Specific Health Care Setting Research Articles

Integrating Science and Engineering to Implement Evidence-Based Practices in Health Care Settings.

Integrating two distinct and complementary paradigms, science and engineering, may produce more effective outcomes for the implementation of evidence-based practices in health care settings. Science formalizes and tests innovations, whereas engineering customizes and optimizes how the innovation is applied tailoring to accommodate local conditions. Together they may accelerate the creation of an evidence-based healthcare system that works effectively in specific health care settings. We give examples of applying engineering methods for better quality, more efficient, and safer implementation of clinical practices, medical devices, and health services systems. A specific example was applying systems engineering design that orchestrated people, process, data, decision-making, and communication through a technology application to implement evidence-based depression care among low-income patients with diabetes. We recommend that leading journals recognize the fundamental role of engineering in implementation research, to improve understanding of design elements that create a better fit between program elements and local context.

Care plan for HIV+ patients in specialized Aids centers inBrazil: Pharmacotherapeutic form and pilot study

The objective of this study is to describe a pharmacotherapy form model to monitor patients' pharmacotherapeutic follow-up (PF) on antiretroviral therapy in a specialized center of Ceara, Brazil. Description comprises its structure up to application. The preparation and application of the PF registration model were carried out by means of a focal group. The following steps were used for the draft: 1. Review of the literature; 2. Diagnosis of place where pharmaceutical care was undertaken; 3. Choice of the PF method; 4. Selection of clinical indicators; 5. Evaluation by a committee of experts; 6. Development of a standard functional procedure with timetable and evaluation frequency of the tool's different sections or blocks. 7. Pilot study for evaluation of the form with 25 patients. PF form featured six sections comprising patient's personal data, pharmaceutical anamnesis and records of adherence evaluation, etc. The description and format of the sections are presented in current essay. Further, 322 issues related to antiretroviral drugs were reported during form filling. The multi- section PF form seemed appropriate and applicable for the report of issues related to antiretroviral drugs in HIV positive patients. It was also a helpful guide for pharmaceutical interventions by a multiprofessional team in specialized healthcare settings.

Risk Factors for Methicillin Resistant Staphylococcus aureus: A Multi-Laboratory Study

BackgroundThe present study aimed to investigate the dose response relationship between the prescriptions of antimicrobial agents and infection/colonization with methicillin resistant Staphylococcus aureus (MRSA) taking additional factors like stay in a health care facility into account.MethodsMulti-centre retrospective study on a cohort of patients that underwent microbiological diagnostics in Belgium during 2005. The bacteriological results retrieved from 17 voluntary participating clinical laboratories were coupled with the individual antimicrobial consumption patterns (July 2004-December 2005) and other variables as provided by pooled data of health insurance funds. Multivariate analysis was used to identify risk factors for MRSA colonization/infection.ResultsA total of 6844 patients of which 17.5% died in the year 2005, were included in a logistic regression model. More than 97% of MRSA was associated with infection (clinical samples), and only a minority with screening/colonization (1.59%). Factors (95% CI) significantly (p≤<0.01) associated with MRSA in the final multivariate model were: admission to a long term care settings (2.79–4.46); prescription of antibiotics via a hospital pharmacy (1.30–2.01); age 55+ years (3.32–5.63); age 15–54 years (1.23–2.16); and consumption of antimicrobial agent per DDD (defined daily dose) (1.25–1.40).ConclusionsThe data demonstrated a direct dose-response relationship between MRSA and consumption of antimicrobial agents at the individual patient level of 25–40% increased risk per every single day. In addition the study indicated an involvement of specific healthcare settings and age in MRSA status.

Systems that prevent unwanted represcription of drugs withdrawn because of adverse drug events: a systematic review.

Represcription of medication that was withdrawn after the occurrence of an adverse drug event (including allergy), is a recognized medication safety issue on a patient level. We performed a systematic review to identify systems (electronic and nonelectronic) that can prevent the represcription of drugs withdrawn because of an adverse drug event and the effects of these systems. The review was performed using PRISMA and Cochrane guidelines. PubMed and Embase were searched for articles describing systems that can prevent represcription of drugs that had been withdrawn for causing an adverse drug event. Information on the characteristics of the studies, systems, and if present results achieved with such systems, was extracted. The results showed that of 6793 articles screened, 137 full-text articles were assessed for eligibility. A total of 45 studies describing 33 systems (28 electronic) were included. The five nonelectronic systems used allergy bracelets or allergy labels on hospital medical records or on drug orders. Systems differed in the way adverse drug events were documented and how users were alerted to drug represcription. Most systems functioned within a specific healthcare setting. Of 12 studies that compared pre- and post-intervention periods or wards with and without intervention, 7 showed a reduction in represcription after adverse drug event. In conclusion, several systems have been developed that can prevent the represcription of drugs that elicited an adverse drug event, but the evidence that these systems are effective is limited.

Overview of systematic reviews of the effectiveness of reminders in improving healthcare professional behavior

ObjectiveThe purpose of this project was to conduct an overview of existing systematic reviews to evaluate the effectiveness of reminders in changing professional behavior in clinical settings.Materials and methodsRelevant systematic reviews of reminder interventions were identified through searches in MEDLINE, EMBASE, DARE and the Cochrane Library in conjunction with a larger project examining professional behavioral change interventions. Reviews were appraised using AMSTAR, a validated tool for assessing the quality of systematic reviews. As most reviews only reported vote counting, conclusions about effectiveness for each review were based on a count of positive studies. If available, we also report effect sizes. Conclusions were based on the findings from higher quality and current systematic reviews.ResultsThirty-five reviews were eligible for inclusion in this overview. Ten reviews examined the effectiveness of reminders generally, 5 reviews focused on specific health care settings, 14 reviews concentrated on specific behaviors and 6 reviews addressed specific patient populations. The quality of the reviews was variable (median = 3, range = 1 to 8). Seven reviews had AMSTAR scores >5 and were considered in detail. Five of these seven reviews demonstrated positive effects of reminders in changing provider behavior. Few reviews used quantitative pooling methods; in one high quality and current review, the overall observed effects were moderate with an absolute median improvement in performance of 4.2% (IQR: 0.5% to 6.6%).DiscussionThe results support that modest improvements can occur with the use of reminders. The effect size is consistent with other interventions that have been used to improve professional behavior.ConclusionReminders appear effective in improving different clinical behaviors across a range of settings.

Aportaciones e inconvenientes de la incorporación de metodología cualitativa en la evaluación de servicios sanitarios. Un caso práctico: la evaluación de una consulta de alta resolución

ObjectiveWe examined the usefulness of incorporating a qualitative phase in the evaluation of the quality of care in a high-resolution medical service carried out with quantitative methods. Design and methodsA quantitative research was performed using a structured questionnaire and selecting interviewees by systematic randomized sampling methods (n=320). In addition, a qualitative research was carried on through semi-structured interviews with patients selected by convenience criteria (n=11), observations in the care assistance circuit, and a group interview with health professionals working in the service. A multidisciplinary research team conducted an individual analysis of the information collected in both quantitative and qualitative phases. Subsequently, three meetings based on group brainstorming techniques were held to identify the diverse contributions of each of the methodologies employed to the research, using affinity graphs to analyse the different results obtained in both phases and evaluate possible bias arising from the use of qualitative methods. ResultsQualitative research allowed examining specific aspects of the health care service that had been collected in the quantitative phase, harmonizing the results obtained in the previous phase, giving in-depth data on the reasons for patient dissatisfaction with specific aspects, such as waiting times and available infrastructures, and identifying emerging issues of the service which had not been previously assessed. ConclusionsOverall, the qualitative phase enriched the results of the research. It is appropriate and recommendable to incorporate this methodological approach in research aimed at evaluating the quality of the service in specific health care settings, since it is provided first hand, by the voice of the customer.

Framework and indicator testing protocol for developing and piloting quality indicators for the UK quality and outcomes framework

BackgroundQuality measures should be subjected to a testing protocol before being used in practice using key attributes such as acceptability, feasibility and reliability, as well as identifying issues derived from actual implementation and unintended consequences. We describe the methodologies and results of an indicator testing protocol (ITP) using data from proposed quality indicators for the United Kingdom Quality and Outcomes Framework (QOF).MethodsThe indicator testing protocol involved a multi-step and methodological process: 1) The RAND/UCLA Appropriateness Method, to test clarity and necessity, 2) data extraction from patients' medical records, to test technical feasibility and reliability, 3) diaries, to test workload, 4) cost-effectiveness modelling, and 5) semi-structured interviews, to test acceptability, implementation issues and unintended consequences. Testing was conducted in a sample of representative family practices in England. These methods were combined into an overall recommendation for each tested indicator.ResultsUsing an indicator testing protocol as part of piloting was seen as a valuable way of testing potential indicators in 'real world' settings. Pilot 1 (October 2009-March 2010) involved thirteen indicators across six clinical domains and twelve indicators passed the indicator testing protocol. However, the indicator testing protocol identified a number of implementation issues and unintended consequences that can be rectified or removed prior to national roll out. A palliative care indicator is used as an exemplar of the value of piloting using a multiple attribute indicator testing protocol - while technically feasible and reliable, it was unacceptable to practice staff and raised concerns about potentially causing actual patient harm.ConclusionsThis indicator testing protocol is one example of a protocol that may be useful in assessing potential quality indicators when adapted to specific country health care settings and may be of use to policy-makers and researchers worldwide to test the likely effect of implementing indicators prior to roll out. It builds on and codifies existing literature and other testing protocols to create a field testing methodology that can be used to produce country specific quality indicators for pay-for-performance or quality improvement schemes.

Development of a Pain Management Protocol for a Paediatric Ward in the Gambia, West Africa

Despite recent advances in our understanding of paediatric pain and its management, pain continues to be undertreated globally, particularly in children and in low income countries. This article describes the development of a paediatric analgesia and sedation protocol, tailored to the specific setting of the Medical Research Council (MRC) paediatric ward in the Gambia, West Africa. An iterative process was used throughout development, with inputs from the medical literature, local providers, and pain experts, incorporated to ensure a safe, effective, and locally appropriate protocol. We demonstrate that evidence-based published guidelines, can and should be adapted to allow for optimal pain management given the resources and capabilities of specific health care settings. It is hoped that the process and protocol described here, will not only help to improve care on the MRC ward, but serve as an example to others working toward improving pain management in similar health care settings.

Budget-Impact Analyses

This article reviews budget-impact analyses (BIAs) published to date in peer-reviewed bio-medical journals with reference to current best practice, and discusses where future research needs to be directed. Published BIAs were identified by conducting a computerized search on PubMed using the search term 'budget impact analysis'. The years covered by the search included January 2000 through November 2008. Only studies (i) named by authors as BIAs and (ii) predicting financial consequences of adoption and diffusion of a new health intervention(s) within a specific healthcare setting were included. Relevant studies were evaluated according to the checklist that focuses on issues unique to BIA, highlighting areas of agreement or dissent between published studies and methodological guidelines. A total of 34 studies met the inclusion criteria, the majority published in 2007-8. Of these, 41% were from the US, 54% were prepared for pharmaceuticals and 65% had BIA as their main aim. The published BIAs were heterogeneous in respect of methods for deriving budget-impact estimates, time horizon and population. There is fairly good agreement between published studies and methodological guidelines within the scope of perspective, comparator, cost included and data sources. Specific issues that need to be addressed and/or improved are reporting format, sensitivity analysis and discounting. The results indicate that, recently, BIAs have appeared more frequently in peer-reviewed journals, providing stimulus to development, validation and dissemination of methods. Many published studies fail to reach the desired quality, but this situation should change with good research practice principles that will help codify and clarify important issues and promote standardization and transparency. Future research needs to be directed to quality assurance of published BIAs and investment in data collection for parameters specific to BIAs.

Lessons from Geographic Variations in Predialysis Nephrology Care

Inadequate access to nephrology subspecialists among patients with advanced chronic kidney disease (CKD) is one of the major public health problems of our discipline. Depending on its definition and the specific geographic and health care setting, between 20 and 66% of patients reaching ESRD do not see a nephrologist in a timely manner to receive adequate management of their progressive kidney failure or the long-term complications of advancing CKD. These patients are also robbed of their ability to receive appropriate education to make informed choices about their preferred treatment modality and to prepare optimally for the treatment option they choose. Thus, it has been shown in numerous countries and health care systems that delayed nephrologic care for patients with advanced CKD is associated with inadequate quality of care during transition from CKD to ESRD and with inferior outcomes on renal replacement therapy (RRT). Patients who have CKD and experience inadequately late nephrologic care are less likely to initiate RRT using peritoneal dialysis,1 and, when they do, their chances for a technique failure increase.2 When they start RRT using hemodialysis, patients seen inadequately late by a nephrologist are more likely to require temporary or tunneled central venous catheterization and are less likely to use a more preferable peripheral access, particularly arteriovenous fistulas, for initiation of dialysis thereafter.3, …

Emotional labour: clinicians' attitudes to death and dying

This paper aims to understand the impact of emotional labour in specific health care settings and its potential effect on patient care. Multi-method qualitative ethnographic study undertaken in a large ICU in Sydney, Australia using observations from patient case studies, ward rounds and family conferences, open ended interviews with medical and nursing clinicians and managers and focus groups with nurses. Clinician attitudes to death and dying and clinicians' capacity to engage with the human needs of patients influenced how emotional labour was experienced. Negative effects were not formally acknowledged in clinical workplaces and institutional mechanisms to support clinicians did not exist. The potential effects of clinician attitudes on performance are hypothesised from clinician-reported data; no evaluation was undertaken of patient care. Health service providers must openly acknowledge the effect of emotional labour on the care of dying people. By sharing their experiences, multidisciplinary clinicians become aware of the personal, professional and organisational impact of emotional labour as a core element of health care so as to explicitly and practically respond to it. The effect of care on clinicians, particularly care of dying people, not only affects the wellbeing of clinicians themselves, but also the quality of care that patients receive. The affective aspect of clinical work must be factored in as an essential element of quality and quality improvement.

Lack of Effectiveness of a Multidisciplinary Fall‐Prevention Program in Elderly People at Risk: A Randomized, Controlled Trial

To assess whether a pragmatic multidisciplinary fall-prevention program was more effective than usual care in preventing new falls and functional decline in elderly people. A two-group, randomized, controlled trial with 12 months of follow-up. University hospital and home-based intervention, the Netherlands. Three hundred thirty-three community-dwelling Dutch people aged 65 and over who were seen in an emergency department after a fall. Participants in the intervention group underwent a detailed medical and occupational-therapy assessment to evaluate and address risk factors for recurrent falls, followed by recommendations and referral if indicated. People in the control group received usual care. Number of people sustaining a fall (fall calendar) and daily functioning (Frenchay Activity Index). Results showed no statistically significantly favorable effects on falls (odds ratio=0.86, 95% confidence interval (CI)=0.50-1.49) or daily functioning (regression coefficient=0.37, CI=-0.90 to 1.63) after 12 months of follow-up. The multidisciplinary fall-prevention program was not effective in preventing falls and functional decline in this Dutch healthcare setting. Implementing the program in its present form in the Netherlands is not recommended. This trial shows that there can be considerable discrepancy between the "ideal" (experimental) version of a program and the implemented version of the same program. The importance of implementation research in assessing feasibility and effectiveness of such a program in a specific healthcare setting is therefore stressed.

Public health and healthcare-associated infections in the Netherlands

Public health can be defined as the science and practice of protecting and improving the health of populations which share a common environment and interact. When healthcare-associated infections are concerned, the healthcare setting is the common environment. This can be very helpful in designing tailored sanitary measures in specific healthcare settings. By 1847 Ignaz Philipp Semmelweis had shown that the transmission of puerperal fever could be traced back to students visiting the maternity ward after performing autopsies, and that puerperal fever could be successfully prevented by hand disinfection.1 In this paper we argue that the common environment for healthcare-associated infections needs to be broadened to the environment outside healthcare, as populations inand outside the healthcare setting interact.

Communication Strategies From High-reliability Organizations

Communication Strategies From High-reliability Organizations

DRG-based prospective pricing and case-mix accounting—Exploring the mechanisms of successful implementation

Escalating health care expenditures have brought on the need for restructuring health care delivery. A common response to this problem has been to seek market-based solutions. In the literature, however, increasing concern has been expressed that hospital management reforms will fail or will have only a limited impact. This longitudinal case study extends our understanding of the effects of implementing DRG-based prospective pricing and case-mix accounting systems for hospital management control in a specific health care setting. Moreover, this study contributes to current knowledge by focusing on the mechanisms explaining successful implementation of new accounting and control systems in the health care sector. A deep understanding of these mechanisms may help us to design better management control systems, and thus circumvent problems in implementing these systems. Our study suggests that successful implementation in the studied context is strongly dependent on the involvement of clinicians in this process. Integrated clinical and financial accountability, assigning responsibility for implementation to clinicians, freedom in choosing appropriate control tools, and flexibility in adoption all facilitated implementation. Furthermore, we argue that this process has also been advanced by the gradual implementation of these reforms and intensifying institutional pressures.

Team Resource Foraging in Event-Driven Task Environments

Although applied in a number of fields (including information science and human-computer interaction), foraging theory has not been used to study role differentiated team dynamics in an event driven environment. Many critical assumptions must be modified and the operational definitions must be enhanced for the theory to be applied in these more complex settings. This paper focuses on research developments leading to conceptual elaborations and expansions of the resource foraging framework, in order to address team-based resource acquisition and utilization strategies. The additional foraging concepts and definitions presented in this paper derive from the authors' research in spaceflight operations and healthcare delivery environments. In the authors' current healthcare research, appropriate resource foraging strategies vary dramatically based on specific healthcare setting, team structure, and other factors. These findings help to empirically validate the expanded construct of resource foraging by teams.

A case study of change management effectiveness within the NHS

In the UK healthcare sector structural change has become increasingly frequent and there are few employees in the NHS who have not experienced this in some form. Anecdotally, many of those affected report negative consequences that have potentially adverse effects on service delivery. The purpose of this research is to evaluate the effectiveness of the management of change in one specific healthcare setting, the Public Health Laboratory Service. It also seeks to make recommendations for managing organisational change that are applicable elsewhere and to consider the validity of existing change management models. This research is set in the context of the creation of a new Special Health Authority (the Health Protection Agency, HPA) and other related changes as outlined in the Chief Medical Officer's strategy document Getting Ahead of the Curve (Department of Health, 2002). The research seeks to analyse this change programme from the perspective of one group of affected individuals, employees of the Public Health Laboratory Service. Recommendations for future management of change at the HPA and elsewhere are made, with observations about the validity of existing change management models. The core contribution of this research is that it has added to the general body of knowledge about organisational change and its management. This is of value to those working in the UK healthcare and wider public sector. Specific recommendations for future research are made.

Concerns, Satisfaction, and Retention of Canadian Community Health Nurses

This study of Canadian community health nurses (N = 1,044) compared the work-related concerns, job satisfaction, and factors influencing the retention of public health, home care, and community care access center (CCAC) nurses. Community health nurses identified similar work-related issues as being of greatest concern to them, but there were significant differences among the 3 groups of nurses in the magnitude of these concerns. There were also significant differences among the 3 groups for satisfaction with their jobs and their immediate supervisors, with CCAC nurses being the least satisfied except for the greater dissatisfaction of home care nurses with their pay and benefits. For the retention factors, the differences were primarily in the areas of job features and supportive work relationships. There are both similarities and differences among public health, home care, and CCAC nurses. Initiatives to address community health nurses' concerns, improve their job satisfaction, and increase their retention will require interventions tailored to the specific community health care setting.

Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety

Standardized, seamless, integrated information technology in the health-care environment used with other industry tools can markedly decrease preventable errors or adverse events and increase patient safety. According to an Institute of Medicine (IOM) report released in 1999, preventable errors have caused between 44,000 and 98,000 deaths per year. Following the report, President Bill Clinton requested that the Agency of Healthcare Research and Quality, a government agency, look into the issue and fund, at the local or state level, processes that can reduce errors. Funding subsequently was made available for research that utilizes best practice tools in clinical practice to increase patient safety. The Joint Commission on Accreditation of Healthcare Organization has placed a great deal of emphasis on strategies to reduce patient identification errors. Fragmented systems tout the individual as well as enhanced safety applications. These applications, however, are related to prevention in specific conditions and in specific health-care settings. Systems are not integrated with common reference data and common terminology aggregated at a regional or national level to provide access to patient safety risks for timely interventions before errors and adverse events occur. Standardized integrated patient care information systems are not available either on a regional or on a national level. This article examines tangible options to increase patient safety through improved state-of-the-art tools that can be incorporated into the health-care system to prevent errors.

Advances in the treatment of depression in older adults

Depressive symptoms in older adults are common, but the minority of elderly meet criteria for major depressive disorder. This has led to confusion regarding the recognition of diagnosis, approach to treatment, and monitoring of outcomes in this needy population. Few depressed older adults are willing to seek treatment from psychiatrists or mental health specialists. Treatment approaches to the depressive spectrum of disorders in late life, which encompasses major and minor depressive disorder, dysthymic disorder, and mood disorders related to medical conditions, must include evidence-based algorithms that can be delivered in a variety of health care settings. Several recent multisite trials have advanced the use of collaborative care models and the systematic stepwise approach to the treatment of depression and anxiety states in older adults. This offers the ability to provide effective treatment of depression for older adults, consistent with current guidelines, in primary care and specialized health care settings.