Issues in patient-focused care for the respiratory care practitioner

Patient-focused care is the redesign of patient care so that personnel and resources are organized around the patient instead of departments. The reasons are many but usually involve cost reductions and improvement in the customer's perception of quality. Goals for this process include grouping patients by diagnosis, decentralizing services, and cross-training staff. The respiratory care practitioner is well prepared to fit into the patient-focused care model. Recent surveys show the impact of hospital restructuring on respiratory care to be rather positive.     

Protocols for clinical care

This paper describes the work of the DILEMMA project to provide protocol-based decision support in a variety of clinical domains. We give an outline of the generic protocol model that DILEMMA has produced, and the protocol task manager (PTM) software developed to assist protocol use in routine clinical practice. We summarise the validation of the model carried out to date, and take a quick look at the place of protocols in the wider context of clinical decision support.     

Documenting for patient-focused care

Hospitals across the country are rethinking the way health care is delivered. With a shift from inpatient to outpatient care, there is an effort to deliver quality, "patient-focused care" in the hospital setting. Multidisciplines have embarked in cross-training to provide immediate services at the bedside. The premise of "nursing" documentation is no longer feasible in multicaregiver environments. One hospital's adaptation to documentation methods to meet the needs of a patient-focused system is described.     

Managed care as a vehicle for delivering more effective chronic care for older persons

Chronic illness is now the dominant feature of health care, and its impact will grow with the aging of the population. Managed care could provide an environment conducive to better care for chronically ill patients. A precondition for these activities is a shift in Medicare payment approaches to managed care organizations to recognize differences in risk. To improve care for the chronically ill, changes need to occur in two major areas: (1) The approach to chronic care needs to become more aggressive, with higher expectations about the benefits from care (even if measured by slowing the rate of decline), and (2) an information infrastructure is needed to help focus clinicians' attention on changes in patients' status. Some of these changes may eventually evolve spontaneously in managed care's search for more efficient ways of meeting its service obligations, but external forces, such as certification and federal mandates, could catalyze the transition.     

Fundamental strategies for skin care

The Agency for Health Care Policy and Research (AHCPR) identified the need to develop clinical practice guidelines for the prevention and treatment of pressure ulcers, a segment of wound and skin diagnoses. The skin is the first line of defense in protecting the body from constant changes in the environment. Far too often, the attention needed for the skin is only realized after the integrity has been disrupted. This article examines the anatomy and physiology of the skin, factors that affect the skin (aging, bathing, cleansers, dryness, friction, lotions, moisturizers, nutrition, soaps and shearing forces), indications and contraindications of topical skin care products, and AHCPR's recommended interventions. These elements are integral to clinicians in proactively developing sound skin care prevention strategies. Yet without a thorough understanding of all components, the skin's integrity remains at risk.     

Preventive health care for children

This article discusses immunization, development, vision, blood pressure, dentition, behavioral, and environmental screening for preschool children. The authors then discuss screening for children in the early school years. Injury and violence prevention and topics of sexuality for the preadolescent are also presented.     

Strategic planning for postacute care

The author examines workable approaches and benefits of using strategic planning to prepare for future postacute care.     

Critical care for organ failure

We retrospectively studied the critical care regimen for multiple organ failure (MOF) in 141 surgical MOF patients treated in the intensive care unit of Chiba University Hospital between January 1988 and April 1998. Patients with gut failure received parenteral instead of enteral nutrition for various reasons such as concomitant ileus. Of the patients with respiratory failure. 138 were placed on a ventilator and 6 received percutaneous cardiopulmonary support. Continuous hemodiafiltration (CHDF) was performed in 98 patients with renal failure. Plasma exchange was carried out in 13 patients with liver failure. Of these patients, 62 (44%) survived. Colloid osmotic pressure was used as an indicator for fluid therapy. For prophylaxis against bacterial translocation, we performed selective digestive decontamination. Recently blood purification methods, particularly CHDF, have become common in the critical care setting. CHDF is efficacious not only as continuous renal replacement therapy but also as a humoral mediator modulator and is currently the first-choice method for blood purification in critical care. In conclusion, there have been many advances in the critical care of patients with organ failure. Multidisciplinary treatment, including artificial support for failing organs, is necessary for the survival of these patients.