Culturally responsive care for Hmong patients. Collaboration is a key treatment component

Since the end of the Vietnam War, tens of thousands of Hmong refugees have resettled in the United States. This ever-increasing population presents specific challenges to the US healthcare system as Hmong seek to preserve their cultural identity while acclimating to American society. Primary care physicians can enhance their interactions with these patients by seeking to understand various elements of Hmong culture, particularly its approach to medicine and healing. By extension, such knowledge and skills will aid physicians in all encounters with patients who belong to minority cultural groups.     

Effects of a program to strengthen general practice care on hospitalisation rates: a comparative observational study

Objective: To determine the effect of a large-scale program to strengthen general practice on hospitalisation rates.

Methods: This observational study compared enrolled patients in the program and a sample of non-participating patients from non-participating GPs in the same geographic area in Germany. Key components of the program are: prompt access to care, comprehensiveness, continuity, empanelment, data-driven quality improvement, computerized decision support, and additional reimbursement of general practices. The outcomes in this study were hospitalisation, rehospitalisation, and avoidable hospital admission up to four years after patient inclusion. Poisson regression models and generalized estimating equations were used to estimate intervention effects.

Results: In the baseline year, 19.1% were hospitalised and 13.6% had a potentially avoidable hospitalisation, 14.5% were rehospitalised within 4 weeks. Across the four observed years, yearly hospitalisations were 9.8 to 14.9% lower in enrolled patients, yearly re-hospitalisations were 5.3 to 11.5% lower, and yearly avoidable hospitalisations were 6.8 to 8.6% lower compared to the control cohort (all differences were statistically significant). The trend in the between-group difference for hospitalisations and re-hospitalisations increased, while it remained stable for avoidable hospitalisations.

Conclusion: This study provides strong indications for the positive impact of strong general practice care on population outcomes.

• Key points

• A program to strengthen general practice in Germany comprised of prompt access to care, comprehensiveness, continuity, empanelment, data-driven quality improvement, computerized decision support, and additional reimbursement of general practices.

• Patients who remained in the program during 4 years had increasingly lowered rates of hospitalisation and rehospitalisation compared to a control group of patients.

• Avoidable hospitalisations were also lower, but no trend of further lowering was found. This might suggest a ceiling effect to impact of strong general practice on hospitalisations.

     

Changes in dental plaque following hospitalisation in a critical care unit: an observational study

Introduction

Previous research has suggested that deterioration in oral health can occur following hospitalisation. The impact of such deterioration could increase the risk of oral disease, reduce quality of life and increase the potential for healthcare-associated infections (HCAI) such as healthcare-associated pneumonia (HAP). However, the strength of the evidence is limited by, amongst other factors, the few observational studies published that assess oral health longitudinally. In view of the microbiological component of oral diseases and HCAIs, the objective of this study was to investigate the microbiological changes in dental plaque following hospitalisation in a Critical Care Unit (CCU): (1) total number of cultivable bacteria and (2) presence and changes in specific HAP pathogens.

Methods

We conducted a prospective, longitudinal observational study in the CCU of University College Hospital, London. Study participants were recruited within 24 hours of admission. Dental plaque samples were collected from up to six sites per patient. The primary outcome was microbiological change from baseline to seven days with additional analysis for participants still present at day 14.

Results

50 patients were recruited with 36 available for review at one week, with early discharge accounting for much of the loss to follow-up. The median total viable count of the plaque microbiota at baseline was 4.40 × 10⁵ cfu/ml and increased at week one to 3.44 × 10⁶ cfu/ml. The total viable microbe counts increased by a median of 2.26 × 10⁶ cfu/ml from baseline to week one (95% CI: 3.19 × 10⁶, 1.24 × 10⁷) and this was statistically significant (P < 0.01). Specific HAP bacteria were detected in 26% of participants sampled, although accounted for a relatively low proportion of the total viable bacteria.

Conclusion

Total bacterial count of dental plaque increases during hospitalisation in CCU. This finding, together with the colonisation of dental plaque by HAP bacteria strengthens the evidence for a deterioration in oral health in CCU and a risk factor for negative health and quality of life outcomes.     

Occupational therapy practice in oncology care: Results from a survey

The everyday landscape of occupational therapy (OT) in oncology is underexplored, hindering targeted improvements. The purpose of the present study was to identify the OT interventions commonly provided and reimbursed in oncology. A survey utilizing snowball sampling was disseminated online to OT working in oncology care; 167 surveys were received from 21 states in the United States. Results found that over 90% of therapists reported focusing on physical impairment, weakness, fatigue, and activities of daily living. Interventions for emotional/social support, self‐advocacy, quality of life, lifestyle management, and cognitive impairment were not directly billed. More than 90% of therapists reported that, in the absence of barriers, they would address quality of life, emotional difficulties, lifestyle management, and home safety. Overall, the findings suggested that OT in the United States primarily provide physical interventions for oncology patients. However, they also provide psychosocial services and client/caregiver education, but often do not bill directly for this care. Reimbursement structures should be modified to allow for the direct billing of mental/psychosocial and educational interventions in OT for cancer care.     

Oral anticoagulant treatment in a medical care district - A descriptive study

Objective - To describe how oral anticoagulant therapy is performed in a defined catchment area in order to improve the quality of care.

Design - Two study periods of 8 weeks were compared with reference to monitoring sites, i.e. hospital departments and primary health care centres.

Setting - the health care district of Umeå in northern Sweden, with 125 300 inhabitants.

Participants - Patients on oral anticoagulant therapy at the department of Internal Medicine, Umeå University Hospital, in 1987 (n=243) were compared with all patients treated in 1990 at health centres (n=175) and at the department of Internal Medicine (n=290) in the Umeä district.

Main outcome measures - the prevalence of treatment failures and complications was calculated per patient year, as well as the relative frequencies of patients within treatment recommendations.

Results - 80-83% of the patients were within treatment recommendations. Treatment failures were 3.6% of hospital patients, and 2.6% of primary care patients. Corresponding figures for bleeding complications were 8.9% and 5.1%, respectively. the differences are partly explained by differences in the studied groups, e.g. age, indications for treatment, and concomitant diseases.     

Incidence of poststreptococcal glomerulonephritis in northwestern Ontario: Cross-sectional study at a tertiary care centre

ObjectiveTo measure the incidence of poststreptococcal glomerulonephritis (PSGN) and resulting complications in northwestern Ontario, including among Indigenous and rural populations.DesignCross-sectional study.SettingAs the only tertiary care hospital in northwestern Ontario, Thunder Bay Regional Health Sciences Centre (TBRHSC) functions as the primary referral centre for most of the region. The catchment population has substantial Indigenous (21.5%) and rural (34.2%) populations.ParticipantsAll cases of PSGN managed at TBRHSC over an 8-year period from January 1, 2010, to December 31, 2017.Main outcome measuresCases were classified as confirmed, probable, or possible based on the type of evidence available. Patients’ rurality and Indigenous status were recorded. Incidence rates and incidence rate ratios of all, pediatric (<18 years), and adult PSGN cases were calculated, as were incidence rates and incidence rate ratios of those requiring dialysis. Linear interpolation and extrapolation were used to estimate the population in non-census years.ResultsOver the 8-year study period, 33 cases of PSGN were observed with annual incidence rates of 0.0 to 4.8 per 100,000 person-years and a mean annual incidence rate of 1.8 (95% CI 1.2 to 2.5) per 100,000 person-years. Of these 33 cases, 28 were confirmed with renal biopsy or clinical and laboratory data. Indigenous patients accounted for 61% (n=17) of confirmed cases and were 6.0 (95% CI 2.8 to 13, P<.001) times as likely to have PSGN and 9.6 (95% CI 3.0 to 31, P<.001) times as likely to require dialysis compared with non-Indigenous patients. Patients living in rural areas accounted for 71% (n=20) of confirmed cases and were 3.2 (95% CI 1.4 to 7.3, P=.006) times as likely to have PSGN and 3.9 (95% CI 1.0 to 10, P=.02) times as likely to require dialysis compared with patients in urban areas.ConclusionThe main burden of PSGN in northwestern Ontario occurs among Indigenous and rural populations. Additional research is required to investigate the true overall burden of PSGN in the region. In collaboration with regional Indigenous groups, advocacy is needed for PSGN to be made reportable and public health action must be taken to address these pronounced disparities.     

Differences in nursing practice environment among US acute care unit types: A descriptive study

BackgroundThe hospital nursing practice environment has been found to be crucial for better nurse and patient outcomes. Yet little is known about the professional nursing practice environment at the unit level where nurses provide 24-hour bedside care to patients.ObjectivesTo examine differences in nursing practice environments among 11 unit types (critical care, step-down, medical, surgical, combined medical–surgical, obstetric, neonatal, pediatric, psychiatric, perioperative, and emergency) and by Magnet status overall, as well as four specific aspects of the practice environment.DesignCross-sectional study.Settings5322 nursing units in 519 US acute care hospitals.MethodsThe nursing practice environment was measured by the Practice Environment Scale of the Nursing Work Index. The Practice Environment Scale of the Nursing Work Index mean composite and four subscale scores were computed at the unit level. Two statistical approaches (one-way analysis of covariance and multivariate analysis of covariance analysis) were employed with a Tukey-Kramer post hoc test.ResultsIn general, the nursing practice environment was favorable in all unit types. There were significant differences in the nursing practice environment among the 11 unit types and by Magnet status. Pediatric units had the most favorable practice environment and medical–surgical units had the least favorable. A consistent finding across all unit types except neonatal units was that the staffing and resource adequacy subscale scored the lowest compared with all other Practice Environment Scale of the Nursing Work Index subscales (nursing foundations for quality of care, nurse manager ability, leadership, and support, and nurse–physician relations). Unit nursing practice environments were more favorable in Magnet than non-Magnet hospitals.ConclusionsFindings indicate that there are significant variations in unit nursing practice environments among 11 unit types and by hospital Magnet status. Both hospital-level and unit-specific strategies should be considered to achieve an excellent nursing practice environment in all hospital units.     

Noise levels in a general intensive care unit: a descriptive study

The aim of this small-scale study was to measure, analyse and compare levels of acoustic noise, in a nine-bedded general intensive care unit (ICU). Measurements were undertaken using the Norsonic 116 sound level meter recording noise levels in the internationally agreed 'A' weighted scale. Noise level data were obtained and recorded at 5 min over 3 consecutive days. Results of noise level analysis indicated that mean noise levels within this clinical area was 56.42 dB(A), with acute spikes reaching 80 dB(A). The quietest noise level attained was that of 50 dB(A) during sporadic intervals throughout the 24-h period. Parametric testing using analysis of variance found a positive relationship (p or= 0.05). While the results of this study may seem self-evident in many respects, what it has highlighted is that the problem of excessive noise exposure within the ICU continues to go unabated. More concerning is that the prolonged effects of excessive noise exposure on patients and staff alike can have deleterious effect on the health and well-being of these individuals.     

Nursing care in labour and patient satisfaction: a descriptive study

This study examined the subjective needs of labouring patients. A convenience sample of 80 postpartum patients was interviewed. They described the nursing care they had received, indicated the most helpful nursing measure received, and rated their satisfaction with their nursing care. These answers were categorized into types of nursing care. These were supportive care nursing, physical care nursing, medications and combinations of these three. X2 calculations done between these categories and satisfaction scores indicated a significant relationship between the type of care a patient received and her satisfaction scores. Patients found combined care very satisfying, but supportive care was the decisive factor in the way patients viewed their nursing care. The most frequently mentioned element in supportive care was the ability of the nurse to be a sustaining presence. The nurse's ability to assess and to meet the patient's need or non-need for her presence was major factor in patient satisfaction with nursing care in this sample. The relationship between congruency (agreement between time wanted and time spent by the nurse at the bedside) and satisfaction scores was highly significant. Thus the ability to recognize and respond to the patient's need or non-need for her presence was a crucial factor in patient satisfaction and in the way in which a nurse allocated her time. The relationships between numbers of nurses caring for a patient, parity, length of labour, presence of visitors, worries about the baby and patient satisfaction scores were examined. All were non-significant. However numbers of nurses caring for a patient was defined as a contributing factor to the delivery of supportive care nursing. More nurses contributed to more supportive care nursing being given, but was not the major factor in the delivery of supportive care nursing. Finally it was shown that the administration of syntocinon to patients in this sample decreased patient satisfaction with nursing care. Implications and possible reasons for these results are discussed.     

Palliative care consultation in The Netherlands: a nationwide evaluation study

Palliative care in The Netherlands is mainly provided by generalist professionals who are part of the regular health care system. In order to provide good quality palliative care, they need options for training and consultation. Therefore, Palliative Care Consultation (PCC) teams were established, which inform, support, and advise professional caregivers involved with patients in palliative care without taking over responsibility. This study is the first nationwide study on PCC teams. Investigated was the nature and effect of consultations by registration and evaluation of consultations given by 19 PCC teams during a one-year period. Sixty-one percent of the requesting caregivers were primary care professionals and the problems discussed covered the entire field of palliative care, although physical problems played a dominant role. Although the patient was often not seen by the consultant, the consultant appeared to be able to identify more problems than initially discussed by the requesting professional. The types of problems discussed were hardly related to patient characteristics but more related to the discipline of the professional caregiver. According to the requesting professionals, consultation was helpful and contributed to improving the quality of palliative care.