Pharmaceutical care for HIV patients on directly observed therapy

BACKGROUND: Inner-city patients infected with HIV can be a challenging group to treat. Homelessness, mental illness, substance abuse, and hepatitis C infection may serve as barriers to effective treatment. A multidisciplinary team including the pharmacist can impact upon the delivery of care to the inner-city HIV patient population. OBJECTIVE: To describe the implementation and provision of pharmaceutical care to inner-city patients taking directly observed therapy (DOT), as well as drug-related problems (DRPs) and their respective outcomes. METHODS: Pharmaceutical care, including the prospective identification and management of DRPs, was provided by a clinical pharmacist. RESULTS: Fifty-seven patients were followed over a 14-month period. Overall, 149 DRPs were identified and >95% were resolved. Those included (1) adverse effects (n = 56; gastrointestinal, central nervous system effects, allergies, laboratory abnormalities), (2) drug interactions (n = 32), (3) drugs indicated for comorbidities (n = 24; safety in pregnancy, tuberculosis, Pneumocystis carinii pneumonia prophylaxis, oral candidiasis, herpes zoster, nutritional supplements), (4) adherence issues (n = 20; altering timing of medication, changing formulation, decreasing pill burden), (5) drugs no longer indicated (n = 10; opportunistic infection prophylaxis, treatment of primary infection), and (6) dosage adjustment (n = 7) for weight and renal insufficiency. CONCLUSIONS: In the provision of pharmaceutical care to HIV-infected patients on DOT, an HIV pharmacist significantly contributed to antiretroviral selection, monitoring of drug therapy, and managing DRPs. An HIV pharmacist can assist in promoting patient adherence and improved outcomes in this setting.     

Enhancing care for cardiac resynchronization therapy patients: device diagnostics and clinical application

Implantation of a cardiac resynchronization device in patients with heart failure does not attenuate the vigilant monitoring required by clinicians. Daily information about symptoms, quality of life, and weight are often part of routine care. Cardiac resynchronization devices also contain data on various heart failure parameters that can be obtained in or out of clinic. A number of cardiac resynchronization devices now have the ability to transmit such data to secure Internet sites, which can be accessed by clinicians. Incorporating these device data into daily practice can enhance current care. For instance, such data can confirm subjective patient reporting, help diagnose changes in the patient's condition, assist in deciding what changes to make in pharmacologic therapy, and assess the impact of device or pharmacologic therapy. Reviewing and utilizing device diagnostics may allow clinicians to intervene before a decompensation event and prevent a subsequent hospitalization. It is also likely that these device diagnostics can reduce the amount of time cardiovascular nurses spend on patient follow-up, thus enhancing efficiency in the clinical setting.     

Implementation of a change process to improve outcomes of patients admitted to epilepsy monitoring unit

A continuous quality improvement in health care, combined with measurement of patient and organizational outcomes, is an international trend that promises improvement in meeting the needs of health care consumers in a cost-effective manner. A clinical improvement workshop was conducted in our institution to study the practical methods that can be used by clinical teams to improve the quality and value of health care. This workshop enabled the Epilepsy Team to identify change strategies that potentially could accelerate clinical improvement efforts in the epilepsy monitoring unit (EMU). The Team was able to develop, plan, and test improvements and link these improvements to patient outcomes.     

Monitoring and evaluation in the special care unit: the JCAHO ten-step process

Monitoring and evaluating the quality and appropriateness of patient care in the special care unit is the basis for quality assurance activities. To make the monitoring and evaluation process helpful, health care professionals in special care units must be involved in each step of the process. The focus must be on patient care, specifically on clinical aspects of care rather than on structural specifications or technical processes. In addition to assisting the special care unit to meet accreditation requirements, ongoing monitoring and evaluation assist that unit to assure high-quality care. Monitoring and evaluation activities also assist the special care unit manager in responding to demands of state and federal regulators by providing an objective assessment of the care provided to Medicare and Medicaid patients. These activities also can provide assistance in responding to concerns about lawsuits involving alleged negligence in provision of special care; and in meeting pressures from third-party payers to reduce costs associated with unnecessary treatment in special care units. This chapter describes how the ten-step monitoring and evaluation process can be used to help assure high-quality patient care in the special care unit.     

Primary care: promoting sexual health and HIV prevention through risk assessment and client education

After 20 years, human immunodeficiency virus (HIV) is still a global health problem, mandating the need to incorporate HIV prevention into primary care. This report presents tips and examples to assist in conducting a clinical, drug use, and sexual risk assessment, using the term TOSSIS to cover HIV transmission sources. Nurse practitioners can also assist in HIV prevention by serving as patient and parent educators.     

Quality assurance to quality improvement: the impact of the agenda for changes

Health care professionals are committed to the continual improvement of the quality of patient care. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has launched a major research and development project intended to improve its ability to evaluate health care organizations and encourage greater attention to the quality of daily patient care. This chapter describes JCAHO's challenge to evaluate capability and performance of health care organizations and practitioners. The intent of JCAHO's agenda for change is to focus on patient outcomes and quality improvement through a more precise and objective evaluation of both clinical and managerial performance. Through the agenda for change, JCAHO and the health care organization will participate in a continuous-flow monitoring system in which clinical and organizational data are transmitted from the field to JCAHO, analyzed, and fed back to the health care organization.     

Pulse oximetry in the accident and emergency department.

The early detection and treatment of hypoxia is important to reduce patient morbidity in the accident and emergency department. At present, the commonly used methods all have practical difficulties in the urgent situations that prevail in the department. Pulse oximetry has recently become a method of choice in many anaesthetic and intensive care units for the continuous monitoring of oxygenation and the early detection of hypoxia. As similar conditions prevail in the accident and emergency department, we have attempted to evaluate its ease of use and the quality of information obtained in our department. Patients presenting with chest pain to an accident and emergency department have their oxygen saturation measured by the pulse oximeter finger probe prior to the commencement of oxygen therapy. After 5 min of oxygen therapy, the measurement was repeated. Our result showed that although no patients could be judged as hypoxic on clinical grounds the pulse oximeter showed, within 30 s of admission, that a number had an abnormal oxygen saturation. Continuous monitoring with the probe after the application of low flow oxygen therapy also aided in monitoring their treatment and this improvement was again easily and quickly recorded. Our experience shows that the pulse oximeter may be a useful tool for evaluating hypoxia and oxygen therapy in the accident and emergency department and we feel that we should be one of the groups who should reply in the positive to Zorab's question, 'Who needs pulse oximetry?' (Zorab, 1988).     

Human Immunodeficiency Virus: What Primary Care Clinicians Need to Know

Human immunodeficiency virus (HIV) has evolved from an illness that consistently led to death to a chronic disease that can be medically managed. Primary care clinicians can provide beneficial care to the individual patient and potentially decrease the transmission of HIV to others through appropriate HIV screening and recognition of clinical clues to both chronic and acute HIV. Most patients who take combination antiretroviral therapy experience immune reconstitution and resume normal lives. These patients benefit from the care of an experienced primary care clinician in addition to a clinician with HIV expertise. Primary care clinicians have expertise providing preventive care, including counseling regarding healthier lifestyle choices and managing cardiovascular risk factors, osteoporosis, hypertension, and diabetes, all of which have become increasingly important for individuals with HIV as they age. This article reviews the many important roles of primary care clinicians with regard to the HIV epidemic and care of patients with HIV.     

A simulation study to improve quality of care in the emergency department of a community hospital

In this article, a computer simulation study to improve the quality of care at the emergency department at a community hospital in Lexington, Kentucky, is presented. The simulation model is capable of evaluating the quality of care in terms of length of stay, waiting times, and patient elopement and has been validated by being compared with the data collected in the emergency department. Sensitivity analyses have been carried out to investigate the impact of workforce and diagnosis equipment on quality performance. The results suggest that, to ensure better clinical outcome, more nurses are needed; in addition, an additional computed tomography scanner is recommended. The model also shows that implementing team nursing policy (for 2 nurses) could lead to significant improvement in the emergency department's quality of care. Such a model provides a quantitative tool for continuous improvement and flow control in the emergency department and is also applicable to other departments in the hospital.     

HIV nursing consultants: patients' preferences and experiences about the quality of care

Aim and objectives. We were interested to find out how human immunodeficiency virus (HIV)‐patients judge the quality of care received from their HIV nursing consultants, compared with the care delivered by HIV specialists and general practitioners. Furthermore, we were interested in how the opinions of HIV patients on the HIV nursing consultant compared with the opinions of patients with rheumatic diseases on the care they receive from their specialized nurses. Background. The role of nurses has changed over the years. For patients with chronic diseases there seems to be an increasing role for nursing consultants in the delivery of care. In evaluating quality of care, patients’ views are considered important especially for the chronically ill who can be seen as experts by experience. Methods. Between February 1999 and June 2000, 250 patients, receiving care from both general practitioner and specialist, received a questionnaire [Quality of Care Through the Patient's Eyes (QUOTE)‐HIV] to assess HIV‐related quality of care, as perceived by them. Aspects were formulated as ‘importance’ and ‘performance’ statements. Items were scored on 4‐point scales. A ratio score (R_ij = P_ij/I_ij) was calculated by dividing the perceived performance score (P) of an individual patient (i), on a health service (j) by his importance score (I). A comparison was made with patients with rheumatic diseases by using data from the QUOTE‐Rheuma. Results. Patients judged the quality of care from the HIV nursing consultant as predominantly good. Five aspects showed an unfavourable ratio score (R < 1.0) which indicates room for improvement. On the dimensions ‘professional performance’ and ‘attitude of the professional’ the HIV nursing consultant scores between the general practitioner and the HIV specialist. Patients with rheumatic diseases seemed to be more satisfied than HIV patients with the care from their nurse consultant. Conclusions. The HIV nursing consultants have an important role in the care of patients infected with HIV. The HIV nursing consultants are judged as good and are ranked in between the general practitioner and the HIV specialist. Given the orientation towards a more integrated care for chronically ill patients, there should be more attention paid to the position of the HIV nursing consultant. Relevance to clinical practice. In the Netherlands and in the United Kingdom there is a tendency to a greater degree of differentiation of tasks in health care. This study shows that there is room for a position like the nursing consultant and that this is highly valued by patients.     

Translating family satisfaction data into quality improvement

BACKGROUND: Improvement of clinical care requires measurement of key dimensions of health care quality and action based on these measurements. Families, data analysts, clinicians, and administrators all have important roles to play. OBJECTIVE: To outline an approach to the measurement and utilization of family satisfaction data so that these data can be translated into health care quality improvement initiatives. DESIGN: Using a synthesis of existing knowledge about translation of satisfaction data into improvement strategies, this approach starts with selecting and implementing a satisfaction survey that reflects the key processes, providers, and places for the delivery of critical care. The survey results can be expressed in a way that prioritizes the opportunities for improvement. A comparison of results across sites, or use of a performance-importance grid, can assist in this prioritization process. High-priority items can then be addressed by the multidisciplinary intensive care unit team using a systematic, evidence-based approach to improvement that includes implementation strategies that have been proven to effectively change clinician behavior.     

Clinical leadership: using observations of care to focus risk management and quality improvement activities in the clinical setting

In an era when patient safety and quality of care are a daily concern for health care professionals, it is important for nurse managers and other clinical leaders to have a repertoire of skills and interventions that can be used to motivate and engage clinical teams in risk assessment and continuous quality improvement at the level of patient care delivery. This paper describes how a cohort of clinical leaders who were undertaking a leadership development program used a relatively simple, patient-focused intervention called the 'observation of care' to help focus the clinical team's attention on areas for improvement within the clinical setting. The main quality and safety themes arising out of the observations that were undertaken by the Clinical Leaders (CLs) were related to the environment, occupational health and safety, communication and team function, clinical practice and patient care. The observations of care also provided the CLs with many opportunities to acknowledge and celebrate exemplary practice as it was observed as a means of enhancing the development of a quality and safety culture within the clinical setting. The 'observation of care' intervention can be used by Clinical Leader's to engage and motivate clinical teams to focus on continuously improving the safety and quality of their own work environment and the care delivered to patients within that environment.     

The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety – A realist evaluation

Primary care streaming was implemented in UK Emergency Departments (EDs) to manage an increasing demand for urgent care. We aimed to explore its effectiveness in EDs with different primary care models and identify contexts and mechanisms that influenced outcomes: streaming patients to the most appropriate clinician or service, ED flow and patient safety.MethodWe observed streaming and interviewed ED and primary care staff during case study visits to 10 EDs in England. We used realist methodology, synthesising a middle-range theory with our qualitative data to refine and create a set of theories that explain relationships between contexts, mechanisms and outcomes.ResultsMechanisms contributing to the effectiveness of primary care streaming were: quality of decision-making, patient flow, redeploying staff, managing patients across streams, the implementation of governance protocols, guidance, training, service evaluation and quality improvement efforts. Experienced nurses and good teamworking and strategic and operational management were key contextual factors.ConclusionWe recommend service improvement strategies, operational management, monitoring, evaluation and training to ensure that ED nurses stream patients presenting at an ED seeking urgent care to the most appropriate clinicians for their needs in a safe and efficient manner.     

The Southern Alberta Renal Program database: a prototype for patient management and research initiatives

The Southern Alberta Renal Program (SARP) database was developed to respond to an urgent need for local information on clinical outcomes, laboratory information, and health care costs, and to enable our local renal program to monitor the implementation of established clinical practice guidelines. The database captures detailed demographic, clinical, and laboratory information and is unique by also capturing comorbidity, health-related quality of life and costing information for patients with end-stage renal disease (ESRD) in southern Alberta, storing the information in one common database. By collecting information on patient comorbidity, health outcomes and costs, the SARP database has enabled many quality assurance initiatives as well as research opportunities for projects involving patients with ESRD. Due to the availability of links with other available local clinical and administrative databases, information is collected with a minimal need for manual data entry. This type of database is a method by which health programs could improve the quality of patient care. Programs caring for patients with chronic medical conditions such as ESRD should examine how computer databases could assist in clinical care and improve the efficiency with which that care is delivered to their patients.     

Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative

Rationale and aims In several countries, collaborative improvement programmes involving multiple health care organizations have been developed to address the issue of patient safety and reliability of care at an organization‐wide level. In the UK, the Health Foundation's Safer Patients Initiative (SPI) was developed to achieve breakthrough improvement in the quality and safety of care in 24 acute hospital Trusts between 2004 and 2008. Research evidence for the effectiveness of programmes of this type and the mechanisms by which positive outcomes are achieved remains limited. We report a multi‐method preliminary study based upon phase 1 of SPI to understand participant's perceptions of the local impact of the programme and to form the basis of future research in this area. Methods Data were collected on the perceived local impact of SPI on a range of clinical, organizational and social dimensions relating to care quality and safety. Data were collected retrospectively from local SPI programme improvement teams using semi‐structured interviews and surveys. Qualitative and quantitative analyses were performed, and the results synthesized under common themes and frameworks. Results Specific dimensions of care systems commonly considered to be affected by SPI, included culture, strategic priority, organizational capability and clinical care delivery. Survey data revealed the perceived importance for success of a range of programme components: quality improvement methodology, learning sessions and programme faculty support, along with predefined clinical practice changes. Safety climate and capability dimensions rated as most sensitive to the effects of the SPI programme related to multi‐professional engagement and communication, the degree of routine monitoring of care processes and the capacity to evaluate the impact of changes to clinical work systems. Conclusions Study findings support the view that programmes such as SPI have considerable impact upon the cultural, inter‐professional, strategic and organizational aspects of care delivery, in addition to clinical working practices. The specific implications for understanding the effects of complex organization‐level interventions and future research design are discussed.     

Cerebral Monitoring in the Operating Room and the Intensive Care Unit: An Introductory for the Clinician and a Guide for the Novice Wanting to Open a Window to the Brain

While there is an increasing body of knowledge in regard to central nervous system function and/or the mode of action of centrally active agents on neuronal function, little is done to develop new techniques on how to measure such changes. Also, monitoring of the cardiovascular system in the past has made extensive progress especially when it comes to evaluate the failing heart. In contrast monitoring of the central nervous system is only done in rare cases where operative procedures likely impede nervous function integrity. Since in the past decade the aging population undergoing operation has rise considerably, the risk of cerebral malperfusion or minute signs of degradation of the aging central nervous system (CNS) to anesthetics and agents being used in the operation room (OR) or the intensive care unit (ICU), needs continuous monitoring of an organ which presents the highest vulnerability and is likely to deteriorate faster than the cardiovascular system. In spite the rapid improvement in technology regarding the electroencephalogram (EEG) and evoked potential monitoring, physicians still are reluctant to use a technology on a routine base, which will give them insight information into brain function and activity. Such "windows to the brain" now not just are reserved to specialists working in the area of neurology and/or psychiatry. More so, cerebral monitoring is getting an integrated part in the overall therapy in patients undergoing operation or who need ventilatory support in the ICU as it effects the well-being and the outcome. The present book therefore, is intended for the practitioners who work with the patient, guide the clinician in his decision making and outlining those situations where cerebral monitoring presents an integrated part in the diagnosis and therapy of patient care. Without going too much into the technical details, representative cases underline the potential use of cerebral monitoring in the underlying clinical situation where either the patient presents borderline perfusion of the CNS, undergoes vascular surgery, or where monitoring of cerebral function in the intensive care in a head trauma patients is an integrated part in therapy.The book therefore is meant for all those clinicians who have to deal with the CNS in a day-to-day situation. This may be the anesthesiologist, the surgeon, the intensive care therapist, the nurse anesthetist as well as all other medical personal involved in intensive care therapy. The aim of the book therefore is to outline the possibilities, the limitations, and the options for therapy when the windows to the brain are opened, how to interpret the data in the light of other physiological parameters and aid the user in the technical details of how to avoid artifacts in recording which may have an impact on final decision making. Therefore, emphasis is placed on the electrode placement, artifact and electrical noise reduction, as well as data interpretation so that cerebral function diagnosis can be made on reliable grounds. The following serves as an introduction to and as a reference guide for Cerebral Monitoring in the OR and the ICU: Gives complete coverage of EEG power spectra analysis. Describes in detail the EEG machines available to be used in the OR and ICU setting. Describes in detail the major features of EEG power spectra and evoked potential measurements, including amplifiers, filter setting and microprocessor algorithm for data reduction. Gives suggestions for assessing and improving signal quality, including noise and artifact rejection, which usually are encountered in the operation room and the intensive care unit, both of which can be considered as electrically contaminated. Gives examples of EEG power spectra and evoked potential monitoring related to different types of anesthesia, in coma, after head trauma, and for the detection of ischemic events. In addition, gives complete coverage of those machines being available for the OR and the ICU, including a list of parameters regarding latency and amplitude in evoked potential As an introductory, recommendations are given for the novice to start cerebral monitoring and guide the beginner in setting up cerebral monitoring in the clinical environment.     

Improving quality of care in nursing facilities. Gerontological clinical nurse specialist as research nurse consultant

It is becoming increasingly common for nursing facilities to use Quality Indicators (QI) derived from Minimum Data Set (MDS) data for quality improvement initiatives within their facilities. It is not known how much support facilities need to effectively review QI reports, investigate problems areas, and implement practice changes to improve care. In Missouri, the University of Missouri-Columbia MDS and Nursing Home Quality Research Team has undertaken a Quality Improvement Intervention Study using a gerontological clinical nurse specialist (GCNS) to support quality improvement activities in nursing homes. Nursing facilities have responded positively to the availability of a GCNS to assist them in improving nursing facility care quality.     

Measuring quality in anatomic pathology

This article focuses mainly on diagnostic accuracy in measuring quality in anatomic pathology, noting that measuring any quality metric is complex and demanding. The authors discuss standardization and its variability within and across areas of care delivery and efforts involving defining and measuring error to achieve pathology quality and patient safety. They propose that data linking error to patient outcome are critical for developing quality improvement initiatives targeting errors that cause patient harm in addition to using methods of root cause analysis, beyond those traditionally used in cytologic-histologic correlation, to assist in the development of error reduction and quality improvement plans.     

Monitoring and treatment of severe bronchial ashma in adults: results of national multicenter trial NABAT

AIM: To study quality of monitoring, features of a course and therapy of severe bronchial asthma (BA) in Russia. MATERIALS AND METHODS: The trial recruited 378 patients with severe bronchial asthma (SBA) in 7 cities of Russia. Each center participating in the study filled in individual case sheets recording demographic, clinical, monitoring, pharmacotherapeutic data. A special focus was on factors influencing the disease course. The chi-square and Mann-Witney criteria were used. RESULTS: It was found that current recommendations of BA patients' management are not used in full. Most of the patients do not receive adequate therapy. Phenotypes of uncontrolled course of severe BA are prevalent. The key role of adequate management of severe BA patients in control of the disease is shown. CONCLUSION: Wider use of updated recommendations on therapy and monitoring of BA with special focus on patients with uncontrolled course of the disease is urgent. Fulfilment of all the components of management of a patient with bronchial asthma recommended by GINA including the patient education and control over the disease triggers contribute much to effective treatment and control over BA.