Quality of care: the need for medical, contextual and policy evidence in primary care

The increasing availability of medical evidence in clinical practice was expected to improve the quality of care. However, this has not been realized. A possible explanation is that quality of care is a complex concept and needs a wider scope. Starting from the Donabedian triangle of structure, process and outcome, a framework for the analysis of quality of care is presented. The need for three types of evidence is identified and discussed: medical, contextual and policy evidence. Although the body of medical evidence is increasing, it has major flaws and gaps hampering its applicability in primary care. There is also a need to focus on the context of the medical encounter, which has been shown to influence outcome, but is still not well researched. Finally, evidence on costs, cost utility and equity needs to be considered. Taking these different aspects of evidence into account, an agenda for research in primary care is set. The analytical framework may provide new insights in the quest for improving quality of health care.     

Changes affecting the initial evaluation and care of the pregnant trauma victim

Pregnant women in American society today are at significant risk of injury during a period when physiologic responses to trauma, as well as expected findings of physical examination and laboratory evaluation are altered by the on-going pregnancy. Changes in anatomy, hemodynamics, respiratory function, gastrointestinal function, and hematologic and hemostatic parameters impact upon the approach to the evaluation and management of injured pregnant women. Maternal outcome is dependent on the nature and extent of injury and on the delivery of appropriate care. Fetal outcome relates to the magnitude of direct injury and the maternal physiologic response. It is imperative that all physicians involved in clinical evaluation and management of injured pregnant women understand the changes engendered by pregnancy and their effects upon the mother, the fetus, and the decision-making process. The best way to secure a favorable outcome for both mother and fetus is a standardized planned approach to care provided by a team cognizant of these changes.     

Assuring quality of care in long-term facilities

A quality assessment and assurance program is an ongoing, global system that compares the structure, process, or outcome of the care provided with established criteria or standards. A successful QA&A program requires a comprehensive, well-maintained medical records system. Main components of a QA&A program include development of specific criteria; identification of expected results indicative of quality of care; development of an ongoing monitoring system; systematic evaluation; and a plan of correction for identified problems. Quality of care encompasses the patient's satisfaction with care, efficacy of care, technical proficiency and performance of care providers, accessibility and continuity of care, and cost-effectiveness.     

Exploratory project for development of nursing outcome criteria in long term care

This exploratory project in developing outcome criteria for long term care was conducted with the view that the individual professional nursing practitioner has a unique, valuable contribution to make to the overall nursing quality assurance effort. Twenty-seven nurses volunteered to design and conduct individual systematic nursing diagnosis/intervention/outcome measurement projects. They were employees of five long term care facilities in New York state. Their contribution to this project was an embodiment of their professional judgement and practice with 107 selected clients under their care. They were prepared for participation through instruction repeated in all five facilities. The North American Nursing Diagnosis Association's Taxonomy of Nursing Diagnoses was used in the instruction, by the practitioners in their practice and data collection, and in the data analysis. Data analysis also included use of Campbell's nursing intervention category scheme. This work demonstrated that professional nurses are able to specify appropriate outcome criteria and to measure these outcomes of their planned nursing interventions. Eighty-seven percent of the expected outcomes were achieved as anticipated or in the anticipated direction. Results provided many leads for future study of nursing diagnosis/intervention/outcome measurement among residents of long term care institutions.     

Assessing quality of care: what are the implications of the potential lack of sensitivity of outcome measures to differences in quality?

Measuring outcome can be an insensitive way to detect differences in the quality of health care. This paper captures the implications of this poor sensitivity for the interpretation of studies of outcome that compare provider performance, and considers in what circumstances monitoring outcome might be useful. When interpreting studies, it is important to consider the size of the effect that a difference in the quality of care might be expected to have on outcome and whether it is likely that important differences in quality might not have been detected. It is argued that outcome measures may be of value when how you do something is as important as what you do, when process measures are invalid or impractical, and when the overall effectiveness of an intervention is critically dependent upon its complication rate.     

A conceptual proposal for the study of the quality of rehabilitation care

Purpose : To propose a framework for the assessment and ongoing, continuous improvement of the quality of rehabilitation care. Method : The generally clarified and accepted approaches to the study of the quality of care are examined in view of the inherent characteristics of medical rehabilitation and the differences between it and other fields of medical practice. Results : The process and outcome of care are distinct but complementary and their elements should, in rehabilitation, be used jointly and simultaneously as indicators of quality. Conclusions : Rehabilitation is of long duration and consists of various phases, each of them focusing on a different issue. It is proposed to monitor activities of rehabilitation professionals (process elements) that constitute the focus of care of a given phase and simultaneously to monitor relevant outcome elements attributable to the activities of the given phase. Comparison of monitored elements (the observed care) to their standards (the expected care) would enable assessment of the quality and its continuous improvement.     

Health-related quality-of-life and health-utility reporting in critical care

Mortality is a well-established patient-important outcome in critical care studies. In contrast, morbidity is less uniformly reported (given the myriad of critical care illnesses and complications of each) but may have a common end-impact on a patient’s functional capacity and health-related quality-of-life (HRQoL). Survival with a poor quality-of-life may not be acceptable depending on individual patient values and preferences. Hence, as mortality decreases within critical care, it becomes increasingly important to measure intensive care unit (ICU) survivor HRQoL. HRQoL measurements with a preference-based scoring algorithm can be converted into health utilities on a scale anchored at 0 (representing death) and 1 (representing full health). They can be combined with survival to calculate quality-adjusted life-years (QALY), which are one of the most widely used methods of combining morbidity and mortality into a composite outcome. Although QALYs have been use for health-technology assessment decision-making, an emerging and novel role would be to inform clinical decision-making for patients, families and healthcare providers about what expected HRQoL may be during and after ICU care. Critical care randomized control trials (RCTs) have not routinely measured or reported HRQoL (until more recently), likely due to incapacity of some patients to participate in patient-reported outcome measures. Further differences in HRQoL measurement tools can lead to non-comparable values. To this end, we propose the validation of a gold-standard HRQoL tool in critical care, specifically the EQ-5D-5L. Both combined health-utility and mortality (disaggregated) and QALYs (aggregated) can be reported, with disaggregation allowing for determination of which components are the main drivers of the QALY outcome. Increased use of HRQoL, health-utility, and QALYs in critical care RCTs has the potential to: (1) Increase the likelihood of finding important effects if they exist; (2) improve research efficiency; and (3) help inform optimal management of critically ill patients allowing for decision-making about their HRQoL, in additional to traditional health-technology assessments.     

A conceptual proposal for the study of the quality of rehabilitation care

Purpose: To propose a framework for the assessment and ongoing, continuous improvement of the quality of rehabilitation care. Method: The generally clarified and accepted approaches to the study of the quality of care are examined in view of the inherent characteristics of medical rehabilitation and the differences between it and other fields of medical practice.

Results: The process and outcome of care are distinct but complementary and their elements should, in rehabilitation, be used jointly and simultaneously as indicators of quality. Conclusions: Rehabilitation is of long duration and consists of various phases, each of them focusing on a different issue. It is proposed to monitor activities of rehabilitation professionals (process elements) that constitute the focus of care of a given phase and simultaneously to monitor relevant outcome elements attributable to the activities of the given phase. Comparison of monitored elements (the observed care) to their standards (the expected care) would enable assessment of the quality and its continuous improvement.     

Severe Traumatic Brain Injury in Austria IV: Intensive care management

OBJECTIVES: The goal of this paper is to describe the ICU management of severe traumatic brain injury (TBI) in Austria. PATIENTS AND METHODS: Data sets from 415 patients included by 5 Austrian hospitals were available. The analysis focused on complications and outcomes of intensive care, monitoring of intracranial pressure (ICP), efficacy of interventions to control ICP, management of hemodynamics and cerebral perfusion pressure (CPP), ventilation, and effects of hyperglycaemia. RESULTS: Overall ICU mortality was 30.8%; 90-day mortality was 35.7%. Final outcome was favorable in 33%, unfavorable in 51%, and in 16% the final outcome was unknown. An ICP monitoring device was used in 64%; most patients received intraparenchymal sensors (77%). Events associated with mortality > 50% were CPP < 50 mm Hg for > 12 hours/day, ICP > 25 mm Hg for > 12 hours/day, and MAP < 70 mm Hg for > 18 hours/day. The use of ICP monitoring was associated with significantly reduced ICU mortality. Interventions that may have improved the outcome included the use of barbiturates (short-term), hypertonic saline, moderate hyperventilation (33 < pCO2 < 37; p < 0.001 vs. aggressive hyper-and normoventilation), and normothermia. Hyperglycaemia was associated with poor outcome. CONCLUSIONS: Our study showed that ICU management of patients with severe TBI mostly follows international guidelines, and that outcome was comparable to or even better than that reported by other authors. Low CPP was associated with poor outcome, and was more often due to low MAP than to elevated ICP. The use of barbiturates and hypertonic saline was more common than expected. CPP should be maintained > 50 mm Hg, the use of catecholamines, fluid loading, barbiturates (short-term), moderate hyperventilation, hypertonic saline, and insulin may improve outcome after severe TBI.     

Value and role of intensive care unit outcome prediction models in end-of-life decision making

In the United States, intensive care unit (ICU) admission at the end of life is commonplace. What is the value and role of ICU mortality prediction models for informing the utility of ICU care?In this article, we review the history, statistical underpinnings,and current deployment of these models in clinical care. We conclude that the use of outcome prediction models to ration care that is unlikely to provide an expected benefit is hampered by imperfect performance, the lack of real-time availability, failure to consider functional outcomes beyond survival, and physician resistance to the use of probabilistic information when death is guaranteed by the decision it informs. Among these barriers, the most important technical deficiency is the lack of automated information systems to provide outcome predictions to decision makers, and the most important research and policy agenda is to understand and address our national ambivalence toward rationing care based on any criterion.     

Quality improvement and changes in diabetic patient outcomes in an academic nurse practitioner primary care practice

PURPOSE: To examine a set of system interventions in the management of patients with diabetes and the outcomes of their care. DATA SOURCES: Preintervention and postintervention data collected from electronic medical records. CONCLUSIONS: The sample size was smaller than expected, contributing to a lack of statistical significance from preintervention to postintervention in the patient outcome measures. The systems-level variables that were under the direct control of the clinic staff (e.g., pneumococcal vaccine given) showed great improvement. In the preintervention period, the percentage of "yes" responses to the system-level variables ranged from 8 to 24 and jumped to 16 to 95 after the intervention. IMPLICATIONS FOR PRACTICE: Unequivocally, this project demonstrated that systems-level changes result in improved care being provided to patients; however, these had minimal impact on the patient outcome variables. Promoting change in patient behavior is difficult, which may have contributed to the lack of significance in this area, while the variables under the direct control of the clinic staff were more easily changed.     

Symbolic interactionism: a framework for the care of parents of preterm infants

Because of stressors surrounding preterm birth, parents can be expected to have difficulty in early interactions with their preterm infants. Care givers who work with preterm infants and their parents can positively affect the early parental experiences of these mothers and fathers. If care givers are consciously guided by a conceptual model, therapeutic care for distressed parents is more likely to be provided. A logical framework, such as symbolic interactionism, helps care givers to proceed systematically in assessing parental behaviors, in intervening appropriately, and in evaluating both the process and outcome of the care. Selected aspects of the symbolic interaction model are described in this article and applied to the care of parents of preterm infants.     

Assessing quality of care: administrative indicators and clinical outcomes in posttraumatic stress disorder

BACKGROUND: Although the use of quality of care indicators based on data collected for administrative purposes has become widespread, the relationship between those measures and clinical outcomes has yet to be evaluated. RESEARCH DESIGN: This study used hierarchical linear modeling to examine the relationship between 12 performance indicators derived from administrative data sets and 6 clinical outcome measures addressing symptoms, substance abuse, and social functions. SUBJECTS: Patient interviews were conducted with 4,165 veterans 4 months after their discharge from 62 specialized VA inpatient programs for treatment of Posttraumatic Stress disorder. RESULTS: Five of twelve administrative measures were significantly associated with at least one of the clinical outcome measures, which was all in the expected directions. The number of hospital readmissions during the 6 months after the index discharge was significantly related to poor outcomes on all 5 of 6 measures. Measures of readmission and post-discharge hospital use were more strongly and consistently related to outcome than to measures of access, intensity, or continuity of outpatient care. CONCLUSION: Administrative data, especially measures of hospital readmission, are significantly related to clinical outcomes. Correlations, however, are small to modest in magnitude indicating that these 2 types of performance measures assess different aspects of quality and can not be substituted for one another.     

带锁髓内钉治疗胫骨中下段骨折60例护理体会

目的:探讨带锁髓内钉治疗胫骨中下段骨折的护理方法。方法:对60例患者进行术前心理护理、术中密切配合、术后加强护理,加强功能锻炼。结果:本组均临床愈合,达到预期目的。结论:根据患者的不同情况选择适当的护理方法,对手术的成功和患者的康复有重要意义。     

Planning: a necessary step in clinical care

Aim.  The aim of this paper is to highlight the significance of care planning and to encourage the integration of a consistent and systematic planning process into nursing practice. Background.  Many factors contribute to the successful achievement of clinical outcomes, including patient–practitioner rapport, comprehensive client assessment, accurate differential diagnosis, evidence‐based care and the objective evaluation of client progress. One element that is of equal importance to these aforementioned factors is the planning of patient care. However, there are concerns that some practitioners may not be adopting a planned approach to client care, possibly because of a lack of understanding, time, skill or interest in care planning. Method.  This is a position paper on the planning of patient care. Results.  The planning of patient care can be effectively implemented using a two‐stage process. In brief, the first step involves the construction of a general goal, which is the overall, desired outcome of care. The expected outcome, or specific goal, forms the second part of the planning process, which clearly directs clinical care by specifically indicating how and when an individual will achieve the general goal of treatment. Conclusion.  This paper highlights the importance of care planning and that the use of a clear, systematic planning framework may help to deliver a more transparent and consistent approach to patient care, which may greatly improve patient health and well‐being by hastening the achievement of clinical outcomes. Relevance to clinical practice.  The knowledge and strategies contained in this paper can be easily adopted by nurses and other clinicians to modify or build upon existing practice. This knowledge may help foster a more client‐centred, participative, individualised approach to care, which may lead to improvements in patient outcomes.     

Clinical outcome of immunonutrition in a heterogeneous intensive care population

Objective To study the effect of a high-protein enteral formula enriched with arginine, glutamine, and antioxidants and containing 3 fatty acids and a mixture of fibers, on the clinical outcome of a heterogeneous intensive care (ICU) population.Design and setting A randomized, prospective, double blind, controlled, two-center clinical trial in two intensive care units in The Netherlands.Patients and participants A total of 597 adult ICU patients expected to require enteral tube feeding for more than 2 days were randomized to receive immunonutrition or an isocaloric control formula. Interventions Patients received either the immunonutrition or the control feed.Measurements and results Intention-to-treat and per-protocol analyses showed no statistically significant difference in clinical outcome parameters between the two groups. Results of the intention-to-treat analysis in control vs. immunonutrition were: median ICU length of stay in days, 8.0 (IQR 5.0–16.0) vs. 7.0 (4.0–14.0); median hospital length of stay in days, 20.0 (IQR 10.0–34.0) vs. 20.0 (10.0–35.0); median days of ventilation, 6.0 (IQR 3.0–12.0) vs. 6.0 (IQR 3.0–12.0); ICU mortality, 26.8% vs. 28.2%; in-hospital mortality, 36.4% vs. 38.5%; infectious complications, 41.7% vs. 43.0%Conclusions The results of this largest randomized, controlled trial found that in the general ICU population immunonutrition has no beneficial effect on clinical outcome parameters. These results are consistent with the literature that is currently available.This revised version was published online in February 2005 with corrections to the heading of a subsection of the Results (A priori subgroup analyses).     

Nurses' well-being in a primary nursing care setting in The Netherlands

A study was conducted in a Dutch hospital to evaluate the effects of the implementation of a Dutch form of Primary Nursing on nurses' well-being in the work situation. The variables used as indicators of well-being at work were job satisfaction, experienced job significance, health complaints and absenteeism. The study included three measuring periods: one pre-intervention (t1) and two post-intervention periods (t2, 8 months after t1, and t3, 14 months after t1). Primary Nursing was implemented in group 1 (consisting of two nursing units) after t1. At this time no changes were introduced into group 2 (three nursing units) but after t2. Primary Nursing was also implemented in group 2. The research variables were measured by means of questionnaires. The results of the study indicate that most of the expected effects of Primary Nursing did not occur. Some methodological and practical explanations for this outcome are given.     

脐带过度扭转产前检查及妊娠结局分析

目的探讨脐带过度扭转对母婴结局的影响。方法对照组（n=215）为正常足月分娩产妇,观察组（n=105）为产后确定为脐带过度扭转的产妇,比较两组的产前胎心监护检查、彩超检查、分娩方式、围产儿结局。结果观察组彩超检查具有特征声像图的发生率、胎心监护异常率高于对照组,观察组脐动脉S／D值高于对照组,差异均有显著性（P〈0．05）;观察组剖宫产率、围产儿并发症发生率显著高于对照组（P〈0．05）。结论产前胎监、彩超检查可为诊断脐带过度扭转提供参考,适时终止妊娠有望改善母婴结局。