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PubMed2004

Aggression towards health care staff in a UK general hospital: variation among professions and departments.

BACKGROUND: Aggression towards health care staff is an increasing problem and although many studies have examined psychiatric settings, few have considered general hospitals and in particular, variation among professions and locations. In addition, studies often fail to include all forms of aggression such as threatening behaviour and verbal aggression. METHODS: This study extends existing research by evaluating physical assault, threatening behaviour and verbal aggression from patients/visitors towards general hospital staff in the context of different professions and departments. RESULTS AND CONCLUSIONS: The survey of staff showed that aggression is widespread. Within the preceding year, 27% of the respondents were assaulted, 23% experienced threatening behaviour from patients and 15.5% experienced threatening behaviour from visitors. Over 68% reported verbal aggression, 25.7% experiencing it more regularly than monthly. By departments, over 42% of the medical department staff, 36% of the surgical staff and over 30% of the Accident and Emergency staff were assaulted. By profession, staff nurses and enrolled nurses reported the most assaults (43.4%) and doctors, the fewest (13.8%). Other nursing grades and health care professions all reported levels of physical assault in excess of 20%. Correspondingly high levels of threatening behaviour and verbal aggression were also reported although the patterns of victimization differed according to the various professions and departments. Independently, significant levels of assault, threatening behaviour and verbal aggression were reported. When aggregated they demonstrate the higher levels of victimization that general hospital staff experienced on a regular basis. RELEVANCE TO CLINICAL PRACTICE: Institutional averages actually obscure the much higher levels of aggression experienced by the particular professions in particular departments. This study helps to localize the problem and identify those at most risk, but more research is needed into the aetiology of the aggression and of vulnerability factors associated with victimization.

Adaptation, Psychological↗

PubMed2005

Modernizing UK health services: 'short-sharp-shock' reform, the NHS subsistence economy, and the spectre of health care famine.

Modernization is the trend for societies to grow functionally more complex, efficient and productive. Modernization usually occurs by increased specialization of function (e.g. division of labour, such as the proliferation of specialists in medicine), combined with increased organization in order to co-ordinate the numerous specialized functions (e.g. the increased size of hospitals and specialist teams, including the management of these large groups). There have been many attempts to modernize the National Health Service (NHS) over recent decades, but it seems that none have significantly enhanced either the efficiency or output of the health care system. The reason may be that reforms have been applied as a 'drip-drip' of central regulation, with the consequence that health care has become increasingly dominated by the political system. In contrast, a 'short-sharp-shock' of radical and rapid modernization seems to be a more successful strategy for reforming social systems - in-between waves of structural change the system is left to re-orientate towards its client group. An example was the Flexner-initiated reform of US medical education which resulted in the closure of nearly half the medical colleges, an immediate enhancement in quality and efficiency of the system and future growth based on best institutional practices. However, short-sharp-shock reforms would probably initiate an NHS 'health care famine' with acute shortages and a health care crisis, because the NHS constitutes a 'subsistence economy' without any significant surplus of health services. The UK health care system must grow to generate a surplus before it can adequately be modernized. Efficient and rapid growth in health services could most easily be generated by stimulating provision outside the NHS, using mainly staff trained abroad and needs-subsidized 'item-of-service'-type payment schemes. Once there is a surplus of critically vital health services (e.g. acute and emergency provision), then radical modernization should rapidly improve the health service by a cull of low-quality and inefficient health care providers.

Efficiency, Organizational↗

PubMed2005

Depression and the perpetuation of an incapacitated identity as an inhibitor of return to work.

The aim of the current study was to conduct a qualitative investigation of attitudes to work among people diagnosed with clinical depression. It was of particular interest to understand the role played by illness in attitudes to recovery. The economic and social burden of adult depression on society is becoming increasingly apparent. It has been argued that recovery from mental illness of this kind is most appropriately understood in 'functional terms' (i.e. 'getting on with life beyond illness'). One important goal in this process is return to work. Accordingly, in-depth semi-structured interviews were conducted with 19 people formally diagnosed with clinical depression. These interviews were the analyzed using Interpretative Phenomenological Analysis: a method of investigation and analysis concerned with making sense of participant experiences and accounts of their ill-health. This process identified three master themes, only one of which is the focus of this paper. This theme pertains to the unwitting role that can be played by the health care system in reinforcing the 'sick role' and in so doing providing a continued justification for an 'off-work' identity. Consequently, this study provides an unusually penetrating insight into the way depression can, through institutional practices, become inextricably part of someone's identity, with important implications for functional recovery.

Depression↗

PubMed2005

Safety and tolerability of emerging pharmacological treatments for bipolar disorder.

OBJECTIVES: Over the past few years numerous new agents have been examined for their efficacy in bipolar disorder (BPD). New antiepileptic agents and atypical antipsychotics currently form the bulk of these emerging agents. As the armamentarium for treating BPD increases, it allows for the possibility of choosing drugs on the basis of their tolerability as well as their efficacy, rather than on efficacy alone. METHODS: Efficacy data for newer antiepileptic drugs (lamotrigine, topiramate, gabapentin, oxcarbazepine) and atypical antipsychotics (olanzapine, clozapine, risperidone, quetiapine, ziprasidone, aripiprazole) are briefly reviewed. The article focuses on relative safety and tolerability of these agents. RESULTS: In general, most of these newer agents have better side effect and tolerability profiles than older agents commonly used to treat BPD (lithium, valproate, carbamazepine); however, these must be weighed against efficacy demonstrated to date in randomized, controlled trials. Cognitive impairment is a concern with topiramate, weight gain and risk of diabetes with some of the atypical antipsychotic agents, and rash with lamotrigine. CONCLUSIONS: Side effects of newer emerging agents for the treatment of BPD can be effectively managed and the risks reduced by instituting practical strategies early in management.

Anticonvulsants↗

PubMed1983

Physicians in alcoholism: a study of current status and future needs.

Members of the American Medical Society on Alcoholism were studied to shed light on medical manpower needs in the alcoholism field. Findings were compared to AMA and federal survey data for all American physicians. AMSA respondents were broadly distributed among specialties: primarily psychiatrists, internists, and family practitioners. They were evenly divided between office-based and institutional practice, and most were on medical school faculties. Regarding alcoholism treatment, they generally agreed that Alcoholics Anonymous is necessary and that nonmedical counsellors are effective, although their attitudes on the etiology of alcoholism were divided. This sample of physicians in alcoholism, although not inclusive of all in the field, represents a diverse group, with differing clinical and educational needs.

Alcoholism↗

PubMed2004

The "nondipper" elderly: a clinical entity or a bias?

OBJECTIVES: To determine the prevalence of nondipper (ND) blood pressure profile in the elderly and to ascertain whether the ND pattern of ambulatory blood pressure in the elderly is an artifact or represents a specific clinical entity. DESIGN: Cross-sectional, observational study. SETTING: Cardiovascular diagnostic center, division of geriatrics, secondary care, institutional practice. PARTICIPANTS: Sixty-five consecutive community-dwelling elderly hypertensive patients referred to the cardiovascular center. MEASUREMENTS: The patients underwent actigraphy and ambulatory blood pressure monitoring and completed a sleep assessment questionnaire. Patients were divided based on the night-time decrease in blood pressure (>10%: "dippers" (n=19); <10%: "NDs" (n=46)). RESULTS: Nondippers displayed poorer quality of sleep, as demonstrated objectively by actigraphic data; they obtained a higher mean score+/-standard deviation on the sleep questionnaire (4.6+/-2.9 vs 3.0+/-1.1, P=.030) and were taking more benzodiazepines (33.1% vs 10.7%, P=.035), indicating that their usual sleep quality was worse than that of dippers. Multivariate analysis showed a strong correlation between nondipper profile and quality of sleep and also with comorbidity, total number of drugs being taken, and pulse pressure. CONCLUSION: Actigraphy demonstrates impaired sleep in the nondipper elderly. Nevertheless, the nondipping pattern seems independent of the discomfort of cuff-inflation during the night and occurs in association with higher comorbidity and polypharmacy; therefore, it cannot be considered a "bias," but is related to detrimental clinical conditions that should be studied in depth.

Aged↗

PubMed2003

The open dialogue approach to acute psychosis: its poetics and micropolitics.

In Finland, a network-based, language approach to psychiatric care has emerged, called "Open Dialogue." It draws on Bakhtin's dialogical principles (Bakhtin, 1984) and is rooted in a Batesonian tradition. Two levels of analysis, the poetics and the micropolitics, are presented. The poetics include three principles: "tolerance of uncertainty," "dialogism," and "polyphony in social networks." A treatment meeting shows how these poetics operate to generate a therapeutic dialogue. The micropolitics are the larger institutional practices that support this way of working and are part of Finnish Need-Adapted Treatment. Recent research suggests that Open Dialogue has improved outcomes for young people in a variety of acute, severe psychiatric crises, such as psychosis, as compared to treatment-as-usual settings. In a nonrandomized, 2-year follow up of first-episode schizophrenia, hospitalization decreased to approximately 19 days; neuroleptic medication was needed in 35% of cases; 82% had no, or only mild, psychotic symptoms remaining; and only 23% were on disability allowance.

Acute Disease↗

PubMedDate not supplied

Family-centered maternity units--fact or fiction?

The author describes discrepancies between nursing education and institutional practices in the area of family-centered maternity care, and questions current limitations in FCMC. The maternity nurse is urged to implement changes which will result in a rewarding childbirth experience in a medically safe environment.

Family↗

PubMed1999

The use of glass ionomer in special needs patients.

Placement of restorations for patients who are physically or intellectually disabled or mentally ill can pose considerable difficulties for the general practitioner. Access to the oral environment is often limited and patient tolerance and concentration may be reduced to rather brief periods of time. Oral hygiene routines may be less than ideal leading to a high caries rate. Enamel surfaces which do not normally become carious can develop broad but shallow lesions with a poorly defined outline. Selection of the most suitable restorative material will be important, with longevity of the restoration as the prime consideration. Other factors such as access, isolation of the lesion and patient co-operation must also be taken into account. Also, forces acting on restorative materials may be less than usual due to poor occlusion, teeth opposing dentures or being completely unopposed. Restoration by indirect techniques will often not be possible so the choice will be limited to the three plastic restorative materials normally used in restorative dentistry: amalgam, resin composite and glass ionomer. As a result of clinical experience it is suggested that glass ionomer will often be the material of choice. This paper describes five years experience with the resin-modified glass ionomers in an institutional practice which is limited to patients with special needs. Clinical significance Placement of restorations, with a reasonable expectation of longevity, can pose considerable problems for the patient with special needs. Resin-modified glass ionomer is a useful alternative material and has been placed with a high degree of success over a period of five years.

Dental Care for Persons with Disabilities↗

PubMedDate not supplied

Redesign of a hospital's internal medicine service.

Hospital internal medicine and family practice care were redesigned in July 1995 at Kaiser Permanente of Colorado. The objectives were to provide for a full time dedicated inpatient team, improve continuity of care, and establish a two-tiered process of admission. Physicians were divided into four tracks that marked varying degrees of time in the hospital. A position of triage physician was created that screened all potential admissions to internal medicine. Hospital inpatient days per thousand members, unadjusted lengths of stay, patient readmission rates, and satisfaction questionnaires were obtained both before and after the change. The change achieved significant reductions in unadjusted average lengths of stay and days per thousand without diminishing quality of care, as reflected by hospital readmission rates and by patient satisfaction surveys.

Admitting Department, Hospital↗

PubMed2001

Blunt abdominal trauma: screening us in 2,693 patients.

PURPOSE: To evaluate the accuracy of screening abdominal ultrasonography (US) in patients with blunt abdominal trauma. MATERIALS AND METHODS: Patients with blunt abdominal trauma underwent US. The abdomen and pelvis were scanned for free fluid, the visceral organs were assessed for heterogeneity, and duplex US was performed if necessary. Empty bladders were filled with 200-300 mL of sterile saline through a Foley catheter. US findings were considered positive if free fluid was present or if parenchymal abnormalities that could be consistent with trauma were detected. Screening US results were compared with findings of diagnostic peritoneal lavage, repeat US, computed tomography (CT), cystography, surgery, and/or autopsy and/or the clinical course. RESULTS: Findings from 2,693 US examinations were evaluated and were positive in 145 of 172 patients with injuries (sensitivity, 84%) and 64 (89%) of 72 patients who ultimately underwent laparotomy with surgical repair of injuries. False-negative findings were retroperitoneal injury, bowel injury, and intraperitoneal solid organ injury without hemoperitoneum. No patient with false-negative findings died. Specificity of US was 96% (2,429 of 2,521 patients), and overall accuracy was 96% (2,574 of 2,693 patients). Positive predictive value was 61% (145 of 237 patients), and negative predictive value was 99% (2,429 of 2,456 patients). CONCLUSION: Abdominal US is useful in screening for injury in patients with blunt abdominal trauma, and its use represents a notable change in institutional practice. Diagnostic peritoneal lavage is rarely performed, and CT is used when screening US findings are positive, when injury is clinically suspected despite negative US findings, or when US is not available.

Abdominal Injuries↗

PubMed1976

Patient work under Fair Labor Standards: the issue in perspective.

The 1973 federal court ruling in Souder v. Brennan required that patient workers in institutions for the mentally ill and mentally retarded be paid in accordance with the minimum wage and other provisions of the Fair Labor Standards Act. The author believes that ruling, which ran contrary to widely accepted institutional practices, is more readily understandable when viewed in the broader context of wage-and-hour legislation. He presents a brief history of the legislation, discusses the provisions relating to the employment of handicapped workers included in the 1966 amendments, and emphasizes that one basic principle underlies all the regulations and procedures: a patient must be paid what he earns. He also urges increased attention to the clinical design of compensated work systems to promote therapeutic and rehabilitative objectives.

Persons with Disabilities↗

PubMed1995

Outcomes of antireflux therapy for the treatment of chronic laryngitis.

This study examined outcomes of antireflux and antacid treatment for the signs and symptoms of chronic laryngitis. Patients from a referral institutional practice with chronic laryngitis symptoms, without other apparent causes of laryngeal inflammation, were followed up and examined at progressive stages of antireflux treatment as a case series outcome study. The cases included unselected individuals with a diagnosis of chronic (> 3 months' duration) laryngitis. Patients with chronic throat complaints were treated with nocturnal antireflux precautions, with addition of famotidine 20 mg or omeprazole 20 mg at bedtime for patients who did not respond to antireflux precautions alone. The outcome measures were resolution of symptoms, and change in findings on telescopic laryngoscopy. Chronic throat symptoms of 93 of 182 patients (51%) responded to nocturnal antireflux precautions alone. The complaints of an additional 48 patients resolved with the addition of famotidine 20mg at bedtime to antireflux precautions (77% response). The symptoms of 34 of the remaining 41 patients responded to treatment with omeprazole 20 mg at bedtime. Therefore, symptoms of 96% of patients responded to treatment aimed at preventing reflux of gastric acid. The remaining patients with refractory symptoms had a partial response or no response or chose fundoplication. Erythema and granular mucositis were the most common laryngoscopic findings. Ulceration and granuloma formation were less common, but also responded to antireflux treatment. Some (7) patients required high doses of omeprazole or fundoplication to achieve symptomatic relief and healing of chronic inflammatory changes of the posterior larynx. Relapse of symptoms was common when treatment was stopped.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMedDate not supplied

Medical decision making in the choice of a thrombolytic agent for acute myocardial infarction. Quebec Acute Coronary Care Working Group.

Little is known about how physicians make decisions when the evidence is incomplete or controversial. While thrombolysis improves survival following acute myocardial infarction (AMI), conflicting evidence exists as to any specific agent's superiority, particularly if cost-effectiveness is considered. Using a Bayesian hierarchical model, the authors examined the patient, physician, and hospital characteristics that are related to the decision-making process concerning the choice of thrombolytic agent in a prospective registry of 1,165 AMI patients receiving thrombolysis. Tissue plasminogen activator (t-PA) was administered to 432 patients (31.8%) and streptokinase (SK) to the remainder. The presence of an anterior infarction, a previous myocardial infarction, low blood pressure, a cardiologist decision maker, younger age, and receiving treatment within six hours after the start of symptoms were independent predictors of receiving t-PA. The levels of importance that physicians accorded to these patient characteristics differed according to their practicing institutions. Generally, they followed evidence-based medicine and reasonably targeted high-risk patients to receive the more expensive t-PA. However, they also preferentially treated younger patients, where only a small absolute advantage appears to exist.

Aged↗

PubMed1997

Efficiency and health.

Efficiency has become of central importance in health care and is seen as wholly laudable. It appears to offer a precise and objective means of evaluating and comparing institutions, practices and individuals, and is a principle that underlies techniques of cost-benefit analysis and other methods of option appraisal. However, there is a need to examine the concept of efficiency and explore the problems of its application within health care. Efficiency is a value laden notion and it cannot be used as a means of making value judgements from purely factual premises. We have to choose the inputs and outputs in our calculations, and what limits to set on their scope. Efficiency calculations may require us to measure what cannot be quantified, and to treat as commensurable what is incommensurable. There are circumstances in which considerations of efficiency are inappropriate or even immoral.

Cost-Benefit Analysis↗

PubMed1984

Pharmacists' views on mandatory patient counseling.

A questionnaire was sent to a randomly selected sample of Florida pharmacists to obtain information on the acceptability of mandatory patient counseling. The results of the questionnaire demonstrated that most Florida pharmacists who responded to the survey do not favor a patient counseling regulation. Factors that correlated with a desire for mandatory counseling include: an institutional practice site; assistant director and staff pharmacist position; and a perceived higher income for the patients served by pharmacists. These data indicated that if the mandatory method is selected to stimulate pharmacist-patient interaction, the interrelated issues of reimbursement, facility changes, technician support, patient profiles, continuing education programs, and pharmacists' attitudes toward regulated practice will need to be addressed.

Attitude of Health Personnel↗

PubMedDate not supplied

Rights and reality: monitoring the public's right to participate.

Exercising the right to a sustainable and healthy environment requires the ability to participate in government and business decisions that affect the environment. A global coalition of public interest groups and research organizations measured the public's ability to participate in such decisions in nine countries representing a range of income levels and development paths. The investigation assessed the three elements of public participation as defined at the Rio Earth Summit in 1992: access to information, access to the decision-making process, and access to redress. The results show that, despite considerable progress in these areas, serious gaps remain in the public's ability to participate in important environmental decisions. These gaps occur in both developed and developing nations, and reflect limited articulation of participation rights in national law and institutional practice. The results also suggest that the public is often unfamiliar with and unaccustomed to exercising the rights they already have.

Community Participation↗

PubMed2002

Evaluation of cervical range of motion and isometric neck muscle strength: reliability and validity.

OBJECTIVE: To examine the test-retest reliability and construct validity of cervical active range of motion and isometric neck muscle strength as measured by the Multi Cervical Rehabilitation Unit (Hanoun Medical Inc., Ontario). DESIGN: A cross-sectional study. SETTING: Institutional practice. SUBJECTS: Twenty-one patients with neck pain and 25 healthy volunteers. METHODS: After a trial-run session, active range of motion (AROM) was measured in the subsequent two sessions, with 2-3 days in between. During each session, three measurements were taken for each direction (flexion, extension, lateral flexions and rotations). The measurement of isometric strength was after a 15-minute break following completion of the measurement of AROM. Three measurements were made for each of the six directions (flexion, extension, lateral flexions, protraction and retraction). The software of the Multi Cervical Rehabilitation Unit automatically recorded and calculated the maximum AROM and isometric strength. RESULTS: There was a good to high level of reliability in the measurement of AROM for both groups of subjects, with intraclass correlation coefficients (ICCs) ranging from 0.81 to 0.96. Results also demonstrated very good to excellent reliability in isometric strength measurement (ICCs ranged from 0.92 to 0.99). Moreover, there was a significant difference in isometric neck muscle strength (p = 0.001) and in AROM (p = 0.034) between the two groups. CONCLUSIONS: The Multi Cervical Rehabilitation Unit was found to be reliable and valid for testing the cervical active range of motion and isometric neck muscle strength for both normal and patient subjects.

Adult↗