Emergency Health Planning

This paper outlines the development of emergency health planning as a function of government. Ten provinces have the basic responsibility for the organization, preparation and operation of medical, nursing, hospital and public health services in an emergency. The Department of National Health and Welfare is responsible for the provision of advice and assistance to the provincial and municipal governments in such matters. Eight provinces have now hired full-time planning staffs to co-ordinate the health planning of the Provincial Departments of Health and Provincial Emergency Measures Organization.Four major programs have been established. The first program provides for the continuity of leadership and guidance by health authorities at the federal, provincial and municipal level. Essential records have been developed and emergency legislation prepared. This program, however, will be of little use unless health services are organized at the municipal level. In this organizational program, advice and assistance have been provided to existing hospitals and departments of health in the conduct of disaster planning. The efforts of these agencies are co-ordinated by municipal health authorities into a community disaster plan. The third program deals with information and education of the general public and the health workers. This program is designed to make the family unit self-sufficient for up to seven days and the health worker prepared to undertake his emergency role. The first three programs are directed to the organization and training of manpower; the fourth program provides the necessary supplies. From the national medical stockpile of $18,000,000, some $12,000,000 has been received, packaged for long-term storage and distributed to regional depots across the country. To ensure their ready availability in time of emergency an agreement has been reached with seven provinces for the release of hospital disaster kits.     

Improving Community Based Pediatric Residencies by Local Affiliation: The Phoenix Experience

Community hospital graduate medical education programs have been judged deficient in several areas when compared with university programs. Generally community programs are smaller, they have a greater percentage of foreign house officers and unfilled house staff positions, and their graduates do less well on specialty board examinations. Difficulties may exist in offering a balanced and broad-based educational exposure. Four separate pediatric residencies in Phoenix became affiliated in 1972. The traditional deficiencies have been overcome, and a very popular and well-balanced program has ensued. Additionally, wasteful duplication has been avoided. Disadvantages have included complex scheduling and loss of continual close contact with house officers. Assigning patients to residents for continuity of care has been difficult. Experiences gained in this amalgamation may well apply to other hospitals facing similar problems. Local consortiums, such as this, fit well into university affiliated programs or statewide organizations.     

PSYCHIATRIC UNITS IN GENERAL HOSPITALS—Problems in Development and Efficient Operation

An adequate 25-bed psychiatric unit can be housed in a wing of a general hospital. Even more important than physical facilities are competent personnel, to be headed by a chief psychiatrist and a psychiatric nurse supervisor, for the unit. Incorporating teaching facilities into the unit helps to integrate psychiatry into the other disciplines of medicine in a continuing educational program.Having psychiatric units in general hospitals enables many voluntary patients to be treated in early stages of the disorder, with a high proportion of recoveries.Medicolegal aspects and the lack of adequate coverage of mental disorders by voluntary prepayment health plans are serious problems in the economy of a unit. Improved hospital administration, expanded training programs, educational work by local mental health societies and modification of laws on malpractice and commitment will go far to help solve these problems.     

PSYCHIATRIC UNITS IN GENERAL HOSPITALS-Problems in Development and Efficient Operation

An adequate 25-bed psychiatric unit can be housed in a wing of a general hospital. Even more important than physical facilities are competent personnel, to be headed by a chief psychiatrist and a psychiatric nurse supervisor, for the unit. Incorporating teaching facilities into the unit helps to integrate psychiatry into the other disciplines of medicine in a continuing educational program. Having psychiatric units in general hospitals enables many voluntary patients to be treated in early stages of the disorder, with a high proportion of recoveries. Medicolegal aspects and the lack of adequate coverage of mental disorders by voluntary prepayment health plans are serious problems in the economy of a unit. Improved hospital administration, expanded training programs, educational work by local mental health societies and modification of laws on malpractice and commitment will go far to help solve these problems.     

The concept of establishing autonomous occupational safety and health in hospitals: an abstraction proposal

Currently, in many hospitals in Indonesia, the Occupation Safety and Health Committee in the Hospital (OSH-CH) is evenly distributed. It is based on the instruction of the Health Department of the Republic of Indonesia that obliges each hospital to establish the committee the main function of which is to prepare necessary equipment for risk management essential in the hospital. OSH-CH must also be responsible for upgrading the accreditation process of the hospital as to work units on occupational safety, fire control and disaster preparedness. However, in fact, OSH-CH has insignificant power as many people, especially the manager of the hospital, may expect. OSH-CH tends to be stagnant and irresponsive. In other words, it tends to be non-professional. The reasons are: (1) the staff of OSH-CH work as part-timers, (2) they have minimum understanding about OSH, (3) they do not have incentive and enough budget, (4) it is only to show that the hospital "obeys" the orders of the authorities, (5) managerial support within the hospital is minimal, and (6) there are no significant cases of work-related accidents and illnesses. These explain the reasons why OSH-CH has no significant power and the progress of its program is so slow. For some large hospitals this often leads to inefficiency and ineffectiveness of the organization, and in some cases it may even tend to create difficulties in conducting risk control. Based on these reasons, it is recommended to establish an autonomous OSH work unit that operates on the basis of structural and formal organizational operations. The paper aims to discuss the proposed concept of the autonomous OSH work unit established in hospitals, particularly for large hospitals. It is urgent to develop long-term capacities of the unit to sustain its reliability.     

Molecular epidemiology of infections caused by methicillin-resistant staphylococci

The review deals with the periodicity of the spread of methicillin-resistant S. aureus (MRSA) strains during the last 40 years, the mechanism of their resistance to methicillin and other beta-lactamic antibiotics, the genetic control of methicillin resistance, the genome organization of mec DNA and its possible cause, as well as the organization of epidemiological surveillance on MSRA in hospitals. The problem of changes in the epidemiology of staphylococcal infections due to the appearance of MRSA in the absence of contacts with carriers, treatment with antibiotics or stay in a hospital is discussed. The concern of public health authorities in connection with the emergence of MRSA strains, moderately resistant or resistant to vancomycin, is also discussed. The most promising programs of the MRSA study, as well as the optimum programs introduced in economically developed counties for the control of hospital infections caused by MRSA, are considered.     

A geriatric day hospital: the Sunnybrook experience.

A review of the first 7 years of experience with the geriatric day hospital at Sunnybrook Medical Centre in Toronto revealed the following about the patients attending the day hospital during that time: most were 60 to 79 years old; over 85% attended 1 or 2 days a week; more than two thirds lived with a spouse or relatives; and more than half had diseases of the circulatory system or mental disorders. The day hospital offers a varied therapeutic program while easing the demands on the energy and time of the patient''s spouse or family and thus helps the elderly to remain in the community rather than live in an institution. The experience at Sunnybrook has shown that geriatric day hospitals can be a valuable component of the broad spectrum of integrated services and programs that must be developed to provide adequate health care for the growing number of older people in our population.     

The Canadian general internist: education and future role.

Available manpower data indicate that for the forseeable future there will be a continuing requirement in Canada for specialists in general internal medicine. While these specialists will be located predominantly in community hospitals, they will also be needed in university medical centres. The major roles of the general internist will be (a) to provide consultative service to primary care physicians and to other specialists, (b) to provide continuing care to patients with complex serious illness and (c) to participate in intensive care, particularly in community hospitals. Therefore training programs in this specialty must provide adequate experience in consultative medicine in both university and community hospitals, an opportunity to follow up patients with chronic serious illness over long periods, and experience in a variety of intensive care settings including surgical intensive care units. In some university departments the organization and supervision of training programs in this discipline have been carried out by a division of internal medicine that has equal status with other specialty divisions within the department. This seems to have been a salutory development.     

The specialty match: a necessity in the equitable resident selection process.

For many years directors of Canadian postgraduate specialty programs have selected candidates in an uncontrolled and haphazard way. Candidates and programs alike have therefore been unfairly treated. Since 1986 the Canadian Intern and Resident Matching Service has offered a centrally coordinated matching program to allow candidates to select specialty programs at centres of their choice and program directors to rate candidates. The result has been an effective method to achieve fairness in the selection of postgraduate trainees for participating Canadian specialty programs.     

Improving physician performance by continuing medical education.

In 1973 the division of continuing medical education of the University of Saskatchewan initiated a 3-year study to determine the effect of hospital-based education on the prescribing accuracy of physicians. This study was undertaken in response to an urgent need to develop more effective methods of continuing medical education and improved techniques of measuring their effectiveness. The educational program focused on common prescribing problems that had previously been defined by experts in the field. Problem frequency was determined by the monitoring of hospital records prior to institution of the educational program and at 3, 6 and 12 months after the program had concluded; this was found to be a satisfactory method of identifying educational needs and is considered to provide a measure of the quality of medical care. Fifteen physicians at three rural hospitals participated in the study. Seventeen physicians at two similar hospitals served as controls. The average problem frequency for topics selected at the study hospitals was reduced by 63% (the percentage of possible improvement), whereas at the control hospitals the frequency of the same problems declined by 32% over the same period. The results of this study provide evidence that an intensive, problem-based program on therapeutics can improve physician performance.     

Evolution and innovations of the National Neonatal and High Risk Screening Program in Costa Rica

We present the evolution, organization and results of the National Neonatal and High Risk Screening Program in Costa Rica (PNT). This program has been working uninterruptedly for more than fourteen years. Costa Rica currently has a literacy rate of 95%. To August 2004 the rate of infant mortality was 9.74 per 1000 births and to 2003, life expectancy was 76.3 years for men and 81.1 years for women. The control of infectious and parasitic diseases, as well as of severe malnutrition, has given room to a prevalence of chronic diseases with a pathology profile similar to that of a developed country. The clinical observation, mainly starting from early 70s, of a growing number of patients with mental retardation and other disabilities caused by congenital hypothyroidism and hereditary metabolic diseases that could have been prevented in many cases with an early diagnosis and opportune treatment, led us to the decision to implement a systematically massive neonatal screening for these diseases. The presence of a single Public System of Social Security in Costa Rica, which currently includes from primary health care up to the hospitals of tertiary attention, with a single Children's Hospital for the whole country, as well as communication facilities, are factors that offered, in principle, favorable conditions for this effort, even for a developing country. To September 2004, 835,217 children have been screened. There is a coverage of 95.1% of the newborns in the country. Also to this date, 259 children with congenital hypothyroidism, 18 with phenylketonuria, 20 with the maple syrup disease, 30 with congenital adrenal hyperplasia and 10 with galactosemia have been detected, confirmed and treated, for a total of 337 children that were spared of mental retardation, other disabilities and even death. Massive neonatal screening for organic acidemias recently started in June of 2004. Cystic fibrosis is under a pilot study and the screening for hemoglobinopathies and toxoplasmosis is planned. The Center for Prevention of Disabilities, which started its functions on September 23, 2002, made feasible to integrate neonatal screening, high risk screening and diagnostic confirmation of the diseases now included in the national screening program as well as those to be added in the future.     

Rehabilitation Aspects of Human Sexuality

The PLISSIT model is a comprehensive program that combines educational strategies with behavioral intervention to integrate human sexuality into the initial rehabilitation of spinal cord-injured persons. Sexuality is treated as a health care issue as important as bowel and bladder care, skin care, psychosocial issues, mobility, self-care and vocational concerns. Patients admitted to the Spinal Cord Injury Program are surrounded by a supportive milieu and an interdisciplinary staff who comfortably incorporate sexuality into discussions about catheter care, positioning, communication styles, assistive devices and so forth. Patients are exposed to a behavioral training program that makes available didactic lectures, group and individual sessions, bibliotherapy, films and opportunities for directed overnight sexual exploration within the hospital. We advocate that sex therapy be integrated into comprehensive rehabilitation programs along with physical therapy occupational therapy, recreation therapy and psychotherapy as an integral and effective form of functional restoration for patients with major physical disabilities.     

Evaluation of weed eradication programs: the delimitation of extent

Eradication is a management strategy that can provide substantial ecological and economic benefits by eliminating incursions of pest organisms. In contrast to eradication efforts that target other pests, weed eradication programs can be very protracted owing to the presence of persistent seed banks and difficulties in detecting the target. Hence there is a need to develop criteria to assist in the evaluation of progress towards eradication. Knowledge of the extent of a weed incursion (the ‘delimitation’ criterion) is considered fundamental for eradication success, as an incursion will progress from any infestations that remain undetected and thus uncontrolled. This criterion is examined with regard to eradication programs targeting Bassia scoparia L. A.J. Scott [= Kochia scoparia L. Schrader], Chondrilla juncea L. (both in Western Australia) and Orobanche ramosa L. in South Australia. The B. scoparia incursion, which has been eradicated, was largely delimited within 12 months of the inception of its eradication program. In contrast, the Western Australian C. juncea incursion has never been delimited, owing to insufficient investment in surveillance during an eradication program spanning 30 years. An exponential decrease in the detection ratio (infested area detected/area searched) over time suggests that delimitation has been approached within 6 years of the inception of the eradication program for O. ramosa. An effective surveillance program is essential for achieving delimitation of a weed incursion.     

Locked wards in Canadian mental hospitals: the return to custodialism

In 1975 a survey of the open- and locked-ward practice of 38 of the 44 Canadian public mental hospitals showed that more than one third of the wards are locked 24 hours a day. This survey is the only one known to have been conducted in the last 16 years and the first to have obtained data from all 10 provinces. Hospitals with fewer than 300 beds have a significantly smaller proportion of locked wards than those with more than 600 beds.The custodial, antitherapeutic environment was the most frequently cited disadvantage of the locked ward, and facilitation of the therapeutic milieu was the most commonly cited advantage of the open ward. The most commonly cited problem of the open ward was the inability to protect the community from the dangerous, violent patient. The most frequently cited factor required to open the wards was a higher nursing staff:patient ratio, but it is suggested that this is an erroneous opinion. What is required is the organization and involvement of the patients in meaningful activities throughout the day, hospitals with fewer beds, and better relations with the community to foster public tolerance.National organizations concerned with mental hospital practice have no data on the open- and locked-ward practice in this country. There are pressures, channelled through the political and judicial systems, to lock the wards, and the Law Reform Commission of Canada has recently recommended transferring mentally ill prisoners to mental hospitals.     

One third of a million days of care at home, 1959 to 1975.

Although articles on studies of organized home care programs are numerous, reports of long-term effectiveness of these programs are scanty. While government spokesmen appear to advocate more widespread use of alternatives to hospitalization, there has been serious criticism of the efficiency and accomplishments of home care services. A medically oriented home care program in Saskatoon (population, less than 150 000) has grown steadily over a 16-year period and is now serving a daily average of 200 individuals. All patients have required "hospital-like care" at home and most have not ordinarily been sufficiently mobile during their time in the program to attend hospital outpatient services. Many have required "concentrated care" through daily visits of professional health personnel. The program is designed for the physically ill and disabled and is administered by the major teaching hospital in the city, although it provides services to the whole community. Over one third of the patients referred in recent years had been at home. Almost one half of the patients have undergone satisfactory rehabilitation at home. The program has also proven to be an acceptable alternative to long-term institutional care for the permanently seriously disabled, a large number of whom are elderly. The program has been able to operate at considerably less cost to the public than inpatient (hospital or institutional) services would have entailed.     

¿Qué pacientes se benefician más de la atención geriátrica hospitalaria en opinión de los especialistas en Geriatría?

Objective

To assess the most appropriate criteria considered by geriatricians to select patients who might benefit the most from geriatric hospital care.

Material and methods

We carried out a survey that consisted of various socio-demographic, clinical, functional and mental criteria included in the definition of the geriatric and frail elderly patient. The survey was sent to all specialists in geriatrics in the different hospitals of the Madrid Health Service. They were asked to answer to each criterion indicating whether they considered it as high priority, priority, low priority or no priority. The responses were clustered by type of hospital: acute hospitals with or without a post-graduate geriatric program for medical residents, and medium and long stay hospitals.

Results

A total of 83 questionnaires were completed (70% of the study population): 42 teaching hospitals a post-graduate geriatric program (74% of possible), 20 of those with an emergency department but without a post-graduate geriatric program (56% of possible), and 21 medium and long stay hospitals (84% of potential). All proposed criteria were considered individually as priority or high-priority by more than 50% of respondents. An age 85 years and over, admission for hip fracture, the presence of severe cognitive or functional impairment, frailty, and unexplained deterioration of health status, were considered individually as criteria for selecting high-priority target population by more than 85% of respondents.

Conclusions

Certain criteria, such as advanced age, or the presence of geriatrics-specific conditions, such as hip fracture or severe functional or cognitive impairment, are identified by geriatricians as useful to select patients to receive geriatric specialist hospital care.     

Characteristics of Geriatric Patients in Mental Hospitals in the Province of Quebec

The results of a questionnaire completed by the superintendents of five of the six major mental hospitals in the Province of Quebec concerning patients aged 60 and over showed that this group made up one-fifth to two-fifths of the total populations. The proportion of the population that was over age 60 when admitted varied from just under one-third to almost three-quarters. The ratio of those who died or were discharged at age 60 or more to the total elderly population varied greatly among institutions.Between 67% and 91% of the elderly were capable of ambulation and self-care with minimal help, and from 13.5% to 53% were considered mentally capable of living in a private home or residential home.Diagnostic types varied, among hospitals, from 28% to 65% functional, 13% to 32% organic and 4% to 33% senile psychoses.Experience with preventive and treatment programs elsewhere is discussed.     

TREATMENT PROGRAM FOR MENTAL HOSPITALS

Many thousands of patients in the “chronic” wards of mental hospitals have been considered unsuitable subjects for active treatment, on the assumption that little could be accomplished. However, a well integrated therapeutic program under skilled psychiatric direction and involving all personnel who will come in contact with the patient gives promise of returning a substantial number of patients to their homes. The program suggested in this paper also retards personality disorganization and refutes the current nihilistic attitude concerning the patient whose mental condition has been deemed to be chronic.     

Peer support among persons with severe mental illnesses: a review of evidence and experience

Peer support is largely considered to represent a recent advance in community mental health, introduced in the 1990s as part of the mental health service user movement. Actually, peer support has its roots in the moral treatment era inaugurated by Pussin and Pinel in France at the end of the 18th century, and has re-emerged at different times throughout the history of psychiatry. In its more recent form, peer support is rapidly expanding in a number of countries and, as a result, has become the focus of considerable research. Thus far, there is evidence that peer staff providing conventional mental health services can be effective in engaging people into care, reducing the use of emergency rooms and hospitals, and reducing substance use among persons with co-occurring substance use disorders. When providing peer support that involves positive self-disclosure, role modeling, and conditional regard, peer staff have also been found to increase participants' sense of hope, control, and ability to effect changes in their lives; increase their self-care, sense of community belonging, and satisfaction with various life domains; and decrease participants' level of depression and psychosis.