Characteristics of patients who are acutely admitted to hospital under surgical care and do not have a surgical procedure – Is there an alternative to admission?

Introduction

Previous work has shown that 56% of all acute surgical admissions in Ireland in 2012 did not have a formal surgical procedure. In light of the pressures on health systems internationally and the lack of relevant data on this topic in the literature, we examined the characteristics of this cohort of patients in Ireland.

实习护生护理关怀行为及影响因素的调查

目的了解实习护生护理关怀行为实施现状及相关影响因素。方法采用方便抽样方法,使用美国学者Wolf关怀行为量表修改版,对在江苏省某三甲医院实习的150名护生进行调查。结果实习护生护理关怀行为得分为(80.98±8.92)分。护生的护理关怀行为主要体现在对患者信息保密(3.76±0.49)、懂得注射和滴注(3.69±0.54)、倾听主诉(3.71±0.50)、对患者表示关心(3.63±0.52)、按时治疗和给药(3.61±0.64)方面;但帮助患者成长(2.91±0.77)、让患者参与护理计划制定(2.88±0.91)得分最低。影响实习护生实施护理关怀行为的因素为护理关怀课程的学习及学历(P<0.05,P<0.01)。结论实习护生护理关怀行为得分呈中等偏上水平,并主要侧重于治疗性关怀,对患者的人文关怀尚欠缺。护理教育者应探讨合适的教学方法,开设护理关怀课程并付诸实践,不断提高护生护理关怀意识和行动力。     

Preparing for an Era of Episode-Based Care in Total Joint Arthroplasty

With a history of steadily rising healthcare costs, the United States faces an unprecedented set of health and financial challenges. The COVID-19 pandemic will only exacerbate these challenges, and it is of paramount importance to reform and refine health systems to maximize the value of care delivered to the patient. Recent developments related to value improvement in total joint arthroplasty suggest that episode-based payment is likely to become standard practice given the current healthcare environment. Consequently, developing episode-based care models for total joint arthroplasty is in the best interests of surgeons, health systems, and patients. In this article, we review important developments related to value-based care in total joint arthroplasty and present an episode-based framework for delivering high-value, patient-centric care. We examine each phase of a total joint arthroplasty episode—preoperative, acute, post-acute, and follow up—and present several ideas with developing bodies of evidence that can improve the value of care delivered to the patient.     

嗜铬细胞瘤的围手术期处理

报告８１例嗜铬细胞瘤，完善的围手术期处理使手术成功率达９７．４％（７９／８１）。结合文献讨论了围手术期处理的经验：（１）控制血压；（２）纠正心律失常；（３）解决扩容问题；（４）改善一般情况及心理准备工作；（５）密切观察各项生命指标的变化。并提出术前术中处理较术后处理更重要。     

Using the intensive care unit to teach end-of-life skills to rotating junior residents

Background

This study tested the effectiveness and perceived value of a palliative/end-of-life (P/EOL) curriculum for junior residents implemented during an intensive care unit (ICU) rotation.

Methods

Residents rotating through the ICU over a 6-month period completed pre- and post-curriculum surveys evaluating their self-assessed efficacy in providing P/EOL care and attitudes towards P/EOL care. Scores were analyzed using a paired Student t test.

Results

Seventeen of 19 (90%) residents completed both the pre- and post-curriculum evaluations. The P/EOL curriculum increased self-assessed efficacy ratings in the domains of pain management (P = .04), psychosocial knowledge (P = .001), communicator knowledge (P = .001), professional knowledge (P = .002), and manager knowledge (P < .001). The rotation was rated as being valuable in preparing residents to care for patients near the end-of-life (P < .05), with surgery residents indicating it to be the most valuable rotation in their training program for learning about P/EOL care.

Conclusions

An ICU P/EOL curriculum improves self-assessed efficacy scores across multiple domains in P/EOL care and is seen as a valuable educational experience.     

A National Survey Assessing the Current Workforce of Transplant Pharmacists Across Accredited U.S. Solid Organ Transplant Programs

Integration of pharmacists into multidisciplinary transplant patient care has advanced in recent years, with limited data available to evaluate the current status of the profession. This was a national survey developed as an AST Pharmacy COP initiative. Responses were solicited from pharmacists practicing at U.S. transplant programs based on UNOS listing; 176 participants from 113 centers (41%) responded, with 79% practicing ≤10 years. There is a median of 1.4 pharmacist full‐time equivalents (FTEs) (range 0.1–7.1) for every 100 transplants. The predominant activities performed by pharmacists during the transplant phase include medication review (95%), lab review (92%), allergy review (88%), medication therapy management (92%), bedside rounds (87%), medication education (79%), documentation (71%), and coordinating discharge medications (58%). Similar activities were reported during the other phases, but participation was less common. The involvement of dedicated transplant pharmacists within multidisciplinary care has become standard at a large number of centers, although expansion is still needed to ensure core pharmaceutical care components are provided to all transplant recipients across all centers. These results inform on the typical responsibilities of pharmacists practicing within the field of transplantation and illustrate that the level of pharmacist involvement significantly varies across transplant centers and the phases of transplantation.     

Edgar J. Poth Memorial Lecture: Lessons learned inside the Beltway: one surgeon's encounters with health care policy

Our health care system continues to undergo transformation in a context of extreme financial pressures. New models of care delivery and financing challenge us to rethink our practices as individual surgeons and as system participants. Understanding the fiscal realities of health care and how we are perceived by health care policy makers can help us to be meaningful participants in channeling reform to create better delivery systems for our patients. This article presents some background information about health care in America with a focus on government programs, and shares insights from my health care policy colleagues.     

The evolution of financial incentives in the U.S. health care system

The U.S. health care system continues to evolve toward value-based payment, rewarding providers based upon outcomes per dollar spent. To date, payment innovation has largely targeted primary care, with little consideration for the role of surgical specialists. As such, there remains appropriate uncertainty surrounding the optimal role of the urologic oncologist in alternative payment models. This commentary summarizes the context of U.S. health care reform and offers insights into supply-side innovations including accountable care organizations and bundled payments. Additionally, and importantly, we discuss the implications of rising out-of-pocket health care expenditures giving rise to health care consumerism and the implications therein.     

ICU患者安宁疗护筛查工具的研制与信效度检验

目的 研制ICU患者安宁疗护筛查工具并检验信效度,为ICU医护人员提供便捷、有效的安宁疗护对象筛查工具。 方法 通过文献分析、专家函询构建ICU患者安宁疗护筛查工具;回顾性分析206例ICU患者的相关资料,检验该筛查工具信效度,并确定安宁疗护触发值。 结果 ICU患者安宁疗护筛查工具包含3个一级条目、17个二级条目。内容效度指数为0.919,评定者间信度为0.979。2种结局（转出或死亡）患者筛查得分比较,差异有统计学意义（P＜0.05）;触发值为8.5分,ROC曲线下面积为0.992［95%CI（0.983,1.000）,P＜0.05］,灵敏度为0.936,特异度为0.969,阳性预测值为0.917,阴性预测值为0.981。 结论 ICU患者安宁疗护筛查工具的信效度良好,可作为ICU安宁疗护对象的筛查工具。     

Development of the trauma emergency care system based on the three links theory

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基于CLHLS的老年人社区养老服务需求及影响因素研究

目的分析社区现有养老服务内容以及老年人对社区养老服务的护理需求,为政府合理分配社区养老服务资源,提高老年人生活质量提供参考。方法基于2017~2018年中国老年人健康长寿影响因素追踪调查数据(CLHLS),采集有关老年人期望社区提供的养老服务需求与社区供给情况,以及老年人人口学、社会经济状况、健康状况相关数据,运用Logistic回归分析方法,探究老年人社区养老服务需求的影响因素。结果共采集到11981名老年人数据资料。75.7%的老年人希望得到保健知识教育服务,42.2%的老年人报告其社区会提供该类服务;64.3%的老年人希望得到居家护理服务,但仅10.2%的老年人报告其社区会提供此类服务;81.0%的老年人希望得到家访照顾,35.0%的老年人报告其社区会提供此类服务;67.3%老年人希望提供心理咨询服务,但仅12.1%的老年人报告其社区会提供此类服务。老年人的年龄、居住地、居住现状、经济情况及健康状况等是影响其社区养老服务需求的主要因素(P<0.05,P<0.01)。结论老年人对社区养老服务需求较大,但我国社区养老仍存在供需不平衡、城乡差距明显以及老年人生活水平差异等。社区养老应以老年人需求为导向,建立多层次、全方位、多元化的养老服务体系,提高社区养老服务质量,满足老年人社区养老服务需求。     

The effect of critical care outreach on postoperative serious adverse events

We proposed that critical care outreach would decrease the incidence of postoperative serious adverse events and so conducted a sequential cohort study with a surveillance-only phase (baseline) followed by an intervention phase. We studied high-risk patients in a large Australian hospital. A critical care qualified nurse reviewed patients for the first three days after return to the general wards. During the intervention phase the nurse intervened in patient care where appropriate. We examined the incidence of 11 categories of serious adverse events per 100 patients during the first three days on the general wards during the surveillance and intervention phases. The surveillance phase had 319 patients and the intervention phase 345 patients. In a subgroup analysis, there were four myocardial infarctions per 100 patients in the surveillance phase and seven per 100 patients during the intervention phase (95% confidence interval: 1-7 infarctions per 100 patients increase). For the other 10 serious adverse events there were 19 per 100 patients in the surveillance phase and 11 per 100 patients in the intervention phase (95% confidence interval: 4-11 serious adverse events per 100 patients decrease). Outreach may have led to greater detection of myocardial infarctions while reducing the incidence of other serious adverse events.     

Paediatric admissions to a district general hospital intensive care unit

The characteristics of all the paediatric admissions made to a district general hospital over a three-year period were analysed in this study. Paediatric admissions averaged 23 per year (10% of the total admissions to the unit over that time). The mean age was six years, median age was four years. Sixty-two per cent were medical admissions and 38% surgical. Forty-seven per cent of the surgical admissions involved head injuries. Seventy-four per cent of medical admissions were directly related to upper and lower airway problems. Mean total admission time was six days, with a median of two days. Fifty-nine per cent (40) of all cases required intubation for a mean period of five days (median = three days). All cases were PRISM scored (Pollack, Ruttimann & Getson 1988). The mean score was 8. Ninety-four percent of admissions surviving to go home. There were a total of four deaths over the three-year period. The PRISM scores of those who died had a mean of 30, which was significantly different (P < 0.05) from the survivors who had a mean PRISM score of six and a median of four. The organs of one of the nonsurvivors were transplanted. Currently there is considerable interest in the feasibility of transferring all paediatric intensive care patients to a regional centre, the consequences of such a policy must be carefully assessed if its implementation is to be a success.