End of life care for people with dementia: The views of health professionals, social care service managers and frontline staff on key requirements for good practice.

BACKGROUND: Evidence consistently shows that people with advanced dementia experience suboptimal end of life care compared to those with cancer; with increased hospitalisation, inadequate pain control and fewer palliative care interventions. Understanding the views of those service managers and frontline staff who organise and provide care is crucial in order to develop better end of life care for people with dementia. METHODS AND FINDINGS: Qualitative interviews and focus groups were conducted from 2013 to 2015 with 33 service managers and 54 staff involved in frontline care, including doctors, nurses, nursing and care home managers, service development leads, senior managers/directors, care assistants and senior care assistants/team leads. All were audio recorded and transcribed verbatim. Participants represented a diverse range of service types and occupation. Transcripts were subject to coding and thematic analysis in data meetings. Analysis of the data led to the development of seven key themes: Recognising end of life (EOL) and tools to support end of life care (EOLC), Communicating with families about EOL, Collaborative working, Continuity of care, Ensuring comfort at EOL, Supporting families, Developing and supporting staff. Each is discussed in detail and comprise individual and collective views on approaches to good end of life care for people with dementia. CONCLUSIONS: The significant challenges of providing good end of life care for people with dementia requires that different forms of expertise should be recognised and used; including the skills and knowledge of care assistants. Successfully engaging with people with dementia and family members and helping them to recognise the dying trajectory requires a supportive integration of emotional and technical expertise. The study strengthens the existing evidence base in this area and will be used with a related set of studies (on the views of other stakeholders and observations and interviews conducted in four services) to develop an evidence-based intervention.

How to set up a robotic-assisted laparoscopic surgery center and training of staff.

The use of computers to assist surgeons in the operating room has been an inevitable evolution in the modern practice of surgery. Robotic-assisted surgery has been evolving now for over two decades and has finally matured into a technology that has caused a monumental shift in the way gynecologic surgeries are performed. Prior to robotics, the only minimally invasive options for most Gynecologic (GYN) procedures including hysterectomies were either vaginal or laparoscopic approaches. However, even with over 100 years of vaginal surgery experience and more than 20 years of laparoscopic advancements, most gynecologic surgeries in the United States were still performed through an open incision. However, this changed in 2005 when the FDA approved the da Vinci Surgical Robotic Systemtm for use in gynecologic surgery. Over the last decade, the trend for gynecologic surgeries has now dramatically shifted to less open and more minimally invasive procedures. Robotic-assisted surgeries now include not only hysterectomy but also most all other commonly performed gynecologic procedures including myomectomies, pelvic support procedures, and reproductive surgeries. This success, however, has not been without controversies, particularly around costs and complications. The evolution of computers to assist surgeons and make minimally invasive procedures more common is clearly a trend that is not going away. It is now incumbent on surgeons, hospitals, and medical societies to determine the most cost-efficient and productive use for this technology. This process is best accomplished by developing a Robotics Program in each hospital that utilizes robotic surgery.

Percepção de enfermeiros sobre utilização do protocolo do sistema de classificação de risco Manchester / Nurses perception on the use of the Manchester risk classification system protocol

O estudo teve como objetivo analisar a percepção de enfermeiros sobre o protocolo do sistema de Classificação de Risco Manchester. Pesquisa qualitativa descritiva, realizada em outubro de 2012, por meio de entrevistas semiestruturadas com 15 enfermeiros do Serviço de Emergência de um hospital universitário da região sul do Brasil. Os dados foram submetidos à análise temática. Os resultados indicam que o protocolo do Sistema de Classificação de risco de Manchester padroniza a conduta dos profissionais, conferindo segurança para priorizar o risco de usuários que buscam atendimento em serviços de emergência. Além disso, propicia respaldo legal aos profissionais, baseando-se em critérios objetivos e previamente definidos. As dificuldades apontadas para a realização da atividade foram: o desconhecimento da população sobre o protocolo, a precariedade do fluxo de encaminhamento para a rede de serviços de saúde e a resistência da equipe médica a um trabalho conjunto. Conclui-se que a utilização do protocolo do sistema de classificação de Manchester propiciou melhoria na organização do fluxo de usuários no serviço de emergência e na qualidade do atendimento prestado.

The study aimed to analyze the perceptions of nurses regarding the Manchester Risk Classification System Protocol. It is a qualitative descriptive research, accomplished in October 2012, by means of semi-structured interviews with 15 emergency service nurses of a university hospital in southern Brazil. The data were submitted to a thematic analysis. The results indicate that the Manchester Risk Classification System Protocol standardizes the conduct of professionals, giving security to prioritize the risk of users who seek care at emergency services. In addition, it provides legal support to professionals, based on objective and previously defined criteria. The pointed out difficulties for the accomplishment of the activity were: the unawareness of the population about the Protocol, the precariousness of the stream of referrals to the network of health services and medical staff resistance to joint work. It is concluded that the use of the Manchester Risk Classification System Protocol led to improvement in organizing the flow of users in emergency services and in the quality of the provided service.

Valuing and selling a practice.

Surgeons, as they contemplate retirement, wrongly believe that their practices do not have financial value. In fact, a well-organized efficiently functioning office with an emphasis on excellent service in combination with a constant stream of patients make it financially ideal for the new surgeon. Being able to assume such a practice can be a very smart financial decision. The practice's worth can be determined by a careful analysis of the practice financials and an evaluation of the functioning of the office and employees. Purchasing such a practice can be, economically, a very smart move by a new surgeon. Payments are made over time at a rate that allows the surgeon to make a good living, leaving him with real equity once the payments are complete. The departing surgeon, who had spent years building this successful practice, gets some of this value back in the form of an income stream to supplement his retirement. This process should be considered in virtually every case. Do not just "close the door."

How to create high-performing teams.

This article is intended to discuss inspirational aspects on how to lead a high-performance team. Cogent topics discussed include how to hire staff through methods of "topgrading" with reference to Geoff Smart and "getting the right people on the bus" referencing Jim Collins' work. In addition, once the staff is hired, this article covers how to separate the "eagles from the ducks" and how to inspire one's staff by creating the right culture with suggestions for further reading by Don Miguel Ruiz (The four agreements) and John Maxwell (21 Irrefutable laws of leadership). In addition, Simon Sinek's concept of "Start with Why" is elaborated to help a leader know what the core element should be with any superior culture.

Campus physicians' tobacco interventions with university students: a descriptive study of 16 Ontario university clinics.

OBJECTIVE: About one-quarter of Canadian post-secondary students smoke cigarettes. We examined how physicians from Ontario university health clinics intervene with these young adult smokers. METHOD: A convenience sample of 16 universities was identified and surveys were hand-delivered to all 228 physicians from these schools. A total of 125 doctors (54.82%) responded; 70 were from universities that were involved in a government-sponsored, coordinated, multi-campus, tobacco control initiative. RESULTS: Twenty percent of doctors reported asking all or almost all patients about tobacco use; 25.22% asked fewer than half. Describing how they respond to patients identified as smokers, 96.00% of physicians advised cessation, 72.00% offered assistance, and 64.00% arranged for follow-up. Doctors discussed patients' tobacco use with 78.59% of smokers. Nicotine replacement therapies were rarely offered to patients wanting to quit. Doctors from universities involved in the tobacco control initiative were more likely to keep patient education materials in the examining room. CONCLUSION: Because most doctors ask only some patients about tobacco use, they may be missing opportunities to provide appropriate advice and assistance to all smokers. PRACTICE IMPLICATIONS: Physician education and support to the clinic are needed to improve the frequency and quality of physician-delivered smoking cessation services to post-secondary students.

Provider perceptions of limited health literacy in community health centers.

OBJECTIVE: To examine techniques used by community health center (HC) providers to care for patients with limited health literacy (LHL). METHODS: Survey mailed to 803 HC providers in 10 Midwestern states. Response rate was 47.5%. Associations between variables were examined using generalized estimating equations (GEE) models to account for clustering of respondents within HCs. RESULTS: The average provider estimates of LHL prevalence among English- and Spanish-speaking patients were 41+/-24% (mean+/-S.D.) and 48+/-30%, respectively. Those with training in health literacy were more likely to have patients repeat instructions back to check understanding (OR=2.05 and p=0.04) and were more likely to give out health education materials designed for patients with LHL (OR=2.80 and p=0.0002). Providers differed by type in encouraging patients to bring friends or family members to appointments (p=0.02). CONCLUSION: Providers estimate LHL to be highly prevalent in their HCs, and use various techniques to assist patients. PRACTICE IMPLICATIONS: Training in health literacy is associated with increased usage of evidence-based techniques to assist patients with LHL. Providers at all levels would likely benefit from LHL training. Most providers believe providing health education materials designed specifically for patients with LHL would be very helpful.

From cure to palliation: agreement, timing, and decision making within the staff.

Important issues in the transition from curative treatment to palliative care are agreement, timing, and decision making. A survey of 309 nurses and 415 physicians in Sweden showed that 61% of the nurses and 83% of the physicians thought agreement was current practice. None said that the decisions were made too early, but 19% of the nurses and 14% of the physicians thought that they often were made too late. Very few respondents stated that such decisions are changed, 0% and 1%, respectively. More than half of the informants made detailed comments on such transitions indicating that awareness and flexibility are desirable to make well-informed decisions. Three themes that emerged from the analysis concerning the decision to stop curative treatment and focus on palliative care were that the staff members should (if possible) make such decisions in agreement and should sometimes make the decisions earlier and that well-based reasons are required to make changes.

A patient satisfaction survey of a nurse-led colorectal clinic.

A new service was set up to achieve government targets to see patients with signs or symptoms of a possible colorectal cancer within two weeks of referral from their GP. The new clinics were nurse-led. A patient satisfaction survey was used to assess patients' opinions about the clinic. The results showed patients had a positive view of the clinic.

The management of adverse clinical events in nursing homes: a 1-year survey study.

OBJECTIVE: In Italian nursing homes (NHs), care delivery at night and during holidays is not regulated by regional laws; some facilities employ staff physicians, others employ physicians engaged from year to year (temporary physicians), and others employ publicly funded National Health System (NHS) physicians. This study was designed to determine whether the use of different kinds of physicians leads to different outcomes with regard to the rate of hospitalization and appropriateness of the management of adverse clinical events. DESIGN: Prospective, nonrandomized-survey data collection. SETTING: Ten nonprofit nursing facilities in Italy. PARTICIPANTS: Three hundred and fifty-two NH residents, staff physicians, temporary physicians, and NHS physicians. MEASUREMENTS: Medical intervention during adverse clinical events occurring at night and during holidays. RESULTS: Three hundred and fifty-two residents experienced 551 adverse clinical events; 78 were hospitalized. The hospitalization rate of NHS physicians was about two times that of the temporary physicians and six times that of the staff physicians. Staff physicians' diagnoses and management were appropriate in the majority of cases; NHS diagnosis and management were doubtful or incorrect in about one-third of all cases. CONCLUSIONS: NH residents frequently experience adverse clinical events; physician characteristics influence the rate of hospitalization and the quality of medical interventions.

Model for optimal space and staff efficiency in an otolaryngology clinic.

Maximizing efficiency of staff and resources is one method of reducing costs without affecting quality. Using a methodology similar to that used to maximize efficiency of airline-gate use, we developed a model with which to evaluate nursing support staff and clinical examining-room resources in a general otolaryngology clinic. For 144 patients over 7 consecutive clinic days, with four otolaryngologists and various combinations of support staff and examining rooms, we measured space and staff resource use, including total clinic time, number of patients seen, patient waiting time, physician and nurse productivity, and examining-room use. A simulation model was used as the medium of analysis to define parameters of the patient encounter. We identified optimal efficiency when there were three examining rooms and one and one-half nursing staff per physician or five examining rooms and three nursing staff for two simultaneously practicing physicians. Compared with a model of two rooms and one nursing staff member, our ideal model increased the percentage of the physicians' time spent in direct contact with patients from 84% to 92%. Visit length decreased from 81 minutes to 57 minutes, the average time from check-in to examination decreased from 47 to 16 minutes, and it became possible for three additional patients to be seen each day. Additional rooms and support staff, in comparison with the optimally efficient distribution, did not significantly affect these parameters. Maximizing efficiency with the use of this methodology can decrease waiting times for patients, resulting in greater patient satisfaction, improved physician productivity, total number of patients seen, and increased total contact time between physicians and patients.

[Work losses of medical personnel of mobile health units while conducting preventive examinations in rural populations]. / Trudovye zatraty meditsinskogo personala pri provedenii profilakticheskikh osmotrov se'lskogo naseleniia v vyezdnykh usloviiakh.

An algorithm and related nomograms used for the determination of labour losses of medical staff while carrying out prophylactic medical examinations of the rural population under field conditions are described.