Length of Stay-Based Patient Flow Models: Recent Developments and Future Directions

Modelling patient flow in health care systems is vital in understanding the system activity and may therefore prove to be useful in improving their functionality. An extensively used measure is the average length of stay which, although easy to calculate and quantify, is not considered appropriate when the distribution is very long-tailed. In fact, simple deterministic models are generally considered inadequate because of the necessity for models to reflect the complex, variable, dynamic and multidimensional nature of the systems. This paper focuses on modelling length of stay and flow of patients. An overview of such modelling techniques is provided, with particular attention to their impact and suitability in managing a hospital service.

An exploration of knowledge and attitudes related to pre-pregnancy care in women with diabetes

Aims: Pre-pregnancy care optimizes pregnancy outcome in women with pre-gestational diabetes, yet most women enter pregnancy unprepared. We sought to determine knowledge and attitudes of women with Type 1 and Type 2 diabetes of childbearing age towards pre-pregnancy care.

Methods: Twenty-four women (18 with Type 1 diabetes and six with Type 2 diabetes) aged 17–40 years took part in one of four focus group sessions: young nulliparous women with Type 1 diabetes (Group A), older nulliparous women with Type 1 diabetes (Group B), parous women with Type 1 diabetes (Group C) and women with Type 2 diabetes of mixed parity (Group D).

Results: Content analysis of transcribed focus groups revealed that, while women were well informed about the need to plan pregnancy, awareness of the rationale for planning was only evident in parous women or those who had actively sought pre-pregnancy advice. Within each group, there was uncertainty about what pre-pregnancy advice entailed. Despite many women reporting positive healthcare experiences, frequently cited barriers to discussing issues around family planning included unsupportive staff, busy clinics and perceived social stereotypes held by health professionals.

Conclusions: Knowledge and attitudes reported in this study highlight the need for women with diabetes, regardless of age, marital status or type of diabetes, to receive guidance about planning pregnancy in a motivating, positive and supportive manner. The important patient viewpoints expressed in this study may help health professionals determine how best to encourage women to avail of pre-pregnancy care

The effect of patient characteristics upon uptake of the influenza vaccination: a study comparing community based older adults in two healthcare systems

Background: Uptake of influenza vaccination represents a simple marker of proactive care of older people. However, many still do not receive the vaccine. To understand this challenge better, we investigated the relationship between patient characteristics (demographic, physical and psychological health, and health service use) and vaccination uptake in a sample of community-dwelling older people in two adjacent but differently structured healthcare systems (Northern Ireland (NI) and the Republic of Ireland (RoI)). Methods: 2,033 randomly selected community-dwelling older adults (65 years and older) were interviewed in their homes. Results: Rates of uptake were 78% in NI and 72% in RoI. Uptake was greater with older age (odds ratio (OR) 1.6, 95% confidence interval (CI) = 1.3-2.1, p

Bereavement Assessment Practice in Hospice Settings: Challenges for Palliative Care Social Workers

The management and delivery of bereavement support services in palliative care settings presents practical and ethical challenges. A national survey, conducted in 2007, examined bereavement practice in ten Marie Curie hospices across the United Kingdom. This qualitative study was undertaken using semi-structured telephone interviews with Bereavement Service Leaders located in each hospice. Although findings revealed that bereavement services were in operation and had been reviewed in response to the National Institute for Clinical Excellence Guidance (2004), and all bereaved families were offered support, there was no standardisation of service delivery across sites. Multi-disciplinary team meetings facilitated shared decision-making for bereavement follow-up, and expanded and clarified documentation completed by nursing staff around the time of the patient’s death. However, there was ambiguity regarding professional ‘duty of care’ and agency responses to bereaved individuals who were suicidal. Questions were raised around clinical effectiveness, reliability and professional accountability. The study highlighted ethical issues centred on documentation, user participation and consent, and found staff training was variable across the 10 hospices. The findings have informed the development of a post-bereavement service model which has been subsequently implemented across Marie Curie Cancer Care.

An evaluation of a domiciliary blood transfusion serivce for palliative care patients in Northern Ireland

Marie Curie Cancer Care (MCCC) is a national charitable organisation which provides specialist palliative care services to patients with cancer and other life limiting illnesses. Marie Curie Nursing Service (MCNS) provides nursing services to patients in their own homes. The administration of blood transfusions to palliative care patients is required to improve symptom management and quality of life; however this procedure often results in unnecessary hospital admissions. Recognising that the majority of patients wish to be cared for and die in their own home, and with National Guidance recommending that specialist palliative care services should be provided to patients in their preferred place of care, a recent service initiative by MCNS was domiciliary blood transfusions. Whilst this is not a new service within domiciliary care, this pilot project aimed to capture patient views to evaluate this service initiative. Telephone interviews were conducted, using a questionnaire, with 11 patients who had received the service. Findings indicated positive evaluation of the service. Domiciliary blood transfusions helped to avoid unnecessary hospital admissions, the quality of life of patients and their families was improved in the palliative phase of illness and they received the service in their preferred place of care.

Research priorities of adult intensive care nurses in 20 European countries: a Delphi study.

Aims: This paper is a report of a three round Delphi study of intensive care nursing research priorities in Europe (October 2006–April 2009).

Background: Internationally, priorities for research in intensive care nursing have received some attention focusing on healthcare interventions and patient needs. Studies as early as the 1980s identified priorities in the United States, United Kingdom, Hong Kong and Australia. Research priorities of intensive care nurses across the European Union are unknown.

Methods: The participants, invited in 2006, included 110 intensive care nurses, managers, educators and researchers from 20 European Critical Care Nursing Associations. Delphi round one was an emailed questionnaire inviting participants to list important areas for research. The list was content analysed and developed into an online questionnaire for rounds two and three. In round two, participants ranked the topics on a scale of 1–6 (not important to extremely important). Mean scores of round two were added to the questionnaire of round three and participants ranked the topics again.

Results: There were 52 research topics in 12 domains. There was a dominance of priorities in five main areas: patient safety; impact of evidence based practice on outcomes; impact of workforce on outcomes; well being of patients and relatives; and impact of end-of-life care on staff and practice.

Conclusions: The results reflect worldwide healthcare concerns and objectives and highlight topics that nurses view as fundamental to the care of critically ill patients. These topics provide a platform for future research efforts to improve clinical practice and care of patients in intensive care.

Promoting Health Behaviour Change in the Cardiac Patient

The importance of giving patients advice in relation to positive health behaviour change geared towards maximizing physical health must not be overlooked and is an important role of the cardiac nurse in contemporary health care. However, over-reliance on offering advice can often be counter-productive and less likely to achieve effective change. Patients are more likely to make positive health behaviour changes when they self-generate their own solutions to the health issues and problems that they face. In this article, the authors encourage cardiac nurses to embrace a less directive and more facilitative approach to patient health behaviour change in light of the mounting evidence that exists to the effectiveness of motivational interviewing techniques.

'Murder or Mercy?' an innovative module helping UK medical students to articulate their own ethical standpoints regarding end-of-life decisions

Objectives This student selected component (SSC) was designed to equip United Kingdom (UK) medical students to respond ethically and with sensitivity to requests they might receive as qualified doctors in regard to euthanasia and assisted dying. The aim was to expose students to relevant opinions and experiences and to provide opportunities to explore and justify their own views and rehearse ethical decision making in a safe learning environment. Method The module is delivered by specialists from a number of disciplines including law, theology, medicine and nursing, each providing students with a working knowledge allowing them to actively discuss cases, articulate their own views and practise ethical reasoning through group and individual study. Visits to local intensive care units, palliative care wards and hospices are integrated effectively with theory. Student assessment comprises a dissertation, student-led debate and reflective commentary. Module impact was evaluated by analysis of student coursework and a questionnaire. Results Students found the content stimulating and relevant to their future career and agreed that the module was well-structured and that learning outcomes were achieved. They greatly appreciated the clinical context provided by the visits and opportunities to apply ethical reasoning to real cases and to debate ethical issues with peers. Students reported an increased discernment of the ethical and legal position and practical considerations and a greater awareness of the range of professional and lay viewpoints held. Student perceptions were confirmed on analysis of their submitted coursework. Many participants were less strongly in favour of euthanasia and assisted dying on module completion than at the outset but all felt better equipped to justify their own viewpoint and to respond appropriately to patient requests. Conclusions The multi-disciplinary nature of this course is helpful in preparing students to deal effectively and sensitively with ethical dilemmas they will encounter in their medical career. Use of an integrated, learner-centred approach equips students to actively engage with their peers in discussion of such issues and to formulate and defend their own position.

Exploring the impact of depressive symptoms and medication beliefs on medication adherence in hypertension-A primary care study

Objective: This Study aimed to assess the levels of adherence in a sample of hypertensive patients being cared for in primary care in Northern Ireland and to explore the impact of depressive symptoms and medication beliefs on medication adherence.

Computational simulation methodologies for mechanobiological modelling: a cell-centred approach to neointima development in stents

The design of medical devices could be very much improved if robust tools were available for computational simulation of tissue response to the presence of the implant. Such tools require algorithms to simulate the response of tissues to mechanical and chemical stimuli. Available methodologies include those based on the principle of mechanical homeostasis, those which use continuum models to simulate biological constituents, and the cell-centred approach, which models cells as autonomous agents. In the latter approach, cell behaviour is governed by rules based on the state of the local environment around the cell; and informed by experiment. Tissue growth and differentiation requires simulating many of these cells together. In this paper, the methodology and applications of cell-centred techniques-with particular application to mechanobiology-are reviewed, and a cell-centred model of tissue formation in the lumen of an artery in response to the deployment of a stent is presented. The method is capable of capturing some of the most important aspects of restenosis, including nonlinear lesion growth with time. The approach taken in this paper provides a framework for simulating restenosis; the next step will be to couple it with more patient-specific geometries and quantitative parameter data.

Utility, Caller, and Patient Profile of a Novel Chemotherapy Telephone Helpline Service Within a Regional Cancer Centre in Northern Ireland

Background: The telephone is an accepted and useful means of communication for the management of patient care. The Chemotherapy Telephone Helpline (CTH) service, located in a large inner-city Trust within the United Kingdom, is a unique nurse-led service within Northern Ireland.

Objective: The objective of the study was to investigate the utility, caller, and patient profile of a novel CTH.

Methods: This was a retrospective study of telephone contacts during 2007 to the CTH. Calls were categorized by caller and patient characteristics, reason for call, and subsequent action.

Results: A total of 7498 calls were made to the CTH during 2007. Of these, 25.6% occurred outside 8AM-4PM. Callers included patients (45.8%), lay carers (31%), and health care professionals (20.5%); 35.2% of calls concerned patients with polysymptomatic problems; 36.8% of calls led directly to patients being medically assessed.

Conclusions: The utility of the CTH service confirms the need of this nurse-led service. This service facilitates access to specialist advice and support for patients, their families, and allied health care professionals.

Implications for Practice: The international significance of these findings for practice includes its demonstration of the multifaceted symptom experience of patients receiving chemotherapy and highlights the importance of rapid access to specialist cancer services for patients and their lay and professional carers. In addition, it demonstrates the capacity of helplines to identify gaps in professional skills and training.

Potentially inappropriate prescribing in an Irish elderly population in primary care.

AIMS Screening tools have been formulated to identify potentially inappropriate prescribing (IP) in older people. Beers’ criteria are the most widely used but have disadvantages when used in Europe. New
IP screening tools called Screening Tool of Older Person’s Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) have been developed to identify potential IP and potential prescribing omissions (PPOs). The aim was to measure the prevalence rates of potential IP and PPOs in primary care using Beers’ criteria, STOPP and START.

METHODS
Case records of 1329 patients 65 years old from three general practices in one region of southern Ireland were studied. The mean age SD of the patients was 74.9 6.4 years, 60.9% were female. Patients’current diagnoses and prescription medicines were reviewed and the Beers’ criteria, STOPP and START tools applied.

RESULTS
The total number of medicines prescribed was 6684; median number of medicines per patient was ?ve (range 1–19). Overall, Beers’ criteria identi?ed 286 potentially inappropriate prescriptions in 18.3% (243) of patients, whilst the corresponding IP rate identi?ed by STOPP was 21.4% (284), in respect of 346 potentially inappropriate prescriptions. A total of 333 PPOs were identi?ed in 22.7% (302) of patients using the START tool.

CONCLUSION
Potentially inappropriate drug prescribing and errors of drug omission are highly prevalent among older people living in the community. Prevention strategies should involve primary care doctors and community pharmacists.