Hospital priority setting with an appeals process: a qualitative case study and evaluation

OBJECTIVE: To describe and evaluate priority setting in the context of hospital priority setting and more specifically to evaluate the use of an appeals process. DESIGN: Qualitative case study and evaluation using the ethical framework 'accountability for reasonableness'. SETTING: The University Health Network (UHN), a network of three large urban teaching hospitals affiliated with the University of Toronto in Toronto, Canada. This study focused on Clinical Activity Target Setting (CATS), the final component of the strategic planning process. PARTICIPANTS: Sixty-six board members, senior administrators, managers, clinical leaders and other hospital staff who participated in the hospital strategic planning exercise. DATA COLLECTION: Three primary sources of data were used: key documents, interviews with participants and stakeholders and observations of group deliberations. DATA ANALYSIS: Open and axial coding using an explicit conceptual framework 'accountability for reasonableness'. RESULTS: This was the first time an appeal process has been described and evaluated. The appeals process was found to be a fundamental component to overall perceived fairness of the priority setting process. The appeals process also enhanced the involvement of stakeholders and increased overall participant satisfaction. In addition, four areas of 'good practice' and ten recommendations for improvement of the larger priority setting process were identified. CONCLUSIONS: This case study has provided an in-depth analysis of a priority setting process at a hospital, with a particular focus on the appeals process. Also, we compared the lessons learned from this study with those from a previous study at a different hospital.     

Regional myocardial blood flow during nicotine infusion after chronic coronary artery occlusion: effect of beta-adrenergic blockade

In eight dogs a portion of the left ventricular free wall (LVFW) was rendered collateral-dependent (CD) by gradual occlusion of the left anterior descending coronary artery with a surgically implanted Ameroid constrictor. Six to 8 weeks later, the dogs were anesthetized and regional myocardial blood flow was measured with 7-10-micron radioactive microspheres during (a) control conditions, (b) nicotine alone (24 micrograms/kg/min i.v.), and (c) nicotine (24 micrograms/kg/min i.v.) after beta-adrenergic blockade with propranolol. During control conditions, mean transmural flow was similar in CD, border, and normal regions of the LVFW. Nicotine alone increased flow in all regions of the LVFW, with normal (+ 104%) greater than CD (+ 56%). These changes in flow were accompanied by increases in mean arterial pressure (+ 34%) and mean aortic flow (+ 54%). Nicotine after beta-adrenergic blockade appreciably raised mean arterial pressure (+ 83%) and mean left atrial pressure (+ 307%), but caused no increase in flow to any region of the LVFW. The results indicate (a) that the nicotine-induced increase in flow is blunted in a CD region, and that (b) beta-adrenergic blockade unmasks coronary vasoconstrictor mechanisms during nicotine infusion which prevent increases in flow to either normal or CD regions despite increased perfusion pressure and augmented myocardial oxygen demands.     

Pre-attack symptomatology and temperament as predictors of children's responses to the September 11 terrorist attacks

BACKGROUND: The aims of this study were to assess the psychological response of children following the September 11, 2001 terrorist attacks in New York and Washington, DC and to examine prospective predictors of children's post-attack responses. METHOD: Children's responses were assessed in a community sample of children in Seattle, Washington, participating in an ongoing study. Symptomatology and temperament assessed prior to the attacks were examined as prospective predictors of post-attack post-traumatic stress (PTS), anxiety, depression and externalizing problems. RESULTS: Children demonstrated PTS symptoms and worries at levels comparable to those in children directly experiencing disasters, with 77% of children reporting being worried, 68% being upset by reminders, and 39% having upsetting thoughts. The most common PTS symptom cluster was re-experiencing, and 8% of children met criteria consistent with PTSD. African-American children reported more avoidant PTS symptoms and being more upset by the attacks than European-American children. Girls reported being more upset than boys. Prior internalizing, externalizing, social competence and self-esteem were related to post-attack PTS; and child inhibitory control, assessed prior to the 9/11 attacks, demonstrated a trend towards an association with post-attack PTS symptoms controlling for prior levels of symptomatology. PTS predicted child-report anxiety and conduct problem symptoms at follow-up, approximately 6 months after 9/11. CONCLUSIONS: Children experiencing a major disaster at a distance or indirectly through media exposure demonstrated worries and PTS symptoms suggesting that communities need to attend to children's mental health needs in response to national or regional disasters. Pre-disaster symptomatology or low self-regulation may render children more vulnerable in response to a disaster, and immediate post-disaster responses predict subsequent symptomatology. These variables might be used in the identification of children in need of intervention.     

The use of seclusion in emergency medicine

INTRODUCTION: Little is known about the use of seclusion in emergency departments (EDs) across the country. The primary purpose of this study was to determine the extent of the use of seclusion in EDs in the United States. The secondary purpose was to describe seclusion use in EDs. METHODS: A survey consisting of questions about the use of seclusion, hospital information, complication rate and related procedures was mailed to a random sample consisting of 20% of the US ED medical directors. The survey was re-mailed to the nonresponders who were also contacted by phone and faxed. The results of the survey were inputted into the SPSS program (SPSS, version 10, Chicago, IL). RESULTS: The survey was returned by 443 of the 1015, or 43.6% of the ED medical directors in the United States who had been selected. Of the valid 442, 123 (25.6%) use seclusion in their ED. The most frequent reason for not using seclusion was physical plant issues (212 of 422, 50.2%). Most used direct visualization (102 of 187, 54.5%) of seclusion rooms that were locked (54 of 120, 45.0%) and that were overwhelmingly located within the ED (112 of 117, 95.7%). The most frequent reason for placing a patient in seclusion was violence (122 of 126, 96.8%). Both adults (123 of 126, 97.6%) and children (41 of 126, 32.5%) were placed in seclusion rooms. The most frequently reported complication was the patient's getting out of the seclusion room (32 of 106, or 30.1%). Patients were also given chemical restraints (79 of 113, 69.9%). The physician almost always ordered the seclusion room (124 of 125 cases, 99.2%), but the patient was commonly placed in the room by a nurse (109 of 122, 89.3%); generally, the staff had formal training (99 of 122, 81.1%). The use of seclusion was correlated with the number of ED beds (F=32.0, df=1, P=.003), ED volume (F=37.7, df=1, P=.001), number of hospital beds (F=22.6, df=1, P=.001), having a psychiatric unit (F=24.7, df=1, P=.001) and teaching EDs (F=10.8, df=1, P=.001). CONCLUSION: Seclusion rooms are used in a minority of EDs across the country. It also identified many outstanding concerns with complications, use in children, addition of chemical sedation, training and seclusion policy.     

Nurses' clinical decision-making regarding the management of pain

Effective pain management remains an elusive goal within the profession of nursing. While considerable improvement has occurred, patients continue to experience inappropriate levels of pain. To date, research has focused on objective factors that influence pain management. Few studies have examined attitudinal factors that may influence nurses' decision-making. This quasi-experiment was based on preliminary data showing that nurses' preconceived notions regarding certain patient groups influenced their management of pain. An intervention was tested for its' effect on nurses' preconceived notions regarding specific patient groups. A significant difference in a positive direction was found. Nurses were more willing to spend time and energy managing pain across all patient groups following the intervention.     

Acromegaly secondary to growth hormone releasing hormone secretion

Background Acromegaly secondary to growth hormone releasing hormone (GHRH) secretion is exceptionally rare. Aim To report a case of acromegaly diagnosed in 1984 and assumed to be pituitary in origin. Sixteen years later, the cause was found to be a GHRH secreting neuroendocrine pancreatic tumour. Method A case report. Conclusion Although ectopic GHRH production is very rare, endocrinologists should be aware of this possibility in acromegaly patients if a pituitary tumour was not detected using pituitary imaging.     

Thrombin activatable fibrinolysis inhibitor and its fibrinolytic effect in normal pregnancy

We investigated changes in both thrombin activatable fibrinolysis inhibitor (TAFI) antigen levels and its functional effect on in vitro fibrinolysis in normal pregnancy. 152 pregnant women and 31 women in the immediate postpartum period were studied, with pregnancy divided into 6 windows at 4 weekly intervals. As TAFI influences and is in turn influenced by components of the protein C (PC) pathway, its measurements were correlated with levels of soluble thrombomodulin, PC, protein S (PS) and the overall phenotype of activated PC resistance (APCR). Compared with mean TAFI levels at booking gestation (6.6 +/- 1.2 microg/ml), levels peaked at 35-39 weeks gestation (9.6 +/- 2 microg/ml, p = 0.001), followed by a significant drop within 24 hours of delivery (7.2 +/- 1.1 microg/ml). In functional terms, the mean clot lysis time (CLT) (101 +/- 13 min at booking) also peaked at 35-39 weeks gestation (141 +/- 42 min, p = 0.007) and dropped after delivery (99 +/- 33 min), and was significantly correlated with gestational age (r = 0.410, p = 0.001) and could be abrogated in the presence of an inhibitor to TAFI activation. A significant negative correlation was found between TAFI levels and APCR (r = -0.478, p <0.001), APCRV (r = -0.598; p <0.001), PS (r = -0.490, P <0.001) and PC (r = -0.198, p = 0.02). In summary, there is a significant increase in TAFI levels, which translates into increased CLT during pregnancy. Furthermore, changes in TAFI contribute to the increasing APCR of pregnancy.     

Nutrient intake and congenital heart defects in maternal phenylketonuria

OBJECTIVE: The purpose of this study was to determine whether nutritional components other than high maternal blood phenylalanine levels (> or = 10 mg/dL) are associated with congenital heart defects in the offspring of women with hyperphenylalaninemia. STUDY DESIGN: Of the 414 subjects who had live births, 249 women (60.1%) started diet treatment before 8 weeks of gestation and had nutritional assessments and infant outcome data. Maternal phenylalanine levels, protein intake, and the incidence of congenital heart defects were determined. Simple contingency table analysis was done by chi(2) and Fisher exact test. RESULTS: A significantly increased incidence of congenital heart defects was observed in offspring of mothers with hyperphenylalaninemia who had an elevated blood phenylalanine level >10 mg/dL at 0 to 8 weeks of gestation and a protein intake of < or = 50% of the recommended dietary allowance (P <.0013). CONCLUSION: An inadequate intake of protein during pregnancy in conjunction with elevated blood phenylalanine levels appear to have an additive effect in the incidence of congenital heart defects in the offspring of women with hyperphenylalaninemia.