The relationship of house staff experience to the cost and quality of inpatient care

The inexperience of house staff has been offered as one explanation for the increased cost of care at teaching hospitals, but conclusive evidence for this has been lacking. We studied the relationship of house staff experience to the cost and quality of inpatient care in a large series of internal medicine patients at one teaching hospital. We defined house staff experience by the month of academic year during which the patient received care. Our measures of cost were length of hospital stay and total hospital charges, while our measures of quality were hospital deaths, hospital readmissions, and nursing home placement. Multiple linear regression analysis on 21,679 hospital discharges revealed increasing house staff experience to be associated with a significant decline in length of stay (95% confidence interval for b, -0.006 to -0.066 days per discharge per month of house staff experience) and total hospital charges (95% confidence interval for b, -0.002 to -0.017 log dollars per discharge per month of house staff experience). These findings constitute an estimated average decline of 0.43 days per discharge and +370 per discharge over the academic year. Logistic regression analysis found no relationship of house staff experience to hospital deaths, readmissions, or nursing home placement. These findings suggest that the process of training inexperienced physicians may represent an important source of inefficiency for teaching hospitals struggling in a competitive environment.     

Morning report. Role of the clinical librarian

The educational value of morning report should be enhanced by thorough evaluation of the medical literature. We added a clinical medical librarian (CML) program to our morning report 2 1/2 years ago to provide rapid, complete access to reference material relevant to topics discussed in morning report. MEDLINE searches and references are made available on a same-day basis; cumulative lists of these are provided to the staff and house staff at bimonthly and yearly intervals. All house staff used the CML service to some degree and the majority found it to be of value in making patient care decisions. Since the inception of the CML program, the medical library has noted a more than twofold increase in the number of on-line reference searches and a similar increase in requests for searches by house staff. Patient care decisions have been improved through ready access to current medical literature, and the teaching program has been enhanced by the creation of the CML program as an integral part of morning report.     

The impact of a new geriatric program in a hospital for the chronically ill.

Reports of the rapidly increasing proportion of persons aged 65 years and more in Canada and the resultant need for changes in the country's health care system prompted experimental changes in the operation and training procedures at St. Mary's of the Lake Hospital, Kingston, Ont. Aimed at better patient care and at better education of medical house staff in geriatrics and long-term care, the revised program is permeated with the philosophy of rehabilitation. It includes full-time staff, a geriatric outpatient clinic, a day hospital, a team approach to patient care (with regular team audits), problem-oriented medical records, a formal physical medicine section with a district inpatient unit, and an intensive inservice education program. After the first year of the program patient outcome had improved and more efficient use was being made of continuing care beds because of larger numbers of patinets being discharged home after shorter stays. This may be one avenue for deceleration of our country's dismal rate of institutionalization.     

Nursing home rounds as a format for teaching residents and medical students

The nursing home has become a focus for education as well as patient care. A format was devised for nursing home rounds that provides for discussion among staff members and specialists and is aimed at teaching and the resolution of specific patient-care and administrative issues. This format is outlined, and records from these twice-weekly rounds are reviewed. The nursing home rounds were consistently attended by members of the nursing and medical staffs, trainees, and nursing and medical directors. As is apparent from the records of these rounds, many complex medical problems were handled without transferring the patients to an acute-care facility. The discussion among participants of specific clinical problems at nursing home rounds has proven invaluable as a tool for education and delivery of patient care.     

Attitudes of house officers toward a hospice on a medical service

A hospice program (HP) was established on the medical service at the Denver Veterans Administration Medical Center (DVAMC) for the care of the terminally ill cancer patients and to integrate such care into house staff training. A two-bed inpatient unit was managed by an intern, a resident, and the attending physician with the aid of a multidisciplinary team. During the program's first year, 29 patients were cared for with an average inpatient stay of 26 days. Twenty-nine out of a possible 33 house officers returned questionnaires evaluating their hospice experience. Twenty-eight respondents felt that the hospice program was appropriate in a teaching hospital. Over half indicated improved awareness of the psychological problems of their patients and families. Two-thirds of the house staff members felt that the HP changed their approach to pain control and made them more comfortable in dealing with terminally ill patients. From this study, it can be concluded that a hospice program can be successfully integrated into an active medical teaching service.     

Expanding the nurse's role to improve preventive service in an outpatient clinic.

To help resolve the conflicting demands of primary and secondary care in hospital medical clinics, a program was developed whereby, with the physicians' agreement, nurses would select and vaccinate clinic patients eligible for influenza vaccination. In a controlled trial the nurses offered vaccination to half of the eligible patients attending morning sessions and vaccinated 35% of them. In contrast, physicians in the afternoon sessions, who were unaware of the program, vaccinated only 2% of similar patients. These results show that, although these physicians agree with guidelines for influenza vaccination, they are not currently providing the service. The use of nursing personnel to provide this and other types of primary medical care for clinic patients is a reasonable alternative.     

Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type

A program that limits the extent of medical treatment in patients with advanced dementia of the Alzheimer type was initiated on an intermediate medical ward. Five levels of care were designed to define options that stress maintenance of patient comfort without striving for a maximal period of survival (hospice approach). An optimal care level for each patient recommended by the staff correlated highly with the severity of dementia, but care levels assigned during meetings of family members with the multidisciplinary team for 40 patients correlated poorly with the staff recommendations and the severity of dementia. Intensive nursing care and comfort measures, which included antipyretics, analgesics, and (if necessary) oxygen and anticholinergics, were provided during the terminal phase. Preliminary results indicate that the mortality did not increase significantly during the first year of this program, although the extent of medical care was limited in all patients, and 62% were not treated with antibiotics if they developed symptoms of pneumonia or urinary tract infection.     

Participation of house staff in group practice: experience at a tertiary care center

In order to improve patient care, provide better teaching in an ambulatory setting, and establish research opportunities for faculty staff, the medical clinic of the Children's Hospital of Philadelphia has been developed into a group practice. The entire house staff is involved in this project, and it appears that the endeavor has resulted in improved patient care and house officers who are better prepared for outpatient problems. Some of the difficulties are discussed.     

流浪精神病患者护理风险分析及护理对策

目的:对流浪精神病患者存在的护理风险进行分析、为改进护理风险管理提供依据,提出针对性护理对策.方法:以临床实践为基础,从病区管理、疾病症状护理、精神科护理人员业务技能培训等方面着手,进行综合性描述.结果:通过多年的探索与实践,提高了护理人员的业务素质和慎独精神,增强了识别流浪精神病人护理风险的能力,使流浪精神病人的护理风险逐渐减少,保证患者和病区管理的安全.结论:护理风险管理是回避护理风险,减少流浪精神病人护理缺陷和医疗纠纷的有效途径.流浪精神病患者的安全隐患具有多发性、隐蔽性、防不胜防的特点,需要护理上采取周密的病区安全管理、疾病管理、技能培训、护士责任意识培养等护理对策,才能保证医患安全,达到预期效果.     

A 'firm' system for graduate training in general internal medicine.

The faculty of the Department of Medicine at Cleveland Metropolitan General Hospital has responded to the challenge of fostering general internal medicine in a graduate training program by organizing a "firm" system of medical care which has appealed to academic internists with broad interests in clinical medicine. This firm system consists of four medical teams which care for distinct patient populations, closely integrating their outpatient and inpatient care. The firms are made up of all the house staff in training in internal medicine together with senior and junior faculty members who are directors for the firms. Medical students in general medicine are also assigned to firms. This firm system is relatively simple to understand and establish and is readily applicable to other academic departments with general medical responsibilities.     

Comparison of clinical assessment with APACHE II for predicting mortality risk in patients admitted to a medical intensive care unit

The APACHE II (Acute Physiology and Chronic Health Evaluation) system has been widely used as an objective means of predicting outcome in critically ill patients. We prospectively evaluated patients consecutively admitted to the medical intensive care unit to compare the predictive accuracy of APACHE II with clinical assessment by critical care personnel. At the time of admission to the intensive care unit, the house staff and nurse responsible for each patient were asked to estimate the patient's hospital mortality risk. The patient's APACHE II score was calculated and a prediction of the patient's hospital mortality risk was then computed on the basis of this score. A total of 366 patients were studied. Mortality predictions were obtained from 57 physicians and 33 critical care nurses. We were unable to demonstrate a significant difference in the accuracy of APACHE II predictions compared with either physicians' or nurses' predictions. Clinical assessment and APACHE II were both highly predictive of outcome.     

Experience with a Diabetic Service in an “Open” Hospital

A survey of the management of diabetes mellitus in an “open” hospital, Calgary General Hospital, was conducted in 1954 by reviewing the records of 100 consecutive diabetic admissions and by interviewing medical, nursing and dietetic staff members. The diabetic state was controlled satisfactorily by diet and insulin, but early diabetic complications and patient education tended to be overlooked by physicians. Diabetic management from the nursing, administrative and dietetic standpoints was considered to be inefficient, unpredictable and incomplete.

In 1955 a comprehensive diabetic service was instituted which co-ordinated the activities of medical, nursing and dietetic staffs and provided for patient education. A repeat survey conducted in 1961, in which the records of 87 consecutive diabetic admissions were reviewed, showed marked improvement in all areas of diabetic patient care.

Objections to voluntary conformity by staff members were surprisingly absent. The institution of a diabetic service is recommended for all hospitals as a means of improving diabetic care.

     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program's first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

中国居家医疗的服务模式探索

目前,以医院为中心的医疗体系已经不适应老龄化社会的需要,老弱患者更需要居家医疗。中国的居家医疗项目极少,服务内容以护理、全科、康复服务为主,服务人员主要是护士。目前服务模式共有4种,包括以社区卫生服务中心为代表的家庭病床服务、以转型期公立医院为代表的上门服务、以医院集团为代表的整合型服务以及以民营医疗为代表的单纯居家医疗服务。这些医疗机构提供居家医疗服务的初衷有所差异,收入模式也不相同,但均在满足老弱患者的需要。本文描述目前中国居家医疗的服务模式以及发展过程中面临的挑战。     

Patient and house officer attitudes on physician attire and etiquette

To study patient preferences on physician attire and etiquette, we interviewed 200 patients on the general medical services of teaching hospitals in Boston and San Francisco. Of these 200 patients, 65% believed physicians should wear a white coat, 27% believed physicians should not wear tennis shoes, 52% believed physicians should not wear blue jeans, 37% believed male physicians should wear neckties, and 34% believed female physicians should wear dresses or skirts. Forty percent of patients wanted physicians to address them by first name, but only 10% of patients wanted to address their physicians by first name. A concurrent mailed survey of 74 medical house staff members at the two hospitals revealed wide variability in physicians' attire and in how patients were addressed at each institution. Thus, many house officers had habits that were less formal than a substantial portion of their patients preferred.     

护理细节管理在危重患者护理中的应用

目的探讨护理细节管理在危重患者护理中的应用效果。方法将2007年12月~2012年12月我院收治的480例危重患者随机分成两组,每组240例。观察组在医疗护理的过程中运用细节管理护理模式,对照组运用常规护理,采用问卷调查的方式针对入院、治疗、出院等一系列的护理过程给予评分,对所给评分进行统计学分析,评价两组患者生活质量及其和家属对护理人员的服务质量、服务态度、需求满意度。结果运用护理细节管理患者生活质量及其和家属对护理人员的服务质量、服务态度、需求满意度明显提高(P<0.05);除用药指导外的其他项目满意度均明显提高且具有统计学意义(P<0.05)。结论护理细节管理可以明显提高危重患者的生活质量,提高患者及家属对医疗护理的满意度,有助于改善护患关系,在临床医疗护理过程中值得推广运用。     

Costs and benefits of medical student training to a health maintenance organization

As health maintenance organizations (HMOs) and managed health care systems expand, they represent an increasing potential as sites for medical student teaching. Considerable difference of opinion exists about the impact of medical training on these prepaid delivery systems. This study presents a methodology for estimating the subjective and objective costs and benefits of medical student training to an independent staff model HMO with a long-standing training program. Data are derived from a provider survey, a consumer survey, and patient visit logs. Principal subjective benefits include increased perceived quality of care, improved patient satisfaction, and enhanced provider education and joy of practice. Objective impacts include a decrease in productivity of 1.1 patient visits per half day and direct physician teaching labor of 46.8 minutes per half day. Applying this methodology to the specific program of ten courses gives rise to a figure of $180 000 ($16 900 per full-time equivalent student per year) for the "opportunity cost" of medical student training to the HMO. Rules of thumb are developed for application of this method prospectively to new programs in similar relationships between staff model HMOs and academic medical centers.     

医护人员对腰椎间盘突出症中医护理体验的质性研究

目的 探讨腰椎间盘突出症中医护理方案临床实施后医护人员的体验,为腰椎间盘突出症中医护理方案优化提供参考依据。方法 采用目的抽样法,选取杭州市6家三级甲等中医医院及中西医结合医院熟悉腰椎间盘突出症中医护理方案的14名骨科及针灸推拿科护士长、中医护理骨干、高年资中医师进行深入访谈。运用Colaizzi分析法分析、提炼主题。结果 方案实施过程中,医护人员呈现正性和负性两种体验。正性体验主要是护士普遍认为该方案对腰椎间盘突出症临床护理指导意义重大,可提升中医护理能力以及提高疾病的关注度;负性体验包括辨证施护存在困惑、技术选择有不确定感、具体实施存在困难、技术应用有利益关系,以及统计评价带来护士的排斥。结论 需要进一步总结优化中医护理方案,提高其临床应用可操作性,简化统计流程,提高效果评价科学性,提升临床护士的中医护理能力并得到医生的配合,从而更好地落实腰椎间盘突出症中医护理方案。     

Association Between TG-to-HDL-C Ratio and In-Stent Stenosis Under Optical Coherence Tomography Guidance

Efficient and effective communication between providers is critical to quality patient care within a hospital system. Hands free communication devices (HFCD) allow instantaneous, closed-loop communication between physicians and other members of a multidisciplinary team, providing a communication advantage over traditional pager systems. HFCD have been shown to decrease emergency room interruptions, improve nursing communication, improve speed of information flow, and eliminate health care waste. We evaluated the integration of an HFCD with an existing alphanumeric paging system on an acute inpatient medicine service. We conducted a prospective, observational, survey-based study over twenty-four weeks in an academic tertiary care center with attending physicians and residents. Our intervention involved the implementation of an HFCD alongside the existing paging system. Fifty-six pre and post surveys evaluated the perception of improvement in communication and the integration of the HFCD into existing workflow. We saw significant improvements in the ability of an HFCD to help physicians communicate thoughts clearly, communicate thoughts effectively, reach team members, reach ancillary staff, and stay informed about patients. Physicians also reported better workflow integration during admissions, rounds, discharge, and teaching sessions. Qualitative data from post surveys demonstrated that the greatest strengths of the HFCD included the ability to reach colleagues and staff quickly, provide instant access to individuals of the care team, and improve overall communication. Integration of an instantaneous, hands free, closed loop communication system alongside the existing pager system can provide improvements in the perceptions of communication and workflow integration in an academic medicine service. Future studies are needed to correlate these subjective findings with objective measures of quality and safety.     

Bus rounds for palliative care education in the community

Increasingly, patients with cancer are dying at home and in continuing care facilities. The purpose of bus rounds is to provide continuing education to physicians and nurse palliative care consultants, to familiarize family physicians with the delivery of care in these settings and to educate family medicine and specialty residents as well as medical students. A total of 18 4-hour bus rounds took place during 1996. A mean of 13 (range 9 to 17) participants attended, to discuss a mean of 3.5 (range 2 to 4) patients and 4.5 (range 3 to 8) journal articles. A questionnaire was filled out anonymously by 18 first-time medical and 24 first-time nursing participants. On a scale from 1 (worst) to 5 (best), they gave the rounds an overall rating of 5 (range 4 to 5). The mean cost per round was $245.40. The authors conclude that bus rounds provide an opportunity for intensive exposure to community-based learning for physicians, nurses and students and are highly satisfactory from the participants' perspective.