Developing a patient self-medication program for the rehabilitation setting

Imaging methods provide an important diagnostic basis to clarify mesenteric ischemia. Angiography is the definitive method of investigation in such cases. Other noninvasive methods such as ultrasonography, computed tomography, and magnetic resonance imaging must still prove their importance. We describe three cases of unspecific abdominal pain where the CT shows a mesenteric venous thrombosis with an infarcted bowel. The venous infarcted bowel is clearly demonstrated by CT when other signs for MTV such as ascites, bowel wall thickening, bowel dilatation, and pneumatosis intestinalis are present. CT seems to be a good procedure in order to identify unspecific abdominal pain as being caused by a vascular insufficiency.     

A computer education program to improve physician awareness of rehabilitation hospital charges

OBJECTIVE: To quantify physician knowledge of hospital charges and determine if computer fiscal feedback would improve physician awareness of hospital charges. DESIGN: Comparison of physicians' knowledge of hospital charges before and 6 months after the instigation of a computer feedback educational program. PARTICIPANTS AND SETTING: All physicians (attendings, residents, and fellows) at a large academic rehabilitation hospital. INTERVENTION: After surveying physicians' knowledge of hospital charges, the billing fees for some items were placed on the computer ordering menu so that these charges were viewed when orders were made by physicians. MAIN OUTCOME MEASURES: Error in physician charge estimates before and after computer education program, and physician confidence in charge estimates. RESULTS: The baseline survey found that physicians had poor awareness of hospital charges, regardless of ordering frequency, relative charge for the item, or physician experience. Physicians expressed little confidence in their knowledge of the charges and were twice as likely to underestimate than to overestimate charges. Six months after the implementation of a computer feedback educational program, improvement was seen in the awareness of hospital charges for all imaging studies and most laboratory tests. Fiscal awareness of items that had not been included in the computer feedback also showed some small improvement. Physicians' confidence in their knowledge of fees improved. Physicians indicated the program was beneficial and should be expanded to include fiscal information on more services. CONCLUSIONS: Immediate computer feedback of hospital charges improves physicians' fiscal awareness and may lead to their practice of more cost-efficient medicine.     

The emergency physician and patient confidentiality: a review

Confidentiality is a promise rooted in tradition, law, and medical ethics. Emergency physicians treat a variety of patients to whom confidentiality is of vital importance: employees, celebrities, victims of violence or disaster, minors, students, criminals, drug abusers, and patients with STDs. EDs should develop methods of ensuring confidentiality for all patients. Although confidentiality is an important principle that should be respected and guarded, it is not absolute. Various laws mandate disclosure of certain patient information; in addition, an overriding moral duty may occasionally require a breach of confidentiality. As Beauchamp and Childress noted, "the therapeutic role may sometimes have to yield to one's role as citizen and as protector of the interests of others." In general, however, circumstances requiring a breach of confidentiality are rare.     

Developing a comprehensive maltreatment intervention program

A questionnaire was sent to a one in five sample (68 GPs) of General Practitioners (GPs) in Argyll and Clyde Health Board to determine attitudes to standard setting in hypertension and the response rate was 80.7% (55 GPs). Thirty-six GPs (65.4%) stated that they would be interested in sharing care with a consultant who had an interest in the subject and 27 GPs (49.1%) stated that they would be interested in taking part in an educational audit of their hypertensive patients. The results of the study suggest that it would be possible to obtain broad agreement among GPs on standards for diagnosis, treatment and appropriate indications for hospital referral in the management of hypertension but in order to develop consensus further it would be necessary to carry out a more detailed study using a larger cohort of GPs.     

Physician recommendations and patient autonomy: finding a balance between physician power and patient choice

Medical care in the United States has rapidly moved away from a paternalistic approach to patients and toward an emphasis on patient autonomy. At one extreme end of this spectrum is the "independent choice" model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician's exercise of power and influence inevitably diminishes the patient's ability to choose freely. It sacrifices competence for control, and it discourages active persuasion when differences of opinion exist between physician and patient. This paper proposes an "enhanced autonomy" model, which encourages patients and physicians to actively exchange ideas, explicitly negotiate differences, and share power and influence to serve the patient's best interests. Recommendations are offered that promote an intense collaboration between patient and physician so that patients can autonomously make choices that are informed by both the medical facts and the physician's experience.     

Rational drug design approach for overcoming drug resistance: application to pyrimethamine resistance in malaria

Pyrimethamine acts by selectively inhibiting malarial dihydrofolate reductase-thymidylate synthase (DHFR-TS). Resistance in the most important human parasite, Plasmodium falciparum, initially results from an S108N mutation in the DHFR domain, with additional mutation (most commonly C59R or N51I or both) imparting much greater resistance. From a homology model of the 3-D structure of DHFR-TS, rational drug design techniques have been used to design and subsequently synthesize inhibitors able to overcome malarial pyrimethamine resistance. Compared to pyrimethamine (Ki 1.5 nM) with purified recombinant DHFR fromP. falciparum, the Ki value of the m-methoxy analogue of pyrimethamine was 1.07 nM, but against the DHFR bearing the double mutation (C59R + S108N), the Ki values for pyrimethamine and the m-methoxy analogue were 71.7 and 14.0 nM, respectively. The m-chloro analogue of pyrimethamine was a stronger inhibitor of both wild-type DHFR (with Ki 0.30 nM) and the doubly mutant (C59R +S108N) purified enzyme (with Ki 2.40 nM). Growth of parasite cultures of P. falciparum in vitro was also strongly inhibited by these compounds with 50% inhibition of growth occurring at 3.7 microM for the m-methoxy and 0.6 microM for the m-chloro compounds with the K1 parasite line bearing the double mutation (S108N + C59R), compared to 10.2 microM for pyrimethamine. These inhibitors were also found in preliminary studies to retain antimalarial activity in vivo in P. berghei-infected mice.     

Initiating a patient service partner program

Rising costs and the need to increase patient satisfaction are driving hospitals to restructure care delivery. At one hospital, housekeeping, food service and nurse technician duties are combined to form one nurse-extender role: the Patient Service Partner (PSP). Findings about patient and nurse satisfaction before and after implementation show that nurses agreed that the PSP program improved patient care delivery and helped control costs. Patients reported the same or higher rating of satisfaction with various aspects of their hospitalization. Call lights were answered more quickly and attitudes of personnel answering the lights were more positive. Nurses are finding more time for patient education and documentation.     

Developing and implementing a community intergenerational program

Although intergenerational programs are becoming increasingly popular, there has been little documentation linking independent yet isolated seniors with children. This article discusses the development and implementation of a community intergenerational program. Elementary school students interacted with seniors at a nearby senior citizen apartment complex during eight 2-hr after-school meetings. Various recruitment strategies were needed to reach this vulnerable senior population, and activities had to be carefully monitored to promote intergenerational exchange. Evaluation of the program showed both the value of such interaction to the students and seniors and the importance of the nurse's role in ensuring that the program's benefits were realized.     

Interpreting educational concepts for the teaching family physician: some parallels between patient care and undergraduate clinical education

Three of the most widely used concepts in education, objectives, curriculum, and evaluation, have direct parallels in primary care. This parallelism suggests an approach which may help family physicians both in understanding these educational concepts and in applying them with judgment. By drawing specific attention to the parallels and by the use of examples drawn both from clinical practice and from teaching, the author hopes to encourage physicians to view their teaching as an analog of clinical skills that are already familiar to them. This approach is applied to the problem of accommodating to individual differences in students, the most difficult obstacle to the proper application of educational concepts.     

The impact of a high dependency unit continuing education program on nursing practice and patient outcomes

Most evaluation studies of continuing education (CE) programs have concentrated on the assessment of learner knowledge and satisfaction and/or learner perceptions of change in professional competence and patient care, rather than on actual changes in nursing practice and patient outcomes. This study aimed to measure and compare frequency of nursing interventions and patient outcomes before and after a high-dependency (HD) CE program. A retrospective review of all HD patient records (n = 92) over the same 2-month periods in 1994 (n = 39) and 1995 (n = 53) was undertaken. Outcome variables were measured by assessing the incidence of cardiorespiratory complications, HD patient admission rates to critical care areas and process measures of nursing interventions with predetermined practice patterns. The before and after groups of patients were similar in age (mean 69 years), severity of illness (mean APACHE II = .12) and HD length of stay (mean 2.6 days). While the average number of critical events per patient was similar in both groups (before 2.03; after 1.96), complications resulting from critical events were 8 per cent fewer in the after group. The implementation and documentation of appropriate nursing interventions improved by 30 per cent following the introduction of the CE program (chi 2 = 25.53, df = 1, p < 0.001, 95 per cent CI 0.1804 to 0.4196, point estimate 0.3). The study revealed that there was a strong association between implementing the HD CE program and improved nursing practice. This may be related to the observed improvement in patient outcomes.     

Developing a CQI program in a family medicine department

BACKGROUND: Efforts to implement continuous quality improvement (CQI) principles in ambulatory or primary care settings still lag behind efforts in the hospital setting. Many physicians view the concept of CQI with unconcealed skepticism; the process of ambulatory care is very different from that of hospital-based care; and the data necessary to guide CQI efforts are often either missing or inaccurate in the outpatient setting. Since fall 1995, the Department of Family Medicine (DFM) at the University of Michigan (Ann Arbor), including approximately 35 faculty members at seven family practice sites, has been engaged in CQI projects. PLANNING AND IMPLEMENTATION: The CQI committee had a six-month deadline to lay out a plan for educating all faculty and staff in the importance of the CQI approach to problems; design methods for all faculty and staff to buy in to the concepts; and develop a plan to address basic clinical CQI activities, administrative systems change and work environment improvement, and larger ad hoc projects in clinical care, educational programs, and research programs. IMPLEMENTATION: CQI activities were incorporated into the routine monthly business agendas at each clinical site, each of which had a functioning local committee and had begun development of at least one CQI project. PROJECTING INTO THE FUTURE AND CONCLUSIONS: Cost cutting has further moved CQI from the sideline to center stage in the DFM's activities. An effective CQI program can be a major asset in the current competitive health care market, but designing and implementing an outpatient CQI program is a difficult and complex process. Three major problems--the ongoing resistance to change, the slow pace of adding CQI projects to already overburdened work schedules, and the need to conduct the program with ever-decreasing resources available-persist.     

Understanding and overcoming parent resistance to play therapy.

Explores the nature and sources of parent resistance to play therapy, questions the concept of resistance as it is often understood, and suggests ways the play therapist can prevent or overcome it, addressing common mistakes therapists make that actually increase client resistance. It is stated that play therapist's own attitudes and the therapist–parent relationship can be used to overcome resistance that might interfere with therapeutic progress. Showing respect and empathy for parents can go far in creating a trusting collaborative therapeutic relationship that is needed for optimum outcomes. Similarly, helping parents see the connections between their problems and the course of therapy being recommended can make it easier for them to engage as partners in the process of change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Implementing and evaluating a patient instructor program

A Patient Instructor (PI) program designed to improve students' data-gathering and interpersonal skills is evaluated. Each student in two consecutive classes of third-year students (class of 1996, n = 60; class of 1997, n = 72) interviewed four patient instructors (PIs) during a three-hour rotation. Each PI portrayed one of six scenarios. PIs assessed students using content checklists and an abbreviated Arizona Clinical Interview Rating Scale (ACIR). After the interview, each PI gave student constructive feedback regarding interpersonal behavior and ability to identify salient content items from the patient's history. Significant improvement was observed on content checklists (p < 0.01) between the first and second rounds. Significant improvement was also noted on the ACIR (p < 0.01) between rounds one, two and three. The results indicate that data-gathering and interpersonal skills can be enhanced by using patient instructors. Student evaluation of the program was positive.