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The Public Psychiatry Training Program offers an education in the unique knowledge, attitudes, and skills essential for working with persons with severe and chronic illness in both hospital and community settings.
Although the risk factors for acquiring infection by extended-spectrum beta-lactamase (ESBL)-producing bacteria have been investigated in hospitalized patients, such risk factors have not been defined in the community setting. In this study, clinical data from a total of 311 nonhospitalized patients with community-acquired urinary tract infection (128 with ESBL-positive strains and 183 with ESBL-negative strains) were obtained. According to a multivariate analysis, the following were identified as independent risk factors: previous hospitalization in the past 3 months (OR=8.95, 95%CI, 3.77-21.25), antibiotic treatment in the past 3 months (OR=3.23, 95%CI, 1.76-5.91), age over 60 years (OR=2.65, 95%CI, 1.45-4.83), diabetes (OR=2.57, 95%CI, 1.20-5.51), male gender (OR=2.47, 95%CI, 1.22-5.01), Klebsiella pneumoniae infection (OR=2.31, 95%CI, 1.17-4.54), previous use of third-generation cephalosporins (P=0.014, OR=15.8, 95%CI, 1.7-143), previous use of second-generation cephalosporins (P<0.0001, OR=10.1, 95%CI, 4.2-24), previous use of quinolones (P=0.001, OR=4.1, 95%CI, 1.8-9.0), and previous use of penicillin (P=0.003, OR=4.0, 95%CI, 1.6-9.0).
We report the conduct and results of a review of recent literature to describe various types of epidemics and outbreaks in Italy or countries with similar epidemiological profiles and to assess vaccine use in outbreak situations. We identified three scenarios most likely to occur in Italy: outbreaks occurring in small closed communities (nursery or a primary school), outbreaks in communities of limited dimensions (small towns or villages) and open community settings in which epidemics occur at regular intervals (person-to-person transmission). In closed communities we recommend vaccination of family members and school personnel living or working in close proximity to the index case as well as classmates. We also recommend vaccination when there is a proof of secondary transmission within the community. In small open communities we recommend vaccination of more susceptible age groups such as children and adolescents. For large open communities the only practicable alternative strategy is vaccination of close family contacts of acute cases couple with non-immunity boosting control measures.
The University of Pennsylvania's Family Practice Residency includes a significant community medicine component in order to accomplish the goals of addressing the health-related needs of the university's neighbors; exposing residents to the knowledge, skills and attitudes necessary to address the health needs of a community; and encouraging health careers with a community focus. It is my belief that these goals further the agenda of the National Institute of Medicine and Healthy People 2000 and 2010. Longitudinal and block community medicine experiences were established to accomplish these goals. This article describes and discusses three measurable outcomes of this curriculum: (1) individual resident projects, (2) resident class projects and (3) significant career foci in community medicine among resident graduates. I believe that our community medicine program exemplifies medical training in a community setting and furthers the national health agenda.
AIMS: To indicate how the system of pharmaceutical regulation of the sale and use of opium in Great Britain continued throughout the first half of the 20th century. DESIGN: An oral history investigation of community pharmacy in Great Britain (n = 50), together with an analysis of standard pharmaceutical texts. SETTING: Community pharmacies in Great Britain during the 20th century. PARTICIPANTS: Retired community pharmacists with experience of the sale and use of opium during the period. MEASUREMENTS: Oral testimony of retired community pharmacists about the use and sale of opium, and quantitative analysis of numbers of official preparations of opium available during the period. FINDINGS: The popular use of opium continued well after the First World War, and its use as an ingredient of prescribed medicines continued well beyond the introduction of the National Health Service in 1948. CONCLUSIONS: Although the role of pharmacy in the regulation of opiates and other drugs was displaced by medicine following the passage of dangerous drugs legislation in the 1920s, pharmacists continued to play an important part in this regulation, exercising considerable discretion in the process.
OBJECTIVES: To determine which outcome measures are best and least suited for assessing long-term functional outcome of individuals with traumatic brain injury (TBI) in the community. DESIGN: Survey of participants in the community an average of 5 years after TBI. A battery of outcome measures was given. SETTING: Community in northern California after inpatient rehabilitation. PARTICIPANTS: Forty-eight adult individuals with prior moderate to severe TBI. All subjects had received inpatient rehabilitation 2 to 9 years previously and could be reached for telephone interview. MAIN OUTCOME MEASURES: The Community Integration Questionnaire, Neurobehavioral Functioning Inventory (NFI), Patient Competency Rating Scale (PCRS), Level of Cognitive Functioning Scale (LCFS), FIM instrument, Functional Assessment Measure (FIM+FAM), Supervision Rating Scale (SRS), Disability Rating Scale (DRS), Revised Craig Handicap Assessment and Reporting Technique (R-CHART), and Glasgow Outcome Scale (GOS). The number of maximal scores on each of the surveys was studied to determine which instruments continued to reveal deficits years after TBI. RESULTS: Most individuals obtained maximum scores, ie, functional independence, on these scales: LCFS, FIM motor subscale and total score, R-CHART physical independence subscale, FIM+FAM, GOS, and the SRS. Measures with the fewest maximum scores (<36%, measuring deficits still extant in the group) were the R-CHART cognition subscale and the NFI memory/attention and communication subscales, and employment subscales. Items, subscales, and total scores that showed good variability and correlated most highly and frequently with other scales also demonstrating good variability were the PCRS, the DRS and FIM+FAM employment items, the R-CHART cognition subscale, and the NFI motor, memory/attention, communication, and depression subscales (the R-CHART cognition subscale and NFI memory/attention subscale were highly correlated with the PCRS;.84,.83). CONCLUSIONS: Measures that appeared to contribute little to assessing functional status of a TBI sample years postinjury were the FIM, FIM+FAM, SRS, GOS, and LCFS. Measures that showed a range of deficits across participants were DRS employability, the NFI, PCRS, and the R-CHART cognition subscale.
This article describes Nurses Improving Care for Healthsystem Elders (NICHE), a project begun in 1992 with four pilot hospitals. These pilot hospitals gathered baseline data using a geriatric institutional assessment profile (GIAP) with a pre- and postdesign to capture changes in staff attitudes, knowledge, and perceptions of the care of older adults. Based on the success of the pilot effort, NICHE, now in its eighth year, has evolved into a program that involves 32 health systems comprising 105 hospitals nationally. To date, more than 10,000 GIAPs have been collected by NICHE hospital staff. All NICHE settings are able to benchmark their GIAP data against comparable institutions (eg, urban, rural, university, community settings) to understand how they compare and then interpret the data at their unique sites. The opportunities for continuous quality improvement through the NICHE program are described.
OBJECTIVE: To examine the current status of bloodstream infections (BSIs) in a community hospital as part of a 25-year longitudinal study. DESIGN: Retrospective descriptive epidemiologic study. SETTING: Community teaching hospital. PATIENTS: All inpatients in 1998 with a positive blood culture who met the CDC NNIS System case definition of BSI. METHODS: Cases were stratified by underlying illness category using case mix adjustment categories (after McCabe) and reviewed for associations among mortality, underlying illness severity, and multiple clinical and laboratory parameters. RESULTS: Of 19,289 patients discharged in 1998, 185 had an episode of infection documented by blood culture (96 cases per 10,000 inpatients). BSI was twice as frequent in patients 65 years and older compared with younger patients. BSIs caused or contributed to the deaths of 22 patients for an overall case-fatality rate of 11.9% compared with 20.7% in 1982 (P = .02). Striking decreases were noted for in-hospital patient mortality in 1998 for BSIs with ultimately and rapidly fatal underlying illnesses (P = .02 and P < .10, respectively). Primary bacteremia decreased compared with 1982. Antibiotic use was vigorous, but resistance was modest in both nosocomial and community-acquired organisms and had changed little from 1982 and 1987. CONCLUSIONS: Compared with previous studies, case-fatality rates in patients with BSI were substantially lower in rapidly fatal and ultimately fatal underlying illness categories. Antibiotic use was extensive but prompt and appropriate. Microorganism resistance to antibiotics changed little from the 1980s.
PURPOSE: Although vasectomy reversal surgery is a common procedure for male factor infertility, little is written on the common practice patterns of the practicing urologist. We designed a questionnaire to assess the practice patterns of community and academic urologists with respect to surgical technique, followup care, patient selection and the definition of success. MATERIALS AND METHODS: A 20-question survey pertaining to vasectomy reversal surgery was mailed to members of the Western Section, American Urological Association and to members of the Society of Government Service Urologists. Survey results were tabulated in a computer data base and statistical analysis was performed. RESULTS: A total of 1,508 questionnaires were mailed and 622 completed questionnaires were returned. Of the respondents 367 (59%) indicated that they perform vasectomy reversals, including 29 (8%) who were fellowship trained in infertility, 86 (23%) who were affiliated with residency training and 252 (69%) who practiced in a community setting. As expected, on average fellowship trained urologists performed more reversals yearly than academic or community urologists (26.4, 12.2 and 7, respectively). Patient selection criteria varied. Of fellowship trained urologists 12.5% would elect not to operate if it were greater than 15 years since vasectomy compared with 41.9% for academic and 57.1% of community urologists. Just more than half (50.2%) of respondents indicated they did not recommend routine gynecologic evaluation of the patient partner. When comparing fellowship, academic and community practitioners, an operating microscope was used in 93%, 65% and 56% of procedures (p <0.001), and vasal fluid was examined in 83%, 75% and 67%, respectively. Fellowship trained urologists also used finer suture material (p <0.001). An average of 8 anastomotic sutures were placed in 2 layers but significant differences existed between fellowship trained urologists, and their academic and community counterparts. Most urologists (71%) defined their success by the presence of sperm in the ejaculate. Only 10.9% of urologists recommended sperm cryopreservation at surgery and 90% recommended postoperative sexual abstinence (average 3 weeks). All urologists recommended postoperative semen analysis done at an average of 3 months. CONCLUSIONS: The practice of vasectomy reversal varies among urologists. Differences in surgical technique, postoperative care and selection criteria exist. Knowledge of these variations may assist practicing urologists to tailor their practice patterns in the selection for and performance of vasectomy reversal.
Mental health care philosophy has moved from the containment of patients within institutions to the integration of clients within the community. 'Caring for People' (a Department of Health report) and the subsequent legislation enshrined the philosophical shift in law. Previous policy reports had indicated that staff required training to move from hospital-based service to a community-based service, but did not propose content, and no systematic study of the needs of mental health staff has been carried out. Therefore, this study aimed to identify the skill and information needs of a group of multidisciplinary staff in preparation for the movement from hospital to community settings. The study design was a descriptive survey sampling of a total multidisciplinary population in Scotland. Data were collected using questionnaires and semistructured interviews with a small volunteer subsample of respondents. This paper presents the first set of study findings related to the demographic and educational issues. Differences between hospital and community staff and between health care assistants and qualified staff are demonstrated for demographic and educational factors. Proposals are made for managers, professionals, educators and researchers.
OBJECTIVE: To assess whether low serum cholesterol concentration increases mortality from any cause. DESIGN: Systematic review of published data on mortality from causes other than ischaemic heart disease derived from the 10 largest cohort studies, two international studies, and 28 randomised trials, supplemented by unpublished data on causes of death obtained when necessary. MAIN OUTCOME MEASURES: Excess cause specific mortality associated with low or lowered serum cholesterol concentration. RESULTS: The only cause of death attributable to low serum cholesterol concentration was haemorrhagic stroke. The excess risk was associated only with concentrations below about 5 mmol/l (relative risk 1.9, 95% confidence interval 1.4 to 2.5), affecting about 6% of people in Western populations. For noncirculatory causes of death there was a pronounced difference between cohort studies of employed men, likely to be healthy at recruitment, and cohort studies of subjects in community settings, necessarily including some with existing disease. The employed cohorts showed no excess mortality. The community cohorts showed associations between low cholesterol concentration and lung cancer, haemopoietic cancers, suicide, chronic bronchitis, and chronic liver and bowel disease; these were most satisfactorily explained by early disease or by factors that cause the disease lowering serum cholesterol concentration (depression causes suicide and lowers cholesterol concentration, for example). In the randomised trials nine deaths (from a total of 687 deaths not due to ischaemic heart disease in treated subjects) were attributed to known adverse effects of the specific treatments, but otherwise there was no evidence of an increased mortality from any cause arising from reduction in cholesterol concentration. CONCLUSIONS: There is no evidence that low or reduced serum cholesterol concentration increases mortality from any cause other than haemorrhagic stroke. This risk affects only those people with a very low concentration and even in these will be outweighed by the benefits from the low risk of ischaemic heart disease.
OBJECTIVES: To explore the use of rapid appraisal in defining the health and social needs of a community and to formulate joint action plans between the residents and service providers. DESIGN: Collection of data by an extended primary care team from three sources: existing documents about the neighbourhood, interviews with a range of informants, and direct observations to build a profile of the community. SETTING: Council estate of 670 homes in Edinburgh. MAIN OUTCOME MEASURES: Perceived problems of the community and suggestions for change. RESULTS: The interviews and focus groups identified six priorities for change, many of which were not health related. These changes have been or are being implemented. CONCLUSIONS: An expanded primary care team can use rapid appraisal as a first step in identifying and meeting local health needs. It facilitates a multidisciplinary approach and complements quantitative methods of assessing need.
Despite criticism from many quarters, the state hospitals continue to perform important roles in patient care, evidenced by increasing admissions in recent years. The hospitals serve as back-up facilities for patients who cannot be treated in community settings, and, because of their size, they are able to offer specialized services that community-based programs cannot provide. In addition, smaller patient populations and stricter rules about adequacy of staff and treatment programs have opened up new opportunities for hospitals to move into other important areas involving affiliation with academic centers, such as professional training and clinical research. Because of the state hospital's central role in a growing number of legal and public policy issues, professionals in such facilities must become active participants in the decision-making processes that shape mental health policy and determine the quality of patient care.
In its much-publicized report (2000) the National Audit Office (NAO) has emphasized the important part surveillance plays in determining infection rates and infection control in general. Community nurses may be forgiven for pointing out that this report concentrates on hospitals, however it strongly recommends that surveillance be extended out into the community. This is a sensible move as studies quoted in the NAO report indicate that 50-70% of surgical wound infection occur during the post-discharge period. The boundaries between acute and primary care are becoming ever more blurred; increasing numbers of susceptible patients are being managed in the community and the number of invasive procedures carried out is rising in line with government policy. Action to control infection extends beyond the narrow boundaries of health care to involve the whole population, and although the idea of extending the surveillance of healthcare related infection from hospital to community settings appears to be relatively new, the surveillance of infectious diseases that occur in the community is not. It is, in effect, a key proactive infection control activity which facilitates targeted and effective infection control measures. This article aims to define and explain surveillance as it relates to infection control and communicable disease control in the community by using examples from history, the current Meningitis C vaccination programme and the surveillance of hospital-acquired infection in the USA.
As children and adults with developmental disabilities and special health care needs are integrated into home, school, and community life, nurses are being required to provide leadership, advocacy, and training in community settings to a much greater extent than in the past. To assess the school and community need for formal graduate preparation for nurses who work with individuals with developmental disabilities and/or special health care needs, 25 nurses in leadership positions representing urban and rural health agencies throughout Minnesota took part in a 5-hour focus group discussion. Analysis of data summarized from this process shows five features of the recommended curriculum necessary for advanced practitioners in this specialty area: (a) discipline-specific core competencies, (b) discipline-specific specialty competencies, (c) genetic competencies not specific to nursing but necessary to function in nursing roles, (d) interdisciplinary and intradisciplinary learning experiences, and (e) clinical experiences with preceptors. The authors recommend the development of interdisciplinary graduate programs designed to prepare nurses to assume leadership roles in school health, public health, home health care, and systems management that will affect public policy and, ultimately, promote change in the systems charged with responsibility to serve this population.
These data provide a preliminary sense of demand for services among older people. They were collected in somewhat limited geographic areas by sponsors who are known in the community. Therefore, responses may reflect perceptions of specific sponsors, the degree to which services are available in various communities, and the level of familiarity with services. However, the data give a strong indication that long-term care services are viewed as complementary, and respondents understand the need for multiple services in assisting older people. The groups or factors were remarkably similar across the six sites, as were the rankings of services according to the percentage of people who rated each one or two on a five-point scale of importance. However, there was a great deal of variation in the percentage of respondents rating the services one or two by site. These results suggest that interest in services as packages is very consistent but that the degree of interest in services may vary from one market to another. Again, this may be the result of perceptions of the sponsor, the degree of availability of services in different markets or idiosyncrasies of different populations. Services are what will allow older people to remain in their homes and to maintain a maximum degree of independence. Whether people opt for a retirement community setting for the camaraderie, security and convenience it offers, or to remain in the broader community, coordination and integration are clearly necessary to appropriate, efficient and effective use and delivery of services. It is becoming clear that older people recognize this fact and will increasingly seek integrated service packages.(ABSTRACT TRUNCATED AT 250 WORDS)
OBJECTIVE: To describe the dental caries and treatment experience of groups of adults from minority ethnic communities living in the South Thames Region of England. DESIGN: Cross-sectional clinical study. SETTINGS: Community, religious and educational centres for adults from minority ethnic communities. PARTICIPANTS: Snowball sample of 928 adults from 44 ethnic groups including: Black Caribbean (141), Black African (134); Pakistani (123); Indian (190); Bangladeshi (78); Chinese/Vietnamese (143) and 119 from other groups. RESULTS: More participants were dentate or had 18 or more sound and untreated teeth than adults living in the same area (Todd and Lader, 1991). Duration of residence in the United Kingdom predicted caries or treatment experience in the sample as a whole and in Chinese/Vietnamese people. Increased DMFT was predicted by age and by history of visiting a UK dentist in the sample as a whole and in the Black African group. CONCLUSIONS: Effect of duration of UK residence on presence and extent of caries suggests that oral health may be better among adults from these ethnic minority groups than among the general population. However, the differences can also be attributed to sampling bias and old comparison data. Better sampling strategies are required for research of this type.
Falls in the elderly are common and a frequent source of injury. Chronic fall risk factors were evaluated in aging individuals with type 2 diabetes from two different settings--an urban day care center (age range: 57 to 83 years) and a rural community center (age range: 62 to 97 years). Six fall-related risk factors were studied: client history/subjective assessment of fall history, daily medication intake, number of medical diagnoses, balance (Tinetti Balance and Gait Tool), lower extremity protective sensation (Semmes-Weinstein monofilament testing), and relaxed gait velocity (timed functional walk test). Both groups demonstrated a high risk for chronic falling with a mean of 4.8 and 4.0 risk factors present in individuals from the urban day care center and the rural community center, respectively. No differences between clients in the two centers with respect to number of medications and comorbidities were found. In both groups, > 50% of individuals reported a history of falling. Loss of protective sensation was detected in 100% of the individuals from the urban day care center compared to 67% in the rural community center. Similarly, 40% of the individuals from the urban day care center demonstrated impaired balance as compared to 29% from the rural community center. A similar ratio of impaired balance to loss of lower extremity protective sensation was demonstrated across the two groups. These data indicate a potential relationship between loss of protective sensation and impaired balance. These findings also indicate that individuals in urban and rural community settings share similar risk factors for chronic falling.