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Recent Soviet reforms in health care policy and financing are expected to have a significant impact on perinatal services. Efforts are under way to upgrade the care of pregnant and birthing women. This paper describes some aspects of the current system of perinatal care and prospects for future change.
In view of the new residency guidelines, which restrict resident work hours, the use of physician assistants (PAs) for patient care continuity during off-hours of residents may become a common practice. The purpose of this study was to assess the quality of patient care during transition from resident- to PA-assisted trauma program (without residents) and comparative simultaneous support. A retrospective analysis of patient care during two 6-month segments was carried out: during resident-assisted program at a level II trauma center in 1998 and a PA-dedicated trauma program in 1999. With reinvolvement of senior surgical residents, a focused analysis for the last quarter of 2002 was done. Regression analysis indicated the only statistically significant outcome was decreased length of stay (LOS) when patients were transferred directly from emergency center (EC) to floor in 1999. The mean LOS was 2.54 +/- 4.65 compared to 3.4 +/- 5.81, and no statistical difference in other assessments was noted. Focused analysis in 2002 showed 100 per cent participation of PAs during the trauma alert compared to 51 per cent by residents. Substitution of residents with PAs had no impact on patient mortality; however, LOS (from EC to floor), was statistically reduced by 1 day. Trauma programs can benefit with collaboration of residents and PAs in patient care.
Practice transition between health care settings is often fraught with frustration, stress, and even traumatic learning experiences for nurses. As the need for qualified infusion therapists in home care increases, more acute care nurses are making the transition from hospital to home. This article is designed to profile the differences between the care settings and offer suggestions to smooth the change from hospital to home care.
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The presentation of diabetes in young people has changed significantly over recent years. Not only has there been a rising incidence of Type 1 diabetes, especially in young children, but also there is an increasing recognition of Type 2 diabetes. Young people are also increasingly being diagnosed with genetic defects of B-cell function and with diabetes in association with cystic fibrosis and other chronic diseases. There have also been significant changes in the pattern of paediatric diabetes care. This is increasingly being provided by a specialized paediatric multidisciplinary team in each health district working to agreed national standards. Despite improvements, diabetes control is still suboptimal with a high incidence of complications being reported in young adults. The challenge over the next few years is the provision of a uniform, equitable and first class paediatric service throughout the UK together with the introduction of new approaches to care, aiming to improve individual diabetic control and reduce long-term complications. Increased collaboration with adult colleagues is needed to enable the transition of care in adolescence to a service that young adults perceive to meet their needs, encourage their attendance and improve their diabetes control and quality of life. A national paediatric diabetes register together with regular audit will encourage these objectives.
Home mechanical ventilation has evolved to permit discharge of patients on portable negative or positive pressure mechanical ventilators. Assessment of the patient for home discharge is initiated by a multidisciplinary team. The nurse, physician, social worker, respiratory therapist, speech therapist, occupational therapist, home health nursing agency, durable medical equipment supplier, and caregivers constitute the team. The crucial links to a successful patient discharge are an involved family and a well-developed plan of care, although patient finances also are important. The nurse develops, coordinates, and implements the teaching plan over a period of 2 or more weeks. The home caregivers provide total care for the patient several days before discharge. The home health agency and the durable medical equipment supplier provide services which ease the transition of care from hospital to home. One alternative to home discharge is placement in an extended care facility.
Nurses are accountable for their care. Understanding the physiology and process behind any intervention improves patient care, while also increasing nursing satisfaction and skill and IABP is no exception. An awareness of IABP will facilitate sound nursing care, ensure early identification of possible complications or patient compromise, and lead to patient and relative satisfaction. It will also assist in the transition from caring for a patient whose needs are relatively straightforward, to caring for one subject to this complex medical intervention.
Quality assurance in long-term care (LTC) diverges from approaches in acute care because of inherent features of LTC: the slower pace, the reliance on "low technology" services, the goals of LTC, and the multiple transitions across care sites typical of LTC users. LTC quality assurance activities should focus on outcomes, using process measures only when they are related to desirable outcomes or are intrinsic to respectful treatment of patients. Outcome measures should compare what is achieved with what can be reasonably expected. Because LTC services can be given interchangeably at various LTC sites (e.g., home care, day care, nursing homes), a data base must be developed that permits monitoring and comparing outcomes across diverse LTC programs.
BACKGROUND: Delirium has recently been shown as a predictor of death, increased cost, and longer duration of stay in ventilated patients. Sedative and analgesic medications relieve anxiety and pain but may contribute to patients' transitioning into delirium. METHODS: In this cohort study, the authors designed a priori an investigation to determine whether sedative and analgesic medications independently increased the probability of daily transition to delirium. Markov regression modeling (adjusting for 11 covariates) was used in the evaluation of 198 mechanically ventilated patients to determine the probability of daily transition to delirium as a function of sedative and analgesic dose administration during the previous 24 h. RESULTS: Lorazepam was an independent risk factor for daily transition to delirium (odds ratio, 1.2 [95% confidence interval, 1.1-1.4]; P = 0.003), whereas fentanyl, morphine, and propofol were associated with higher but not statistically significant odds ratios. Increasing age and Acute Physiology and Chronic Health Evaluation II scores were also independent predictors of transitioning to delirium (multivariable P values < 0.05). CONCLUSIONS: Lorazepam administration is an important and potentially modifiable risk factor for transitioning into delirium even after adjusting for relevant covariates.
The new political era in South Africa offers unique opportunities for the development of more equitable health care policies. However, resource constraints are likely to remain in the foreseeable future, and efficiency therefore remains an important concern. This article describes the guiding principles and methods used to develop a coherent and objective plan for comprehensive primary health care facilities in Soweto. The article begins with an overview of the context within which the research was undertaken. Problems associated with planning in transition are highlighted, and a participatory research approach is recommended as a solution to these problems. The article goes on to describe how the research methods were developed and applied in line with the principles of participatory research. The methods were essentially rapid appraisal techniques which included group discussions, detailed checklists, observation, record reviews and the adaptation of international and local guidelines for service planning. It is suggested that these methods could be applied to other urban areas in South Africa and elsewhere, and that they are particularly appropriate in periods of transition when careful facilitation of dialogue between stakeholders is required in tandem with the generation of rapid results for policy-makers.
Findings are reported from a prospective study of 20 persons on the experience of providing informal care to partners or family members with HIV syndrome. In-depth, focused interviews were completed. Data were initially coded using an inductive technique and thematically analyzed. The informal care providers were found to engage in a variety of interacting, and often conflicting, psychosocial and instrumental processes that occurred over three emergent phases: (a) transitions to care, (b) living the burden, and (c) facing the void. Although the care providers struggled with various sources of uncertainty and distress, when periods of equanimity were realized, they experienced a heightened sense of coherence and personal growth.
OBJECTIVES: The effectiveness of case-managed residential care (CMRC) in reducing substance abuse, increasing employment, decreasing homelessness, and improving health was examined. METHODS: A five-year prospective experiment included 358 homeless addicted male veterans 3, 6, and 9 months during their enrollment and at 12, 18, and 24 months after the completion of the experimental case-managed residential care program. The customary control condition was a 21-day hospital program with referral to community services. RESULTS: The experimental group averaged 3.4 months in transitional residential care with ongoing and follow-up case management for a total of up to 1 year of treatment. The experimental group showed significant improvement compared with the control group on the Medical, Alcohol, Employment, and Housing measures during the 2-year period. An examination of the time trends indicated that these group differences tended to occur during the treatment year, however, and to diminish during the follow-up year. CONCLUSIONS: Within groups, significant improvements were observed with time from baseline to all posttests on the four major outcomes. We learned, however, that veterans had access to and used significant amounts of services even without the special case-managed residential care program. This partially may account for improvements in the control group and may have muted the differences between groups.
Three models of transitional residential community care for substance abuse patients are defined on the basis of the differential provision of health and treatment services: a psychosocial model, a supportive rehabilitation model, and an intensive treatment model. Facilities that provided a high level of on-site health and treatment services were categorized as following an intensive treatment model; these facilities had the strongest emphasis on medical, dual diagnosis, and family treatment orientations. These facilities also had clearer policies and provided their residents more opportunities to participate in setting policies; however, staff were not more accepting of patient impairment or problem behavior. Patients in facilities with intensive treatment programs obtained more outpatient mental health after care. In each of the three types of facilities, a longer length of care was associated with a lower readmission rate; patients who dropped out of psychosocial model facilities had especially high readmission rates. Overall, the findings identify substantial variations among community residential facilities for substance abuse patients, but show relatively little matching of patients' needs with facility services and programs.
Pathophysiologic, psychosocial, and economic considerations are important in nutritional assessment of infants and children who are HIV-infected. Nutritional assessment guidelines vary based on the child's circumstances. Specific assessment guidelines are proposed for (a) ongoing ambulatory care; (b) when growth decelerates or its below the fifth percentile; (c) acute illness; and (d) home and community care. The guidelines are based on data collected from a sample of 16 children who were HIV-infected and their families during a pilot study of transitional nursing care using advanced practice nurses. The guidelines were inductively derived from patient care records and from a review of the literature.
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While the care of cystic fibrosis (CF) patients has been mainly the province of pediatricians, great improvements in the therapy and life span of CF patients often results in their transition to care by adult physicians. In this review of CF, we begin with an overview of the epidemiology and genetics of the disease, with a discussion of the recently found ion abnormalities that lead to the clinical manifestations. This is followed by a discussion of the pathophysiology. Methods of diagnosis, ranging from the gold standard, the sweat test, to recent advances based on a greater understanding of the genetics of the disease are reviewed. This is followed by a discussion of therapy primarily geared to the treatment of the respiratory complications, as they are the most common lethal factors of the disease. We point out controversies where they exist. Newer forms of therapy such as lung transplantation are discussed, and we finish with a discussion about future therapeutic modalities, some of which are being approved as the paper is in print.
The statistical associating fluid theory of Wertheim is applied to describe binary mixtures with associating between unlike-pair molecules. The phase behavior of this binary mixture would fall into five different types (I, II, III, V, and VI) of the classification scheme of van Konynenburg and Scott by varying the associating strength and the energy parameters. Both interfacial wetting behavior and wetting transitions are carefully examined in all the vapor-liquid-liquid (gamma-beta-alpha) three-phase-coexisting regions of the binary mixtures. The global wetting behavior and wetting transitions are delineated by scanning the parameter space. In certain regions, the middle beta phase exhibits interfacial phase transitions sequentially, nonwetting --> partial-wetting --> nonwetting, at the interface separating lower alpha and upper gamma phases along with increasing temperature.
With improved medical technology, many chronic medical conditions of childhood are now recognized as conditions of childhood onset. Appropriate treatment of these conditions in the adult patient is required. The pediatric setting is not appropriate in terms of philosophy, service delivery, and relationship with the patient. To design a suitable transition protocol, a survey of teenage patients with cystic fibrosis was carried out and the process was discussed with the relevant clinicians. The results of the survey indicated that young people identified transition to an adult service as necessary and accepted, provided that good preparation is given from the pediatric setting. This article provides a detailed example of a model of transition for cystic fibrosis services to encourage practice and evaluation of provision.