Possibilities for cost containment in intensive care

An intensive care unit (ICU) is valuable but consumes a disproportionately high amount of health-care resources. Accordingly, cost containment has been deemed a mandatory task. A review of the literature from many countries was completed to determine the strategies for reducing the cost of care in the ICU. The results of this review show that cost reduction can be achieved by using a variety of the following strategies: (i) instituting a closed ICU, where all the patient care is directed by intensivists or full-time critical care trained physicians; (ii) the utilization of interdisciplinary approaches to the care of patients in the ICU; (iii) developing and implementing a program of television-guided remote intensivists; (iv) the use of an alerting and reminding system; and (v) increasing the number of intermediate care beds for patients who require only monitoring and intensive nursing. The conclusion reached is that many of these strategies provide evidence for hospital manager decisions regarding cost containment strategies for the delivery of health care in the ICU.     

Evidence-based practice. A philosophical and political analysis: some matters for consideration by professional practitioners

This paper evaluates the concept of evidence-based practice (EBP) and appraises critically the implementation process of the EBP initiative, noting its consonance with the aspirations of the dominant political culture and offering a critique of the inherent contradictions and ethical dilemmas associated with it. A critical evaluation of the implications for practitioners and service users is offered and the authors argue that while the concept of EBP is a laudable one, there is a need to exercise caution about uncritical acceptance and evidence that a more eclectic and less reductionist approach to EBP is essential for quality service development.     

护理疏忽与护理职业道德及法律责任的相关性分析

在执行专业权责时,医护人员的行为同时被职业道德和法律所规范和约束。当医护人员的医疗行为出现问题时,多方的责问便接踵而 来。通过对临终护理的案件分析,理清“照顾疏忽”在职业道德及法律上的含义,探讨因“照顾疏忽”而导致的责任追究问题。刻意的“照顾疏 忽”是职业道德及法律所不允许的;若因无意造成的“照顾疏忽”,护士须了解医疗事故的法例是在公平公正的原则下保护医患双方的合法权 益。因此,护士应坦诚面对问题,并懂得如何对其护理行为的法、理、情等依据做出论证。通过护士与患者及其家属的沟通,建立互相信赖的护 患关系。     

当前我国护士实行医疗责任保险的现状分析与对策

综述了当前为护士实行医疗责任保险的必要性 ,分析了制约其发展的因素 ,例如 :缺乏护理职业保险专业性、观念落后、人才缺乏、缺少法律认同的统一的赔付标准等 ,并对护理人员实行医疗责任保险提出了建议     

Snyder v. American Association of Blood Banks: a re-examination of liability for medical practice guideline promulgators

Medical practice guidelines are playing an increasingly important role in both the medical and the legal context. As tools for the health practitioner, it is thought that medical practice guidelines may contribute to an increase in the quality of patient care and cost-effectiveness. In the legal setting, guidelines may improve the functioning of the medical malpractice system by creating more rational, predictable standards of care. The development and promulgation of medical practice guidelines, while increasing, are still evolving. A number of concerns, especially in the areas of physician autonomy, physician control, and ethics, as well as efficacy, need to be resolved. The use of such guidelines as the legal standard of care in malpractice cases evokes similar concerns, along with fears that the use of guidelines at trial may either lower the standard of care, or, conversely, raise the standard of care to levels that are difficult to meet. Adding to this controversy is the recent case of Snyder v. American Association of Blood Banks (1996), in which the New Jersey Supreme Court upheld a jury finding that the American Association of Blood Banks (AABB) was liable to a plaintiff who contracted AIDS from an HIV-tainted transfusion, for negligent failure to adopt guidelines requiring blood testing for surrogate markers. This opinion is significant as the first to find a duty of care running from a medical guideline promulgator to a third person, the injured patient. The opinion is examined in depth and within the context of other relevant case law. The impact the opinion will have is difficult to gauge. The somewhat unique facts of the case, as well as the court's unusually stinging critique of the defendant, AABB, and its motivations informing its response to the concerns about blood contamination, may limit its value as precedent. However, precedent does exist in analogous non-medical cases for promulgator liability. The pros and cons of promulgator liability are weighed. While closer regulation of guideline development and promulgation or promulgator immunity may be warranted, it is premature to consider either seriously until the impact of the Snyder opinion can be appreciated.     

Effects of a preceptorship programme on turnover rate,cost, quality and professional development

Aim and objectives. The purpose of the present study was to design a preceptorship programme and to evaluate its effects on turnover rate, turnover cost, quality of care and professional development. Background. A high turnover rate of nurses is a common global problem. How to improve nurses’ willingness to stay in their jobs and reduce the high turnover rate has become a focus. Well‐designed preceptorship programmes could possibly decrease turnover rates and improve professional development. Design. A quasi‐experimental research design was used. Methods. First, a preceptorship programme was designed to establish the role and responsibilities of preceptors in instructing new nurses. Second, a quasi‐experimental design was used to evaluate the preceptorship programme. Data on new nurses’ turnover rate, turnover cost, quality of nursing care, satisfaction of preceptor’s teaching and preceptor’s perception were measured. Results. After conducting the preceptorship programme, the turnover rate was 46·5% less than the previous year. The turnover cost was decreased by US$186,102. Additionally, medication error rates made by new nurses dropped from 50–0% and incident rates of adverse events and falls decreased. All new nurses were satisfied with preceptor guidance. Conclusions. The preceptorship programme effectively lowered the turnover rate of new nurses, reduced turnover costs and enhanced the quality of nursing care, especially by reducing medication error incidents. Positive feedback about the programme was received from new nurses. Relevance to clinical practice. Study findings may offer healthcare administrators another option for retaining new nurses, controlling costs, improving quality and fostering professional development. In addition, incentives and effective support from the organisation must be considered when preceptors perform preceptorship responsibilities.     

The new Japanese postgraduate medical education and quality of emergency medical care

Background

The new postgraduate medical education (PGME) was recently introduced to improve quality of emergency care in Japan.

Objectives

To compare the quality of care and confidence in provision of emergency medicine between physicians who completed the old and new PGME programs.

Methods

A cross-sectional survey was sent to 279 physicians of postgraduate years 4–9, and 208 responses (75%) were received. Quality of care in emergency medicine was measured using 26 questions on treatment choices for various clinical conditions. Each question had six responses, including a single correct choice. Effect size was obtained by dividing the total difference in score by the standard deviation of the score distribution. Confidence in emergency medicine was rated using four self-reported items on the level of confidence in treating acute illnesses in various emergency medicine settings.

Results

The mean score for quality of care was significantly higher in the new PGME group (15.3) compared to the old PGME group (12.8). The difference in scores was 2.5 (p < 0.01) and the effect size (0.47) indicated a moderate difference. Linear regression of total scores adjusted for physician covariates produced similar results of an adjusted score difference of 2.5 (p < 0.01) and an adjusted effect size of 0.47. The new PGME group also had significantly greater confidence in provision of emergency medicine based on significant differences between the groups for all four self-reported items (all p < 0.05).

Conclusions

Japanese physicians who complete the new PGME program are likely to provide higher quality of care and have greater confidence in emergency medicine compared to those who completed the old PGME program.     

医疗费用纠纷的原因分析及防范措施

笔者分析医疗收费纠纷的因素：物价指数上涨；医疗体制改革；新诊疗项目的应用；人群综合素质提高：信息系统收费目录初始化不完善；护士操作信息系统及护理技术不规范；护理人员自律不严等。提出防范措施：充分发挥医院信息系统的管理效应，从费用发生点、医嘱录入关抓起。规范护理人员的操作。培养护理人员的良好职业道德，完善网络建设和管理。     

论医学实习生心理健康教育

就业与考研的压力以及实习的环境是影响医学实习生心理健康的主要因素。通过学校科学岗前培训和医院创造良好的条件等构建心理健康教育体系,可有效预防和早期干预医学实习生的心理问题,有利于提高学生的身心健康水平和临床实习质量。     

The impact of management of change projects on practice: a description of the contribution that one educational programme made to the quality of health care

This paper is based on the authors' experience of teaching and supervising the first intake of the management unit of the diploma for charge nurses offered by the Department of Professional Development and Training, Glasgow College of Nursing and Midwifery, Glasgow, Scotland. The students on this course undertake a project comprising of a documented research-based action plan aimed at the achievement of a selected topic for change directly linked with their practice. All the students except one were G grade charge nurses from a wide variety of clinical backgrounds. This paper will briefly consider the work of Barriball et al. who suggest categories of outcomes of continuing professional education. This is contrasted with Scheller, who highlights three problems when attempting to measure the impact of continuing education on practice. Despite these problems, it is beneficial to attempt to consider the impact of continuing professional education on practice. The work of Francke et al. will be featured in which they ascertain the determinants of changes in nurses' behaviour after continuing professional education. The authors believe that the management of change project, undertaken by the students, enhances the possibility that knowledge gained from the management unit will impact on their practice. Two examples of students' projects will be used to support the paper. The first concerns changing to a 12-hour shift pattern in an intensive care setting and the second relates to the implementation of the named nurse system.     

Assessment of individual vaccine status in a vaccinology experts' group

Rationale  Worldwide, experts in vaccinology have promoted the broad annual coverage of health care workers with the influenza vaccine. Furthermore, pertussis vaccination is now recommended for young adults and health care workers working with newborns.
Aim  To analyse the compliance with these guidelines among experts responsible for the development or dissemination of national immunization schedules.
Method  A cross-sectional survey was conducted in a vaccinology workshop group of French experts, using a self-administered questionnaire.
Results  Among 44 experts, the average rate of influenza vaccination was 69.5% (95% confidence interval, 61.6% to 77.3%) between the 2003/04 and 2005/06 flu seasons, whereas the rate of pertussis vaccination during this period was only 30%. The main reasons that the experts gave for not being vaccinated were a lack of time or simply not remembering to do so.
Conclusion  Experts had low coverage rates for influenza and pertussis vaccination. To improve these rates, a multifaceted intervention combining audit and feedback strategy with a vaccine day is planned.     

Clinical indicators as measures of mental health nursing standards of practice in New Zealand

This paper discusses the utility of Consumer Notes Clinical Indicators (CNCI) as a means to monitor mental health nursing clinical practice against the Australian and New Zealand College of Mental Health Nurses' (ANZCMHN) Standards of Practice for mental health nursing in New Zealand. CNCI are statements describing pivotal mental health nursing behaviours for which evidence can be found in the nurses' case notes. This paper presents 25 valid and reliable CNCI that can be used to monitor mental health nursing practice against the ANZCMHN's Standards of Practice for mental health nursing in New Zealand. The bicultural clinical indicators were generated in focus groups of Maori and non-Maori mental health nurses, prioritized in a three-round reactive Delphi survey of expert mental health nurses and consumers, pilot tested, and applied in a national field study. This paper reports the development and validation of the CNCI, for which achievement is assessed by an audit of the nursing documentation in consumer case notes. The CNCI were tested in a national field study of 327 sets of consumer case notes at 11 District Health Board sites. The results of the national field study show wide variation in occurrence of individual indicators, particularly in the areas of informed consent, information about legal rights, and provision of culturally safe and recovery-focused care. We discuss the implications of using the CNCI to assess the professional accountability of mental health nurses to provide quality care. Recommendations are made regarding the application of the clinical indicators and future research required, determining appropriate benchmarks for quality practice. The CNCI could be adapted for application in other mental health nursing and other mental health professional clinical settings.