Treatment Patterns and Clinical Outcomes After the Introduction of the Medicare Sepsis Performance Measure (SEP-1).

BACKGROUND: Medicare requires that hospitals report on their adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). OBJECTIVE: To evaluate the effect of SEP-1 on treatment patterns and patient outcomes. DESIGN: Longitudinal study of hospitals using repeated cross-sectional cohorts of patients. SETTING: 11 hospitals within an integrated health system. PATIENTS: 54 225 encounters between January 2013 and December 2017 for adults with sepsis who were hospitalized through the emergency department. INTERVENTION: Onset of the SEP-1 reporting requirement in October 2015. MEASUREMENTS: Changes in SEP-1-targeted processes, including antibiotic administration, lactate measurement, and fluid administration at 3 hours from sepsis onset; repeated lactate and vasopressor administration for hypotension within 6 hours of sepsis onset; and sepsis outcomes, including risk-adjusted intensive care unit (ICU) admission, in-hospital mortality, and home discharge among survivors. RESULTS: Two years after its implementation, SEP-1 was associated with variable changes in process measures, with the greatest effect being an increase in lactate measurement within 3 hours of sepsis onset (absolute increase, 23.7 percentage points [95% CI, 20.7 to 26.7 percentage points]; P < 0.001). There were small increases in antibiotic administration (absolute increase, 4.7 percentage points [CI, 1.9 to 7.6 percentage points]; P = 0.001) and fluid administration of 30 mL/kg of body weight within 3 hours of sepsis onset (absolute increase, 3.4 percentage points [CI, 1.5 to 5.2 percentage points]; P < 0.001). There was no change in vasopressor administration. There was a small increase in ICU admissions (absolute increase, 2.0 percentage points [CI, 0 to 4.0 percentage points]; P = 0.055) and no changes in mortality (absolute change, 0.1 percentage points [CI, -0.9 to 1.1 percentage points]; P = 0.87) or discharge to home. LIMITATION: Data are from a single health system. CONCLUSION: Implementation of the SEP-1 mandatory reporting program was associated with variable changes in process measures, without improvements in clinical outcomes. Revising the measure may optimize its future effect. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Nurses' perceptions of systems and hierarchies shaping their responses to child abuse and neglect.

Nurses have an important role in preventing and responding to child abuse and neglect. This paper reports on nurses' perceptions of how organisational systems and hierarchies shaped their capacity to respond to child abuse and neglect. This is one of four key themes identified through an inductive analysis of data from a broader qualitative study that explored nurses' perceptions and experiences of keeping children safe. The study was guided by social constructionist theory, and data were collected through in-depth interviews with nurses working with children in Australia (n = 21). Key findings showed that nurses experienced many challenges to responding to child abuse, including difficulties sharing information, fear of making mistakes and inflexible systems of care. This was underpinned by an organisational 'rule-centred' culture of following policies at the expense of maintaining an explicit focus on children's needs. These findings demonstrate first the importance of creative and flexible thinking from individual professionals, so policies are enacted with a clear child focus. Second, they highlight the need for leadership to enact organisational and systemic cultural change that maintains a genuinely child-centred approach.

Exemption committees as an alternative to legal procedure in cases of sibling sexual abuse: The approaches of Israeli CAC professionals.

BACKGROUND: Sibling sexual abuse (SSA) is a widespread form of intrafamilial child sexual abuse frequently regarded as play or normal sexual behavior, and therefore highly underreported. Israeli law allows Child Protection Officers (CPOs) to suspend police intervention after the disclosure of SSA, and refer the family to therapy, by applying to an "exemption committee." OBJECTIVE: This study will examine the characteristics of cases referred to the exemption committee or legal procedure and the justifications provided by CPOs to support the decisions. PARTICIPANTS AND SETTING: The study was based on 40 family cases referred to the Child Advocacy Center in Jerusalem: twenty cases were referred to an exemption committee and the rest to legal procedure. METHOD: Qualitative document analysis conducted on the two groups of cases (N = 40). Files were then analyzed using the thematic analysis approach. RESULTS: During the decision-making process, CPOs assess each of the cases in a broad and holistic manner, basing their decisions on various contextual factors, including the characteristics of the survivor, the perpetrator, the parents and other siblings, and the types of sexual acts involved. CONCLUSIONS: This comprehensive approach to understanding and handling the complex family story and nature of SSA underscores the need to address SSA and subsequent interventions - legal or therapeutic - not exclusively in terms of quantifiable criteria, but also in terms of a crisis involving the relationships in the entire family, past and future course of treatment, and the perceptions of family members involved.

Violence against the elderly: the conceptions of nursing professionals regarding detection and prevention. / Violência contra idosos: concepções dos profissionais de enfermagem acerca da detecção e prevenção.

OBJECTIVE: To analyze the conceptions of the nursing professionals working in Basic Health Units regarding the detection and prevention of violence against the elderly. METHODS: Descriptive, exploratory, qualitative study. Performed in two BHUs in Mossoró/RN, using a semi-structured interview script, from March to August of 2013. Sample composed of four nurses and six nursing technicians. The content analysis, pre-analysis, material exploration, and treatment of results were performed. RESULTS: Four categories were identified: Strategies used to identify violence against the elderly; Types of violence against the elderly; Conduct used after finding a suspicion of violence; SUS and the problem of violence against the elderly. Many professionals recognize/distrust possible cases, however, they do not know how to proceed. The dimension of the problem requires that pragmatic interventions be performed in the clinical setting and in the social context. FINAL CONSIDERATIONS: There is a need for continuing education for professionals and greater communication between the bodies responsible for reporting and embracement.

Neurobiology of Sexual Assault and Osteopathic Considerations for Trauma-Informed Care and Practice.

Sexual assault is a traumatic event with potentially devastating lifelong effects on physical and emotional health. Sexual assault is associated with gastrointestinal, neurologic, and reproductive symptoms, as well as obesity, diabetes, and chronic pain. With 1 in 3 women and 1 in 6 men experiencing some form of unwanted sexual violence in their lifetime, sexual assault is a significant public health problem that necessitates attention in the medical community. This review discusses relevant literature on the neurobiologic changes that occur as a consequence of sexual assault, such as how the brain responds during a traumatic experience and the impact of trauma on memory. Osteopathic considerations for trauma-informed care and practice and how all physicians can better serve patients with a history of sexual assault are also discussed.

Violência contra idosos: concepções dos profissionais de enfermagem acerca da detecção e prevenção / Violencia contra ancianos: conceptos de profesionales de enfermería sobre la detección y prevención / Violence against the elderly: the conceptions of nursing professionals regarding detection and prevention

Resumo OBJETIVO Analisar as concepções dos profissionais de enfermagem atuantes em Unidades Básicas de Saúde quanto à detecção e prevenção de idosos violentados. MÉTODOS Estudo descritivo, exploratório, qualitativo. Realizado em duas UBS, Mossoró/RN, utilizando roteiro de entrevista semiestruturada, em março a agosto de 2013. Amostra composta por quatro enfermeiros e seis técnicos de enfermagem. Realizada análise de conteúdo. RESULTADOS Identificaram-se 4 categorias: Estratégias utilizadas para identificar a violência contra o idoso; Tipos de violências contra o idoso; Conduta utilizada após constatação de uma suspeita de violência; SUS e a problemática da violência contra o idoso. Muitos profissionais reconhecem/desconfiam dos possíveis casos, entretanto, não sabem como proceder. A dimensão do problema exige que sejam realizadas intervenções pragmáticas no meio clínico e no contexto social. CONCLUSÕES Há necessidade de educação permanente para profissionais e maior comunicação entre as instâncias responsáveis pela denúncia e acolhimento.

Resumen OBJETIVO Analizar los conceptos de enfermeros activos en unidades básicas de la salud sobre la detección y prevención del maltrato hacia personas ancianas. MÉTODOS Estudio exploratorio, descriptivo y cualitativo, realizado en dos UBS, en Mossoro/RN, por medio de entrevistas semiestructuradas entre marzo y agosto de 2013. Se realizó el estudio con cuatro enfermeros y seis técnicos de enfermería. Se llevó a cabo el análisis de contenido. RESULTADOS El análisis se divide en 4 categorías: Estrategias utilizadas para identificar la violencia contra ancianos; Tipos de violencia contra personas mayores; Acción utilizada luego de detectarse la violencia; y SUS y el tema de la violencia contra ancianos. Muchos profesionales reconocen/desconfían de los posibles casos, sin embargo, no saben cómo proceder. La magnitud del problema requiere de intervenciones pragmáticas que se lleven a cabo en el ámbito clínico y en el contexto social. CONSIDERACIONES FINALES Existe la necesidad de una educación continua para profesionales y una mayor comunicación entre los organismos responsables de la queja y acogida.

Abstract OBJECTIVE To analyze the conceptions of the nursing professionals working in Basic Health Units regarding the detection and prevention of violence against the elderly. METHODS Descriptive, exploratory, qualitative study. Performed in two BHUs in Mossoró/RN, using a semi-structured interview script, from March to August of 2013. Sample composed of four nurses and six nursing technicians. The content analysis, pre-analysis, material exploration, and treatment of results were performed. RESULTS Four categories were identified: Strategies used to identify violence against the elderly; Types of violence against the elderly; Conduct used after finding a suspicion of violence; SUS and the problem of violence against the elderly. Many professionals recognize/distrust possible cases, however, they do not know how to proceed. The dimension of the problem requires that pragmatic interventions be performed in the clinical setting and in the social context. FINAL CONSIDERATIONS There is a need for continuing education for professionals and greater communication between the bodies responsible for reporting and embracement.

Caracterização dos casos de violência física contra mulheres notificados na Bahia / Characterization of cases of physical violence against women notified in Bahia

Introdução:A violência é um fenômeno social e histórico na humanidade que acarreta impactos diretos sobre a saúde, por meio de lesões físicas ou emocionais, traumas e mortes, representando um problema de saúde pública no Brasil e no mundo. Nesse sentido exige formulação de políticas específicas e organização de práticas e de serviços peculiares ao setor de saúde integral à mulher a fim de se prestar uma assistência integral e humanizada. Objetivo:descrever os casos de violência física (VF) contra a mulher notificados ao Sistema de Informação de Agravos de Notificação (SINAN) na Bahia, nos anos de 2009 a 2014. Material e Métodos: estudo descritivo, transversal, utilizando-se dados secundários do SINAN, referentes a violência física praticada contra mulheres na Bahia, no período de 2009 à 2014. Resultados: foram notificados 9590 casos de VF contra mulheres na faixa etária entre 20 a 39 anos (56%), pertencentes às raças parda e negra (58,5%), com ensino fundamental incompleto (20,9%); o ato era praticado com maior frequência pelo cônjuge (24,2%), na residência das vítimas (52,2%), utilizando-se a força corporal e/ou espancamento (67,2%). Conclusão: A violência é um fenômeno frequente no cotidiano das mulheres e seu enfrentamento ainda é um desafio, havendo a necessidade de revisão das políticas públicas nacionais e internacionais que embora tenham avançado na garantia de punição do agressor, ainda carece de maior assistência holística e integral após as denúncias.

Introduction: Violence is a social and historical phenomenon in mankind that has a direct impact on health, through physical or emotional injuries, trauma and death, representing a public health problem in Brazil and in the world, requiring the formulation of specific policies and organization of practices and services peculiar to the integral health sector for women in order to provide comprehensive and humanized assistance. Objective: To describe the cases of physical violence (FV) against women notified to the Notification of Invalidity Information System (SINAN) in Bahia from 2009 to 2014. Material and methods: a descriptive, cross-sectional study using secondary data of SINAN, referring to the physical violence practiced against women in Bahia from 2009 to 2014. Results: 9,590 cases of FV were reported against women in the age group between 20 and 39 years old (56%), belonging to the brown and black races (58.5%), with incomplete elementary education (20.9%); (52.2%), using corporal force and / or beating (67.2%), was the most frequently practiced by the spouse (24.2%). Conclusion: Violence is a frequent phenomenon in women's daily lives and their confrontation is still a challenge, and there is a need to review national and international public policies that, although they have advanced the guarantee of punishment of the aggressor, still require greater holistic and integral assistance after the denunciations.

[Poisonings in Germany : Poisons Centres, Medical Management and National Monitoring]. / Vergiftungen in Deutschland : Giftinformationszentren, medizinische Versorgung und nationales Monitoring.

BACKGROUND: Illnesses caused by exposure to extracorporeal artificial substances play a major role in emergency medicine, family medicine, and environmental medicine. OBJECTIVE: The current situation of medical poisoning management and national reporting of poisonings in Germany are described. MATERIALS UND METHODS: The information and data presented here are derived from a literature review and from stakeholder interviews. RESULTS AND CONCLUSION: Eight poison centres (PCs) offer consultation supporting the diagnosis and treatment of poisoning cases in Germany today. Furthermore, those affected, their relatives and first aiders contact these German PCs, mainly because of a suspected poisoning. German PCs are also contacted by those affected and by institutions in other situations when expert toxicological judgement is needed, especially in cases with an environmental background. Often, interpretation of analytical laboratory results of body fluid samples or environmental samples are requested, or reference to environmental medicine treatment facilities is made. The PCs and the German Federal Institute for Risk Assessment (BfR) cooperate on the national reporting of the risks of poisoning for the population. In addition, the BfR collects and evaluates poisoning reports from German medical doctors that have been directly submitted. A pilot project on a national monitoring of poisonings should collate future case reports. An extensive and current overview of poisonings in Germany is a prerequisite for the identification of unsafe products and to fully comply with the international reporting needs of the German Federal Government in the case of chemical outbreaks and the resulting suspected cases.

What prevents Chinese parents from reporting possible cases of child sexual abuse to authority? A holistic-interactionistic approach.

The reporting of suspected CSA cases to authorities in a timely manner is important in preventing continued abuse and protecting abused children at early ages. The current study seeks to explore parents' intentions of reporting their own children's CSA experiences to authorities as well as their reporting willingness when they become aware of possible CSA cases happening to children in other families. Two rounds of semi-structured interviews were conducted among a sample of 26 parents in Beijing; these parents were purposefully selected so as to be diverse in terms of gender, age, and socioeconomic status. The data were analyzed thematically. The findings showed that the reporting of suspected CSA to authorities was a choice made by only a few Chinese parents; it was often even a last resort. By using a holistic-interactionistic approach, the interaction between Chinese parents' intentions of reporting CSA and the Chinese socio-cultural context was analyzed as a dynamic and continuously ongoing process. The impacts of the definition and perceptions of CSA on reporting, the balance of children's rights and parents' power, and the double effect of informal social control are discussed. The implications, both locally and globally, are also discussed.

Without reporting, FGM remains a hidden crime.

Though it has been illegal in the UK since 1985, no one has ever been prosecuted for FGM. Under laws rolled out last year in England and Wales, nurses, midwives, doctors and teachers have a mandatory duty to report FGM cases in under-18s to police.

Integrated care: an Information Model for Patient Safety and Vigilance Reporting Systems.

Quality management information systems for safety as a whole or for specific vigilances share the same information types but are not interoperable. An international initiative tries to develop an integrated information model for patient safety and vigilance reporting to support a global approach of heath care quality.

Surveillance of infant pertussis in Sweden 1998-2012; severity of disease in relation to the national vaccination programme.

In Sweden, pertussis was excluded from the national vaccination programme in 1979 until acellular vaccination was introduced in a highly endemic setting in 1996. The general incidence dropped 10-fold within a decade, less in infants. Infant pertussis reached 40-45 cases per 100,000 in 2008 to 2012; few of these cases were older than five months. We present an observational 15-year study on the severity of infant pertussis based on 1,443 laboratory-confirmed cases prospectively identified from 1998 to 2012 in the national mandatory reporting system and followed up by telephone contact. Analyses were made in relation to age at onset of symptoms and vaccination history. Pertussis decreased in non-vaccinated infants (2003 to 2012, p<0.001), indicating herd immunity, both in those too young to be vaccinated and those older than three months. The hospitalisation rates also decreased (last five-year period vs the previous five-year periods, p <0.001), but 70% of all cases in under three month-old infants and 99% of cases with apnoea due to pertussis were admitted to hospital in 1998 to 2012. Median duration of hospitalisation was seven days for unvaccinated vs four days for vaccinated infants aged 3-5 months. Nine unvaccinated infants died during the study period.

Measuring general animal health status: Development of an animal health barometer.

The development of an animal health barometer, an instrument to measure the general health of the Belgian livestock population on a yearly basis and to monitor its evolution over time, is described. The elaboration of a set of 13 animal health indicators (AHIs) as the basis for the animal health barometer is discussed. These indicators were weighted by experts - including scientists, policy makers and agro-industrial representatives - to determine their relative weight in the barometer. The result of the barometer is expressed as a comparison with a previous year. Based on the results of the 13 AHIs, it is concluded that general animal health in Belgium shows a positive evolution since 2008. The animal health barometer provides a composite view of the status of livestock health in Belgium and is a tool to communicate in an intelligible, comprehensible manner on aspects of animal health to consumers and professional stakeholders in the animal production and food chain. Together with the food safety barometer (Baert et al., 2011. Food Res. Int. 44, 940) and the plant health barometer (Wilmart et al., 2014. Eur. J. Plant Pathol. doi: 10.1007/s10658-014-0547-x), the animal health barometer is one of the three instruments to provide a holistic view on the overall status of the safety of the food chain in Belgium.

Teaching dental students to interact with survivors of traumatic events: development of a two-day module.

Dentists are likely to treat patients who have experienced a wide range of traumatic life events, including child abuse and neglect, domestic violence, sexual assault, elder abuse, and exposure to combat. In order to effectively treat survivors of traumatic events, dentists must understand how these patients may present in oral health settings, the basic mandated reporting requirements related to abuse and neglect, and communication strategies to help engage trauma survivors in dental treatment. A traditional lecture-format educational module on trauma-informed care was developed and implemented for second-year dental students (N=92) at one U.S. dental school, after which a needs assessment was performed (all 92 students participated). This assessment then informed development of an enhanced module for the subsequent group of second-year dental students (N=102) at the same school. The revised (final) module was more interactive in nature, expanded to multiple sessions, and included more discussion of mandated reporting and appropriate dentist-patient communication in relation to traumatic events. All 102 students participated in assessments of the revised module. Comparison of pre and post tests and needs assessments between the initial and final modules indicated that the extended, more interactive final module was more effective in meeting the educational objectives. Results showed that the final module increased the students' knowledge in the health-related manifestations of traumatic events and slightly improved their confidence levels in treating survivors of trauma. Dentists who are prepared to deliver trauma-informed care may help individual patients feel more at ease and increase engagement in regular preventive care. Suggestions for future educational efforts in this area are discussed.