Planning of specialized health facilities: size vs. cost and effectiveness in heart surgery.
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During 1979 and 1980, widely circulated newspaper stories in British Columbia reported nurse shortages in the province and warned of dire consequences from what was perceived to be a worsening situation. Because the reports were unsupported by empirical evidence, we undertook to directly monitor net requirements for health care personnel in the province. Focusing on difficult-to-fill positions, we found that geographic location and size of facility figured prominently in the distribution of vacancies, but that public-sector cost containment policies had a dominant impact in reducing vacancies in the health care sector. Health manpower planning may thus depend as much on predicting the size and disposition of the revenue base as on quantifying the perceived need for health care services.
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This study was undertaken to improve understanding of current oral hygiene care practices in intermediate care facilities. Questionnaires were sent to directors of nursing of all licensed intermediate care facilities in Iowa. Results show that an estimated 57% of residents needed direct oral hygiene assistance. In all intermediate care facilities, the majority of direct oral hygiene care was provided by aides. Oral hygiene care was often not provided at an optimal level, and the main reasons reported for this lack of care were uncooperative residents (82%), lack of perceived need by aides (68%), and inadequate time/personnel (49%). Development and promotion of oral hygiene care programs in intermediate care facilities must take into consideration the realities and problems involved. Otherwise, efforts to introduce or implement new or improved care programs will fail.
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BACKGROUND: Nosocomial infections have been recognized as a source of morbidity and mortality throughout the world for several decades. In the United States, an estimated 2.1 million nosocomial infections occur annually in acute care hospitals alone. Infection surveillance and control programs (ISCPs) play a vital role in addressing this problem, but no national studies have described the status and composition of these programs since the 1970s. METHODS: In January 1997, a voluntary survey was sent by mail to members of the Association for Professionals in Infection Control and Epidemiology, Inc. Only one response per facility was requested. The survey asked for information for the years 1992 to 1996 (study period), and questions pertained to characteristics of the health care facility in which the respondent worked, characteristics of the ISCP and its personnel, and the overall level of administration support for infection control activities. RESULTS: Completed questionnaires were received from personnel at 187 health care facilities located in 40 states and the District of Columbia. The majority (76.5%) of responding facilities were nongovernment owned, and 57.2% were classified as general acute care facilities. The number of licensed beds at these facilities remained stable throughout the study period, but all other measures of facility size and activity (eg, number of patient days and number of nurses) decreased by as much as 28.9%. In 1992, ISCPs were most likely to be organizationally located in the Nursing Department, but by 1996, many had been transferred to departments of Medical Records, Quality Assurance, or Risk Management. Throughout the course of the study period, the number of facilities performing surveillance for health care-associated infections in outpatient settings increased by 44.0%, from 100 to 144. In 1996, only 47.6% of facilities had a hospital epidemiologist (HE), and HEs devoted a median of 15% or less of their time to infection control activities. For the most part, HEs were trained in infectious diseases, and few had certification in infection control. Infection control professionals (ICPs) were much more common than were HEs (ICPs were reported at 97.9% of respondents' facilities in 1996), and they spent the majority (80% in 1996) of their time on infection control activities. During the course of the study period, increasing numbers of facilities had ICPs who had certification in infection control. Furthermore, most respondents did not report a change over time in the level of administration support for infection control activities. CONCLUSIONS: Health care delivery has changed dramatically during the past 20 years. This study presents an updated description of ISCPs in the United States. Our results illustrate several changing parameters, such as departmental shifts and increased outpatient surveillance, that reflect adjustments in health care priorities during the study period. As the transformation of the health care system continues, continued evaluation of the status of ISCPs on a national level will be necessary. Diligent monitoring, proactive measures, and collaboration between infection control organizations and government agencies will be vital for the prevention and control of health care-associated infections in the future.
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OBJECTIVE: To quantify the appropriateness of medication prescriptions in nursing home residents. DESIGN: Prospective, cohort study. SETTING: Twelve nursing homes in the greater Los Angeles area. PARTICIPANTS: A total of 1106 nursing home residents. MAIN OUTCOME MEASURES: The appropriateness of medication prescriptions was evaluated using explicit criteria developed through consensus by 13 experts from the United States and Canada. These experts identified 19 drugs that should generally be avoided and 11 doses, frequencies, or durations of use of specific drugs that generally should not be exceeded. RESULTS: Based on the consensus criteria, 40% of residents received at least one inappropriate medication order, and 10% received two or more inappropriate medication orders concurrently; 7% of all prescriptions were inappropriate. Physicians prescribed a greater number of inappropriate medications for female residents. Regression analysis, corrected for clustering effects within facilities, showed that a greater number of inappropriate medication prescriptions were ordered in larger nursing homes. Inappropriate prescriptions were not related to the proportion of Medicaid (Medi-Cal) residents or the number of physicians practicing in the homes. CONCLUSIONS: Inappropriate medication prescribing in nursing homes is common. Female residents and residents of large nursing homes are at the greatest risk for receiving an inappropriate prescription.