Primary care: nurse-led telephone triage and advice out-of-hours

In this article the authors report on the evaluation of an out-of-hours telephone triage and advice service in general practice. A computer-based decision support tool was used to guide nurses in the assessment of patients and outcome for calls. Data from the computer system were analysed for all calls over a six-month period. The researchers found that the nurses were able to handle just over half the calls received by giving advice alone. Overall, the service appeared to be remarkably consistent in the decisions taken by nurses, and training and organisational issues to be considered in the future development of the service were identified.     

After-hours telephone calls in a family practice residency: volume, seriousness, and patient satisfaction

BACKGROUND: After-hours calls are common in primary care physicians' practices. Calls may be unnecessary from the physician's perspective, but patients may have a different concept of the importance of reaching their physician immediately. This study's purpose was to compare physician and patient perceptions of the same telephone call episode. METHODS: Family practice residents (n = 19) recorded all patient-initiated after-hours telephone contacts (n = 192) during July 1993. Study personnel then telephoned, within 1 week of their call, the patients who made the calls. Patients were asked about the reason for their call, its seriousness, and their satisfaction with the handling of their problem. RESULTS: During the study month, 1.1 after-hours calls were received for every 10 office visits. A substantial minority of patients (29%) rated their problems in the highest severity category, while physicians assigned only 8% of calls the highest severity rating. The majority of patients (76.7%) were satisfied with how their after-hours calls were handled. CONCLUSIONS: In matched cases, physicians and patients perceive about the same proportion of calls to be routine versus more severe. Although patient satisfaction was high, further research into causes of dissatisfaction is needed.     

Knowledge of the utilization of preventive practices through a telephone survey

OBJECTIVES: To determine knowledge and use of preventive practices (cervical cytology, mammography and taking blood pressure) through a telephone survey. DESIGN: Crossover study. SETTING: Billabona Health Centre (Guipúzcoa). PARTICIPANTS: People over 15 in the Health Centre's catchment area. MAIN RESULTS: The sample size was 800 people. It reached 80% telephone coverage with a reply rate of 86.09% (278 men and 273 women). 76.5% of women stated they had heard of cervical cytology; and 80.2% mammography. 87.5% had had their blood pressure taken on some occasion. CONCLUSIONS: Both cervical cytology and mammography are well-known preventive procedures, although they could always be improved, whereas taking blood pressure is a widespread practice in all age-groups.     

Evaluation of the PAPNET system for prescreening triage of cervicovaginal smears

OBJECTIVE: To assess the PAPNET System for prescreening triage of cervical smears. STUDY DESIGN: We prospectively prescreened 5,170 consecutive cervicovaginal smears with the PAPNET System. The slides were then manually screened by cytotechnologists blinded to the PAPNET diagnoses. Cases identified as abnormal by either PAPNET or manual screening were reviewed by a cytopathologist. The PAPNET and manual diagnoses were correlated. RESULTS: Diagnostic concordance between PAPNET and manual screening was seen in 4,340 (84%) of the cases (3,167 negative, 1,038 abnormal and 135 unsatisfactory). Noncorrelation between PAPNET and manual diagnosis occurred in 794 cases (543 abnormal by PAPNET and negative manually, 228 negative by PAPNET and abnormal manually, 8 abnormal by PAPNET and unsatisfactory manually, 29 unsatisfactory by PAPNET and negative manually, 7 negative by PAPNET and unsatisfactory manually). The diagnostic sensitivity of the PAPNET System was 82%, diagnostic specificity 85%, predictive value of a positive test 66% and predictive value of a negative test 93.4%. The false negative fraction of PAPNET was 6.4% for low grade squamous intraepithelial lesion and above. CONCLUSION: PAPNET performed effectively for prescreening triage, increasing the accuracy of screening and reducing the screening time.     

Trauma care reimbursement in rural hospitals: implications for triage and trauma system design

American College of Surgeons triage guidelines recommend rapid identification and transfer of seriously injured patients to regional trauma centers, bypassing local hospitals if necessary. This approach raises concerns about the potential negative financial impact of implementing such triage strategies on already strained rural hospitals. OBJECTIVE: The purpose of this study was to determine the association between injury severity and reimbursement for trauma care in rural hospitals. It was our hypothesis that the seriously injured would be high cost and relatively low reimbursement patients, and thus be a significant financial liability to the rural hospital. This would imply that concerns by the rural hospital about triage of such patients to trauma centers would be unfounded. METHODS: Data on every injured patient seen in the emergency department during two 3-month periods were obtained from three rural hospitals in the state using the American College of Surgeons Trauma Registry data base. RESULTS: One thousand six hundred thirty patients had complete data available for analysis. The analyses demonstrated that as the injury severity increased, there was an increase in hospital charges, length of stay, and risk of dying. In contrast, the reimbursement changed little as the charges and severity increased. Thus, hospital losses increased in an exponential fashion as injury severity increased above 15. CONCLUSION: The study demonstrates that as injury severity increases, costs and charges increase, but reimbursement does not keep pace with these increased charges. The rural hospital was projected to lose an average of $25,000 for each patient with an Injury Severity Score over 15. This study supports the rapid triage and transport of the seriously injured patient from the rural hospital to the regional trauma center both for improved patient outcome and for the hospital's best interest. The potential impact of such a system on the trauma center also needs to be addressed.     

Development of an expert system for pediatric auditory brainstem response interpretation

Expert systems are computer programs which incorporate artificial intelligence technology and are created to emulate the decision-making abilities of human experts. The advantage of such systems lies in their ability to capture and model expert problem solving knowledge in a domain and make it available to an unlimited number of consumers in an economic and efficient way. The purpose of this project was to develop an expert system to interpret infant auditory brainstem response data as entered by the user. The resulting system provides diagnostic conclusions regarding hearing status, type of hearing loss, and brainstem function at an accuracy level equal to that of a human expert.     

Clinical evaluation of the rapid telephone access system for radiology reporting

The Rapid Telephone Access System (RTAS) for radiology reporting was evaluated clinically among patients undergoing fluoroscopy, excretory urography, or cholecystography at a community-based teaching hospital. After the radiologist has dictated his report in the customary manner, it can be heard by the referring physician using any telephone. Reports can be reduced to hard copy by a typist, or an automatic typewriter can be programmed to print normal or standard reports. Time between dictation and access of the report was significantly reduced after installation of the RTAS (p less than 0.001). There was also a trend toward reduced hospital stay (p less than 0.05) for patients in the study group. The system has been readily accepted by radiologists and referring physicians.     

企业年金管理信息系统设计开发及应用

本系统是一套较为完善的企业年金管理信息系统,解决企业年金个人账户管理、投资收益分配、待遇支付管理、年金账务信息记录、查询等问题,有效防范年金运营风险,确保年金的保值增值,以互联互通安全使用为要求,调整优化管理流程,缩短办事流程,提高办公效率.     

Diagnosing pediatric epilepsy: an update for the primary care clinician

Epilepsy is a chronic disorder that first appears in childhood. Seizure types and presentation vary from dramatic and obvious to subtle and discrete. Accurate identification of the seizure type is imperative to ensure proper disease management. The International league Against Epilepsy has developed two classification systems--the classification of Epileptic Seizures and the classification of Epilepsies and Epileptic Syndromes--to assist in the provision of an International language of epilepsy, to improve the diagnosis and management of seizures, and to establish prognostic criteria. Knowledge of the classification systems of seizures, seizure types, and management of seizures is essential in the delivery of health promotion, disease prevention, and anticipatory guidance for the child with epilepsy. The primary care practitioner is often the first person consulted when medical questions or problems arise, and therefore is in a key position to detect seizures, monitor treatment, and educate the family. A comprehensive knowledge of pediatric epilepsy will allow the practitioner to provide the additional resources needed to coordinate the care of this special population.     

Health care coverage and access for children in an urban state: the New York perspective

To clarify the role of the intestine, kidney, and bone in maintaining calcium homeostasis during pregnancy and lactation and after the resumption of menses, a longitudinal comparison was undertaken of 14 well-nourished women consuming approximately 1200 mg Ca/d. Measurements were made before conception (prepregnancy), once during each trimester of pregnancy (T1, T2, and T3), early in lactation at 2 mo postpartum (EL), and 5 mo after resumption of menses. Intestinal calcium absorption was determined from the enrichment of the first 24-h urine sample collected after administration of stable calcium isotopes. Bone mineral of the total body and lumbar spine was measured by dual-energy X-ray absorptiometry and quantitative computerized tomography, respectively. Twenty-four-hour urine and fasting serum samples were analyzed for calcium, calcitropic hormones, and biochemical markers of bone turnover. Despite an increase in calcium intake during pregnancy, true percentage absorption of calcium increased from 32.9+/-9.1% at prepregnancy to 49.9+/-10.2% at T2 and 53.8+/-11.3% at T3 (P < 0.001). Urinary calcium increased from 4.32+/-2.20 mmol/d at prepregnancy to 6.21+/-3.72 mmol/d at T3 (P < 0.001), but only minor changes in maternal bone mineral were detected. At EL, dietary calcium and calcium absorption were not significantly different from that at prepregnancy, but urinary calcium decreased to 1.87+/-1.22 mmol/d (P < 0.001) and trabecular bone mineral density of the spine decreased to 147.7+/-21.2 mg/cm3 from 162.9+/-25.0 mg/cm3 at prepregnancy (P < 0.001). Calcium absorption postmenses increased nonsignificantly to 36.0+/-8.1% whereas urinary calcium decreased to 2.72+/-1.52 mmol/d (P < 0.001). We concluded that fetal calcium demand was met by increased maternal intestinal absorption; early breast-milk calcium was provided by maternal renal calcium conservation and loss of spinal trabecular bone, a loss that was recovered postmenses.     

The birds and the bees: an analysis of advice given to parents through the popular press

There is a growing need for parents to communicate with their adolescents about sexuality, as teenage pregnancies and sexually transmitted diseases are on the rise. Many parents indicate that they lack information and feel uncomfortable communicating with their children about sex. The popular press regularly publishes articles on parenting issues, including how to discuss sex. In this study, 26 articles from 1984 to 1993 were reviewed, and the tone, quality of information, and advice given to parents on how to communicate were analyzed. The articles reflected current research regarding parent-child sexual communication and provided much more detailed advice about how best to approach the topic with an adolescent. However, readership seemed to be primarily white and mothers in traditional families, and little advice was offered on how to handle more difficult issues, such as contraception and AIDS. The findings suggest that the popular press could serve as an informational vehicle for educating both youth and parents about sexuality and how to have productive discussions regarding this issue.     

The role of the triage nurse practitioner in general medical practice: an analysis of the role

A 2-year pilot study was undertaken in a group general practice to evaluate the nurse practitioner triage role. The study was undertaken in several stages which included a patient satisfaction questionnaire survey, follow-up interviews with 30 patients from the questionnaire survey, and analysis of the nurse practitioner's work at different points over the 2-year study period. This paper describes the work of the nurse practitioner in comparison with that of seven general practitioners in a group general medical practice over a 5-day period in February 1996 and included patients' perceptions of their consultation. In this particular group medical practice, as in others throughout the country, many patients request same day appointments, often for self-limiting conditions, social advice and health education. This study demonstrates that the nurse practitioner can deal with such patients effectively and is undertaking an expanded and extended role in order to provide an holistic service to patients with which they are highly satisfied. It can be concluded that given the right kind of education and training and a supportive framework within the practice, the nurse practitioner undertaking a triage role can provide a highly effective service to patients and is a valuable member of the primary health care team.     

Overview of health-related quality-of-life measures for pediatric patients: application in the assessment of pharmacotherapeutic and pharmacoeconomic outcomes

Health-related quality of life (HRQOL) is an important dimension in assessing health care. Several methodologic considerations are related to the manner in which these data are obtained in children. Few multidimensional generic measures of quality of life (QOL) have been developed for children and adolescents. Most published research concerns the development of tools to be used in a disease-specific manner for clinical trials. Although several authors point out numerous advantages in assessing HRQOL in clinical practice, several barriers must be overcome for this to occur. In the current era of economic restraint, HRQOL measures must be integrated into pharmaco-economic analyses to assess fully the impact of a drug on health care resources and outcomes.     

Meat inspection: an overview of present practices and future trends

This is a review of meat inspection literature, its history, current concerns and needs for the future. The value and limitations of meat inspection are discussed, along with the possible modifications or changes that are being developed to modernize an increasingly outdated method of safeguarding public health. The potential of on-farm risk assessment of slaughter animals and the practical considerations that need to be overcome are outlined. The needs of the consumer and subsequent challenges to the meat and farming industry are proposed as the driving force behind the changes occurring in veterinary public health. The current risk to consumers, from such microbial pathogens as Salmonella, Escherichia coli O157:H7 and Campylobacter infection, are highlighted.     

配煤过程专家控制及集散控制系统的设计和应用

介绍一个已用于焦化厂配煤过程实时控制和在线管理的具有两级结构的专家控制及集散控制系统。基于配煤和炼焦过程的统计数据及经验知识，建立了焦炭质量预测的数学西医 计算配煤比的规则模型。通过把数学模型和规则模型相结合设计了计算配煤比的专家控制。采用Ｓ９０００系列的集散控制系统，使实际的配煤比跟踪给定的配煤比。实际运行表明配煤准确率、焦炭质量稳定率和预测精度分别达到了９６％、９０％和９５％。     

ASP及其在基于Web的图书馆咨询系统中的应用

基于 Web的动态、交互式综合页面形式是图书馆咨询系统的发展方向 .通过对 ASP的结构、特点 ,以及 ASP交互访问 Web数据库方法的分析 ,提出了 ASP在基于 Web形式的图书馆咨询系统中的应用设计方案     

控冷温度命中率现场判定系统研发

为了实现控冷温度命中率的自动统计,在武钢热轧总厂中厚板分厂现有的轧后控冷系统基础上,研发了温度命中率现场判定及网络查询系统。该系统采用OPC技术现场采集数据,把现场数据计算加工后,上传到本厂的数据中心。通过架设Web服务器,对数据中心的数据进行sql查询来实现网络查询功能。此系统提高了对于控冷产品的质量监控和追溯管理,便于工艺人员根据统计数据改进工艺。     

Analytic design and clinical application of an intelligent control system for pharmacotherapy with insulin--1

To determine whether insulin dosage recommendations provided by a computer system are as effective as those given by human experts, we developed an intelligent control system and prospectively studied its use in 42 type-1 diabetics attending a diabetes education center. Control algorithms were based on blood glucose self-monitoring and included parameter estimations to determine glucose metabolism. The algorithms were implemented in a vest pocket-sized system. Over a period of 32 days, 21 patients used the computer to determine the necessary dose of insulin, while a second group of 21 patients followed the recommendations of the diabetes specialists. Baseline HbA1 levels (9.8 +/- 1.6 vs 9.9 +/- 1.6%) were identical in the two groups. The mean serum glucose over the last two weeks of the study was lower in the computer group (151.3 +/- 25.2 vs 165.7 +/- 36.0 mg/dl; p < 0.01) although the rates of hypoglycaemic episodes were equal (1.7 vs 2.3%). Metabolic control, measured by the day-to-day standard deviation of the serum glucose (46.8 +/- 14.4 vs 50.4 +/- 16.2 mg/dl; p < 0.01), was more stable in the computer group. We conclude that metabolic control and safety were comparable in the two groups, and suggest that such an intelligent control system may be of benefit for use at home, when the help of doctors or diabetes educators is not available.