Dissertations / Theses on the topic 'Nursing|Health care management|Computer science'

Not much has changed for the migrant farmworker in the last thirty years. In one of the wealthiest countries on earth, migrant farmworker health status remains comparable to that found in Third World countries because of poor sanitation, poor nutrition and exposure. Current estimates show that migrant clinics are serving less than 20% of this population, leaving about 2,000,000 farmworkers without medical care. The barriers to health care for this population are numerous. This study will focus on the barrier to care resulting from lack of continuity in care due to poor inter-clinic communication. In this study it has been shown that computer disks and a standard word-processing program can be used to create a portable medical health history for the migrant to improve inter-clinic communication. In the process of carrying out this study, it was also shown how other barriers to care for this vulnerable population might be removed as well.

This thesis presents the design and implementation of a Nursing Workload Manager module for a Patient Data Management System in an intensive care unit. The Nursing Workload Manager aids in the planning and documentation of the nurse's workload. It automates the generation of the nursing care plan and automatically assigns a score to the care plan based on a nursing workload measurement system. In the thesis a literature survey of patient data management systems, nursing workload measurement systems and system evaluation methods is presented. This is followed by an overview of the work environment of an intensive care unit. The functionality of the Nursing Workload Manager is described and details of the software environment and application implementation are discussed. Finally, the results of a user evaluation of the module are presented, and future work on the module is discussed.

US asthma prevalence increased by five million in the last decade and health care spending for the disease increased from $53 billion to $56 billion. Children are more likely than adults to have an asthma attack and its estimated that 1-in-10 youth has asthma. Despite initiatives to promote adherence to practice guidelines, childhood asthma emergency room) visits, and hospitalizations remain steady while the number of asthma deaths have increased over a 17-year period. Preliminary studies find the majority of adolescents prefer smartphones as a means of education and guidance. A modified Technology Acceptance Model (TAM) survey was comprised of 15 statements that explored providers’ acceptance of smartphone applications (apps) as an adjunct strategy for management of asthma among adolescents in the outpatient setting. Current insight in adolescent asthma demonstrates multifaceted disparities in care stemming from biological and developmental transitions unique to adolescents. The quantitative, descriptive design of the project assessed two factors integral to the TAM related to provider acceptance and perception: 1) Perceived use (PU), and 2) Perceived ease of use (PEU). The survey sample consisted of 18 providers. Overwhelmingly, the majority of providers surveyed favored use of a smartphone app for adolescent asthma and believed apps had the potential to improve the quality of adolescent asthma management. Most participants agreed; smartphone apps might help accomplish benchmarks for adolescent asthma management. Numerous studies demonstrate adolescents’ preference for technological interventions for self-management of their asthma symptoms. The survey results reinforce the willingness of providers to accept asthma smartphone apps as a potential adjunct management strategy for adolescent asthma. Additional studies involving providers are required to further explore provider attitudes of acceptance and rejection relating to smartphone apps for chronic health conditions.

The rapid growth of medical sciences and technologies created the need to manage data generated by sophisticated medical equipment (e.g. lab results, vital signs, etc.). This class of equipment, especially in the modern Intensive Care Unit (ICU), emits large quantities of latient data which medical staff usually records on log sheets.
This thesis presents a database design that allows abstract definition of data types, and offers a unified view of data during the development phase, distinct levels of data management and a higher degree of system flexibility. This database model is an implementation of a database for a Patient Data Management System (PDMS) developed for use in the ICU of the Montreal Children's Hospital. The PDMS has a variety of application modules that handle and process various types of data according to functionality requirements.

Computerization has had a large impact on hospital intensive care units, allowing continuous monitoring and display of physiological patient data. Treatment of the critically ill patient, however, now requires assimilating large amounts of patient data.
Computers can help by processing the data and displaying the information in easy to understand formats. Also, knowledge-based systems can provide advice in diagnosis and treatment of patients. If these systems are to be effective, they must be integrated into the total hospital information system and the separate computer data must be jointly integrated into a new database which will become the primary medical record.
This thesis presents the design and implementation of a computerized database for an intensive care unit patient data management system being developed for the Montreal Children's Hospital. The database integrates data from the various PDMS components into one logical information store. The patient data currently managed includes physiological parameter data, patient administrative data and fluid balance data.
A simulator design is also described, which allows for thorough validation and verification of the Patient Data Management System. This simulator can easily be extended for use as a teaching and training tool for PDMS users.
The database and simulator were developed in C and implemented under the OS/2 operating system environment. The database is based on the OS/2 Extended Edition relational Database Manager.

Objectives: First, to identify the core Electronic Health Records (EHR) functionalities available to physicians who work in private and public health care facilities in Trinidad and Tobago and the extent to which physicians are using each function. Second, to understand the rate of adoption of Electronic Health Records in private and public hospitals/clinics, and finally, to identify the barriers to adoption of Electronic Health Records in private and public hospitals/clinics in Trinidad and Tobago. Background: The two largest public hospitals in Trinidad and Tobago, Port of Spain General Hospital and San Fernando General Hospital, utilized paper medical records. In Trinidad and Tobago, there is little known about the EHR functions available and being used, adoption rates, and barriers to adoption of EHR in the private and public sectors. Method: Electronic Health Records (n = 130) questionnaires were sent to number of health care practices in the private and public facilities in the five regions of Trinidad and Tobago, in order to understand availability and use of EHR, adoption rates, and barriers to the use of EHR. Results: The most commonly available function for the private and public physicians was Health Information and Data with respective scores of 58% and 29%. Sixty-three percent of the private physicians who adopted EHR reported using the Result Management and Order Management functions. The public physicians who had adopted EHR reported they were not utilizing the Decision Support, Result Management, and Order Management functions. There was no statistical difference between private and public physicians for the available and used functions. A total of 53 private and 19 public physicians responded to the survey (55% response rate). Thirteen (25%) private physicians reported adopting EHR and 2(11%) public physician reported adoption of EHR. Private and public physicians cited start-up cost and technical limitations of systems as the barriers to their practices' adoption of EHR. Conclusion: Findings showed the same availability and use of core functionalities, as well as adoption rate among the private and public facilities, and slightly fewer barriers in the private practices. A larger sample is merited to understand if there is any statistically significant difference between the two groups.

This research investigated the question of whether automatic or system-generated information classification methods can help humans better manage information. A series of four experiments were conducted; they investigated the usability (i.e., usefulness) of two automatic approaches to information classification, the concept space approach and a Kohonen-based SOM approach in the context of information retrieval. The concept space approach was evaluated in three different domains: Electronic Brainstorming (EBS) sessions, the Internet, and medical literature (the CancerLit collection). The Kohonen-based SOM approach was evaluated in the Internet and medical literature (CancerLit) domains only. In each case, the approach under investigation was compared with existing systems in order to demonstrate performance viability. The basic premise that information management, in particular information retrieval, can be successfully supported by system-based information classification techniques and that humans would find such techniques viable and useful was supported by the experiments. The concept space approach was more successful than the Kohonen-based SOM approach. After modifications to the algorithms based on user feedback from the EBS experiments had been made, users found the concept space approach results to be comparable (in the Internet study) or superior (in the CancerLit study) to existing information classification systems. The key future enhancement will be incorporation of better ways to identify document descriptors through syntactic and semantic front-end processing. The Kohonen-based SOM approach was considered difficult to use in all but one specialized case (the dynamic SOM created as part of the CancerLit prototype). This can probably be attributed to the fact that its associative organization does not match with the standard mental models (hierarchical and alphabetic) for information classification.

The healthcare service is under pressure to do more with less, and changing the way the service is modelled could be the key to saving resources and increasing efficacy. This change could be possible using patient-centric care models. This model would include straightforward and easy-to-use telemonitoring devices and a flexible data management structure. The structure would maintain its state by ingesting many sources of data, then tracking this data through cleaning and processing into models and estimates to obtaining values from data which could be used by the patient. The system can become less disease-focused and more health-focused by being preventative in nature and allowing patients to be more proactive and involved in their care by automating the data management. This work presents the development of a new device and a data management and analysis system to utilise the data from this device and support data processing along with two examples of its use. These are signal quality and blood pressure estimation. This system could aid in the creation of patient-centric telecare systems.

The Remote Consultation and Diagnosis (RCD) in Global Picture Archiving and Communication System (Global PACS) is a unique suite of multimedia telemedicine applications developed at the University of Arizona. The applications support real-time patients' data, image files, audio and video consultation and diagnosis annotation exchanges. The RCD enables joint collaboration between pathologists, radiologists, or physicians while they are at distant geographical locations. This project provides four RCD scenarios, i.e., Case Review, Case Acquire, Store and Forward Analysis, as well as Interactive Diagnosis and Consultation. The RCD Global PACS environment consists of heterogeneous, autonomous, and legacy resources. The Common Object Request Broker Architecture (CORBA), Java Database Connectivity (JDBC), and Java language provide the capability to combine the RCD Global PACS resources into an integrated, interoperable, and scalable system. The underneath technology, including IDL, ORB, Event Service, IIOP, JDBC/ODBC, legacy system wrapping and Java implementation are explored. This distributed collaborative CORBA/JDBC based framework will challenge the advanced, medical information management requirements. It also makes the RCD Global PACS both hardware and software technologically independent. As our research and development extend, we will continue to incorporate the latest advances in computer technology. RCD Global PACS is not another new tool in telemedicine, but rather a new paradigm for the delivery of health services that requires process reengineering, cultural changes, as well as organizational changes. It is a whole new way of practicing in telemedicine. We ensure that the RCD Global PACS project has long-term, comprehensive solutions for today and tomorrow's healthcare needs.

Providing healthcare to the ever-rising elderly population has become a severe challenge and a top priority. Emerging innovations in healthcare, such as remote health monitoring technologies, promise to provide a better quality of care and reduce the cost of healthcare. However, many elderly people reject healthcare innovations. This lack of adoption constitutes a big practical problem because it keeps the elderly from benefiting from technology advances. The phenomenon is even more pronounced among elderly women, who represent the majority of the elderly population.

A plethora of studies in the field of technology adoption resulted in sound, but highly generalized theories that are too parsimonious to provide practical insight into the phenomenon of elderly healthcare technology adoption (EHTA). There is a call to arms for novel approaches that facilitate the creation of models that expand technology adoption theories to the specifics of EHTA. This dissertation is a response to this call to arms, and it contributes to modeling practice in the EHTA field. It uses fuzzy cognitive mapping to design a novel mixed-methods modeling approach. Since elderly women constitute the majority of the elderly population, this dissertation treats elderly women’s health technology adoption (EWHTA) as the case-in-point.

This research study was conducted to examine changes in cost and service utilization of nurse case managed clients. A secondary analysis was conducted using a pre-test/post-test design. Data for this analysis were collected by Papenhausen (1995) for a study to measure the effect of nurse case management intervention on client outcomes. Cost data for 53 subjects for the periods six months before and six months after nurse case management intervention was initiated were compared. Statistically significant decreases were found in the frequencies of inpatient admissions and emergency visits, as well as in inpatient length of stay and the total cost of services. This cost, including that of nurse case management service, as determined by Huggins (1996), represented a 61% decrease from the total cost before nurse case management was started.

The benefits of using electronic medical records (EMRs) have been well documented; however, despite numerous financial benefits and cost reductions being offered by the federal government, some healthcare professionals have been reluctant to implement EMR systems. In fact, prior research provides evidence of failed EMR implementations due to resistance on the part of physicians, nurses, and clinical administrators. In 2010, only 25% of office-based physicians have basic EMR systems and only 10% have fully functional systems. One of the hindrances believed to be responsible for the slow implementation rates of EMR systems is resistance from healthcare professionals not truly convinced that the system could be of substantive use to them. This study used quantitative methods to measure the relationships between six constructs, namely computer self-efficacy (CSE), perceived complexity (PC), attitude toward EMR (ATE), peer pressure (PP), anxiety (AXY), and resistance to use of technology (RES), are predominantly found in the literature with mixed results. Moreover, they may play a significant role in exposing the source of resistance that exists amongst American healthcare professionals when using Electronic Medical Records (EMR) Systems. This study also measured four covariates: age, role in healthcare, years in healthcare, gender, and years of computer use. This study used Structural Equation Modeling (SEM) and an analysis of covariance (ANCOVA) to address the research hypotheses proposed. The survey instrument was based on existing construct measures that have been previously validated in literature, however, not in a single model. Thus, construct validity and reliability was done with the help of subject matter experts (SMEs) using the Delphi method. Moreover, a pilot study of 20 participants was conducted before the full data collection was done, where some minor adjustments to the instrument were made. The analysis consisted of SEM using the R software and programming language. A Web-based survey instrument consisting of 45 items was used to assess the six constructs and demographics data. The data was collected from healthcare professionals across the United States. After data cleaning, 258 responses were found to be viable for further analysis. Resistance to EMR Systems amongst healthcare professionals was examined through the utilization of a quantitative methodology and a cross-sectional research measuring the self-report survey responses of medical professionals. The analysis found that the overall R2 after the SEM was performed, the model had an overall R2 of 0.78, which indicated that 78% variability in RES could be accounted by CSE, PC, ATE, PP, and AXY. The SEM analysis of AXY and RES illustrated a path that was highly significant (β= 0.87, p < .001), while the other constructs impact on RES were not significant. No covariates, besides years of computer use, were found to show any significance differences. This research study has numerous implications for practice and research. The identification of significant predictors of resistance can assist healthcare administrators and EMR system vendors to develop ways to improve the design of the system. This study results also help identify other aspects of EMR system implementation and use that will reduce resistance by healthcare professionals. From a research perspective, the identification of specific attitudinal, demographic, professional, or knowledge-related predictors of reference through the SEM and ANCOVA could provide future researchers with an indication of where to focus additional research attention in order to obtain more precise knowledge about the roots of physician resistance to using EMR systems.

To ensure the safety for both patients and personnel using medical equipment there are several regulations. The regulations differ between countries and the largest markets are the US and Europe. There are regulations regarding both risk and requirement management and for a digitized signature process. This report shows a way of digitizing parts of the quality management system and workflows that fulfills these requirements, including both an approval process and a requirement hierarchy. For the development of a digitized system several workshops and interviews were performed to understand the workflow used. This to reduce the changes in the new system where the existing processes worked, but at the same time make changes possible where the users noticed problems in the workflow earlier used. The main advantage of a digitized quality management system is that the linking between the different objects are easier to follow which gives a perspicuous traceability. A digitized system can generate reports, e.g. for traceability and requirement without a test, automatically that will decrease the manual work and by that both increase efficiency and reduce the risk of human errors.

In developing countries, acute respiratory infections (ARIs) are responsible for two million deaths per year. Most victims are children who are less than 5 years old. Pneumonia kills 5000 children per day. The statistics for cardiovascular diseases (CVDs) are even more alarming. According to a 2009 report from the World Health Organization (WHO), CVDs kill 17 million people per year. In many resource-poor parts of the world such as India and China, many people are unable to access cardiologists, pulmonologists, and other specialists. Hence, low skilled health professionals are responsible for screening people for ARIs and CVDs in these areas. For example, in the rural areas of the Philippines, there is only one doctor for every 10,000 people. By contrast, the United States has one doctor for every 500 Americans. Due to advances in technology, it is now possible to use a smartphone for audio recording, signal processing, and machine learning. In my thesis, I have developed an Android application named Smart Auscultation. Auscultation is a process in which physicians listen to heart and lung sounds to diagnose disorders. Cardiologists spend years mastering this skill. The Smart Auscultation application is capable of recording and classifying heart sounds, and can be used by public or clinical health workers. This application can detect abnormal heart sounds with up to 92-98% accuracy. In addition, the application can record, but not yet classify, lung sounds. This application will be able to help save thousands of lives by allowing anyone to identify abnormal heart and lung sounds.

Problem: Medical and nursing literature poorly identify primary care providers' (PCP) relationship to care coordination (CC). Primary care providers' education, experience, and perspective, contribute to: (a) assessments of patient's care coordination needs, and (b) variability in behavior to address needs. Dissimilar approaches to CC by PCPs affect work relationships and office flow.

Purpose: To pre-pilot a new tool describing PCPs' knowledge, perception, and behavior regarding CC. Methods: Primary care physicians, nurse practitioners, and physician assistants were surveyed.

Analysis: Frequencies and percentages provided sample characteristics. Descriptive statistics analyzed provider responses within and between groups. Narratives were analyzed for themes. Tool refinement is suggested however, the tool does describe PCPs and CC activities.

Significance: A tool was developed to evaluate areas of CC activity performed by PCPs. Information from surveys of PCPs can illuminate behaviors that lead to improved work flow, efficiency, and patient outcomes. Doctors of Nursing Practice who are PCPs contribute to primary care CC through leadership, experience, and descriptive evidence.

Thesis (M.Eng.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 2001.
Includes bibliographical references (leaves 75-76).
by Kartik M. Mani.
M.Eng.

The purpose of this thesis is to investigate and analyze the implementation process of KANBAN, a lean technique, into a section of Volvo IT (i.e. BEAT). The KANBAN implementation into BEAT when ‘resistance for change’ and ‘forces for change’ arise is also analyzed. This implementation of KANBAN is equivalent to change taking place in the Volvo IT’s operational process. The thesis follows theories and literature on change management and lean principles in order to support the research investigation. How has KANBAN, with respect to change management, been implemented into an IT organization for its service production? How has KANBAN changed the operational process of the organization?  The research conducted in the thesis is based on qualitative case study. Focused and in-depth interviews, combined with observations, are carried out to obtain the primary data for the case study. The collected primary and secondary data stems from the literature reviewed, which covers the lean principles, KANBAN, and change management. Moreover, the thesis adopts an abductive approach that goes back-and-forth between the theory and the empirical findings in order to develop a model. Due to various factors already existing in the BEAT, minimal resistance to change implementation was found to be present in Volvo IT. This finding indicates that change initiatives found a way to implementation because the predominance of the ‘forces for change’, as compared to, the ‘resistance to change’ is higher in BEAT. The KANBAN implementation into the IT service production is identified to be aligned with Volvo IT’s change implementation objectives. The visualization of the ‘intangible service’ workflow on the Kanban board contributes to identify the source of bottlenecks, which has been removed through effective communication in the BEAT team and better linkages between tasks. The KANBAN effectively deals with change implementation by modifying the way team members work.

A large number of emerging infectious diseases (including influenza epidemics) has been identified during the last century. The emergence and re-emergence of infectious diseases have a negative impact on global health. Influenza epidemics alone cause between 3 and 5 million cases of severe illness annually, and between 250,000 and 500,000 deaths. In addition to the human suffering, influenza epidemics also impose heavy demands on the health care system. For example, hospitals and intensive care units have limited excess capacity during infectious diseases epidemics. Therefore, it is important that increased influenza activity is noticed early at local levels to allow time to adjust primary care and hospital resources that are already under pressure. Algorithms for the detection and prediction of influenza epidemics are essential components to achieve this. Although a large number of studies have reported algorithms for detection or prediction of influenza epidemics, outputs that fulfil standard criteria for operational readiness are seldom produced. Furthermore, in the light of the rapidly growing availability of “Big Data” from both diagnostic and prediagnostic (syndromic) data sources in health care and public health settings, a new generation of epidemiologic and statistical methods, using several data sources, is desired for reliable analyses and modeling. The rationale for this thesis was to inform the planning of local response measures and adjustments to health care capacity during influenza epidemics. The overall aim was to develop a method for detection and prediction of influenza epidemics. Before developing the method, three preparatory studies were performed. In the first of these studies, the associations (in terms of correlation) between diagnostic and pre-diagnostic data sources were examined, with the aim of investigating the potential of these sources for use in influenza surveillance systems. In the second study, a literature study of detection and prediction algorithms used in the field of influenza surveillance was performed. In the third study, the algorithms found in the previous study were compared in a prospective evaluation study. In the fourth study, a method for nowcasting of influenza activity was developed using electronically available data for real-time surveillance in local settings followed by retrospective application on the same data. This method includes three functions: detection of the start of the epidemic at the local level and predictions of the peak timing and the peak intensity. In the fifth and final study, the nowcasting method was evaluated by prospective application on authentic data from Östergötland County, Sweden. In the first study, correlations with large effect sizes between diagnostic and pre-diagnostic data were found, indicating that pre-diagnostic data sources have potential for use in influenza surveillance systems. However, it was concluded that further longitudinal research incorporating prospective evaluations is required before these sources can be used for this purpose. In the second study, a meta-narrative review approach was used in which two narratives for reporting prospective evaluation of influenza detection and prediction algorithms were identified: the biodefence informatics narrative and the health policy research narrative. As a result of the promising performances of one detection algorithm and one prediction algorithm in the third study, it was concluded that both further evaluation research and research on methods for nowcasting of influenza activity were warranted. In the fourth study, the performance of the nowcasting method was promising when applied on retrospective data but it was concluded that thorough prospective evaluations are necessary before recommending the method for broader use. In the fifth study, the performance of the nowcasting method was promising when prospectively applied on authentic data, implying that the method has potential for routine use. In future studies, the validity of the nowcasting method must be investigated by application and further evaluation in multiple local settings, including large urbanizations.

This study examined the effects of care coordination on diabetes management processes and outcomes. The study predicted care coordination increases the likelihood of daily blood glucose monitoring, hemoglobin A1C checks at least twice a year, annual foot exams, annual eye exams, diabetes care plan being developed and a written copy provided to the patient, and self-confidence in ability to control and manage diabetes. The study also predicted a correlation between lack of care coordination and diabetics' non-adherence to diabetes medications, as well as a correlation between lack of care coordination and greater number of emergency room visits and hospitalizations among diabetics for diabetes-related issues.

Data obtained from the 2011-2012 California Health Interview Survey (CHIS) was analyzed using t-test and Chi-square. Though not all hypotheses were supported, the results of the study showed a significant relationship between care coordination and increased likelihood of hemoglobin A1C checks at least twice a year, annual foot exams, and diabetes care plans being developed and written copy provided to the patient. The study findings warrant further research on the effects of care coordination on diabetes management processes. Additional research on the effects of diabetes management processes on diabetes outcomes is recommended.

The purpose of this study was to determine the perceptions of residents, family members, and nursing staff regarding quality of care and the physical environment in the nursing home. Relationships among quality of care, the physical environment, and selected organizational characteristics were then described. The Quality of Care Scale (QoCS) and the Environment Description Scale (EDS) were given to a convenience sample of 100 subjects. A significant difference in perceptions of quality of care was found between the nurse assistants and residents. Significant relationships were obtained between perceptions of quality of care and the physical environment for Registered Nurses, Licensed Practical Nurses, and families. Defining quality of care and determining the significance of the physical environment from the consumer perspective may contribute to both quality of life and quality of care in the nursing home.

Nurse-driven guidelines existed for the management of sedation in adult population; however, there is a lack of guidelines for the critically ill children. Nurses play significant roles in the management of sedation for mechanically ventilated patients in the Pediatric Intensive Care Unit (PICU), nonetheless, comprehensive guidelines for the management of sedation does not exist. The purpose of this systematic literature review was to evaluate and synthesize evidence-based research that can be used to adapt a pediatric clinical guideline for sedation management. The ACE star model and the evidence-based practice model were used as a framework to guide this review. The practice question focused on investigating the available best practices that can be used to support the nursing management practice of sedated patients in the PICU. This is important because inadequate sedation management can lead to multiple adverse outcomes for patients. The design of this project was a systematic literature review method. The sources of the data were gathered from Medline, PubMed, CINAHL, Joanna Briggs institute and Google Scholar. This review included 17 studies, of which 84.2% showed improvement with positive patient outcomes such as decreased sedation use, decreased length of stay, and improved nursing practice. The results also support recommendations for evidence-based practice guidelines in the clinical nursing practice setting. In conclusion, despite the recommendation for the use of sedation guidelines, this systematic review found that there are few studies comprehensively evaluating the impact of nurse-driven sedation management in the PICU. The social implication of this review is that more studies involving pediatric patients utilizing nurse-driven sedation protocol is needed, before it can be adopted in the PICU.

The American Academy of Pediatrics (AAP) delineated four criteria for management of perinatal care and discharge (DC) of high-risk neonates: 1) physiological stability, 2) tracking and surveillance of growth and development for each infant, 3) active parental involvement with the infant's care, and 4) follow-up care arranged with experienced primary care provider. Registered Nurses in California Neonatal Intensive Care Units (NICUs) were surveyed about NICU DC transitioning programs to 1) identify current common standards of care used in DC transitioning and 2) define the nature and extent of additional criteria and procedures used in DC transitioning. Useable surveys were obtained from 32 of the 79 facilities queried (41%): 17 (53%) Level II, 10 (31%) Level III, and 5 (16%) Level IV. All responding facilities were located in communities of 100,000 people or more. All but one of the facilities (97%) used all four AAP criteria for determining readiness for DC. Facilities differed in whether they also used weight, corrected gestational age, or both as criteria for DC. They differed in the definition of active parental involvement with care, the degree to which parents participated in DC planning, who arranged for post-DC primary care, and how outcomes of DC planning practices were evaluated. Profiles derived from these data can be used to expand procedures, guidelines, and policies for DC transitioning of the NICU graduate.

Physiologic insulin protocols are replacing conventional sliding-scale practices in hospitals because of their flexibility in adapting doses to the patient's nutritional intake and insulin sensitivity. Although many noncritical wards have updated their prandial therapy to insulin-to-carbohydrate ratios, most hospitals continue fixed preprandial dosing. If patients are receiving fixed dose insulin based on prescribed nutrition and they are not consuming what is provided, the obvious outcome is an increased risk for hypoglycemia. Despite this, there are no studies aimed at profiling nutritional intake for patients with diabetes in the noncritical setting. This study was conducted for that purpose. The results validated the positivistic knowledge that these patients do not generally eat all of their rations. Further, this study included an ancillary investigation for the quality of compliance to new diabetic protocols as recorded in paper-based patient records compared to computerized medical records.

Thesis (Ph.D.)--University of California, San Francisco, 2009.
Source: Dissertation Abstracts International, Volume: 70-04, Section: B, page: 2206. Advisers: Mary A. Blegen; Charlene A. Harrington. Includes supplementary digital materials.

The healthcare application domain has potential for research in the computer science field and Android domain. The built-in sensors and interfaces for virtual reality plugged in to the Android platform makes it a viable option for developers and end users. The B-Activ Android application builds a platform, which unlike other healthcare applications, ensures that the user is provided with essential input to indulge in an active life. External factors such as climate, pollution levels in the vicinity, and the user’s Body Mass Index (BMI) affect a person’s involvement in exercise and are central to the B-Activ application. B-Activ allows users to interact through traffic and pollution updates with people in the same city. The scope of B-Activ is to ensure that the user is active enough through simple exercises in order to control the cholesterol level and obesity thereby reducing the chances of deadly diseases.

Skin integrity is one of the quality indicators used to evaluate nursing care of patients in long-term care and rehabilitation settings and yet pressure ulcers continue to occur at alarming rates among this population group. Using Patricia Benner’s: From Novice to Expert model, the IOWA Evidence Based Model, and the Ottawa Model of Research Use (OMRU) a quality improvement practice change was implemented in a long-term care and rehabilitation facility located in the Mid-Atlantic region of the United States. The target population consisted of registered nurses and licensed practical nurses caring for patients with pressure ulcers. The sample size included ten registered nurses, twenty License Practical Nurses, and seventy-four patients with pressure ulcers. The Casper Report, Braden Scale scores, Pressure Ulcer Score for Healing (Push Tool), and Pieper Pressure Ulcer Knowledge test was used to measure the project outcomes. The project results of the pressure ulcer education program indicated that all thirty nurses completed the exam. Descriptive analysis was used and showed pre-test scores with a mean and standard deviation of 79/7.99 and post test scores of 86.6/3.69 validating an increase of knowledge retained by the nurses after the education session. Pressure ulcer data during incidence and prevalence rounds indicated a decrease in healing times of pressure ulcers using the PUSH Tool. A decrease in pressure ulcer rates were noted by the number of pressure ulcers resolved each week in wound rounds. Retrospective chart reviews confirmed improved documentation and accurate Braden score documentation by nurses throughout the facility. The overall project results are anticipated to continually improve pressure ulcer outcomes of this population and can be used as a model for long-term care and rehabilitation facilities globally.

Health care systems in many countries are experiencing a growing demand while their resources remain limited. The discrepancy between demand and capacity creates many problems – long waiting times for treatment, overcrowding in hospital wards, high workload, etc. More efficient delivery of health care services can be achieved by better planning of its resources so that the mismatch between demand and capacity is minimized. Planning health care resources, including hospital resources, is difficult due to system complexity and variability in both resource availability and demand. Discrete-event simulation and other operational research methods can be used for solving planning problems in health care, and have been gaining increased attention from researchers during recent decades. Despite the growing number of academic publications, simulation appears to be less used in health care than in other application areas and only a small proportion of simulation studies is actually implemented. The aim of this thesis is to contribute to increased use of discrete-event simulation in hospital resource planning. The separate studies regarding intensive care unit capacity planning, operating room allocation strategies and the management of emergency patient flow in a radiology department highlight both the possibilities and the requirements for practical application of discrete-event simulation in hospital resource planning. The studies are described in five papers. In the first paper, the relationship between intensive care unit (ICU) occupancy and patient outcomes was investigated and the results showed that risk adjusted mortality was higher in the group of patients who were treated during high levels of occupancy. This indicates that appropriate planning of ICU resources is necessary to avoid adverse effects on patient outcomes. In the second paper, analysis of a relatively simple care chain consisting of two hospital departments – emergency and radiology – revealed a process that was not very well defined and measured. Investigation into data availability uncovered disparate information systems storing incompatible and fragmented data. It suggests that the current degree of process orientation and the current IT infrastructure does not enable efficient use of quantitative process analysis and management tools such as simulation. In the third paper, the value and possibilities of using simulation modelling in hospital resource planning were examined through the development and use of a simulation model for improved operating room time allocation and patient flow in a hospital operating department. The model was initially used for studying overcrowding in a post-anaesthesia care unit. Advanced planning logic implemented in the model enabled evaluation of several different scenarios aiming to improve the utilization of operating room resources. The results showed that it is possible to achieve slightly better and more even resource utilization, as well as provide greater flexibility in scheduling operations. In the fourth paper, a generic ICU model was developed and validated using data from four different hospital ICUs. The model was adapted and calibrated stepwise in order to identify important parameters and their values to obtain a match between model predictions and actual data. The study showed that in presence of high quality data and well defined process logic it is possible to develop a generic ICU simulation model that could provide accurate decision support for planning critical care resources. In the fifth paper, a number of factors that can contribute to successful implementation of simulation results in health care were identified. The timing of the simulation study must be right to support a critical decision, the benefit from implementation should clearly outweigh the cost of making the necessary changes and the model should be thoroughly validated to increase the credibility of the results. Staff involvement in simulation modelling activities, availability of good quality data, as well as proper incentives to improve the system contribute to implementation as well. These findings can help in establishing the conditions for successful implementation in future applications of simulation modelling in health care.
Hälso- och sjukvårdssystemen i många länder möter en växande efterfrågan samtidigt som resurserna är begränsade. När efterfrågan överstiger kapaciteten skapas många problem, bland annat långa väntetider för behandling, överbeläggningar i sjukhusavdelningar och hög arbetsbelastning för personalen. En effektivare sjukvård kan uppnås genom bättre planering av resurserna, så att obalansen mellan efterfrågan och kapacitet minimeras. Planering av hälso- och sjukvårdsresurser, inklusive sjukhusresurser, är svårt på grund av systemkomplexitet och variation i både resurstillgänglighet och efterfrågan. Simulering och andra operationsanalytiska metoder som används för att lösa planeringsproblem inom tillverkning, logistik och andra områden, kan med fördel användas också inom sjukvården och har fått ökad uppmärksamhet av forskare under de senaste årtiondena. Trots det växande antalet akademiska publikationer verkar simulering användas betydligt mindre inom sjukvården än i andra tillämpningsområden och endast en liten del av resultaten omsätts i praktiken. Syftet med denna avhandling är att bidra till ökad användning av simulering vid planering av sjukhusresurser. De separata studierna i avhandlingen behandlar kapacitetsdimensionering av intensivvård, allokering av operationssalsresurser samt hantering av akutpatientflödet på en röntgenavdelning, och lyfter därigenom fram både möjligheterna och kraven för praktisk tillämpning av diskret händelsesstyrd simulering för planering av sjukhusresurser. Intensivvårdsavdelningar anses vara bland de dyraste resurserna på ett sjukhus. Det är därför ekonomiskt önskvärt att ha en hög utnyttjandegrad av en sådan resurs. Samtidigt är det viktigt att alltid ha utrymme för kritiskt sjuka patienter. I en studie där förhållandet mellan beläggningen på intensivvårdsavdelningar och patientutfall undersöktes visade resultaten att riskjusterad dödlighet var högre för patienter som behandlades när beläggningen på avdelningen var hög, vilket understryker att bra planering av intensivvårdsresurser är mycket viktigt. Hög grad av processorientering och tillgång till data som möjliggör undersökning av patientflödet över gränserna av sjukhusets organisatoriska och funktionella enheter är exempel på förutsättningar för användning av simulering för hela vårdkedjor. En analys av en relativt enkel vårdkedja bestående av två sjukhusavdelningar avslöjade dock en process som inte var särskilt väldefinierad, och där olika informationssystem lagrade inkompatibla och fragmenterade data. Avsaknaden av processorientering och den befintliga IT-infrastrukturen är hinder för effektiv användning av kvantitativa processanalysverktyg som simulering. Värdet av att utnyttja simulering och modellering för planering av sjukhusresurser användes vidare för att hitta en bättre och jämnare fördelning av operationssalsresurser. Modellen användes för att undersöka ett antal scenarier och resultatet visade att det är möjligt att uppnå ett jämnare utnyttjande av operationssalar och en större flexibilitet vid schemaläggning av operationer. Generiska simuleringsmodeller, som med hjälp av ett antal parameterinställningar kan omvandlas till en ny modell av en given sjukhusenhet, skulle sannolikt öka användningen av simulering. Dock kan det vara svårt att visa hur dessa modeller avbildar varje specifik enhet på ett tillräckligt trovärdigt sätt. En generisk modell för kapacitetsdimensionering av intensivvårdsavdelningar har utvecklats och validerats med hjälp av data från fyra olika sjukhus. Studien visade att när data är av hög kvalitet och processlogiken är väldefinierad är det möjligt att utveckla en sådan generisk simuleringsmodell som kan ge beslutsstöd vid planering av intensivvårdsresurser. Flera litteraturundersökningar har visat att endast en liten del av publicerade simuleringsstudier inom sjukvården har implementerats. Genom att studera ett flerårigt simuleringsprojekt identifierades ett antal faktorer som kan bidra till att simuleringsresultat faktiskt används för att förändra verksamheten. Tidpunkten för simuleringsstudien måste vara välanpassad för att stödja ett kritiskt beslut, fördelar med förändringen bör tydligt överväga kostnaden för att genomföra den och modellen bör grundligt valideras för att öka resultatens trovärdighet. Personalens engagemang i modelleringsaktiviteter, tillgång till data av god kvalitet samt lämpliga incitament för att förbättra systemet bidrar också till genomförandet. Resultaten kan hjälpa till att skapa förutsättningar för framgångsrik framtida användning av simulering vid planering av sjukhusresurser.

Background: Electronic personal health records (ePHRs) are consumer-centric tools that enable consumers to securely access, manage and share their health information with health care providers. Although the potential for ePHRs to improve healthcare is significant, there is no available evidence on health care professionals' use of ePHRs for their own health management. Nurses have a tremendous opportunity to assist and educate patients in ePHRs. Research has shown that ePHR adoption among patients were influenced by perceived usefulness and ease of use using the technology acceptance model (TAM). This study expanded the TAM adding perceived data privacy security protections and health promoting role models for the ePHR acceptance model.

Purpose: This study examined (1) characteristics associated with ePHR use by nurses: health, technology experience, and attitudes about privacy of electronic health information, (2) psychometric properties of the measures in the research model, (3) association of ePHR acceptance constructs: perceived usefulness, ease of use, data privacy and security protections, and health promoting role model with ePHR use, and (4) moderating effects of nurses characteristics: age, chronic illness and/or medication use, providers use of electronic personal health record (EHR) on the relationships between ePHR acceptance constructs and ePHR use.

Methods: Registered nurses working in hospitals and members of the nursing informatics community (NIC) completed an anonymous online survey in the Fall of 2013 (n=847). Differences between groups were examined using t-tests and χ² tests. The associations between nurses' characteristics and ePHR use were examined via multiple logistic regression models that also held constant possible confounding covariates and interaction terms.

Results: Less than half (41%) of the hospital nurses were ePHR users. The odds of ePHR use was significantly greater among those with chronic medical conditions/medication use (OR=1.64, 95% CI=1.06-2.53) and those whose health care providers used EHRs (OR=3.62, 95% CI=2.45-5.36) controlling for age, marital status, current positions and specialty area. ePHR use was more common among NIC nurses (72%). The odds of ePHR use was also increased among NIC nurses with providers that used EHRs (OR=5.99, 95% CI=1.40-25.61), but users were 70% less concerned about privacy of health information online than nonusers (OR=0.32, 95% CI=0.14-0.70) controlling for ethnicity, race and practice regions. The majority of both ePHR users and nonusers would grant access to their primary care providers. However, fewer ePHR users in both nursing groups granted permission to designated family members or friends, other care providers who care for them, or pharmacists to view ePHRs than nonusers who answered hypothetically. Sufficient reliability for usefulness, ease of use, and privacy and security protections, and health promoting role model scales were found (all Cronbach alphas>0.70). Three constructs contributed significantly to ePHR use after adjusting nursing group, age, chronic illness and medication use, and health care providers use of EHR (usefulness, OR=0.87, 95% CI=0.85-0.89; data privacy and security protection, OR=1.04, 95% CI=1.01-1.07; and health promoting role model, OR=1.07, 95% CI=1.04-1.11). Significant interactions existed between perceived data privacy and security protections and providers EHR use, and between perceived health promoting role model and age on ePHR use (p<0.05).

Conclusion: The study findings suggest practical insights for nurses. With the experience of using ePHRs, nurses can leverage use of ePHRs for patient education on chronic illness and medication management. Nurses in NIC can also play an important role in practical ePHR design to enhance functionality and security in ePHR with their specialties in nursing informatics.

This exploratory study utilized Donabedian's Quality model to develop a framework to study patients who must migrate for health care. One year of the Arizona Department of Health Services Discharge Database was used to analyze patient characteristics that influenced discharge travel and the impact of distance on risk adjusted patient outcomes. Geographic Interface software was used to identify rural patients, defined as those with zip codes farther than thirty miles from hospitals. Zip Code analysis was used to create distance variables between 31 and over 300 miles. The key findings for patients who traveled greater distances included larger hospitals, emergency admission type, private insurance, critical care services, and Neuro/Ortho/Trauma diagnosis group. Patients which traveled shorter distances included smaller hospitals, referral or transfer admit source, AHCCCS insurance (or Medicaid) and Women's Health diagnosis group. Outcomes were risk adjusted using age and distance was significant for both number of procedures and length of stay. Patients who traveled farther received fewer procedures and had a greater length of stay. A preliminary cost analysis of the length of stay outliers identified approximately four million dollars in potentially non-reimbursable charges.

Incivility is a low-level form of violence that has been found to threaten safety and has gained increasing attention from healthcare leaders. Incivility at work causes distractions and threatens the culture of safety. Locations providing mental health services are among such high-risk areas. The purpose of this study was to evaluate the effectiveness of a nurse leader’s educational approach to improve civility in the mental health (MH) nursing workplace using assertiveness training with role-play.

The civility score in this study was measured by staffs’ perceptions of eight items: respect; conflict resolution; cooperation; anti-discrimination; value differences; diversity acceptance; personal interest; and reliability of team members. In this study, the principal investigator (PI), a MH nurse leader, prepared and implemented a six-month plan of evidence-based actions intended to improve civility and to strengthen the sense of community.

Role-play exercises were included in assertiveness training sessions. Personalized brochures that summarized information and future direction for improving civility were prepared and distributed.

Civility awareness and assertiveness were reinforced by sharing literature, facilitating discussions, and practicing occasional role-plays to problem-solve past and current incivilities as they surfaced. Follow-up measurements showed a rapid and sharp increase in civility, with improved scores for each of the eight items. These findings support continued use of assertiveness training with role-play as an effective approach for improving civility in a culturally diverse MH nursing staff. Limitations of this study are discussed.

Short-sighted cost containment strategies and lack of proactive policies in Canadian health care have brought about a national nursing workforce shortage. A shortage in staff creates challenges in terms of access to, quality of, and cost of care for Canadians in a universal health care system. The focus of this quantitative correlational study was to determine the relationship between retention and both nurses’ views of leadership styles and attitudes towards unions in a Canadian acute care setting. The study supports the findings that contingent reward leadership styles and transformational leadership have a positive relationship to retention in a Canadian acute care setting. The study also supports that laissez-faire leadership has a moderately high negative linear relationship to retention. In addition, the study revealed that nurses’ attitudes towards unions have no relationship to retention. The implications of these findings for nursing leadership were also reviewed.

A previously unexamined issue, innovation durability relative to perceived environmental uncertainty and nursing unit culture among staff nurses (N = 48), was investigated. The Differentiated Group Professional Practice (DGPP) in Nursing project was selected for this five-year follow-up study. Verran, Milton, Murdaugh, and Gerber developed the DGPP model in two urban hospitals and one rural hospital in Arizona in 1988. Model implementation and evaluation was completed in 1992. The theoretical model incorporated elements of contingency and learning organization theories. A descriptive correlation research design was used to explore the relationships among environmental uncertainty, nursing unit culture, innovation durability and two innovation outcomes: control over nursing practice and work satisfaction. Data were collected in October 1997 at three selected patient care units in one rural hospital. The hospital was selected because the implementation of the DGPP model was successful, and no other redesign activity was implemented between 1992 and 1997. Structured self-report scales were used to measure each of the concepts within this study. RNs' perceptions of the current nursing practices suggested that the DGPP model was in existence on the three patient care units at the time data were collected. Nursing unit culture (β = .53) was the best predictor of the DGPP model durability (R² = .28) and its subcomponents of group governance (R² = .24) and shared values (R² = .49). Group governance and innovation related behaviors showed significant individual and combined effects on RNs' perceived control over nursing practice (R² = .55). Decision making, innovation related behaviors, and group governance accounted for the variance in RNs' overall work satisfaction (R² = .50). Although perceived control over nursing practice remained unchanged over a period of 5 years, decreases were found in overall work satisfaction and satisfaction with organizational policies. The findings provided support for the conceptual model as expected with one exception, the positive correlation between DGPP model durability and perceived uncertainty in the internal environment. In summary, the findings suggested the inclusion of environmental uncertainty and nursing unit culture in studies of innovation durability and innovation outcomes.

Death from medical error at time of writing is the third leading cause of the death in the United States. Creating a world where patients and those who care for them are free from harm is the priority in the patient safety movement. A strong culture of prioritizing safe practices is the foundation for safe patient care; this culture can be developed and maintained by the implementation of daily safety huddles. By engaging the team in safety behaviors to achieve the goal of reducing preventable patient harm, daily safety huddles have the potential to impact the safety culture at both the unit and organizational level. Daily safety huddles are deliberate, intentional, purposed conversations in a non-punitive environment from the leader with their team about safety events, concerns, and needs so that situational awareness is created, the team has a shared mental model, and resources can be assigned to reduce the risk of potential events of harm to patients, families, and the health care team. This change project evaluated the impact of daily safety huddles on unit-level safety culture as measured by the Safety Organizing Scale (SOS) survey which is based on the principles of high reliability utilizing a pre-posttest quantitative design. Descriptive statistics were used to describe the characteristics of the inclusive of gender, race, age, experience level, and educational level. Results indicated an overall increase in mean scores from the pre-test to the post-test for all behavioral indices of safety culture with the exception of one question describing handoff communication. A statistically significant positive difference was noted between groups with p = .03 for the SOS question on discussion of mistakes and how to learn from them as a result of huddle implementation. Thus, the implementation of huddles demonstrated a clinically significant improvement in unit level safety culture and a statistically significant improvement in one domain.