Rural hospital health promotion: Programs,methods, resource limitations

Most hospitals provide health promotion programs for community residents. There is little information concerning the specific types of services offered by rural hospitals. A questionnaire was sent to every acute care hospital in Iowa (N=124), including 99 rural hospitals and 25 urban hospitals. Surveys were returned from 95 rural hospitals (96%) and 20 urban hospitals (80%). Results indicated that 98.9% of rural hospitals offered health promotion services to community residents. These services provided on average 7.5 programs on a regular basis, while using only 1.2 full-time equivalent (FTE) employees. Urban hospitals provided 9.5 regular programs with 2.4 FTE. The most common types of rural promotion programs were blood pressure screening, cholesterol screening, safety and protection programs, diet/nutrition programs, prenatal/maternal health, and breast cancer screening. Over 40% of rural respondents stated that other less common programs, including substance abuse prevention and mental health promotion, were needed but could not be offered because of resource limitations; these types of services were offered more commonly in urban hospitals. Rural hospital health promotion programs are attempting to meet a wide variety of programming needs with limited resources, and attention may be well directed towards finding how best to provide various programs with limited resources to maximize their impact on community health.Michael S. Hendryx is an Associate in the Graduate Program in Hospital and Health Administration and Center for Health Services Research, University of Iowa, Iowa City, Iowa.Supported by a grant from the Department of Iowa Ladies' Auxiliary, Veterans of Foreign Wars, through the University of Iowa Cancer Center. The author acknowledges the assistance of Richard DeGowin, M.D., for helpful comments during the course of this study.     

Changes in billing for nutrition support services and dietetics staff resources between 1984 and 1986

Changes in hospital funding resulting from the Prospective Payment System have been recognized as a major force in hospitals in the 1980s. The Dietitians in Nutrition Support (DNS) Practice Group examined these changes using a survey sent to 1,000 clinical nutrition managers at American Hospital Association (AHA) hospitals. The goals of the survey were (a) to evaluate changes in billing for nutrition services and (b) to evaluate changes in resources available to dietetics staff members. Although income from nutrition services to inpatients had increased only 18% since 1984, 45% of respondents reported an increase in payment for outpatient services. Prior to 1984, larger hospitals reported screening for malnutrition more often than smaller hospitals, and the responsibility for screening was handled more often by dietetic technicians than by RDs. Larger hospitals also reported establishment of a home nutrition support company more often than smaller hospitals. Computer and academic course costs were paid more frequently by nonprofit and tertiary hospitals. Although the number of hospitals billing for nutrition services to patients was small, most reported receiving payment. We conclude that charges for nutrition services by dietitians to outpatients have increased, and that most dietitians who bill for services receive payment. Academic and technological resources for RDs have increased in general, though smaller primary-care and for-profit hospitals report such supports less consistently than larger, tertiary-care, and not-for-profit hospitals.     

Intensive Care in Critical Access Hospitals

CONTEXT: Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. PURPOSE: To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community. METHODS: A semistructured interview of directors of nursing at CAHs that provide intensive care services. RESULTS: Two thirds of CAHs that provide intensive care do so in a distinct unit. Most have continuous or computerized electrocardiography and ventilators. Other ICU equipment common in larger hospitals was reported less frequently. Nurse:patient ratio ranged from 1:1 to 1:3, and some or all nursing staff have advanced cardiac life support certification. Most CAHs admit patients to the ICU daily or weekly, primarily treating cardiac, respiratory, gastrointestinal, endocrine, and drug- or alcohol-related conditions. ICUs are also used for postsurgical recovery. Respondents felt that closure of the ICU would be burdensome to patients and families, result in lost revenue, negatively impact staff, and affect the community's perception of the hospital. CONCLUSIONS: Intensive care services provided by CAHs fall along a continuum, ranging from care in a unit that resembles a scaled-down version of ICUs in larger hospitals to care in closely monitored medical-surgical beds. Nurse to patient ratio, not technology, is arguably the defining characteristic of intensive care in CAHs. Respondents believe these services to be important to the well-being of the hospital and of the community.     

Nutrition-related knowledge, beliefs and practices of Australian nursing staff

Objective: The purpose of the study was to examine the general food and nutrition‐related beliefs and knowledge of nursing professionals attending post‐partum women. Design: Data were collected by self‐administered questionnaire. Subjects: Three hundred and sixty‐two hospital‐based nursing staff responsible for the care of post‐parturient women. Setting: Eight metropolitan and regional hospitals in Queensland and three maternity hospitals in Canberra. Main outcome measures: Beliefs, opinions and intentions relating to food, nutrition and weight; knowledge of requirements of core foods; and sources of nutrition information. Statistical analysis: Standard statistical tests were used to measure frequencies and assess bivariate relationships. Results: Almost all participants (97.8%) were confident they could give good advice to their patients about a healthy balanced diet. The majority (65.5%) reported providing such advice at least weekly, 27.9% daily, and 19.5% rarely or never gave nutritional advice. The food‐related beliefs of most participants (>85%) were in line with current knowledge for 78% of questions. However, their knowledge of core food requirements for adults was inadequate; only 0.6% gave correct answers to all four food intake questions, 16.8% gave three correct answers, 62% two and 20.7% one correct answer. The most commonly cited sources of nutrition information were professional training (51.4%), reading (38.7%), media (14.9%), self‐education and work‐related experience (10.8%), dietitian (10.5%), school (7.5%), family (6.4%) and dieting (5.0%). Conclusion: Nursing staff frequently provide nutritional advice to post‐partum women. There is a need to ensure such information is accurate. Further research should explore ways in which this can be achieved.     

Structural and process indicators of nutritional care: a comparison between Austrian hospitals and nursing homes

ObjectiveThe aim of this study was to describe and compare structural and process indicators of nutritional care in Austrian hospitals and nursing homes.MethodsA multicenter, cross-sectional study was performed using a standardized and tested questionnaire. Data were collected on patient and institutional levels of hospitals and nursing homes.ResultsData from 18 Austrian hospitals (n = 2326 patients) and 18 Austrian nursing homes (n = 1487 residents) were collected. The prevalence of malnutrition was 23.2% in hospitals and 26.2% in nursing homes. All hospitals and 83.3% of the nursing homes employed dietitians. Guidelines for the prevention and treatment of malnutrition were used infrequently. Nutritional screening at admission was performed in 62.6% of the hospitalized patients and 93.4% of the nursing home residents. Nutritional screening tools were used in 28.9% of the nursing home residents and 14.5% of the hospitalized patients. Oral nutritional support was preferred to enteral and parenteral nutrition in the two settings. Dietitians were consulted in 27.5% of the malnourished hospitalized patients and 74.7% of the malnourished nursing home residents.ConclusionThe study demonstrated that nursing homes fulfilled more structural indicators and performed nutritional screening at admission more often than hospitals. Nevertheless, the prevalence of malnutrition was high in the two settings and a substantial number of malnourished patients/residents received no nutritional intervention at all. These results show the necessity for improvements in the nutritional care in Austria, for instance, through the routine use of nutritional screening tools followed by tailored nutritional interventions in patients/residents in need.     

Geriatric nutrition assessment: comparison of a screening tool to a dietitian assessment

A priority in nutrition care is early identification of patients at risk of developing nutrition disorders. Simple identification measures such as nutrition screening on admission must be demonstrated to be as effective as the more lengthy traditional nutrition assessment. This study compares a nutrition screen to a clinical assessment in a geriatric setting. Seventy-two consecutive admissions to a geriatric assessment unit were both screened and individually assessed by different staff dietitians. Results of the assessment and the screen corresponded in classifying those at nutrition risk 92% of the time and those not at nutrition risk 77% of the time. The screen was found to be highly sensitive (88%) and specific (83%). A geriatric nutrition screen that has a high degree of agreement with a lengthier assessment may be a useful tool for the clinical practitioner in early identification of patients at nutritional risk.     

Pre-admission screening of nursing home applicants: implications for home care.

An increasing number of states are developing programs to evaluate nursing home applicants prior to admission. The purpose of these Pre-Admission Screening (PAS) programs is to assure that nursing home placement is needed and appropriate. Both the number and scope of these programs have grown considerably in the last decade as states attempt to reduce inappropriate placements and control nursing home costs and utilization. The increase in PAS can have a significant impact on community services as clients are diverted from nursing homes to home care. This article uses the results of a recently completed national survey of state-administered PAS programs to indicate the impact of PAS on community care. PAs was defined as an on-site assessment of the need or appropriateness of nursing home care conducted by a disinterested third party prior to nursing home admission. State administrators of Medicaid and/or PAS in all states and the District of Columbia were contacted by phone to determine whether or not their state conducted PAS. States with PAS were sent a comprehensive mail survey, and 25 of these (81%) returned a survey. Data is presented regarding the scope of PAS programs, the types of clients participating in PAS, the variety of services coordinated or funded in conjunction with PAS, the types of recommendations made by screening teams (institutional vs. home care), and how respondents felt that PAS was impacting community services. The article concluded with a discussion of these results.     

Pre-Admission Screening of Nursing Home Applicants

An increasing number of states are developing programs to evaluate nursing home applicants prior to admission. The purpose of these Pre-Admission Screening (PAS) programs is to assure that nursing home placement is needed and appropriate. Both the number and scope of these programs have grown considerably in the last decade as states attempt to reduce inappropriate placements and control nursing home costs and utilization. The increase in PAS can have a significant impact on community services as clients are diverted from nursing homes to home care. This article uses the results of a recently completed national survey of state-administered PAS programs to indicate the impact of PAS on community care. PAS was defined as an on-site assessment of the need or appropriateness of nursing home care conducted by a disinterested third party prior to nursing home admission. State administrators of Medicaid and/or PAS in all states and the District of Columbia were contacted by phone to determine whether or not their state conducted PAS. States with PAS were sent a comprehensive mail survey, and 25 of these (81 %) returned a survey. Data is presented regarding the scope of PAS programs, the types of clients participating in PAS, the variety of services coordinated or funded in conjunction with PAS, the types of recommendations made by screening teams (institutional vs. home care), and how respondents felt that PAS was impacting community services. The article concludes with a discussion of these results.     

The evaluation of an undernutrition risk score to be used by nursing staff in a teaching hospital to identify surgical patients at risk of malnutrition on admission: a pilot study

Background The purpose of this study was to evaluate an undernutrition risk score (URS) developed by the Dietetic Department of an acute tertiary referral hospital in Dublin with the aim that the URS could be used by nursing staff, to identify surgical patients at risk of malnutrition on admission.
Methods Forty surgical patients (16 males and 24 females) were recruited, within 5 days of admission. A standard objective nutritional assessment was carried out on each patient. This consisted of a 3-day diet history, anthropometric indices including: weight, armspan, mid-upper arm circumference, mid-arm muscle circumference and hand grip dynamometry. A nutrition risk index (NRI) screening tool was also used by a single observer to categorize patients as having low, moderate or severe risk of malnutrition. The indices used for the NRI were serum albumin and percentage weight loss. The URS assessed patients with respect to changes in weight and appetite, gut function and disease status and was completed by nursing staff by interview for each of the patients recruited.
Results The URS was successful in detecting 71.4% ( n  = 10) of surgical patients who were classified as being at some risk (moderate/severe) for undernutrition by the NRI. However, 11.8% ( n  = 4) of the patients who were categorized by the NRI as being at moderate risk for undernutrition were classified as being at low risk by the nursing staff using the URS. The URS was found to be most sensitive in the detection of those at low or severe risk for undernutrition and least sensitive for those at moderate risk.
Conclusion The undernutrition risk score in this study provided an accurate and consequently useful screening tool that could be used for surgical patients who are capable of feeding themselves independently.     

An investigation of the disabled elderly in a geriatric health services facility in an urban area of Japan and attitudes of their family caregiver

We investigated characteristics of 72 clients in a geriatric health services facility (hereafter called GHSF), conditions of their family caregivers, and the factors associated with the caregivers choice of discharge destination. Most of the clients were elderly females with a low degree of independence, and dementia was observed in about 60% of them. The clients had children, but many of them lived alone before admission to the GHSF. The rate of admission from hospitals was high (54%), and that of discharge to hospitals was also high (50%). Sixty-seven percent of the clients stayed in for a period of over six months. Most of the family caregivers were daughters or daughters-in-law, and considered themselves to be healthy. Sixty-three percent of them had jobs, and most of the caregivers had no sub-caregiver to assist them. The family caregivers desired the client's home (19.4%), hospital or another GHSF (54.2%), or nursing home (26.4%) as the discharge destination from the GHSF. According to Hayashi's quantification theory type II, the factors related to the home as the discharge destination desired by client's family caregivers are as follows; caregivers used formal home public health nursing visit service before entering the GHSF, the job of the caregiver was a part-time job, the client did not show dementia, the period of care experience was shorter than one year.     

Perspectives from the Veterans Health Administration about opportunities and barriers in telemedicine

We used qualitative interviews to examine the perceptions of direct providers of telemedicine services, primary care providers (PCPs) and hospital administrators about opportunities and barriers to the implementation of telemedicine services in a network of Veterans Health Administration hospitals. A total of 37 interviews were conducted (response rate of 28%) with 17 direct telemedicine providers, nine PCPs and 11 administrators. The overall inter-coder reliability across all themes was high (Scott's pi = 0.94). Direct telemedicine providers generally agreed that telemedicine improved rapport with patients, and respondents in all three groups generally agreed that telemedicine improves access, productivity, and the quality and coordination of care. Respondents mentioned several benefits to home telemedicine, including the ability to better manage chronic diseases, provide frequent clinician contact, facilitate quick responses to patient needs and provide care in patient's homes. Most respondents anticipated future growth in telemedicine services. Barriers to telemedicine implementation included technical challenges, the need for more education and training for patients and staff, preferences for in-person care, the need for programme improvement and the need for additional staff time to provide telemedicine services.     

The impact of computerization of the nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines: report for the years 2000-2003

BACKGROUND & AIMS: To improve hospital health care delivery by identifying malnutrition in all admitted patients and following up those identified to be malnourished and "at risk of developing malnutrition" a hospital nutrition support program based on the JCAHO system was initiated in 1999. Two major problems were encountered: first, the inability to perform a nutrition surveillance process due to failure by the staff to implement existing nutrition screening tools and second, the lack of awareness and support from the medical staff in this initiative. Two solutions were implemented in 2000: computerization of the nutrition screening and nutrition support process and synchronizing this with the whole nutrition support program. METHODS: A computer program was developed which performs BMI-based nutrition screening, produces lists of all malnourished patients, and computes the different formulas for either nutritional requirement or parenteral and/or enteral formulation. It also generates patient status reports based on encoded data from the nutrition support team, which prioritized these patients for management based on the data output. RESULTS: From 2000 to 2003, improvement was seen in these areas: entry of height and weight in the patient record increased from 30% to 90%; nutrition surveillance shows nutritional status distribution to be: normal (58%), underweight (9%), overweight (25%), and obese (8%), referrals to the nutrition support team based on the screen notification increased from 37% to 100%, patient coverage by nutrition support services increased from 7374 (38.8%) in 2000 to 11,369 (83%) in 2003, and critical care patients seen increased from 10% in 2000 to 99% in 2003. More improvement is needed in physician response to nutrition support recommendations, which still remains low (11.2-24%). CONCLUSIONS: Computerization helps to improve nutrition support delivery in the hospital, but more cooperation and support from the medical staff is still needed for better results.     

The epidemiology of diabetic acidosis: a population-based study

A 12-month epidemiologic study in 1979 and 1980 of all diabetic acidosis admissions to all acute care hospitals in Rhode Island detected 152 episodes occurring in 137 persons. Eleven per cent of diabetic acidosis admissions presented in coma and the overall death-to-case ratio was 9%. Newly diagnosed diabetes accounted for 20% of these episodes, while persons having multiple episodes during the year accounted for 15% of the admissions. The annual rate of diabetic acidosis was 46 per 10,000 diabetics. Highest rates of diabetic acidosis were found for the elderly, those admitted from nursing homes and those residing in one geographic area of the state. For known diabetics with an admission for acidosis, 87% were on insulin prior to admission and 81% were nonobese. Patients seldom contacted physicians prior to admission. Insulin dose or frequency was often (40%) changed in the two weeks prior to admission. Most of the known diabetic cases of acidosis had emergency admissions for diabetes in the three-year period prior to admission and few had any structured diabetic outpatient education. Infection and noncompliance were the most frequently identified precipitants of diabetic acidosis occurring in known diabetics.     

Malnutrition in Dutch health care: Prevalence,prevention, treatment,and quality indicators

ObjectiveIn most health care organizations there is still insufficient awareness for recognizing and treating malnourished patients. To gain more insight into nutritional care policies in Dutch health care organizations, this study investigated screening, treatment, and other quality indicators of nutritional care.MethodsIn 2007 a cross-sectional multicenter study was performed that included 20 255 patients (hospitals, n = 6021; nursing homes, n = 11 902; home care, n = 2332). A standardized questionnaire was used to study nutritional screening and treatment at the patient level and quality indicators at institutional and ward levels (e.g., malnutrition guidelines/protocols, nutritional education, and weighing policy).ResultsNutritional screening was performed more often in nursing homes (60.2%) than in hospitals (40.3%) and home care (13.9%, P < 0.001). In general, one in every five patients was malnourished, and nutritional treatment was applied in fewer than 50% of all malnourished patients in nursing homes, hospitals, and home care. At ward level nursing homes focused more on the quality of nutritional care than did hospitals and home care, especially with respect to controlling the use of nutritional guidelines (54.6%, P < 0.03), weighing at admission (82.9%, P < 0.01), and mealtime ambiance (91.8%, P < 0.01).ConclusionThis large-scale study shows that malnutrition is still a considerable problem in one of every five patients in all participating health care settings. It furthermore demonstrates that recognizing and treating malnutrition continues to be problematic. To target the problem of malnutrition adequately, more awareness is needed of the importance of nutritional screening, appropriate treatment, and other nutritional quality indicators.     

End-of-life care: perspectives of family members of deceased patients

This study was undertaken to determine the opinions of family members of deceased patients regarding end-of-life care. This multisite cross-sectional survey was administered to 969 volunteer participants during 1997 to 2000. Eligible participants included immediate family members of deceased patients at five local institutions in a regional health system. Among 969 respondents, most (84.4 percent) indicated that the care for their family member was excellent. Reasons cited for satisfaction included overall care (40.2 percent), staff effort (23.2 percent), and communication (16.4 percent). Reasons cited for dissatisfaction included perceived incompetence (9.7 percent), perceived uncaring attitude (8.4 percent), and perceived understaffing (3.7 percent). Respondents were more satisfied with communication from nursing staff (88 percent) than physicians' communication (78 percent, p < 0.001, Bowker's test). Respondents indicated higher overall satisfaction with nursing (90 percent) and pastoral care (87 percent), than with physician care (81 percent, p < 0.001 and p = 0.006, Bowker's test). A unique survey instrument can be used to measure family perceptions and opinions regarding end-of-life care.     

The role of the clinical dietitian: II. Staffing patterns and job functions

On the basis of responses to a telephone questionnaire, this study evaluated--from the viewpoint of nutrition support dietitians, general clinical dietitians (dietitians who are not members of a nutrition support team and who provide general clinical dietetic services), and other health professionals--the current job functions that nutrition support and general clinical dietitians perform in hospitals. Anticipated staffing needs and desired job functions were also assessed. For the nutrition support and general clinical dietitians, as viewed by themselves and other health professionals, there was considerable overlap in many job activities. However, a significantly larger proportion of directors of nursing thought that nutrition support dietitians were more involved than general clinical dietitians in the evaluation of nutritional status (42% vs. 14%) and in contributing expertise to medical team discussions (48% vs. 12%). A significantly larger proportion of physicians viewed the nutrition support dietitian as more involved than the general clinical dietitian in in-service programs for medical and nursing staffs (32% vs. 6%). A large proportion of directors of nursing (62%), hospital administrators (34%), and physicians (56%) believed that dietetic involvement in the supervision of food preparation, especially by general clinical dietitians, was much greater than did the dietetic staff. The outlook for the future suggests a greater participation by both the nutrition support and the general clinical dietitian in direct patient care functions and less involvement in food preparation and clerical tasks.     

Self-report of delivery of clinical preventive services by U.S. physicians. Comparing specialty, gender, age, setting of practice, and area of practice.

OBJECTIVES: To summarize national survey results for key clinical preventive services provided by primary care physicians, characterize the results by demographic and practice attributes of the respondents, and compare the results to those obtained in other studies. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 3881 clinicians who provided primary care at least 50% of their time, randomly sampled from the professional associations representing family practitioners, pediatricians, internists, and OB-GYNs. MEASURES: The Primary Care Providers Survey instrument of 1992, administered through the Office of Disease Prevention and Health Promotion, designed to assess the provision of clinical preventive services by primary caregivers. MAIN RESULTS: Few of the physicians surveyed reported providing most indicated clinical preventive services more than 80% of the time. For the purposes of this paper, > 80% provision of preventive services is considered adequate. Female physicians reported providing more preventive services involving exercise, diet, alcohol/drugs, seatbelts, sexual activity, family planning, immunizations, and screening procedures. Physicians aged < 50 reported providing more preventive services involving smoking, alcohol/drugs, seatbelts, sexual activity, and family planning. Older physicians generally reported more delivery of vaccines and screening procedures. Practitioners from big metropolitan areas reported more preventive services involving alcohol/drugs and family planning while respondents in rural areas reported less immunizations and screening procedures. When analyzed by specialty, physicians reporting the most preventive care varied by type of preventive care. CONCLUSIONS: Small differences in the self-report of provision of clinical preventive services between specialties and demographic subgroups did exist. At the time of this survey, however, no group of primary care physicians reported providing clinical preventive services to their patients at adequate levels.     

Culturally acceptable health care services for Saudi's elderly population: the decision-maker's perception

This article reports on a study carried out in 1993 to elicit the opinions of decision makers (medical and non-medical) as to the types of facilities, locations and culturally acceptable levels of health care appropriate for the elderly in Saudi Arabia. In addition, the study sought to find out the procedures and likely constraints in the development of future health care services for the elderly. An opinion survey was carried out on a randomly selected sample of decision makers, drawn from: hospitals of 100-bed capacity or more; and, from directorates of education, agriculture, police, municipalities, commerce, transport and media, in each of the regions of Saudi Arabia. A predesigned Arabic questionnaire was completed by the respondents during February-April, 1993. Of the 244 respondents, the most important categories of elderly to be cared for were considered to be those with handicaps, the chronically ill, and those without family support. The non-medical decision makers gave higher scores to these alternatives than did the medical decision makers (P < 0.05). Use of the family home for elderly health care was rated as the most appropriate, followed by medical rehabilitation centres, and only then by hospitals. Non-medical respondents gave more emphasis on rehabilitation centres (P < 0.02). Medical respondents thought that primary care doctors (87.2%), physiotherapists (87.2%) and general nurses (78.2%) can adequately fulfil the needs of most elderly patients. In contrast, non-medical respondents demanded the presence of specialist doctors (72.3%), specialist nurses (78.9%), laboratory and X-ray facilities to run such services (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)