Programme de soins psychiatriques : Etude de l'expérience de jeunes patients par une méthode qualitative: Psychiatric care program: A qualitative study of the experience of young patients.

OBJECTIVE: Ambulatory care without consent is widely used, but it is controversial, and its effectiveness has not yet been proven. The patient experience remains largely unstudied in France, particularly that of young patients, yet their adherence to care in the early stages of the disease is complex and has an impact on their prognoses. The aim of this study is to investigate the experience of young patients undergoing a program of care (POC) in order to suggest ways of optimizing their care and to enrich the debate on the use of POCs. METHOD: Semi-structured interviews were conducted with 11 patients between ages 20 and 32, who were either undergoing a POC or had done so in the previous 5 years, followed by a semi-pragmatic phenomenological analysis of the resulting transcripts. RESULTS: (1) The outpatient experience with restraints is contradictory, ranging from deprivation and intrusion to support and protection. (2) The POC is portrayed as a framework for developing awareness of disorders and acceptance of care. (3) Patients report a lack of information about care with restraints, even to the point of being unaware of its existence. Patient-psychiatrist interactions within the POC are complicated by the restraints, but remain perceived as a care relationship. (4) They report constraints in their daily lives in connection to the POC, which can complicate professional involvement. CONCLUSION: The results support the importance of nurturing the therapeutic relationship within the POC and involving patients more in their care, starting with better information. They support the use of POCs as a temporary tool to be combined with work on adherence to treatment and support for social and professional reintegration. SPECIALTY: Psychiatry.

OBJECTIF: Les dispositifs de soins ambulatoires sans consentement sont largement utilisés, mais ils sont controversés et leur efficacité n'est pas prouvée à ce jour. L'expérience des patients concernés reste très peu étudiée en France, et notamment celui des jeunes patients, or leur adhésion aux soins en début de maladie est complexe et a un impact sur le pronostic futur. L'objectif est d'étudier l'expérience de jeunes patients suivis en programme de soins (PDS) afin de proposer des perspectives pour optimiser leur prise en charge et d'enrichir la réflexion sur l'utilisation des PDS. MÉTHODE: Des entretiens semi-directifs ont été réalisés auprès de 11 patients de 20 à 32 ans suivis en PDS ou l'ayant été dans les 5 dernières années, puis une analyse phénoménologique de type sémio-pragmatique a été réalisée sur les verbatims obtenus. RÉSULTATS: (1) L'expérience de la contrainte en ambulatoire est contrastée avec un vécu de privation de libertés et d'intrusion, mais aussi de soutien et de protection. (2) Le PDS est représenté comme un cadre permettant l'évolution de la conscience des troubles et de l'acceptation des soins. (3) Les patients rapportent un manque d'information sur les modalités de soins sous contrainte, pouvant aller jusqu'à la méconnaissance de l'existence de cette mesure. Les interactions patient-psychiatre au sein du PDS sont complexifiées par la contrainte mais restent perçues comme une relation de soin. (4) Ils rapportent des contraintes dans la vie quotidienne liées au PDS et qui peuvent compliquer l'insertion professionnelle. CONCLUSION: Les résultats soutiennent l'importance de soigner la relation thérapeutique au sein du PDS et d'impliquer davantage le patient dans sa prise en charge, en commençant par une meilleure information. Ils soutiennent une utilisation du PDS comme un outil temporaire à associer à un travail sur l'adhésion aux soins et à un accompagnement à la réinsertion sociale et professionnelle. SPÉCIALITÉ: Psychiatrie.

Housing Status as a Predictor for Outpatient Care Following an Emergency or Urgent Care Encounter with a Behavioral Health Diagnosis: A Multivariable Analysis.

Individuals without stable housing experience high rates of mental illness and seek behavioral health care in emergency care settings. Little is known about the effect of homelessness on outpatient follow-up after utilizing emergency or urgent care for behavioral health care. Patient encounters with behavioral health diagnoses among 7 emergency department (ED) or urgent care (UC) locations over 4 years were used to determine the correlation between housing status and outpatient follow-up within 90 days. Of 1,160,386 visits by 269,615 unique patients, 55,738 (23%) encounters included a behavioral health diagnosis. Patients with stable housing were twice as likely to follow up with a primary care provider (PCP) and with an outpatient behavioral health provider than patients without housing (aOR 2.60; aOR 2.00, p < 0.0001). Homelessness is associated with difficulty in accessing follow-up behavioral health care. UCs and EDs may use specific interventions to improve outpatient follow-up.

[SaxoForN-a transregional primary care research network in Dresden and Frankfurt am Main : Design of a practice-based research infrastructure]. / SaxoForN ­ Transregionales allgemeinmedizinisches Forschungspraxennetz Dresden und Frankfurt am Main : Konzept einer innovativen Forschungspraxeninfrastruktur.

Establishing primary care research networks (PCRNs) makes it easier to conduct clinical trials and health services research in a general-practice setting. Since February 2020, the German Federal Ministry of Education and Research (BMBF) has sponsored the development of six PCRNs and a coordination unit throughout Germany, with the aim of setting up a sustainable outpatient research infrastructure to raise the quantity and quality of primary care.The present article describes the design of a PCRN in Dresden and Frankfurt am Main - SaxoForN - and explains its structure and how it operates. The network is a transregional alliance between the two regional PCRNs named "SaxoN" (Dresden/Saxony) and "ForN" (Frankfurt am Main/Hesse), both of which run transregional and local research projects. For this purpose, joint standards and harmonized structures, for example with respect to the data infrastructure, qualifications, participation, and accreditation, were agreed upon and implemented at both sites.A critical success factor will be whether and to what extent the standards and structures, as well as resource planning, can be designed sustainably enough to permit the PCRNs to carry out high-quality research over the long term. To achieve this, the PCRNs will have to attract new practices and build up lasting relationships with them, qualify the research practices in order to standardize processes as far as possible, and regularly document their basic information and healthcare data.

[BeoNet-Halle-development of a multifunctional database for the automated extraction of healthcare data from general practitioner and specialist practices]. / BeoNet-Halle ­ Aufbau einer multifunktionalen Datenbank zur automatisierten Extraktion von Versorgungsdaten aus Haus- und Facharztpraxen.

The Beobachtungspraxennetzwerk Halle (BeoNet-Halle) is an innovative database of outpatient care that has been collecting patient data from participating primary care and specialty practices throughout Germany since 2020 and making it available for research and care. The database is set up and maintained by the Institute of Medical Epidemiology, Biometrics and Informatics and the Institute of General Practice and Family Medicine of the Martin Luther University Halle-Wittenberg. Furthermore, the Data Integration Center of the University Medical Center Halle is involved in the project. In principle, anonymized and pseudonymized patient data from all commercially available practice management systems should flow into the databases.In this article, we describe the structure and methods of the multi-purpose database BeoNet and quantify the current data stock. The workflow of collection, transfer, and storage of broad consents is described and advantages and limitations of the database are discussed.BeoNet-Halle currently contains anonymized data of approximately 73,043 patients from five physician practices. Furthermore, it includes data from more than 2,653,437 ICD-10 diagnoses, 1,403,726 prescriptions, and 1,894,074 laboratory results. Pseudonymized data were successfully exported from 481 patients.BeoNet-Halle enables an almost seamless representation of the care provided in the participating practices. In the future, the database will map patient treatment pathways across practices and provide high-quality care data to contribute to health policy decision-making and optimization of care processes.

[Impact of the COVID-19 pandemic above a universal electronic consultation program (e-consultation) between general practitioners and cardiologists]. / Impacto de la pandemia por COVID-19 sobre un programa de consulta electrónica universal (e-consulta) entre médicos de Atención Primaria y cardiólogos.

Blackground and objective: Virtual healthcare models, usually between healthcare professionals and patients, have developed strongly during the coronavirus disease 2019 (COVID-19) pandemic, but there are not data of models between clinicians. Our objective is to analyse the impact of the COVID-19 pandemic on the activity and health outcomes of the universal e-consultation program for patient referrals between primary care physicians and the Cardiology Department in our area. Methods: Patients with at least one e-consultation between 2018 and 2021 were selected. We analysed the impact of the COVID-19 pandemic on activity and waiting time for care, hospitalizations and mortality, taking as a reference the consultations carried out during 2018. Results: We analysed 25,121 patients. Through logistic regression analysis, it was observed that a shorter delay in care and resolution of the e-consultation without the need for face-to-face care were associated with a better prognosis. The COVID-19 pandemic periods (2019-2020 and 2020-2021) were not associated with worse health outcomes compared to 2018. Conclusions: The results of our study show a significant reduction in e-consult referrals during the first year of the COVID-19 pandemic with a subsequent recovery in the demand for care without the pandemic periods being associated with worse outcomes. The reduction in the time elapsed for solving the e-consult and no need for in-person visit were associated with better outcomes.

How to implement person-centred care and support for dementia in outpatient and home/community settings: Scoping review.

BACKGROUND: Little prior research focused on person-centred care and support (PCCS) for dementia in home, community or outpatient care. We aimed to describe what constitutes PCCS, how to implement it, and considerations for women who comprise the majority of affected persons (with dementia, carers). METHODS: We conducted a scoping review by searching multiple databases from 2000 inclusive to June 7, 2020. We extracted data on study characteristics and PCCS approaches, evaluation, determinants or the impact of strategies to implement PCCS. We used summary statistics to report data and interpreted findings with an existing person-centred care framework. RESULTS: We included 22 studies with qualitative (55%) or quantitative/multiple methods design (45%) involving affected persons (50%), or healthcare workers (50%). Studies varied in how PCCS was conceptualized; 59% cited a PCC definition or framework. Affected persons and healthcare workers largely agreed on what constitutes PCCS (e.g. foster partnership, promote autonomy, support carers). In 4 studies that evaluated care, barriers of PCCS were reported at the affected person (e.g. family conflict), healthcare worker (e.g. lack of knowledge) and organizational (e.g. resource constraints) levels. Studies that evaluated strategies to implement PCCS approaches were largely targeted to healthcare workers, and showed that in-person inter-professional educational meetings yielded both perceived (e.g. improved engagement of affected persons) and observed (e.g. use of PCCS approaches) beneficial outcomes. Few studies reported results by gender or other intersectional factors, and none revealed if or how to tailor PCCS for women. This synthesis confirmed and elaborated the PCC framework, resulting in a Framework of PCCS for Dementia. CONCLUSION: Despite the paucity of research on PCCS for dementia, synthesis of knowledge from diverse studies into a Framework provides interim guidance for those planning or evaluating dementia services in outpatient, home or community settings. Further research is needed to elaborate the Framework, evaluate PCCS for dementia, explore determinants, and develop strategies to implement and scale-up PCCS approaches. Such studies should explore how to tailor PCCS needs and preferences based on input from persons with dementia, and by sex/gender and other intersectional factors such as ethnicity or culture.

Hygiene management for long-term ventilated persons in the home health care setting: a scoping review.

BACKGROUND: Evidence and recommendations for hygiene management in home mechanical ventilation (HMV) are rare. In Germany, few regionally limited studies show poor hygiene management or a lack of its implementation. This scoping review of international literature identified the evidence in hygiene management for ventilated patients in the home care setting which has to be implemented for infection prevention and control. METHODS: A review of international literature was conducted in CINAHL, PubMed and Web of Science. The search focused on four key domains: HMV, hygiene management, home care setting, and methicillin-resistant Staphylococcus aureus (MRSA). Data of included studies were extracted using a data charting sheet. Extracted data were assigned to the categories (1) study description, (2) setting and participants, and (3) hygiene management. RESULTS: From 1,718 reviewed articles, n = 8 studies met inclusion criteria. All included studies had a quantitative study design. The approaches were heterogeneous due to different settings, study populations and types of ventilation performed. Regarding aspects of hygiene management, most evidence was found for infectious critical activities (n = 5), quality management for hygiene (n = 4), and training and education (n = 4). This review identified research gaps concerning kitchen hygiene, relatives and visitors of HMV patients, and waste management (n = 0). DISCUSSION: Overall evidence was rather scarce. Consequently, this review could not answer all underlying research questions. No evidence was found for measures in hygiene management relating to ventilated patients' relatives. Evidence for kitchen hygiene, waste management and interaction with relatives is available for inpatient care settings. However, this may not be transferable to outpatient care. Binding legal requirements and audits may help regulate the implementation of HMV hygiene measures. CONCLUSION: Infection control programmes included qualified personnel, hygiene plans, and standards for MRSA and multidrug-resistant organisms (MDRO). The appropriateness of hygiene management measures for outpatient care is the basis for their application in practice.

Where the public health principles meet the individual: a framework for the ethics of compulsory outpatient treatment in psychiatry.

BACKGROUND: Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment (COT) in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT. MAIN BODY: The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002-2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT. CONCLUSION: Ross Upshur's principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice.

Examining the critical role of advanced practice providers on a multidisciplinary transplant team.

It is well documented that Physician Assistants (PAs) and Nurse Practitioners (NPs), collectively known as Advanced Practice Providers (APPs), have a beneficial role beyond the field of primary care. APPs broad spectrum of knowledge make them particularly well suited for specializing in complex fields such as transplant. Variations in practice across transplant centers lead to questions regarding optimal use of APPs. Using job descriptions from transplant centers currently employing APPs, we sought to examine the critical role of transplant APPs beyond clinical care alone. In this review, we explore not only the general training of APPs and current utilization of APPs in transplant, but also safety, cost effectiveness, and comparison of APPs to other transplant providers. We aimed to highlight the importance of recruitment and retention of transplant specific trained APPs to provide continuity in transplant programs. Additionally, APPs expansion into transplant research, quality improvement, leadership, and management must be considered. We challenge transplant centers utilizing APPs to consider these important aspects when seeking ways to expand and optimize the critical role APPs provide on the transplant team.

When do physicians perceive the success of a new care model differently?

BACKGROUND: The health care innovation "MamBo - people with multimorbidity in outpatient care: patient-focused and needs-oriented healthcare management" aims to improve the efficiency and quality of care for multimorbid patients by delegating tasks (e.g. taking over house calls or coordinating specialist appointments) to a monitoring and coordination assistant (MoniKa). Participating physicians are very important for the success of the health care innovation due to their direct involvement as practitioners and their task of enrolling patients. The aim of this part of the evaluation study is therefore to identify the physicians' personal values, which influence the individual perception of the project's advantages and thus possibly the acceptance and sustainable implementation of new care structures. METHODS: Two Focus groups (n = 4; n = 6) and three individual interviews with general practitioners and specialists who decided to implement the health care innovation within the first year were conducted. The semi-structured guidelines were developed by the research team. The interviews were analysed according to the content analysis by Mayring. We used the learning model of operant conditioning to place our study results in a theoretical context. RESULT: Two central personal values of the participants, which determine the desired advantages of the health care innovation were identified: More patient-oriented and more economic-oriented values. Participants with more patient-oriented values quickly perceived advantages, which seems to be beneficial for the acceptance of the new care structures. Economic-oriented participants tended to be more critical. The benefits of the health care innovation, which was expressed, for example, in an improvement of the practice routine, has not yet been perceived by this group, or only to a limited extent. CONCLUSIONS: The results suggest that the respective values of the participants define the individual perceived advantages and thus, the assessment of the success of the health care innovation in general. These findings could be used in the implementation process by increasing the motivation of the project participants through typified supervision. TRIAL REGISTRATION: The study has been registered in the German Clinical Trials Register ( DRKS00014047 ).

[The impact of the COVID-19 pandemic on first-line primary care in southeastern France: Feedback on the implementation of a real-time monitoring system based on regional health insurance data]. / L'impact de l'épidémie de COVID-19 sur les soins de premier recours en région Provence-Alpes-Côte d'Azur : retour d'expérience sur la mise en place d'un dispositif de surveillance en temps réel à partir des données régionales de l'Assurance maladie.

BACKGROUND: Starting in spring 2020, the COVID-19 pandemic markedly impacted the French healthcare system. Lockdown and risks of exposure to the coronavirus induced patients to modify their ways of use. The objective of this article was to share feedback on the implementation of a real-time monitoring system concerning (a) the activity of private practitioners in southeastern France, and (b) the evolution of reimbursements for drugs prescribed to persons with diabetes, for treatment of mental health disorders, and for performance of some vaccines. METHODS: Data regarding 2019 and 2020 were extracted from regional health insurance databases. They were used to elaborate several indicators relative to the general health insurance scheme, which were calculated and updated each week, starting with week 2. RESULTS: We observed a drop in private physician activity during the lockdown (-23% for general practitioners; -46% for specialist doctors), followed by a return to a semblance of normalcy. Concomitantly, a boom in teleconsultations occurred: at the height of the crisis they represented 30% of medical acts. The initial stage of the lockdown was characterized by peak provisioning for drugs, whereas vaccination strongly declined (-39% regarding measles, mumps and rubella vaccine among children aged less than 5 years; -54% regarding human papillomavirus vaccine among girls aged 10 to 14 years). CONCLUSION: The COVID-19 pandemic could lead to health effects other than those directly attributable to the coronavirus itself. Renouncing care may result in healthcare delays highly deleterious for people and society. Public authorities are preoccupied with these questions; they have set up action plans aimed at encouraging patients to seek treatment without delay. That said, the COVID-19 pandemic crisis has also created opportunities, such as the expansion of telemedicine. Although partial, these indicators can provide useful information enabling public decision makers to be reactive and to implement specific actions to meet the health needs of the population.

Economic evaluation of a reduced dosage of ready-to-use therapeutic foods to treat uncomplicated severe acute malnourished children aged 6-59 months in Burkina Faso.

Ready-to-use therapeutic foods (RUTF) used to treat children with severe acute malnutrition (SAM) are costly, and the prescribed dosage has not been optimized. The MANGO trial, implemented by Action Contre la Faim in Burkina Faso, proved the non-inferiority of a reduced RUTF dosage in community-based treatment of uncomplicated SAM. We performed a cost-minimization analysis to assess the economic impact of transitioning from the standard to the reduced RUTF dose. We used a decision-analytic model to simulate a cohort of 399 children/arm, aged 6-59 months and receiving SAM treatment. We adopted a societal perspective: direct medical costs (drugs, materials and staff time), non-medical costs (caregiver expenses) and indirect costs (productivity loss) in 2017 international US dollar were included. Data were collected through interviews with 35 caregivers and 20 informants selected through deliberate sampling and the review trial financial documents. The overall treatment cost for 399 children/arm was $36,550 with the standard and $30,411 with the reduced dose, leading to $6,140 (16.8%) in cost savings ($15.43 saved/child treated). The cost/consultation was $11.6 and $9.6 in the standard and reduced arms, respectively, with RUTF accounting for 56.2% and 47.0% of the total. The savings/child treated was $11.4 in a scenario simulating the Burkinabè routine SAM treatment outside clinical trial settings. The reduced RUTF dose tested in the MANGO trial resulted in significant cost savings for SAM treatment. These results are useful for decision makers to estimate potential economic gains from an optimized SAM treatment protocol in Burkina Faso and similar contexts.

Outpatient Telehealth Implementation in the United States during the COVID-19 Global Pandemic: A Systematic Review.

Background and objectives: Ambulatory (outpatient) health care organizations continue to respond to the COVID-19 global pandemic using an array of initiatives to provide a continuity of care and related patient outcomes. Telehealth has quickly become an advantageous tool in assisting outpatient providers in this challenge, which has also come with an adaptation of U.S. government policy, procedures, and, as a result, organizational protocols surrounding the delivery of telehealth care. Materials and methods: This systematic review identified three primary facilitators to the implementation and establishment of telehealth services for the outpatient segment of the United States health care industry: patient engagement, operational workflow and organizational readiness, and regulatory changes surrounding reimbursement parity for telehealth care. Results: Researchers identified three barriers impacting the implementation and use of telehealth resources: patient telehealth limitations, lack of clinical care telehealth guidelines, and training, technology, and financial considerations. Conclusions: This systematic review's identified facilitators and barriers for telehealth implementation initiatives in the United States can assist future outpatient providers as the global pandemic and associated public health initiatives such as physical distancing continue.

Waiting time for outpatient specialist care in Lombardy Region: evaluating accessibility and quality of information on websites of public health agencies and healthcare structures.

BACKGROUND: Waiting time for outpatient specialist care is an ever-present problem for all Countries with a universal healthcare system. In Italy, information about waiting times must be available on all websites belonging to public health agencies and healthcare structures. The aim of the present descriptive study is to evaluate the accessibility and quality of such information on websites of all public health agencies and healthcare structures in Lombardy Region. METHODS: All websites belonging to 8 health agencies (ATS), 27 public hospitals (ASST), 4 research and teaching hospitals (IRCCS) were analyzed using a newly designed 30-item checklist. The items were scored 0/1 and grouped in five categories: Accessibility, Architecture, Content, Interactivity, Utility. RESULTS: In all, 76.3% of websites reported their waiting times directly, but three did not update data at least monthly as required by current legislation. Less than half of websites provided information aimed at raising awareness and tackling no-shows, and only 10.5% explained the role of private practice in public structures when maximum waiting times are exceeded. CONCLUSIONS: The lack of exposition of waiting times on some websites belonging to ATS, ASST and IRCCS appears to be a relevant issue. There is also little empowering information that may help tackle waiting times themselves. These results warrant further efforts to improve accessibility, quality and transparency of information for all citizens.

Targeting Zero Infections in the Outpatient Dialysis Unit: Core Curriculum 2020.

Although overall mortality rates in dialysis patients have improved during the last decade or so, infections remain a leading cause of death, second only to cardiovascular disease. In addition, infections account for a major share of hospitalizations in this patient population. Receiving hemodialysis treatments in an outpatient dialysis facility significantly contributes to patients' risks for infection. In dialysis units, patient-to-patient transmission of viral pathogens such as hepatitis B virus, hepatitis C virus, and human immunodeficiency virus can occur; proper screening and vaccination of patients can decrease the risk for transmission. Strict adherence to hand hygiene, use of appropriate personal protective equipment, transmission-based precautions, and maintaining aseptic technique while connecting the access to the hemodialysis machine can substantially decrease the likelihood of bacterial infections. With an effective infection control program in place, infection prevention becomes part of the dialysis facility's culture and results in improved patient safety. In this installment of the Core Curriculum series, we highlight best practices that should be followed by health care workers in the dialysis unit and discuss the role of the medical director in promoting initiatives to reduce infection rates.

Wie Pflegekräfte im ambulanten Bereich den Einsatz von Telepräsenzsystemen einschätzen - Eine qualitative Studie.

How nurses assess telepresence systems in outpatient care. A qualitative study Abstract. Background: Robotic assistance devices are reviewed as being promising technological developments in healthcare to assist elderly patients and to foster autonomy in their home environment as long as possible. Also, telepresence systems (tps) currently in use to facilitate several nursing tasks are reviewed under the same perspective. AIM: The study aims to describe how nurses estimate the use of a tps in outpatient care. METHOD: After a presentation of a tps, focus groups of nurses (n = 4) in Saxony-Anhalt discussed freely on possible applications, concerns and potential of the system in outpatient care. The analysis followed the documentary method developed by Bohnsack, Nentwig-Gesemann & Nohl (2007). RESULTS: The tps presented was considered rather unsuitable for practical application in outpatient care. As main reasons nurses voiced theirs and patients' lack of technical competence; limited mobility functions of the device; ethical and financial concerns. The opportunity to intensify contact between patients and relatives was considered very positive. Faster contact in case of emergency as well as nurse supervised intake of medication were considered as important further practical applications of the device. CONCLUSIONS: Tps are not suitable yet for practical implementation in outpatient care. Acquiring appropriate technical knowledge during nursing education programs can help nurses to participate in the engineering development process this way increasing the potential of such devices and more in general can help nurses to handle more easily further technical innovations in healthcare.

Day clinic vs. hospital care of pneumonia and severe malnutrition in children under five: a randomised trial.

OBJECTIVES: To evaluate the clinical outcomes and costs of managing pneumonia and severe malnutrition in a day clinic (DC) management model (outpatient) vs. hospital care (inpatient). METHODS: Randomised clinical trial where children aged 2 months to 5 years with pneumonia and severe malnutrition were randomly allocated to DC or inpatient hospital care. We used block randomisation of variable length from 8 to 20 and produced computer-generated random numbers that were assigned to one of the two interventions. Successful management was defined as resolution of clinical signs of pneumonia and being discharged from the model of care (DC or hospital) without need for referral to a hospital (DC), or referral to another hospital. All the children in both DC and hospital received intramuscular ceftriaxone, daily nutrition support and micronutrients. RESULTS: Four hundred and seventy children were randomly assigned to either DC or hospital care. Successful management was achieved for 184 of 235 (78.3%) by DC alone, vs. 201 of 235 (85.5%) by hospital inpatient care [RR (95% CI) = 0.79 (0.65-0.97), P = 0.02]. During 6 months of follow-up, 30/235 (12.8%) in the DC group and 36/235 (15.3%) required readmission to hospital in the hospital care group [RR (95% CI) = 0.89 (0.67-1.18), P = 0.21]. The average overall healthcare and societal cost was 34% lower in DC (US$ 188 ± 11.7) than in hospital (US$ 285 ± 13.6) (P < 0.001), and costs for households were 33% lower. CONCLUSIONS: There was a 7% greater probability of successful management of pneumonia and severe malnutrition when inpatient hospital care rather than the outpatient day clinic care was the initial method of care. However, where timely referral mechanisms were in place, 94% of children with pneumonia and severe malnutrition were successfully managed initially in a day clinic, and costs were substantially lower than with hospital admission.

OBJECTIFS: Evaluer les résultats cliniques et les coûts de la prise en charge de la pneumonie et de la malnutrition sévère dans un modèle de prise en charge en clinique de jour (CJ) (patients ambulatoires) par rapport à des soins hospitaliers (patients hospitalisés). MÉTHODES: Essai clinique randomisé où les enfants âgés de 2 mois à 5 ans avec une pneumonie et une malnutrition sévère ont été répartis de façon aléatoire en CJ ou à des soins hospitaliers. Nous avons utilisé la randomisation par blocs de longueur variable de 8 à 20 et avons généré des nombres aléatoires par ordinateur qui ont été attribués à l'une des deux interventions. Une prise en charge réussie a été définie comme la résolution des signes cliniques de pneumonie et la sortie du modèle de soins (CJ ou hospitalisation) sans nécessiter un transfert à un hôpital (CJ), ni à un autre hôpital. Tous les enfants du bras CJ et du bras soins hospitaliers ont reçu de la ceftriaxone par voie intramusculaire, un soutien nutritionnel quotidien et des micronutriments. RÉSULTATS: 470 enfants ont été assignés aléatoirement soit à des soins en CJ ou hospitaliers. Une prise en charge réussie a été obtenue pour 184 patients sur 235 (78,3%) en CJ seule contre 201 sur 235 (85,5%) en soins hospitaliers [RR (IC95%) = 0,79 (0,65 - 0,97), p = 0,02]. Au cours des six mois de suivi, 30/235 (12,8%) du groupe CJ et 36/235 (15,3%) du groupe soins hospitaliers ont nécessité une réadmission à l'hôpital [RR (IC95%) = 0,89 (0,67 - 1,18), p = 0,21]. Le coût moyen global des soins de santé et pour la société était de 34% plus faible dans le groupe CJ (188 ± 11,7 USD) que dans le groupe soins hospitaliers (285 ± 13,6 USD) (p < 0,001) et les coûts pour les ménages étaient de 33% inférieurs. CONCLUSIONS: La probabilité d'une prise en charge réussie de la pneumonie et de la malnutrition sévère était 7% plus élevée lorsque les soins hospitaliers plutôt que les soins en CJ étaient les moyens initiaux. Cependant, là où des mécanismes de référence rapides étaient en place, 94% des enfants atteints de pneumonie et de malnutrition sévère ont été pris en charge avec succès dans une clinique de jour et les coûts étaient nettement inférieurs à ceux de soins hospitaliers.

Nursing interventions in adult psychiatric outpatient care. Making nursing visible using the Nursing Interventions Classification.

AIM: To describe and to clarify the work of nurses in psychiatric outpatient care using a standardized nursing terminology and to describe the potential benefits and challenges in the use of the terminology. DESIGN: A qualitative study of ethnographically grounded fieldwork in four adult outpatient units located in three major cities in Finland. METHODS: A two-phase ethnographically oriented study, consisting of observations and focus group interviews in four psychiatric outpatient care units (in January-March 2018). During this process, the identified nursing interventions were mapped into the Nursing Interventions Classification. RESULTS: We identified 93 different nursing interventions, covering all seven domains. Categories describing potential benefits and challenges were as follows: giving words to nurses' work and the challenge of overlapping interventions. CONCLUSION: Our findings indicate that the Nursing Interventions Classification is a suitable means to describe nursing in the psychiatric outpatient care setting. Our findings support the theory that describing nurses' work using a nursing terminology can make nursing visible and further empower nurses and help them to structure their work. The lack of other professionals, especially physicians, has led to nurses taking over new tasks officially and unofficially and we suggest that the issue needs to be studied further. IMPACT: Nurses' role in the psychiatric outpatient care has been described as invisible and difficult to describe. Our findings suggest that a nursing terminology can make nursing visible, not only from the perspective of patient health records but is also a way to conceptualize nurses' work.

[Antibiotic therapy in Bielefeld (AnTiB)-a local project for the promotion of rational antibiotic prescribing in the outpatient pediatric sector]. / Antibiotische Therapie in Bielefeld (AnTiB) ­ Ein lokales Projekt zur Förderung der rationalen Verordnung von Antibiotika in der ambulanten Kinder- und Jugendheilkunde.

BACKGROUND: Antimicrobial resistance is an increasing problem - a consequence of uncritical use, especially of "last-resort" antibiotics. Approaches towards a more rational use of antibiotics have so far focused on the inpatient sector, whereas the majority of antibiotics are prescribed in the outpatient sector. Therefore, there is demand for innovative approaches for the latter sector. The project Antibiotic Therapy in Bielefeld ("AnTiB"), founded in 2016 by pediatricians active in the outpatient pediatric sector, developed respective structures and measures at the local level. OBJECTIVES: The development of local recommendations, suitable for everyday practice, for antibiotic prescription in frequent infectious conditions, are described. MATERIALS AND METHODS: In order to develop these recommendations, evidence from the literature and practice guidelines was collected. In a structured process, mainly via quality circles, the contents were consented locally and then put under external expert review. Together with the Association of Statutory Health Insurance Physicians of Westphalia-Lippe (KVWL), antibiotic prescription data were collected exemplarily for 2016. RESULTS: The first version of the respective pediatric recommendations was published in January 2017. Meanwhile, comparable recommendations for outpatient gynecologists and adult GPs were released. Antibiotic prescription data from 2016 show an important spread of antibiotic prescription prevalences in general as well as with respect to single agent classes. CONCLUSIONS: Locally consented practical recommendations may contribute to a local "culture" of antibiotic prescription behavior. The pediatric recommendations locally have so far gained good coverage and high acceptance. Transfer to other regions or medical disciplines seems possible and reasonable. In the future, the effects of such projects on the prescription behavior will be measurable by the comparison of prescription data.

[Telemedicine in heart failure]. / Telemedizin bei Herzinsuffizienz.

Improved outpatient care of heart failure patients is considered crucial to avoiding unplanned cardiovascular hospitalizations and reducing mortality. Making up for regional and rural differences in heart failure care poses a further challenge. Telemedical care as a supplement to outpatient point-of-care medicine by the general practitioner and medical specialist is considered relevant to implementing this goal. This article presents the technical and organizational basics of telemedical methods in outpatient heart failure care. Current evidence on the efficacy of telemedical co-management is also explained based on the results from the nine most important randomized studies on telemedicine in heart failure. Particular attention is paid to the TIM-HF2 study published in 2018, which showed the superiority of telemedical co-management in terms of mortality and morbidity following recent hospitalization for heart failure. Pre-stratified subgroup analysis revealed no significant interactions in terms of the primary endpoint between urban and rural regions. Scalability is required in order to translate the telemedical study concept from TIM-HF2 to a nationwide care program for all patients in Germany. Telemed5000 is the first project to set its goal as the development of a telemedicine center for the telemedical co-management of up to 5000 patients using artificial intelligence. It is being funded by the Federal Ministry of Economics and Technology for the period 2019-2022.