Public Hospital Network Research Articles

The impact of palliative care training for oncologists and integrative palliative service in a public-funded hospital cluster-a retrospective cohort study.

Oncological care of advanced cancer patients was provided by multiple departments in Hong Kong. One of these departments, the clinical oncology department (COD), introduced systematic palliative care training for its oncologists since 2002. The COD was recognized as a European Society for Medical Oncology (ESMO) Designated Centre of Integrated Oncology and Palliative Care since 2009. This retrospective cohort study aims to review the impact of integrative training and service on palliative care coverage and outcome. Clinical information, palliative service provision, and end-of-life outcomes of patients who passed away from lung, colorectal, liver, stomach, or breast cancer in the Hong Kong West public hospital network during July 2015 to December 2015 were collected. A total of 307 patients were analyzed. Around half (49.2%) were attended primarily by COD, and 68.9% received palliative service. There are significantly fewer patients referred to palliative care from other departments (p < 0.001), with only 19.9% of this patient group receiving palliative referral. COD patients had longer palliative coverage before death (median 65days versus 24days, p < 0.001), higher chance of receiving end-of-life care at hospice units (36.4 versus 21.2%, p = 0.003), lower ICU admission (0.66 versus 5.1%, p = 0.02), and higher percentage of receiving strong opioid in the last 30days of life (51.0 versus 28.9%, p < 0.001) compared to other departments. In multivariable analysis, COD being the primary care team (odds ratio 12.2, p < 0.001) was associated with higher palliative care coverage. The study results suggested that systematic palliative care training of oncologists and integrative palliative service model was associated with higher palliative service coverage and improved palliative care outcomes.

The Relationship Between Latent Tuberculosis Infection and Acute Myocardial Infarction.

Tuberculosis has been associated with an increased risk of cardiovascular disease (CVD), including acute myocardial infarction (AMI). We investigated whether latent tuberculosis infection (LTBI) is associated with AMI. We conducted a case-control study in 2 large national public hospital networks in Lima, Peru, between July 2015 and March 2017. Case patients were patients with a first time diagnosis of type 1 (spontaneous) AMI. Controls were patients without a history of AMI. We excluded patients with known human immunodeficiency virus infection, tuberculosis disease, or prior LTBI treatment. We used the QuantiFERON-TB Gold In-Tube assay to identify LTBI. We used logistic regression modeling to estimate the odds ratio (OR) of LTBI in AMI case patients versus non-AMI controls. We enrolled 105 AMI case patients and 110 non-AMI controls during the study period. Overall, the median age was 62 years (interquartile range, 56-70 years); 69% of patients were male; 64% had hypertension, 40% dyslipidemia, and 39% diabetes mellitus; 30% used tobacco; and 24% were obese. AMI case patients were more likely than controls to be male (80% vs 59%; P < .01) and tobacco users (41% vs 20%; P < .01). LTBI was more frequent in AMI case patients than in controls (64% vs 49% [P = .03]; OR, 1.86; 95% confidence interval [CI], 1.08-3.22). After adjustment for age, sex, hypertension, dyslipidemia, diabetes mellitus, tobacco use, obesity, and family history of coronary artery disease, LTBI remained independently associated with AMI (adjusted OR, 1.90; 95% CI, 1.05-3.45). LTBI was independently associated with AMI. Our results suggest a potentially important role of LTBI in CVD.

Efficiency Analysis of Integrated Public Hospital Networks in Outpatient Internal Medicine.

Healthcare systems are evolving towards a complex network of interconnected services due to the increasing costs and the increasing expectations for high service levels. It is evidenced in the literature the importance of implementing management techniques and sophisticated methods to improve the efficiency of healthcare systems, especially in emerging economies. This paper proposes an integrated collaboration model between two public hospitals to reach the reduction of weighted average lead time in outpatient internal medicine department. A strategic framework based on value stream mapping and collaborative practices has been developed in real case study settled in Colombia.

The representativeness of direct oral anticoagulant clinical trials to hospitalized patients with atrial fibrillation

Trials of the direct oral anticoagulants (DOACs) dabigatran, rivaroxaban and apixaban provide the basis for prescribing for the prevention of stroke and systemic embolism in atrial fibrillation (AF). The objective of this study was to assess the representativeness of the three pivotal DOAC randomized controlled trials of dabigatran, rivaroxaban and apixaban for unselected hospitalized patients with AF. A cross-sectional study was undertaken. All patients discharged with AF between 2012 and 2015 from a large public hospital network in Melbourne, Australia, were identified. Inclusion and exclusion criteria from the DOAC trials were applied. The proportions of hospitalized patients with AF who would have been eligible for the dabigatran (RE-LY), rivaroxaban (ROCKET-AF) and apixaban (ARISTOTLE) trials were estimated, as was pooled eligibility for all three trials. Characteristics of eligible and ineligible patients were compared. For the 4734 patients, application of the inclusion and exclusion criteria resulted in 60.5, 52.6 and 35.8% eligibility for the trials of apixaban, dabigatran and rivaroxaban, respectively. Pooled eligibility across all three trials demonstrated that 33.4% of the patients would have been eligible for all three trials but 36.7% ineligible for any trial. Ineligible patients who met exclusion criteria were older and experienced more comorbidities. The apixaban and dabigatran trials may be the most representative of hospitalized patients with AF. The DOAC trial results can readily be extrapolated to, and guide prescribing for, at least two thirds of patients discharged from a large metropolitan health service in Australia.

Prevalence of tuberculosis infection in healthcare workers of the public hospital network in Medellín, Colombia: a Bayesian approach.

A latent tuberculosis infection (LTBI) prevalence survey was conducted using tuberculin skin test (TST) and Quantiferon test (QFT) in 1218 healthcare workers (HCWs) in Medellín, Colombia. In order to improve the prevalence estimates, a latent class model was built using a Bayesian approach with informative priors on the sensitivity and specificity of the TST. The proportion of concordant results (TST+,QFT+) was 41% and the discordant results contributed 27%. The marginal estimate of the prevalence P(LTBI+) was 62·1% [95% credible interval (CrI) 53·0-68·2]. The probability of LTBI+ given positive results for both tests was 99·6% (95% CrI 98·1-99·9). Sensitivity was 88·5 for TST and 74·3 for QFT, and specificity was 87·8 for TST and 97·6 for QFT. A high LTBI prevalence was found in HCWs with time-accumulated exposure in hospitals that lack control plans. In a context of intermediate tuberculosis (TB) incidence it is recommended to use only one test (either QFT or TST) in prevalence surveys or as pre-employment tests. Results will be useful to help implement TB infection control plans in hospitals where HCWs may be repeatedly exposed to unnoticed TB patients, and to inform the design of TB control policies.

Selected aspects of the logistics network of public hospitals in the competitive market of health services

Selected aspects of the logistics network of public hospitals in the competitive market of health services

Geographically weighted regression for modelling the accessibility to the public hospital network in Concepción Metropolitan Area, Chile.

Accessibility models in transport geography based on geographic information systems have proven to be an effective method in determining spatial inequalities associated with public health. This work aims to model the spatial accessibility from populated areas within the Concepción metropolitan area (CMA), the second largest city in Chile. The city's public hospital network is taken into consideration with special reference to socio-regional inequalities. The use of geographically weighted regression (GWR) and ordinary least squares (OLS) for modelling accessibility with socioeconomic and transport variables is proposed. The explanatory variables investigated are: illiterate population, rural housing, alternative housing, homes with a motorised vehicle, public transport routes, and connectivity. Our results identify that approximately 4.1% of the population have unfavourable or very unfavourable accessibility to public hospitals, which correspond to rural areas located south of CMA. Application of a local GWR model (0.87 R2 adjusted) helped to improve the settings over the use of traditional OLS methods (multiple regression) (0.67 R2 adjusted) and to find the spatial distribution of both coefficients of the explanatory variables, demonstrating the local significance of the model. Thus, accessibility studies have enormous potential to contribute to the development of public health and transport policies in turn to achieve equality in spatial accessibility to specialised health care.

Development and validation of the clinician palliative perception scale (CPPS).

179 Background: Worldwide healthcare systems identify a need to provide better evidence based service models for palliative care. There is little data and no standard tool that informs clinicians’ perceptions on palliative care to identify areas for service improvement and education. We aimed to develop and validate a tool to determine perceptions of hospital staff on palliative care provision, self confidence in providing palliative care, and predictors and barriers to requesting assistance. Methods: 604 hospital clinicians were recruited in person and online from a large metropolitan public tertiary teaching hospital network involving 5 campuses and 2 medical schools. They completed the CPPS (Clinician Palliative Perception Scale). Principal components analysis, exploratory factor analysis, and logistic regression were performed to examine the factor structure and relationship to clinical practice. Results: Four factors were extracted: confidence in providing palliative care, requesting assistance, global perceptions on palliative care provision, and barriers to referring. Increased confidence was significantly associated with increased likelihood of referring or requesting assistance and also associated with a good global perception on palliative care provision. Confidence was also significantly associated with years of experience and with spending &gt; 50% time looking after dying patients. Good perception of palliative care provision was highest among oncologists. Conclusions: This is the largest quantitative study ever done looking at perceptions of palliative care provision among health professionals. The CPPS is a valid and reliable tool useful for both practice and research. Its 4 identified constructs are consistent with literature on perceptions and utilisation of palliative care services. Barriers to referring involved misconceptions that palliative care would prematurely shorten patient lifespans. Others did not refer due to confidence in their own skill. This tool can be used to correlate these constructs against other solid outcome measures to assist in service improvement and identifying research needs. It can also be used to determine clinicians’ educational requirements.

Are hospital clinicians aware of legislation surrounding provision of palliative care?

118 Background: Many deaths require medical treatment to be withheld or withdrawn. Patients or their substitute decision makers may disagree with these decisions, and sometimes refuse the right to appropriate palliative care. An awareness of legal frameworks surrounding end of life decisions is vital to navigate through these conflicts. Without this, patients suffer unnecessarily. Methods: 542 hospital doctors and nurses were recruited from a large metropolitan public tertiary teaching hospital network involving 5 campuses and 2 medical schools. A questionnaire examined their regarding legislation surrounding end of life care, both in adults with and without capacity. Results: Approximately a quarter of respondents did not believe that the “Not for Resuscitation Form” is legally a medical decision. Most doctors (68%), but not nurses, believed competent patients cannot demand futile treatment. Most clinicians (79% doctors and 85% nurses) erroneously believe that competent patients can refuse appropriate palliative care. There was significant confusion regarding the roles of substitute decision makers. Most clinicians could not find the advance directive. Groups with most correct answers were doctors, had 5-10 years experience, and were in palliative care and critical care specialties. Conclusions: This study confirms poor knowledge regarding legislation surrounding provision of palliative care. An unusually high proportion believed patients could refuse appropriate palliative care. Most clinicians could not locate advance directives. Most nurses believed patients could legally demand futile treatment. Both junior and senior staff had comparably poor knowledge in this area.

Signs and symptoms of temporomandibular joint disorders in elderly population treated within the public hospital network of Medellin (Colombia)

Objective: To determine prevalence of temporomandibular joint disorders signs and symptoms of elderly adults in Medellin as well as related factors. Material and methods: The present was a crosssectional study conducted at the «Metrosalud» hospital network.The study was composed of 342 adult patients ≥ 65 years, (57.8% females) Variables: Socio-demographical and social support (Duke- 11); Self-perceived stress, mental health, self-perceived general health, satisfaction with respect to dental circumstances, self-perceived oralhealth, oral problems (previous 30 days), number of teeth present, presence of prostheses (upper/lower), Helkimo Anamnestic Index and clinical assessment. Prevalence of temporomandibular joint disorders- Helkimo Anamnestic Index was assessed with respect to health and socio-demographic variables, temporomandibular joint disorders was assessed according to clinical evaluation. Association between temporomandibular joint disorders-Helkimo Anamnestic Index and health indicators was evaluated as well as clinical temporomandibular joint disorders by means of logistic regression calculating crude and adjusted Odds Ratio with 95% (CI95%) confi dence intervals. Results: Prevalence of severe symptoms was higher in males (32%), females exhibited higher prevalence of mild symptoms (18.8%); differences were found according to socio-demographic factors. Subjects reporting symptoms tended to report higher prevalence of poor oral and general health indicators. Higher association was found for patients with dental problems in the previous 30 days. (aOR 3.57; CI95% 1.80-7.08) in the case of women and, for men, the indicator was poor mental health (aOR 2.83; CI95% 1.31-6.09) Even though females exhibited greater risk of reporting TMJ related problems (except for the presence of articular noises) no statistical signifi cant associations were found. Conclusions: Further epidemiological surveillance systems are required in order to suitably and clearly establish associations found in the present study.

Hospital-based surveillance for radiological pneumonia in children under 5 years of age in Uttar Pradesh and Bihar

Abstract Background and rationale Pneumonia is responsible for about 1.4 million deaths in children under five years of age, mostly in developing countries, including India. In India, Streptococcus pneumoniae (SP) and Haemophilus influenzae (HI) are the common bacterial etiologic agents of pneumonia, and often cause abnormal chest radiology. Vaccine against HI has already been introduced in India. Pneumococcal conjugate vaccine (PCV) roll out will begin in 2017–2018 in a phased manner using Gavi funding. Objectives (1) To estimate the annual incidence of radiological pneumonia in children between 2 and 59 months of age, in prespecified districts. (2) To document the clinical and demographic characteristics of cases of WHO-defined community-acquired pneumonia (CAP) with lower chest in-drawing (LCI) and severe CAP, by establishment of hospital-based surveillance network. Study design In a prospective design, surveillance for WHO-defined radiological pneumonia in patients hospitalized for CAP is being done in two districts each of Uttar Pradesh and Bihar. For this, a pneumonia surveillance network of public and private hospitals has been established. Data are abstracted from hospital records. One copy of routine chest X-ray is also collected, digitalized, and archived electronically. An independent panel of radiologists interprets the X-rays. Five milliliters of urine of a subset of cases is being stored at −20 °C for future antigen testing. In Phase I, procedures were standardized, hospital network established, and recruitments initiated from Lucknow district. This was expanded in Phase II to include Etawah district, Uttar Pradesh and Patna and Darbhanga districts of Bihar. Progress A pneumonia surveillance network was established, having 120 health facilities in Lucknow, 60 in Patna, 64 in Darbhanga and 17 in Etawah. From 1st January 2015 to 30th April 2016, 745 CAP cases were enrolled in Lucknow. From 1st January to 30th April 2016 Patna recruited 229, Darbhanga 321 and Etawah 80 cases. Chest X-rays of all cases have been archived for interpretation by the panel of radiologists. Implications Baseline incidence of radiological pneumonia in Uttar Pradesh and Bihar will be estimated and follow-up data will enable assessment of the impact of PCV introduction.

Accesibilidad geográfica a los servicios de salud: un estudio de caso para Barranquilla

En este artículo se utiliza la ampliación de la red pública hospitalaria de Barranquilla para evaluar los avances en la accesibilidad geográfica y la equidad en la prestación del servicio de salud. Se emplean medidas de gravedad para calcular la accesibilidad consi­derando restricciones a la movilidad, así como información de demanda por servicios de salud. Adicionalmente, se utilizan indicativos de satisfacción para evaluar los niveles de equidad logrados con la ampliación de la red pública. Los resultados muestran avan­ces significativos en accesibilidad geográfica entre 2008 y 2013, especialmente para los habitantes de las localidades más pobres. En términos de equidad, se encontró que los factores socioeconómicos siguen siendo determinantes de la satisfacción de los usuarios del sistema de salud.

Impact of a priority system on patients in waiting lists for knee arthroplasty.

The Agency for Health Quality and Assessment of Catalonia (AQuAS) developed a system for the prioritization of patients on non-urgent waiting lists for cataract as well as knee and hip arthroplasty. The aim was to evaluate the impact of the priority system's application for primary knee arthroplasty (PKA). A retrospective evaluative study with data from the Data Tracking and Management Registry of the CatSalut Waiting Lists for PKA of hospitals in the public hospital network in the period 2003-2009. A description of the characteristics of patients on waiting lists was made and the association between priority scoring and waiting time and the order of operation analysed. Finally, waiting times were simulated that patients would have experienced if being operated on strictly according to a first in first out system or one of priority scoring, to compare them with real waiting times. The number of people included on waiting lists for PKA was 67403. 67% had a priority score. The distribution of the priority score was negatively skewed with an average score of 70 points. The association with the priority score for the waiting time as well as the order of the operations performed was practically null. The study concludes that, globally, the prioritization system for PKA has been implemented but had no effect on the prioritization of patients based on their severity. Nevertheless, in some centres, a moderate correlation between the order of operations performed and the priority score was identified.

Lessons from the past: Historical perspectives of mental health in the Eastern Cape

&lt;p&gt;The development of mental health services in the Eastern Cape Province is inextricably entwined in South Africa’s colonial history and the racist policy of apartheid. Prior to the development of mental hospitals, mental health services were provided through a network of public and mission hospitals. This paper explores the development of early hospital and mental health services in the Eastern Cape from the time of the Cape Colony to the dissolution of apartheid in 1994, and highlights the influence of colonialism, race and legislation in the development of mental health services in this province. The objective is to provide a background of mental health services in order to identify the historical factors that have had an impact on the current shortcomings in the provision of public sector mental health services in the province. This information will assist in the future planning and development of a new service for the province without the stigma of the past. This research indicates that one lesson from the past should be the equitable distribution of resources for the provision of care for all that inhabit this province, as enshrined in South Africa’s constitution.&lt;/p&gt;&lt;div&gt; &lt;/div&gt;

Medical support at a large-scale motorsports mass-gathering event: the inaugural Formula One United States Grand Prix in Austin, Texas.

Formula One returned to the United States on November 16-18, 2012, with the inaugural United States Grand Prix in Austin, Texas. Medical preparedness for motorsports events represents a unique challenge due to the potential for a high number of spectators seeking medical attention, and the possibility for a mass-casualty situation. Adequate preparation requires close collaboration across public safety agencies and hospital networks to minimize impact on Emergency Medical Services (EMS) resources. To report the details of preparation for an inaugural mass-gathering motorsports event, and to describe the details of the medical care rendered during the 3-day event. A retrospective analysis was completed utilizing postevent summaries, provided by the medical planning committee, by the Federation Internationale de L'Automobile (FIA), and Austin Travis County Emergency Medical Services (ATCEMS). Patient data were collected from standardized patient care records for descriptive analysis. Medical usage rates (MURs) are reported as a rate of patients per 10,000 (PPTT) participants. A total of 566 patients received medical care over the 3-day period with the on-site care rate of 95%. Overall, MUR was 21.3 PPTT attendees. Most patients had minor problems, and there were no driver injuries or deaths. This mass-gathering motorsport event had a moderate number of patients requiring medical attention. The preparedness plan was implemented successfully with minimal impact on EMS resources and local medical facilities. This medical preparedness plan may serve as a model to other cities preparing for an inaugural motorsports event.

La gestación en medio de la inseguridad alimentaria: Percepciones de un grupo de adolescentes embarazadas

Describing pregnant adolescents' perceptions regarding food insecurity in their households.Quantitative methodology involving an ethnographic approach was used; seventeen adolescents in their third trimester of pregnancy were included in the study; they were registered in the Medellin public hospital network's prenatal control program and living in households classified as being food insecure.Some adolescents said that initially their pregnancies were unwanted; however, feeling a baby in their wombs became an act of love and became acceptance of their unborn children. Single-parent families headed by women and a background of adolescent pregnancy amongst the participants' mothers were striking findings. Although pregnant adolescents recognized the type of nutrition which should have been consumed according to their physiological period, beliefs and preferences, their financial difficulties and the situation that they lived in limited their access to food, thereby making the most valuable food in nutritional terms become the least consumed by them.Poverty spreads the experience of food insecurity and hunger within a household and generates concern in mothers-to-be about the future of their unborn children's nutrition, feelings of intense pain, helplessness and hopelessness concerning the future.

P321 – 2129 Stroke in children from a public hospital network: a series of cases

P321 – 2129 Stroke in children from a public hospital network: a series of cases

Supervision of a Music Therapy Team in Medicine

This paper discloses how supervision is conducted with a Music Therapy team,specialized in Music Therapy in Medicine. The team works at Rivadavia Hospital, ageneral acute care hospital, which is part of the public hospital network of the cityof Buenos Aires (Argentina). It shows the different levels of supervision performed,and is illustrated with an example of how music therapists can elaborate the feelingscaused by the daily work with pain and death.

Attention to the parturient adolescent: access and reception - a descriptive study

Aim: To analyze the access and reception of adolescent mothers in the parturition stage in obstetrics emergencies. Method: This is a descriptive study, with data collected through the interviewing and observation of twelve adolescent mothers, in the Sector of Obstetrics in a tertiary hospital of the public hospital network of the municipality of Fortaleza, Brazil. Results: The first category was the access that adolescent mothers had to a hospital unit, including the journeys that they made and the physical structure of the hospital. The second category was the reception that the adolescent mother received at the obstetric emergency. Discussion: This study observed the precariousness of the physical structure of secondary hospitals, which leads to mass transference of pregnant women to higher complexity hospitals. Some women reported positive feedback as a result of the cordial and affectionate attitudes of the professionals they encountered. Other women, however, commented on the lack of understanding amongst health managers and policymakers regarding their specific needs. Conclusion: Greater attention needs to be paid to adolescent mothers, especially during the delivery stage, where it is essential that genuine bonds are generated for the benefit of the parturients.

Establishing Clinical Pharmacy Services in the Operating Suite

ABSTRACTDespite having well‐established clinical roles in many specialties, hospital pharmacists have not traditionally provided clinical services in the operating suite (OS). This paper describes the introduction of a clinical pharmacy service in the OS of a large metropolitan public hospital network. The initial focus of the service was on non‐clinical issues that were priorities for pharmacy and OS staff, such as medication supply, waste minimisation, expenditure, interdepartmental communication and legal compliance. Once ongoing funding for the positions was secured, cognitive clinical pharmacy services have become the focus. Benefits of the service have been demonstrated in medication safety, antibiotic stewardship and quality use of medicines. The 2 pharmacists have now become essential members of the OS. Work is underway to further develop pharmacists' roles in areas such as perioperative antimicrobial prescribing and perioperative management of patient's regular medication regimens to optimise the continuum of care.