Patient involvement and institutional logics: A discussion paper.

The research into patient involvement is seldom concerned with the significance of cultural and structural factors. In this discussion paper, we illustrate our considerations on some of the challenges in implementing the ideal of patient involvement by showing how such factors take part in shaping the ways in which the intentions to involve patients are converted to practical interventions. The aim was to contribute to the approach dealing with contextual and structural factors of significance for patient involvement. With the idea of "institutional logics," borrowed from the Danish scholar, Erik Riiskjaer, we first demonstrate, with examples from our own research, how patient involvement is interpreted differently within the different logics. Then, we show how the different interpretations of patient involvement meet and conflict in mutual competition as the ideals are sought to be converted to practical interventions. At last, we argue that an adequate theoretical model for the development in the future health care system should be expanded with a "patient logic."

A new look at the supposed risks of early institutional rearing.

The main focus is on the assessment of the effects of early institutional care and compares three longitudinal studies from Romania, Greece and Hong Kong/China. The findings have been strikingly contrasting. The review asks if the risks are dependent on whether or not the institutional rearing is accompanied by gross pervasive deprivation (as it was in Romania) and investigates the methodological issues to explore the causal influence of the outcomes. Evidence is considered on changing institutional practices and the benefits of doing so. Comparison is made between institutions with major deprivation and those without global deprivation. A small number of studies are discussed that look at direct comparisons between institutional and community care. The empirical and conceptual implications of the findings are discussed.

How we provide transfusion support for neonatal and pediatric patients on extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) provides lifesaving hemodynamic and respiratory support to neonatal and pediatric patients with a variety of congenital or acquired cardiopulmonary defects. Successful ECMO support requires close collaboration among multiple services, including critical care medicine, perfusion, and transfusion medicine services. Neonatal and pediatric ECMO patients require significant transfusion support, both at the time of cannulation and after the ECMO circuit has been established, often with little advance notice. Thus a number of communication and logistic issues must be addressed through a multidisciplinary approach to ensure both good patient outcome and judicious use of resources. In this article, we describe our protocol for transfusion support for ECMO and potential ECMO patients, which was developed to address a number of issues, including identifying and stratifiying ECMO candidate patients, streamlining the ordering and communication processes, and improving blood product turnaround times and availability. Additional measures of quality improvement are also discussed. As the number of centers performing ECMO procedures remains high, we believe that our experience may be of interest to our colleagues in transfusion medicine and critical care.

If Disney ran your security department.

This article describes a program that has built relationships for the Security Department using customer service techniques which have added value to the hospital and the surrounding community.

Time to bring down the twin towers in poor Aboriginal hospital care: addressing institutional racism and misunderstandings in communication.

Improvements in Aboriginal health have been slow. Research demonstrates ongoing discrimination towards Aboriginal Australians based on race, including in health services, leads to poor health outcomes. Using an eclectic methodology based on observations and discussions with health practitioners experienced in working with Aboriginal patients, this paper identifies how cross-cultural misunderstandings undermine the quality of care to Aboriginal patients in hospital and offers suggestions for improving practice. It also explores the concept of institutional racism and challenges doctors to reflect on their role in perpetuating power imbalances. We argue that physicians and healthcare providers need to do more than just deliver evidence-based interventions, by critically reflecting on their own attitudes to and practices with Aboriginal Australians and work collectively to effect systemic change which creates a more inclusive and safe environment for all people accessing healthcare.

Institutional practice and outcome variation in the management of congenital diaphragmatic hernia and gastroschisis in Canada: a report from the Canadian Pediatric Surgery Network.

BACKGROUND: Perinatal management of congenital diaphragmatic hernia (CDH) and gastroschisis (GS) remains nonstandardized and institution specific. This analysis describes practice and outcome variation across a national network. METHODS: A national, prospective, disease-specific database for CDH and GS was evaluated over 4 years. Centers were evaluated individually and defined as low (low-volume center [LVC]) or high (high-volume center [HVC]) volume based on case mean. RESULTS: Congenital diaphragmatic hernia. Two hundred fifteen liveborn cases were studied (mean, 14.3 cases/center) across 15 centers (8 LVCs and 7 HVCs). Significant interinstitutional practice variation was noted in rates of termination (0%-40%) and cesarean delivery (0%-61%). Centers demonstrated marked variation in ventilation strategies, vasodilator and paralytic use, timing of surgery, and rates of primary closure. Overall survival was 81.4% (LVC, 76.9%; HVC, 82.4%; P = .43). Gastroschisis. Four hundred sixteen cases were investigated (mean, 26 cases/center; range, 6-72) across 16 centers (10 LVCs and 6 HVCs). Cesarean delivery rates varied widely between centers (0%-86%) as did timing of closure (early vs delayed, 1%-100%). There was no difference in length of stay, days on total parenteral nutrition, and overall survival (94.3% vs 97.2%; P = .17) between LVCs and HVCs. CONCLUSIONS: The existence of perinatal practice and outcome variation for GS and CDH suggests targets for improved delivery of care and justifies efforts to standardize treatment on a national basis.

Institutional challenges for mining and sustainability in Peru.

Global consumption continues to generate growth in mining. In lesser developed economies, this growth offers the potential to generate new resources for development, but also creates challenges to sustainability in the regions in which extraction occurs. This context leads to debate on the institutional arrangements most likely to build synergies between mining, livelihoods, and development, and on the socio-political conditions under which such institutions can emerge. Building from a multiyear, three-country program of research projects, Peru, a global center of mining expansion, serves as an exemplar for analyzing the effects of extractive industry on livelihoods and the conditions under which arrangements favoring local sustainability might emerge. This program is guided by three emergent hypotheses in human-environmental sciences regarding the relationships among institutions, knowledge, learning, and sustainability. The research combines in-depth and comparative case study analysis, and uses mapping and spatial analysis, surveys, in-depth interviews, participant observation, and our own direct participation in public debates on the regulation of mining for development. The findings demonstrate the pressures that mining expansion has placed on water resources, livelihood assets, and social relationships. These pressures are a result of institutional conditions that separate the governance of mineral expansion, water resources, and local development, and of relationships of power that prioritize large scale investment over livelihood and environment. A further problem is the poor communication between mining sector knowledge systems and those of local populations. These results are consistent with themes recently elaborated in sustainability science.

[Biological procedures, civil and military health facilities, and recommendations of good practice and hospital reform: the example of diabetes management]. / Actes de biologie, établissements de santé civils et militaires, recommandations de bonnes pratiques et réformes hospitalières: exemple de la prise en charge du diabète.

In the context of implementing hospital reforms, the objective of this work was to compare practice in relation to evidence-based guidelines and recommendations for good practice in diabetes screening and management. Laboratory test consumption was determined for patients hospitalized for diabetes in 2005 in three public hospitals (one civilian, two military) taking care of diabetic patients and performing related biological tests. For the 395 admissions in these three hospitals during 2005 [Diagnosis-related group (DRG) 10M02V "Diabetes, age 36 to 69 years without co-morbidity"], the average length of stay and the number of biological acts ["B"] performed were lower than those given by the French national health cost study scale and by the Montpellier University Hospital database. In terms of qualitative coherence between the guidelines for treatment and the recommendations, the total number of biological acts ["B"] is higher than if one were to strictly apply the good practice suggested by the French Health Authority. These three hospitals have and apply different guidelines for practice in the area of diabetes management. The implementation of reforms such as DRG-based payment scales may be an additional leverage to ensure that the recommendations of best practices are effective. Improved methods and tools for data collection and monitoring are essential, especially for estimating revenue and expenditure.

Interventions that improved a practice environment: "making a difference".

This paper reports on the intervention phase of a participatory action study designed to improve the practice environment within a critical care unit in a research teaching hospital. The intervention strategy involved the hiring of a facilitator who worked with unit staff to engage in a process of addressing their priority issues related to the practice environment. Examples of interventions included staff retreats, communication workshops, task groups and leadership training. Challenges and key learnings are reported.

[Consulting the nursing home physician; an interesting but less used option]. / De verpleeghuisarts in consult: een te weinig benutte toegevoegde waarde.

OBJECTIVE: To describe the current use of the consultation function of nursing home physicians. Setting Descriptive inventory study. METHODS: A questionnaire (with 16 questions regarding the consultation function of nursing home physicians) was sent to the head of the medical staff of all nursing homes in The Netherlands (n=323). RESULTS: The response to the questionnaire was 78%. The use of the consultation function appeared to be very low. Only 20% of respondents answered that their medical staff was involved in weekly or monthly consultations upon request of general practitioners. Respondents mentioned unfamiliarity with the expertise of nursing home physicians as the main reason for this low consultation frequency. A positive relationship was found between the consultation frequency and some organizational parameters. CONCLUSION: Nursing home physicians are not often consulted by general practitioners. Compared to 7 years ago even a decline in the consultation frequency has occurred. Paradoxically, the current trend in chronic care to offer care and treatment as long as possible in the home situation of patients, leads to a situation in which Dutch nursing homes offer more and more complementary nursing and medical support to community care for chronically ill and disabled patients, still living at home. This trend stresses also the importance of more collaboration between general practitioners and nursing home physicians. Further research concerning the added value of this collaboration is necessary

Using local microbiologic data to develop institution-specific guidelines for the treatment of hospital-acquired pneumonia.

BACKGROUND: While current guidelines recommend consideration of local microbiologic data when selecting empiric treatment for hospital-acquired pneumonia (HAP), few specifics of how to do this have been offered. METHODS: We conducted a retrospective analysis of HAP pathogens in 111 consecutive patients who acquired HAP during July to December 2004 and had a corresponding positive culture finding for a bacterial pathogen. These data were used to develop institution-specific guidelines. RESULTS: The most common bacteria identified were Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa, which were associated with 38%, 25%, and 19% of pneumonias, respectively. Susceptibility of Gram-negative bacteria to piperacillin-tazobactam and cefepime was 80% and 81%, respectively. The isolation of organisms resistant to piperacillin-tazobactam or cefepime was significantly more frequent in patients who had been hospitalized > or = 10 days. Of Gram-negative isolates resistant to piperacillin-tazobactam or cefepime, ciprofloxacin was active against < 10%, while amikacin was active against > 80%. New treatment guidelines were developed that divided the American Thoracic Society/Infectious Diseases Society of America "late onset/risk of multidrug-resistant pathogens" group of patients into two subcategories: "early-late" pneumonias (< 10 days of hospitalization) and "late-late" pneumonias (> or = 10 days of hospitalization). Guideline-directed treatment regimens would be predicted to provide adequate initial therapy for > 90% of late-onset pneumonias at our institution. CONCLUSIONS: Current guidelines suggest adding either an aminoglycoside or a fluoroquinolone to beta-lactam therapy for empiric Gram-negative coverage. However, in our institution, adding ciprofloxacin would not appreciably enhance the likelihood of providing initial appropriate antibiotic coverage. This underscores the importance of employing a systematic analysis of local data when developing treatment guidelines.

Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine.

BACKGROUND: The extent of clinical exposure needed to ensure quality care has not been well determined during internal medicine training. We aimed to determine the association between clinical exposure (number of cases seen), self- reports of clinical competence, and type of institution (predictor variables) and quality of care (outcome variable) as measured by clinical vignettes. METHODS: Cross-sectional study using univariate and multivariate linear analyses in 11 teaching hospitals in Japan. Participants were physicians-in-training in internal medicine departments. Main outcome measure was standardized t-scores (quality of care) derived from responses to five clinical vignettes. RESULTS: Of the 375 eligible participants, 263 (70.1%) completed the vignettes. Most were in their first (57.8%) and second year (28.5%) of training; on average, the participants were 1.8 years (range = 1-8) after graduation. Two thirds of the participants (68.8%) worked in university-affiliated teaching hospitals. The median number of cases seen was 210 (range = 10-11400). Greater exposure to cases (p = 0.0005), higher self-reports of clinical competence (p = 0.0095), and type of institution (p < 0.0001) were significantly associated with higher quality of care, using a multivariate linear model and adjusting for the remaining factors. Quality of care rapidly increased for the first 100 to 200 cases seen and tapered thereafter. CONCLUSION: The amount of clinical exposure and levels of self-reports of clinical competence, not years after graduation, were positively associated with quality of care, adjusting for the remaining factors. The learning curve tapered after about 200 cases.

Patient advocacy and professional associations: individual and collective responsibilities.

Professions have traditionally treated advocacy as a collective duty, best assigned to professional associations to perform. In North American nursing, advocacy for issues affecting identifiable patients is assigned instead to their nurses. We argue that nursing associations' withdrawal from advocacy for patient care issues is detrimental to nurses and patients alike. Most nurses work in large institutions whose internal policies they cannot influence. When these create obstacles to good care, the inability of nurses to affect change can result in avoidable distress for them and for their patients. We illustrate this point with a case study: the circumstances of the death of Michael Joseph LeBlanc, an inmate at Kingston Penitentiary Regional Hospital (Ontario). We conclude that patient and their nurses will suffer unnecessarily unless or until nursing associations cease to burden individual nurses with the responsibility for patient advocacy.

Information exchange between general practitioner and nursing home physician in The Netherlands.

BACKGROUND: In response to the specific characteristics of nursing home residents, the Netherlands has become the only country to develop the specialty of nursing home medicine. The "nursing home physician" has attained independent status. This development has, however, created a division between medical care in the community and medical care in nursing homes, which challenges the quality of the transitional processes taking place when a patient is admitted to or discharged from nursing home care. OBJECTIVES: To give insight into the type of medical information exchanged between general practitioners (GPs) and nursing home physicians (NHPs) at the time of admission, while a patient is under care of the NHP, and at the time of discharge. METHODS: Questionnaires were sent to a sample of 780 GPs, who were selected using a 2-phase sample strategy. Three hypothetical patient vignettes, involving the admission of a patient to a nursing home, to day care, and to an outreaching nursing home care project, were constructed and presented in the questionnaire. GPs were asked to answer questions about the information exchanged during the care of a patient illustrated in each vignette only if they were really familiar with a patient such as presented. The advantage of hypothetical patient vignettes is that each physician reacts to a standardized situation. RESULTS: In the case of admitting a patient to or discharging a patient from the nursing home, results indicate that the continuity of care at those moments will be better ensured if GPs have more frequent personal contacts with NHPs. In the case of day care patients, the study also reveals that GPs who have frequent personal contact with NHPs will share relevant patient information significantly more often at the start of the day care program, both during day care and also when intercurrent medical problems occur. Similar findings can be expected in patients receiving outreaching nursing home care. CONCLUSIONS: The findings indicate the advantages of personal contacts between different medical professionals in exchanging specific patient information. It can be expected that this will lead to more tailor-made medical care for the patient. Adequate exchange of relevant information is an important aspect of mutual collaboration between professionals. Recommendations as to how to achieve more personal contact and a better collaboration among medical professionals are proposed.