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PubMed1997

Critical pathways for head and neck surgery. Development and implementation.

OBJECTIVE: To design, implement, and study the effectiveness of 4 new critical pathways relevant to head and neck oncological care. DESIGN: Before-after trial. SETTING: Tertiary referral academic institution. PATIENTS: Sixty-eight patients admitted for head and neck oncological surgery or chemotherapy from December 1, 1995, through May 31, 1996; 30 patients with similar diagnoses and who underwent surgical procedures from December 1, 1994, to December 1, 1995, who served as historical controls. INTERVENTIONS: Implementation of 4 critical pathways: chemotherapy, clean head and neck surgery, clean contaminated head and neck surgery, clean contaminated head and neck surgery with reconstructive flap. MAIN OUTCOME MEASURES: Length of stay, cost of hospitalization, and variance tracking (deviations from established standards). RESULTS: The length of stay for the clean contaminated group without flap reconstruction decreased by 1.5 days, and costs decreased by $7407 per patient (P < .05, Student t test). The length of stay decreased 1.6 days in the clean contaminated group with flap reconstruction, and costs decreased $9845 per patient (P < .05, Student t test). Nine patients (13%) experienced a prolonged length of stay while on a critical pathway. CONCLUSIONS: Implementation of critical pathways has resulted in a decreased overall length of stay and cost of hospitalization. It has also allowed for better coordination and documentation of patient care, while the tracking of variances has simplified problem identification and correction.

Critical Pathways↗

PubMed2000

Sustaining the implementation of an evidence-based guideline for bronchiolitis.

OBJECTIVE: To describe the changes occurring over a 3-year period after implementation of an evidence-based clinical practice guideline for the care of infants with bronchiolitis. DESIGN: Before and after study. SETTING: Children's Hospital Medical Center, Cincinnati, Ohio. PATIENTS: Infants 1 year or younger admitted to the hospital with a first-time episode of typical bronchiolitis. INTERVENTION: The guideline was implemented January 15, 1997. Data on all patients discharged from the hospital with bronchiolitis, from January 15 through March 27, in 1997, 1998, and 1999, were stratified by year and compared with data on similar patients discharged from the hospital in the same periods in the years 1993 through 1996. MAIN OUTCOME MEASURES: Patient volumes, length of stay for admissions, and use of specific laboratory and therapeutic resources ancillary to bed occupancy. RESULTS: After implementation of the guideline, admissions decreased 30% and mean length of stay decreased 17% (P<.001). Nasopharyngeal washings for respiratory syncytial virus were obtained in 52% fewer patients (P<.001); 14% fewer chest x-ray films were ordered (P<.001). There were significant reductions in the use of all respiratory therapies, with a 17% decrease in the use of at least 1 beta(2)-agonist inhalation therapy (P<.001). In addition, 28% fewer repeated inhalations were administered (P<.001); mean costs for all resources ancillary to bed occupancy fell 41% (P<.001); and mean costs for respiratory care services fell 72% (P<.001). CONCLUSIONS: An evidence-based clinical practice guideline for the care of patients encountered in major pediatric care facility has been successfully sustained beyond the initial year of its introduction to practitioners in southwest Ohio.

Algorithms↗

PubMed2006

Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines.

OBJECTIVE: To describe the effect of implementing the Joint Commission on Accreditation of Healthcare Organization's guidelines for procedural sedation and analgesia (PSA) on the frequency of adverse events occurring during sedation. DESIGN: Prospective, descriptive study. SETTING: Urban, tertiary care children's hospital. PARTICIPANTS: Patients requiring PSA. INTERVENTIONS: A PSA committee and a standardized protocol for PSA were developed during a 6-month period. Institutional oversight was initiated to monitor practitioner compliance with the program. Data were abstracted from the sedation record. MAIN OUTCOME MEASURES: The change in incidence of adverse events during PSA during the study. The strength of the association was determined by computing the Pearson product moment correlation. RESULTS: A total of 14 386 patients received PSA between July 1, 2001, and June 30, 2004. During the study, 7.6% of patients had an adverse event, with the most common being hypoxemia (39.7% of all adverse events). A trend toward a decrease in the incidence of adverse events was found during the study (Pearson product moment correlation, -0.68; P<.001). CONCLUSIONS: Implementation of the 2001 Joint Commission on Accreditation of Healthcare Organizations guidelines for the provision of PSA appeared to lead to a decrease in the incidence of adverse events during the study. Implementation of uniform standards of monitoring and care for the provision of PSA may lead to safer conditions for pediatric patients undergoing PSA.

Adolescent↗

PubMed1997

An ethics curriculum for the pediatric residency program. Confronting barriers to implementation.

BACKGROUND: The 1997 Residency Review Committee requirements in pediatrics mandate a structured curriculum in medical ethics for all accredited pediatric residency programs. To our knowledge, there are no published models for the development of an ethics curriculum for pediatric residents. Several obstacles may confront those attempting to begin an ethics teaching program. OBJECTIVE: To describe the successful implementation of a structured ethics curriculum for pediatric residents. METHODS: Our program was designed to overcome the following obstacles: (1) time constraints of faculty and residents, (2) scheduling difficulties and lack of continuity, (3) attitudes of residents toward the material, and (4) inadequate ethics training among faculty. In addition to traditional topics in medical ethics, the curriculum focuses on issues that confront residents primarily during their training, issues that may shape their professional values in important ways. RESULTS: This ethics curriculum has been successfully implemented in our own program and offers solutions to common barriers faced by those seeking to implement an ethics curriculum for pediatric residents. CONCLUSION: We present the ethics curriculum currently in use at our institution as a tool that may be adopted as it stands or as altered by others as they develop their own program's ethics curriculum. We believe the proposed curriculum directly confronts many of the barriers to successful ethics education of pediatric residents.

Curriculum↗

PubMed2000

Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial.

CONTEXT: Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation. OBJECTIVES: To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs. DESIGN: Randomized controlled trial conducted June 1, 1994, to August 31, 1998. SETTING AND PARTICIPANTS: A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each. INTERVENTION: The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives. MAIN OUTCOME MEASURES: Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes. RESULTS: Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95 % confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20). CONCLUSION: Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.

Advance Directives↗

PubMed2000

Homicide and suicide rates associated with implementation of the Brady Handgun Violence Prevention Act.

CONTEXT: In February 1994, the Brady Handgun Violence Prevention Act established a nationwide requirement that licensed firearms dealers observe a waiting period and initiate a background check for handgun sales. The effects of this act have not been analyzed. OBJECTIVE: To determine whether implementation of the Brady Act was associated with reductions in homicide and suicide rates. DESIGN AND SETTING: Analysis of vital statistics data in the United States for 1985 through 1997 from the National Center for Health Statistics. MAIN OUTCOME MEASURES: Total and firearm homicide and suicide rates per 100,000 adults (>/=21 years and >/=55 years) and proportion of homicides and suicides resulting from firearms were calculated by state and year. Controlling for population age, race, poverty and income levels, urban residence, and alcohol consumption, the 32 "treatment" states directly affected by the Brady Act requirements were compared with the 18 "control" states and the District of Columbia, which had equivalent legislation already in place. RESULTS: Changes in rates of homicide and suicide for treatment and control states were not significantly different, except for firearm suicides among persons aged 55 years or older (-0.92 per 100,000; 95% confidence interval [CI], -1.43 to -0.42). This reduction in suicides for persons aged 55 years or older was much stronger in states that had instituted both waiting periods and background checks (-1.03 per 100,000; 95% CI, -1.58 to -0.47) than in states that only changed background check requirements (-0.17 per 100,000; 95% CI, -1.09 to 0.75). CONCLUSIONS: Based on the assumption that the greatest reductions in fatal violence would be within states that were required to institute waiting periods and background checks, implementation of the Brady Act appears to have been associated with reductions in the firearm suicide rate for persons aged 55 years or older but not with reductions in homicide rates or overall suicide rates. However, the pattern of implementation of the Brady Act does not permit a reliable analysis of a potential effect of reductions in the flow of guns from treatment-state gun dealers into secondary markets. JAMA. 2000;284:585-591

Adult↗

PubMed2000

Changes in youth cigarette use and intentions following implementation of a tobacco control program: findings from the Florida Youth Tobacco Survey, 1998-2000.

CONTEXT: Many states are developing tobacco use prevention and reduction programs, and current data on tobacco use behaviors and how these change over time in response to program activities are needed for program design, implementation, and evaluation. OBJECTIVES: To assess changes in youth cigarette use and intentions following implementation of the Florida Pilot Program on Tobacco Control. DESIGN, SETTING, AND PARTICIPANTS: Self-administered survey conducted prior to program implementation (1998), and 1 and 2 years (1999, 2000) later among a sample of Florida public middle school and high school students who were classified as never users, experimenters, current users, and former users of cigarettes based on survey responses. MAIN OUTCOME MEASURES: Changes in cigarette use status, intentions, and behaviors among students over a 2-year period. RESULTS: Surveys were completed by 22,540, 20,978, and 23, 745 students attending 255, 242, and 243 Florida public middle and high schools in 1998, 1999 and 2000, respectively. Response rates for the 3 survey years ranged from 80% to 82% and 72% to 82% for the middle school and high school surveys, respectively. After 2 years, current cigarette use dropped from 18.5% to 11.1% (P<.001) among middle school students and from 27.4% to 22.6% (P =.01) among high school students. Prevalence of never use increased from 56.4% to 69. 3% (P<.001) and from 31.9% to 43.1% (P =.001) among middle school and high school students, respectively. Prevalence of experimenting decreased among middle school and high school students from 21.4% to 16.2% (P<.001) and from 32.8% to 28.2% (P<.001), respectively. Among never users, the percentage of committed nonsmokers increased from 67.4% to 76.9% (P<.001) and from 73.7% to 79.3% (P<.001) among middle school and high school students, respectively. Among experimenters, the percentage of students who said they will not smoke again increased from 30.4% to 42.0% (P<.001) in middle school and from 44.4% to 51.0% (P<.001) in high school. CONCLUSIONS: Progress toward reduction of youth tobacco use was observed in each of the 2 years of Florida's Pilot Program on Tobacco Control. Our results suggest that a comprehensive statewide program can be effective in preventing and reducing youth tobacco use. JAMA. 2000;284:723-728

Adolescent↗

PubMed2006

Prevalence of HIV-1 in blood donations following implementation of a structured blood safety policy in South Africa.

CONTEXT: The South African National Blood Service collects more than 700,000 units of blood annually from a population in which 11.4% is infected with human immunodeficiency virus 1 (HIV-1). The prevalence of HIV-1 in blood donations increased to 0.26% (1:385) in 1998, indicating that a significant number of window-period infective units were entering the blood supply (risk 3.4/100,000). OBJECTIVES: To determine whether the implementation of a new donor selection policy and educational program introduced in 1999 was associated with reductions in the incidence and prevalence of HIV-1 in blood donations and the reduced transmission risk. DESIGN: We compared the prevalence of HIV-1 in 880,534 blood donations collected from 1999 through 2000 with the 791,639 blood donations collected from 2001 through 2002. We estimated the incidence of HIV-1 in 93,378 (1999-2000) and 67,231 (2001-2002) first-time donations and the residual risk for all donations in 2001-2002 using the less-sensitive enzyme-linked immunoassay and incidence-window period model. SETTING: All blood donors in the Inland region of the South African National Blood Service were analyzed. INTERVENTION: Donor clinics in high HIV prevalence areas were closed. Programs targeting repeat donors and youth were initiated and HIV risk behavior education programs were developed. Structured donor interviews and an enhanced donor self-exclusion questionnaire were institutionalized. RESULTS: The prevalence of HIV-1 in blood donations declined from 0.17% in 1999-2000 to 0.08% in 2001-2002 after the implementation of the new donor selection and education policy. The number of high-risk donations collected decreased from 2.6% to 1.7% (P<.001), and the likelihood of these donations being infected decreased from 4.8% to 3.25%. The likelihood of first-time donors being recently infected with HIV-1 decreased from 18% to 14% (P = .07) and respective incidence of high-risk donations collected decreased from 2.6% to 1.7%. Donations from the majority black population declined from 6.6% to 4.2% (P<.001). Analysis of HIV-1 incidence in 2001-2002 suggests a residual risk of collecting a window period infectious unit of 2.6/100,000. CONCLUSION: The implementation of enhanced education and selection policies in South Africa was associated with decreased prevalence of HIV-1 in blood donations.

Adolescent↗

PubMed1999

Implementation of quantitative FAIR perfusion imaging with a short repetition time in time-course studies.

Flow-sensitive alternating inversion recovery (FAIR) is a pulsed arterial spin labeling magnetic resonance imaging method for perfusion quantification. In its standard implementation for quantification with full longitudinal relaxation between acquisitions, its use in time-course investigations of rapidly changing flow values is limited. The time efficiency can be improved by decreasing the repetition time but quantification becomes problematic. This situation is further complicated if a whole-body radiofrequency transmit coil is not used since fresh blood spins will flow in from outside the coil. To alleviate these problems, the use of global pre-saturation is proposed. The resulting expression for the flow signal depends on the relationship between the imaging parameters and the coil inflow time and can be significantly simplified under certain combinations of these parameters. With this implementation of FAIR, quantitative flow maps of gerbil brains were obtained with a 3 minute time resolution in a study of the effects of reperfusion. The pre-occlusion flow measurements were in good agreement with values obtained by the standard FAIR implementation and by other techniques, but the low values following occlusion were underestimated due to the increased transit times.

Animals↗

PubMed1992

Implementing right-to-know legislation for health care workers in Manitoba: a bipartite sectoral train-the-trainer approach.

In October 1988, right-to-know legislation was introduced in Canada. This presented a technical and administrative challenge to the health care sector. With over 170 health care facilities in Manitoba to be brought into compliance, some large, some small, some rural, some urban, a cooperative approach was needed. A labor-management steering committee with representatives from a cross-section of facilities as well as the various health care unions was formed to design and implement a train-the-trainer program. A small-group, highly participatory modular program was developed with input from all parties, and delivered across the province by trainers selected jointly by labor and management. The program achieved its goal of assisting member facilities to implement the legislation. Follow-up surveys and discussions with health care workers showed improved understanding of labelling requirements, material safety data sheet interpretation, and requirements for hazard control. This first bipartite program empowered the health care workforce to use its newly acquired right-to-know, and has provided the incentive to implement other cooperative safety and health programs.

Evaluation Studies as Topic↗

PubMed2005

Developing and implementing future stroke therapies: the potential of telemedicine.

Stroke is a major public health concern with few positive phase III clinical trials and a shortage of stroke care expertise. Drug development likely can be enhanced by adapting new outcome measures and following guidelines generated by consensus groups. To enhance rates of drug implementation and to improve stroke care, some states are requiring that acute care hospitals obtain primary stroke center certification, and this mandate necessitates that smaller hospitals join larger ones in stroke care networks. Cutting-edge technology in the form of telemedicine is being implemented in stroke care networks to combat the lack of stroke care expertise by extending the availability of physician stroke expertise. The telemedicine network can be used to transmit real-time data from stroke care-certified community hospitals (spokes) to a tertiary center (hub). Telemedicine can be used to educate physicians in spoke hospitals about new stroke treatments. The advent and development of telemedicine has the potential to ensure that patients with stroke have a greater opportunity to receive the full range of therapeutic options currently available and those that will become available in the future. The implementation of future drug therapies through telemedicine-organized stroke networks will likely substantially influence the future of acute stroke therapy.

Humans↗

PubMed2006

Design and implementation of a web-based, database-driven histology atlas: technology at work.

At Vanderbilt University, the "Human Cell and Tissue Biology" course is a required lecture and laboratory course with 2 full-time instructors and 106 students. To address demands placed on faculty for individual attention, an interactive Web-based histology atlas was developed and implemented in January 2005. This atlas was specifically designed to complement the existing laboratory manual and to transform the manual into an interactive educational tool whereby students could view high-resolution images of histological specimens online. By utilizing a computer scripting language, interactive highlighting of histological structures was accomplished through the implementation of a simple mouse-rollover function. This computer-aided instruction software allows students to preview histological structures of interest prior to entering the laboratory, to have additional faculty-directed contact hours during laboratory, and to review material efficiently. The conversion of the originally developed static application into a database-driven tool streamlined the development and modification of the atlas while facilitating the creation of advanced features. Six weeks after launching this interactive atlas, Vanderbilt medical students logged 1,200 hr of use. Through the cooperative efforts of faculty and students, the interactive atlas evolved to meet the educational demands of medical students owing to the development and implementation of a database structure. The functionality and educational value of the interactive atlas in facilitating self-learning was ultimately measured by positive student feedback and use.

Anatomy, Artistic↗

PubMed2004

Implementation of a specialist-led service for the management of acute gallstone disease.

BACKGROUND: The 'gold standard' treatment for acute cholecystitis and biliary colic requiring hospital admission is urgent laparoscopic cholecystectomy. This is not routinely available in all hospitals. METHODS: A retrospective audit of emergency admissions with acute cholecystitis or biliary colic from January to December 2000 led to the development and implementation of a specialist-led protocol for the urgent management of acute gallstone disease. A second audit was carried out covering the 6 months after implementation. RESULTS: One hundred and fifty-eight patients were admitted with acute cholecystitis or biliary colic in the first audit period and 110 in the second interval. The rate of cholecystectomy at index admission increased from 37.3 to 67.3 per cent, at a median of 3 days after admission, and the conversion rate to open surgery fell from 32 to 12 per cent. Median hospital stay fell from 9 to 5.5 days, and the unplanned readmission rate decreased from 19.0 to 3.6 per cent. CONCLUSION: Urgent cholecystectomy for the management of acute gallstone disease is feasible and achievable in an acute services hospital with a specialist upper gastrointestinal team. It can lead to a reduced conversion rate, shorter hospital stay, fewer unplanned readmissions, an acceptable operating time and a low complication rate. The protocol is recommended for implementation in other hospitals.

Acute Disease↗

PubMed2003

Guideline implementation in a multicenter study with an estimated 44% relative cardiovascular event risk reduction.

BACKGROUND: The extent of cardiovascular risk reduction by implementing coronary prevention guidelines needs to be documented in various population samples. HYPOTHESIS: This is a multicenter study to assess the impact of risk reduction in cardiovascular events upon implementation of coronary prevention guidelines in patients with or at high risk for coronary heart disease (CHD) in the setting of clinical practice. METHODS: Enrolled volunteers numbered 2,021. Inclusion criteria postulated a minimum of 20-40% cardiovascular event risk in the subsequent 10 years as estimated from the risk table of the European Society of Cardiology (ESC) Guidelines. The estimated CHD risk reduction was assessed in terms of the Framingham risk scores at baseline and at 12 months, computed from the data of each individual. Data of the compliant group (making up half of the initial participants) at the end of the study, along with absolute and relative risk reductions in the compliant group, were analyzed. RESULTS: Mean global risk burden was 25.9% at baseline, reduced through multilateral preventive measures in absolute terms by 9.4% at 6 months and by 11.7% at 12 months; the latter represents a relative risk reduction of 44%. Independent variables determining the (enhanced) reduction in risk level at the end of 12 months included (high) level of baseline risk, (high) degree of compliance with treatment, younger age, female gender, smoking, and (high) baseline triglyceride/high-density lipoprotein cholesterol (TC/HDL-C) ratio. While the relative reduction in patients with CHD amounted to 43%, a reduction of 46% (p<0.001) was obtained in the setting of primary prevention. Diabetes emerged as a factor modestly limiting the extent of risk reduction. While subjects without hypertension revealed a decline of coronary risk by merely 8.7%, those with hypertension showed a decline by 12.7% (p<0.001). Risk reductions were accompanied by a decrease of mean low-density lipoprotein cholesterol (LDL-C) level of 25.4%, a rise in mean HDL-C level of 5 mg/dl, a decrease in mean systolic blood pressure of 26 mmHg. Forty-five percent of smokers succeeded in discontinuing the habit. CONCLUSION: By implementing standard prevention guidelines in the Turkish population among 1,000 compliant high-risk men and women and among 1,000 patients with CHD, prevention of cardiovascular events could be expected in 117 persons in the subsequent 10 years.

Cardiovascular Diseases↗

PubMed2026

Clinical Function Assignment of NAT2 Alleles by the Clinical Pharmacogenetics Implementation Consortium Pharmacogene Curation Expert Panel.

NAT2 encodes arylamine N-acetyltransferase 2, a key enzyme in the phase II metabolism of arylamines and arylhydrazines. NAT2 is highly polymorphic, resulting in variable distributions of rapid and poor metabolizers across global populations. Here, we detail the process undertaken by the Clinical Pharmacogenetics Implementation Consortium (CPIC) NAT2 Pharmacogene Curation Expert Panel (PCEP) to assign clinical function to NAT2 star (*) alleles using CPIC's standard terminology. Given the observed impact of NAT2 genetic variability on drug response, CPIC convened the NAT2-PCEP to standardize clinical allele function assignments. The NAT2-PCEP is comprised of multidisciplinary and international members, including researchers, clinicians, and implementers with expertise in pharmacogenomics and NAT2 molecular biology. Extensive in vitro and clinical literature was curated from PubMed and other sources to assess NAT2 genotype-to-phenotype concordance as well as the biochemical function of NAT2 star alleles. The NAT2-PCEP assigned allele clinical function using CPIC's standard terminology (increased, decreased, uncertain, and unknown function) to 59 star alleles cataloged by the Pharmacogene Variation Consortium (PharmVar). Two alleles, NAT2*1 and NAT2*4, were assigned increased function (historically known as rapid), 40 alleles were assigned decreased function (historically known as slow), 10 alleles were assigned uncertain function, and seven alleles were assigned unknown function. Rigorous evidence review and in-depth PCEP discussion were crucial in determining these function assignments. The findings reported here underscore the importance of standardized allele functional terms and diplotype-to-phenotype assignments to further the clinical implementation of NAT2 pharmacogenetic test results.

Arylamine N-Acetyltransferase↗

PubMed2002

Design and implementation of algorithms for focus automation in digital imaging time-lapse microscopy.

BACKGROUND: Digital time-lapse microscopy using Nomarski-DIC requires that an autofocusing system adapt to changes in cell shape, size, and position while contending with drift, noise, and hysteresis in the microscope and imager. We have designed and implemented an autofocusing system that tracks subjects under dynamic conditions and maintains focus within a threshold of discriminability. METHODS: With the use of proven and novel algorithms for autofocusing in Nomarski, we performed "virtual" experiments on recorded image stacks to simulate drift and sudden displacements and test the search algorithm response. RESULTS: We found that combining a simple [1, -1] contrast function with an adaptive "warmer-colder" focusing algorithm yields a reasonable compromise between focusing precision and noise tolerance. This method was implemented to record growth kinetics of yeast cells in single and multiple fields of view over several hours. CONCLUSIONS: We have implemented a robust digital autofocus that maintains focus on optically complex samples imaged at high resolution. The tolerance of this system of drift and vibration suggests that it is a practical system for time-lapse imaging in many biological applications.

Algorithms↗

PubMedDate not supplied

The proof of the reform is in the implementation.

In 2000, TDR funded a series of studies to examine the opportunities and threats of health sector reform to the control of tropical diseases. This article is a cross-case analysis of ten of those studies, exploring the similarities in patterns across the countries covered: Colombia, China, Nigeria, the Philippines, Sudan, Tanzania and Uganda. The implementation experiences across countries were strikingly similar despite very different socio-economic and epidemiological situations. The reform implementation was neither complete nor clean and had in all the countries found some sort of least-energy equilibrium where the processes had stopped at a sub-optimal stage needing considerable renewed 'change-energy' to achieve its objectives. The role of the state had, in several cases, been reduced to a situation where it neither pursued the interest of the public nor protected the individual against harm caused by the behaviours of others. Whether one should follow a dedicated disease control programme or a systems approach is not a relevant question. Effective disease control cannot be implemented without strong and functioning health systems and health system performance cannot be improved without considering which purpose the system is to serve.

Communicable Disease Control↗

PubMedDate not supplied

Implementing nursing case management.

While nursing literature abounds with information on nursing case management (NCM), articles discussing actual NCM implementation problems, particularly in the acute rehabilitation setting, are virtually nonexistent. As hospitals seek ways to combat the economic and quality problems stemming from fragmented care, nursing case management provides a viable approach. Yet, it is imperative that those seeking to implement case management realize the importance of careful planning in avoiding common pitfalls. This article discusses NCM and uses a case analysis approach to illustrate problems commonly encountered in implementing the care delivery model. Recommendations for ensuring a smooth transition from primary nursing to nursing case management are presented.

Humans↗