A Multisite Case Study of Caregiver Advise, Record, Enable Act Implementation.

BACKGROUND AND OBJECTIVES: The Commonwealth of Pennsylvania passed the Caregiver Advise, Record, Enable (CARE) Act on April 20, 2016. We designed a study to explore early implementation at a large, integrated delivery financing system. Our goal was to assess the effects of system-level decisions on unit implementation and the incorporation of the CARE Act's three components into routine care delivery. RESEARCH DESIGN AND METHODS: We conducted a multisite, ethnographic case study at three different hospitals' medical-surgical units. We conducted observations and semi-structured interview to understand the implementation process and the approach to caregiver identification, notification, and education. We used thematic analysis to code interviews and observations and linked findings to the Promoting Action on Research Implementation in Health Services framework. RESULTS: Organizational context and electronic health record capability were instrumental to the CARE Act implementation and integration into workflow. The implementation team used a decentralized strategy and a variety of communication modes, relying on local hospital units to train staff and make the changes. We found that the system facilitated the CARE Act implementation by placing emphasis on the documentation and charting to demonstrate compliance with the legal requirements. DISCUSSION AND IMPLICATIONS: General acute hospitals will be making or have made similar decisions on how to operationalize the regulatory components and demonstrate compliance with the CARE Act. This study can help to inform others as they design and improve their compliance and implementation strategies.

Detaining patients in the general hospital - current practice and pitfalls.

AIMS: Much has been written about the use of the Mental Health Act in psychiatric settings. There is, however, little written on its use to detain patients with mental disorder in general hospitals. METHOD AND RESULTS: We therefore carried out a survey of the use of the Mental Health Act in general hospital settings in Aberdeen, and also posted a questionnaire to Scottish Liaison Psychiatrists, asking about their experience of the use of the Mental Health Act in general hospitals. Over a six-month period in Aberdeen Royal Infirmary, we identified 39 detentions. Out of hours, the use of Emergency Detention Certificates was more common than use of Short Term Detention Certificates - the latter is recommended by the Mental Welfare Commission, as patients are afforded more rights. When psychiatric staff were not directly involved, procedural and administrative errors were more likely to occur. Liaison psychiatrists elsewhere in Scotland reported similar observations. CONCLUSION: General hospital clinicians are unfamiliar with the Mental Health Act and its use. Errors in its application therefore arise, and are more common when psychiatric staff is not involved. Better education, including the provision of written information and consideration of an electronic system, may improve current practice.

Quality of death certificates in hospitals.

The cause-of-death-statistics and the release of the body for burial depend primarily on the information contained in the death certificate. How to handle the death certificate has been critically discussed in professional circles again and again. A retrospective review of 1,315 deaths from six acute care hospitals in Germany was carried out with regard to the quality of the death certificates, taking into account information contained in the medical records. The review covered the readability of the death certificate, the quality of the epicrisis, misclassifications relating to the manner of death and the degree of certainty regarding the cause of death. In 93 % of cases (n= 1,221), death certificates were clearly legible. In about half the cases (43.3 %, n=569), the quality of the entries in the "epicrisis" section was good. In 45 % of cases (n= 592), no details were provided in the "epicrisis " section. In 3.9 % (n = 42) of deaths classified as natural, information was given indicating a non-natural death. Most of these deaths occurred in connection with a fall or an injury (n = 27) or possible errors relating to treatment or care (n = 7). Overall, the review showed that clinicians handled the medical death certificate in a competent and careful manner. However, based on the content of the files, the review identified individual and avoidable misclassifications as to the manner of death and improbable causes of death; it also demonstrated that information on the epicrisis is often missing and needs significant improvement.

Stroke Legislation Impacts Distribution of Certified Stroke Centers in the United States.

BACKGROUND AND PURPOSE: The number of certified primary stroke centers (PSCs) have increased dramatically during the past decade in the United States We aimed to understand the factors affecting PSC distribution in the United States, including the impact of state stroke legislation. METHODS: PSCs certified by national organization or state until December 2013 were searched from available databases. The proportion of PSC among short-term general hospitals in each state was calculated and factors affecting its distribution were analyzed. RESULTS: By the end of 2013, the proportion of PSC varied from 4% to 100% among the 50 states and District of Columbia. The 18 states that had legislation in designating stroke centers and regulating stroke triage had higher PSC percentages (median, 43%; range, 13%-100%) than the remaining states (median, 13%; range, 4%-75%; P<0.001). State stroke legislation, urbanization, state economic output, and larger hospital size independently increased the likelihood of a hospital to be stroke certified. From 2009 to 2013, states with stroke legislation had greater increase of PSC percentages when compared with the states without legislation (median increase, 16% versus 6%; P=0.0067). Among the 1505 stroke centers, 74% were certified by the Joint Commission, 20% by state, and 6% by other organizations. Stroke centers certified only by state were smaller in size by hospital bed count compared with those certified by the Joint Commission (P<0.001). CONCLUSIONS: State stroke legislation, a generalizable intervention, increased the number of certified stroke centers in the United States, potentially improving accessibility of standardized care for patients with acute ischemic stroke.

Code status discussions in psychiatric and medical inpatients.

BACKGROUND: The Patient Self-Determination Act along with regulatory standards and institutional standards of care highlight the need for collaboration between care providers and patients with respect to goals of care and, in emergency situations, code status and measures to be taken in keeping with patients' wishes. Addressing code status may be lacking in patients who require psychiatric hospitalization due to the nature of psychiatric illness, relative medical stability, and a general expectation of survival. We sought to compare code status documentation and discussion between psychiatric and medical inpatients, as this knowledge will help shape future interventions for process improvement. METHOD: We conducted a retrospective chart review of hospitalized patients in psychiatric and medical units during a 12-month period in 2008. For those with multiple admissions, we reviewed only the index (or first) hospitalization. Data collected included demographic information, clinical information regarding cancer as a primary diagnosis or a diagnosis that met National Hospice and Palliative Care Organization (NHPCO) guidelines, code status order and discussion documentation, the presence of an advance directive, length of stay, and 1-year mortality. Data were summarized using mean values, percentages, and frequencies. The 2 groups (psychiatric and medical groups) were compared. RESULTS: The charts of 276 psychiatric patients and 317 general medical patients were reviewed. More psychiatric patients had dementia (P < .001). Medical inpatients had a higher rate of code status order documented on admission (96% vs 65%, P < .001) and "full-code, discussed" order (67% vs 33%, P < .001). Psychiatric inpatients had more "do not resuscitate/do not intubate" orders (20% vs 13%, P = .037), more frequent changes in code status order (18% vs 7%, P < .001), and a higher percentage of advance directives (46% vs 25%, P < .001). CONCLUSIONS: A code status discussion with hospitalized patients needs to occur at admission regardless of reason for admission. Strategies are needed to improve this process for psychiatric inpatients.

The labor market effects of California's minimum nurse staffing law.

In 2004, California became the first state to implement statewide minimum nurse-to-patient ratios in general hospitals. In spite of years of work to establish statewide staffing regulations, there is little evidence that the law was effective in attracting more nurses to the hospital workforce or improving patient outcomes. This paper examines the effects of this legislation on employment and wages of registered nurses. By using annual financial data from California hospitals, I show that nurse-to-patient ratios in medical/surgical units increased substantially following the staffing mandate. However, survey data from two nationally representative datasets indicate that the law had no effect on the aggregate number of registered nurses or the hours they worked in California hospitals, and at most a modest effect on wages. My findings suggest that offsetting changes in labor demand due to hospital closures, combined with reclassification of workers within hospitals, and mitigated the employment effects of California's staffing regulation. This paper cautions that California's experience with minimum nurse staffing legislation may not be generalizable to states considering similar policies in very different hospital markets.

The state of antimicrobial stewardship programs in California.

OBJECTIVE: To assess antimicrobial stewardship programs (ASPs) and strategies in California general acute care hospitals and to describe the effect of state legislation (Senate Bill 739) requiring hospitals to develop processes for evaluating the judicious use of antimicrobials. DESIGN: Web-based survey of general acute care hospitals. PARTICIPANTS: All 422 general acute care hospital campuses in California were invited to participate. RESULTS: Responses from 223 (53%) of California's general acute care hospital campuses were included and were statistically representative of all acute care hospital campuses by region but not bed size or rurality. Community hospitals represented 73% of respondents. Fifty percent of hospitals described a current ASP and 30% reported planning an ASP; of these, 51% reported measuring outcomes. Twenty percent of hospitals reported no planned ASP or uncertainty whether an ASP existed and described barriers including staffing constraints (47%), lack of funding (42%), and lack of initiation of a formal proposal to start an ASP (42%). Of 135 responding hospitals, 22% reported that Senate Bill 739 influenced initiation of their ASP. CONCLUSIONS: Although many studies have been published that describe hospital-specific ASPs, most have been described within academic centers, and there are limited assessments of ASP strategies across hospital systems. Our study verifies that many ASPs exist in California, particularly in community settings where a scarcity of antimicrobial restriction was thought to exist. Additionally, Senate Bill 739 appears to have played a role in initiating many hospital ASPs, which supports the adoption of similar legislation in other states and nationally.

The Mental Health Care Act No 17 - South Africa. Trials and triumphs: 2002-2012.

The Mental Health Care Act 17 of 2002 (MHCA) was promulgated in 2004. It has been hailed as one of the most progressive pieces of mental health legislation. A true measure of its merit is the degree to which it has transformed mental health services and in particular improved the quality of care. This paper will describe the impact of the Act on mental health care service delivery in the country. Literature pertaining to the MHCA published from 2006-2012, a report compiled by the South African Society of Psychiatrists and the results of a national survey conducted among Heads of Departments of Psychiatry, Mental Health Review Boards and Provincial Directors of Mental Health was reviewed. The MHCA has been successful in shifting the emphasis of care from psychiatric institutions to general hospitals. However, the integration of services has been hampered by infrastructure constraints and shortages of mental health personnel. It has been less successful in integrating mental health care into primary health services where the focus remains largely on the pharmacological maintenance treatment of the chronically mentally ill. Little attention has been given to the health promotion, disease prevention and rehabilitation aspects of care. Mental health review boards contend with limited resources, administrative challenges and limited political support. Isolated pockets of success characterised the implementation of the MHCA across the country. Greater investment of resources is needed to ensure the comprehensive implementation of the Act.

[Forced medical treatment: existent law and its limitations in a general hospital].

The conditions in which we can provide medical treatment without informed consent are detailed in the Israeli Law for Treating the Mentally Ill [1991), and the Law of Patient Rights (1996). Our clinicaL experience in a general hospital indicates that the law does not provide a satisfactory solution in cases where the patient is actively resisting emergency treatment. This may be the case for patients suffering from dementia, personality disorders or substance abuse disorders. Not infrequently, the physician finds himself perplexed in face of a genuine ethical/juridical dilemma, without being able to use the law efficiently or, at times, even implement it pragmatically. in this article, we review the array of laws by which Israeli physicians in general, and psychiatrists in particular, operate upon when deciding to treat a patient against his will in a general hospital. We describe and discuss a clinicaL case that raises fundamental questions concerning the existing law. We also discuss other complex cases, such as anorexia, debating the possibility of coercing medical treatment on someone who is not mentally ill--psychotic according to Israeli juridical system. Finally, we raise a few ideas as to how the present condition can be improved.

Client satisfaction in support of service planning within a regulatory framework: experience of a research hospital.

Research Operations at UHN provide services to a large, complex client research community with varying needs. This requires complex coordination and continual refining of service and resource targets to meet client, government and external stakeholder requirements. The UHN Research Operations model focuses on six key enablers: client education, service team expertise, direct communication, process improvement, quality assurance, and, systems and tools. Service departments that have deployed these enablers experience improved client satisfaction.

Informed consent in blood transfusion: knowledge and administrative issues in Uganda hospitals.

Blood as a transplant is not free of risks. Clinicians and patients ought to know the parameters of a transfusion informed consent. A mixed methodology to explore patients' and clinicians' knowledge and opinions of administration and strategies to improve the transfusion informed consent process was conducted. The clinicians' level of knowledge was limited to provision of information about and the right to consent to a transfusion. They disagreed on administrative issues but had acceptable opinions on improving the process. Patients perceived this process as a way of assurance of blood safety. This process is important and should not be omitted.

Effects of smoking ban in a general hospital psychiatric unit.

INTRODUCTION: Many psychiatric facilities allow patients to smoke cigarettes even though this habit is especially harmful for mental patients. METHODS: We studied the untoward effects produced by the smoking ban in 40 consecutive inpatients admitted to a psychiatric ward of a general hospital. RESULTS: A total of 52.2 % out of 40 patients were smokers; the mean Fagerstrom score was 5.9. The most frequent diagnostic groups were: schizophrenia and delusional disorders; mood disorders; and personality disorders. There were only two untoward effects related with the smoking ban during the study period. CONCLUSIONS: This study shows that the smoking ban can be successfully implemented in a general hospital psychiatric unit without causing unfavorable effects.

Constant Observation in the general hospital: a review.

The role of Constant Observation (COb) in the general hospital is addressed. The difficulties of managing acute psychological disturbance in the general hospital are described. Concerns about confused behavior and suicidal risk appear to be the most common reasons for ordering COb. Organic brain syndrome is the most common diagnosis made in patients receiving COb. Medico-legal, ethical and therapeutic aspects of COb are noted. To our knowledge there is no research evidence that COb significantly decreases the rate of suicide in the general hospital. It appears that the role of COb is enshrined in the general hospital as a result of medico-legal process in addition to its therapeutic role. Further research in this area is needed.

An eight-year follow-up national study of medical school and general hospital ethics committees in Japan.

BACKGROUND: Ethics committees and their system of research protocol peer-review are currently used worldwide. To ensure an international standard for research ethics and safety, however, data is needed on the quality and function of each nation's ethics committees. The purpose of this study was to describe the characteristics and developments of ethics committees established at medical schools and general hospitals in Japan. METHODS: This study consisted of four national surveys sent twice over a period of eight years to two separate samples. The first target was the ethics committees of all 80 medical schools and the second target was all general hospitals with over 300 beds in Japan (n = 1457 in 1996 and n = 1491 in 2002). Instruments contained four sections: (1) committee structure, (2) frequency of annual meetings, (3) committee function, and (4) existence of a set of guidelines for the refusal of blood transfusion by Jehovah's Witnesses. RESULTS: Committee structure was overall interdisciplinary. Frequency of annual meetings increased significantly for both medical school and hospital ethics committees over the eight years. The primary activities for medical school and hospital ethics committees were research protocol reviews and policy making. Results also showed a significant increase in the use of ethical guidelines, particularly those related to the refusal of blood transfusion by Jehovah's Witnesses, among both medical school and hospital ethics committees. CONCLUSION: Overall findings indicated a greater recognized degree of responsibilities and an increase in workload for Japanese ethics committees.

Detention on a general ward: understanding and applying the law.

From April 2007 there will be two acts of parliament that govern the legal detention of patients in hospitahl: the Mental Health Act 1983 and the Mental Capacity Act 2005. This article addresses common questions posed to liaison psychiatrists by hospital doctors: how to legally detain patients on general wards and how these Acts are applied.