Feasibility and Acceptability to Patients of a Longitudinal System for Evaluating Cancer-Related Symptoms and Quality of Life: Pilot Study of an e/Tablet Data-Collection System in Academic Oncology

Programmed, notebook-style, personal computers (“e/Tablets”) can collect symptom and quality-of-life (QOL) data at the point of care. Patients use an e/Tablet in the clinic waiting area to complete electronic surveys. Information then travels wirelessly to a server, which generates a real-time report for use during the clinical visit. The objective of this study was to determine whether academic oncology patients find e/Tablets logistically acceptable and a satisfactory means of communicating symptoms to providers during repeated clinic visits. Sixty-six metastatic breast cancer patients at Duke Breast Cancer Clinic participated. E/Tablets were customized to electronically administer a satisfaction/acceptability survey, several validated questionnaires, and the Patient Care Monitor (PCM) review of symptoms survey. At each of the four visits within six months, participants completed the patient satisfaction/acceptability survey, which furnished data for the current analysis. Participant demographics were: mean age of 54 years, 77% Caucasian, and 47% with less than a college education. Participants reported that e/Tablets were easy to read (94%), easy to navigate (99%), and had a comfortable weight (90%); they found it easy to respond to questions using the e/Tablet (98%). Seventy-five percent initially indicated satisfaction with PCM for reporting symptoms; this proportion increased over time. By the last visit, 88% of participants indicated that they would recommend the PCM to other patients; 74% felt that the e/Tablet helped them remember symptoms to report to their clinician. E/Tablets offered a feasible and acceptable method for collecting longitudinal patient-reported symptom and QOL data within an academic, tertiary care, breast cancer clinic.     

Rehabilitation needs of an inpatient medical oncology unit

OBJECTIVE: To identify prospectively functional impairments and rehabilitation needs in an acute care medical oncology unit. DESIGN: Prospective cohort study. SETTING: Inpatient medical oncology unit at a Veterans Affairs hospital. PARTICIPANTS: Fifty-five patients admitted over a 6-month period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM instrument, functionally based physical examination, Rehabilitation Needs Assessment, and Recreational Needs Assessment. RESULTS: On admission, the mean FIM total score was 105 out of 126, the FIM motor score was 72 out of 91, and the FIM cognitive score was 34 out of 35. The functionally based physical examination did not generally correlate with scores obtained on the FIM. Forty-eight (87%) patients had rehabilitation needs on admission. Forty-six (84%) patients had rehabilitation needs on discharge. Rehabilitation Needs Assessment on admission showed deconditioning in 42 (76%) patients; mobility impairment in 32 (58%) patients; a significant decrease in range of motion in 23 (42%) patients; deficits in activities of daily living in 12 (22%) patients; a need for recreational therapy in 7 (13%) patients; potential for benefit from patient education in 30 (55%) patients; and a need for modalities, edema control, or wound care in fever than 5% of patients. The most commonly requested recreational activity was reading. CONCLUSIONS: Patients admitted to inpatient medical oncology units have many unmet, remediable rehabilitation needs that may not be recognized by nonrehabilitation physicians and other clinical staff. These findings suggest that assessment of medical oncology patients may be enhanced by consultation with rehabilitation medicine specialists.     

Knowledge,practice and faith on Total Quality Management principles among workers in the Health Care System: Evidence from an Italian investigation

Background The implementation of Total Quality Management (TQM) principles in the sanitary field, in order to be effective, requires a radical change in management practice as well as the organizational culture and its philosophy. The need to monitor such a transformation emerges too. Objectives This study surveys how well TQM principles are known and understood by health care professionals from the employees' point of view and the factors affecting it. Research design and subjects The Health Care System in Trieste was surveyed. Measures The Total Quality Test was used, a novel and quick instrument aimed at routine assessment of the penetration and interiorization of TQM principles within the health care structure. Results Direct exposure to public, job role and time spent working within the same structure have been proved related to the penetration of TQM principles, whereas previous formative intervention did not prove to be associated with the penetration of TQM principles. Conclusions The implementation of a quick and simple instrument to monitor the TQM implementation highlighted several critical areas for intervention.     

Initial management of candidemia at an academic medical center: evaluation of the IDSA guidelines

Treatment of candidemia is more complicated because of the changing epidemiology of Candida and introduction of newer antifungal agents. Utilization and benefit of practice guidelines and infectious disease consultation for the management of candidemia has not been previously described in the routine clinical setting. We prospectively studied the impact of the Infectious Disease Society of America (IDSA) guidelines for the management of candidemia and infectious disease consultation on clinical outcomes in 119 patients with candidemia at a tertiary care hospital. Medical records were reviewed to capture data concerning use of antifungal agents, management of central venous catheters, and infectious disease consultation. Initial antifungal therapy was consistent with the IDSA guidelines in 76% of patients. Variation from the guidelines was independently associated with higher mortality (24% versus 57%, P = 0.003). Infectious disease consultation was independently associated with lower mortality (18% versus 39%, P < 0.01). Use of the IDSA guidelines and infectious disease consultation service was found to improve patient outcomes in patients with candidemia at our institution. Further studies should be performed to validate newer guidelines in a clinical setting at other institutions.     

Toward Spanning the Quality Chasm: An Examination of Team Functioning Measures

Objective

To examine the effect of 5 measures of team functioning on patient outcomes.

Design

Observational, exploratory, measurement. Team functioning surveys and patient outcomes collected 1 year apart in a clinical trial were analyzed. The findings are discussed in context of the domains of team functioning, team effectiveness, and quality improvement.

Setting

27 Veterans Affairs medical centers.

Participants

Staff (t1: N=356; t2: N=273) on inpatient teams and patients (t1: N=4266; t2: N=3213) treated by the teams.

Interventions

Not applicable.

Main Outcome Measures

Five measures of team functioning (Physician Engagement, Shared Leadership, Supervisor Team Support, Teamness, and Team Effectiveness scales) and 3 measures of patient outcomes (functional improvement, discharge destination, and length of stay) were assessed at 2 time points with hierarchical generalized linear models to evaluate the association between team functioning measures and changes in patient outcomes.

Results

Associations (P<.05) between team functioning measures and patient outcomes were found for 3 of the 15 analyses over the study period. Higher Physician Engagement scale score was associated with lower length of stay (P=.017), and increased scores on Teamness and Team Effectiveness scales correlated with higher rates of community discharge (P=.044 and .049, respectively).

Conclusions

This exploratory analysis revealed trends that team functioning corresponds with patient outcomes in clinically relevant patterns. An increase in community discharge and a decrease in length of stay were associated with higher scores of team functioning. Here, we find evidence that modifiable attributes of team functioning have a measurable effect on patient outcomes. Such findings are promising and support the need for further research on team effectiveness.     

医护同步责任管理模式的应用效果

目的探讨医护同步责任管理模式的临床应用。方法将病房责任护士分层组合并纳入医疗组与医生同步共同对患者实施医疗护理的医护同步责任管理模式（管理后）,与传统责任管理模式（管理前）比较患者对护理工作满意度、护士对自身工作满意度及护理质量。结果管理前患者对护理工作满意度平均（90．18±3．05）分,管理后平均（97．24±2．78）分,管理后高于管理前（t=5．274,P〈0．01）;管理前护士对自身工作满意度平均（88．36±4．11）分,管理后平均（96．91±3．53）分,管理后高于管理前（t=12．420,P〈0．01）。护理质量各项指标消毒隔离管理、规范化服务、护理文件书写、基础护理、分级护理、病区规范化管理、健康教育知晓率管理后均比管理前明显提高,差异均具有统计学意义（t值分别为6．528,4．773,4．569,5．031,4．983,6．249,7．667;P值均〈0．01）。结论医护同步责任管理模式可提升患者对护理工作的满意度,提高护士的工作满意度,调动护理人员工作积极性和主动性,提高工作效率,提升护理质量。     

Computer-supported telephone nurse triage: an evaluation of medical quality and costs

AIM: To evaluate a telephone nurse triage model in terms of appropriateness of referrals to the appropriate level of care, patient's compliance with given advice and costs. BACKGROUND: A key concern in each telephonic consultation is to evaluate if appropriate. METHOD: An evaluative design in primary health care with consecutive patients (N = 362) calling telephone nurse triage between November 2002 and February 2003. RESULTS: The advice was considered adequate in 325 (97.6%) cases. The patients' compliance with self-care was 81.3%, to primary health care 91.1% and to Accident and Emergency department 100%. The nurses referred self-care cases (64.7%) and Accident and Emergency cases (29.6%) from a less adequate to an appropriate level of care. The cost saving per call leading to a recommendation of self-care was euro 70.3, to primary health care euro 24.3 and to Accident and Emergency department euro 22.2. CONCLUSIONS: The telephone nurse triage model showed adequate guidance for the patients concerning level of care and released resources for the benefit of both patients and the health care system.     

Outcomes-based trial of an inpatient nurse practitioner service for general medical patients

Although teaching hospitals are increasingly using nurse practitioners (NPs) to provide inpatient care, few studies have compared care delivered by NPs and housestaff or the ability of NPs to admit and manage unselected general medical patients. In a Midwest academic teaching hospital 381 patients were randomized to general medical wards staffed either by NPs and a medical director or medical housestaff. Data were obtained from medical records, interviews and hospital databases. Outcomes were compared on both an intention to treat (i.e. wards to which patients were randomized) and actual treatment (i.e. wards to which patients were admitted) basis. At admission, patients assigned randomly to NP-based care (n = 193) and housestaff care (n= 188) were similar with respect to demographics, comorbidity, severity of illness and functional parameters. Outcomes at discharge and at 6 weeks after discharge were similar (P>0.10) in the two groups, including: length of stay; charges; costs; consultations; complications; transfers to intensive care; 30-day mortality; patient assessments of care; and changes in activities of daily living, SF-36 scores and symptom severity. However, after randomization, 90 of 193 patients (47%) assigned to the NP ward were actually admitted to housestaff wards, largely because of attending physicians and NP requests. None the less, outcomes of patients admitted to NP and housestaff wards were similar (P>0.1). NP-based care can be implemented successfully in teaching hospitals and, compared to housestaff care, may be associated with similar costs and clinical and functional outcomes. However, there may be important obstacles to increasing the number of patients cared for by NPs, including physician concerns about NPs' capabilities and NPs' limited flexibility in managing varying numbers of patients and accepting off-hours admissions.     

Quality of life in adult survivors of critical illness: A systematic review of the literature

Objective: To determine how the quality of life (QOL) of intensive care unit (ICU) survivors compares with the general population, changes over time, and is predicted by baseline characteristics. Design: Systematic literature review including MEDLINE, EMBASE, CINAHL and Cochrane Library. Eligible studies measured QOL 30 days after ICU discharge using the Medical Outcomes Study 36-item Short Form (SF-36), EuroQol-5D, Sickness Impact Profile, or Nottingham Health Profile in representative populations of adult ICU survivors. Disease-specific studies were excluded. Measurements and results: Of 8,894 citations identified, 21 independent studies with 7,320 patients were reviewed. Three of three studies found that ICU survivors had significantly lower QOL prior to admission than did a matched general population. During post-discharge follow-up, ICU survivors had significantly lower QOL scores than the general population in each SF-36 domain (except bodily pain) in at least four of seven studies. Over 1–12 months of follow-up, at least two of four studies found clinically meaningful improvement in each SF-36 domain except mental health and general health perceptions. A majority of studies found that age and severity of illness predicted physical functioning. Conclusions: Compared with the general population, ICU survivors report lower QOL prior to ICU admission. After hospital discharge, QOL in ICU survivors improves but remains lower than general population levels. Age and severity of illness are predictors of physical functioning. This systematic review provides a general understanding of QOL following critical illness and can serve as a standard of comparison for QOL studies in specific ICU subpopulationsAn erratum to this article can be found at     

Quality of end-of-life treatment for cancer patients in general wards and the palliative care unit at a regional cancer center in Japan: a retrospective chart review

Goals In Japan, most cancer patients die in the hospital. The aim of this study was to assess the quality of end-of-life treatment for dying cancer patients in general wards and palliative care unit (PCU). Materials and methods A retrospective chart review study was conducted. The following data on cancer patients who died in general wards (N = 104) and PCU (N = 201) at a regional cancer center were collected: do-not-resuscitate (DNR) decisions, treatments in the last 48 h of life, and aggressiveness of cancer care for dying patients. Main results DNR orders were documented for most patients (94% in general wards, 98% in PCU, p = 0.067) and families usually consented (97%, 97%, p = 0.307). Comparison of general wards with PCU showed that, in the last 48 h of life, significantly more patients in general wards received life-sustaining treatment (resuscitation, 3.8%, 0%, p = 0.001; mechanical ventilation, 4.8%, 0%, p = 0.004), large volume hydration (>1,000 ml/day, 67%, 10%, p < 0.001) with continuous administration (83%, 5%, p = 0.002) and fewer palliative care drugs (strong opioids, 68%, 92%, p < 0.001; corticosteroids, 49%, 70%, p < 0.001; nonsteroidal anti-inflammatory drugs, 34%, 85%, p < 0.001). Regarding aggressiveness of cancer care, patients received a new chemotherapy regimen within 30 days of death (3.0%), chemotherapy within 14 days of death (4.3%), and intensive care unit admission in the last month of life (3.3%). Conclusion We found that families, not patients, consented to DNR, and life-sustaining treatments were appropriately withheld; however, patients on general wards received excessive hydration, and the use of palliative care drugs could be improved. Application of our findings can be used to improve clinical care in general wards.     

Long-term persistence of quality improvements for an intensive care unit communication initiative using the VALUE strategy

Purpose

Communication in the intensive care unit (ICU) is an important component of quality ICU care. In this report, we evaluate the long-term effects of a quality improvement (QI) initiative, based on the VALUE communication strategy, designed to improve communication with family members of critically ill patients.

Materials and Methods

We implemented a multifaceted intervention to improve communication in the ICU and measured processes of care. Quality improvement components included posted VALUE placards, templated progress note inclusive of communication documentation, and a daily rounding checklist prompt. We evaluated care for all patients cared for by the intensivists during three separate 3 week periods, pre, post, and 3 years following the initial intervention.

Results

Care delivery was assessed in 38 patients and their families in the pre-intervention sample, 27 in the post-intervention period, and 41 in follow-up. Process measures of communication showed improvement across the evaluation periods, for example, daily updates increased from pre 62% to post 76% to current 84% of opportunities.

Conclusions

Our evaluation of this quality improvement project suggests persistence and continued improvements in the delivery of measured aspects of ICU family communication. Maintenance with point-of-care-tools may account for some of the persistence and continued improvements.     

Impact of Blood Pressure Dysregulation on Health-Related Quality of Life in Persons With Spinal Cord Injury: Development of a Conceptual Model

Objectives

To identify medically relevant aspects of blood pressure dysregulation (BPD) related to quality of life in individuals with spinal cord injury (SCI), and to propose an integrated conceptual framework based on input from both individuals with SCI and their clinical providers. This framework will serve as a guide for the development of a patient-reported outcome (PRO) measure specifically related to BPD.

Design

Three focus groups with individuals with SCI and 3 groups with SCI providers were analyzed using grounded-theory based qualitative analysis to ascertain how blood pressure impacts health-related quality of life (HRQOL) in individuals with SCI.

Setting

Focus groups were conducted at 2 Veterans Affairs medical centers and a research center.

Participants

Individuals with SCI (n=27) in 3 focus groups and clinical providers (n=25) in 3 focus groups.

Interventions

Not applicable.

Main Outcome Measures

Not applicable.

Results

Qualitative analysis indicated that all focus groups spent the highest percentage of time discussing symptoms of BPD (39%), followed by precipitators/causes of BPD (16%), preventative actions (15%), corrective actions (12%), and the impact that BPD has on social or emotional functioning (8%). While patient/consumer focus groups and provider focus groups raised similar issues, providers spent more time discussing precipitators/causes of BPD and preventative actions (38%) than patient/consumer groups (24%).

Conclusions

These results suggest that BPD uniquely and adversely impacts HRQOL in persons with SCI. While both individuals with SCI and their providers highlighted the relevant symptoms of BPD, the SCI providers offered additional detailed information regarding the precipitators/causes and what can be done to prevent/treat BPD. Further, the results suggest that persons with SCI are aware of how BPD impacts their HRQOL and are able to distinguish between subtle signs and symptoms. These findings exemplify the need for a validated and sensitive clinical measurement tool that can assess the extent to which BPD impacts HRQOL in patients with SCI.     

Team type,team maturity and team effectiveness in specialist palliative home care: an exploratory questionnaire study

ABSTRACT

To meet complex needs in persons and families within specialist palliative care, care team members are expected to work together in performing a comprehensive assessment of patient needs. Team type (how integrated team members work) and team maturity (group development) have been identified as components in team effectiveness and productivity. The aim of the study reported in this paper was to identify team types in specialist palliative care in Sweden, and to explore associations between team type, team maturity and team effectiveness in home care teams. A national web-based survey of team types, based on Thylefors questionnaire, and a survey of healthcare professionals using the Group Development Questionnaire (GDQ-SE3) to assess team developmental phase, effectiveness and productivity were used in an exploratory cross-sectional design. The participants were: Specialist palliative care teams in Sweden registered in the Palliative Care Directory (n = 77), and members of 11 specialist palliative home care teams. Teams comprised physicians, registered nurses, social workers, physiotherapists and/or occupational therapists, full-or part-time. Our national web survey results showed that the 77 investigated teams had existed from 7 to 21 years, were foremost of medium size and functioned as inter- or transprofessional teams. Results from the 61 HCPs, representing 11 teams, indicated that more mature teams tended to work in an integrated manner, rather than in parallel. The effectiveness ratio varied from 52% to 86% in teams. Recommendations arising from our findings include the need for clarification of team goals and professional roles together with prioritizing the development of desirable psychosocial traits and team processes in clinical settings.     

疗养院健康体检管理中心开展优质护理服务的管理和实践

近年来疗养院健康体检管理中心开展优质护理服务,采用问卷调查的形式,了解体检客户对护理服务的意见,着重提高业务技能,重点塑造服务形象。不仅提高了护士的综合素质,也提升了体检中心的整体社会形象。     

General practice – a fertile lagoon in the ocean of medical knowledge

General practitioners (GPs) often find that linear, deductive knowledge does not provide a sufficient map for clinical management. But experience, accompanied by enduring familiarity with individual patients, may offer unique complementary skills to interpret a patient’s symptoms and navigate skilfully through diagnosis, treatment, follow-up and prevention.In this article, we draw attention to the nature of this tacit knowing that is executed by many GPs every day. We argue that the nonlinear, unpredictable complexity of this domain nurtures a particular logic of clinical knowing. This kind of knowledge is not intuition and can to some extent be intersubjectively accessible. We substantiate and discuss how and why general practice research can contribute to knowledge development by transforming reflection-in-action to reflection-on-action.We briefly present some concepts for reflection-on-action of clinical knowing in general practice. The VUCA model (volatility, uncertainty, complexity, ambiguity) embraces dynamic and confusing situations in which agile work (adaptive, flexible and responsive behaviour and cognitive creativity) is assumed to be an appropriate response. Using such perspectives, we may sharpen our gaze and apply reflexivity and analytic elaboration to interpret unique incidents and experiences and appreciate the complexity of general practice. In this way, exploratory research can fertilize general practice and offer innovation to the entire domain of clinical knowledge.