Technology in the birthing room

The use of technology is not benign. As with any health care intervention, there are associated risks and benefits. The practitioner needs to constantly consider the benefits of the technology versus the naturalistic birth experience. The use of technology should optimize birth outcomes while maintaining a balance that provides for the best possible human birth experience. Technology, however, does have merit in the birth setting, regardless of location, but its use should be evaluated on an individual, as needed, basis. The most common technological advances currently available for assessment and maternal/fetal care during birth include electronic fetal monitoring, ultrasonography, blood pressure screening, maternal/fetal pulse oximetry, and infusion pumps. All obstetrical care providers must be familiar with the forms of technology currently available and be aware of emerging technologies for use during the birthing process.     

What are the criteria that mentors use to make judgements on the clinical performance of student mental health nurses? An exploratory study of the formal written communication at the end of clinical nursing practice modules

Issues concerning the assessment of student nurse performance in clinical practice have pre-occupied nurse educationalists for some time and continue to pose problems. The debate in the nursing literature tends to revolve around two seemingly mutually exclusive positions related to competence vs. learning outcomes. These are views that seem to be held by academics with little reference to clinical nurses who have responsibility for the assessment of student performance in clinical practice. This paper adds to the wider debate on clinical assessment by reporting on a small research study that explored the written comments that 150 mentors made in relation to the performance of student mental health nurses following periods of clinical practice. An extensive literature review is provided in order to place the debate in context, followed by a brief outline of the research study, its findings, discussion and conclusion. This analysis of findings demonstrates that student learning is of major concern to mentors, and that the assessment of student performance in clinical practice is not restricted by pre-determined behavioural learning outcomes. Personal characteristics of students exert a great influence on judgements about clinical performance. This paper does not offer solutions to the search for the perfect clinical assessment, but it does call for an increased dialogue between educationalists and mentors to discuss the implications of this research for the development of an appropriate clinical assessment tool.     

Categorizing outcomes of health care delivery

After a patient presents with symptoms of illness and undergoes treatment, there are three features of care that require assessment: the impact of delivering care on the patient, the benefits and harms of treatment, and the functioning of the health care system. This formulation leads to three types of outcomes of care delivery that require assessment: 1) patient outcomes, which reflect the impact on patients of undergoing care; 2) treatment outcomes, which reflect the intended and unintended medical consequences of undergoing therapy; and 3) system outcomes, which reflect the impact on the system of delivering health care to a group of patients. In this paper, examples of these three types of outcomes are presented, with particular reference to coronary artery bypass graft surgery. It is argued that the current focus of computer simulation models on system outcomes should be expanded to include patient and treatment outcomes.     

Pearls for Treating Geriatric Patients With Coronary Heart Disease

Heart disease is the most significant contributor to morbidity and mortality in older adults. Care decisions are complex because patients may have multiple comorbidities, frailty, cognitive impairment, and polypharmacy. Additionally, older adults often have vague symptomology, nondiagnostic electrocardiograms, and a reported delay of treatment. Although multiple clinical guidelines are available, the applicability of guidelines to the older population needs to be evaluated based on a holistic, individualized basis. Emphasis should be on patient-centered outcomes and priorities, incorporating risk-benefit assessment, quality of life, functional assessment, and frailty assessment when making treatment decisions.     

床旁超声量化评估重症患者肌肉的研究进展

重症监护室(ICU)患者意识水平的限制给肌力评估带来巨大的挑战,而肌肉超声检查无需患者配合,且能够客观地观察到肌肉横截面积、厚度、回声强度和羽状角等参数的显著变化,可在ICU早期识别肌肉萎缩。同时,肌肉超声技术易被ICU医生和护士掌握,表现出良好的信度,对识别ICU获得性衰弱高风险患者有一定的意义。此外,超声量化评估肌肉对预测患者结局具有良好的价值。目前仍缺乏超声对ICU获得性衰弱诊断价值的大样本研究,标准化的超声评估方案亦需进一步探讨。     

Clinical formulation for mental health nursing practice

There are problems for mental health nurses in using psychiatric diagnoses as outcomes of their nursing assessments and nursing diagnoses present similar issues. However, there is a need in practice to link the assessment to nursing interventions in a meaningful way. This paper proposes that the clinical formulation can be regarded as central to providing this cohesion. The formulation does not merely organize the assessment findings but is also an interpretation or explanation, made in consultation with the client, of what meaning can be attributed to the issues explored in the assessment process. Because this interpretation is dependent on both the client's and the nurse's explanatory frameworks, there are multiple ways of developing the formulation. It is also an evolving and dynamic statement of understanding. A case example is provided in the paper to illustrate how the same case can be interpreted in different ways and the implications this has for the nursing interventions provided.     

Measuring nursing activities using an ecological momentary assessment method

The ecological momentary assessment method proved to be an effective and efficient method for conducting a study to assess nursing activities across a number of hospital settings and geographic distances. Nurse administrators and outcomes researchers who are seeking to measure and assess nurse activities should consider using this approach.     

Spinal cord compression: an oncologic emergency associated with metastatic cancer: evaluation and management for the home health clinician

Spinal cord compression is an oncologic emergency that needs to be identified, evaluated, and treated promptly for favorable patient outcomes. Although there are nonmalignant types of spinal cord compression, this article focuses on patients presenting with metastatic cancer. Home care clinicians should be knowledgeable with current assessment strategies aimed at recognizing this potentially debilitating condition. Using an assessment tool could assist clinicians with early detection of spinal cord compression, which could improve the overall quality of life.     

护理硕士专业学位研究生临床能力考核探讨

目的了解护理硕士专业学位研究生临床能力培养与考核中存在的问题。方法采用床旁整体护理查房、操作考核、病历与轮转记录检查、带教教师访谈等方式进行考核。结果护理硕士专业学位研究生的职业思想评价良好,病历书写和整体护理能力较为薄弱。结论护理硕士专业学位研究生的临床能力培养有待加强,应充分调动导师和带教教师的积极性,建立和完善临床能力考核机制和考核结果处置管理制度。     

Patient- and clinician-rated outcome measures for clinical decision making in rehabilitation

Outcome measures can be classified as clinician rated and patient rated. Clinician-rated measures predominantly assess impairments, whereas patient-rated measures, also known as patient-based measures, are designed to evaluate the impact of the injury on a patient's daily activities, work, and recreation. Currently, there is a greater reliance on clinician-rated impairment measures for clinical decision making, specifically with treatment planning and assessing outcomes of care. To comprehensively evaluate the effect of an injury, patient-rated outcome measures must be used because they allow for the assessment of a patient's ability to perform daily activities and participate in work and recreation that is affected by an injury. Clinician-rated impairment measures should be used to guide the development of a treatment program, and patient-rated measures should be used for both treatment program development and assessing treatment outcomes in daily clinical practice. The purposes of this article are to describe patient- and clinician-rated outcome measures and to provide guidance and illustrate the benefits of the use of these measures in clinical decision making and documenting outcomes of care.     

Program evaluation as a method of assessing the quality of care in physiotherapy

Assessing quality of care is a topical subject in physiotherapy. This paper traces the involvement of the Canadian Physiotherapy Association in quality assessment, and describes the components of the quality assessment process in relation to professionally defined standards. It considers available information as to whether process studies, outcome studies, or a combination of these should be undertaken in determining the quality of care. Finally it proposes the use of a comprehensive program evaluation to assess the quality of care in a physiotherapy program for stroke patients. Four steps in the use of this model are outlined: assessment of needs; formulation of program goals; definition of program and design of evaluation; and assessment of process and outcome. The use of this model is advocated for it provides information on how and why a program does or does not make its desired impact.     

Clinical outcomes assessment in sport rehabilitation

Evidence-based practice is an established guiding principle in most medical and health care disciplines. Central to establishing evidence-based practice is the assessment of clinical outcomes. Clinical outcomes represent a form of evidence on which to base medical decisions, as well as providing the mechanism for assessing the effectiveness of evidence-based interventions. However, clinical outcomes are not routinely assessed in sport rehabilitation. If sport rehabilitation clinicians fail to incorporate clinical outcomes assessment and, as a result, evidence into daily practice, they may be missing an opportunity to improve patient care and putting their professional reputation at risk within the medical community. The purposes of the article are to highlight the emergence of clinical outcomes assessment in the medical community and the current health care system, illustrate the role of clinical outcomes assessment as it pertains to providing the best patient care, and identify challenges that could potentially impede the implementation of outcomes assessment in sport rehabilitation.     

Beyond health outcomes: the advantages of measuring process

The use of process measures in the assessment of the quality of care has been neglected of late. The outcomes movement has gathered momentum and process measurement appears to have been left trailing in the wake. Yet process measures can be sensitive indicators of the quality of care and have many advantages over outcomes. They are readily measured and can easily be interpreted; comparisons are not essential (as they are with outcomes monitoring) but even if used they are little bothered by the case-mix arguments which bedevil outcomes assessment. Further, the direct measurement of process can directly indicate deficiencies of care which need to be remedied. Finally, there are some aspects of care which are only amenable to study using measures of process. These benefits come at a price: first there must be good evidence that links the processes of care to desirable outcomes. This paper explores the advantages of measuring processes of care in quality assessment and advocates a balanced approach to the process vs. outcome debate.     

Quality-of-care assessment. II. Outpatient medical care following hospital dismissal after myocardial infarction.

This study was undertaken to compare process and outcome methods of quality assessment of medical care in outpatient office practice. Follow-up care after hospitalization for first acute myocardial infarction was used as the model. One hundred fifty-two patients followed up for a minimum of 2 years comprised the study group. An expert committee of cardiologists and internists in community practice established the process criteria for satisfactory care and predicted outcomes of continuing disability and mortality. Using weighted process criteria and a weighted performance index permitted demonstration of a significant association between process items performed at the first posthospitalization visit and 2-year mortality. A significant association could not be demonstrated between later process of care and outcome at 2 years. The outcome assessment study disclosed that predicted disability and mortality rates compared closely with observed outcomes. However, this method for evaluating the quality of outpatient medical care is weakened because little information is available to provide the basis of prediction of satisfactory outcome rates in complicated cases. Although both the process and outcome methods of quality assessment have short comings, the latter method is recommended because satisfactory outcomes is the essential criterion of quality medical care. Moreover, when process items are not specified outcome assessment maintains the flexibility of individual physician practice. Refinement of satisfactory outcome prediction for common illnesses managed in office practice should be the goal for future studies.     

A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy

BACKGROUND: Opioid analgesics are the cornerstone of management for malignant pain. Their use in managing chronic, nonmalignant pain, albeit controversial, has increased in recent years. The decisions about whether to initiate opioid therapy or continue it over time should be guided by a comprehensive patient assessment. During long-term treatment, this assessment should focus on a broad range of outcomes, each of which should be documented in the medical record. OBJECTIVE: The goal of this study was to develop an instrument, the Pain Assessment and Documentation Tool (PADT), to focus on key outcomes and provide a consistent way to document progress in pain management therapy over time. METHODS: Items that assess 4 domains (pain relief, patient functioning, adverse events, and drug-related behaviors) were generated with input from a MEDLINE literature search and experts in pain and addiction management. The original tool was field tested by clinicians who applied it to the assessment of patients receiving long-term opioid therapy for the management of chronic, nonmalignant pain. Data analysis and debriefing telephone interviews with a formalized set of questions were then used to rephrase, delete, and refine items to create the final tool. RESULTS: A 6-member expert panel contributed to the initial development of the PADT. Twenty-seven clinicians completed the preliminary version of PADT for 388 patients. The original 59-item tool was modified to create a 41-item tool. The revised PADT was formatted for use as a chart note designed to assist clinicians in assessing and documenting 4 main outcome domains during long-term opioid use. CONCLUSIONS: In this study, the PADT appeared to be a useful tool for clinicians to guide the evaluation of several important outcomes during opioid therapy and provide a simple means of documenting patient care.     

Keeping the hospice spirit alive in client satisfaction surveys

Funding bodies and accreditation organizations now demand objective data from hospice evaluations, and quantitative measures assessing outcomes. This is despite the fact that the goals and outcomes of hospice practice are not reductionist and are not easily quantified. One alternative to this bureaucratic challenge that does not necessitate compromise to hospice ideology is to develop an assessment tool through qualitative research using phenomenological data on carers' insights with regard to hospice practice. In this article, the findings from the qualitative research that preceded the development of the assessment tool provide an insight into the key issues that carers give priority in evaluating a hospice. These findings provide valuable baseline data for understanding aspects of hospice practice that are valued by carers. The information gathered is a significant affirmation of the success of the hospice ideology and highlights the need to protect this precious philosophy. In short, it is an important statement about the need to keep the hospice spirit alive in client satisfaction. The findings from the qualitative study for the questionnaire can be interpreted as an affirmation to hospice workers that their vision and beliefs are valued and appreciated by those they serve.     

T ACTICAL E MERGENCY C ARE,M ILITARY AND O PERATIONAL O UT-OF -H OSPITAL M EDICINE

To improve the outcomes of stroke patients, public awareness of stroke must be increased and emergency medical services (EMS) response to stroke calls optimized. Rapid response to stroke is key, as emphasized in the American Stroke Association's “Stroke Chain of Survival,” which consists of four components—rapid recognition of and reaction to stroke warning signs through immediate use of the 9-1-1 system; rapid EMS assessment; priority transport with prenotification of the receiving hospital; and rapid and accurate diagnosis and treatment at the hospital. Neither the risk factors for stroke nor the most common warning signs are adequately known to the public in general, and in particular, to the groups at highest risk for stroke. Effective education through mass media and health care professionals is paramount in increasing the public's awareness of stroke. Whether tools to aid dispatchers and paramedics in stroke diagnosis, assessment, and management can improve stroke patients' outcomes requires further study, as does the value of designated stroke centers. Overall, according stroke the same urgency as acute myocardial infarction, from both the public and the prehospital provider perspectives, might improve stroke patient outcomes.     

Perspectives on research in patient teaching

Selection of outcome measures needs to go beyond assessment of knowledge gains to include indicators of adherence to the self-care regimen and health outcomes. Because standard didactic approaches are relatively ineffective in fostering participation in self-care, program content should be individualized and may need considerable reinforcement. In studies of program effectiveness, both the experimental and the comparison conditions should be monitored. Although a wide variety of patient, educator, and situational characteristics may mediate program efficacy, a lack of theoretically based studies and insufficient replication precludes generalizable conclusions about these or other aspects of patient teaching.