Nutritional guidelines and menu checklist for residential and nursing homes

Care home residents should receive a varied diet that meets their nutritional needs in appropriate surroundings.This booklet ensures residential and nursing home managers and care providers have access to guidelines that help them achieve the aims set out by the Regulation and Quality Improvement Authority (RQIA), ie.�empowerment of, and positive engagement with, residents in all aspects of their care, including nutrition.It also provides practical nutrition advice and menu guidance.

Weekend versus weekday admission and mortality after acute pulmonary embolism.

BACKGROUND: Optimal management of acute pulmonary embolism (PE) requires medical expertise, diagnostic testing, and therapies that may not be available consistently throughout the entire week. We sought to assess whether associations exist between weekday or weekend admission and mortality and length of hospital stay for patients hospitalized with PE. METHODS AND RESULTS: We evaluated patients discharged with a primary diagnosis of PE from 186 acute care hospitals in Pennsylvania (January 2000 to November 2002). We used random-effect logistic models to study the association between weekend admission and 30-day mortality and used discrete survival models to study the association between weekend admission and time to hospital discharge, adjusting for hospital (region, size, and teaching status) and patient factors (race, insurance, severity of illness, and use of thrombolytic therapy). Among 15 531 patient discharges with PE, 3286 patients (21.2%) had been admitted on a weekend. Patients admitted on weekends had a higher unadjusted 30-day mortality rate (11.1% versus 8.8%) than patients admitted on weekdays, with no difference in length of stay. Patients admitted on weekends had significantly greater adjusted odds of dying (odds ratio 1.17, 95% confidence interval 1.03 to 1.34) than patients admitted on weekdays. The higher mortality among patients hospitalized on weekends was driven by the increased mortality rate among the most severely ill patients. CONCLUSIONS: Patients with PE who are admitted on weekends have a significantly higher short-term mortality than patients admitted on weekdays. Quality-improvement efforts should aim to ensure a consistent approach to the management of PE 7 days a week.

Physicians' estimates of the 10 year cardiovascular risk in hypertensive patients: an evaluation in primary care physicians in training.

To evaluate how young physicians in training perceive their patients' cardiovascular risk based on the medical charts and their clinical judgment. Cross sectional observational study. University outpatient clinic, Lausanne, Switzerland. Two hundred hypertensive patients and 50 non-hypertensive patients with at least one cardiovascular risk factor. Comparison of the absolute 10-year cardiovascular risk calculated by a computer program based on the Framingham score and adapted for physicians by the WHO/ISH with the perceived risk as assessed clinically by the physicians. Physicians underestimated the 10-year cardiovascular risk of their patients compared to that calculated with the Framingham score. Concordance between methods was 39% for hypertensive patients and 30% for non-hypertensive patients. Underestimation of cardiovascular risks for hypertensive patients was related to the fact they had a stabilized systolic blood pressure under 140 mm Hg (OR = 2.1 [1.1; 4.1]). These data show that young physicians in training often have an incorrect perception of the cardiovascular risk of their patients with a tendency to underestimate the risk. However, the calculated risk could also be slightly overestimated when applying the Framingham Heart Study model to a Swiss population. To implement a systematic evaluation of risk factors in primary care a greater emphasis should be placed on the teaching of cardiovascular risk evaluation and on the implementation of quality improvement programs.

Oportunidades de mejora del servicio de metadona en atención primaria, desde el punto de vista profesional

Objective: To identify and prioritize improvement opportunities, according to the European Foundation for Quality Management model (EFQM) model, of the methadone dispensing service in Andalusian Primary Health Care, from the point of view of professionals. Method: Delphi consensus method, implemented from September 2007 to March 2008 by means of three rounds of interviews with questionnaires administered by electronic mail to 39 professionals. The Panel of experts was made up of Dispensers and Prescribers of methadone as well as Coordinators of welfare services from the Methadone Treatment Program (MTP). Selection criteria were: Being in active employment with a minimum of 3 years experience. Sample diversification variables: Professional role, geographical environment and type of habitat. Recruitment: By means of key professional bodies from different institutions. Results: 48 improvement opportunities were identified. Thirteen of these obtained a high level of agreement in the final round. According to the EFQM model, the dimensions that obtained the most consensus in relation to improving the care service were: Leadership, Alliances and Resources. The dimension that caused the greatest disagreement was Processes. Conclusions: In spite of its having been implemented since 1997 in Andalusian Primary Health Care, the methadone dispensing service is at an implementation phase, rather than what could be classed as a fully deployed stage

Assaig d’ aclarida química en raïm de vinificació garnatxa negra

La Garnatxa negra és la varietat negra autòctona i majoritària a la Denominació d’OrigenEmpordà. La facilitat actual per obtenir rendiments elevats (selecció clonal, terrenys fèrtils, pràctiques agrícoles, ...) obliga a regular-ne la producció per obtenir collites de qualitat. L’eliminació d’una part de la collita mitjançant l’aclarida manual ha estat una pràctica efectiva i àmpliament utilitzada per la millora de la qualitat en situacions puntuals de sobreproducció. Però els seuselevats costos de mà d’obra la fan privativa per a la majoria de productors. L’aclarida química amb Etefon es perfila com una bona alternativa a l’hora de regular la producció amb uns costos d’execució acceptables. L’objectiu del treball era provar l’eficàcia de l’Etefon com a aclaridor químic en vinya per a la varietat Garnatxa negra com a alternativa a l’aclarida manual tradicional

La gestión por procesos, una herramienta de calidad en la protección de la salud

Boletín semanal para profesionales sanitarios de la Secretaría General de Salud Pública y Participación Social de la Consejería de Salud

Improving integrated care in chronic kidney failure patients with a standard-based interoperability framework.

This paper introduces the evaluation report after fostering a Standard-based Interoperability Framework (SIF) between the Virgen del Rocío University Hospital (VRUH) Haemodialysis (HD) Unit and 5 outsourced HD centres in order to improve integrated care by automatically sharing patients' Electronic Health Record (EHR) and lab test reports. A pre-post study was conducted during fourteen months. The number of lab test reports of both emergency and routine nature regarding to 379 outpatients was computed before and after the integration of the SIF. Before fostering SIF, 19.38 lab tests per patient were shared between VRUH and HD centres, 5.52 of them were of emergency nature while 13.85 were routine. After integrating SIF, 17.98 lab tests per patient were shared, 3.82 of them were of emergency nature while 14.16 were routine. The inclusion of a SIF in the HD Integrated Care Process has led to an average reduction of 1.39 (p=0.775) lab test requests per patient, including a reduction of 1.70 (p=0.084) in those of emergency nature, whereas an increase of 0.31 (p=0.062) was observed in routine lab tests. Fostering this strategy has led to the reduction in emergency lab test requests, which implies a potential improvement of the integrated care.

Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study.

BACKGROUND: Prehospital oligoanalgesia is prevalent among trauma victims, even when the emergency medical services team includes a physician. We investigated if not only patients' characteristics but physicians' practice variations contributed to prehospital oligoanalgesia. METHODS: Patient records of conscious adult trauma victims transported by our air rescue helicopter service over 10 yr were reviewed retrospectively. Oligoanalgesia was defined as a numeric rating scale (NRS) >3 at hospital admission. Multilevel logistic regression analysis was used to predict oligoanalgesia, accounting first for patient case-mix, and then physician-level clustering. The intraclass correlation was expressed as the median odds ratio (MOR). RESULTS: A total of 1202 patients and 77 physicians were included in the study. NRS at the scene was 6.9 (1.9). The prevalence of oligoanalgesia was 43%. Physicians had a median of 5.7 yr (inter-quartile range: 4.2-7.5) of post-graduate training and 27% were female. In our multilevel analysis, significant predictors of oligoanalgesia were: no analgesia [odds ratio (OR) 8.8], National Advisory Committee for Aeronautics V on site (OR 4.4), NRS on site (OR 1.5 per additional NRS unit >4), female physician (OR 2.0), and years of post-graduate experience [>4.0 to ≤5.0 (OR 1.3), >3.0 to ≤4.0 (OR 1.6), >2.0 to ≤3.0 (OR 2.6), and ≤2.0 yr (OR 16.7)]. The MOR was 2.6, and was statistically significant. CONCLUSIONS: Physicians' practice variations contributed to oligoanalgesia, a factor often overlooked in analyses of prehospital pain management. Further exploration of the sources of these variations may provide innovative targets for quality improvement programmes to achieve consistent pain relief for trauma victims.

Iowa Conservation Reserve Enhancement Program, Helping Landowners Protect Iowa’s Natural Resources,January 2009

The Iowa Conservation Reserve Enhancement Program is a state, federal, local, and private partnership that provides incentives to landowners who voluntarily establish wetlands for water quality improvement in the tile-drained regions of Iowa. The goal of the program is to reduce nitrogen loads and movement of other agricultural chemicals from croplands to streams and rivers. In addition to improving water quality, these wetlands will provide wildlife habitat and increase recreational opportunities.

Carbon stock and its compartments in a subtropical oxisol under long-term tillage and crop rotation systems

Soil organic matter (SOM) plays a crucial role in soil quality and can act as an atmospheric C-CO2 sink under conservationist management systems. This study aimed to evaluate the long-term effects (19 years) of tillage (CT-conventional tillage and NT-no tillage) and crop rotations (R0-monoculture system, R1-winter crop rotation, and R2- intensive crop rotation) on total, particulate and mineral-associated organic carbon (C) stocks of an originally degraded Red Oxisol in Cruz Alta, RS, Southern Brazil. The climate is humid subtropical Cfa 2a (Köppen classification), the mean annual precipitation 1,774 mm and mean annual temperature 19.2 ºC. The plots were divided into four segments, of which each was sampled in the layers 0-0.05, 0.05-0.10, 0.10-0.20, and 0.20-0.30 m. Sampling was performed manually by opening small trenches. The SOM pools were determined by physical fractionation. Soil C stocks had a linear relationship with annual crop C inputs, regardless of the tillage systems. Thus, soil disturbance had a minor effect on SOM turnover. In the 0-0.30 m layer, soil C sequestration ranged from 0 to 0.51 Mg ha-1 yr-1, using the CT R0 treatment as base-line; crop rotation systems had more influence on soil stock C than tillage systems. The mean C sequestration rate of the cropping systems was 0.13 Mg ha-1 yr-1 higher in NT than CT. This result was associated to the higher C input by crops due to the improvement in soil quality under long-term no-tillage. The particulate C fraction was a sensitive indicator of soil management quality, while mineral-associated organic C was the main pool of atmospheric C fixed in this clayey Oxisol. The C retention in this stable SOM fraction accounts for 81 and 89 % of total C sequestration in the treatments NT R1 and NT R2, respectively, in relation to the same cropping systems under CT. The highest C management index was observed in NT R2, confirming the capacity of this soil management practice to improve the soil C stock qualitatively in relation to CT R0. The results highlighted the diversification of crop rotation with cover crops as a crucial strategy for atmospheric C-CO2 sequestration and SOM quality improvement in highly weathered subtropical Oxisols.

Prescription footwear for severe injuries of foot and ankle: effect on regularity and symmetry of the gait assessed by trunk accelerometry.

After foot and/or ankle fracture, the restoration of optimal gait symmetry is one of the criteria of recovery. Orthotic insoles and orthopaedic shoes improve gait symmetry and regularity by controlling joint motion and improving alignment. The aim of the present study was to assess the effect of prescription footwear on gait quality by using accelerometers attached to the lower back. Sixteen adult patients with persistent disability after ankle and/or foot fractures performed two 30-s walking trials with and without prescription footwear (insoles and stabilizing shoes). Sixteen control subjects were also tested for comparison. The autocorrelation function was computed from the acceleration signal and the first two dominant periods were assessed (d1 and d2). Two parameters were used: (1) Stride Regularity (SR) which expresses the similarity between strides over time (d2), and (2) Stride Symmetry (SS) a ratio (d1/d2) which expresses the left/right similarity of gait independently of repeatability in the successive movements of each limb. In control subjects, SR and SS were 0.86+/-0.05 (correlation coefficient) and 81+/-10%, respectively. In the patient group, the effect of footwear was significant (SR: 0.88+/-0.06 vs. 0.90+/-0.05, SS: 38+/-23% vs. 46+/-27%). Pain was also significantly reduced (-34%). By using a rapid and low-cost method, we objectively quantified gait quality improvement after footwear intervention, concomitant to pain reduction. Substantial inter-patient variability in the footwear outcome was observed. In conclusion, we believe that trunk accelerometry can be a useful tool in the field of gait rehabilitation.

Impact of a program to prevent incivility towards and assault of healthcare staff in an ophtalmological emergency unit: study protocol for the PREVURGO On/Off trial.

BACKGROUND: The emergency department has been identified as an area within the health care sector with the highest reports of violence. The best way to control violence is to prevent it before it becomes an issue. Ideally, to prevent violent episodes we should eliminate all triggers of frustration and violence. Our study aims to assess the impact of a quality improvement multi-faceted program aiming at preventing incivility and violence against healthcare professionals working at the ophthalmological emergency department of a teaching hospital. METHODS/DESIGN: This study is a single-center prospective, controlled time-series study with an alternate-month design. The prevention program is based on the successive implementation of five complementary interventions: a) an organizational approach with a standardized triage algorithm and patient waiting number screen, b) an environmental approach with clear signage of the premises, c) an educational approach with informational videos for patients and accompanying persons in waiting rooms, d) a human approach with a mediator in waiting rooms and e) a security approach with surveillance cameras linked to the hospital security. The primary outcome is the rate of incivility or violence by patients, or those accompanying them against healthcare staff. All patients admitted to the ophthalmological emergency department, and those accompanying them, will be enrolled. In all, 45,260 patients will be included in over a 24-month period. The unit analysis will be the patient admitted to the emergency department. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: The strengths of this study include the active solicitation of event reporting, that this is a prospective study and that the study enables assessment of each of the interventions that make up the program. The challenge lies in identifying effective interventions, adapting them to the context of care in an emergency department, and thoroughly assessing their efficacy with a high level of proof.The study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02015884).

09008-005 Hewitt Creek Final Report

The primary goal of the Hewitt Creek watershed council is to have Hewitt-Hickory Creek removed from the Iowa impaired waters (303d) list. Hewitt Creek watershed, a livestock dense 23,005 acre sub-watershed of the Maquoketa River Basin, is 91.2% agricultural and 7.5% woodland. Since 2005, sixty-seven percent of 84 watershed farm operations participated in an organized watershed improvement effort using a performance­ based watershed management approach, reducing annual sediment delivery to the stream by 4,000 tons. Watershed residents realize that water quality improvement efforts require a long-term commitment in order to meet their watershed improvement goals and seek funding for an additional five years to continue their successful watershed improvement project. Cooperators will be provided incentives for improved environmental performance, along with incentives and technical support to address feedlot runoff issues and sub-surface nitrate-nitrogen loss. The Phosphorus Index, Soil Conditioning Index and cornstalk nitrate test will be used by producers as measures of performance to refine nutrient and soil loss management and to determine effective alternatives to reduce nutrient and sediment delivery. Twenty-five livestock operations will improve feedlot runoff control systems and five sub-surface bioreactors will be installed to reduce nitrate delivery from priority tile-drained fields. The Hewitt Creek council will seek additional cost-share funding for high-cost feedlot runoff control structures, sediment control basins and stream bank stabilization projects.

1009-004 Lost Island Lake Watershed Final Report

The Lost Island Lake watershed is located in the prairie pothole region, a region dotted with glacial wetlands and shallow lakes. At 1,180 acres, Lost Island Lake is the state's fifth largest natural lake and its watershed is comprised of nearly 1,000 acres of wetland habitat, including Iowa 's largest natural wetland – Barringer Slough. Unfortunately, Lost Island and its associated wetlands are not functioning to their fullest ecological and water quality potential. In 2002 and 2004, Lost Island Lake was categorized as '·impaired'" on Iowa's Impaired Waters List. Frequent algal blooms and suspended solids drastically increase turbidity levels resulting in its impairment. To investigate these concerns, a two-year study and resulting Water Quality Improvement Plan were completed. The water quality study identified an overabundance of non-native common carp (Cyprinus carpio) in the lake and its surrounding wetlands as a primary cause of impairment. The goal of the Lost Island Lake Watershed Enhancement Project is to restore ecological health to Lost Island Lake and its intricate watershed resulting in improved water quality and a diverse native plant and wildlife community. The purpose of this grant is to obtain funding for the construction of two combination fish barriers and water control structures placed at key locations in the watershed within the Blue Wing Marsh complex. Construction of the fish barriers and water control structures would aid restoration efforts by preventing spawning common carp from entering wetlands in the watershed and establishing the ability to manage water levels in large wetland areas. Water level management is crucial in wetland health and exotic fish control. These two structures are part of a larger construction project that involves a total of four combination fish barriers and water control structures and one additional fish barrier. The entire Lost Island Lake Watershed Enhancement Project is a multi-year project, but the construction phase for the fish barriers and water control structures will be completed before December 31, 2011.

06014-007 Lower Coldwater-Palmer Creek Watershed Final Report

Lower Coldwater and Palmer Creeks in Butler and Floyd counties are subwatersheds of the Cedar River, which provides drinking water to Cedar Rapids, IA. The increasing concentration of nitrate+nitrate in the river is of concern to the Cedar Rapids water utility, and IDNR snapshot monitoring shows Coldwater and Palmer to be significant potential sources (above the 90th percentile for subwatersheds monitored). Both creeks are also on the Iowa Section 303(d) list of impaired waters (aquatic life). Citizens of these predominantly agricultural watersheds organized the Coldwater-Palmer Watershed Improvement Association to deal proactively with nonpoint source pollutants from crop and livestock operations through a performance-based environmental management program. The locally-adapted program implemented by the Coldwater-Palmer watershed council rewards participants for environmental accomplishments - soil quality improvement and nutrient source reduction as measured by accepted, scientifically-based tests and models. Most of the locally­appropriate BMPs used to improve performance are undertaken voluntarily at participants' initiative. WIRB funds will be combined with funding from the Iowa Com Growers Association and significant in-kind support from the Cedar River Watershed Monitoring Coalition, Iowa State University Extension and other partners. The project will result in sustainable reduction in nutrient loading achieved with voluntary participation of a majority of watershed farm operators.