Care of dying patients in hospital.

OBJECTIVE--To study the process of care of dying patients in general hospitals. DESIGN--Non-participant observer (MM) carried out regular periods of continuous comprehensive observation in wards where there were dying patients, recording the quantity and quality of care given. Observations were made in 1983. SETTING--13 wards (six surgical, six medical, and one specialist unit) in four large teaching hospitals (bed capacity 504-796) in west of Scotland. SUBJECTS--50 dying patients (29 female, 21 male) with mean age of 66 (range 40-89); 29 were dying from cancer and 21 from non-malignant disease. RESULTS--Final period of hospitalisation ranged from 6 hours to 24 weeks. More than half of all patients retained consciousness until shortly before death. Basic interventions to maintain patients'' comfort were often not provided: oral hygiene was often poor, thirst remained unquenched, and little assistance was given to encourage eating. Contact between nurses and the dying patients was minimal; distancing and isolation of patients by most medical and nursing staff were evident; this isolation increased as death approached. CONCLUSIONS--Care of many of the dying patients observed in these hospitals was poor. We need to identify and implement practical steps to facilitate high quality care of the dying. Much can be learned from the hospice movement, but such knowledge and skills must be replicated in all settings.     

The quality of health care in prison: results of a year's programme of semistructured inspections.

OBJECTIVES: To assess, as part of wider inspections by HM Inspectorate of Prisons, the extent and quality of health care in prisons in England and Wales. DESIGN: Inspections based on a set of "expectations" derived mainly from existing healthcare quality standards published by the prison service and existing ethical guidelines; questionnaire survey of prisoners. SUBJECTS: 19 prisons in England and Wales, 1996-7. MAIN OUTCOME MEASURES: Appraisals of needs assessment and the commissioning and delivery of health care against the inspectorate''s expectations. RESULTS: The quality of health care varied greatly. A few prisons provided health care broadly equivalent to NHS care, but in many the health care was of low quality, some doctors were not adequately trained to do the work they faced, and some care failed to meet proper ethical standards. Little professional support was available to healthcare staff. CONCLUSIONS: The current policy for improving health care in prisons is not likely to achieve its objectives and is potentially wasteful. The prison service needs to recognise that expertise in the commissioning and delivery of health care is overwhelming based in the NHS. The current review of the provision of health care in prisons offers an opportunity to ensure that prisoners are not excluded from high quality health care.     

Equal opportunities and positive action in the British National Health Service: some lessons from the recruitment of minority ethnic groups to nursing and midwifery

The National Health Service [NHS] remains one of the most significant employers of minority ethnic groups. However, evidence suggests that members of such groups are significantly disadvantaged in NHS employment. In this article we present research evidence about the recruitment of minority ethnic groups into nursing and midwifery. In case studies of nurse education centres we identified few positive action provisions which were part of a systematic strategy for improving recruitment from minority ethnic communities. The arguments for positive action were neither widely understood nor embraced, and the problem was compounded by the fragmented organizational structure of the NHS. We conclude that what is required is an effective national strategy to build on the NHS's underlying principle of equitable and effective health care for all. This entails linking the moral imperatives of service delivery to a diverse patient community to a business case for equality of opportunity and positive action.     

Plural infection by Salmonella O7 group that hospital infection was doubted]

In Aug, 2002 (heisei 14), a 74-year-old male inpatient had been complaining of fever and diarrhea. A feces culture test was done and a few colonies were discovered and were suspected to be Salmonella O7 and were later confirmed to be as such. A further investigation and interviewing of patients was undertaken. As a result we suspected an internal infection, and did feces culture tests with 7 out of 15 inpatients who had recently had a stomachache or diarrhea and were able to be tested, and 2 discharged patients. Salmonella O7 was detected by direct fulguration in 4 of them and by enrichment in 2, for a total of 6 out of 9 patients. We considered the source to be food poisoning originating in hospital meals and in adherence to the Food Hygiene Law, turned to the proper authorities, which was the Nagaoka Board of Health, for administrative guidance. To search for the cause of this infection, environmental inspections of the patients' rooms and hospital kitchen were undertaken. Further interviews with the patients were also done but they cleared neither the infection source nor the infection route. Even without a genic test, the biotypes were all the same as 53525040. This was discovered by an Autoscan 4 (DADE BEHRING) and the result gave a strong suspicion of an internal infection. The Nagaoka Board of Health was of the opinion that there was a low possibility of the hospital meals being a source of the infection. The reasons were because the diarrhea did not present at the same time among all the patients, there were a distinct few cases of diarrhea among the hospital meal fed patients, and there were no contamination factors found by their investigation of the staff or the system for preparing the meals. Three patients were given an antimicrobic and the measures for training and educating the staff, maintaining a clean environment and fighting infection were re-examined. The case was brought to its conclusion after about 40 days.     

National survey of hospital patients.

OBJECTIVE--To survey patients'' opinions of their experiences in hospital in order to produce data that can help managers and doctors to identify and solve problems. DESIGN--Random sample of 36 NHS hospitals, stratified by size of hospital (number of beds), area (north, midlands, south east, south west), and type of hospital (teaching or non-teaching, trust or directly managed). From each hospital a random sample of, on average, 143 patients was interviewed at home or the place of discharge two to four weeks after discharge by means of a structured questionnaire about their treatment in hospital. SUBJECTS--5150 randomly chosen NHS patients recently discharged from acute hospitals in England. Subjects had been patients on medical and surgical wards apart from paediatric, maternity, psychiatric, and geriatric wards. MAIN OUTCOME MEASURES--Patients'' responses to direct questions about preadmission procedures, admission, communication with staff, physical care, tests and operations, help from staff, pain management, and discharge planning. Patients'' responses to general questions about their degree of satisfaction in hospitals. RESULTS--Problems were reported by patients, particularly with regard to communication with staff (56% (2824/5020) had not been given written or printed information); pain management (33% (1042/3162) of those suffering pain were in pain all or most of the time); and discharge planning (70% (3599/5124) had not been told about warning signs and 62% (3177/5119) had not been told when to resume normal activities). Hospitals failed to reach the standards of the Patient''s Charter--for example, in explaining the treatment proposed and giving patients the option of not taking part in student training. Answers to questions about patient satisfaction were, however, highly positive but of little use to managers. CONCLUSIONS--This survey has highlighted several problems with treatment in NHS hospitals. Asking patients direct questions about what happened rather than how satisfied they were with treatment can elucidate the problems that exist and so enable them to be solved.     

Clinico-epidemiologic characteristics of group illness caused by Bac. cereus food poisoning]

The authors describe an outbreak of food poisoning caused by Bac. cereus embracing 80% of persons who catered at the same catering establishment. The poisoning occurred in the course of 15 hours after the moment of eating a sauce stored in warm place. In the majority of cases the course of the disease was mild; 77.8% of the patients displayed phenomena of enteritis, 20.2%--of entercolitis, and 2.0%--of gastroenterocolitis. All the patients recovered without any treatment in the course of 1--2 days.     

Benefits of recruitment in honey bees: effects of ecology and colony size in an individual-based model

Why do some social insects have sophisticated recruitment systems,while other species do not communicate about food source locationsat all? To answer this question, it is necessary to identifythe social or ecological factors that make recruitment adaptiveand thus likely to evolve. We developed an individual-basedmodel of honey bee foraging to quantify the benefits of recruitmentunder different spatial distributions of nondepleting resourcepatches and with different colony sizes. Benefits of recruitmentwere strongly dependent on resource patch quality, density,and variability. Communication was especially beneficial ifpatches were poor, few, and variable. A sensitivity analysisof the model showed that under conditions of high resource densityrecruitment could even become detrimental, especially if foragingduration was short, tendency to scout was high, or recruitsneeded a long time to find communicated locations. Colony size,a factor often suspected to influence recruitment evolution,had no significant effect. These results may explain the recentexperimental findings that in honey bees, benefits of waggledance recruitment seem to vary seasonally and with habitat.They may also explain why some, but not other, species of socialbees have evolved a strategy to communicate food locations tonest mates.     

Environmental temperatures and the incidence of food poisoning in England and Wales

The incidence of food poisoning in England and Wales has been increasing for many years and it is now a major public health problem. Superimposed on this general rising trend is a well-established tendency for the number of cases of food poisoning to rise during the summer when warm weather favours the multiplication of pathogenic micro-organisms. This paper shows that weekly notifications of food poisoning in England and Wales are strongly associated with environmental temperatures, but that there are some important time lags in this relationship. The number of cases of food poisoning in a given week was only weakly correlated with the temperature of that week and the one preceding it. This suggests that factors operating close to the point of consumption within or outside the home are not the principal cause of the rise in food poisoning associated with warm summer conditions. There was a much stronger association with temperatures 2–5 weeks earlier, pointing to the importance of factors operating earlier in the food production or distribution system. The results of this study suggest that the food poisoning problem requires action by food producers and distributors as well as by consumers. Received: 15 May 2000 / Revised: 17 October 2000 / Accepted: 18 October 2000     

Integrated production and distribution planning for perishable food products

Certain types of food, such as catering foods, decay very rapidly. This paper investigates how the quality of such foods can be improved by shortening the time interval between production and delivery. To this end, we develop an approach that integrates short-term production and distribution planning in an iterative scheme. Further, an aggregation scheme is developed as the interface between the production scheduling and distribution problem. The production scheduling problem is solved through an MILP modeling approach which is based on a block planning formulation. Our implementation shows promising results, elaborated in a numerical investigation, which recollects the real settings of a catering company located in Denmark.     

Deaths of two hospital inpatients poisoned by pilocarpine.

Two inpatients of one hospital ward died. Pilocarpine poisoning was suspected and subsequently confirmed by analysis of urine. The circumstantial evidence strongly suggested that the food given to the patients in the ward had been adulterated. Police inquiries failed to elicit any further information, and open verdicts were returned at the inquest. Precautions taken subsequently to prevent a similar event--sealing food containers and trolleys--entailed a capital cost of 43,000 pounds. In addition, food stores were kept locked and tighter control kept on drugs stored in ward pharmacies.     

Costs and cost-minimisation analysis.

Whatever kind of economic evaluation you plan to undertake, the costs must be assessed. In health care these are first of all divided into costs borne by the NHS (like drugs), by patients and their families (like travel), and by the rest of society (like health education). Next the costs have to be valued in monetary terms; direct costs, like wages, pose little problem, but indirect costs (like time spent in hospital) have to have values imputed to them. And that is not all: costs must be further subdivided into average, marginal, and joint costs, which help decisions on how much of a service should be provided. Capital costs (investments in plant, buildings, and machinery) are also important, as are discounting and inflation. In this second article in the series Ray Robinson defines the types of costs, their measurement, and how they should be valued in monetary terms.     

Use of hospital beds: a cohort study of admissions to a provincial teaching hospital.

An instrument was developed to study the use of hospital beds and discharge arrangements of a cohort of 847 admissions to the John Radcliffe Hospital, Oxford, for a three week period during February-March 1986. For only 38% of bed days were patients considered to have medical, nursing, or life support reasons for requiring a provincial teaching hospital bed. The requirements for a bed in the hospital decreased with the patient''s age and length of stay in hospital. For only a tenth of patients was the general practitioner concerned in discussions with hospital staff about the patient''s discharge and less than one third of patients had been given more than 24 hours'' notice of discharge. Several features might increase the proportion of bed days that are occupied by patients with positive reasons for being in hospital. Among these are an increased frequency of ward rounds by consultants, or delegating discharge decisions by consultants to other staff; providing diagnostic related protocols for planning the length of stay in hospital; planned discharges; and providing liaison nurses to help with communication with primary care staff.     

Measures to prevent outbreaks of hospital infections

On the basis of the analysis of 69 outbreaks of hospital infections registered in the USSR in 1986-1989, as well as additional observations made by the authors, a number of factors which determined the present state of the problems concerning this kind of morbidity in the USSR were established: an insufficient level (in cases of enteric infections) or a low level (in cases of purulent septic infections) of etiological diagnosis; poor efficiency of the epidemiological investigation of outbreaks; defects in the work on the prophylactic detection of potential sources of infection among medical staff, parturient women or mothers taking care of their infants. Some possible solutions on these aspects were proposed. Cases of outbreaks of hospital infections among newborns were used as an example demonstrating that such outbreaks were caused mainly by breaches of antiepidemic and sanitary rules in respective hospitals; thus, in one-third of the cases of outbreaks such breaches were observed in maternity clinics with insufficient material and technical equipment. The prevention of these breaches is considered to be the main road to the solution of the whole problem of the prevention of epidemic outbreaks in hospitals.     

Impact of the NHS reforms on English hospital productivity: an analysis of the first three years.

OBJECTIVES: To evaluate the effect of purchaser mix, market competition, and trust status on hospital productivity within the NHS internal market. METHODS: Hospital cost and activity data were taken from routinely collected data for acute NHS hospitals in England for 1991-2 to 1993-4. Cross sectional and longitudinal regression methods were used to estimate the effect of trust status, competition, and purchaser mix on average hospital costs per inpatient, after adjusting for outpatient activity levels, casemix, teaching activity, regional salary variation, hospital size, scale of activity, and scope of cases treated. RESULTS: Real productivity gains were apparent across the study period for NHS hospitals on average. Casemix adjustment drastically improved cross sectional comparisons between hospitals. Gaining trust status and increasing host district purchaser share were associated with productivity increases after adjustment for casemix, regional salary differences, and hospital size and scope. Hospitals that became trusts during the study period were on average less productive at the beginning of the period than those that did not, and there were no significant productivity differences between trust waves at the end of the period in 1993-4. Market concentration was not associated with productivity differences. CONCLUSION: Further analysis is needed to determine whether overall and trust associated productivity gains are transient effects, one off shifts, or self perpetuating reorientations of organisational behaviour. Hospitals may have chosen to become trusts because they anticipated being able to increase productivity. Increases in the proportions of small purchasers were associated with increasing costs. Importantly, this study could not adjust for changes in the quality of care.     

Barriers in the Delivery of Emergency Obstetric and Neonatal Care in Post-Conflict Africa: Qualitative Case Studies of Burundi and Northern Uganda

Objectives

Maternal and neonatal mortality and morbidity rates are particularly grim in conflict, post-conflict and other crisis settings, a situation partly blamed on non-availability and/or poor quality of emergency obstetric and neonatal care (EmONC) services. The aim of this study was to explore the barriers to effective delivery of EmONC services in post-conflict Burundi and Northern Uganda, in order to provide policy makers and other relevant stakeholders context-relevant data on improving the delivery of these lifesaving services.

Methods

This was a qualitative comparative case study that used 42 face-to-face semi-structured in-depth interviews and 4 focus group discussions for data collection. Participants were 32 local health providers and 37 staff of NGOs working in the area of maternal health. Data was analysed using the framework approach.

Results

The availability, quality and distribution of EmONC services were major challenges across the sites. The barriers in the delivery of quality EmONC services were categorised into two major themes; human resources-related challenges, and systemic and institutional failures. While some of the barriers were similar, others were unique to specific sites. The common barriers included shortage of qualified staff; lack of essential installations, supplies and medications; increasing workload, burn-out and turnover; and poor data collection and monitoring systems. Barriers unique to Northern Uganda were demoralised personnel and lack of recognition; poor referral system; inefficient drug supply system; staff absenteeism in rural areas; and poor coordination among key personnel. In Burundi, weak curriculum; poor harmonisation and coordination of training; and inefficient allocation of resources were the unique challenges. To improve the situation across the sites, efforts are ongoing to improve the training and recruitment of more staff; harmonise and strengthen the curriculum and training; increase the number of EmONC facilities; and improve staff supervision, monitoring and support.

Conclusions

Post-conflict health systems face different challenges in the delivery of EmONC services and as such require context-specific interventions to improve the delivery of these services.     

Guideline adherence in hospital recruited and population based COPD patients

Background

Evidence from several studies show poor guideline adherence to COPD treatment, but no such study has been undertaken in Norway. The objectives of this study, was to estimate and compare the guideline adherence to COPD treatment in general population-based and hospital-recruited COPD patients, and find possible predictors of guideline adherence.

Methods

From the prospective, observational EconCOPD-study, we analysed guideline adherence for 90 population-based COPD cases compared to 245 hospital-recruited COPD patients. Overall guideline adherence was defined as correct pharmacological treatment, and influenza vaccination the preceding year, and having received smoking cessation advice. Multivariate logistic regression analysis was performed with the dichotomous outcome overall guideline adherence adjusting for relevant variables.

Results

The overall guideline adherence for population-based COPD cases was 6.7%, significantly lower than the 29.8% overall guideline-adherence amongst hospital-recruited COPD patients. Adherence to pharmacological treatment guidelines was 10.0 and 35.5%, for the two recruitment sources, respectively. GOLD-stage 3 to 4 was associated with significantly better guideline adherence compared to GOLD-stage 2 (OR (95% CI) 18.9 (8.37,42.7)). The unadjusted difference between the two recruitment sources was completely explained by degree of airflow obstruction.

Conclusion

Overall guideline adherence was very low for both recruitment sources. We call for increased attention from authorities and healthcare personnel to improve the quality of care given to this patient group.

     

Personal commentaryExternal quality assessment (EQA) in gynaecological cytology: radical rethinking required?

Accepted for publication 19 February 1999
THE PAST
The value of EQA in pathology, including proficiency testing in gynaecological cytology, has been the subject of much recent lively debate^1–6. In summary, the proven role of EQA in the monitoring of personal performance and ability is still uncertain. Furthermore, its potential to prevent critical incidents remains purely speculative. Also, whether EQA would be better replaced, for some or all professional groups, by other methods of quality assurance is unknown. Similarly, whether EQA can justify the considerable professional time, effort and expense involved has not been resolved.  

THE PRESENT

Not surprisingly, events at Kent & Canterbury Hospitals abruptly halted much of the debate about the foregoing issues⁷. Indeed, as a direct consequence of this and other incidents, the NHS Executive stipulated unilaterally that EQA is now mandatory within the NHS Cervical Screening Programme (CSP)⁸ and reinforced the necessity for all qualified laboratory staff to participate^8–10. A surprise, however, was the Executive's enlightened comments on EQA. First, and of greatest significance, that the principal function of EQA in pathology is to improve standards and advance quality through personal education. Second, that EQA should be seen to complement other QA systems for the early identification of potential problems which might affect patient care. Third, that the identification of individual poor performance through EQA will be exceptional and in essence is a by-product of the basic educational exercise. The latter conclusion was drawn, as far as one can judge, from previous experience with the NHS Breast Screening Programme (NHSBSP) EQA.  

THE FUTURE—PERSONAL SUGGESTIONS FOR OPEN DEBATE

     

Daily scheduling of home health care services using time-dependent public transport

This paper presents a real-world optimization problem in home health care that is solved on a daily basis. It can be described as follows: care staff members with different qualification levels have to visit certain clients at least once per day. Assignment constraints and hard time windows at the clients have to be observed. The staff members have a maximum working time and their workday can be separated into two shifts. A mandatory break that can also be partitioned needs to be scheduled if the consecutive working time exceeds a certain threshold. The objective is to minimize the total travel- and waiting times of the care staff. Additionally, factors influencing the satisfaction of the clients or the care staff are considered. Most of the care staff members from the Austrian Red Cross (ARC) in Vienna use a combination of public transport modes (bus, tram, train, and metro) and walking. We present a novel model formulation for this problem, followed by an efficient exact solution approach to compute the time-dependent travel times out of the timetables from public transport service providers on a minute-basis. These travel time matrices are then used as input for three Tabu Search based solution methods for the scheduling problem. Extensive numerical studies with real-world data from the ARC show that the current planning can be improved significantly when these methods are applied.     

Considerations regarding the food of the hospital staff

The question concerning the food of the hospital staff has drawn attention only tardily. However, food is a faithful mirror in which the knowledge, the capacities, the values and the imaginary ones of an institution are reflected. It is in 1905 that the reform made by the "Administration générale de l'Assistance Publique de Paris" is specifically concerned, for the first time, by the food of the hospital staff. It is a change in the practices, founded until then on the principle of equality in food treatment, resulting probably from the monastic form of the hospital in the earliest times. The introduction of the system into force today was done gradually in the years 1930. From now on, hospital staff pay their meal to the administration which establishes the account of it on the basis of a refectory card. At the end of this evolution, nothing is similar any more in the hospital on the ground of the hierarchical relations between the administration and its staff. The era of self-service restaurants has open, transforming the consumer into an autonomous active and participative individual, in an institution converted into the play of democraty company.