OUT-OF-HOSPITAL CHILDBEARING CENTERS IN THE UNITED STATES: A DESCRIPTIVE STUDY OF THE DEMOGRAPHIC AND MEDICAL-OBSTETRIC CHARACTERISTICS OF WOMEN BEGINNING LABOR THEREIN 1972-1979

There is currently much interest in the appropriate use of obstetrical technology, cost containment and meeting consumers' needs for safe and satisfying maternity care. At the same time, there has been an increase in professionally unattended home births. In response, a new type of service, the out-of-hospital childbearing center (CBC) has been developed which is administratively and structurally separate from the hospital. In the CBC, maternity care is provided by certified nurse-midwives to carefully screened low risk childbearing families in conjunction with physician and hospital back-up.^ It was the purpose of this study to accomplish the following objectives: (1) To describe in a historical prospective study the demographic and medical-obstetric characteristics of patients laboring in eleven selected out-of-hospital childbearing centers in the United States from May 1, 1972, to December 15, 1979. Labor is defined as the onset of regular contractions as determined by the patient. (2) To describe any differences between those patients who require transfer to a back-up hospital and those who do not. (3) To describe administrative and service characteristics of eleven selected out-of-hospital childbearing centers in the United States. (4) To compare the demographic and medical-obstetric characteristics of women laboring in eleven selected out-of-hospital childbearing centers with a national sample of women of similar obstetric risk who according to birth certificates delivered legitimate infants in a hospital setting in the United States in 1972.^ Research concerning CBCs and supportive to the development of CBCs including studies which identified factors associated with fetal and perinatal morbidity and mortality, obstetrical risk screening, and the progress of technological development in obstetrics were reviewed. Information concerning the organization and delivery of care at each selected CBC was also collected and analyzed.^ A stratified, systematic sample of 1938 low risk women who began labor in a selected CBC were included in the study. These women were not unlike those described previously in small single center studies reported in the literature. The mean age was 25 years. Sixty-three per cent were white, 34 per cent Hispanic, 88 per cent married, 45 per cent had completed at least two years of college, nearly one-third were professionals and over a third were housewives. . . . (Author's abstract exceeds stipulated maximum length. Discontinued here with permission of school.) UMI ^

THE DISCHARGED PSYCHIATRIC PATIENT: POST-HOSPITAL ADJUSTMENT AND FACTORS AFFECTING REHOSPITALIZATION

Discharged psychiatric patients were studied six months post-discharge to determine those demographic, social and clinical characteristics affecting positive or negative adjustment and the degree to which the use of mental health services and medication compliance mediated the effects. With the exception of those with primary or secondary diagnoses of OBS, substance abuse or mental retardation, sixty-three psychiatric subjects between the ages of eighteen and sixty-four were chosen from all admissions into the hospital and interviewed six months after discharge using a specially designed questionnaire.^ The subjects' adjustment to community living was found to be marginal. Although not engaged in destructive activities, over half were living with their family members who supported them financially and emotionally. Most were unemployed and had been so for a long time. Others worked sporadically and frequently changed residences. Most did have substantial social ties with extended family and with friends with whom they interacted regularly, but one-fourth were socially isolated. Almost three-quarters continued to obtain regular mental health services after discharge and followed medication instructions under the supervision of their physician. The use of mental health services after discharge and the use of medication did not appear to affect the subjects' community adaption or their rate of rehospitalization.^ Forty percent of those discharged were rehospitalized by the end of the follow-up period. Four levels of risk of rehospitalization emerged. The highest risk was associated with a history of five or more prior hospitalizations, living alone, and social isolation. One third or more of the subjects expressed a need for more counseling, leisure time activities, case-manager assistance, vocational guidance, supervised housing, and placement into a transitional residential treatment program.^ Recommendations were made to enhance the ability to predict recidivism, to develop interorganizational casework management programs linking the patient and family to the community mental health system and to create computerized tracking and monitoring programs that systematically report patient treatment regimen and progress cross-sectionally and longitudinally. ^

Assessing the impact of electronic health record technology adoption on hospital labor efficiency

Information technology (IT) in the hospital organization is fast becoming a key asset, particularly in light of recent reform legislation in the United States calling for expanding the role of IT in our health care system. Future payment reductions to hospitals included in current health reform are based on expected improvements in hospital operating efficiency. Since over half of hospital expenses are for labor, improved efficiency in use of labor resources can be critical in meeting this challenge. Policy makers have touted the value of IT investments to improve efficiency in response to payment reductions. ^ This study was the first to directly examine the relationship between electronic health record (EHR) technology and staffing efficiency in hospitals. As the hospital has a myriad of outputs for inpatient and outpatient care, efficiency was measured using an industry standard performance metric – full time equivalent employees per adjusted occupied bed (FTE/AOB). Three hypotheses were tested in this study.^ To operationalize EHR technology adoption, we developed three constructs to model adoption, each of which was tested by separate hypotheses. The first hypothesis that a larger number of EHR applications used by a hospital would be associated with greater staffing efficiency (or lower values of FTE/AOB) was not accepted. Association between staffing efficiency and specific EHR applications was the second hypothesis tested and accepted with some applications showing significant impacts on observed values for FTE/AOB. Finally, the hypothesis that the longer an EHR application was used in a hospital would be associated with greater labor efficiency was not accepted as the model showed few statistically significant relationships to FTE/AOB performance. Generally, there does not appear a strong relationship between EHR usage and improved labor efficiency in hospitals.^ While returns on investment from EHR usage may not come from labor efficiencies, they may be better sought using measures of quality, contribution to an efficient and effective local health care system, and improved customer satisfaction through greater patient throughput.^

Relationship between nurse leader emotional intelligence and registered nurse job satisfaction

Aim: To determine the relationship between nurse leader emotional intelligence and registered nurse job satisfaction. ^ Background: Nurse leaders influence the work environments of nurses working at the bedside. Nursing leadership plays an important role in fostering work environments that attract and retain nurses. ^ Methods: A non-experimental, predictive design study conducted in 5 hospitals evaluated relationships between 31 nurse leaders and 799 registered nurses. The nurse leaders were administered the MSCEIT and MBTI. The registered nurses participated in the 2010 NDNQI RN Job Satisfaction Survey. ^ Measurements and Results: The sample population completed two online instruments, the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Myers Brigg Trait Inventory (MBTI). Nurse leader demographic data was collected consisting of age, sex, race, educational level, certification status and years in the profession of nursing. The relationships among characteristics of the nurse leader and staff nurses were examined using regression analysis and stepwise deletion. The results from the MBTI were obtained electronically from CPP. Inc. and the results of MSCEIT were obtained electronically from MHS, Inc. The nurse leader response rate was 46% and the NDNQI RN Job Satisfaction response rate was 62%. The sample of 31 nurse leaders were 65 percent female and 67.7% were White, 12.9% Black, and 19.4% Hispanic. The most prevalent MBTI type was ESTJ (19.35%), followed by ENFJ and ISFJ (9.68% each). The nurse leader sample was primarily extroverts (n=20), sensing (n=18), thinking (n=16) and judging (n=19). The nurse leaders' overall MSCEIT scores ranged from 69 to 111 (implying a range from those who should consider development to competent) with a mean score of 89.84 (consider improvement). The nurse leaders scored highest in the MSCEIT Facilitating subscale with scores ranging from 69 to 121 (consider development to strength) and a mean score of 95.19 (low average score). The overall mean MSCEIT mean scores for the entire sample ranged from 89.90 to 95.19 (consider emotional intelligence improvement to low average score) Overall, staff nurse participants in the NDNQI RN Job Satisfaction Survey were moderately satisfied with the nurse leaders as noted by a mean t score of 55.03 of 60 and this score was consistent with the comparison hospitals that participated in the 2010 NDNQI RN Job Satisfaction Survey (American Nurses Association, 2010). Staff nurses gave nurse leaders a mean score of 4.50 for patient assignments appropriate, and rated a mean score of 4.35 and moderately agreeing to recommend the hospital to a friend. ^ Conclusions: Future research is needed to determine if there is a relationship between nurse leader emotional intelligence ability and registered nurse job satisfaction. Additional research is also needed to determine what to measure in regards to nurse leader emotional intelligence, ability or behavior. Another issue that emerged in the examination of EI is the moderating relationship between the nurse leaders span of control and staff nurse satisfaction on the NDNQI. ^

Evaluation of elevator shafts as a pathway for fungal spores and particles to enter a hospital housing immuno-compromised patients

Background. It is estimated that hospitals spend between 28 and 33 billion dollars per year as a result of hospital-acquired infections. (Scott, 2009) The costs continue to rise despite the guidance and controls provided by hospital infection control staff to reduce patient exposures to fungal spores and other infectious agents. With all processes and controls in place, the vented elevator shaft represents an unprotected opening from the top of the building to the lower floors. The hypothesis for this prospective study is that there is a positive correlation between the number of Penicillium/Aspergillus-like spores, Cladosporium, ascospores, basidiospores in spores/m3 as individual spore categories found in the hoistway vent of an elevator shaft and the levels of the same spores, sampled near-simultaneously in the outdoor intake of the elevator shaft. Specific aims of this study include determining if external Penicillium/Aspergillus-like spores are entering the healthcare facility via the elevator shaft and hoistway vents. Additional aims include determining levels of Penicillium/Aspergillus-like spores outdoors, in the elevator shafts, and indoors in areas possibly affected by elevator shaft air; and, finally, to evaluate whether any effect is observed due to the installation of a hoistway vent damper, installed serendipitously during this study. ^ Methods. Between April 2010 and September 2010, a total of 3,521 air samples were collected, including 363 spore trap samples analyzed microscopically for seven spore types, and polymerase chain reaction analyses on 254 air samples. 2178 particle count measurements, 363 temperature readings and 363 relative humidity readings were also obtained from 7 different locations potentially related to the path of air travel inside and near a centrally-located and representative elevator shaft. ^ Results. Mean Penicillium/Aspergillus-like spore values were higher outside the building (530 spores/m3 of air) than inside the hoistway (22.8 spores/m3) during the six month study. Mean values inside the hospital were lower than outside throughout the study, ranging from 15 to 73 spores/m3 of air. Mean Penicillium/Aspergillus-like spore counts inside the hoistway decreased from 40.1 spores/m3 of air to 9 spores/m3 of air following the installation of a back draft damper between the outside air and the elevator shaft. Comparison of samples collected outside the building and inside the hoistway vent prior to installing the damper indicated a strong positive correlation (Spearman's Rho=0.8008, p=0.0001). The similar comparison following the damper installation indicated a moderate non-significant inverse correlation (Spearman's rho = −0.2795, p=0.1347). ^ Conclusion. Elevator shafts are one pathway for mold spores to enter a healthcare facility. A significant correlation was detected between spores and particle counts inside the hoistway and outside prior to changes in the ventilation system. The insertion of the back draft damper appeared to lower the spore counts inside the hoistway and inside the building. The mold spore counts in air outside the study building were higher in the period following the damper installation while the levels inside the hoistway and hospital decreased. Cladosporium and Penicillium/Aspergillus -like spores provided a method for evaluating indoor air quality as a natural tracer from outside the building to inside the building. Ascospores and basidiospores were not a valuable tracer due to low levels of detection during this study. ^ Installation of a back draft damper provides additional protection for the indoor environment of a hospital or healthcare facility, including in particular patients who may be immunocompromised. Current design standards and references do not require the installation of a back draft damper, but evaluation of adding language to relevant building codes should be considered. The data indicate a reduction in levels of Penicillium/Aspergillus -like spores, particle counts and a reduction in relative humidity inside of the elevator shaft after damper installation.^

MOLECULAR AND GENOMIC BASED INSIGHTS INTO THE EVOLUTION OF ENTEROCOCCUS FAECIUM FROM COMMENSAL TO HOSPITAL-ADAPTED PATHOGEN

The basis for the recent transition of Enterococcus faecium from a primarily commensal organism to one of the leading causes of hospital-acquired infections in the United States is not yet understood. To address this, the first part of my project assessed isolates from early outbreaks in the USA and South America using sequence analysis, colony hybridizations, and minimal inhibitory concentrations (MICs) which showed clinical isolates possess virulence and antibiotic resistance determinants that are less abundant or lacking in community isolates. I also revealed that the level of ampicillin resistance increased over time in clinical strains. By sequencing the pbp5 gene, I demonstrated an ~5% difference in the pbp5 gene between strains with MICs <4ug/ml and those with MICs >4µg/ml, but no specific sequence changes correlated with increases in MICs within the latter group. A 3-10% nucleotide difference was also seen in three other genes analyzed, which suggested the existence of two distinct subpopulations of E. faecium. This led to the second part of my project analyzing concatenated core gene sequences, SNPs, the 16S rRNA, and phylogenetics of 21 E. faecium genomes confirming two distinct clades; a community-associated (CA) clade and hospital-associated (HA) clade. Molecular clock calculations indicate that these two clades likely diverged ~ 300,000 to > 1 million years ago, long before the modern antibiotic era. Genomic analysis also showed that, in addition to core genomic differences, HA E. faecium harbor specific accessory genetic elements that may confer selection advantages over CA E. faecium. The third part of my project discovered 6 E. faecium genes with the newly identified “WxL” domain. My analyses, using RT-PCR, western blots, patient sera, whole-cell ELISA, and immunogold electron microscopy, indicated that E. faecium WxL genes exist in operons, encode bacterial cell surface localized proteins, that WxL proteins are antigenic in humans, and are more exposed on the surface of clinical isolates versus community isolates (even though they are ubiquitous in both clades). ELISAs and BIAcore analyses also showed that proteins encoded by these operons bind several different host extracellular matrix proteins, as well as to each other, suggesting a novel cell-surface complex. In summary, my studies provide new insights into the evolution of E. faecium by showing that there are two distantly related clades; one being more successful in the hospital setting. My studies also identified operons encoding WxL proteins whose characteristics could also contribute to colonization and virulence within this species.

An evaluation of the centers for Medicare & Medicaid Services' Hospital Acquired Conditions and Present on Admission Indicator Reporting program

Objective: This dissertation evaluated three aspects of the Centers for Medicare and Medicaid Services' Hospital Acquired Conditions and Present on Admission Indicator Reporting program (HACPOA program) to produce three journal articles for publication. ^ Methods: All payer admission records from state inpatient databases from Arizona, New Jersey and Washington states were analyzed for the year 2008. However some analyses required a sample of adult only Medicare patients in the first two studies. California's inpatient data (2004 – 2010) was also analyzed in the third study to examine the reporting and non-payment program elements' impact on the incidence of hospital acquired conditions. ^ Results: Majority diagnoses reported in inpatient prospective payment systems hospitals were present on admission. However, some diagnoses are still coded as "not present on admission" and "insufficient documentation to determine whether or not conditions are present on admission or not". This is important because it reveals that hospital complications still occur in hospitals. Hospital fall and trauma injuries were the most common hospital acquired conditions observed in this study. Predictors of hospital fall injuries include age, gender, number of diagnoses, number of procedures, number of chronic conditions while predictors of hospital trauma injuries include number of e-codes, number of diagnoses and the presence of chronic conditions on a patient's admission records. Finally, the implementation of the present on admission reporting requirement increased reports of certain hospital acquired conditions while the non-payment policy element in the Hospital Acquired Conditions program reduced the incidence of hospital fall and trauma injuries in particular. ^ Conclusion: The implementation of the Hospital Acquired Conditions and Present on Admission Indicator Reporting program has made the state inpatient database a more useful source of data capable of now identifying hospital complications. The reporting and nonpayment program elements in the HACPOA program have also impacted the incidence of hospital acquired conditions. ^

Optimization methods for the operating room management under uncertainty: stochastic programming vs. decomposition approach

The operating theatres are the engine of the hospitals; proper management of the operating rooms and its staff represents a great challenge for managers and its results impact directly in the budget of the hospital. This work presents a MILP model for the efficient schedule of multiple surgeries in Operating Rooms (ORs) during a working day. This model considers multiple surgeons and ORs and different types of surgeries. Stochastic strategies are also implemented for taking into account the uncertain in surgery durations (pre-incision, incision, post-incision times). In addition, a heuristic-based methods and a MILP decomposition approach is proposed for solving large-scale ORs scheduling problems in computational efficient way. All these computer-aided strategies has been implemented in AIMMS, as an advanced modeling and optimization software, developing a user friendly solution tool for the operating room management under uncertainty.

The human placental proteome is affected by maternal smoking

Acknowledgements This paper belongs to the studies carried out by Kuopio Birth Cohort consortium (www.KuBiCo.fi). We thank Ms Pirjo Hänninen for expert laboratory assistance at University of Eastern Finland, Ms Margaret Fraser, Dr Panagiotis Filis and the Proteomics Core Facility at the University of Aberdeen for their expert assistance. We also thank the staff of the Department of Obstetrics and Gynaecology in Kuopio University Hospital for skilful collection of these specimens. This work was supported by the Academy of Finland [122859/2007], the Helena Vuorenmies Foundation, the Emil Aaltonen Foundation, the University of Eastern Finland Doctoral Programme in Drug Research and the Medical Research Council, UK [MR/L010011/1]. The funders played no roles in study design, data collection, data analysis, manuscript preparation and/or publication decisions.

Assistência de fisioterapia na UTI está relacionada a redução de custos de internação?

Introdução: A unidade de terapia intensiva (UTI) é conhecida por ser um setor de alta complexidade dos pacientes e por seu alto custo ao sistema hospitalar. A gravidade da doença, o tempo de internação na UTI e a necessidade de ventilação mecânica invasiva (VMI) são fatores conhecidos como influenciadores no custo destas unidades, sendo que aproximadamente 30% dos pacientes internados em UTI necessitam de VMI. Os objetivos deste estudo foram avaliar os custos de internação em UTI comparando unidades com assistência de fisioterapia 24 horas e unidades com assistência de fisioterapia 12 horas e analisar o impacto da fisioterapia nos referidos custos. Método: Este é um estudo observacional, prospectivo, realizado em um hospital geral, público e de grande porte, localizado na cidade de São Paulo. Foram incluídos pacientes clínicos e cirúrgicos com 18 anos de idade ou mais, que estiveram em VMI por um período >= 24 horas e que receberam alta da UTI para a enfermaria. A coleta de dados incluiu diagnóstico de internação hospitalar, diagnóstico de admissão na UTI, gravidade do paciente no momento da admissão na UTI através do Acute Physiology and Chronic Health Disease Classification (APACHE II), tempo de VMI e tempo de internação na UTI; para a análise de custos utilizamos a ferramenta Omega French Score. Um modelo de regressão linear múltipla foi construído para verificar a associação entre o custo de internação em UTI com o turno diário de assistência fisioterapêutica. Resultados: Foram incluídos na amostra 815 pacientes, distribuídos em dois grupos conforme o turno de fisioterapia existente na UTI: 332 pacientes em UTI\'s com 24 horas de assistência fisioterapêutica (PT-24) e 483 pacientes em UTI\'s com 12 horas de assistência fisioterapêutica (PT-12). Os grupos não apresentaram diferença quanto ao APACHE II (p=0,65); comparado ao grupo PT-12 o grupo PT-24 era mais velho (p < 0,001), apresentou menor tempo de VMI (p < 0,001) e de internação na UTI (p=0,013). Quanto a análise de custos o grupo PT-24 apresentou custos menores indicados pela menor pontuação no Omega 3 (p=0,005) e Omega Total (p=0,010), menor custo direto, custo com equipe médica e enfermagem (p=0,010). A análise de regressão linear múltipla indicou associação do custo da internação em UTI com as variáveis APACHE II (p < 0,001), tempo de internação da UTI (p < 0,001) e assistência fisioterapêutica em turnos de 24 horas (p=0,05). Conclusão: O grupo com assistência de fisioterapia em turnos de 24 horas apresentou custos menores sendo que a severidade da doença, o tempo de internação na UTI e a assistência de fisioterapia foram variáveis preditoras para redução de custo de internação na UTI

Interpersonal relations and nurses' job satisfaction through knowledge and usage of relational skills

Background/rationale: Many interpersonal labor disputes stem from the lack of communication skills and the relational problems in the interactions between health professionals. Aims/methods: A qualitative study was conducted in a Spanish hospital in order to get to know how the communicative interaction between hospital nurses is like in relation to the nurses' interpersonal interaction and communication skills developed in their working relationships. Twenty-one hospital nurses between 29 and 55 years old, working in different wards, were interviewed. Open-ended interview discourses were transcribed verbatim and analyzed using qualitative content analysis. Results: The following four key themes were analyzed: communication and sender; communication and awareness of who has the problem; non-verbal communication; communication and recipient. Conclusion: The results of this study highlight the need to broaden nurses' relational–communication skills in order to increase job satisfaction.

La gestión de los cuidados enfermeros en el hospital San Juan de Dios de Alicante: a propósito de tres fuentes documentales inéditas del siglo XVIII

Se propone como objetivo principal mostrar y analizar tres fuentes documentales inéditas del siglo XVIII, localizadas en el Archivo Municipal Sant Joan d’Alacant que aportan información sobre la gestión de enfermería realizada en el Hospital San Juan de Dios de Alicante. Son tres las fuentes documentales que se transcriben y analizan, una “relación jurada de Fray Joseph Martínez Maza”, fechando el documento entre 1710 y 1718; un “Real privilegio de S.M. para amortizar la cantidad de 120 libras libres de sello y demás”. Dado en 23 de enero de 1794, a favor del convento hospital de N.P. San Juan de Dios de la ciudad de Alicante y un “formulario o modelo para dar cumplimiento a la orden del nuncio de su Santidad referente a las rentas, gravámenes, limosnas y otras entradas, con la curación a pobres, enfermos, con arreglo a los libros de caja”, datando el documento entre 1748 y 1760.

Hábitos alimentares durante a gravidez : identificação dos hábitos alimentares e fontes de informação consultadas pelas utentes da consulta pré-natal do Hospital de Santa Maria

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Bulletin of the Johns Hopkins Hospital.

Title from caption.

A historical account of the Royal hospital for seamen at Greenwich. M, DCC, LXXXIX ...

Prepared by John Cooke and John Maule, chaplains.