Preanalytical mistakes in samples from primary care patients.

BACKGROUND Preanalytical mistakes (PAMs) in samples usually led to rejection upon arrival to the clinical laboratory. However, PAMs might not always be detected and result in clinical problems. Thus, PAMs should be minimized. We detected PAMs in samples from Primary Health Care Centres (PHCC) served by our central laboratory. Thus, the goal of this study was to describe the number and types of PAMs, and to suggest some strategies for improvement. METHODS The presence of PAMs, as sample rejection criteria, in samples submitted from PHCC to our laboratory during October and November 2007 was retrospectively analysed. RESULTS Overall, 3885 PAMs (7.4%) were detected from 52,669 samples for blood analyses. This included missed samples (n=1763; 45.4% of all PAMs, 3.3% of all samples), haemolysed samples (n=1408; 36.2% and 2.7%, respectively), coagulated samples (n=391; 10% and 0.7%, respectively), incorrect sample volume (n=110; 2.8% and 0.2%, respectively), and others (n=213; 5.5% and 0.4%, respectively). For urine samples (n=18,852), 1567 of the samples were missing (8.3%). CONCLUSIONS We found the proportion of PAMs in blood and urine samples to be 3-fold higher than that reported in the literature. Therefore, strategies for improvement directed towards the staff involved, as well as an exhaustive audit of preanalytical process are needed. To attain this goal, we first implemented a continued education programme, financed by our Regional Health Service and focused in Primary Care Nurses.

Utility of the mini-cog for detection of cognitive impairment in primary care: data from two spanish studies.

Objectives. To study the utility of the Mini-Cog test for detection of patients with cognitive impairment (CI) in primary care (PC). Methods. We pooled data from two phase III studies conducted in Spain. Patients with complaints or suspicion of CI were consecutively recruited by PC physicians. The cognitive diagnosis was performed by an expert neurologist, after formal neuropsychological evaluation. The Mini-Cog score was calculated post hoc, and its diagnostic utility was evaluated and compared with the utility of the Mini-Mental State (MMS), the Clock Drawing Test (CDT), and the sum of the MMS and the CDT (MMS + CDT) using the area under the receiver operating characteristic curve (AUC). The best cut points were obtained on the basis of diagnostic accuracy (DA) and kappa index. Results. A total sample of 307 subjects (176 CI) was analyzed. The Mini-Cog displayed an AUC (±SE) of 0.78 ± 0.02, which was significantly inferior to the AUC of the CDT (0.84 ± 0.02), the MMS (0.84 ± 0.02), and the MMS + CDT (0.86 ± 0.02). The best cut point of the Mini-Cog was 1/2 (sensitivity 0.60, specificity 0.90, DA 0.73, and kappa index 0.48 ± 0.05). Conclusions. The utility of the Mini-Cog for detection of CI in PC was very modest, clearly inferior to the MMS or the CDT. These results do not permit recommendation of the Mini-Cog in PC.

Effectiveness of two interventions based on improving patient-practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care.

BACKGROUND In the last decades the presence of social inequalities in diabetes care has been observed in multiple countries, including Spain. These inequalities have been at least partially attributed to differences in diabetes self-management behaviours. Communication problems during medical consultations occur more frequently to patients with a lower educational level. The purpose of this cluster randomized trial is to determine whether an intervention implemented in a General Surgery, based in improving patient-provider communication, results in a better diabetes self-management in patients with lower educational level. A secondary objective is to assess whether telephone reinforcement enhances the effect of such intervention. We report the design and implementation of this on-going study. METHODS/DESIGN The study is being conducted in a General Practice located in a deprived neighbourhood of Granada, Spain. Diabetic patients 18 years old or older with a low educational level and inadequate glycaemic control (HbA1c > 7%) were recruited. General Practitioners (GPs) were randomised to three groups: intervention A, intervention B and control group. GPs allocated to intervention groups A and B received training in communication skills and are providing graphic feedback about glycosylated haemoglobin levels. Patients whose GPs were allocated to group B are additionally receiving telephone reinforcement whereas patients from the control group are receiving usual care. The described interventions are being conducted during 7 consecutive medical visits which are scheduled every three months. The main outcome measure will be HbA1c; blood pressure, lipidemia, body mass index and waist circumference will be considered as secondary outcome measures. Statistical analysis to evaluate the effectiveness of the interventions will include multilevel regression analysis with three hierarchical levels: medical visit level, patient level and GP level. DISCUSSION The results of this study will provide new knowledge about possible strategies to promote a better diabetes self-management in a particularly vulnerable group. If effective, this low cost intervention will have the potential to be easily incorporated into routine clinical practice, contributing to decrease health inequalities in diabetic patients. TRIAL REGISTRATION Clinical Trials U.S. National Institutes of Health, NCT01849731.

Identification of factors associated with diagnostic error in primary care.

BACKGROUND Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason's taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed. METHODS Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician's initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians' perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified. DISCUSSION This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.

Adhésion thérapeutique du patient chronique: des concepts a la prise en charge ambulatoire [Medication adherence in chronic patients: from its concepts to its management in primary care].

Medication nonadherence is common and its determinants are diverse. Adherence is influenced by many parameters, such as patient's self-efficacy, knowledge of health risk, outcome expectations, benefits of change, and barriers and facilitators. The sociocognitive theory helps professionals to structure their approach and to support patients in managing their treatment. Professionals need skills and time, and benefit from coordination in care, in particular between physicians and pharmacists. This article presents the key elements of a medication adherence program as well as tools and some useful questions.

Douteurs thoraciques en médecine ambulatoire. Sans oublier les patients qui n'ont "rien au coeur" [Thoracic pain in primary care. Don't forget the patients without heart disease].

Thoracic pain in primary care. Don't forget the patients without heart disease Thoracic pain is a frequent medical complaint. Diagnostic and therapeutic guidelines have been developed and evaluated mostly in emergency and hospital settings. The primary care practitioner, as the emergency room doctor, has to identify quickly any severe condition needing urgent and highly specialized treatment. But in primary care, the process is not finished then! A patient with no vital and urgent problem still needs a diagnosis, information and adequate treatment. This review goes over the presentation of thoracic pain, the differential diagnoses and the challenge of treating such patients in ambulatory care.

Le suivi prénatal des femmes accouchant dans le canton de Vaud: etude rétrospective de 854 cas. [Prenatal care of women delivering in the Vaud canton: retrospective study of 854 cases].

The association between prenatal care and infant health has been shown in many studies. Therefore, accurate information on prenatal care is required to assess the organization of preventive measures aiming at a reducing in neonatal mortality any morbidity. We retrospectively collected data on 854 pregnancies. According to a classification scheme developed by Kessner, 61.6% of women had access to adequate prenatal care. Overall, the proportion of adequate prenatal care was lower among multiparas, and in this subgroup we found a lower rate for women with base line insurance. In the primiparas subgroup we found a lower rate of adequate prenatal care for foreigners, women under 20 years or unmarried mothers, and for women without professional activity during pregnancy, besides preterm birth was more frequent amongst women in the group of prenatal care qualified as intermediate or inadequate. The frequency of pregnancy visits and the Kessner index are discussed in a literature review. The association between socio-economic indicators and prenatal care was unexpected considering the overall wealth of Switzerland. With a 6.8% infant mortality registered in 1989, this country can be considered to have one of the lowest rates in the world. These findings nevertheless suggest the way to possible additional gains by interventions targeted to specific socio-economic groups.

Cross Mapping Of Nursing diagnoses In Infant Health Using the International Classification of Nursing Practice

This was a descriptive, retrospective study, with a quantitative method, with the aim of analyzing the nursing diagnoses contained in the records of children of 0 to 36 months of age who attended infant health nursing consults. A documentary analysis and the cross-mapping technique were used. One hundred eighty-eight different nursing diagnoses were encountered, of which 33 (58.9%) corresponded to diagnoses contained in the Nomenclature of Nursing Diagnoses and Interventions and 23 (41.1%) were derived from ICNP® Version 1.0. Of the 56 nursing diagnoses, 43 (76.8%) were considered to be deviations from normalcy. It was concluded that the infant health nursing consults enabled the identification of situations of normalcy and abnormality, with an emphasis on the diagnoses of deviations from normalcy. Standardized language favors nursing documentation, contributing to the care of the patient and facilitating communication between nurses and other health professionals.


The Construction Of Ethical Competence In The Perception Of Primary Care Nurses


The study intended to understand the perception of nurses of Primary Care Services about the construction of ethical competence on their formation and practices. This is a qualitative study, with an interpretative phenomenological approach and interviews with ten nurses of the community health services of Porto Alegre, RS. The results showed that the interviewed professionals had already experienced situations with ethical conflicts and knew what ethical competence means. The central themes point out three fundamental issues in the construction of the ethical competence: personal values, education and practice. Taking into account that ethical competence is in permanent construction, the study shows the importance to promote organizational and educational activities in a transversal manner, as a tool to cope the moral stress and contribute in improving the quality of care in the primary health attention.


Supervision of Community Health Agents in the Family Health Strategy: the perspective of nurses

Objective Analyzing the conceptions of supervision of nurses in the Family Health Strategy (ESF - Estratégia Saúde da Família) in relation to community health workers (ACS – Agente Comunitário de Saúde), taking for reference the work process and the power relations. Method A qualitative study, in which 18 interviews were carried out with nurses from the ESF in the countryside of the state of Goiás. Following transcription, the data were subjected to thematic content analysis and the following categories were identified: Supervision with that sees it all and Supervision is participating and working together. Results Among the findings, it is clear the character of control and monitoring that is carried out primarily through printed instruments and home visits, which constitute vertical and impositive relations, and suffer influence of the local health management. Another finding is the supervision as acting together and with the educational perspective. Conclusion The supervision carried out does not provide the changes intended by the ESF.

Management of basic health units in municipalities of different size: profile and management instruments

Objective To identify the characteristics of managers and their use of management instruments in primary care and to analyze differences in these features among municipalities of different sizes. Method The present cross-sectional descriptive study was conducted at 108 basic health units from 21 municipalities in northern Paraná, Brazil. The data were collected using a semi-structured questionnaire during the second half of 2010. Results Most managers had graduate degrees and were female and nurses. The managers from the small municipalities were younger, their payment was lower, and they had less work experience. The use of management instruments was expressive for both the organization and work management; however, the instruments were used less in the small municipalities. Conclusion The managers were committed to their role; it is recommended that policies and guidance should be formulated at the federal and state levels to support small municipalities.

Performance evaluation of primary care services for the treatment of tuberculosis

Objective Evaluating the performance of primary care services for the treatment of tuberculosis according to the assessment referential of health services (structure/process) in Cabedelo, a port city in the state of Paraíba. Method An evaluation quantitative, cross-sectional study, in which were carried out 117 interviews with health professionals using a structured instrument. The analysis was based on the construction of indicators using a standardized value for the reduced variable (z=1). Results The structural indicators showed regular performance for the following variables: professional training, access to record instruments and coordination with other services. The process indicators related to external actions and information about the disease had unsatisfactory performance. The directly observed treatment and the flows of reference/counter-reference had regular performance. Conclusion The focused professional qualification, the fragmentation of practices and the unsystematic home care constitute obstacles for carrying out actions aimed at providing expanded, continuous and resolute care.



The role of primary care in the prevention and control of healthcare associated infections

Little research has been conducted to date on the role of primary health care (PHC) in the prevention of healthcare associated infections (HCAIs). The present article is a theoretical study of the principle of primum non nocere and aims to promote reflection on the role of PHC in HCAI prevention with emphasis on practical recommendations. The indirect and direct roles of PHC in HCAI prevention are debated in light of this guiding principle. With respect to the indirect role of PHC, we discuss the issues of hospital-centrism and ambulatory care-sensitive conditions. The article outlines a number of challenges faced by health services related to PHC’s direct role in HCAI prevention, highlights seven key components of HCAI prevention programmes within the PHC sphere and provides practical recommendations for HCAI control and prevention.


Determinants of emergency contraception non-use among women in unplanned or ambivalent pregnancies

Objective To analyze the determinants of emergency contraception non-use among women in unplanned and ambivalent pregnancies. Method Cross-sectional study with a probabilistic sample of 366 pregnant women from 12 primary health care units in the city of São Paulo, Brazil. A multinomial logistic regression was performed, comparing three groups: women who used emergency contraception to prevent ongoing pregnancies (reference); women who made no use of emergency contraception, but used other contraceptive methods; and women who made no use of any contraceptive methods at all. Results Cohabitation with a partner was the common determinant of emergency contraception non-use. No pregnancy risk awareness, ambivalent pregnancies and no previous use of emergency contraception also contributed to emergency contraception non-use. Conclusion Apart from what is pointed out in the literature, knowledge of emergency contraception and the fertile period were not associated to its use.

Limits and possibilities experienced by nurses in the treatment of women with chronic venous ulcers

Objective To understand the experiences and expectations of nurses in the treatment of women with chronic venous ulcers. Method Phenomenological research was based on Alfred Schütz, whose statements were obtained in January, 2012, through semi-structured interviews with seven nurses. Results The nurse reveals the difficulties presented by the woman in performing self-care, the perceived limitations in the treatment anchored in motivation, and the values and beliefs of women. It showed professional frustration because venous leg ulcer recurrence, lack of inputs, interdisciplinary work and training of nursing staff. There was an expected adherence to the treatment of women, and it emphasized the need for ongoing care, supported self-care and standard practices in treatment. Conclusion That treatment of chronic venous leg ulcers constitutes a challenge that requires collective investment, involving women, professionals, managers and health institutions.