[Nursing unit: nurses co-ordinating hospital care--an answer to new challenges in acute medicine]

Some patients at university hospital no longer need frequent medical treatment but complex professional nursing care. At University Hospital (Inselspital) Bern a Nursing Unit with six beds was run as a pilot project based on experiences in British Nursing Development Units. The care concept was specifically developed and based on a definition of professional nursing, an evidence-based practice approach, resource oriented self management, and caring. Primary nursing was used, and the primary nurse was responsible for the coordination and steering of patient care. The project was evaluated prospectively. During the pilot phase, 37 patients were cared for on the NU. On average, 85% of the beds were occupied, patients were hospitalized for 21.5 days and had a mean age of 68.9 years. They were older than the University Hospital's average patient, and cases were more complex than the University Hospital's average case. The nurses' experiences were mainly positive. Their enhanced responsibility and the structured care process were seen as a challenge allowing them to enlarge their abilities. With this project, the University Hospital built up innovative services for patients with complex nursing problems. The project showed that well trained nurses can take on more responsibility for this patient group than in the context of conventional care models.

Can outcome prediction data change patient outcomes and organizational outcomes?

PURPOSE OF REVIEW: Intensive care medicine consumes a high share of healthcare costs, and there is growing pressure to use the scarce resources efficiently. Accordingly, organizational issues and quality management have become an important focus of interest in recent years. Here, we will review current concepts of how outcome data can be used to identify areas requiring action. RECENT FINDINGS: Using recently established models of outcome assessment, wide variability between individual ICUs is found, both with respect to outcome and resource use. Such variability implies that there are large differences in patient care processes not only within the ICU but also in pre-ICU and post-ICU care. Indeed, measures to improve the patient process in the ICU (including care of the critically ill, patient safety, and management of the ICU) have been presented in a number of recently published papers. SUMMARY: Outcome assessment models provide an important framework for benchmarking. They may help the individual ICU to spot appropriate fields of action, plan and initiate quality improvement projects, and monitor the consequences of such activity.

Can RapidTEG accelerate the search for coagulopathies in the patient with multiple injuries?

Hypothesis: Early recognition of coagulopathy may improve the care of patients with multiple injuries. Rapid thrombelastography (RapidTEG) is a new variant of thrombelastography (TEG), in which coagulation is initiated by the addition of protein tissue factor. The kinetics of coagulation and the times of measurement were compared for two variants of TEG--RapidTEG and conventional TEG, in which coagulation was initiated with kaolin. The measurements were performed on blood samples from 20 patients with multiple injuries. The RapidTEG results were also compared with conventional measurements of blood coagulation. The mean time for the RapidTEG test was 19.2 +/- 3.1 minutes (mean +/- SD), in comparison with 29.9 +/- 4.3 minutes for kaolin TEG and 34.1 +/- 14.5 minutes for conventional coagulation tests. The mean time for the RapidTEG test was 30.8 +/- 5.72 minutes, in comparison with 41.5 +/- 5.66 minutes for kaolin TEG and 64.9 +/- 18.8 for conventional coagulation tests---measured from admission of the patients to the resuscitation bay until the results were available. There were significant correlations between the RapidTEG results and those from kaolin TEG and conventional coagulation tests. RapidTEG is the most rapid available test for providing reliable information on coagulopathy in patients with multiple injuries. This has implications for improving patient care.

Patients with oral tumors. Part 2: Quality of life after treatment with resection prostheses. Resection prosthetics: evaluation of quality of life

In the present study, the oral health-related quality of life of 18 patients (13 men and 5 women) was evaluated using validated questionnaires as proposed by the European Organization of Research and Treatment of Cancer (EORTC). The patients belonged to a cohort of 48 patients, whose prosthetic treatment was performed during the years 2004-2007. In the course of tumor resection, 12 patients underwent graft surgery and 14 patients radiotherapy. One patient required a nasal epithesis since resection of the nose became necessary. Five patients underwent a full block resection of the mandible, and tumor resection in 3 patients resulted in a large oronasal communication. Prosthetic rehabilitation was performed in all patients, and the follow-up period with regular care covered a minimum of 3 years. Eleven patients received dental implants for better support and retention of the prostheses. In spite of compromised oral conditions, functional restrictions, and some difficulties with the prostheses, the answers to the questionnaire were quite positive. The majority judged their general health as good or even excellent. The subjective perception of the patients may contradict the objective view by the dentist. In fact, the individual patient's history and experience provide a better understanding of the impact of oral tumors on daily life. The overall assessment identified 4 items that were perceived as major problems by all patients: swallowing solid food, dry mouth, limited mouth opening, and appearance. Prosthetic rehabilitation has only a limited influence on such problems.

Schul-, Praxis- und habituelles Herrschaftswissen. Bildung ländlicher Eliten mit Blick auf die korporative Selbstverwaltung in der frühmodernen Schweiz (18. und 19. Jahrhundert)

Knowledge taught at schools, everyday skills and practical know-how. The relevancy of formation for local elites and the corporative self-government of Early Modern Switzerland Daniel Schläppi, Bern There were different kinds of rural elites in Early Modern Switzerland. The diverse parts of the country developed in very dissimilar ways politically and economically. Some regions were dominated by traditional types of agriculture. Some territories were ruled by major cities. In some of the rural Cantons like Uri, Schwyz, Unterwalden, Glarus and Zug a political elite took control over generations and practiced a cultural lifestyle comparable to the famous aristocracies in cities like Bern, Basel, Freiburg, Luzern, Solothurn and Zurich. Intense proto-industrialization formed a completely different sort of elite with strong affinities to industry and trade in other regions. Meanwhile the habitants of the valley close-by stayed farmers like their ancestors (like in Appenzell). In the most conservative parts of the country mercenary business played an important role till the very end of the Ancien Regime and even furthermore. In summery the variety of historical circumstances caused heterogeneous elites all over. Such socio-political diversity provoked a variety of educational backgrounds. I an academic understanding of the term we know only little about literacy in local rural elites. But there is strong evidence that a lively culture of reading and story-telling existed. This means that even simple countrymen seem to have been in possession of some books. The organisation and capacity of the school system is subject of controversial discussions among up to date researchers. The state of research makes us suppose that the people designed to political careers learned their essential skills not only in school but also in everyday life or on the job. Based on the fact that every community and countless public corporations managed their affairs by their own it’s evident that the local elite’s key-players had a large repertoire of techniques and skills like writing, calculating, strategic thinking or knowledge of oral tradition, old usage or important rituals. Unfortunately the historical actors left not that many sources that would tell us precisely how knowledge and know-how were transferred in former times. Hardly any private account books or common correspondence have been conserved. But a huge bunch of sources that originate from corporative self-administration shows us that most local elites were well-educated and had the necessary skills anyway. Above all other sources like for instance the «Topographische Beschreibungen» (topographic descriptions) that were initiated by the «Ökonomische Gesellschaft» of Berne since the sixties of the 18th century provide an insight into pre-modern classrooms. More important information on the historical formation-reality can be gained by the autobiography of the famous poor peasant Ulrich Bräker (1735‒1798) or some of the novels by Albert Bitzius (1797‒1854, better known as Jeremias Gotthelf). The pedagogic writings by Johann Heinrich Pestalozzi (1746‒1827) and the influences by his mentors Johann Rudolf Tschiffeli (1716‒1780) or Philipp Emanuel von Fellenberg (1771‒1884) are quite illustrative as well.

Use of an Online Photo Management and Sharing Application to Create a Searchable Digital Dental Radiograph Repository

Problem: Dental radiographs generally display one or more findings/diagnoses, and are linked to a unique set of patient demographics, medical history and other findings not represented by the image. However, this information is not associated with radiographs in any type of meta format, and images are not searchable based on any clinical criteria (1,2). The purpose of this pilot study is to create an online, searchable data repository of dental radiographs to be used for patient care, teaching and research. [See PDF for complete abstract]

An analysis of the shortage of registered nurses (RNs) in acute care hospitals in El Paso, Texas

The purpose of this analysis of the shortage of Registered Nurses (RNs) in acute care hospitals in El Paso, Texas, was to evaluate twenty-two specific organizational and/or patient care unit (nursing unit) characteristics that effect the retention and turnover of professional nurses. Vacancy Rates were used to measure the level of the shortage in each hospital and nursing unit in the study. Vacancy Rates are a function of both RN retention and RN turnover. Seventy-three patient care units in five acute care hospitals were included in the study population.^ Fredrick Herzberg's motivational - hygiene theory was used to explain the types of characteristics or factors that can effect worker dissatisfaction. Dissatisfiers (hygiene factors) are those work place characteristics that influence workers to leave the job. The twenty-two potentially dissatisfying work place characteristics were either organizational or patient care unit specific in nature. The focus of the study was to evaluate high vacancy rates caused by both low retention of RNs and high turnover rates. Retention and turnover are a function of workers (RNs) not staying in their jobs, therefore hygiene factors were appropriate characteristics to study.^ Various multivariate analysis techniques were used to assess both the individual and combined effects of the hygiene factors on Vacancy Rates, Retention and Turnover. Results suggest that certain organizational and patient care unit characteristics are associated with and have a statistically significant effect on vacancy rates, and the retention and turnover of RNs. The type of Hospital was of particular interest in this regards. For-Profit facilities were less effected by most of the study variables than the Not-for-Profits. ^

The evolution and assessment of pharmaceutical care: Structure, processes, and outcomes

The evolution of pharmaceutical care is identified through a complete review of the literature published in the American Journal of Health-System Pharmacy, the sole comprehensive publication of institutional pharmacy practice. The evolution is categorized according to characteristics of structure (organizational structure, the role of the pharmacist), process (drug delivery systems, formulary management, acquiring drug products, methods to impact drug therapy decisions), and outcomes (cost of drug delivery, cost of drug acquisition and use, improved safety, improved health outcomes) recorded from the 1950s through the 1990s. While significant progress has been made in implementing basic drug distribution systems, levels of pharmacy involvement with direct patient care is still limited.^ A new practice framework suggests enhanced direct patient care involvement through increase in the efficiency and effectiveness of traditional pharmacy services. Recommendations advance internal and external organizational structure relationships that position pharmacists to fully use their unique skills and knowledge to impact drug therapy decisions and outcomes. Specific strategies facilitate expansion of the breadth and scope of each process component in order to expand the depth of integration of pharmacy and pharmaceutical care within the broad healthcare environment. Economic evaluation methods formally evaluate the impact of both operational and clinical interventions.^ Outcome measurements include specific recommendations and methods to increase efficiency of drug acquisition, emphasizing pharmacists' roles that impact physician prescribing decisions. Effectiveness measures include those that improve safety of drug distribution systems, decrease the potential of adverse drug therapy events, and demonstrate that pharmaceutical care can significantly contribute to improvement in overall health status.^ The implementation of the new framework is modeled on a case study at the M.D. Anderson Cancer Center. The implementation of several new drug distribution methods facilitated the redeployment of personnel from distributive functions to direct patient care activities with significant personnel and drug cost reduction. A cost-benefit analysis illustrates that framework process enhancements produced a benefit-to-cost ratio of 7.9. In addition, measures of effectiveness demonstrated significant levels of safety and enhanced drug therapy outcomes. ^

Home care service utilization in British Columbia: Substitute or complement to acute care?

The desire to promote efficient allocation of health resources and effective patient care has focused attention on home care as an alternative to acute hospital service. in particular, clinical home care is suggested as a substitute for the final days of hospital stay. This dissertation evaluates the relationship between hospital and home care services for residents of British Columbia, Canada beginning in 1993/94 using data from the British Columbia Linked Health database. ^ Lengths of stay for patients referred to home care following hospital discharge are compared to those for patients not referred to home care. Ordinary least squares regression analysis adjusts for age, gender, admission severity, comorbidity, complications, income, and other patient, physician, and hospital characteristics. Home care clients tend to have longer stays in hospital than patients not referred to home care (β = 2.54, p = 0.0001). Longer hospital stays are evident for all home care client groups as well as both older and younger patients. Sensitivity analysis for referral time to direct care and extreme lengths of stay are consistent with these findings. Two stage regression analysis indicates that selection bias is not significant.^ Patients referred to clinical home care also have different health service utilization following discharge compared to patients not referred to home care. Home care nursing clients use more medical services to complement home care. Rehabilitation clients initially substitute home care for physiotherapy services but later are more likely to be admitted to residential care. All home care clients are more likely to be readmitted to hospital during the one year follow-up period. There is also a strong complementary association between direct care referral and homemaker support. Rehabilitation clients have a greater risk of dying during the year following discharge. ^ These results suggest that home care is currently used as a complement rather than a substitute for some acute health services. Organizational and resource issues may contribute to the longer stays by home care clients. Program planning and policies are required if home care is to provide an effective substitute for acute hospital days. ^

The scholarly networks of Albrecht von Haller and the Economic Society of Bern – a multi-level network analysis

Here, by the example of the transfer of cultivated plants in the context of the correspondence networks of Albrecht von Haller and the Economic Society, a multi-level network analysis is suggested. By a multi-level procedure, the chronological dynamics, the social structure, the spatial distribution and the functional networking are analyzed one after the other. These four levels of network analysis do not compete with each other but are mutually supporting. This aims at a deeper understanding of how these networks contributed to an international transfer of knowledge in the 18th century.

Die Sakralisierung des Alpenraums: Kulturelle Interpretationsmuster der rätischen Kapuzinermission (17. und 18. Jh.)

The Capuchins of the Rhaetic Missions had to deal with local forms of catholic piety, which for them were almost as exotic as the religious practices of non-Christian communities in Asia or America. Therefore they regarded it as their task to propagate the true faith among the “schismatic” Catholics from the Grisons. For this purpose, the Capuchins developed a particular pattern of interpretation: They created a sacred territory in which the divine grace can be experienced by the faithful. Hence the missionaries built new churches and chapels, decorated the old ones in baroque style and brought numerous of holy relics from Italy. Thus, they enforced the sacralisation of the alpine space. Recent developments in cultural studies and social sciences make it possible to capture such processes of spacing more precisely. In the course of the “spatial turn”, space is no longer conceived as a physical entity but now is regarded as a human construct. The paper discusses possibilities and limitations of “space” as an analytical category for the study of mission within Catholicism. The sociological concept of space developed by Martina Löw (2001) is used as starting point. This allows the simultaneous consideration of social interactions and cultural contexts in construction of “sacred space”.

«Einige Zeit aufs Singen verwendet». Musik als Kernressource dörflicher Kultur am Beispiel des schweizerischen 18. Jahrhunderts

Dealing with popular music in premodern times historical research usually focuses on so called “Volksmusik”. But already in the 18th century researchers were disappointed to find only few traces of imaginary “traditional” music in Switzerland. They unfortunately overlooked that common people kept on with their own stubborn musical culture: Beginning with the Reformation the authorities encouraged the communities to employ schoolmasters who were able to teach music. Their goal was that everybody should be able to participate in liturgical music actively. Over generations even people with no special musical talent adopted their own repertoire of psalms plus techniques of reading music and polyphonic singing. Spontaneous choral singing evolved into a common everyday practice. The most ambitious and brightest teachers even taught instrumental lessons at home on their proper pianos and chamber organs or encouraged the villagers to build new prestigious organs in their churches. The financial burden of such instruments weighted heavily on the communities. Some of them received financial support from the government, albeit unwillingly because it was obvious to the rulers that the villages just wanted to overtop each other. Homemade music was the most important issue in the cultural life of most parishes. Rich communes spent a lot of money to win the best voices on-site for their church choirs. Belonging to an elitists’ singer association paved the way to the farmer-village’s highlevel sociability.

Developing a point-of-care electronic medical record system for TB/HIV co-infected patients: experiences from Lighthouse Trust, Lilongwe, Malawi.

BACKGROUND Implementation of user-friendly, real-time, electronic medical records for patient management may lead to improved adherence to clinical guidelines and improved quality of patient care. We detail the systematic, iterative process that implementation partners, Lighthouse clinic and Baobab Health Trust, employed to develop and implement a point-of-care electronic medical records system in an integrated, public clinic in Malawi that serves HIV-infected and tuberculosis (TB) patients. METHODS Baobab Health Trust, the system developers, conducted a series of technical and clinical meetings with Lighthouse and Ministry of Health to determine specifications. Multiple pre-testing sessions assessed patient flow, question clarity, information sequencing, and verified compliance to national guidelines. Final components of the TB/HIV electronic medical records system include: patient demographics; anthropometric measurements; laboratory samples and results; HIV testing; WHO clinical staging; TB diagnosis; family planning; clinical review; and drug dispensing. RESULTS Our experience suggests that an electronic medical records system can improve patient management, enhance integration of TB/HIV services, and improve provider decision-making. However, despite sufficient funding and motivation, several challenges delayed system launch including: expansion of system components to include of HIV testing and counseling services; changes in the national antiretroviral treatment guidelines that required system revision; and low confidence to use the system among new healthcare workers. To ensure a more robust and agile system that met all stakeholder and user needs, our electronic medical records launch was delayed more than a year. Open communication with stakeholders, careful consideration of ongoing provider input, and a well-functioning, backup, paper-based TB registry helped ensure successful implementation and sustainability of the system. Additional, on-site, technical support provided reassurance and swift problem-solving during the extended launch period. CONCLUSION Even when system users are closely involved in the design and development of an electronic medical record system, it is critical to allow sufficient time for software development, solicitation of detailed feedback from both users and stakeholders, and iterative system revisions to successfully transition from paper to point-of-care electronic medical records. For those in low-resource settings, electronic medical records for integrated care is a possible and positive innovation.

UHC Patient Safety Net® Progress To Date : An “A+” Report Card for JDH Staff!

Safety in Numbers It’s been eight months since we implemented UHC Patient Safety Net® (“PSN”) at John Dempsey Hospital, and we are delighted with its success. As you know, PSN is a web-based reporting tool for reporting patient safety-related events. Frontline staff are doing a great job entering data on patient care events. Here’s how PSN works: