients with intestinal failure (IF) is widely accepted and a standard of care (SOC) endorsed by NZ National Intestinal Failure Service (NIFS), this includes access to psychological support services. Clinical network (CN) feedback indicated aspects of the SOC were unable to be delivered due to variability and availability of psychological care. In order to advocate for appropriate services, it was necessary to understand the current psychological and psychiatry services for IF patients. Method: A web based survey was developed to identify psychological services, referral pathways, appropriateness and desired levels of service provision for IF patients in NZ. The survey contained questions allocated to five categories including occupation details, current psychological care services, access to psychological care and NZ NIFS SOC. The survey was sent to 502 members of the NZ NIFS CN in August 2017. Responses were collated and analysed using Microsoft Excel to identify themes and regional variance. Results: Forty-one clinicians from 13 of 20 District Health Boards (DHB) completed the survey representing a response rate of 8.2%. Of note, most DHBs contribute multiple staff to the CN and collated responses were sent on behalf of their DHB. Responses confirmed that there is a lack of psychological care services available nationally. This applied equally to both adult and paediatric IF services. It is particularly concerning that respondents identified mental health deficiencies as a reason that 2 of the 10 NZ NIFS SOCs could not be met. Themes highlighted include inconsistencies in availability and adequacy of services between and within DHBs. There is a lack of knowledge of access and referral pathways available for psychological care services. Conclusion: Findings highlight a disparity in provision of psychological care services in NZ which represents a risk to the NZ Health Strategy 2016 close to home model of healthcare. Every IF patient requires appropriate psychological care as a minimum SOC. Whilst acknowledging that current services have limited capacity the NZ NIFS will continue to advocate for the provision of appropriate and equitable psychological care and engage the CN to identify local psychology and psychiatry services in their DHB.

Insights from outside BJOG

Insights from outside BJOG

English

Antenatal care (ANC) has been recommended as a service that can reduce both maternal and newborn mortalities. However, even in areas recording high ANC attendance, there are unevenly high levels of maternal and new born mortalities. Evidence of a weak relationship between ANC use and maternal and newborn survival has motivated recent calls to focus on content and quality of care provided rather than mere ANC attendance. This was a descriptive cross sectional study which was designed to evaluate the quality of antenatal care services in two health facilities in Lusaka and two in Mumbwa districts of Zambia. The health facilities were selected purposively based on poor maternal outcomes such as high maternal mortality ratio. Women attending antenatal clinics were selected using simple random sampling. Data was collected using a client exist interview schedule designed by World Health Organization for assessing quality of antenatal care. Data was analyzed using Statistical Package for Social Scientist (SPSS) version 24.0. The study revealed a lot of variations in the care provided at the four sites. None of the women had all the blood tests for haemoglobin, grouping and X-match, HIV and syphilis conducted from three out of the four health facilities, while at the fourth, only 30% of women had all the blood tests conducted. Furthermore, less than 20% of women had a full head to toe examination. While less than 10% of women from each of the facility reported that the health providers met the requirements for provision of privacy. Despite not meeting the minimum standards of care, only less than 5% of women categorized the care as poor. All the four health facilities recorded low quality of care on all domains of antenatal care. Therefore, if antenatal care has to achieve its intended purpose of reducing adverse maternal and new born outcomes, then quality of care delivered during pregnancy should be the focus as opposed mere attendance. Key words: Quality, antenatal care services, evaluation.

Performance-based funding: A case study in Madagascar

Aims: To successfully introduce a digital performance-based funding system into Sambava Hospital in the SAVA region of Madagascar in order that surgeons and clinical care workers would be incentivized to provide high-quality care to a greater number of patients.&#x0D; Methods: We used a combination of monetary and non-monetary incentives, the first is that we provide a cash transfer when Dr. Fidèle and his team perform in line with our minimum standards of care; the quality of surgery and the entire continuum of care is measured by the use of Operation Fistula’s Global Obstetric Fistula Electronic Registry (GOFER) application. The non-monetary incentives include visualisations of Dr. Fidele’s surgical progress so that he can more effectively monitor the practices of the team.&#x0D; Results: This pilot in Sambava Hospital revealed that the data collection tool serves three purposes: It ensures that the surgeries performed and nursing care maintained meet a minimum standard of care; It acts as a verification mechanism that triggers payment; and The data collected enables Dr. Fidèle to track and measure his own surgical progress, with our surgical dashboards.&#x0D; Conclusions: The initial outcome of this pilot program has yielded positive results. From March to September, the treatment of 40 patients has been accounted for and transfers have been made, on receipt of corresponding data.&#x0D; Keywords: Funding, high quality care, patients

The Internet of Things, Artificial Intelligence, Blockchain, and Professionalism

This article describes how technology can be impactful when applied to solve precise and measurable problems. Technologies such as Artificial Intelligence (AI), Internet of things (IoT), robotic process automation (RPA), and blockchain hold tremendous potential when integrated for specific solutions. In addition to these technologies, the professional designers, engineers, and developers are fundamental to solving problems. People are our most critical element in envisioning the future and solving challenges with the help of technologies. We recognize that in order to truly maximize our efforts with these technologies, the solutions must be used within the ethics of our communities, with a responsibility to safeguard the public’s health, safety, security, and environment with a minimum standard of care ultimately governed by people in a constantly evolving network. With proper oversight on a secure platform and architecture, we will see that the convergence of IoT/RPA, AI, and blockchain make a significant difference in our everyday lives.

Peer review of rural and tertiary Queensland paediatric diabetes services: A pilot project from the National Health Service

Peer review is one component of the improvement of diabetes care delivered by the National Health Service (NHS) in England and Wales. Queensland has a decentralised model of service provision with an established state diabetes network. The NHS scheme was adapted for use in Australia, and seven trained reviewers were recruited to visit 14 'hub' centres, which in turn covered 29 'spoke' units delivering care to over 95% of all public patients <16 years old in the state. Details of control as measured by glycosylated haemoglobin (HbA1c), the rate of presentation of diabetic ketoacidosis (DKA), the use of state guidance and staffing levels were recorded. Thirteen minimum standards of care were used as a basis for assessment. A report for the use of each inspected unit was produced at the end of the process. Most units had not previously collected outcome data; 45% of new cases presented with DKA. The centre mean HbA1c was 9.1%, and only 21% of patients achieved the Australian recommended level of <7.5%. Only three centres met some of the internationally recommended staffing levels. Only two centres provided transitional care to adult services. Of 13 NHS minimum standards of care, a mean of 5 were achieved (range 1-8), a mean of 4.6 partially achieved (range 3-6) and a mean of 3.9 not achieved (range 0-9). The care for 68 patients with type 2 diabetes was particularly poor. Paediatric diabetes care in Queensland is suboptimal. Recommended remedial actions are suggested that may be applicable to other states.

Quality of Care in Patients With Inflammatory Bowel Disease.

The rising burden of inflammatory bowel disease (IBD) has the potential to have a negative impact on the quality of care delivered to patients with IBD. Quality of care has been described by the World Health Organization as "the extent to which health care services provided to individuals and patient populations improve desired health outcomes." Variation in care has been identified as a key barrier to achieving quality of care in IBD. Assessment of quality of care attempts to minimize variation in care. Quality indicators have been developed in IBD as a minimum standard of care according to evidence-based guidelines. Models of care to achieve and maintain quality include integrated care, participatory care, and value-based health care. In this review, we outline current approaches to the assessment of quality of care in IBD and explore models of care currently being used to achieve and maintain quality.

Providing safe and effective pleural medicine services in the UK: an aspirational statement from UK pleural physicians

Physicians face considerable challenges in ensuring safe and effective care for patients admitted to hospital with pleural disease. While subspecialty development has driven up standards of care, this has been...