Ventilator-associated pneumonia: Improving outcomes through guideline implementation

Ventilator-associated pneumonia (VAP) is associated with increased duration of mechanical ventilation and increased risk of death for critically ill patients. Although scientific advances have the potential to improve the outcomes of critically ill patients who are at risk of or who have VAP, the translation of research knowledge on effective strategies to prevent, diagnose, and treat VAP is not uniformly applied in practice in the intensive care unit. Knowledge about VAP may be used more effectively at the bedside by a systematic process of knowledge translation through implementation of clinical practice guidelines. Unfortunately, there remain large gaps in our understanding of guideline implementation in the intensive care unit, specifically as it applies to guidelines for the prevention, diagnosis, and treatment of VAP.     

Implementation,reliability testing,and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients

OBJECTIVE: To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients. DESIGN AND SETTING: Prospective, observational study in a level 1 trauma unit of a tertiary care, university-based medical center. PATIENTS: Acutely injured patients admitted to the trauma unit between 1 February 2006 and 16 April 2006. MEASUREMENTS AND RESULTS: Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond Agitation-Sedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period the nurses completed a postimplementation survey. The expert evaluator performed 1,011 random CAM-ICU assessments within 1[Symbol: see text]h of the bedside nurse's assessments. Nurses completed the CAM-ICU assessments in 84% of evaluations. Overall agreement (kappa) between nurses and expert evaluator was 0.77 (0.721-0.822; p[Symbol: see text]<[Symbol: see text]0.0001), in TBI patients 0.75 (0.667-0.829; p[Symbol: see text]<[Symbol: see text]0.0001) and in mechanically ventilated patients 0.62 (0.534-0.704; p[Symbol: see text]<[Symbol: see text]0.0001). The survey revealed that nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training that they received. It also acknowledged obstacles to implementation including nursing time and failure of physicians/surgeons to address treatment approaches for delirium. CONCLUSIONS: The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction.     

试论思想道德修养与法律基础课程教学中德与法融合的实现路径

在思想道德修养与法律基础课程教学中实现法律与道德的融合,面临一些现实的制约因素.对教材中的道德与法律的双重解读不能面面俱到,要抓住重点章节,同时注重典型案例的选取,以案例教学为中心,架起德与法融合的桥梁.小悦悦和药家鑫两则案例的双重分析,为德与法的融合路径提供了良好的范本.道德的追求并非空洞的说教,更是一种理性的思考.只有结合实例的双重分析,才能不断增进理性和成熟心智,这才是德与法融合的精神实质和内涵所在.     

Using digital images with young children: challenges of integration

Despite evidence that young children have the ability to take a degree of responsibility for arranging their own classroom activities, the majority of British primary schools still use a directive teaching approach, based on a model of the child as a dependent learner. We consider reasons why this view prevails, then draw on published studies and experience with four negotiating classrooms to describe in both general and practical terms how child autonomy or self‐responsibility in the primary classroom can work. Finally, we itemise and discuss a number of queries that teachers commonly raise in connection with negotiating classrooms.     

优质服务在医院保障体系消毒供应中心中的建立与实施

目的探讨优质服务在医疗保障体系消毒供应中心的实践。方法采取科室文化的创建,工作质量的管理,服务流程的优化,特色服务的提升以及专科技能的培训等方式为临床一线提供优质服务。结果服务实施后工作缺陷下降,工作效率提高,工作质量达标,临床满意度上升。结论消毒供应中心为临床提供优质服务,能够让患者、政府、社会、护士满意,需要进一步推广。     

数字治理推动医保经办增能：应用逻辑与实现路径

数字治理推动医保经办增能，其应用逻辑是以需求导向为应用理念，以履行第三方购买机制为重点应用场域，以多主体无边界数字治理平台为应用基础，以权力运行机制变革为应用支撑。实现路径是从循证决策走向“循数决策”；从行政管制式经办走向契约式治理；从粗放式基金管理走向精细化；从人工监管走向智能算法监管以及从人力密集型组织建设向技术密集型转变。     

城市生活垃圾处理收费政策目标与实施效果分析

在分析我国城市生活垃圾处理费收费政策目标及实施效果的基础上,指出导致政策实施效果与预期目标之间差距的主要原因是垃圾处理行业的外部性特征、社会的认知度以及政策制定者的决策偏好.     

Knowledge barriers to PACS adoption and implementation in hospitals

PURPOSE: Drawing on the classical theory of diffusion of innovations advanced by Rogers [E.M. Rogers, Diffusion of Innovations, 4th ed., Free Press, New York, NY, 1995] and on the theory of barriers to innovation [P. Attewell, Technology diffusion and organizational learning: the case of business computing. Organ. Sci. 3 (1992) 1-19; H. Tanriverdi, C.S. Iacono, Knowledge barriers to diffusion of telemedicine. Proceedings of the 20th International Conference on Information Systems, Charlotte, NC, 1999, pp. 39-50; S. Nambisan, Y.-M. Wang, Roadblocks to web technology adoption? Commun. ACM, 42 (1) (1999) 98-101], this study seeks a better understanding of challenges faced in PACS implementations in hospitals and of the strategies required to ensure their success. METHODS: To attain this objective, we describe and analyze the process used to adopt and implement PACS at two Canadian hospitals. RESULTS: Our findings clearly demonstrate the importance of treating any PACS deployment not simply as a rollout of new technology but as a project that will transform the organization. Proponents of these projects must not lose sight of the fact that, even if technological complexity represents a significant issue, it must not garner all the project team's attention. This situation is even more dangerous, inasmuch as the greatest risk to the implementation often lies elsewhere. It would also appear to be crucial to anticipate and address organizational and behavioral challenges from the very first phase of the innovation process, in order to ensure that all participants will be committed to the project. CONCLUSIONS: In order to maximize the likelihood of PACS success, it appears crucial to adopt a proactive implementation strategy, one that takes into consideration all the technical, economic, organizational, and human factors, and does so from the first phase of the innovation process.     

国家慢性病综合防控示范区建设总体实施现状研究

目的 了解国家慢性病综合防控示范区（示范区）自创建以来各项活动总体开展情况,为进一步开展示范区建设活动提供参考。方法 采用依据实施方案设计的问卷,调查全国参与示范区创建的机构各项目活动开展情况,每个示范区选取8个机构部门共完成12份问卷调查。结果 示范区实施情况实际得分占总分的71.8%。示范区要求开展的7项活动中,百分制得分较高的为监测（88.0%）、保障措施（75.0%）、健康教育和健康促进（75.0%）;得分相对较低的是全民健康生活方式行动（67.7%）、社区诊断（66.7%）、高危人群发现和干预（64.7%）、患者管理（60.9%）。东、中、西三个地区在保障措施、健康教育和健康促进及高危人群发现和干预专项得分的差异有统计学意义。总体来讲,东部示范区实施情况优于中部和西部。示范区慢性病防控工作指标体系中的23项活动开展情况中,百分制得分最高的5项分别为政策保障、死因监测、肿瘤登记、心脑血管事件报告和烟草控制;得分最低的5项为平衡膳食、患者自我管理、口腔卫生、示范创建和基本公共卫生服务均等化。23项活动总体得分结果为东部地区得分高于中部和西部地区,中部和西部地区得分基本一致。结论 国家慢性病示范区创建各项工作总体实施情况良好,高危人群发现和干预,以及患者管理是示范区今后工作重点。