Pain management--continuum of care for surgical patients

A pain management process improvement team was created to develop a unified and consistent way to address pain management for surgical patients. Team members evaluated patient satisfaction ratings, patient and family member education, use of specific pain scales, patient comfort function goals, staff member education, and use of physician standing orders and protocols. Team members were proactive in their efforts to improve pain management outcomes for surgical patients and to improve patient satisfaction. They also integrated protocols to comply with pain management standards established by the Joint Commission on Accreditation of Healthcare Organizations.

[The free delivery of drugs during hospital consultations]

INTRODUCTION

In France, the access to treatment has become a priority and a right. Hence, the supply of care has been reorganised in order to improve the management of the health scourges for all the patients, whether they can pay for what they need or not. The free delivery of drugs (FDD) is part of the services offered by the public hospitals for the low income patients or those who do not yet benefit from social security coverage. As such, it is inscribed within the context of the right to treatment and is a corner stone to a new mission of the public hospital services and care networks.

METHOD

The polyclinic of the Max Fourestier hospital is one of hospitals in the Paris area that supplies medical and surgical consultations to the population and provides drugs free of charge. From April 1, 1999 to the end of June 2000, all the FDD were studied for all the non-hospitalised outpatients who came to the consultations with a prescription for drugs, which could not be supplied in a pharmacy because of lack of revenues or social security coverage.

RESULTS

The diseases encountered in the context of FDD were the same as those of the general population. No specificity was revealed in the prescriptions related to vulnerability. If it were necessary, this would confirm the fact that the management of persons in difficulty should be integrated in the provisions of common rights. The treatments concerned were essential, and for some persons life saving, and justifying the interest of FDD without which the health of these individuals would rapidly decline. Furthermore, this study shows the need for careful management of FDD in order to avoid the anarchical and uncontrolled delivery of several prescriptions, source of deleterious drug interactions and iatrogenia. This is the reason for the recommendation to all the staff delivering free drugs that they systematically ask the patients to meet a referring physician and contact the hospital pharmacist when necessary.

COMMENTS

The FDD request is an ideal occasion for a physician to meet the patient and, because of the professional secrecy, to learn more of the patient's life style, and reveal, other than the diseases, the patients risk factors or elements of vulnerability that interact with the general state of health. The access to rights, on the occasion of FDD, is a fundamental public health strategy, since it provides the patient with access to preventive and primary care health measures. This is why we propose that FDD, other than the medical consultation, become systematically coupled with a consultation with a social care worker, to permit the rapid return of the patients to their common rights.

CONCLUSION

Free drug delivery should not be conceived as a traditional pharmaceutical delivery, it should be the pretext for the reintegration of persons to their social rights and with a strategy of improved medical care. Organised in this manner, FDD is a precious tool for access to care and prevention, but also to the construction of a social relationship.

Noncompliance in heart transplantation: a role for the advanced practice nurse

Many organ transplant recipients experience organ rejection because they are noncompliant with the requirements of the health care regimen. The advanced practice nurse is in an ideal position to assess predictors of noncompliance as well as to implement interventions to enhance patient compliance. The purpose of this paper is to present a case study of a young female heart transplant recipient whose death due to organ rejection was related to noncompliance. The role of the advanced practice nurse in reducing noncompliance is identified and relevant nursing interventions are discussed.

Bridging the gap: transitional rehabilitation services for people with spinal cord injury

PURPOSE

To review the current international rehabilitation and healthcare climate and describe a new model of service delivery aimed at enhancing the continuity of care for people with spinal cord injury (SCI).

METHOD

An extensive literature review was undertaken and a new model of service delivery conceptualized and implemented in the Australian context of SCI rehabilitation.

RESULTS

This new model of service delivery aims to improve the rehabilitation continuum for people with SCI by reducing the time spent in hospital, increasing consumer control over the rehabilitation environment and enhancing community re-integration. The new model recognizes the changing nature of the healthcare system, the legislative frameworks within which rehabilitation services are provided and the increasing role of the consumer.

CONCLUSIONS

Models of rehabilitation that address the need for shorter periods of hospitalization and attempt to improve client outcomes are integral to ensure sustainable rehabilitation services in the future.

Mortality and morbidity associated with osteoporosis drug treatment following hip fracture

This study examined post-fracture osteoporosis drug treatment in hip fracture patients and the association of treatment with mortality and morbidity. Pre- and post-fracture demographic/health information was collected on a cohort of hip fracture patients aged 65+ years. Post-fracture administrative data on prescription drug use and health care utilization was linked to the cohort data. Five classes of osteoporosis drugs were available during the study period: hormone replacement therapy (HRT), bisphosphonates (BSP), calcitonin, selective estrogen receptor modulators (SERMs) and vitamin D(3) (Rocaltrol). Pre-fracture, 38 of 449 patients (8%) were on osteoporosis medications. Post-fracture, 81 of 356 patients (23%) were treated; 63 of these patients were untreated prior to fracture. Both treated and untreated patients had similar rates of subsequent hip fracture (6% and 4%, respectively) and Colles fracture (2%). Regardless of treatment status, patients were also equally likely to be hospitalized, both in the short-term (28% in treated, 27% in untreated) and in the long-term (43% versus 37%). However, mortality was significantly lower in the treated group. The lower mortality in the treated group, combined with the knowledge that antiresorptive drugs reduce fractures and increase bone density, merit undertaking a randomized trial to confirm our findings that antiresorptive therapy should be considered in all patients post-hip fracture.

The effect of HMO competition on gatekeeping, usual source of care, and evaluations of physician thoroughness

OBJECTIVES

To examine the effects of HMO enrollment and HMO competition on evaluations of physician thoroughness through their effects on gatekeeping and having a usual source of care and to determine whether the effects of HMO competition spill over to individuals not enrolled in HMOs and whether these effects differ in those enrolled vs not enrolled in HMOs.

STUDY SAMPLE

A nationally representative sample of 27 441 adults from the household component of the Community Tracking Study-Round 1 (July, 1996, through July, 1997).

STUDY DESIGN

A retrospective econometric analysis of Community Tracking Study data merged with measures of HMO competition.

METHODS

Gatekeeping was regressed on HMO enrollment, HMO competition, and control variables using ordered logistic regression. Usual source of care was regressed on gatekeeping, HMO enrollment, HMO competition, and control variables using logistic regression. Evaluation of physician thoroughness was regressed on gatekeeping, usual source of care, HMO enrollment, HMO competition, and control variables using multivariate regression.

RESULTS

HMO competition increases use of gatekeeping and gatekeeping increases having a usual source of care for all individuals. For HMO enrollees, HMO competition increases having a usual source of care, whereas for those not in HMOs, it decreases having a usual source of care. For all individuals, having a usual source of care increases evaluation of physician thoroughness. For those in HMOs, gatekeeping decreases evaluation of physician thoroughness.

CONCLUSIONS

For HMO enrollees, the overall effect of HMO competition is to increase evaluations of physician thoroughness. For those not in HMOs, although there are HMO competition spillover effects, they are offsetting, resulting in no overall effect of HMO competition on evaluations of physician thoroughness.

Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district

The aim of this study was to investigate the adherence of nursing documentation to clinical guidelines in leg ulcer patients. Using two audit instruments, 100 patient records from primary health care were reviewed. The nursing content in the records was assessed according to instructions for documentation in local clinical guidelines for leg ulcers and the comprehensiveness of the nursing process in recording was reviewed. The results indicated deficiencies in the documentation of aspects of relevance in the care of leg ulcer patients. In addition, the findings indicated flaws in the adoption of the nursing process in recording. Only one problem in one patient record was recorded that consistently used the nursing process. The conclusion is that, despite specific and locally developed guidelines for care of leg ulcer patients, nursing records did not provide a precise audit of the care process. Because patient record information without a clear structure following the nursing process tends to impede communication and evaluation of care, such defective information is likely to have a significant impact on the continuity and quality in patient care.

Designs that make a difference: the Cardiac Universal Bed model

Information contained in this article includes some of the findings from a joint research project conducted by Corazon Consulting and Ohio State University Medical Center on national trends in Cardiac Universal Bed (CUB) utilization. This article outlines current findings and "best practice" standards related to the benefits of developing care delivery models to differentiate an organization with a competitive advantage in the highly dynamic marketplace of cardiovascular care. (OSUMC, a Corazon client, is incorporating the CUB into their Ross Heart Hospital slated to open this spring.)

Bali 12 months on.... Providing for continuing care and recovery

BACKGROUND

Traumatic events such as the bombings in Bali may cause many people to develop post-traumatic stress, traumatic grief, anxiety or depression.

OBJECTIVE

This article outlines the requirements of recovery, indications of its progress and the role of general practitioners in preventive care, support and referral.

DISCUSSION

Research indicates that more than half of those involved in traumatic events can expect to recover without developing a disorder. However, even optimal recovery from tragedy is a protracted and arduous task that severely taxes physical, emotional and social health. The consequences of this may show as degraded health in the second year following a tragedy.

[Follow-up of patients who seek treatment for grief]

INTRODUCTION

Based on several contributions and studies on evolutive aspects of grief, this study aims to focus on the two-year follow-up of patients from the Community Mental Health Service of Pa rla who came to the clinic in relationship with grief.

METHODS

Based upon a previous research, the authors have performed a follow-up study at two years in a sample of 51 patients, carried out by a telephone interview that examined subjective improvement, coping strategies and grieving process, biographical continuity and later life events.

RESULTS

Two years after the first visit, most of the patients considered that they had coped well with the loss and were able to resume their normal activities. They ranked their clinical situation as <<much better>>. One out of every four reported a partial or marked detention in their biographical course.

CONCLUSIONS

In the long term evolution of a visit due to grief, a positive outcome might be expected in the most of the cases. Factors associated with a worst outcome are a problematic bond with the deceased, and the son/daughter loss. Positive outcome was associated with social support and psychotherapy.

Development of integrated care in England and the Netherlands: managing across public-private boundaries

This paper addresses the impact of the public-private mix in the Dutch and English health and social care systems on the development and delivery of integrated care. Integrated care is conceived of as an organisational process of coordination which seeks to achieve seamless and continuous care, tailored to the patients' needs and based on a holistic view of the patient. We describe both systems' structures and characteristics from a historical perspective, which means that developments and processes within the systems are put in the spotlight. We demonstrate that the dividing- or fault-lines, such as the financial split between short-term and long-term care in the Netherlands and the divisions between health and social care as well as between the public, private and voluntary sectors in England have hindered integrated care development and delivery in both countries. Contradictory interests, differences in professional and organisational cultures, power relations, and mistrust between and within these sectors have had a clear impact on integrated care development and delivery within networks of public authorities and public and/or private providers. We explain these phenomena in terms of network theory as a basis for drawing lessons for policy makers and those developing integrated care networks.

Length of stay, referral to aftercare, and rehospitalization among psychiatric inpatients

OBJECTIVE

This retrospective study explored the interrelationship among aftercare, length of hospital stay, and rehospitalization within six months of discharge in a sample of psychiatric inpatients.

METHODS

Data were analyzed for 1,481 patients who had received inpatient care at a state psychiatric hospital from November 1991 to July 1994. Logistic regression models were estimated to predict the likelihood of referral to aftercare and of readmission to a hospital within six months of the index discharge. Variables controlled for were patients' characteristics; psychiatric status at the time of discharge, including length of stay; and the availability of informal support.

RESULTS

Sixteen percent of the patients received a referral to aftercare, and about 13 percent of the patients were readmitted within six months of discharge. White patients were twice as likely as African Americans to receive a referral to aftercare. Length of hospitalization and having a diagnosis of schizophrenia were also predictors of referral to aftercare. Referral to aftercare was not shown to mediate the relationship between length of stay and rehospitalization. However, having a schizoaffective disorder, a poor discharge prognosis, and a high number of previous admissions were associated with an increased risk of readmission. No other demographic characteristics were related to readmission within six months of discharge, but referral to aftercare significantly increased the risk of readmission.

CONCLUSIONS

The study suggested the possibility of racial disparities in referral to aftercare and a complex relationship between referral and rehospitalization. Both these findings warrant further investigation that gives particular attention to individual-level indicators of need and system-level barriers to and facilitators of psychiatric care.

Perfect storm: organizational management of patient care under natural disaster conditions

Managing uncertainty is an essential attribute of organizational leadership and effectiveness. Uncertainty threatens optimal decision making by managers and, by extension, reduces the quality of patient care. Variation in the work flows of everyday patient caregiving reflects management's steps to control uncertainty, which include strategies for contending with potential disaster scenarios. Little exists in the literature that reveals how management's strategic response to controlling uncertainty in a real disaster event differs from strategies practiced in disaster simulations, with the goal of protecting patient care. Using organization theory, this article presents the application of uncertainty management to the catastrophic flooding of a major teaching hospital. A detailed description of management's strategies for patient rescue and evacuation is provided. Unique aspects of managing uncertainty stemming from a natural disaster are highlighted. Recommendations on organization responses to disasters that optimize patient care, safety, and continuity are offered to managers.

The importance of follow-up examinations in patients with carcinoid tumor

Carcinoid tumors are rare forms of gastrointestinal tumors, although lately they have been found with increasing frequency. We report here the combined diagnosis of an intestinal metastasized carcinoid tumor. A 67-year-old patient was followed up during a nine-year period. In 1990 the patient was diagnosed with carcinoid tumor of intestinal origin with multiple liver metastases. Initial treatment consisted of partial resection of the intestine and resection of the liver. Since multiple liver metastases were found, chemoembolization was also performed. After this therapy the patient was free of complaints until 1996. That year the patient reported upper abdominal pain with occasional diarrhea. Given his past medical history and multiple hepatic metastases proven by three-dimensional ultrasonography, combined octreotide and interferon therapy was started following octreoscan scintigraphy. During a three-year period the patient was without complaints and the tumor marker value decreased to almost normal. In 1998 the patient at a regular follow-up visit complained about colic abdominal pain around the umbilical region. Abdominal ultrasonography showed a local wall thickening in the intestinal region. The computed tomography and selective enterography were positive as well. The surgical treatment and histology demonstrated intestinal recurrence of the tumor in the ileal region. After the operation we started a long-acting sandostatin and interferon treatment. We conclude that an ultrasound with a high index of clinical suspicion is a useful test for the diagnosis of carcinoid tumor in detection and in follow-up examinations.

Writing the prescription and informing the patient

BACKGROUND

Having decided on the generic drug to prescribe the prescription needs to be written and the patient informed regarding the treatment.

OBJECTIVE

This article discusses some regulatory requirements for writing a legal prescription, but predominantly discusses important aspects of informing patients regarding drug therapy.

DISCUSSION

The actual writing of a prescription is a small part of the prescribing process and needs to comply with local regulations. Including patients in the decision to embark on a treatment and informing them of drug treatment is a very important part of the prescribing process. There is no simple formula, but patients need to be informed on what they want to know, when they want to know it, and in the way that is most acceptable to them. It is important to use both verbal and written forms of communication and to allow patients to reflect over the information, ask questions, and be further informed over subsequent consultations. Consumer medicine information leaflets can be a useful aid, but require that the clinician understand and be prepared to answer questions raised by them.

Medicaid managed care meets developmental disabilities: proceed with caution

This article examines Medicaid managed care's potential impact on people with developmental disabilities. The authors discuss how the philosophy behind the skills/functional model of service provision for people with developmental disabilities is incongruent with the medical model of managed care. They discuss the policy issues that various states have had to face concerning Medicaid managed care's administration of health benefits for people with developmental disabilities. They extrapolate from the research on managed care to formulate potential models that states might use to administer the health benefits for people with developmental disabilities. Finally, the authors propose policy and research agendas to begin investigating Medicaid managed care's potential impact on people with developmental disabilities.