Relationship between use of increased primary health care service and other care in a Swedish urban area. III. Utilization of emergency house calls

The Matteus Primary Health Care Centre (MPHCC) is a pilot project with fullscale established future primary health care. Before the project began, the average district of a general practitioner consisted of 9 000 inhabitants. After the start of MPHCC the district level was 3 000 inhabitants per general practitioner in the study district. The populations utilization of the Stockholm emergency car service (SCS) has been analysed both before and after the establishing of the MPHCC in the northern inner city of Stockholm. The results confirm the hypotheses that the establishment of MPHCC reduces the workload on the SCS by 24%. The reduction is significant in all ages and for both men and women. The main period of the reduction is on weekdays 7 a.m. to 5 p.m. when the MPHCC is open.     

A new role for nurses as Primary Care Cancer Lead Clinicians in Primary Care Trusts in England

AIM: The aim of this study was to evaluate the Primary Care Cancer Lead Clinician initiative in England. One of the objectives was to examine the impact of the Primary Care Cancer Lead Clinicians' clinical background on how they perform their role. This study compares nurses and General Practitioners in the Primary Care Cancer Lead Clinician role. BACKGROUND: The Primary Care Cancer Lead Clinician initiative developed from the National Health Service Cancer Plan. Primary Care Cancer Lead Clinicians are expected to work strategically to raise the standards of cancer care within primary care. METHODS: A postal questionnaire survey was sent to Primary Care Cancer Lead Clinicians and one manager in each Primary Care Trust in England. Telephonic interviews were also undertaken with a range of stakeholders in six case study areas. RESULTS: There were striking similarities between nurses and General Practitioners in the Primary Care Cancer Lead Clinician role. Differences related to the wider roles of the two groups. Nurses placed greater emphasis on fitting in whereas General Practitioners were more likely to expect to take charge and look for administrative support. CONCLUSIONS: There is evidence to show that whether the Primary Care Cancer Lead Clinician was a nurse or a General Practitioner was less important than having local credibility and the support of their Primary Care Trust.     

Primary care groups and trusts: a threat or an opportunity for the development of community-based nursing in England

AIMS OF THE STUDY: To examine the role of Primary Care Groups and Trusts (PCG/T) in relation to nurses working in general practice and community health services. BACKGROUND: Over the past two decades there have been rapid changes in the numbers and roles of nurses working in primary care and community based settings. The establishment of Primary Care Groups offers health care professionals, including nurses, the chance to develop local primary care services and to integrate community and primary care nursing. These developments may offer opportunities or pose threats to nursing staff. RESEARCH METHODS: Data are drawn from a longitudinal study of a randomly selected sample of Primary Care Groups in England (n = 72). In a second survey of Groups carried out in autumn/winter 2000, Primary Care Group chairs and chief officers were interviewed by telephone. RESULTS: Response rates were 97% for both chairs and chief officers (69 of each). Chairs indicated that in most areas Primary Care Groups were consulting with local nurses to develop policy. Fifty-seven (85%) reported that investment in nursing staff and nursing services was a high priority in their area. Twenty-eight (41%) indicated that nurse-led services designed to increase patient access had already been established in their area, and 20 (29%) were planning new nurse-led services. Many developments had been initiated by Primary Care Groups. Initiatives to integrate community and general practice based staff were underway in most areas. CONCLUSIONS: Primary Care Groups and Trusts are initiating changes in general practice and community based services which are likely to have long-term and important implications for nurses in terms of their roles, conditions of work and future careers. It is important that nurses are consulted and are involved in developing and implementing policy change.     

Sports Medicine Training and Practice Opportunities for Emergency Physicians

Background

There is growing interest among emergency physicians to seek additional training in Sports Medicine (SM) and to add it to their clinical practice. This presents unique training and practice management issues. The majority of Primary Care SM fellowship programs list that they will accept emergency physicians, and approximately one-third have already had an emergency physician as an SM fellow.

Objectives

The objective of this article is to provide an overview of the key elements for emergency physicians to consider as they pursue SM career goals.

Discussion

Training needs such as continuity of care as it pertains to the athlete, SM skills development, and practice management are reviewed. Practice challenges such as malpractice insurance and billing issues are discussed. Examples of several practice models are presented. Evolving trends in SM practice and training opportunities for emergency physicians are discussed as well.

Conclusions

Sports Medicine is a viable career option for emergency physicians and may complement their skills set in the management of acute injuries. Practice and training opportunities will continue to evolve as this pathway into the practice of SM gains further recognition.     

Codes, classifications, terminologies and nomenclatures: definition, development and application in practice

The Primary Care Informatics Working Group of EFMI is working to help develop the core theory of primary care informatics (PCI). Codes, classifications, terminologies and nomenclatures form an important part of the science of PCI, as they allow clinical information to be readily stored and processed in information systems. This article provides definitions and a history of the International Classification for Primary Care (ICPC), and of the Read code and the Systematized Nomenclature for Medicine (SNOMED). The Working Group wishes to encourage shared definitions and an understanding of the practical application of structured data to improve quality in clinical practice.     

Assessment and communication excellence for safe patient outcomes (ACCELERATE): A stepped-wedge cluster randomised trial protocol

BackgroundNurses play a major role in patient safety. Poor nursing assessment and communication practices are associated with higher incidence of the adverse events of undetected deterioration, falls, and pressure injuries. Despite widespread adoption of patient safety systems, occurrence of these events continues.AimTo implement and evaluate the feasibility and effectiveness of an organisational ward-level intervention to facilitate comprehensive systematic assessment and improved communication in clinical handover to reduce medical emergency team calls; unplanned Intensive Care Unit admissions; falls; and pressure injuries.DesignA stepped-wedge cluster randomised trial sequentially implemented over 12 months.MethodsEvidence-based implementation strategies will be employed to support implementation of an intervention focusing on comprehensive systematic patient assessment and improved nurse bedside clinical handover and multidisciplinary communication involving the patient. These are – intervention tailoring to individual wards through barrier and enabler identification; action plans; education; clinical champions; outreach visits; facilitation; clinician engagement; and reminders. Primary outcome measures will be a composite of Medical Emergency Team calls and unplanned intensive care unit admissions for deterioration. Secondary outcomes will be all categories of inpatient falls; stage 2–4 pressure injuries; nurse-reported perceptions of: teamwork; safety culture, and engagement; and patient-reported experience measures of receiving safe and patient-centred care. An a priori process evaluation will determine factors influencing intervention uptake and inform strategies for future upscale and spread.DiscussionThis feasibility trial will provide evidence regarding the use of systematic comprehensive patient assessment, combined with clinical handover re-design involving patients, to reduce clinical deterioration, falls and pressure injuries.     

Design of a clustered observational study to predict emergency admissions in the elderly: statistical reasoning in clinical practice

OBJECTIVE: To describe the statistical design issues and practical considerations that had to be addressed in setting up a clustered observational study of emergency admission to hospital of elderly people. STUDY DESIGN AND SETTING: Clustered observational study (sample survey) of elderly people registered with 18 general practices in Halton Primary Care Trust in the north-west of England. RESULTS: The statistical design features that warranted particular attention were sample size determination, intra-class correlation, sampling and recruitment, bias and confounding. Pragmatic decisions based on derived scenarios of different design effects are discussed. A pilot study was carried out in one practice. From the remaining practices, a total of 4000 people were sampled, stratified by gender. The average cluster size was 200 and the intra-class correlation coefficient for the emergency admission outcome was 0.00034, 95% confidence interval (0-0.008). CONCLUSION: Studies that involve sampling from clusters of people are common in a wide range of healthcare settings. The clustering adds an extra level of complexity to the study design. This study provides an empirical illustration of the importance of statistical as well as clinical reasoning in study design in clinical practice.     

Connecting Chronically Ill,Uninsured Patients Who Use the Emergency Department as a Medical Home: A Process Improvement Project

IntroductionThe use of the emergency department by uninsured patients with chronic health problems may adversely affect those patients’ health outcomes. Successful interventions have involved the use of patient navigators to connect the uninsured adult population with medical coverage and a medical home. The aim of this project was to use principles of patient navigation in a nurse-led process improvement intervention to connect uninsured patients to medical homes.MethodED nurses were trained to refer uninsured patients with chronic health problems to care coordinators when they were discharged from emergency departments. The care coordinator was provided by the Health Care District, a community-funded medical department. Patients were therefore connected to community-funded medical homes.ResultsED nurses improved their knowledge about the overuse of the emergency department and successfully referred uninsured patients who were discharged. The referred patients successfully made contact with members of the Health Care District by phone or by attending their appointments.ConclusionThe role of patient navigators is essential in the emergency department. They assist patients to navigate through the various health care resources available in their communities, which can help to reduce ED overuse.     

Trauma system development and future directions

Traumatic injury, both unintentional and intentional, is a serious public health problem. Trauma care systems play a significant role in reducing mortality, morbidity, and disability due to injuries. However, barriers to the provision of prompt and appropriate emergency medical services still exist in many areas of the United States. Title XII of the Public Health Service Act provides for programs in support of trauma care planning and system development by states and localities. This legislation includes provisions for: 1) grants to state agencies to modify the trauma care component of the state Emergency Medical Services (EMS) plan; 2) grants to improve the quality and availability of trauma care in rural areas; 3) development of a Model Trauma Care System Plan for states to use as a guide in trauma system development; and 4) the establishment of a National Advisory Council on Trauma Care Systems.     

Role of advanced paediatric nurse practitioners

Children's attendance at emergency departments (EDs) is increasing every year, yet many children present with minor, self-limiting illnesses that could be managed at home. In light of Williams et al (2009) suggestion that healthcare professionals should improve the care available to patients at point of contact rather than try to change their health-seeking behaviours, this article describes how Tameside and Glossop Primary Care Trust has developed an advanced paediatric nurse practitioner (APNP) service in the ED to improve the care of children, and to reduce the number of admissions. The APNPs treat children in the ED then divert them to more appropriate services where support is given to the families to care for their children at home. The role contributes to meeting ED clinical quality indicators, frees up medical staff to deal with more seriously ill patients, and makes financial savings for the trust.     

Watchfully checking rapport with the Primary Child Health Care nurses - a theoretical model from the perspective of parents of foreign origin

Background  

Worldwide, multicultural interaction within health care seems to be challenging and problematic. This is also true among Primary Child Health Care nurses (PCHC nurses) in the Swedish Primary Child Health Care services (PCHC services). Therefore, there was a need to investigate the parents' perspective in-depth.     

Primary Health Care in the Mental Health Workplace: Insights from the Australian Experience

In Australia, Primary Health Care and the mental health sector have always shared a philosophy. In 1978, Primary Health Care was first put forward as a strategy to improve “health for all.” Recently, the Australian Government included mental health as a national health priority, identifying six strategies consistent with a Primary Health Care approach to address the mental health of all Australians. Throughout this time, Primary Health Care has been highlighted in all models of care. However, in reality, it appears that in mental health services, mental health nurses, despite good intentions, are not delivering care in a planned or systematised way and that much needs to be done to further improve the situation for individuals accessing the health care system. Services currently focus on those identified as seriously mentally unwell; in order to really make an impact it is argued that services should be broader, offered to the population at large and, further, that the emphasis on case work at an individual level should be changed to an approach that considers prevention, maintenance, and follow-up as well as crisis intervention. This article reflects the Australian experience and offers some insights from that experience.     

情景演练提高急诊监护室护士急救技能水平的效果分析

目的:探讨情景演练对提高急诊监护室护士急救技能水平培训的效果。方法:选择2018年1月—2019年12月北京大学第一医院急诊监护室的64名护士为研究对象,根据培训方式的不同分为对照组和观察组,各32名。对照组给予常规培训,观察组给予情景演练模式,比较两组护士培训前后所掌握的理论知识、应急反应总能力、操作能力以及急救思维能力评分。结果:培训前,两组护士的理论知识、操作技能以及应急反应能力考核评分比较,差异无统计学意义(P>0.05);培训后,观察组护士的理论知识、操作技能以及应急反应能力考核评分明显高于对照组,差异均有统计学意义(P<0.05)。结论:情景演练在急诊监护室护士应急能力培训中的效果显著,可有效培其养急救思维能力,提高其理论知识水平和临床操作能力,进而提高急救水平。     

Closing Evidence to Practice Gaps in Emergency Care: The Australian Experience

The National Institute of Clinical Studies (NICS) was established in 2000 by the Australian government to improve health care by closing evidence-practice gaps. Improving emergency care through use of evidence is a priority area of work for NICS. This article describes the NICS Emergency Care Program and the current application of a "Community of Practice" to support emergency clinicians to implement best practices research. This approach combines aspects of evidence implementation science, quality improvement techniques, and knowledge management within a social network model to provide a mechanism for rapid sharing of explicit and tacit knowledge. Through the Community of Practice, the clinical community guides the priorities for the Emergency Care Program and is actively engaged in the development and implementation of initiatives.     

Moving toward a United States strategic plan in primary care informatics: a White Paper of the Primary Care Informatics Working Group, American Medical Informatics Association

The Primary Care Informatics Working Group (PCIWG) of the American Medical Informatics Association (AMIA) has identified the absence of a national strategy for primary care informatics. Under PCIWG leadership, major national and international societies have come together to create the National Alliance for Primary Care Informatics (NAPCI), to promote a connection between the informatics community and the organisations that support primary care. The PCIWG clinical practice subcommittee has recognised the necessity of a global needs assessment, and proposed work in point-of-care technology, clinical vocabularies, and ambulatory electronic medical record development. Educational needs include a consensus statement on informatics competencies, recommendations for curriculum and teaching methods, and methodologies to evaluate their effectiveness. The research subcommittee seeks to define a primary care informatics research agenda, and to support and disseminate informatics research throughout the primary care community. The AMIA board of directors has enthusiastically endorsed the conceptual basis for this White Paper.     

Identifying abuse among women: use of clinical guidelines by nurses and midwives

Title.  Identifying abuse among women: use of clinical guidelines by nurses and midwives.
Aim.  This aim of this study to identify the incidence of violence against women seeking healthcare services and evaluate the use of clinical guidelines to identify interpersonal violence.
Methods.  A cross-sectional survey was carried out. Data were collected over a period of 7 months in 2005 and 2006. The samples consisted of 14 nurses, 10 midwives and 208 women in Iceland (101 women visiting the Emergency Department and 107 receiving prenatal care at the High Risk Prenatal Care Clinic).
Results.  Twenty women (19·6%) who visited the Emergency Department and 21 women (19·8%) who came to the High Risk Prenatal Care Clinic had been sexually abused at some point in their lives by close family members. Within the preceding 12 months, 18 women at the Emergency Department (19·1%) and eight at the High Risk Prenatal Care Clinic (7·5%) reported physical abuse, and 22 women (22·2%) at the Emergency Department and 12 (11·5%) at the High Risk Prenatal Care Clinic reported emotional abuse. A majority of the nurses and midwives indicated that the guidelines were efficient for assessing/screening for gender violence in emergency and high risk clinical settings.
Conclusion.  Screening for abuse of women at emergency and high risk clinics is crucial, not only to offer the women the immediate interventions they might need, but also to ensure the future provision of appropriate healthcare services.     

Association of functional status and hospital-acquired functional decline with 30-day outcomes in medical inpatients: A prospective cohort study

BackgroundThere is growing evidence that patients with functional decline are at increased risk of readmission, mortality and institutionalization. Instruments to measure the status of self-care could provide important information for efficient care planning. The widely used Self Care Index serves as an indicator for the severity of nursing dependency. To date, no evidence is available on the association of the instrument with rehospitalization, mortality and institutionalization.ObjectivesTo examine the association of functional status measures (Self Care Index on admission, at discharge and functional decline) with 30-day mortality, readmission and institutionalization in hospitalized non-surgical patients.DesignProspective cohort study.ParticipantsWe included 4540 emergency medical patients at a single hospital in Switzerland.MethodsPrimary outcome was 30-day mortality rate; secondary outcomes were 30-day readmission and institutionalization. We analyzed the association of the functional status with the binary endpoints using logistic regression models and C-statistics for discrimination.ResultsAll of the examined measures were significant predictors of overall 30-day mortality; Self Care Index on admission: adj. OR: 0.90 (95% CI: 0.87–0.92); Self Care Index at discharge: adj. OR: 0.86 (95% CI: 0.83–0.88); functional decline: adj. OR: 1.22 (95% CI: 1.14–1.31) and all Self Care Index single items. A combined model (functional status on admission and functional decline during hospitalization) showed a good accuracy with regard to the AUC: adj. AUC: 0.80 (95% CI: 0.74–0.86).ConclusionsSeveral functional measures were associated with 30-day mortality. Self Care Index total score, five single items and a combined model showed the best performance.     

Relationship between use of increased primary health care and other out-patient care in a Swedish urban area. I. Utilisation of public primary health care

The Swedish National Health and Medical Care program is currently undergoing a change. The aim of this gradual change is a more decentralized system where the primary care service is expanded to cater for the transfer of patients from the hospitals over to primary care. This study, which is one part of a longitudinal design aims to show changes in public utilization of the services of general practitioners and district nurses after the expansion of the Matteus Primary Health Care Centre (MPHCC), city of Stockholm. The analysis is based partly on the annual statistical records and partly on medical chart studies of visits to the general practitioner by a selected population. The results showed that the population in the study district made twice as many visits to general practitioners and district nurses after the establishment of the MPHCC. It was also shown that the number of individuals visiting the general practitioners more than doubled during an 18-month period following the expansion of MPHCC. These results corresponds well with the aims associated with the expansion in primary care in future medical care services.