Relationship between day care and health care providers

Effective control and prevention of infectious diseases in child day care depend on affirmative relationships between parents, day care providers, public health authorities, and primary health care providers (especially pediatricians). The role played by each of these groups varies in accordance with the specific infectious disease problems, legal requirements, and voluntary relationships that exist in a given locality, but each of these roles is important. Major barriers to productive working relationships between day care and health providers are inadequacy of communication channels, uncertainty in role definition, and overlap in function of different health providers. Public health authorities can play a major role in improving the relationship between day care and health providers, largely by disseminating information regarding disease-reporting laws and other legal requirements, prescribed measures for control and prevention of diseases, and resources that are available for these activities.     

A role for the infection control specialist in child day care?

Infection control services for child care are currently provided through the cooperative efforts of physicians, nurses, and other providers in the private health care sector; public health agencies; and academic-based infectious disease experts. However, the effectiveness of infection control practices is not uniform and varies considerably by locality. One approach to ameliorating these differences may be through the development of an "infection control specialist for child day care". Possible responsibilities for and uses of the infection control specialist in child day care include disease surveillance, outbreak control activities, implementation of primary prevention measures, and facilitation of communication among parents and day care and health providers. There are potential impediments to the development of this role, such as conflicts of interest and difficulties in obtaining adequate funding.     

Potential health benefits of child day care attendance

Despite fears that child day care attendance enhances the transmission of infection among attending children, there are positive aspects of the day care experience that, from the standpoint of infectious diseases, directly and indirectly contribute to the child's well-being. Quality child day care first requires a preadmission physical examination and then requires that the child begin the series of prescribed immunizations, which might not have been received if care were provided at home by a care giver who was not knowledgeable of available mechanisms for the prevention of disease. Once enrolled, the child and parents can be exposed to health education, which benefits them in terms of overall good health for the entire family. The child day care environment, like every other place where children congregate, is subject to the transmission of infectious agents among child and staff. But the risk of infection can be minimized and the health benefits maximized, and child day care can make positive contributions toward the social and physical development of the child.     

Infectious diseases in day care: parallels between psychologically and physically healthy care

A review of day care practices in the United States indicates a substantial increase since 1977 in out-of-home care for infants and toddlers, with a preponderance of care in unlicensed family day care homes. The effects of group care on infants and toddlers depend largely on the facility's success at meeting certain criteria for group size, staff-to-child ratio, and staff training. Parallels exist between providing psychologically healthy day care and minimizing the spread of infectious disease in day care facilities. Many of the same factors involved in providing psychologically safe day care are also involved in providing disease-free care. Financial and regulatory obstacles to high-quality care are considerable; however, supplementary child care for working parents is essential, and efforts to address such problems as infectious diseases must keep this perspective.     

Altering the standard of care in disasters--unnecessary and dangerous

After September 11, 2001, the United States began examining approaches to the delivery of medical care during disasters when demand exceeds available resources. One seemingly popular option is the creation of "crisis" or "altered" care standards meant to reduce the legal standard or duty of care for medical responders. However, evidence supporting the need for reduced care standards is lacking. Concern for liability exists but it is not evidence based. The actual risk for litigation is minimal, according to experience with multiple disasters during the last 15 years. Even if a lower legal standard or duty of care were to be adopted, it is unlikely this would reduce the risk of liability because violation of this lower standard could still result in an allegation of malpractice. Creating algorithms to equitably and rationally allocate scarce resources is necessary and appropriate, but altering the legal standard of care will not contribute to this process. Rather than inhibiting the creation of these protocols, the current legal standard of care helps guarantee that disaster policies are created in an ethical and transparent manner. Adoption of a lower legal care standard would encourage implementation of less effective approaches and could undermine the impetus to constantly improve the care of disaster victims. Once lowering the legal standard of care becomes accepted practice, it becomes unclear what will prevent this process from moving downward indefinitely. The most rational approach buttressed by evidence to date supports maintaining the current legal standard of care defined by the actions of reasonably prudent physicians under the same or similar circumstances.     

Viral hepatitis as an occupational disease in Poland

Background

In medical terms, occupational diseases are defined as health disorders specifically associated with the working environment of people and their occupational activity. From the medical and legal perspectives, the vast majority of European countries consider particular diseases to be of occupational origin if they are mentioned in the current list of occupational diseases and caused by exposure to factors in the working environment that are harmful to health.

Objectives

The aim of this study was to analyze the occurrence of cases of viral hepatitis certified as an occupational disease in Poland during 1979-2009. This article presents the medical, economic, and legal aspects of the epidemiology of hepatitis as an occupational disease in Poland.

Materials and Methods

Publically available statistical data on certified occupational diseases in Poland and data contained in individual "occupational disease diagnosis cards" (based on data used in Poland statistical form), regarding certified cases of hepatitis among health care professionals, which were collected by the Department of Occupational Hygiene of the Polish Public Health Service, were analyzed in this study.

Results

In Poland, the highest number of cases of hepatitis certified as an occupational disease was observed in 1987. A gradual reduction in the number of cases of hepatitis as an occupational disease has been noted since then. Currently, hepatitis C as an occupational disease is certified more frequently than hepatitis B. In Poland, the number of women with hepatitis certified as an occupational disease is higher than that of men. However, among health care professionals, particularly nurses, this difference is insignificant because women outnumber the men. The existence of such a situation is due to the significant quantitative predominance of women over men among medical personnel, especially among nurses.

Conclusions

Immunization of health care professionals against the hepatitis B virus (HBV), introduced in Poland in 1988, was an important factor involved in reducing the number of cases of occupational viral hepatitis. Socioeconomic and financial factors affected the epidemiological data on cases of hepatitis certified as an occupational disease in Poland. An additional problem associated with the diagnosis of occupational diseases is the lack of obligatory testing for anti-hepatitis C virus (HCV) and anti-hepatitis B surface antigen (HBsAg) antibodies and examinations to ensure the efficacy of HBV vaccination among medical staff before and during employment.     

Legal consequences of standard setting for competitive athletes with cardiovascular abnormalities

This paper addresses the issue of whether establishing consensus standards for the treatment of particular medical conditions increases a physician's exposure to legal liability. The conclusion reached is that the legal effects of standard setting, rather than representing a significant threat of liability, should be seen as beneficial to the medical profession. A fundamental point is that the legal test for liability is entirely dependent on the medical profession's definition of what constitutes adequate care. The law incorporates the standard of care defined by the medical profession and does not impose an external norm. In the absence of formally stated standards, the process of defining relevant medical criteria will involve a great deal of uncertainty. Outcomes of legal contests will be affected by such extraneous factors as the relative experience of the lawyers involved, their access to knowledgeable expert witnesses, and their strategic decisions made with respect to tactics and procedures. Establishment of formal standards has the salutory effect of limiting the influence of these factors and thus reducing the randomness of the results reached. Formal standards also have the advantage of being easily replicated in unrelated proceedings and thereby contribute to the development of a consistent, evenly applied rule of liability. Finally, even if formal standards are either more, or less, progressive than the actual state of medical practice, there is relatively little risk that they will produce untoward results.     

Legal aspects of the team approach to diabetes treatment

Expansion of the team approach to diabetes care will most likely have significant ramifications in malpractice liability law as applied to diabetes educators, physicians, treatment teams, and supporting hospitals. This analysis focuses on the nature of the team approach to diabetes care, nationally promulgated standards for its practice, and predictions of the parameters of malpractice law. The establishment of a national certification procedure identifies specialists in diabetes education, allowing for the expanded roles of diabetes educators, and promotes a minimum standard of care to which practitioners may be held. Likewise, the criteria for recognition by the American Diabetes Association (ADA) serve as guidelines for diabetes education programs. Current legal decisions suggest that these standards may be applied nationally as measures of malpractice liability. Application of certification guidelines may minimize allegations of malpractice.     

Impact of child day care on infectious diseases in adults.

The authors review diseases that occur in day care centers and their impact on day care providers and parents. Acute infections of the gastrointestinal and respiratory tracts are the most commonly transmitted illnesses from children in day care centers to adults. The most important infections acquired by adults are those with the potential for significant clinical morbidity, such as hepatitis A, or those that generate concern, such as cytomegalovirus and parvovirus B19, because of their potential to produce congenital infections in pregnant women.     

Effects of the medical liability system in Australia, the UK, and the USA

Although the direct costs of the medical liability system account for a small fraction of total health spending, the system's indirect effects on cost and quality of care can be much more important. Here, we summarise findings of existing research on the effects of the medical liability systems of Australia, the UK, and the USA. We find systematic evidence of defensive medicine--medical practice based on fear of legal liability rather than on patients' best interests. We conclude with discussion of four avenues for reform of traditional tort compensation for medical injury and several suggestions for future research.     

If you want to cure their asthma, ask about their job.

Occupational asthma is the most common occupational respiratory disorder and accounts for 15% of cases of adult asthma. A recent systematic review of evidence and management has clarified patient care for General Practitioners (GPs) who are key professionals in early diagnosis. Exposure to respirable agents in the work environment by means of dust, water aerosol or gases, causes an allergic sensitisation process in the respiratory tract. Initial rhinitis and night cough may progress to patterns of work-related wheezing from two weeks to six months after starting employment. The absence of symptoms while on holiday or sick leave suggests the diagnosis. Serial peak flow recordings show characteristic patterns. Smoking and atopy have a variable influence on whether a worker will develop the disease with exposure. Early identification and removal from exposure is essential for the worker since it improves prognosis. Other workers will be at risk, and occupational hygienists are required to measure and improve the working environment by means of ventilation and extraction of toxic fumes. Workplaces with workers who are at risk of occupational asthma, such as paint sprayers, food processors, welders and animal handlers, require health surveillance programmes for new and existing employees, as well as reinforcement of the more important primary safety measures of environmental monitoring and respiratory protection. All clinicians responsible for asthma management need to be aware of the potential for occupational asthma in new cases of adult asthma or unexplained worsening of pre-existing asthma. Specialist help is required to confirm the diagnosis, which has substantial legal and economic implications for the worker and their employer.     

Cost-effective application of the Centers for Disease Control Guideline for Prevention of Surgical Wound Infections

Surgical wound infections present a serious hazard to patients and an important legal and economic liability to health care providers. This Guideline furnishes infection control practitioners with several excellent cost-saving concepts and, if implemented, would result in a reduction in the rates of surgical wound infections.     

Expert witness malfeasance: how should specialty societies respond?

There is little doubt that severe distortions are present in the legal adjudication of professional medical liability. The medical expert witness plays an important, often crucial, role in the medical liability cases. The expert assesses medical information, interprets and explains medical uncertainty, medical research, and customary practice for a nonscientific jury, and offers an expert level opinion as to whether the standard of medical care was met. When expert witnesses not merely disagree, but misrepresent data, misrepresent their background credentials and expertise, and offer egregiously false testimony, the legal process is violated and verdicts may be distorted. Many medical and surgical professional organizations, including the American Medical Association, have adopted programs that provide guidelines for members who serve as medical expert witnesses in professional liability cases. The American Association of Neurological Surgeons (AANS) was the first to develop a program to deal with irresponsible expert witness testimony. That program involves a published code of conduct, which outlines the expectations of society regarding expert witness testimony, and potential consequences for noncompliance. To date, the AANS program has withstood court challenge, in fact, has received judicial praise. Other medical societies, including the American College of Gastroenterology (ACG), have reviewed efforts by others and are considering developing their own programs.     

Erwachsene mit angeborenen Herzfehlern

By improvement of the medical care, children with congenital heart disease survive in much greater numbers: the figure of ACHD-patients in Germany is estimated up to 203,000 to 301,000. The need for a specialized care of these patients is accepted by the scientific societies, who introduced a certification for doctors and centers and created guidelines. The medical problems include imaging, treatment of arrhythmia, congestive heart failure and cyanosis, prophylaxis of infectious endocarditis, exercise and pregnancy. For the most frequent defects, indication for treatment and postoperative care is summarized.     

Transmission of Mycobacterium tuberculosis from an infant.

SETTING: This report investigates the unusual transmission of Mycobacterium tuberculosis from a 12-week-old infant with nosocomially acquired tuberculosis (TB). Compliance with recommendations on the post-exposure management of young children is described. DESIGN: Contacts of an infant case of TB were identified and recommended to undergo baseline and post-exposure tuberculin skin tests (TST) as per Canadian TB standards. TST conversion was measured at least 8 weeks post exposure. Children aged <6 years were recommended to initiate preventive treatment with isoniazid (INH) until their post-exposure TST. Information on TST results and adherence to therapy were analysed from existing medical records. RESULTS: Overall, 17 TST conversions were documented among 732 contacts: both parents, two health care workers (HCWs) who provided close care, and several patients, visitors and one staff member without obvious close contact. Of 65 eligible children, 46% completed post-exposure therapy as recommended. The most common reasons for treatment failure were concern about side effects, perception of low risk and lack of physician support. CONCLUSION: This investigation suggests that all children, including infants, with cough and numerous bacilli or extensive pulmonary disease should be considered infectious. Health care provider education is necessary to resolve the observed low compliance with current post-exposure management guidelines.     

1991～2006年新疆法定传染病疫情动态分析

目的 探讨新疆维吾尔自治区法定传染病的流行趋势.方法 用描述流行病学方法 分析1991～2006年新疆传染病疫情.结果 新疆维吾尔自治区16年间法定传染病总发病率是上升的.其中血源及性传播疾病、呼吸道传染病上升最明显.发病以肺结核、病毒性肝炎、痢疾为主.结论 应加强对各类传染病的防治,尤其在流动人口众多的地方,更要加强防治力度.     

Day care homes: the "silent majority" of child day care

Family day care--child day care provided in a private home other than the child's own--includes more children than any other mode of day care in the United States. Day care homes have traditionally cared for a large proportion of younger children, particularly infants and toddlers, who are most likely to contract and spread infectious diseases. The majority of homes are run on an informal basis and are neither licensed nor registered; a small minority of homes are regulated or operated under sponsorship of an umbrella agency. Homes generally have fewer children than do day care centers, and when children of different ages are cared for, they usually mix freely. Care givers in homes, especially in those that are not registered, are unlikely to have had child care-specific training. Parent fees in homes and centers appear roughly comparable, with fees in nonregulated homes generally lower than those in regulated or sponsored homes. It is difficult to compare the actual costs of child care in these settings. Results of the small number of studies comparing the occurrence of infectious diseases among children in day care centers, day care homes, and at home suggest that the rates of some infections may be lower in day care homes than in centers; this effect may vary by age and infections. Because of the large population of young ages of children involved in family day care, additional study and recommendations regarding infections in this setting are needed.     

Occurrence of infectious symptoms in children in day care homes

Transmission of enteric pathogens is facilitated in child day care centers, including family day care homes, by frequent and intimate exposure among susceptible hosts, with diaper changing as the highest-risk procedure for such transmission. The objective of this study was to evaluate the effectiveness of an intervention program in decreasing the incidence of infectious disease symptoms in children attending family day care homes during a 12-month period. Each of 24 family day care homes was randomly assigned to an intervention or control group. The intervention included four components: (1) a handwashing educational program and (2) use of vinyl gloves, (3) use of disposable diaper changing pads, and (4) use of an alcohol-based hand rinse by the day care provider. Symptoms of enteric disease (diarrhea and vomiting) were significantly reduced in intervention family day care homes (p less than or equal to 0.05), whereas respiratory symptoms were not significantly different between intervention and control family day care homes (p = 0.35). Diarrhea was reported in 1 of every 100 child care days, representing one diarrhea episode per month in a typical family day care home.     

Occupationally-induced progressive scleroderma and the heart

A 60-year-old man with progressive systemic sclerosis (PSS) had worked as underground miner in ore mining for 26 years with intensive exposure to crystalline silica. The PSS was acknowledged as an occupational disease. Parallel to the progress of the PSS there developed disturbances of the conduction system and cardiac rhythm with left heart failure. Despite treatment sudden death set in. A myocardial fibrosis was found histopathologically. This is a consequence of the PSS and therefore the occupational disease is the cause of death. Cardiac involvement means a poor prognosis and necessitates both evaluation of the damage in percent caused by the occupational disease and interdisciplinary teamwork in the dispensary care of patients.     

Malpractice reform must include steps to prevent medical injury

In the current malpractice insurance crisis, physicians have focused their advocacy and energy primarily on rapidly increasing liability premiums; problems in access to care; and demands for legal reform, especially caps on damages. An even more important focus, however, is prevention of injury and improvement of patient safety. Physicians largely control patient care and can play a critical role in systematically reducing injury. Reforms should go beyond liability issues; they should also harness and enhance physicians' ability to act. More visible efforts by physicians to reduce harm, better communication with patients and others, and true evidence of improved patient safety should reduce patient anger and litigiousness. Individually and collectively, physicians can and should ensure that "doing no harm" comes first in the malpractice debate.