Changing Use of Hospital Beds by the Elderly

Recent changes in the age structure of the mental hospital population in the Birmingham Region are first examined. The proportion of patients aged 65 and over of the total in residence has steadily increased and at the end of 1967 was 43%, and more than half the female patients are now in this age group.Admissions of elderly persons to both psychiatric and general hospitals have increased, and these hospitals have responded to the increased demand on their services by increasing bed-turnover rates. During 1967 on average one-fifth of all patients occupying beds for acute cases (excluding maternity) were 65 years of age or over.In the geriatric hospital service, on the other hand, accommodation per head of the population decreased between 1961 and 1967, as did the total annual number of admissions and the rate of turnover. This suggests that the geriatric service is overstretched and that it is under-organized, understaffed, or undercapitalized—possibly all three. The enforced expedient of admitting “excess” elderly patients to mental hospitals does not recommend itself.     

The new role of the hospital emergency department

The volume of medical services delivered within hospital emergency departments in the City of Saskatoon is increasing rapidly. These probably are not “new” medical services but rather represent a transfer of “old” services to the emergency departments from other sites where they were previously rendered. The visit to the emergency department is initiated more often by the patient than the doctor and once there the patient is treated in a relatively short period of time. The illnesses so managed do not have a diagnostic, therapeutic or prognostic uniformity but rather are characterized by their acute and totally unexpected onset. This acute and non-programmable nature of the illness makes it difficult to deliver the service in a physician''s office where the appointment system prevails and efficiently deals with the great majority of his patients. Data to determine whether or not this is a desirable development have not yet been obtained but it is clear that in its present usage the emergency department must be thought of as a facility which not only provides exceptional diagnostic and therapeutic equipment but as one which also provides a treatment facility without prior appointment available at any hour of the day or night.     

Fish and Phytoplankton Exhibit Contrasting Temporal Species Abundance Patterns in a Dynamic North Temperate Lake

Temporal patterns of species abundance, although less well-studied than spatial patterns, provide valuable insight to the processes governing community assembly. We compared temporal abundance distributions of two communities, phytoplankton and fish, in a north temperate lake. We used both 17 years of observed relative abundance data as well as resampled data from Monte Carlo simulations to account for the possible effects of non-detection of rare species. Similar to what has been found in other communities, phytoplankton and fish species that appeared more frequently were generally more abundant than rare species. However, neither community exhibited two distinct groups of “core” (common occurrence and high abundance) and “occasional” (rare occurrence and low abundance) species. Both observed and resampled data show that the phytoplankton community was dominated by occasional species appearing in only one year that exhibited large variation in their abundances, while the fish community was dominated by core species occurring in all 17 years at high abundances. We hypothesize that the life-history traits that enable phytoplankton to persist in highly dynamic environments may result in communities dominated by occasional species capable of reaching high abundances when conditions allow. Conversely, longer turnover times and broad environmental tolerances of fish may result in communities dominated by core species structured primarily by competitive interactions.     

Availability of Cadaveric Kidneys for Transplantation

The availability of cadaveric donor kidneys for transplantation has been estimated from a retrospective survey of hospital deaths in Wales during 1969. Seventy-six “probable donors” and 167 “possible donors” were identified, indicating that the potential supply of donor kidneys is sufficient to meet the present demands of patients needing kidney transplantation.     

Downsizing of acute inpatient beds associated with private finance initiative: Scotland's case study

ObjectivesTo evaluate whether the projected 24% reduction in acute bed numbers in Lothian hospitals, which formed part of the private finance initiative (PFI) plans for the replacement Royal Infirmary of Edinburgh, is being compensated for by improvements in efficiency and greater use of community facilities, and to ascertain whether there is an independent PFI effect by comparing clinical activity and performance in acute specialties in Lothian hospitals with other NHS hospitals in Scotland.DesignComparison of projected and actual trends in acute bed capacity and inpatient and day case admissions in the first five years (1995-6 to 2000-1) of Lothian Health Board''s integrated healthcare plan. Population study of trends in bed rate, hospital activity, length of stay, and throughput in Lothian hospitals compared with the rest of Scotland from 1990-1 to 2000-1.ResultsBy 2000-1, rates for inpatient admission in all acute, medical, surgical, and intensive therapy specialties in Lothian hospitals were respectively 20%, 6%, 28%, and 38% below those in the rest of Scotland. Day case rates in all acute and acute surgical specialties were 13% and 33% lower. The proportion of delayed discharges in staffed acute and post-acute NHS beds in Lothian hospitals exceeded the Scottish average (15% and 12% respectively; P<0.001).ConclusionThe planning targets and increase in clinical activity in acute specialties in Lothian hospitals associated with PFI had not been achieved by 2000-1. The effect on clinical activity has been a steeper decline in the number of acute beds and rates of admission in Lothian hospitals compared with the rest of Scotland between 1995-6 and 2000-1.

What is already known on this topic

The full business cases for the 15 first wave private finance initiative (PFI) hospitals in England and Scotland projected reductions in acute beds of about 30% in the five years before the opening of the new replacement hospitalsThe new PFI Royal Infirmary of Edinburgh, which will fully open in 2003, is the cornerstone of Lothian Health Board''s healthcare plan for its acute hospitals

What this study adds

Compared with other Scottish NHS hospitals, service delivery has been reduced across Lothian associated with PFI developmentThe planning targets and increase in clinical activity in acute specialties in Lothian hospitals had not been achieved by 2000-1There is evidence of an independent “PFI effect” on hospital downsizing and bed reductions, which in Lothian has resulted in severe capacity constraints across all acute specialties with a need for immediate expansion in acute and community provisionFurther hospital and community service downsizing may be required to meet the financial deficit, which is principally due to the high costs of PFI     

A More Efficient Use of Hospital Beds?

Faced with a shortage of trained nursing staff and a high wastage rate among learners the management of a district general hospital decided to close some of its acute beds. A beds committee attempted to minimize the effects of these closures by introducing a bed bureau, “pooling,” and a simple system for forecasting waiting list admissions.The figures for recruitment and wastage of nurses improved, and a very high turnover per available bed was achieved. This increased efficiency in numerical terms was not mirrored by an improvement in the morale of the doctors and nurses working on the wards, who were subjected to new pressures and considered that at times the standard of patient care deteriorated.     

Steps,challenges and lessons in developing community mental health care

This paper summarises our own accumulated experience from developing community-orientated mental health services in England and Italy over the last 20-30 years. From this we have provisionally concluded that the following issues are central to the development of balanced mental health services: a) services need to reflect the priorities of service users and carers; b) evidence supports the need for both hospital and community services; c) services need to be provided close to home; d) some services need to be mobile rather than static; e) interventions need to address both symptoms and disabilities; and f) treatment has to be specific to individual needs. In this paper we consider ten key challenges that often face those trying to develop community-based mental health services: a) dealing with anxiety and uncertainty; b) compensating for a possible lack of structure in community services; c) learning how to initiate new developments; d) managing opposition to change within the mental health system; e) responding to opposition from neighbours; f) negotiating financial obstacles; g) avoiding system rigidities; h) bridging boundaries and barriers; i) maintaining staff morale; and j) creating locally relevant ser- vices rather than seeking “the right answer” from elsewhere.     

AN “INTEGRATION CONFERENCE” IN A GENERAL HOSPITAL

An “integration conference” has been devised to bring about an integrated approach by the whole staff of a hospital to the whole patient in his whole environment. The aspects of the environment which the conference served to integrate included the family, the hospital, and all its disciplines, and the community and all its available resources. The conference was found to be of value to the patient, his parents, the interns and residents, the specialties in the hospital, the hospital as a whole and the community.     

General-practitioner Hospital Beds: A Review

This paper reviews literature related to general-practitioner hospital beds. In England and Wales 21% of all maternity beds are controlled by general practitioners rather than consultants, and the proportion has increased considerably since 1955. Nearly one in five of these 21% are sited in the wards of a consultant hospital. General-practitioner beds, other than maternity, represent 3% of all hospital beds (excluding psychiatric beds) and this proportion has remained constant over the past 15 years. Only about 1% of these general-practitioner beds are located in a consultant hospital.In the discussion three questions are raised: Will general-practitioner inpatient care have a useful function in the future? What might that function be? Where should the care be located? The broader issue of the future role of the general practitioner needs to be considered before these questions can be satisfactorily answered. Unless a “hospital orientated” role of the general practitioner prevails there seems little place for practitioner inpatient care in urban areas. In the more rural areas, however, whatever the role of the practitioner becomes, certain groups of patients might advantageously receive inpatient care from their practitioners. Firmer answers to the questions raised cannot be given until a co-ordinated programme of research and development concerning different patterns of care is started.     

Niche theory‐based modeling of assembly processes of viral communities in bats

Understanding the assembly processes of symbiont communities, including viromes and microbiomes, is important for improving predictions on symbionts’ biogeography and disease ecology. Here, we use phylogenetic, functional, and geographic filters to predict the similarity between symbiont communities, using as a test case the assembly process in viral communities of Mexican bats. We construct generalized linear models to predict viral community similarity, as measured by the Jaccard index, as a function of differences in host phylogeny, host functionality, and spatial co‐occurrence, evaluating the models using the Akaike information criterion. Two model classes are constructed: a “known” model, where virus–host relationships are based only on data reported in Mexico, and a “potential” model, where viral reports of all the Americas are used, but then applied only to bat species that are distributed in Mexico. Although the “known” model shows only weak dependence on any of the filters, the “potential” model highlights the importance of all three filter types—phylogeny, functional traits, and co‐occurrence—in the assemblage of viral communities. The differences between the “known” and “potential” models highlight the utility of modeling at different “scales” so as to compare and contrast known information at one scale to another one, where, for example, virus information associated with bats is much scarcer.     

The frequency of genetic disease and congenital malformation among patients in a pediatric hospital

A sample of 12,801 admissions to a pediatric hospital was surveyed in 1969-70 to determine the prevalence of disease which could be classified as “genetic” in origin or related to “congenital malformation”.“Genetic” admissions accounted for 11.1% of the total while 18.5% were for congenital malformations; about 2% (unknown group) were probably genetic. Therefore about one third of all admissions represent the effect of abnormal gene-environment interrelations at some point in the development or life of the patient.The “genetic” patient is admitted more often to a medical service while the patient with congenital malformation usually goes to a surgical service; the former stays 7.3 days and the latter 8.6 days. A disproportionate number of patients staying longer than 10 days were found in the group with congenital malformations. Seventy percent of the patients with multiple admissions (3.2% of all admissions) have genetic illness or congenital malformation.     

Experience with the Use of Frozen Blood

The long-term preservation of blood by conventional methods, i.e. beyond five to six weeks, has not progressed significantly since World War I. In the past 10 years, freezing techniques have opened new avenues in this field; it is now possible to store blood for periods of five years or more. Several techniques have been developed, either using liquid nitrogen and the rapid-freezing principle or using “cryophylactic agents” such as glycerol, where the rate of freezing is unimportant and the blood is kept at -85°C. The latter methods require washing of the blood before transfusion to remove the intracellular glycerol and thus avoid post-transfusion osmotic hemolysis. At the National Defence Medical Centre in Ottawa, the Huggins'' technique of freeze-preservation of blood has been adopted. This novel method of deglycerolization is based on the “reversible agglomeration” of erythrocytes in electrolyte-free sugar solutions. The in vitro and in vivo studies have yielded satisfactory results, and certain applications of the method are discussed.     

What Is a “Community Perception” of REDD+? A Systematic Review of How Perceptions of REDD+ Have Been Elicited and Reported in the Literature

Reducing emissions from deforestation and forest degradation (REDD+) is expected to generate co-benefits and safeguard the interests of people who live in the forested regions where emissions are reduced. Participatory measurement, reporting and verification (PMRV) is one way to ensure that the interests of local people are represented in REDD+. In order to design and use PMRV systems to monitor co-benefits and safeguards, we need to obtain input on how local people perceive REDD+. In the literature, this is widely discussed as “community perceptions of REDD+.” We systematically reviewed this literature to understand how these perceptions have been assessed, focusing specifically on how individual perceptions have been sampled and aggregated into “community perceptions.” Using Google Scholar, we identified 19 publications that reported community perceptions of REDD+, including perceptions of its design, implementation, impacts, relationship with land tenure, and both interest and actual participation by local people. These perceptions were elicited through surveys of probability samples of the local population and interviews with purposively selected community representatives. Many authors did not provide sufficient information on their methods to interpret the reported community perceptions. For example, there was often insufficient detail on the selection of respondents or sampling methods. Authors also reported perceptions by unquantified magnitudes (e.g., “most people”, “the majority”) that were difficult to assess or compare across cases. Given this situation in the scholarly literature, we expect that there are even more severe problems in the voluminous gray literature on REDD+ not indexed by Google Scholar. We suggest that readers need to be cognizant of these issues and that publication outlets should establish guidelines for better reporting, requiring information on the reference population, sampling methods, and methods used to aggregate individual responses into “community perceptions.”     

The Effectiveness of a ‘Train the Trainer’ Model of Resuscitation Education for Rural Peripheral Hospital Doctors in Sri Lanka

Background

Sri Lankan rural doctors based in isolated peripheral hospitals routinely resuscitate critically ill patients but have difficulty accessing training. We tested a train-the-trainer model that could be utilised in isolated rural hospitals.

Methods

Eight selected rural hospital non-specialist doctors attended a 2-day instructor course. These “trained trainers” educated their colleagues in advanced cardiac life support at peripheral hospital workshops and we tested their students in resuscitation knowledge and skills pre and post training, and at 6- and 12-weeks. Knowledge was assessed through 30 multiple choice questions (MCQ), and resuscitation skills were assessed by performance in a video recorded simulated scenario of a cardiac arrest using a Resuci Anne Skill Trainer mannequin.

Results/Discussion/Conclusion

Fifty seven doctors were trained. Pre and post training assessment was possible in 51 participants, and 6-week and 12-week follow up was possible for 43, and 38 participants respectively. Mean MCQ scores significantly improved over time (p<0.001), and a significant improvement was noted in “average ventilation volume”, “compression count”, and “compressions with no error”, “adequate depth”, “average depth”, and “compression rate” (p<0.01). The proportion of participants with compression depth ≥40mm increased post intervention (p<0.05) and at 12-week follow up (p<0.05), and proportion of ventilation volumes between 400-1000mls increased post intervention (p<0.001). A significant increase in the proportion of participants who “checked for responsiveness”, “opened the airway”, “performed a breathing check”, who used the “correct compression ratio”, and who used an “appropriate facemask technique” was also noted (p<0.001). A train-the-trainer model of resuscitation education was effective in improving resuscitation knowledge and skills in Sri Lankan rural peripheral hospital doctors. Improvement was sustained to 12 weeks for most components of resuscitation knowledge and skills. Further research is needed to identify which components of training are most effective in leading to sustained improvement in resuscitation.     

Foetal Blood Sampling in the Regional Hospital

Several difficulties arise in the introduction of foetal blood sampling in a regional hospital. Ideally there should be a unit sufficient to provide continuous registrar cover (anaesthetic cover and medical cover) of the labour suite. In our hospital duties have been reallocated in an attempt to attain this standard. Both consultant and registrar staff must take adequate study leave to understand the principle and practice of blood sampling. Regular lectures and demonstrations must be given to nursing and resident staff. The cost of the initial equipment is abut £1,000.‡Foetal blood sampling has been employed in the unit since January 1968. Its principal use has been the assessment of “foetal distress” Except for one case no low pH value has been found in a “high risk” patient unless the foetus showed signs of clinical distress.     

Ward Design in Relation to Postoperative Wound Infection: Part I

The incidence of postoperative wound infection in a general surgical unit is reported both before and after transfer from a “Nightingale” type multibed ward to a new “race-track” type of surgical ward with controlled ventilation and with 40% of its beds in single rooms. Following transfer postoperative wound infection was reduced by about 55%.With the use of certain types of staphylococcal infection as an index of cross-infection it was shown that transfer was followed by a 72% reduction in cross-infection of wounds.A case is made for control of hospital cross-infection in surgical wards. The principal change in ward architecture resulting from the transfer was the extensive division of ward space into separate compartments (40% of single-bed rooms), which make controlled ventilation easier.     

Evaluation of results and costs of high precision radiotherapy (VMAT) compared with conventional radiotherapy (3D) in the treatment of cancer patients with spinal cord compression of metastatic origin

BackgroundThe aim of this study was to evaluate the results and economic costs of using volumetric modulated arc therapy (VMAT) (5 fr × 5 Gy), compared with other conventional 3D radiotherapy schemes such as “5 × 4 Gy” and “10 × 3 Gy”.Materials and methodsThe data about the direct costs for the public health system was obtained from the Economic Information “Management per Patient” System available at the Integrated Health Organization Ezkerraldea Enkarterri Cruces. It is a model of real costs per patient which uses a bottom-up methodology which connects all sources of information generated in clinical practice, integrating healthcare information with economic information. This system presents the real cost per individualized patient, and shows the traceability of all clinical care. The costs of “typical patients” requiring hospital admission were identified for each of the three radiotherapy schemes based on the clinical activity and the material and human resources that were used.ResultsThe 5 × 5 Gy scheme has a cost of EUR 4,801.48, which is 1.64% higher (EUR 77) than the “5 × 4 Gy” scheme (EUR 4,724.05). The “10 × 3 Gy” scheme has a cost of EUR 8,394.61, which is 74.8% higher (EUR 3,593) than the “5 × 5 Gy” scheme. The main cost factor in the “10 × 3 Gy” scheme is hospitalization, since patients are at hospital for 2 weeks compared with 1 week in the “5 × 5 Gy” scheme.ConclusionsThe cost per patient of the VMAT “5 × 5 Gy” radiotherapy scheme is notably lower than that of the “10 × 3 Gy” scheme (conventional 3D radiotherapy), with the advantage of being administered in half the time. In relation to the scheme with 5 Gy × 4 sessions, the cost is similar to that of the “5 × 5 Gy” scheme.     

Patient Knowledge on Malaria Symptoms Is a Key to Promoting Universal Access of Patients to Effective Malaria Treatment in Palawan,the Philippines

Introduction

Palawan, where health care facilities are still limited, is one of the most malaria endemic provinces in the Philippines. Since 1999, microscopists (community health workers) have been trained in malaria diagnosis and feasibility of early diagnosis and treatments have been enhanced throughout the province. To accelerate the universal access of malaria patients to diagnostic testing in Palawan, positive health seeking behavior should be encouraged when malaria infection is suspected.

Methods

In this cross-sectional study, structured interviews were carried out with residents (N = 218) of 20 remote malaria-endemic villages throughout Palawan with a history of suspected malaria from January to February in 2012. Structural equation modeling (SEM) was conducted to determine factors associated with appropriate treatment, which included: (1) socio-demographic characteristics; (2) proximity to a health facility; (3) health seeking behavior; (4) knowledge on malaria; (5) participation in community awareness-raising activities.

Results

Three factors independently associated with appropriate treatment were identified by SEM (CMIN = 10.5, df = 11, CFI = 1.000, RMSEA = .000): “living near microscopist” (p < 0.001), “not living near private pharmacy” (p < 0.01), and “having severe symptoms” (p < 0.01). “Severe symptoms” were positively correlated with more “knowledge on malaria symptoms” (p < 0.001). This knowledge was significantly increased by attending “community awareness-raising activities by microscopists” (p < 0.001).

Conclusions

In the resource-limited settings, microscopists played a significant role in providing appropriate treatment to all participants with severe malaria symptoms. However, it was considered that knowledge on malaria symptoms made participants more aware of their symptoms, and further progressed self-triage. Strengthening this recognition sensitivity and making residents aware of nearby microscopists may be the keys to accelerating universal access to effective malaria treatment in Palawan.     

Germline genome editing: Moratorium,hard law,or an informed adaptive consensus?

With the development of practical means of human germline genome editing (HGGE) in recent years, there have been calls for stricter regulation and oversight over HGGE interventions with potential for heritable changes in the germline. An international moratorium has been advocated. We examine the practicality of such a proposal, as well as of a regulation through the “traditional” mechanisms of international and municipal laws. We argue that these mechanisms are unlikely to achieve their intended objectives and that the better approach is to engage the international community of stakeholders, researchers, scientists, clinicians, and other workers directly involved in the field in working toward the development of an “informed adaptive consensus”. We offer suggestions as to how this may be achieved and how existing indirect levers of regulation may be harnessed toward this end.