A Nurse-Led Care Program for Breast Cancer Patients in a Chemotherapy Day Center: A Randomized Controlled Trial.

BACKGROUND: Healthcare providers are facing the challenge of helping cancer patients cope with the impact of outpatient-based chemotherapy. A nurse-led care program was proposed to address this challenge. OBJECTIVE: The aim of this study was to examine the effects of a nurse-led care program for patients receiving outpatient-based chemotherapy. METHODS: This was a single-center, open-label, 2-arm parallel trial with equal randomization (NCT02228200). Breast cancer patients in Hong Kong were randomly allocated to the intervention arm or the control arm. The control arm received routine hospital care. The intervention arm received the nurse-led care plus the routine hospital care. The quality of life, self-efficacy, symptom distress levels, and satisfaction with care were evaluated with questionnaires before randomization (T0), in the middle of chemotherapy (T1), and 1 month after chemotherapy (T2). Individual interviews were conducted with some participants in the intervention arm at T2. RESULTS: The intervention arm participants reported significantly lower distress levels from oral problems, fatigue, peripheral neuropathy, distressful feelings, and higher satisfaction with care. According to the satisfaction evaluation and the interviews, the participants stated that the service was helpful in providing information and communication opportunities, filling the service gap after drug administration, providing psychological support, relieving discomfort, and building confidence. CONCLUSION: Breast cancer patients received support from the provision of comprehensive, continuous, and individualized care. IMPLICATIONS FOR PRACTICE: The nurse-led care program could be applied to breast cancer patients in other hospitals in Hong Kong. Exploring its applicability to cancer settings in other countries is recommended.

Throughput efficiency and service quality after process redesign at a cancer day care unit: Two sides of the coin?

This study was designed to focus on the patient perspective in a reorganisation of care processes at a cancer day care unit (CDU). The effects of dose banding and of taking blood samples one day (or more) before the day care treatment (on Day -1) are investigated in terms of throughput efficiency and perceived service quality. Data were collected by mapping patient processes in detail and surveying patients in two CDUs at a university hospital (n = 308). A univariate model was used to investigate the effect of these factors on patient throughput time, and perceived service quality was examined with multiple linear regression. Taking blood samples on Day -1 decreases patient throughput time and increases the perceived service quality by improving the patient's perception of technical expertise and the outcome. This has a globally positive effect on patients' perceived service quality. Dose banding affected neither patient throughput time nor perceived service quality. Taking the pretreatment blood sample on Day -1 can be considered an important process design characteristic, as it increases both efficiency and service quality.

A simple care bundle to reduce unplanned admission rate for day case pediatric circumcision.

BACKGROUND: An electronic review of unplanned day case admission rates in our hospital demonstrated an average annual rate for pediatric circumcision of 2%-3% in recent years with high levels of perioperative strong opiate use. This lay above target unplanned admission rates (<2%) set out by the Royal College of Anaesthetists for day case surgery. A targeted quality improvement initiative was undertaken to improve patient flow through the pediatric day case surgery unit for elective circumcision. Among the reasons for unplanned admission, factors modifiable by the anesthetist (pain, postoperative nausea and vomiting, somnolence) are significant contributors. METHODS: A prospective audit was undertaken over a 3-month period. Our practice was compared with evidence-based analgesic and antiemetic interventions in accordance the Association of Paediatric Anaesthetists of Great Britain and Ireland. Perioperative strong opiate administration rates occurred in 44% of cases. Four strategic interventions were selected based on quality of evidence, ease of implementation, and low cost: selection of higher concentration local anesthetic use for penile blocks, intravenous dexamethasone, and preoperative paracetamol combined with maximum dose nonsteroidal anti-inflammatory. RESULTS: The audit was duplicated a year later demonstrating a significant increase in application of these interventions with a parallel fall in strong opiate use from 44% to 9% and an unprecedented zero unplanned admission rate in our unit for 10 months in a row after implementation. CONCLUSION: Regular scrutiny of patient electronic data helps identify high impact areas for audit and intervention. Unplanned admission in pediatric day case surgery is an area amenable to such targeted intervention.

[Observational study of outpatient unit duration of stay depending on the route of administration (intravenous vs subcutaneous) for a targeted therapy]. / Étude observationnelle du temps passé en hôpital de jour selon la voie d'administration (intraveineuse vs sous-cutanée) d'une thérapie ciblée.

New routes of administration available for some targeted therapies, especially subcutaneous injections, have an impact not only on the patients' daycare experience, but also on the unit's organization. This observational study conducted on 48 voluntary patients at the Institut universitaire du cancer Toulouse-Oncopole shows that the mean duration of the outpatient unit stay is diminished by one hour when a subcutaneous injection is used instead of an intravenous route. This duration decrease is mainly caused by an 82% average reduction in treatment duration. However, the waiting times before and after the treatment itself are not significantly impacted. Organizational methods related to the treatment prescription and preparation remain indeed the same. Anticipated prescription is not noticeably impacted either. This reduction of the duration of stay will truly be obtained if the whole unit's organization is adapted.

Day hospital and psychosocial care center: Expanding the discussion of partial hospitalization in mental health.

INTRODUCTION: Since the second half of the twentieth century the discussions about mental patient care reveal ongoing debate between two health care paradigms: the biomedical/biopsychosocial paradigm and the psychosocial paradigm. The struggle for hegemony over the forms of care, on how to deal optimally with the experience of becoming ill is underpinned by an intentionality of reorganizing knowledge about the health/disease dichotomy, which is reflected in the models proposed for the implementation of actions and services for the promotion, prevention, care and rehabilitation of human health. OBJECTIVE: To discuss the guidelines of care in mental health day hospitals (MHDH) in contrast to type III psychosocial care centers (CAPS III). METHOD: Review of mental health legislation from 1990 to 2014. RESULTS: A definition of therapeutic project could not be found, as well as which activities and techniques should be employed by these health services. CONCLUSION: The MHDH and PCC III are services that replace psychiatric hospital admission and are characterized by their complementarity in the care to the mentally ill. Due to their varied and distinctive intervention methods, which operate synergistically, the contributions from both models of care are optimized. Discussions on the best mental health care model reveal polarization between the biomedical/biopsychosocial and psychosocial paradigms. This reflects the supremacy of the latter over the former in the political-ideological discourse that circumscribes the reform of psychiatric care, which may hinder a better clinical outcome for patients and their families.

Day hospital and psychosocial care center: Expanding the discussion of partial hospitalization in mental health / Hospital-dia e Centro de Atenção Psicossocial: ampliando o debate da internação parcial em saúde mental

Summary Introduction: Since the second half of the twentieth century the discussions about mental patient care reveal ongoing debate between two health care paradigms: the biomedical/biopsychosocial paradigm and the psychosocial paradigm. The struggle for hegemony over the forms of care, on how to deal optimally with the experience of becoming ill is underpinned by an intentionality of reorganizing knowledge about the health/disease dichotomy, which is reflected in the models proposed for the implementation of actions and services for the promotion, prevention, care and rehabilitation of human health. Objective: To discuss the guidelines of care in mental health day hospitals (MHDH) in contrast to type III psychosocial care centers (CAPS III). Method: Review of mental health legislation from 1990 to 2014. Results: A definition of therapeutic project could not be found, as well as which activities and techniques should be employed by these health services. Conclusion: The MHDH and PCC III are services that replace psychiatric hospital admission and are characterized by their complementarity in the care to the mentally ill. Due to their varied and distinctive intervention methods, which operate synergistically, the contributions from both models of care are optimized. Discussions on the best mental health care model reveal polarization between the biomedical/biopsychosocial and psychosocial paradigms. This reflects the supremacy of the latter over the former in the political-ideological discourse that circumscribes the reform of psychiatric care, which may hinder a better clinical outcome for patients and their families.

Resumo Introdução: desde a segunda metade do século XX, as discussões em torno da assistência ao doente mental revelam o debate, ainda inacabado, entre dois paradigmas de atenção à saúde: o paradigma biomédico/biopsicossocial e o paradigma psicossocial. A luta pela hegemonia sobre as formas do cuidado, sobre a melhor maneira de lidar com a experiência do adoecimento, subjaz a uma intencionalidade de reorganização dos saberes sobre o binômio saúde/doença, que se reflete nos modelos propostos para a execução das ações e serviços de promoção, prevenção, assistência e reabilitação da saúde humana. Objetivo: problematizar as diretrizes do cuidado do Hospital-dia em Saúde Mental (HDSM) em contraste com o Centro de Atenção Psicossocial tipo III (CAPS III). Método: revisão da legislação em saúde mental entre 1990-2014. Resultados: não foi encontradas a definição de projeto terapêutico e as atividades e técnicas que devem ser empregadas por esses serviços de saúde. Conclusão: o HDSM e o CAPS III são serviços substitutivos à internação hospitalar psiquiátrica que se caracterizam pela complementaridade na atenção ao doente mental. Pelos seus variados e distintos métodos de intervenção, em ação sinérgica, potencializam-se com as contribuições tanto de um modelo quanto do outro modelo de atenção. As discussões em torno do melhor modelo de atenção em saúde mental mostram-se polarizadas entre os paradigmas biomédico/biopsicossocial e psicossocial, condição que reflete a supremacia do segundo sobre o primeiro no discurso político-ideológico que circunscreve a reforma da assistência psiquiátrica, fato que pode prejudicar o desfecho clínico para o paciente e sua família.

[Structural quality in inpatient and daycare child and adolescent psychiatry- indicators for planning future staff ratios for the era following the Psychiatry Personnel Act]. / Strukturqualität in der stationären und teilstationären Kinder- und Jugendpsychiatrie.

The German Psychiatry Personnel Act, which went into effect in 1990, has led to a decrease in the number of child and adolescent psychiatry inpatient beds, to a decrease in the length of stay, and to an increase in inpatient psychotherapy. Today, this act is outdated~ for a number of reasons, such as changes in the morbidity of the population, the rising number of emergencies, and new professional standards such as documentation. In addition, new legal provisions and conventions (like the UN Convention on the Rights of the Child) necessitate a complete reevaluation. Child and adolescent psychiatry needs a normative act to enable the necessary implementation. Many different rationales are available to support the debate.

[Palliative care day hospital and nursing coordination]. / L'hôpital de jour de soins palliatifs et la coordination infirmière.

The palliative care day hospital is still underdeveloped in France, unlike in Anglo-Saxon countries. Its main mission is to help improve the quality of life at home of the patient suffering from a serious and progressive disease. It offers an inter-disciplinary and global approach in which the nurse's role is quite specific.

Promoting collaboration between hospice and palliative care providers and adult day services for individuals with intellectual and developmental disabilities.

While end-of-life issues are increasingly gaining more attention, people with intellectual and developmental disabilities (IDD) continue to receive significantly less consideration in research, education, and clinical practice compared with the general population. This is a growing concern especially since the sheer number of persons aging with IDD is expected to double in the next 17 years. Furthermore, policies are shifting to reflect a preference for home and community-based services as an alternative to institutionalization, and it becomes evident that adult day services (ADS) may be ideal settings for receipt of end-of-life care, especially among individuals with IDD. However, end-of-life care and advance planning most commonly occur in long-term care settings for the general population and have historically been less of a priority in ADS and residential services for people with IDD. This article discusses the attitudes of, and collaboration between, ADS and end-of-life providers for aging adults including persons with IDD and explores how ADS may be a great pathway for delivering end-of-life care to the IDD population. Implications and recommendations will also be examined.

[The Quality of Inpatient Treatment of Elderly with Major Depression]. / Die Qualität der stationären Versorgung von Menschen mit Depressionen im Alter.

OBJECTIVE: There are highly effective treatments either in inpatient or day hospital settings available for elderly with major depression. It is important to consider some specific needs of elderly people (e. g. higher somatic comorbidities). METHODS: On the base of a large routine data set (139 307 patients in hospital treatment) differences between elderly and younger people with major depression are investigated. RESULTS: Elderly with major depression receive significantly less day hospital treatment and psychotherapy. Surprisingly, the mean length of hospital stay was significantly longer in younger patients with major depression. CONCLUSION: The results from such routine data should be interpreted with caution. Never the less our results suggest that there is still room for improvement for elderly people with major depression.

Differences in adult day services center characteristics by center ownership: United States, 2012.

KEY FINDINGS: Data from the National Study of Long-Term Care Providers. In 2012, 40% of the 4,800 adult day services centers were for-profit entities, serving nearly one-half of the 272,300 center participants. About 60% of adult day services centers used a standardized tool to screen for cognitive impairment, and about 20% used a standardized tool for depression screening. A greater percentage of for-profit than nonprofit centers used these tools. More than one-half of adult day services centers provided skilled nursing, therapeutic, and social work services, while less than one-half of centers provided mental health, pharmacy, and dental services. With the exception of social work services, a greater percentage of for-profit than nonprofit centers provided these services. Almost all adult day services centers provided daily transportation to and from the center. The most recent data estimate that 4,800 adult day services centers nationwide serve nearly a quarter million participants daily (1). Unlike other long-term care providers, such as nursing homes, home health agencies, hospices, and residential care communities, the majority of adult day services centers are nonprofit (1). However, for-profit ownership of adult day services centers appears to be increasing, from 27% in 2010 to 40% in 2012 (2). Using data from the National Study of Long-Term Care Providers, this report presents national estimates for characteristics of adult day services centers in 2012 and compares them by type of center ownership.

Should alternatives to conventional hospitalisation be promoted in an era of financial constraint?

BACKGROUND: Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow-up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded. MATERIALS AND METHODS: Narrative review. RESULTS: The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost-effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital-at-home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness. CONCLUSIONS: Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.

'I am closer to this place'--space, place and notions of home in lived experiences of hospice day care.

In the United Kingdom hospice day care services are the fastest growing yet least researched of the palliative care services. Using photo-elicitation interviews with 11 day care patients attending a specialist hospice day care setting we explored their experiences of the hospice as a place and how these changed over time. Informed by concepts from existential and humanistic geography we propose three existential modes of being--Drifting, Sheltering and Venturing--which characterize the patients' lived experiences of the hospice. Our phenomenological analysis shows that the hospice is (re)constructed purposefully to achieve a sense of 'home' and 'homelikeness', creating an important therapeutic landscape for patients.

The management pattern carried out in a cataract surgery day ward.

PURPOSE: To evaluate the management practice and process of a cataract surgery day ward. METHODS: From January to December in 2012, a portion of the cataract patients were evaluated for the pattern of day ward management. Methods were as follows: 1) Establish the cataract day ward. 2) Enroll the patients who met the following criteria: voluntary, local residents or outsiders who stayed in a hotel near the hospital, accompanied by family, and who had simple senile cataract without any systemic major diseases. 3) Establish the hospitalization process. 4) Analyze the nursing process. After cataract day surgery, the patients were followed for 2 hours and completed a questionnaire about their needs and sentiments. RESULTS: A total of 3971 cases were observed in this study; 49 cases were switched to a normal pattern of hospitalization because of operative complications, 1 case had a strong desire to switch to a normal pattern of hospitalization because of ocular discomfort, 8 cases went back to the hospital for treatment because of ocular pain, and 52 cases called on the phone to seek help. Overall, 3820 cases(96.2%) returned on time the next day to visit the doctor. No patients showed severe postoperative complications and 98% expressed great satisfaction with the day ward process. Only 200 cases expressed great concern about not knowing how to deal with postoperative pain, the changes in condition outside the hospital, the therapeutic effects, and the problem of expense reimburse-ment. CONCLUSION: Day ward cataract surgery is an efficient and safe mode, and has the potential to relieve the demand for inpatient beds and to ensure timely treatment of the patients. In addition, it helps the patients enjoy health care at public expense, reserving reimbursement for those who need to be hospitalized. Nurses should pay more attention to systemic evaluation of the patients, health education, and psychological guidance, and keep in close communication with doctors, which is the key to ensure the safety of day ward practice.

[Day-care hospitalisation in the dermatology departments of French university hospitals]. / Organisation et activité des hôpitaux de jour des services de dermatologie des CHU en France : étude transversale prospective.

BACKGROUND: Day hospital is a unit allowing the provision of several services together in a single day such as complex or specific therapy, or investigations requiring the services of different technical departments. This paper describes the structure and activity of dermatological day hospitals within French university hospitals (CHU). PATIENTS AND METHODS: A transverse prospective study was performed over a 2-week period in 2009 based on a first questionnaire which assessed the organisation and structure of the day hospitals (one questionnaire per day hospital unit), while the second assessed the activity of the day hospitals (one questionnaire for each patient attending day hospitals) throughout the period covered by the survey. RESULTS: Twenty-eight of the 44 dermatology French university hospital day centres responded to the survey (participation rate: 63 %). Six had access to shared day hospital facilities while the 22 others had dedicated dermatology facilities. The day hospital unit was part of a national reference centre in 13 of 24 cases. The median number of beds per day-hospital structure was six for a median of eight patients admitted per day and 1500 sessions recorded each year. On average, the teams comprised two full-time doctors, two nurses, 1.25 hospital workers and one secretary. The mean number of administrative documents generated per unit each week was 57. There were 793 admissions to day hospitals throughout the survey period, for examinations in 61 % of cases and for treatment in 37 % of cases. Fifteen percent of patients were seen without prior arrangement for a variety of intercurrent events. The mean amount of doctor's time devoted to each patient was 25 min. Among the main diseases seen at dermatology day hospitals, we noted cancer (44 % of admissions, 322 cases), psoriasis (7 % of admissions, 54 cases) and chronic wounds (5 % of admissions, 43 cases). DISCUSSION: Dermatology day hospitals serve to provide treatment for complex or costly diseases requiring a variety of specialised laboratory examinations in a single unit all at one time. A considerable workload is generated, particularly in medical and administrative terms. These are well-adapted structures with their own staff, a selection of technical means and upstream scheduling allowing multidisciplinary patient management. Day hospitals meet a real need in dermatology.

[Dermatology day-care: between official rules and reality]. / Hôpital de jour de dermatologie : entre circulaire frontière et réalité

BACKGROUND: Official rules published in 2006 and 2010 concerning ambulatory care rates in France led to artificial redistribution of this activity from day-care hospitalization to consultations. In our dermatological day-care establishment, we compared the financial costs engendered for patients admitted for day-care hospitalization and those seen at consultations. PATIENTS AND METHODS: From 2011/01/10 to 2011/02/04, for each patient, we prospectively analyzed the following data: day-care hospitalization or consultation, age, sex, diagnosis, laboratory and radiological examination, non-dermatological consultations, time spent with the patient by doctors (interns, senior doctors) and nurses, with timing by a stop-watch. The hospital cost was the total for medical examinations (official nomenclature), non-dermatological consultations, physicians' and nurses' salaries and establishment overheads (216 €). The hospital revenue regarding the consultation group consisted of the sum of reimbursement for medical examination, dermatological and non-dermatological consultations, and regarding the day-care hospitalization group, the dermatology rate (670 €) or chemotherapy sessions (380 €). Results were compared using a Chi(2) test and a Student's t-test (P ≤ 0.05). RESULTS: One hundred and twenty-seven patients were included: 67 in the day-care hospitalization group and 60 in the consultation group. Patients in the day-care hospitalization group were older and had significantly more radiological examinations and non-dermatological consultations, but the number of laboratory examinations and skin biopsies did not differ between the two groups. The mean time spent by doctors was similar in both groups but the time spent by senior doctors without the help of interns was significantly greater and longer than the time for a standard consultation. Nurses spent a mean 72 minutes with each hospitalized patient and 35 minutes with consultation patients (P = 0.007). Hospital costs were identical in both groups at around 415 €. The hospital showed a profit for day-care hospitalization patients (252 €) and a loss (244 €) for consultation patients. DISCUSSION: Half of the patients studied were in day-care hospitalization and half were seen in consultations. The high number of bed-ridden patients with bullous pemphigoid accounts for the fact that day-care patients were older. The reasons for the significantly longer time spent by nurses with day-care hospitalized patients were administration and supervision of chemotherapy, skin care and nursing of bed-ridden patients. However, nurses spent 35 min with each consultation patient, justifying the need to maintain the posts of these staff in such day-care units. The availability of physicians for patients with severe dermatoses and the organization of medical examinations in the same place in the same day underscore the need for medical structures like day-care hospitalization. At present, time spent on intellectual work involving reflection is regrettably not taken into account, which is detrimental to this specialty. The hospital was in profit for day hospitalizations while consultations resulted in losses, in particular because of the absence of social security reimbursement of the establishment's overheads. CONCLUSION: Rules are in need of modification in order to allow the treatment of patients with more complicated conditions.

Value of specialized preanesthetic clinic for cardiac and major vascular surgery patients.

In a complicated and specialized population, such as patients undergoing cardiac and major vascular procedures, patients, clinicians, and hospitals may be best served and resources conserved with a specialized preanesthesia clinic. A specialized preanesthesia clinic for cardiac and major vascular procedures has a focused staff usually consisting of practitioners with cardiac and major vascular surgical care experience designed to address the patient evaluation, the information gathering, the necessary consultations, the required testing, and specific needs for the day of cardiac and major vascular surgery. Specialized preanesthesia clinics increase patient satisfaction and may also provide cost containment by decreasing the amount of indiscriminate ordering of expensive preoperative tests and potentially may decrease patient litigation. Resident trainee education can also be enhanced by a specialized preanesthesia clinic for cardiac and major vascular rotations. The ultimate goal of a specialized preanesthesia clinic is to ensure a safe and efficient perioperative cardiac and major vascular surgical experience in complicated patients undergoing complex procedures.

[Decrease in hospitalizations due to polyvalent medical day hospital]. / Ingresos evitados por el hospital de día médico polivalente.

INTRODUCTION: The day hospital is an alternative to hospitalization. This alternative improves accessibility and comfort of the patients, and avoids hospitalizations. Nevertheless, the efficacy of the polyvalent medical day hospital in avoiding hospitalizations has not been evaluated. OBJECTIVE: To analyze hospital stays avoided by the polyvalent medical day hospital of a university hospital of the Andalusian Health Service. METHODS: An observational prospective study of the patients studied and/or treated in the polyvalent medical day hospital of the Hospital Universitario Puerto Real over a one year period. RESULTS: A total of 9640 patients were attended to, with 1413 procedures and 4921 i.v. treatments. There were 3182 visits to the priority consultation of the polyvalent medical day hospital. The most frequent consultation complaints were constitutional symptoms (15.9%) and anemia (14.5%). After the first visit, 21.5% of the patients were discharged and fewer than 3% were hospitalized. Hospitalization was avoided in 16.8% of the patients, there being a 6.0% decrease in the need for hospital beds (5.0% reduction in the internal medicine unit). Inadequate hospitalizations and 30-day readmissions decreased 93.3% and 4.2%, respectively. The most frequent diagnosis was neoplasm (26.0%), and most of the beds freed up were generated by patients diagnosed of neoplasm (26.7%). CONCLUSION: With this type of polyvalent medical day hospital, we have observed improved efficiency of health care, freeing up hospital beds by reducing hospitalizations, inadequate hospitalizations and re-admissions in the medical units involved.