Transportation Burden Associated With Hemodialysis in Canada: A Qualitative Study of Stakeholders.

Rationale & Objective: For patients requiring in-center hemodialysis, suboptimal transportation arrangements are commonly cited as a source of ongoing stress and anxiety and have been associated with a reduced quality of life and increased mortality risk. Transportation-related problems are especially pronounced in Canada given its size, low population density, and long, often snowy winters. We aimed to identify and better understand transportation options for hemodialysis patients in Canada and to describe stakeholder experiences. Study Design: We used a qualitative descriptive research design to explore stakeholder experiences and perspectives of transportation to and from dialysis facilities. Setting & Participants: We recruited participants from a large urban hemodialysis program in Western Canada and included 11 participants from a project group, 45 participants from an open forum, and a survey of 8 social workers. Data collection occurred at a series of project group meetings and an open forum (n=45). In addition, we asked 8 renal social workers based in major cities across Canada to comment on the provision of transport for patients in their area via email or telephone consult. Analytical Approach: We used conventional content analysis to explore stakeholder experiences. Results: Traveling to and from dialysis facilities remains a source of stress and anxiety for many patients and their families. Patients described several factors contributing to these feelings including: the challenges of physically getting to the treatment center, particularly in adverse weather conditions; being a burden on family and friends; difficulties accessing the treatment facility; issues with public transport; and financial worries related to high costs. Limitations: Findings may not be relevant in low- and middle-income countries and those with a warmer climate. Conclusions: Without a concerted and collaborative approach to address the barriers identified here, it is likely that travel to and from in-center hemodialysis will continue to adversely affect patients' quality of life.

Impact of Breastfeeding Support Services on Mothers' Breastfeeding Experiences When Provided by an MD/IBCLC in the Pediatric Medical Home.

Addressing breastfeeding issues enables mothers to reach their breastfeeding goals. We embedded a breastfeeding consultation service run by a pediatrician/International Board Certified Lactation Consultant (MD/IBCLC) in a medical home. This mixed-methods study investigated breastfeeding preparedness and the service's perceived benefits. Mothers with breastfeeding issues/concerns identified at well-baby appointments were referred to the service. Telephone interviews and chart reviews were conducted with 28 participating mothers approximately 1 month after the visits. Breastfeeding Self-Efficacy Scale scores improved significantly from the time of the in-person appointment to 1 month later. Most mothers felt unprepared for breastfeeding despite prenatal efforts. Trust in the pediatrician's recommendation, easy access, and insurance coverage were key factors in seeking the service. Reassurance provided by the MD/IBCLC increased mothers' confidence to breastfeed. The COVID-19 pandemic heightened feelings of isolation and anxiety due to lack of hands-on support from friends and family during the birth hospitalization and when at home.

An Exploratory Study of Person-Centered Care in a Large Urban Hemodialysis Program in Canada Using a Qualitative Case-Study Methodology.

BACKGROUND: Person-centered care (PCC) can benefit patients, clinical staff, and health care organizations, but has not yet been widely adopted into practice. Hemodialysis is a unique care environment in which clinical staff can be involved with patients for protracted periods of time each week and often over a number of years. While kidney care is arguably more holistic than other chronic condition management programs, most patients requiring hemodialysis do not receive care that is optimally person-centered. OBJECTIVE: The purpose of this research was to explore how care is experienced and provided in a large urban hemodialysis program in western Canada in relation to key principles of PCC. In addition, we wanted to understand what factors at an individual, unit, and organizational level facilitate or inhibit PCC in this environment. METHODS: We used a qualitative case-study approach to explore multiple perspectives of care provision using a number of data sources including semi-structured interviews with patients, family members, clinical staff, and administrative staff, as well as observing patterns of clinical practice in local hemodialysis units. FINDINGS: In our study of a single hemodialysis program, we found limited evidence of PCC. Overall, patients reported that their care was good and they had positive relationships with their care team. However, they did not feel involved in decisions regarding their care or consider it to be individualized. In general, providers acknowledged the potential benefits of PCC but were constrained in their practice by a number of factors, including individual perceptions of their role, a prescriptive care environment, and an organizational focus on managing demand. CONCLUSIONS: Evidence of PCC within hemodialysis services was limited, with a number of individual, unit level, and organizational barriers mitigating against its adoption and spread.

CONTEXTE: Les soins axés sur le patient sont bénéfiques pour les patients eux-mêmes, mais également pour le personnel clinique et les établissements de santé. Néanmoins, ils demeurent peu adoptés en pratique. L'hémodialyse constitue un contexte de soins unique où le personnel clinique est impliqué auprès des patients pendant de longues périodes chaque semaine et souvent, pendant plusieurs années. Les soins en néphrologie sont probablement plus holistiques que les autres programs de prise en charge des maladies chroniques, mais la plupart des patients qui nécessitent des traitements d'hémodialyse ne reçoivent toujours pas des soins individualisés. OBJECTIF: Cette étude visait à examiner, du point de vue des principes clés de la prestation de soins individualisés, la façon dont les soins sont prodigués et reçus dans un vaste program d'hémodialyse en milieu urbain dans l'Ouest canadien. Nous souhaitions également connaître les facteurs au niveau de l'individu, de l'unité de soins et de l'établissement de santé, qui facilitent ou entravent la pratique de soins davantage axés sur le patient dans un tel environnement. MÉTHODOLOGIE: Nous avons adopté une approche des études de cas qualitative pour examiner un certain nombre de modèles de prestation de soins en utilisant plusieurs sources de données, notamment des entretiens semi-structurés avec les patients, leurs proches et des membres du personnel clinique et administratif, et l'observation des modèles de pratique clinique dans les unités locales d'hémodialyse. RÉSULTATS: Dans notre étude, menée dans un seul program d'hémodialyse, nous avons recueilli peu de preuves d'une prestation de soins personnalisée. Dans l'ensemble, les patients ont indiqué recevoir de bons soins et entretenir de bonnes relations avec le personnel soignant; tout en ajoutant ne pas se sentir impliqués dans les décisions relatives à leurs soins, ni considérer que ces derniers étaient personnalisés. De leur côté, les fournisseurs de soins reconnaissaient les avantages potentiels des soins personnalisés, mais se disaient limités dans leur pratique par un certain nombre de facteurs, notamment la perception individuelle de leur rôle, un environnement de soins normatif et une orientation organisationnelle axée sur la gestion de la demande. CONCLUSION: Les données probantes attestant d'un program de soins individualisé dans le contexte de l'hémodialyse se sont avérées limitées; et un certain nombre d'obstacles, tant sur le plan individuel, de l'unité de soins que de l'établissement de santé, ont atténué l'adoption et la propagation de ces soins.

Identifying Mobile Applications Aimed at Self-Management in People With Chronic Kidney Disease.

BACKGROUND: A growing number of mobile applications (apps) target people with chronic illness as the primary user. There is increasing evidence that digital technology can improve health outcomes for users but the sheer number of apps available is likely to overwhelm many potential users. OBJECTIVE: The purpose of this study was to systematically search for apps aimed at people with chronic kidney disease. An important secondary objective was to develop a search strategy that could be used to identify similar apps in the future. DESIGN: A systematic review of the scientific and gray literature including app stores, clearinghouses, and Google. SETTING/PATIENTS: The focus of this research was the identification of apps that may be of use to people interested in self-management of chronic kidney disease. METHODS: Three reviewers independently searched app stores, websites, and databases to identify apps of potential interest and any information related to the function and efficacy of these. Apps that met the inclusion criteria were short-listed, reviewed in more detail, and cross-referenced with other sources such as clearinghouses, Google, and kidney care organizations. A population, intervention, comparison, outcome, and design framework was used to search selected databases. RESULTS: Of the 1464 apps purporting to be for chronic kidney disease, only 15 were eligible for inclusion. Searching the 2 major app stores (iOS and Android) appeared to be the most productive way of identifying apps of potential interest. An increasing number of public and private clearinghouses have been established to assist users with finding apps. Privacy and security of user information is a particular and valid concern of health care professionals and organizations. LIMITATIONS: The breadth and depth of information relating to each app varied and made it difficult to systematize the evaluation of apps. Due to the large number of health care apps and the challenges to searching app stores and websites, it is possible that some apps were missed during our searches. Similarly, while there are many kidney care-related websites that contain useful information, these were not captured by our study. CONCLUSION: There are very few available apps aimed specifically at people with chronic kidney disease; those that are available are best identified by manually searching the 2 major app stores. Privacy and confidentiality of user information when using the apps is a concern among health care providers in particular.

CONTEXTE: Un nombre croissant d'applications (apps) mobiles cible les personnes atteintes d'une maladie chronique comme utilisateur principal. Il apparait de plus en plus évident que la technologie numérique peut améliorer l'état de santé des utilisateurs, mais ceux-ci pourraient être dépassés par la quantité effarante d'applications disponibles. OBJECTIFS: Cette étude visait à rechercher systématiquement les applications s'adressant aux personnes atteintes de néphropathie chronique. On souhaitait également élaborer une stratégie de recherche qui pourrait être employée ultérieurement pour repérer les applications similaires. TYPE D'ÉTUDE: Une revue systématique de la littérature scientifique et de la littérature grise, y compris des boutiques d'applications (app stores), des centres d'échange d'information en ligne et de Google. SUJET: On cherchait plus précisément à répertorier les applications susceptibles d'être utiles aux personnes intéressées par l'autogestion de leur insuffisance rénale. MÉTHODOLOGIE: Trois réviseurs ont scruté, de façon indépendante, les boutiques d'applications, les sites Web et les bases de données afin de repérer les applications présentant un intérêt potentiel et les renseignements relatifs à leur fonction et à leur efficacité. Les applications satisfaisant les critères d'inclusion ont été retenues, revues en détail et comparées avec celles provenant d'autres sources telles que les centres d'échange d'information, Google et les organismes de santé rénale. Un cadre de population, d'intervention, de comparaison, de résultats et de conception a été employé pour chercher dans les bases de données choisies. RÉSULTATS: Des 1 464 applications recensées qui prétendaient traiter de néphropathie chronique, seules quinze étaient admissibles à l'inclusion. Il appert que consulter les deux principales boutiques d'applications (iOS et Android) est la façon la plus efficace de repérer les applications présentant un intérêt potentiel. Un nombre grandissant de centres d'échange d'informations publics et privés ont été créés pour aider les utilisateurs à trouver des applications. L'utilisation de ces dernières soulève des préoccupations chez les professionnels de la santé et certains organismes en santé rénale qui s'inquiètent du respect de la vie privée des utilisateurs et de la confidentialité de leurs renseignements personnels. LIMITES: L'ampleur et la profondeur de l'information relative à chaque application variaient beaucoup et ont rendu difficile la systématisation de l'évaluation. Vu le très grand nombre d'applications en santé et de la difficulté de chercher dans les boutiques d'applications et sur les différents sites Web, il est possible que nos recherches n'aient pas recensé toutes les applications disponibles. Aussi, bien qu'il existe plusieurs sites Web traitant de santé rénale et contenant des renseignements utiles, ceux-ci n'ont pas été retenus par notre étude. CONCLUSION: Il existe très peu d'applications mobiles ciblant spécifiquement les personnes atteintes d'insuffisance rénale chronique. La meilleure façon de les repérer est encore de chercher manuellement dans les deux principales boutiques d'applications. L'utilisation de ces applications soulève des préoccupations de la part des fournisseurs de soins quant au respect de la vie privée et à la confidentialité des renseignements personnels des utilisateurs.

Current issues in the diagnosis and management of pediatric empyema.

Empyema is a rare but recognized complication of bacterial pneumonia in children. The incidence of empyema may be rising as vaccination practices and antibiotic prescribing practices promote the emergence of more virulent and resistant organisms. Diagnostic methods vary widely, from thoracentesis to plain radiographs to detailed computed tomography scans. Treatment practices also vary, with some practitioners preferring medical treatment, others employing chest tube drainage or fibrinolytic therapy, and still others aggressively pursuing surgical options. Further study is needed to define the ideal management of empyema. The authors review the current literature and propose an updated management algorithm that incorporates accepted practices as well as emerging trends in diagnosis and management of empyema.