Dissertations / Theses on the topic 'Levels of care'

Thesis (MScMedSc (Interdisciplinary Health Sciences. Speech-Language and Hearing Therapy))--University of Stellenbosch, 2007.
Noise is a noxious stimulus with possible negative physiological effects on the infant, especially in the Neonatal Intensive Care Unit (NICU). The present study conducted a detailed noise assessment in a NICU of a state hospital in the Cape Metropole and documented 6 infants’ physiological responses to noise levels. Noise levels ranged from 62.3-66.7dBA (LAeq), which exceed all American and British standards (50dBA -60dBA) for a NICU. Continuous exposure to noise of these levels is potentially harmful to the infants’ auditory system and health stability. The general well-being of the staff working in the NICU may also be compromised. Analysis of the noise events revealed that staff conversations were the largest single contributor to the number of noise events, while the largest single non-human contributor was the alarm noise of the monitors. No significant correlations were found between the heart rates and noise levels and the respiratory rates and the noise levels for any of the participants in either room. The NICU was found to be an extremely reverberant environment, which suggested that the NICU noise levels were largely a result of reverberant noise reinforcements. NICU nursing staff’s most common suggestion for noise abatement strategies was reduction of staff conversation. Results of this study highlight the need for NICU noise abatement to optimise newborn patient care, reduce the risk of acoustic trauma and to improve the neonate’s quality of life, thus enhancing the infant’s physiologic stability, growth and health.

Health care professionals play a pivotal role in contributing towards the sustainability of a healthy economy and the standard of quality health care. It is therefore important that organisations understand what influences the job satisfaction levels of health care professionals as it could have an impact on their motivational levels and ultimately the quality of health care that is provided. The aim of this study was to assess the levels of job satisfaction amongst health care professionals in a public hospital in the Eastern Cape. Research for this study included a literature review to define what job satisfaction is and to establish a theoretical foundation to identify the factors that influence job satisfaction. Various motivational theories were explored after which Herzberg’s two-factor theory was identified to serve as a theoretical basis for investigating the job content and organisational factors that influence job satisfaction. Selected demographic factors that could possibly influence levels of job satisfaction were also identified. An empirical study, consisting of a survey with a questionnaire as measuring instrument, was conducted amongst 146 health care professionals at a public hospital in the Eastern Cape. The purpose of the questionnaire was to determine the extent to which job content factors and organisational factors that were associated with job satisfaction were present in the jobs of health care professionals in state hospitals. In addition, the purpose was also to determine whether selected demographic variables had an influence on the responses provided to the factors that were associated with job satisfaction and the job satisfaction levels of the target group. The major findings of the study indicated that all job content and organisational factors had an influence on the job satisfaction levels of health care professionals in a public hospital. Three factors namely Achievement, Responsibility and Work itself were identified to have a significant positive influence on the job satisfaction levels. Relationships between the demographic variables and the job content and organisational factors were identified. Work itself, Responsibility and Achievement were the top three factors whilst leadership/supervision, Human Resource systems and policies and Remuneration and benefits were the bottom three factors in terms of presence in the organisation and influence on the job satisfaction levels of health care professionals. Safety aspects, work environment standards, availability of resources, remuneration and benefits were amongst the major concerns highlighted. The job content factors were identified to be overall more present than the organisational factors. Recommendations were suggested to address the areas of concern that were highlighted in this study in order to ensure high levels of job satisfaction amongst the health care professionals.

The purpose of the study was to examine the relationship of exercise of self-care agency and serum cholesterol levels. The American Heart Association (1986) and the National Heart, Lung and Blood Institute (1987) have identified the reduction of serum cholesterol as a major factor in decreasing the risk for coronary artery disease. Orem's theory of self-care identified diet and exercise management as activities well being (Orem, 1971). It was hypothesized that high levels of self-care are inversely related to serum cholesterol levels. A retrospective study was conducted. A convenience sample of 176 individuals who have obtained cholesterol screening at a Nursing Center for Family Health was obtained. Written consent was obtained to review individual files for serumcholesterol levels, information related to demographic variables, nutrition and exercise habits; and for the Exercise of Self-Care Agency. Each participant completed the "Exercise of Self-Care Agency" tool. Confidentiality was maintained and responses were coded for analysis only. Correlational statistics were utilized to analyze the data obtained. The hypothesis was tested using Pearson r analysis and demonstrated poor correlation and no significant relationship. Research questions related to diet, exercise, age and the exercise of self-care agency were tested by a 3x2x2 ANOVA and showed no significant difference. Recommendations for future study should include replication of the study with a larger sample and randomization of the sample.
School of Nursing

Type 2 diabetes impacts the lives of adults in the low-income, middle-income, and high-income brackets in the United States and globally. More research was needed on how adults 45 years and older in Marion County managed their diabetes and the care they received based on their income. This case study involved investigating how adults 45 years and older in Marion County self-managed their diabetes and the quality of care they received based on their income. The health belief model supported the conceptual framework for the study. Data were collected through face-to-face and telephone interviews with 15 purposefully selected participants. Data were analyzed using the open-coding technique to reveal categories and themes. Results of the study indicated that adults in Marion County engaged in diabetes self-care practices but lacked the collective knowledge of the importance of self-care measures. Results also revealed that individuals had access to quality care including medication therapy, diet, exercise, and blood glucose monitoring. However, results indicated that within the 3 income groups (low, middle, and high), low-income individuals saw a doctor less frequently due to cost and out-of-pocket expense. Also, social support played an important role in access to health care and self-care management. The study results could provide educators and health care providers with insight on how people in Marion County are self-managing their diabetes and empower them to implement more programs to provide the needed education to these adults with Type 2 diabetes mellitus. The positive social change because of this study includes bringing more awareness about the importance of diabetes self-care management to individuals, families, and communities.

Introducción La alta especialización en la provisión de la atención, los rápidos avances en la tecnología y la diversificación de los proveedores promueve que los pacientes sean atendidos por varios profesionales de diferentes disciplinas en organizaciones y servicios diferentes. Estas tendencias, junto con los cambios demográficos y epidemiológicos, hacen que el paciente, cada vez más, esté expuesto a una atención fragmentada. La atención fragmentada, o la atención coordinada insuficientemente entre los proveedores, pueden perjudicar al paciente, debido a la duplicación de pruebas diagnósticas, la poli-medicación inapropiada y los planes de tratamiento incompatibles. Los sistemas de salud y las organizaciones disponen de diferentes intervenciones que pueden implementar para facilitar la coordinación de servicios que se proveen a los individuos y la población, como por ejemplo la introducción de organizaciones sanitarias integradas. Estas organizaciones son definidas como un conjunto de proveedores de salud que ofrece una atención coordinada a través del continuo asistencial a una población determinada y se responsabiliza de los costes y resultados de salud de la población. Sus objetivos finales son la mejora de la eficiencia global, equidad en el acceso y la calidad de la atención, a través de la mejora de la coordinación y de la continuidad entre niveles asistenciales. La continuidad asistencial es la percepción del paciente sobre la coordinación de los servicios y se puede definir como el grado de coherencia y unión de las experiencias en la atención que percibe el usuario a lo largo del tiempo. Abarca tres tipos: la continuidad de gestión clínica y la continuidad de información entre niveles de atención y la continuidad de relación con el médico de atención primaria y el médico de atención especializada. En Cataluña (España), organizaciones sanitarias integradas emergieron como una respuesta a la diversidad de proveedores en la gestión de la atención primaria, secundaria y sociosanitaria. No obstante, su desempeño ha sido analizado principalmente desde la perspectiva de los proveedores, es decir, en relación a la coordinación entre niveles asistenciales. Los estudios sobre la percepción de la continuidad asistencial, los factores que influyen y las consecuencias desde el punto de vista de los usuarios del sistema nacional de salud de Cataluña siguen siendo escasos. Objetivo Explorar la percepción del usuario sobre la continuidad entre niveles asistenciales en las diferentes áreas del sistema nacional de salud catalán, así como los factores que influyen y las consecuencias sobre la calidad de la atención, con la finalidad de contribuir a su mejora en el sistema de salud. Métodos La investigación consistió en tres estudios que abordan diferentes aspectos de la continuidad asistencial. 1) Análisis de la evidencia internacional sobre la continuidad asistencial desde la perspectiva del paciente, mediante una meta-síntesis de estudios cualitativos basada en la búsqueda bibliográfica en diferentes bases de datos electrónicas (Medline, Web of Science y Cochrane Library Plus). La estrategia de búsqueda incluyó la combinación de "continuidad asistencial" o términos relacionados, estudios cualitativos y la perspectiva del paciente. 25 estudios originales, publicados entre 1999 y 2009 que cumplieron con los criterios de inclusión fueron incluidos en la síntesis. Se realizó un análisis de contenido mediante la identificación de temas y categorías y la agregación de los resultados de los tres tipos de continuidad asistencial. 2) Análisis de la percepción de la continuidad asistencial de los pacientes con EPOC atendidos en cuatro organizaciones sanitarias integradas del sistema nacional de salud de Cataluña, mediante un estudio de caso múltiple de los pacientes con EPOC. Se seleccionó una muestra teórica en dos etapas: (i) cuatro organizaciones sanitarias integradas, (ii) dos casos de estudio de cada organización que incluían un paciente con EPOC, su médico de atención primaria, su neumólogo y su historia clínica. La información fue recogida mediante entrevistas individuales semiestructuradas con los pacientes y sus médicos y la revisión de las historias clínicas. Todas las entrevistas fueron grabadas y transcritas literalmente. Se llevó a cabo un análisis temático de contenido, segmentando la información por organización y caso, con una triangulación de fuentes y la participación de diferentes analistas. 3) Análisis de la continuidad asistencial en las diferentes áreas sanitarias del sistema nacional de salud catalán, enfocando el análisis en los tres tipos de continuidad asistencial, los factores que influyen y las consecuencias en la calidad de la atención. Se seleccionó una muestra teórica en dos etapas: (i) contexto de estudio: tres áreas sanitarias que representan la diversidad de modelos de gestión para la provisión de los servicios sanitarios y (ii) los usuarios de los servicios sanitarios. Se realizaron entrevistas individuales semiestructuradas con los usuarios de los servicios sanitarios (de 14 a 18 por área) hasta alcanzar la saturación de la información. Todas las entrevistas fueron grabadas y transcritas textualmente. Se llevó a cabo un análisis de contenido temático, segmentando la información por área de estudio, con una generación mixta de categorías y la participación de diferentes analistas para garantizar la calidad de los resultados. Se obtuvo la aprobación ética de los protocolos de estudio. Resultados En general, los pacientes atendidos en el sistema nacional de salud catalán percibieron la existencia de los tres tipos de continuidad asistencial con algunos elementos de discontinuidad identificados en todas las áreas y organizaciones sanitarias integradas de estudio. Con relación a la continuidad de la gestión clínica entre niveles asistenciales, los pacientes percibieron que habían recibido el mismo diagnóstico y tratamiento por los médicos de los diferentes niveles asistenciales, sin repeticiones innecesarias de pruebas, y con las derivaciones oportunas al otro nivel de atención cuando era necesario. Además, los pacientes señalaron de manera consistente tiempos de espera adecuados a la atención especializada en casos urgentes, incluidos las exacerbaciones de los pacientes con EPOC, y después de una derivación. Sólo unos pocos pacientes de todas las áreas identificaron elementos de discontinuidad, por ejemplo las diferentes opiniones sobre su tratamiento, algunas duplicaciones de pruebas, falta de derivaciones a la atención especializada cuando las necesitaban y tiempos de espera excesivos para algunas pruebas específicas y la derivación a la atención especializada no urgente. En referencia a la continuidad de la información entre niveles asistenciales, los pacientes de ambos estudios realizados en Cataluña, en general, percibieron que la información clínica se registró, fue transferida entre niveles mediante el ordenador y utilizada por los médicos, con la excepción de un área de estudio (Ciutat Vella en Barcelona), donde se percibió que la información fue compartida parcialmente. Además, algunos pacientes de todas las áreas destacaron que alguna información no fue compartida a través del ordenador y que algunos médicos, especialmente los médicos de urgencias y los médicos suplentes, no siempre consultaron la información de la historia clínica. Finalmente, en cuanto a la continuidad de relación, la mayoría de los pacientes señalaron que en general fueron atendidos por el mismo médico de atención primaria durante un largo periodo y por médicos suplentes en algunas ocasiones. Sin embargo, los pacientes con EPOC de algunas organizaciones sanitarias integradas destacaron una alta rotación del personal de atención primaria. Con referencia a la atención especializada, numerosos pacientes de ambos estudios señalaron inconsistencias; aunque muchos pacientes no las identificaron como un problema al considerar que todos los médicos de la atención especializada eran competentes para tratar su problema de salud y que se compartía la información clínica. Casi todos los pacientes que percibieron una consistencia del personal también desarrollaron una relación continua basada en la confianza con los médicos y el conocimiento acumulado. Se identificaron varios factores que influyen en (la falta de) la continuidad asistencial, que se clasificaron en los factores relacionados con el sistema de salud, las organizaciones y los médicos. En relación con el sistema de salud, los pacientes de ambos estudios consideraron que la clara distribución de roles y responsabilidades entre los médicos de atención primaria y especializada favoreció la consistencia del diagnóstico y tratamiento y evitó incompatibilidades en la medicación prescrita y duplicaciones de pruebas. Sin embargo, según algunos pacientes, la función de puerta de entrada del médico de atención primaria podría también extender los tiempos de espera o incluso impedir el acceso a la atención especializada. Con respecto a las organizaciones sanitarias, los usuarios consideraron que los mecanismos de coordinación implementados (historia clínica compartida, reuniones presenciales), los mecanismos de comunicación informal (uso del correo electrónico y teléfono) y la colocalización de los médicos en el centro de atención primaria, que emergieron sólo en algunas áreas de estudio, influyeron positivamente en la recepción de un tratamiento consistente, la transferencia y uso de información adecuada y las derivaciones oportunas a la atención especializada. Por otro lado consideraron que los insuficientes los recursos disponibles, evidenciados por la falta de médicos, causó largos tiempos de espera para la atención secundaria y un uso insuficiente de la información clínica. En cuanto a la continuidad de relación, según los pacientes, los pequeños centros de atención primaria en dos áreas de estudio y un sistema para la obtención de citas adecuado favorecen la consistencia del personal; mientras que la re-organización de listas de pacientes la dificultan. Por último, en relación con los factores relacionados con los médicos, la competencia técnica del médico de atención primaria promovió derivaciones adecuadas y oportunas a la atención secundaria. Consideraron que la disposición del médico a colaborar influyó en el uso de la información y evitó duplicaciones de pruebas e inconsistencias en el tratamiento. La práctica médica adecuada, así como una comunicación médico-paciente efectiva favorecieron el desarrollo de una relación médico-paciente basada en la confianza y el conocimiento acumulado mutuo. El compromiso del médico en el cuidado del paciente pareció influir tanto en el uso de la información como en el establecimiento de una confianza mutua. Los pacientes identificaron diferentes consecuencias de los tres tipos de continuidad asistencial relacionadas con la calidad de la atención y, en menor medida, con los resultados de salud. Respecto con la continuidad de la gestión clínica, los pacientes percibieron que la falta de consistencia de la atención y de acceso entre niveles resultó en un uso inadecuado de recursos, debido a que se duplicaron visitas. Además produjo angustia y posibles efectos negativos para la salud, cuando se dieron largos tiempos de espera a la atención especializada después de una derivación, que llevó a que el paciente buscara atención médica privada. En cuanto a la continuidad de la información, los pacientes destacaron que el intercambio de la información clínica entre niveles evitó la duplicación de pruebas e intervenciones médicas y la prescripción de medicamentos incompatibles. Además, los pacientes no necesitaban guardar y llevar los resultados de las pruebas al médico del otro nivel de atención. Por último, en cuanto a la continuidad de relación, los pacientes relacionaron la consistencia del personal con menos derivaciones innecesarias, sin modificaciones en el plan de tratamiento que pudieran perjudicar al paciente ni duplicaciones de pruebas. Además, percibieron que una relación continúa basada en la confianza y el conocimiento acumulado facilitó el diagnóstico y dio lugar a una sensación de seguridad y comodidad así como que el paciente siguiera adecuadamente el plan de tratamiento. Conclusiones Esta tesis contribuye con el aporte de información sobre la continuidad asistencial, un tema escasamente analizado, mediante una mejor comprensión del fenómeno percibido por los usuarios de los servicios sanitarios del sistema nacional de salud de Cataluña. Los resultados sugieren que el paciente es capaz de percibir los tres tipos de continuidad asistencial refiriéndose a atributos concretos de cada dimensión. Los tres tipos de continuidad asistencial parecen estar relacionados entre sí; particularmente la continuidad de información afecta a la continuidad de gestión clínica, y la continuidad de relación juega un papel importante al influir en la continuidad de gestión clínica y de información. Los pacientes en general perciben la existencia de los tres tipos de continuidad asistencial. Sin embargo, también señalan algunas interrupciones en la continuidad en todas las áreas de estudio. Se identificaron varios factores que influyen en la (dis)continuidad asistencial, relacionados con el sistema de salud, las organizaciones sanitarias y los médicos. Como resultado del estudio, se identificaron diferentes consecuencias de los tres tipos de continuidad asistencial en la calidad de la atención y la salud del paciente. Los elementos de discontinuidad identificados sirven para indicar donde hay margen de mejora, y los factores que influyen en la continuidad pueden ofrecer información valiosa a los directivos y profesionales de las organizaciones sanitarias en estos y otros contextos sobre dónde dirigir sus esfuerzos de coordinación asistencial; que supuestamente también mejoraría la experiencia de una trayectoria fluida a lo largo del continuo asistencial del paciente.
Introduction: Specialization in health care, rapid advances in technology and the diversification of providers cause that patients receive care from several professionals of different disciplines in various settings and institutions. These trends together with demographic and epidemiological changes increasingly expose the patient to fragmented care delivery, which can be harmful to them due to duplication of diagnostic tests, inappropriate poly-pharmacy and conflicting care plans. Continuity of care is the patient’s perception of the coordination of services and can be defined as how one patient experiences care over time as coherent and linked. It embraces three types: continuity of clinical management and information across the care levels and continuity of relation with the primary and the secondary care physician. Studies on continuity of care from the point of view of healthcare users of the national health system of Catalonia are still scant. The objective is to explore the user’s perception of continuity of health care in different healthcare areas in the Catalan national health system, as well as its influencing factors and consequences on quality of care, in order to contribute to its improvement in the healthcare system. Methods: The research consisted of three individual studies addressing different aspects of continuity of care: 1) Analysis of the international evidence on continuity of care from the patient’s perspective, employing a meta-synthesis of qualitative studies based on a literature search in various electronic databases. 2) Analysis of COPD patients’ perceptions of continuity of care in four integrated health care networks of the national health system of Catalonia, using a multiple-case study of patients. Data were collected by means of individual semi-structured interviews with patients and physicians and the review of clinical records. 3) Analysis of continuity of care in different healthcare areas of the Catalan national health system (representing the diversity of management models for the delivery of service). Individual semi-structured interviews with healthcare users (49) were employed until data saturation was reached. Ethical approval of the study protocols was obtained. Results: Results suggest that patients are able to perceive the three types of continuity of care by referring to concrete attributes of each dimension. Patients served in the Catalan national health system generally perceived that the three types were existent with a few elements of discontinuity identified in all study areas including the integrated health care networks. A number of factors influencing (dis)continuity of care were identified, which were classified into factors related to the healthcare system, the organizations and the physicians. Different consequences of continuity of care for quality of care and the patient’s health emerged from the study findings. The three types of continuity of care appeared to be interrelated; particularly continuity of information affecting continuity of clinical management, and relational continuity playing an important role by influencing the other two types. Conclusions: This thesis contributes to filling the existing knowledge gap on continuity of care by providing a better understanding of the phenomenon as perceived by users of the national health system of Catalonia. The identified elements of discontinuity serve to indicate where there is room for improvement, and the factors influencing continuity can offer valuable insights to managers and professionals of health care organizations in these and other contexts on where to direct their care coordination efforts; which supposedly would also enhance the patient’s experience of a smooth trajectory along the care continuum. Introducción: La alta especialización en la provisión de la atención, los rápidos avances en la tecnología y la diversificación de los proveedores promueve que los pacientes sean atendidos por varios profesionales de diferentes disciplinas en diferentes organizaciones y servicios. Estas tendencias, junto con los cambios demográficos y epidemiológicos, hacen que el paciente, cada vez más, esté expuesto a una atención fragmentada, lo que le puede perjudicar debido a la duplicación de pruebas diagnósticas, la poli-medicación inapropiada y los planes de tratamiento incompatibles. La continuidad asistencial es la percepción del paciente sobre la coordinación de los servicios y se puede definir como el grado de coherencia y unión de las experiencias en la atención que percibe a lo largo del tiempo. Abarca tres tipos: la continuidad de gestión clínica y la continuidad de información entre niveles de atención y la continuidad de relación con el médico de atención primaria y el médico de atención especializada. Los estudios sobre la continuidad asistencial desde el punto de vista de los usuarios del sistema nacional de salud de Cataluña son escasos. El objetivo es explorar la percepción del usuario sobre la continuidad asistencial en las diferentes áreas del sistema nacional de salud catalán, así como los factores que influyen y las consecuencias sobre la calidad de la atención, con la finalidad de contribuir a su mejora en el sistema de salud. Métodos: La investigación consistió en tres estudios que abordan diferentes aspectos de la continuidad asistencial: 1) Análisis de la evidencia internacional sobre la continuidad asistencial mediante una meta-síntesis de estudios cualitativos basada en la búsqueda bibliográfica en diferentes bases de datos electrónicas. 2) Análisis de la percepción de la continuidad asistencial de los pacientes con EPOC atendidos en cuatro organizaciones sanitarias integradas del sistema nacional de salud de Cataluña, mediante un estudio de caso múltiple de los pacientes. La información fue recogida mediante entrevistas individuales semiestructuradas con los pacientes y sus médicos y la revisión de las historias clínicas. 3) Análisis de la continuidad asistencial en diferentes áreas sanitarias (representando la diversidad de modelos de gestión para la provisión de servicios sanitarios). Se realizaron entrevistas individuales semiestructuradas con usuarios de los servicios sanitarios (49) hasta alcanzar la saturación de la información. Se obtuvo la aprobación ética de los protocolos de estudio. Resultados: Los resultados sugieren que los pacientes son capaces de percibir los tres tipos de continuidad asistencial refiriéndose a atributos concretos de cada dimensión. En general, los pacientes atendidos en el sistema nacional de salud catalán percibieron la existencia de los tres tipos de continuidad con algunos elementos de discontinuidad identificados en todas las áreas y organizaciones sanitarias integradas de estudio. Se identificaron varios factores que influyen en la (dis)continuidad, relacionados con el sistema de salud, las organizaciones sanitarias y los médicos. Se identificaron diferentes consecuencias en la calidad asistencial y la salud del paciente. Los tres tipos parecen estar relacionados entre sí; particularmente la continuidad de información afecta a la continuidad de gestión clínica, y la continuidad de relación juega un papel importante al influir en los otros dos tipos. Conclusiones: Esta tesis contribuye al conocimiento sobre la continuidad asistencial, un tema escasamente analizado, mediante una mejor comprensión del fenómeno percibido por los usuarios del sistema nacional de salud catalán. Los elementos de discontinuidad identificados sirven para indicar donde hay margen de mejora, y los factores que influyen pueden ofrecer información valiosa a los directivos y profesionales de las organizaciones sanitarias en estos y otros contextos sobre dónde dirigir sus esfuerzos de coordinación asistencial; que supuestamente también mejoraría la experiencia de una trayectoria fluida a lo largo del continuo asistencial.

Title from PDF of title page (University of Missouri--Columbia, viewed on March 10, 2010). The entire thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file; a non-technical public abstract appears in the public.pdf file. Thesis advisor: Dr. James Keller. Includes bibliographical references.

This research evaluates a health care program's effect on obesity, some associated health issues and boredom level of a special population of sexually violent persons in a restricted environment. The use of a simple pre-post test experimental design evaluated the Body Mass Index (BMI), free time boredom, blood pressure and health diagnoses of the participants. A health and fitness program by the name of Health Care Fitness (HCU) Program with a 12 week education course was the intervention in this study. The participants' BMI, free time boredom, blood pressure and health diagnoses were evaluated at the beginning and the end of the 12 week education course. No statistical significance was found in any of these areas which may be due to the small sample size and time of data collection. The Free Time Boredom Assessment (Ragheb and Merydith, 1995) indicated an average level of low normal free time boredom for this population. Even though no statistical significance was reached, the experimental group participants displayed a greater decrease in blood pressure compared to the control group. This research offers an example of a study conducted on a unique population.

Numerous scholars have reported that inconsistent incubator humidity in the neonatal intensive care unit (NICU) requires attention. Evidence synthesis was needed to assist the identification of optimal incubator humidity levels and duration to decrease transepidermal water loss (TEWL) and the potential for infection. The purpose of this doctoral project was to appraise and synthesize the evidence of preterm outcomes related to incubator humidity. The practice-focused question addressed what patient outcomes were impacted by incubator humidity level and duration in premature infants < 32 0/7 weeks cared for in the NICU. The foundation of this project was the Joanna Briggs Institute method for systematic reviews. Mefford’s theory of health promotion for the preterm infant was used to address the wholeness of the preterm infant’s body system. Evidence was classified using the Johns Hopkins evidence-based practice levels and quality of evidence. The search was conducted in 8 databases, and citation searching was used to identify 340 articles, 12 of which met the inclusion criteria. The evidence demonstrates that the practice of incubator humidity is warranted; however, it does not come without risks. Microbial growth was increased in high levels of incubator humidity. Unnecessary TEWL was prevented by lowering high levels of incubator humidity after the 1st week, improving skin barrier formation. Incubator humidity of 60%–70% in the 1st week was effective in preventing TEWL in infants born ≥ 26 weeks; however, future research is needed for infants < 26 weeks. When optimal levels and duration of incubator humidity are achieved, positive social change will occur from the improved outcomes of the smallest neonatal patients.

Pathogens on surfaces in child care centers can contribute to illness among attendees and may thereby contribute to medical visits as well. This intervention study was conducted to assess the effect of using specific sanitizing products and cleaning protocols in child care centers on the incidences of lower respiratory infections, diarrheal illness, antibiotic use, and medical visits among children attending the centers and on the levels and antibiotic resistance of indicator bacteria in those centers. During the ten-week study period, children from twelve centers were observed. Six of the centers were randomly assigned to the intervention. The other six were controls. Intervention centers were given cleaning protocols and sanitizing products. Control centers were asked to retain their original procedures and products.Acute illness was determined from records kept by the center directors and telephone calls made to parents of ill children. A call was also made to one randomly selected healthy child's parents for every two ill children recorded. Parents were given a questionnaire requesting information including bedroom sharing status, environmental tobacco smoke exposure, and chronic illnesses.After controlling for within-center clustering and zero-inflation, statistically non-significant trends of reduction were seen in the weeks of lower respiratory infections, diarrheal illness, and medical visits. Multivariable zero-inflated Poisson regression revealed that the number of weeks intervention center children were using antibiotics was 32% lower than among the control center children. This was a statistically significant reduction (95% CI = 0.54-0.86; p = 0.001).Bacterial samples were collected from ten sites within each center at the beginning and the end of the study period to determine the effect of the intervention on the microbial population. The study determined the heterotrophic plate count bacteria numbers and the rates of resistance to ampicillin and cephalothin. Neither heterotrophic bacterial concentrations nor antibiotic resistance rates significantly changed over the course of the study.

Aim: This thesis reports the outcomes of a study designed to explore whether and how ethical and responsive interviewing of children in care with varying levels of sensitivity to topics that may threaten their felt security can be achieved. Background: Children come into care with a complex array of developmental challenges. They have often experienced maltreatment, loss and disrupted attachment relationships. Little is known about the effects of interviewing children in care with varying sensitivity to questioning strategies designed to measure felt security and their perceptions of being in care. Methods: The present study was iteratively designed using an exploratory mixed qualitative design. Children’s reports (N= 12) were collected using a series of iteratively designed interview methodologies supplemented by information provided by their kinship carers. Results: The following factors influence the comfort experiences of children in care: interviewer skill, interviewer and child role, child competence (perceived and real), child characteristics, external factors, ethical factors and the interview methods. The potential influence of mental health status and age were less clear. Factors related to felt insecurity were: relational, self-perceived competence and confidentiality related factors. The maintenance of the comfort experience of children in care when interviewing, cuts across many dimensions of the research context including relational, performance and methodological aspects. Children engaged in strategies to mediate their comfort, this was somewhat reliant on the methodologies and interviewer competency. Overall acceptable levels of comfort were reported to be maintained over the span of the research process. Conclusions: Children in care have vulnerabilities that need to be addressed when including them in research. Careful consideration to the design of studies and interview methodologies will ensure children in care can participate in protective research environments. The benefits to this are reflected in the gathering of quality data which can contribute to the timely provision of the appropriate services for children in care. The present study findings provide guidance for future research involving children in various types of alternate care.

In 2014, Louisiana experienced substantive issues with quality of care in nursing homes. The state had the lowest nurse staffing level among all states, and 7,666 deficiencies for immediate jeopardy violations were recorded from 2011 to 2013. Despite ample research on nurse staffing and quality of care, there is no consensus on how higher nurse staffing relates to quality. The purpose of this quantitative, correlational research was to determine the relationship between nurse staffing levels and quality measures in Louisiana. Donabedian's category structure, process, and outcome was the conceptual framework used to develop the research questions. The data included the quality of care deficiency score and the quality measures found in the Centers for Medicare and Medicaid datasets. The quality measures were the deficiencies and the prevalence of nursing home residents with pressure ulcers, urinary tract infections, and physical restraints. Generalized linear models were used to analyze the relationship between nurse staffing levels and the quality measures. The findings suggested that RNs, nonprofits, chain-affiliated nursing homes, and smaller facilities are important to improve the quality of care in Louisiana nursing homes. These variables were associated with fewer quality of care deficiencies and fewer pressure ulcers. These findings have implications for social change. This information may help inform and direct policy makers in the development and implementation of Medicaid-managed long-term services and supports programs in order to improve the quality of care of a vulnerable population: the elderly and disabled.

Core notions from social movement research and Sociology of Law studies are integrated into development theory and power/inequality arguments to evaluate the relative importance of internal social organizations of groups, resource dependency, and the impact of the organizational learning process on Native American tribes' inclinations to take greater amounts of control over their economic, political, and social development. This frames development as a political problem, not just an economic one. An analytical model is developed that can be applied to many indigenous groups. This model is used to answer the following question: when new opportunities for sovereign expression are created through changes in the law, which sociological factors impact the ability to take advantage of it? This study raises and addresses some theoretical questions about the conditions under which collectivities opt for more self-determination and develop greater institutional autonomy. It also addresses public policy issues by identifying factors that have proven to be barriers for tribes to pursue greater degrees of self-determination.

Research report (MMed) -- Interdisciplinary Health Sciences, Stellenbosch, 2010.
ENGLISH ABSTRACT: Background The referral system is an important component of the health care system. In public health facilities, a high number of patients’ attendance has lead to a huge burden on the secondary and tertiary level of the care system in terms of manpower, equipments and resources. Public health in South Africa consumes around 11% of the government's total budget. The state contributes about 40% of all expenditure on health; the public health sector is under pressure to deliver services to about 80% of the population. Despite the huge spending on health care in most developing countries, health outcomes and services remain poor. Few studies are available to give insights into reasons for this disparity. Therefore the findings of this may help to explain some of the reasons for this overburden of public health facilities and further to make recommendations on how health service delivery may be improve on. The results of this study can be useful in future planning; this may lead to a reduction in huge health expenditure incurred by most developing countries. Methods A cross sectional survey of three different groups of people which comprises of 273 patients, 28 referral centre participants and 19 referring centre participants was carried out. All patients referred from Motherwell community health centre to Dora Nginza hospital were eligible for the study. Questionnaires were interview administered to patients after they had finished consultations in Dora Nginza Hospital. Health professionals from both facilities were also interviewed with the use of self administered questionnaires. Results Three out of every four patients interviewed were of the opinion that their referral to hospital was appropriate which is consistent with the results from referring health professionals, eighteen of nineteen respondents. However, only one-quarter (7) of the referral centre health professionals felt the referrals from referring centre to hospital were appropriate p<0.01.The majority of the patients were satisfied with the level of service received at the referral centre. 77% (210) reported that the staff at the referral centre was friendly and 84% (230) were happy with the explanation given for their illness. However, a source of concern is that, in most of the referred patients 58% (215), there was no formal response back to their primary care. In the referring centre, participants identified transportation of patients to referral centre as the major problem encountered when referring patients 68 % (13), whereas 32 % (6) felt it is communication. In addition, 73 % (14) were of the opinion that transportation was inadequate and 89 % (17) reported the response rate of transport was unsatisfactory. In the referral centre, results showed participants were more concerned about the adequacy of information provided in the referral letters with 78% (22) reporting they were often not adequate information on the referral letters. However, half of the respondents agreed that they do not have clear referral guidelines. Conclusion Primary care health professionals and patients in this study view the referrals to higher levels of care as appropriate. However, the referral centres health professionals were of the opinion that most referrals were inappropriate. The opinion of the referral centre can be attributed to their negative attitudes towards referrals. The referral centres needs to provide more support to primary care for a more efficient referral system .They also need to improve on the continuity of care by providing feedback to referrals. On the other hand, the primary health care needs to be strengthened in terms of resource allocation in order to gain more confidence from both patients and referral centres.
AFRIKAANSE OPSOMMING: geen opsomming

Sound levels in the neonatal intensive care unit often exceed the recommended level of 45 dBA. Various sounds contribute to the extraneous noise that envelops this fragile environment. Increase in noise and high levels of sound can be detrimental to the health of premature infants, which can cause both short and long-term developmental delays and negative physiologic responses. Music therapy interventions in the NICU have addressed numerous needs of this population, with a positive effect on development, physiologic responses, and hospital stay. The purpose of this study was to investigate the effect of music therapy on decreasing the sound levels in the NICU. Two different pods in a 66-bed NICU were used to measure sound levels for four consecutive days, alternating between days of baseline and music therapy intervention. A dosimeter was used to collect data, which was later analyzed to determine Lmin, and Lmax, and Leq. Results indicated an overall decrease in the sound levels average when music therapy intervention was present. Future studies should use multiple settings and collect data for an extended amount of time to further examine the sound levels of the NICU environment and any additional effects music therapy can have.

The purpose of this study was to determine the effects of adult after-school supervision and the number of parents living at home on health-related fitness levels. Participants for the study were approximately 250 boys and girls in grades three, four and five from Selma Elementary School. The AAHPERD Physical Best Test (1988) was used to assess health-related fitness. This test measured the following components: a) flexibility (sit-and-reach test), b) cardiovascular endurance (timed run/walk test), c) body composition (sum of triceps and calf skinfolds) and d) muscular strength/endurance (timed sit-ups). A questionnaire and consent form were sent home to the parents of all participants. The questionnaire asked the child's name, grade, gender, number of parents/guardians living at home, and who supervises the child after-school. Each third-, fourth- and fifth-grade class completed two days of testing during physical education class time. The mile run/walk was administered on the first day. The second day consisted of three stations: 1) sit-and-reach, 2) skinfold assessment and 3) timed sit-ups. A 2 X 2 MANOVA was used to analyze the data. There was no significant difference between children with after-school supervision and those without after-school supervision. There was also no significant difference between children from one-parent families and children from two-parent families. However, there was a significant interaction between the number of parents and whether or not there was supervision [F(4, 109)= 4.23, p= .003]. An examination of the accompanying univariate Ftests showed that this interaction was mainly due to the difference on the variable sit-ups [F(1, 1 12)= 4.94, p= .028]. A post-hoc simple effects analysis of variance for one-parent families showed that the mean value for sit-ups for children without after-school supervision (x= 39.75) [F= 1, 112)= 5.27, p= .024] was significantly greater than the mean value for situps for children with after-school supervision(x= 34.33). The analysis also showed for two-parent families that there was no difference in the mean number of sit-ups between children with supervision (x= 35.94) [F(1, 112)= .36, p=.549] and those without supervision (x= 34.94).
Institute for Wellness

For a brief moment in the 1980s, a number of local authorities across England and Wales declared themselves ‘custody free zones’ (Rutherford, 2002), symbolising an intent that children should not be incarcerated for their offending behaviour within the local authority boundary. While this lofty aspiration was not always fulfilled, on occasion it was. More importantly, such declarations can be seen as manifestations of a widespread commitment, extending well beyond those ‘zones’, to the idea that the use of custody for children should be avoided wherever possible. During the course of the decade, that commitment found expression in an unprecedented fall in the number of young people deprived of their liberty by the criminal courts. The 1990s proved to be very different. A sea-change in the treatment of children in conflict with the law led to an escalation in custody every bit as sharp as the decline that had preceded it. This thesis seeks to explain that shift in order to understand the implications for practice if the imprisonment of children is to be reduced. The explanatory account is set against a longer term background of social, economic and political change that yielded what Garland (2002) has characterised as the ‘crisis of penal modernism’. It invokes what Foucault (1991) calls a ‘history of the present’ in which patterns of incarceration since the late 1960s are analysed to shed light on the systemic determinants of the current high level of youth custody. Local variations in the use of child imprisonment are also interrogated in the context of the historical experience to ascertain the nature of political, systemic and cultural factors that are consistent with lower rates of detention. The thesis concludes that the recent rise in custody cannot be understood in isolation: the same underlying dynamic that fuelled the carceral explosion impacted equally on other aspects of the youth justice system; and necessitated a significant cultural shift on the part of the those who might previously have been expected to resist the use of detention. Without an understanding of these corresponding changes, strategies for custody reduction that rely heavily on the provision of ‘robust’ community based alternatives, or those that seek to reduce the population of the secure estate simply by ‘nipping in the bud’ (Straw, 1997) children’s offending, are unlikely to lead to the desired outcome.

Background: South Africa is a country with the unique quadruple burden of disease and a shortage of health care workers (HCWs). This increased HCWs: patient ratio creates an excessive workload on HCWs. HCWs that are trying to compensate for the shortage may be more vulnerable to suffer burnout. The aim of the study was to measure burnout among HCWs at Tshwane clinics; compare the difference in burnout among the clinics; and identify possible reasons and root causes of burnout. Method: A cross sectional study was conducted on Tshwane HCWs in 4 public clinics. A shortened burnout Maslach inventory questionnaire was used for data collection amongst HCWs. A structured interview was conducted with management to clarify uncertainties raised or observed during data collection. Approval was granted by the University of Pretoria, Faculty of Health Research Ethics Committee. Results: Of the n=289 targeted, 69% (n=199) received questionnaires. 31% did not return the questionnaires or returned it unanswered. 14% did not complete all sections of the questionnaires handed out. A final sample size of n=109 of the 199 was achieved from the 4 clinics that took part in the study. Nurses represented 57.8% of participants studied. Years of experience, occupational status and type of clinic had a significant influence on burnout variables. High depersonalization, emotional exhaust and total burnout with a median of 3.29, 3.38 and 9.14 respectively, were observed. High depersonalization (p=0,0024) and low personal accomplishment (p=0,0034) were observed to have a significant influence on occupational status. Clinic 4 was ranked the highest for emotional exhaustion, depersonalisation and personal accomplishment. Conclusion: It should be noted that clinics where employees suffered the most burnout were those that operate for 24 hours. The possible root causes of burnout might be workload and moral constrains. Recommendations: The National Department of Health should invest more resources to reduce workload. A program to identify HCWs that may suffer burnout needs to be implemented to assist and manage HCWs with burnout.
Dissertation (MPH)--University of Pretoria, 2014.
tm2015
School of Health Systems and Public Health (SHSPH)
MPH
Unrestricted

Alcohol abuse has been a major burden on the society. In the fight against it a key issue the education of the primary care nurses has been ignored. This study evaluates the effect of education program on the attitudes, beliefs, and confidence levels of primary care nurses regarding alcohol abuse and its treatment. Data from the Project Mainstream educational intervention were used with permission from the investigators. Two hundred one students and faculty of nursing at Vanderbilt University participated in the intervention, which was designed to train primary care providers in the Brief Negotiated Intervention technique for early detection and treatment of alcohol problems. Participants completed questionnaires before and after the educational intervention. Analysis of the data using paired samples t-test and one way analysis of variance showed statistically significant positive change in the nurses' attitudes, beliefs, and confidence levels regarding alcohol abuse and its treatment after the educational intervention. This study has shown the importance of educational intervention in dealing with alcohol abuse.

Studie I

Bakgrunn

Formålet med studie I var å evaluere kvaliteten på den skriftlige kommunikasjonen mellom kommune- og spesialisthelsetjenesten ved innleggelse i og utskriving fra sykehus med et spesielt fokus på hvem som hadde oppfølgingsansvaret. I tillegg skulle det estimeres hvor mange pasienter som eventuelt kunne blitt behandlet utenfor sykehus i stedet for innleggelse i sykehus.

Materiale og metode

I studie 1 bestod pasientutvalget av 100 innleggelsesskriv og epikriser for pasienter på over 75 år fortløpende innlagt ved ortopedisk, lunge- og kardiologisk avdeling ved St. Olavs Hospital fra Trondheim og Malvik kommuner vinteren 2002. Vurderingene ble gjort ved hjelp av en Delfi-teknikk med to forskjellige ekspertpanel bestående en erfaren spesialist i allmennmedisin, en sykepleier fra kommunen med erfaring fra omsorgstjenester og en sykehusspesialist. Panelene vurderte kvaliteten på beskrivelsen av sykehistorie, aktuelt, funn, medisiner, ADL, sosialt nettverk, behov for omsorgstjenester, og foretok en vurdering av nytte av sykehusopphold og om pasientene kunne ha blitt behandlet i allmennpraksis, på en akuttpoliklinikk eller på et sykehjem.

Resultater

I henvisningsbrevene var sykehistorie, funn og medikamenter svært godt beskrevet i henholdsvis 39 %, 56 % og 39 % av tilfellene. I epikrisene var tilsvarende områder beskrevet svært godt i 92 %, 55 % og 82 % av tilfellene. Bare halvpartene av epikrisene hadde tilfredsstillende beskrivelse av ADL. Ca 2/3 av pasientene ble vurdert til å ha svært god nytte av sykehusoppholdet, og en av seks pasientene kunne ha blitt behandlet uten innleggelse i sykehuset. Mens sykehusspesialistene vurderte at 77 % av pasientene hadde stor nytte av innleggelsen, vurderte allmennlegene at bare 59 % hadde stor nytte av oppholdet. En av fire epikriser beskrev ikke hvem som hadde oppfølgingsansvaret,

Konklusjon studie I

Både innleggesskrivene og epikrisene manglet viktig medisinsk informasjon. Innleggeselsskrivene manglet så mye informasjon at i mange tilfeller kunne dette representere en helserisiko for pasientene. Det var også dårlig samsvar mellom på første- og andrelinjenivå om hva som ble forstått som god kvalitet på innleggelsesskriv og epikriser. Det var heller ikke enighet om hvilke pasienter som hadde god nytte av sykehusoppholdet.

Studie II

Bakgrunn

Formålet med studien var å sammenlikne bruk av helse- og omsorgstjenester, kostnader og død under seks og 12 måneders oppfølging av pasienter sluttbehandlet på en intermediæravdeling i sykehjem med tradisjonell behandling i sykehus.

Materiale og metode

I en randomisert kontrollert studie ble 142 pasienter over 60 år innlagt St. Olavs Hospital for akutt sykdom eller forverring av kronisk sykdom slutt- og etterbehandlet på en intermediæravdeling i et sykehjem eller på sykehuset. Intervensjonsgruppen, 72 pasienter, ble mens de var innlagt på sykehuset, randomisert til sluttbehandling på sykehjemmet, mens sykehusgruppen, 70 pasienter, ble randomisert til standard viderebehandling på sykehuset. Resultatene er basert på intention-to-treat analyser og justert for alder, kjønn, ADL og diagnoser.

Resultater

Reinnleggelser

I intervensjonsgruppen ble 14 pasienter (19,4 %) reinnlagt sammenlignet med 25 pasienter (35,7 %) i sykehusgruppen (p=0,03).

Resultater etter seks måneder

Etter seks måneder var det 18 (25,0 %) klarte seg selv i intervensjonsgruppen sammenlignet med syv (10,0 %) (p=0,02) i sykehusgruppen. Det var en ikke signifikant reduksjon av antall døde i intervensjonsgruppen med en ikke signifikant økning i dager innlagt i institusjon for den initiale behandlingsperioden. Samlede gjennomsnittlige behandlings- og omsorgskostnader per pasient var for de første seks månedene NOK 78632 (95 % CI 59168-98096) i intervensjonsgruppen sammenlignet med NOK 112568 (95 % CI 85736-139392) i sykehusgruppen (p=0,003). Gjennomsnittlige forskjell behandlings- og omsorgskostnader per pasient og observasjonsdag var NOK 296 (95 % CI 8-568) (p=0,003).

Resultater etter 12 måneder

Etter 12 måneder var 13 (18,1 %) døde i intervensjonsgruppens og 22 døde (31,4 %) i sykehusgruppen (p=0,03). Pasientene i intervensjonsgruppen var under observasjon i en lengre tidsperiode enn sykehusgruppen: 335,7 (95 % CI 312,0-359,4) sammenlignet med 12 292,8 (95 % CI 264,1-321,5) dager (p=0,01). Det var ingen statistiske forskjeller i behovet for kommunal langtidsomsorg, antall sykehusinnleggelse eller dager i sykehus mellom gruppene.

Gjennomsnittlige behandlings- og omsorgskostnader per pasient og observasjonsdag var NOK 606 (95 % CI 450-761) i intervensjonsgruppen sammenlignet med NOK 802 (95 % CI 641-962) i sykehusgruppen (p=0,03).

Konklusjon studie II

Sluttbehandling på intermediært nivå i et sykehjem medførte færre reinnleggelser, at flere pasienter klarte seg selv uten kommunale omsorgstjenester og lavere mortalitet. Samtidig var behandlingstilbudet kostnadseffektivt.

Study I

Background

Optimal care of patients is dependent on good professional interaction between general practitioners and general hospital doctors, and this collaboration is mainly based upon the quality of the written communication. The main objectives of study I were to evaluate the quality of the written communication between physicians, the description of follow-up responsibility and to estimate the number of patients that could have been treated at primary level instead of in a general hospital.

Methods

The sample of study I comprised referral and discharge letters for 100 patients above 75 years of age hospitalised at the orthopaedic, pulmonary and cardiological departments at the city general hospital in Trondheim. The assessments were done using a Delphi survey with two expert panels each with one general hospital specialist, one general practitioner and one public health nurse using a standardised evaluation protocol with a visual analogue scale (VAS) from one to eight. The panels assessed the quality of the description of medical history, signs, medication, ADL, network, need for care and the level of benefit gained from general hospital care.

Results

In study I information in referral letters on medical history, signs and medications were assessed to be of high quality in 39 %, in 56 % and in 39 %, respectively. The corresponding information assessed to be of high quality in discharge letters were for medical history 92 %, signs 55 % and medications 82 %. Only half of the discharge letters had satisfactory information on ADL. Some two-thirds of the patients were assessed to have had large health benefits from the general hospital stay in question. One of six patients could have been treated without a general hospital admission. The specialists assessed that 77 % of the patients had had a large benefit from the general hospital admission; however the general practitioners assessment was only 59 %. One of four of the discharge letters did not define who was responsible for follow-up care.

Conclusions Study I

Both referral and discharge letters lack vital medical information, and referral letters to such an extent that it might represent a health hazard for the patients. Health professionals at primary and secondary level do not agree as to the definition of good quality as far as referral and discharge letters are concerned. Furthermore they do not agree as to the benefits of admission to a general hospital.

Study II

Background

Demographic changes combined with increasing pressure on general hospital beds and other health services by the elderly make allocation of resources to the most efficient care level a vital issue. The aim of study II was to study the efficacy of intermediate care at a community hospital compared to standard prolonged care at a general hospital over a period, with six and 12 months follow-up.

Methods

In a randomised controlled trial, study II, of 142 patients, aged 60 or more admitted to a general hospital due to acute illness or exacerbation of a chronic disease, 72 (intervention group) were randomised to intermediate care at a community hospital and 70 (general hospital group) to prolonged general hospital care. The results are based on intention-to-treat analyses and are adjusted for age, gender, ADL and diagnosis.

Results

Readmissions to general hospital

In the intervention group 14 patients (19.4 %) were readmitted compared to 25 patients (35.7 %) in the general hospital group (p=0.03).

Results after six months

After 26 weeks 18 (25.0 %) patients in the intervention group were independent of community care compared to seven (10.0 %) in the general hospital group (p=0.02). There was an insignificant reduction in the number of deaths and an insignificant increase in the number of days of inpatient care in the intervention group. The number of patients admitted to long-term nursing homes from the intervention group was insignificantly higher than from the general hospital group. Mean total health services costs per patient in the intervention group for the first six months were EUR 9829 (95 % CI 7396-12262) compared to EUR 14071 (95 % CI 10717-17424) in the general hospital group. The mean difference in costs was EUR 4242 (95 % CI 152-8331) 9

(p=0.003), and mean difference in cost per day at risk per patient was EUR 37 (95 % CI 1-71) (p=0.003).

Results after 12 months

Thirty-five patients, 13 (18.1 %) of all patients included in the intervention group and 22 (31.4 %) in the general hospital group, died within 12 months (p= 0.03). Patients in the intervention group were observed during a longer period of time than in the general hospital group; 335.7 (95 % CI 312.0-359.4) versus 292.8 (95 % CI 264.1-321.5) days (p=0.01). There were statistically no differences in the need for long-term primary level care or in the number of admissions or days spent in general hospital beds.

Average total health services costs per patient per observed day were EUR 76 (95 % CI 56- 95) for the intervention group and EUR 100 (95 % CI 80-120) for the general hospital group (p=0.03).

Trial registration

ClinicalTrials.gov NCT00235404

Conclusions Study II

Intermediate care in a community hospital significantly decreased the number of readmissions for the same disease to general hospital and a significantly higher number of patients were independent of community care after 26 weeks of follow-up. There was no increase in mortality and number of days in institutions. Care at intermediate level in a community hospital was cost effective from a health service perspective and contributes to better patient outcome as more patients had better functional status and significantly fewer patients were dead after 12 months follow-up.

Hyperglycemia has been shown to have many negative consequences in the critically ill patient. Many physicians and nurses have been searching for ways to provide quality care for the critically ill and decrease the hyperglycemia found in the diabetic and nondiabetic Intensive Care Unit (ICU) patient. Many physicians and nurses around the world are studying the use of the insulin infusion protocol to combat the hyperglycemia and therefore decrease the negative consequences associated with hyperglycemia. This study was a retrospective chart review of medical ICU patients in three months in 2003 and the same three months in 2004 in order to determine the statistical variance of blood glucose readings while on an insulin infusion protocol (IIP). There is little literature about the nurses' experience with the IIP. The study used medical patients from the Billings Clinic ICU in Billings, Montana who met inclusion criteria. Patients from the 2003 population utilized an IIP from 2002 and patients in the 2004 population utilized an IIP from 2003. Blood glucose readings were recorded and analyzed using SPSS 14.0. The study found no statistical difference in blood glucose readings due to a small sample size. There were interesting trends in the blood glucose data from 2003 to 2004. The results of the trends could be related to a more proficient understanding of the protocol and the rationale behind the protocol from the bedside nurse, as they are the sole operator of the protocol. Imogene King's Theory of Goal Attainment is one to be utilized for nurses operating the IIP. The goal of the IIP is to decrease hyperglycemia, therefore increasing the health of a person. Imogene Kings' theory integrates a personal, interpersonal, and social systems level to attain the ultimate goal, health. Nurses operating the IIP can utilize Imogene King's theory to attain health for the patient.

Previous research into the accuracy of referrals for glaucoma has shown that a large number of referrals to the Hospital Eye Service are false positive. Research in areas of healthcare other than ophthalmology has shown that psychological distress can be caused by false positive referrals. The present study aimed to evaluate the quality of referrals to the HES for all ocular pathologies, and also to quantify the proportion of these referrals that were false positive. Any commonality between false positive referrals was investigated. The psychological effect of being referred to the HES was also evaluated using the Hospital Anxiety and Depression Scale (HADS) and State-Trait Anxiety Inventory (STAI). Both scales were validated in this population with Rasch analysis before use. A final aim was to develop an improvement to the present referral pathway in order to reduce numbers of false positive referrals. The accuracy of referrals to the HES appears to improve as clinicians become more experienced, and greater numbers of false positive referrals are generated by female clinicians. Optometrists refer patients with a wide range of ocular diseases and in most cases include both fundus observations and visual acuity measurements in their referrals. GPs mainly refer patients with anterior segment disorders, particularly lid lesions, based on direct observation and symptoms. Illegibility and missing clinical information reduce the quality of many optometric referrals. Patients referred to the HES experience raised levels of anxiety as measured by the STAI and raised levels of depression as measured by the HADS-Depression subscale. As a method of assessing psychological distress, the questionnaires HADS-T (all items), STAI-S (State subscale) and STAI-T (Trait subscale) show good discrimination between patients when administered to a population of new ophthalmic outpatients, despite all having a floor effect. Subsequently a referral refinement service was developed which reduced numbers of unnecessary referrals and reduced costs for the NHS.

Research shows that one of the major contributors for an extended stay in a long-term care facility is lack of knowledge regarding goals for rehabilitation after being discharged from an acute care facility. It is important to determine patients’ levels of engagement because individuals who are actively involved in discharge planning and rehabilitation goals are able to manage their ongoing care more effectively, which results in increased quality of life. The data was collected using a survey method and the instrument used was the Patient Activation Measure or PAM which is a highly accurate and reliable tool. The 22 question survey was used to determine the level of patient activation among patients who are currently receiving rehabilitation services at a rehabilitation or long-term care facility. Determining the level of engagement in patients receiving rehabilitation services will provide health care providers insight into the how willing patients are to be engaged in their own care. A total of 11 surveys were completed by patients varying age, gender, and length of stay. Each patient was currently receiving rehabilitation services at National Healthcare Corporation of Johnson City or John M. Reed Health and Rehabilitation Facility in Limestone.

Previous research into the accuracy of referrals for glaucoma has shown that a large number of referrals to the Hospital Eye Service are false positive. Research in areas of healthcare other than ophthalmology has shown that psychological distress can be caused by false positive referrals. The present study aimed to evaluate the quality of referrals to the HES for all ocular pathologies, and also to quantify the proportion of these referrals that were false positive. Any commonality between false positive referrals was investigated. The psychological effect of being referred to the HES was also evaluated using the Hospital Anxiety and Depression Scale (HADS) and State-Trait Anxiety Inventory (STAI). Both scales were validated in this population with Rasch analysis before use. A final aim was to develop an improvement to the present referral pathway in order to reduce numbers of false positive referrals. The accuracy of referrals to the HES appears to improve as clinicians become more experienced, and greater numbers of false positive referrals are generated by female clinicians. Optometrists refer patients with a wide range of ocular diseases and in most cases include both fundus observations and visual acuity measurements in their referrals. GPs mainly refer patients with anterior segment disorders, particularly lid lesions, based on direct observation and symptoms. Illegibility and missing clinical information reduce the quality of many optometric referrals. Patients referred to the HES experience raised levels of anxiety as measured by the STAI and raised levels of depression as measured by the HADS-Depression subscale. As a method of assessing psychological distress, the questionnaires HADS-T (all items), STAI-S (State subscale) and STAI-T (Trait subscale) show good discrimination between patients when administered to a population of new ophthalmic outpatients, despite all having a floor effect. Subsequently a referral refinement service was developed which reduced numbers of unnecessary referrals and reduced costs for the NHS.

The quality of care in United States' nursing homes has been of concern to consumers, government agencies, and researchers for several decades. Nurse staffing has been identified as a key factor influencing the quality of care in nursing homes. The purpose of this quantitative, correlational research was to determine if relationships existed between nurse staffing levels and three quality care outcomes in the state of Georgia. Donabedian's quality conceptual framework guided the study. The framework encompasses three interrelated dimensions of quality including structure, process, and outcomes. Nurse staffing levels and facility bed size represented the structure of nursing homes and pressure ulcers, falls with major injury, and urinary tract infections each represented facility outcomes. The sample included 348 nursing homes in Georgia. Data was collected from the Nursing Home Compare website. The predictor variables in this study were nurse staffing levels of registered nurses, licensed practical nurses, certified nursing assistants, and total nurse staffing levels. The outcome variables were pressure ulcers, urinary tract infections, and falls with major injury. A cross sectional design and multiple regressions were used to analyze the relationship between nurse staffing and quality of care outcomes. While the results of the study did not reveal significant relationships between variables, the study nonetheless offers useful insight on how future studies can be enhanced. These findings have implications for social changes as they may help to inform Georgia policy makers in decisions regarding regulations that mandate minimum nurse staffing standards.

Integrated primary care (IPC) may help palliate the demand for mental health services and barriers to such care. There are varying degrees of integration (Blount, 2003; Doherty, 1995; Strosahl, 1998), with suppositions that certain patients may fare better in certain levels/models of IPC than in others (Doherty, McDaniel, & Baird, 1996; Mauer, 2006). No research to date has examined the interface between levels of care and patient behavioral and physical health demands, hence the aim of the current study. The current study utilized Mauer’s (2006) Four Quadrant Model to ascertain patient differences in behavioral and physical health demands and utilization across three levels of care: co-located, integrated, and a hybrid (receipt of both colocated and integrated care) for a general adult population within a community-based nurse practitioner-led FQHC. Total time spent in behavioral health treatment, total number of behavioral health sessions, number of presenting behavioral health concerns at baseline, and number of behavioral health no-shows and cancellations since baseline, differed significantly across the levels of integration. Number of past-year medical visits, number of chronic illnesses, and number of active medications at baseline did not differ significantly between groups, indicating that patient differences between levels of care were based more on behavioral health variations than physical variables. Moreover, patients were no more or less likely to be represented in one level/model of care over another based on patient quadrants, or combinations of high and low physical and behavioral health demands. This study is the first to our knowledge to examine the intersect of patient quadrants and levels/models of IPC. Future research should examine the intersect and impact of level/model of care and patient behavioral and physical health demands on outcome.

OBJECTIVE: To measure urinary triclosan levels and their variability across pregnancy, and to identify sources of triclosan exposure among Canadian pregnant women. METHODS: Single spot and serial urine samples, as well as consumer product use information were collected across pregnancy and post-partum from 80 healthy pregnant women in Ottawa. Analyses included descriptives, linear mixed effects and parametric trend modeling, and surrogate category analysis. RESULTS: Triclosan was detected in 87% of maternal urine samples (LOD=3.0 µg/L). Triclosan concentrations varied by time of day of urine collection (p=0.0006), season of sampling (p=0.019), and parity (p=0.038). Triclosan was included in 4% of all personal care products used by participants; 89% of these triclosan products were varying brands of toothpaste and hand soaps. CONCLUSION: This study provided the first data on temporal variability urinary triclosan levels, and on source attribution data in Canadian pregnant women. Results will assist with population-specific exposure assessment strategies.