Patient Care Demands Research Articles

A workforce in crisis: a case study to expand allied ophthalmic personnel

ObjectiveTo examine how the development of allied ophthalmic personnel training programs affects human resource capacity. DesignUsing a qualitative case study method conducted at a single Ontario institution, this article describes 6 years of establishing a 2-tiered allied ophthalmic personnel training program. ParticipantsThe Kingston Ophthalmic Training Centre participated in the study with 8 leadership and program graduate interviews. MethodsTo assess regional eye health workforce needs, a case study and iterative process used triangulations of the literature, case study, and qualitative interviews with stakeholders. This research was used to develop a model for establishing allied ophthalmic personnel training programs that would result in expanding human resource capacity. ResultsCurrent human resource capacity development and deployment is inadequate to provide the needed eye care services in Canada. A competency-based curriculum and accreditation model as the platform to develop formal academic training programs is essential. Access to quality eye care and patient services can be met by task-shifting from ophthalmologists to appropriately trained allied ophthalmic personnel. ConclusionEstablishing formal training programs is one important strategy to supplying a well-skilled, trained, and qualified ophthalmic workforce. This initiative meets the criteria required for quality, relevance, equity, and cost-effectiveness to meet the future demands for ophthalmic patient care.

Adding Nurse Practitioners to Inpatient Teams: Making the Financial Case for Success

Nurse practitioners (NPs) are increasingly being added to inpatient care teams to meet demands for cost-effective, high quality, and safe patient care. NPs have been shown to increase adherence to evidence-based processes of care, decrease unnecessary resource utilization, enhance positive patient experience, and improve patient care outcomes such as ideal length of stay, reduced unexpected readmissions, and reduced hospital-acquired complications. 1–14 National reports have emphasized the evidence supporting the use of this unique provider type and have emphasized the need to expand this workforce and continue to explore their impact within the health care team, on cost effectiveness and on quality outcomes. 15–17 Despite evidence supporting the case for NPs, organizational economic and financial drivers demand a comprehensive business case before implementation of an NP team. This article reviews an academic medical center's experience with advanced practice proposals and the development of a standardized mechanism for submission and evaluation.

Changing demands of health care require extended nursing roles.

Developing the skills of nurses, healthcare assistants and other non-medical staff is the only way the NHS can meet the changing demands of patient care.

Critical Patient Severity Classification System predicts outcomes in intensive care unit patients

The CPSCS was developed to assess the nursing care demands of patients in intensive care units (ICUs). This study aimed to examine the Critical Patient Severity Classification System (CPSCS) score as an independent predictor of patient hospital outcomes. This study was a secondary analysis. Data from 6380 cases were extracted from the electronic medical records in ICUs at a tertiary hospital in Korea during 2010-2012. To examine the association of the CPSCS score with 30-day ICU mortality, the Cox proportional hazards model and Kaplan-Meier survival curves were used, and generalized linear regression models of gamma distribution were developed for ICU length of stay (LOS). More patients were admitted to surgical ICUs than medical ICUs (4664 versus 1716) during the study period. Medical ICU patients had longer ICU LOS, higher 30-day ICU mortality and a higher mean CPSCS score than surgical ICU patients. Cox analysis indicated that the mid and high CPSCS score groups had 1·687 and 2·913 times higher mortality risk, respectively, than the low CPSCS score group after adjusting for age, sex and primary diagnosis. The CPSCS score significantly predicted ICU mortality in both medical and surgical ICUs. Multivariate generalized linear regression indicated that CPSCS score was a significant predictor of ICU LOS after adjusting for other covariates. The CPSCS score can be used to efficiently predict ICU mortality and LOS in patients admitted to the medical and surgical ICUs, although only the high CPSCS score group had significantly high mortality than the low CPSCS score group in the medical ICU. The findings of this study contribute to valuable evidence that nursing-related factors have an impact on patient outcomes such as ICU mortality and LOS and that they have implications for hospital management, clinical practice and future research.

Guidelines for a Comprehensive Care Program to Ostomized Patients and Families: a Nursing proposal.

Objectives:describe care needs and demands that mark the discursive practices of ostomized clients and family members and discuss guidelines for a comprehensive care program to ostomized clients and their families, organized by macrosociological categories. Method:Creative and Sensitive, involving 17 ostomized subjects and family members at a municipal outpatient clinic. The ethical aspects were complied with. A characterization form was used, as well as Creativity and Sensitivity Dynamics: "speaking map", "body-knowledge" and "calendar". Critical Discourse Analysis was applied. Results:the health needs and care demands of the ostomized patients and their family members, in their multiple dimensions, were constituted in the home and community, outpatient and social context, implying new orientations for nursing care. The unveiling of the data brought elements that constituted guidelines, in a macrosociological approach, to achieve the expanded integrality of nursing care. Conclusion:the ostomized clients are unique in their genre/peculiar from Latin sui generis, calling for strategies that respond to and distinguish their specificities. Elaborating a Public Health Policy that improves and reorganizes the care demands, taking into account these individual biopsychosocial and spiritual aspects, is a possible and irrevocable target in the attempt to achieve better conditions of health and wellbeing.

Physical Therapy Residency and Fellowship Education: Reflections on the Past, Present, and Future.

The physical therapy profession continues to respond to the complex and changing landscape of health care to meet the needs of patients and the demands of patient care. Consistent with this evolution is the rapid development and expansion of residency and fellowship postprofessional programs. With the interested number of applicants exceeding the number of residency and fellowship slots available, a "critical period" in the educational process is emerging. The purposes of this perspective article are: (1) to analyze the state of residency and fellowship education within the profession, (2) to identify best practice elements from other health professions that are applicable to physical therapy residency and fellowship education, and (3) to propose a working framework grounded in common domains of competence to be used as a platform for dialogue, consistency, and quality across all residency and fellowship programs. Seven domains of competence are proposed to theoretically ground residency and fellowship programs and facilitate a more consistent approach to curricular development and assessment. Although the recent proliferation of residency and fellowship programs attempts to meet the demand of physical therapists seeking advanced educational opportunities, it is imperative that these programs are consistently delivering high-quality education with a common focus on delivering health care in the context of societal needs.

Solving the worldwide emergency department crowding problem - what can we learn from an Israeli ED?

ED crowding is a prevalent and important issue facing hospitals in Israel and around the world, including North and South America, Europe, Australia, Asia and Africa. ED crowding is associated with poorer quality of care and poorer health outcomes, along with extended waits for care. Crowding is caused by a periodic mismatch between the supply of ED and hospital resources and the demand for patient care. In a recent article in the Israel Journal of Health Policy Research, Bashkin et al. present an Ishikawa diagram describing several factors related to longer length of stay (LOS), and higher levels of ED crowding, including management, process, environmental, human factors, and resource issues. Several solutions exist to reduce ED crowding, which involve addressing several of the issues identified by Bashkin et al. This includes reducing the demand for and variation in care, and better matching the supply of resources to demands in care in real time. However, what is needed to reduce crowding is an institutional imperative from senior leadership, implemented by engaged ED and hospital leadership with multi-disciplinary cross-unit collaboration, sufficient resources to implement effective interventions, access to data, and a sustained commitment over time. This may move the culture of a hospital to facilitate improved flow within and across units and ultimately improve quality and safety over the long-term.

Should we marry a pharmacist? With or without separate property

Background In health care, there are increasing demands for efficiency and safe patient care. Concomitantly, requirements to patient-related documentation have risen among others for medication. Documentation is, however, time consuming and therefore not always done diligently, perhaps especially on weekends. One proven way to improve patient safety is the review of medication by a pharmacist after admission to the hospital to ensure correct medication (and documentation). Should we accept that pharmacists perform a medication review for us?

Reviewing roles: nurses vs physician assistants.

Primary care is under tremendous pressure because of the ageing population, resource constraints, and technological changes that make care at home possible. Finding ways to extend the capacity of the GP service are needed if care is to be refocused in the community. A variety of solutions have been proposed, including the introduction of physician assistants (PA) to the primary care workforce. Physician assistants have a 2-year training working to the medical model, which builds upon a science degree. Physician assistants have existed for 40 years in the US, and early studies (Woodin et al, 2005; Farmer et al, 2011) of their employment in the UK were favourable in terms of their competency and greater diagnostic skills compared with nurses in extended roles. Drennan et al (2011) found that PAs were a helpful addition to the general practice team enabling the meeting of patient care demand within budgetary constraints. In more recent years, a larger evaluation (Drennan et al, 2014) reported that PAs were a flexible resource to general practice and increased clinician time for same-day appointments within their practices. Although their appointment times were slightly longer than those of the GPs and they saw younger and fewer patients with chronic diseases, there were no differences in procedures undertaken or prescriptions issued. Moreover, the patients were equally satisfied with the PA and GP consultations, and 90% said they would would be satisfied to consult a PA again. The costs of PAs was also cheaper than that of a GP. Why haven’t nurse practitioners (NPs) been championed as a potential solution to increasing the capacity of the GP service? Unlike the US where ‘nurse practitioner’ is the registered title of more than 200 000 advanced practice nurses, mostly working in primary care with Medicare and Medicaid patients (American Association of Nurse Practitioners, 2015), NP is not a recognised title in the UK. One is left to wonder whether the recent debates about whether nurses are now ‘too posh to wash’ has spilled over to create a reputational legacy that nurses cannot be both clever and capable of advanced clinical decision making, as well as simultaneously compassionate—not a charge that is levelled at GPs. While clarity about the purpose and expectations of RNs is clearly important, the ongoing debate is a distraction if we wish to see RNs as key contributors to solutions to general practice workforce capacity issues. After all, nurses work within a regulatory framework, can prescribe unlike PAs, and patients have similar health outcomes if treated by NPs compared with GPs and report higher care satisfaction (Horrocks et al, 2002). It would be good to see the potential contribution of nurses highlighted alongside the emergent role of pharmacists within GP surgeries (Royal Pharmaceutical Society, 2014; Royal College of General Practitioners, 2015). BJCN

Pharmacy awareness: a continuous process.

JCPH – Vol. 68, no 2 – mars–avril 2015 182 of Pharmacy Regulatory Authorities, the Canadian Pharmacists Association, the Canadian Association of Pharmacy in Oncology, the Association des pharmaciens des etablissements de sante du Quebec, the Canadian Patient Safety Institute, the Institute for Safe Medication Practices Canada, and the Canadian Association of Pharmacy Technicians. CSHP’s advocacy efforts at both the National and Branch levels are necessary and appropriate, but advocacy at the grassroots level is crucial. At the front line, dealing with the daily workload and patient care demands, individual practitioners often find it difficult to see how they personally can be advocates for change and for the profession. I would invite you to consider the possibility that each and every interaction that a pharmacist has with either a health care professional or a patient is a moment of advocacy, not just for the profession, but also for the patient. What a powerful combination.

ClinSeK: a targeted variant characterization framework for clinical sequencing.

Applying genomics to patient care demands sensitive, unambiguous and rapid characterization of a known set of clinically relevant variants in patients’ samples, an objective substantially different from the standard discovery process, in which every base in every sequenced read must be examined. Further, the approach must be sufficiently robust as to be able to detect multiple and potentially rare variants from heterogeneous samples. To meet this critical objective, we developed a novel variant characterization framework, ClinSeK, which performs targeted analysis of relevant reads from high-throughput sequencing data. ClinSeK is designed for efficient targeted short read alignment and is capable of characterizing a wide spectrum of genetic variants from single nucleotide variation to large-scale genomic rearrangement breakpoints. Applying ClinSeK to over a thousand cancer patients demonstrated substantively better performance, in terms of accuracy, runtime and disk storage, for clinical applications than existing variant discovery tools. ClinSeK is freely available for academic use at http://bioinformatics.mdanderson.org/main/clinsek.Electronic supplementary materialThe online version of this article (doi:10.1186/s13073-015-0155-1) contains supplementary material, which is available to authorized users.

Pre-implementation studies of a workforce planning tool for nurse staffing and human resource management in university hospitals.

To investigate the reliability, validity and feasibility of the RAFAELA workforce planning system (including the Oulu patient classification system - OPCq), before deciding on implementation in Dutch hospitals. The complexity of care, budgetary restraints and demand for high-quality patient care have ignited the need for transparent hospital workforce planning. Nurses from 12 wards of two university hospitals were trained to test the reliability of the OPCq by investigating the absolute agreement of nursing care intensity (NCI) measurements among nurses. Validity was tested by assessing whether optimal NCI/nurse ratio, as calculated by a regression analysis in RAFAELA, was realistic. System feasibility was investigated through a questionnaire among all nurses involved. Almost 67000 NCI measurements were performed between December 2013 and June 2014. Agreement using the OPCq varied between 38% and 91%. For only 1 in 12 wards was the optimal NCI area calculated judged as valid. Although the majority of respondents was positive about the applicability and user-friendliness, RAFAELA was not accepted as useful workforce planning system. Nurses' performance using the RAFAELA system did not warrant its implementation. Hospital managers should first focus on enlarging the readiness of nurses regarding the implementation of a workforce planning system.

Status of nurse staffing and nursing care delivery in Pudong, Shanghai

Aim: To evaluate nurse staffing levels and nursing care delivery in adult general medical or surgical wards of hospitals in the Pudong district of Shanghai, China.Background: Rapid economic development and improved Chinese living standards have spurred increased demands for high-quality health care. Thus, the quality of nursing services has become a focus of attention.Design: A cross-sectional, descriptive design was used for the study.Methods: We used an anonymous survey to collect data from 1614 nurses from 98 wards in seven general hospitals in Pudong, Shanghai.Results: During day shifts, the nurse-to-patient ratios were >1:10. However, these ratios were much higher during evening and night shifts. The clinical frontline nursing workforce primarily consisted of nurses with junior college degrees that had limited working experience. Junior nurses with different educational backgrounds, professional levels and work experiences were assigned almost similar nursing care work as senior nurses.Conclusions: In the surveyed hospitals in the Pudong district, nurse staffing levels and skill mix may be inadequate to meet the increasing demands of patient care. The clinical nursing workforce needs to be strengthened and used effectively to enhance the quality and safety of patient care.Relevance to clinical practice: We should focus on the quantity and quality of the nursing workforce, as well as nursing skill utilisation.

The clinical practice of oncology nursing in Brazil: realities and challenges in the training of specialist nurses.

The clinical practice of oncology nursing in Brazil: realities and challenges in the training of specialist nurses.

Status of nurse staffing and nursing care delivery in Pudong, Shanghai.

Abstract Aim To evaluate nurse staffing levels and nursing care delivery in adult general medical or surgical wards of hospitals in the Pudong district of Shanghai, China. Background Rapid economic development and improved Chinese living standards have spurred increased demands for high quality health care. Thus, the quality of nursing services has become a focus of attention. Design A cross-sectional, descriptive design was used for the study. Methods We used an anonymous survey to collect data from 1614 nurses from 98 wards in seven general hospitals in Pudong, Shanghai. Results During day shifts, the nurse-to-patient ratios were >1:10. However, these ratios were much higher during evening and night shifts. The clinical front-line nursing workforce primarily consisted of nurses with junior college degrees that had limited working experience. Junior nurses with different educational backgrounds, professional levels, and work experiences were assigned almost similar nursing care work as senior nurses. Conclusions In the surveyed hospitals in the Pudong district, nurse staffing levels and skill mix may be inadequate to meet the increasing demands of patient care. The clinical nursing workforce needs to be strengthened and used effectively to enhance the quality and safety of patient care. Relevance to clinical practice We should focus on the quantity and quality of the nursing workforce, as well as nursing skill utilization.

Impact of a quality improvement intervention on nurses' management of same-day primary care flow.

To evaluate the impact of an interdisciplinary intervention designed to improve the capacity of nurses to manage walk-in patient demand for primary health care. Implementation of a programme to expand nursing practice is a complex process that requires the application of context-appropriate measures and adaptation when results do not meet expectations. A longitudinal, uncontrolled intervention study with a 3-year follow-up, from 2009 to 2012, was carried out in Catalonia (northeast Spain). The intervention included three training periods focused on clinical and instrumentation topics. The capacity of nurses to manage walk-in patient demand was assessed by determining the number of cases resolved and of return visits for the same complaint within 72hours. In total, 2751 patient care demands were evaluated. Resolved cases increased (χ(2) =54.624, df=1, P<0.001) and the number of return visits decreased (χ(2) =54.585, df=1, P<0.001) significantly from baseline to the end of the study period. Nurses' capacity to manage walk-in patient demand improved after an interdisciplinary intervention using a mutually agreed upon, locally adapted approach. To improve outcomes, nurses in management positions should systematically consider the need for skills training, specific academic courses, leadership development and, as appropriate, legislative initiatives.

Patient demand for care: How much does this contribute to inappropriate tests and treatments?

6530 Background: There are many calls for physicians to provide more cost-effective care. Physicians sometimes claim that patients demand high cost or low value tests and treatments. How frequently...

Preventing transmission of MRSA: A qualitative study of health care workers’ attitudes and suggestions

Health care workers' (HCWs) perceptions and attitudes affect implementation of precautions to prevent transmission of drug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA). Identification of challenges and barriers to recommended practices is a critical component of promoting a safe clinical environment of care. Semistructured interviews addressed how MRSA affects HCWs, prevention of transmission, and challenges and barriers HCWs experience when entering a MRSA isolation room and performing appropriate hand hygiene. The purposive sample of 26 acute care HCWs (16 registered nurses; 1 physician; 6 allied health professionals; and 3 support staff) self-selected from 276 responding to a questionnaire on MRSA. Analysis identified 18 themes across seven categories. Most participants reported feeling responsible for preventing transmission, and having the knowledge and desire to do so. However, many also reported challenges to following consistent hand hygiene and use of contact precautions. Barriers included patient care demands, equipment and environmental issues such as availability of sinks, time pressures, the practices of other HCWs, and the need for additional signs indicating which patients require contact precautions. The HCWs reported a need for improved clarity of isolation protocols throughout patients' hospital journey, additional rooms and staff for isolation patients, improved education and communication (including timely and appropriate signage), and an emphasis on involving all HCWs in reducing contamination.

A simulation study of outpatient scheduling with multiple providers and a single device

AbstractEffective outpatient appointment scheduling aims at reducing patient waiting time and operational costs, and improving resource utilization, especially given the stochastic nature of patient arrivals. Unlike many western developed countries, China faces challenges due to imperfect appointment systems and ineffective resource allocation. Those challenges lead to long patient waiting times and significant pressure to provide accurate and reliable medical diagnosis that can handle the increasing demand for patient care. In this paper, an outpatient appointment scheduling model for primary care settings was developed. The model was structured for a multi-provider clinic with a single medical device that allows for revisit (i.e., follow-up) procedures. A total of six scheduling rules were designed and tested. Then, sensitivity analysis was performed with respect to two parameters: the percentage of patients with fixed appointments and walk-ins, and the scheduled physician assessment times. The experime...

Toward the modelling of safety violations in healthcare systems

When frontline staff do not adhere to policies, protocols, or checklists, managers often regard these violations as indicating poor practice or even negligence. More often than not, however, these policy...