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1.
BMC Health Serv Res ; 19(1): 797, 2019 Nov 05.
Artículo en Inglés | MEDLINE | ID: mdl-31690304

RESUMEN

BACKGROUND: Although not an inevitable part of ageing, frailty is an increasingly common condition in older people. Frail older patients are particularly vulnerable to the adverse effects of hospitalisation, including deconditioning, immobility and loss of independence (Chong et al, J Am Med Dir Assoc 18:638.e7-638.e11, 2017). The 'Systematic Approach to improving care for Frail older patients' (SAFE) study co-designed, with public and patient representatives, quality improvement initiatives aimed at enhancing the delivery of care to frail older patients within an acute hospital setting. This paper describes quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people. These improvement initiatives were aligned to five priority areas identified by patients and public representatives. METHODS: The co-design work was supported by four pillars of effective and meaningful public and patient representative (PPR) involvement in health research (Bombard et al, Implement Sci 13:98, 2018; Black et al, J Health Serv Res Policy 23:158-67, 2018). These pillars were: research environment and receptive contexts; expectations and role clarity; support for participation and inclusive representation and; commitment to the value of co-learning involving institutional leadership. RESULTS: Five priority areas were identified by the co-design team for targeted quality improvement initiatives: Collaboration along the integrated care continuum; continence care; improved mobility; access to food and hydration and improved patient information. These priority areas and the responding quality improvement initiatives are discussed in relation to patient-centred outcomes for enhanced care delivery for frail older people in an acute hospital setting. CONCLUSIONS: The co-design approach to quality improvement places patient-centred outcomes such as dignity, identity, respectful communication as well as independence as key drivers for implementation. Enhanced inter-personal communication was consistently emphasised by the co-design team and much of the quality improvement initiatives target more effective, respectful and clear communication between healthcare personnel and patients. Measurement and evaluation of these patient-centred outcomes, while challenging, should be prioritised in the implementation of quality improvement initiatives. Adequate resourcing and administrative commitment pose the greatest challenges to the sustainability of the interventions developed along the SAFE pathways. The inclusion of organisational leadership in the co-design and implementation teams is a critical factor in the success of interventions targeting service delivery and quality improvement.


Asunto(s)
Cuidados Críticos/organización & administración , Vías Clínicas/organización & administración , Fragilidad/terapia , Mejoramiento de la Calidad/organización & administración , Anciano , Anciano de 80 o más Años , Participación de la Comunidad , Anciano Frágil/psicología , Anciano Frágil/estadística & datos numéricos , Personal de Salud/psicología , Investigación sobre Servicios de Salud , Humanos , Participación del Paciente
2.
Presse Med ; 48(11 Pt 1): 1301-1305, 2019 Nov.
Artículo en Francés | MEDLINE | ID: mdl-31727486

RESUMEN

Menopause requires the implementation of organized screening and dedicated care pathways in collaboration with the attending physician, the gynaecologist-obstetrician and the cardiovascular physician. It will be necessary to take into account the hormonal specificities of the cardiovascular risk, in order to know-how to properly prescribe hormonal treatments.


Asunto(s)
Vías Clínicas/organización & administración , Hipertensión/terapia , Menopausia , Cardiología , Femenino , Francia , Ginecología , Humanos , Hipertensión/diagnóstico , Persona de Mediana Edad , Obstetricia , Grupo de Atención al Paciente/organización & administración
3.
BMC Med ; 17(1): 184, 2019 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-31570106

RESUMEN

BACKGROUND: The healthcare system can be understood as the dynamic result of the interaction of hospitals, patients, providers, and government configuring a complex network of reciprocal influences. In order to better understand such a complex system, the analysis must include characteristics that are feasible to be studied in order to redesign its functioning. The analysis of the emergent patterns of pregnant women flows crossing municipal borders for birth-related hospitalizations in a region of São Paulo, Brazil, allowed to examine the functionality of the regional division in the state using a complex systems approach and to propose answers to the dilemma of concentration vs. distribution of maternal care regional services in the context of the Brazilian Unified Health System (SUS). METHODS: Cross-sectional research of the areas of influence of hospitals using spatial interaction methods, recording the points of origin and destination of the patients and exploring the emergent patterns of displacement. RESULTS: The resulting functional region is broader than the limits established in the legal provisions, verifying that 85% of patients move to hospitals with high technology to perform normal deliveries and cesarean sections. The region has high independence rates and behaves as a "service exporter." Patients going to centrally located hospitals travel twice as long as patients who receive care in other municipalities even when the patients' conditions do not demand technologically sophisticated services. The effects of regulation and the agents' preferences reinforce the tendency to refer patients to centrally located hospitals. CONCLUSIONS: Displacement of patients during delivery may affect indicators of maternal and perinatal health. The emergent pattern of movements allowed examining the contradiction between wider deployments of services versus concentration of highly specialized resources in a few places. The study shows the potential of this type of analysis applied to other type of patients' flows, such as cancer or specialized surgery, as tools to guide the regionalization of the Brazilian Health System.


Asunto(s)
Vías Clínicas/estadística & datos numéricos , Parto Obstétrico/estadística & datos numéricos , Servicios de Salud Materna/estadística & datos numéricos , Transferencia de Pacientes/estadística & datos numéricos , Adulto , Brasil/epidemiología , Cesárea/estadística & datos numéricos , Ciudades/epidemiología , Ciudades/estadística & datos numéricos , Vías Clínicas/organización & administración , Vías Clínicas/normas , Estudios Transversales , Prestación de Atención de Salud/organización & administración , Prestación de Atención de Salud/normas , Parto Obstétrico/métodos , Parto Obstétrico/normas , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Servicios de Salud Materna/organización & administración , Servicios de Salud Materna/normas , Transferencia de Pacientes/organización & administración , Embarazo , Indicadores de Calidad de la Atención de Salud , Derivación y Consulta/estadística & datos numéricos , Análisis de Sistemas , Transporte de Pacientes/estadística & datos numéricos
4.
J Clin Nurs ; 28(23-24): 4434-4446, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31408555

RESUMEN

AIMS AND OBJECTIVES: To examine the lived experience of healthcare professionals providing care for patients with total hip and knee arthroplasty and to understand healthcare professionals' proposed eHealth needs in elective primary fast-track hip and knee arthroplasty journey. BACKGROUND: There is little evidence in nursing literature to indicate how to develop new eHealth services to support surgical care journeys. Evidence is particularly lacking regarding the development of eHealth solutions. DESIGN: This was a qualitative interview study. METHODS: Semi-structured interviews were conducted with four surgeons, two anaesthesiologists, ten nurses and four physiotherapists in a single joint replacement centre during autumn 2018. The data were analysed using an inductive content analysis method. NVivo qualitative data analysis software was used. The COREQ checklist for qualitative studies was followed. RESULTS: Our research addressed the gap in evidence by focusing on the four main parts of the patient journey in the selected context. Analysis of the data revealed nine main categories for the proposed eHealth needs: eligibility criteria, referrals, meeting the Health Care Guarantee, patient flow, postdischarge care, patient counselling, communication, transparency of the journey and receiving feedback. In addition, the requirements and further development needs for eHealth solutions were generally identified. CONCLUSIONS: From the point of view of healthcare professionals, eHealth solutions have huge potential in supporting the elective primary fast-track hip and knee arthroplasty journey. However, it is important to acknowledge that these needs may be very different depending on the technological and organisational environment in question. RELEVANCE TO CLINICAL PRACTICE: More effective use of information and communication technologies is needed for organisational optimisation resulting in a streamlined pathway, better access to healthcare services, improved outcomes and an improved patient experience. These results can be used in the development of new eHealth solutions to support surgical care journeys and patient education.


Asunto(s)
Artroplastia de Reemplazo de Cadera/enfermería , Artroplastia de Reemplazo de Rodilla/enfermería , Personal de Salud/organización & administración , Evaluación de Necesidades , Telemedicina/organización & administración , Vías Clínicas/organización & administración , Femenino , Humanos , Entrevistas como Asunto , Investigación Cualitativa
5.
Am J Health Syst Pharm ; 76(16): 1219-1225, 2019 Aug 01.
Artículo en Inglés | MEDLINE | ID: mdl-31369118

RESUMEN

PURPOSE: Results of a study incorporating real-world results into a predictive model to assess the cost-effectiveness of procalcitonin (PCT)-guided antibiotic use in intensive care unit patients with sepsis are reported. METHODS: A single-center, retrospective cross-sectional study was conducted to determine whether reductions in antibiotic therapy duration and other care improvements resulting from PCT testing and use of an associated treatment pathway offset the costs of PCT testing. Selected base-case cost outcomes in adults with sepsis admitted to a medical intensive care unit (MICU) were assessed in preintervention and postintervention cohorts using a decision analytic model. Cost-minimization and cost-utility analyses were performed from the hospital perspective with a 1-year time horizon. Secondary and univariate sensitivity analyses tested a variety of clinically relevant scenarios and the robustness of the model. RESULTS: Base-case modeling predicted that use of a PCT-guided treatment algorithm would results in hospital cost savings of $45 per patient and result in a gain of 0.0001 quality-adjusted life-year. After exclusion of patients in the postintervention cohort for PCT test ordering outside of institutional guidelines, the mean inpatient antibiotic therapy duration was significantly reduced in the postintervention group relative to the preintervention group (6.2 days versus 4.9 days, p = 0.04) after adjustment for patient sex and age, Charlson Comorbidity Index score, study period, vasopressor use, and ventilator use. Total annual hospital cost savings of $4,840 were predicted. CONCLUSION: Real-world implementation of PCT-guided antibiotic use may have improved patients' quality of life while decreasing hospital costs in MICU patients with undifferentiated sepsis.


Asunto(s)
Antibacterianos/uso terapéutico , Infecciones Bacterianas/tratamiento farmacológico , Monitoreo de Drogas/economía , Polipéptido alfa Relacionado con Calcitonina/sangre , Sepsis/tratamiento farmacológico , Anciano , Infecciones Bacterianas/sangre , Infecciones Bacterianas/mortalidad , Biomarcadores/sangre , Ahorro de Costo , Análisis Costo-Beneficio , Vías Clínicas/economía , Vías Clínicas/organización & administración , Estudios Transversales , Costos de los Medicamentos , Monitoreo de Drogas/métodos , Femenino , Implementación de Plan de Salud/economía , Costos de Hospital , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos/economía , Unidades de Cuidados Intensivos/organización & administración , Masculino , Persona de Mediana Edad , Modelos Económicos , Evaluación de Programas y Proyectos de Salud , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos , Sepsis/sangre , Sepsis/mortalidad
6.
G Ital Med Lav Ergon ; 41(2): 78-104, 2019 05.
Artículo en Italiano | MEDLINE | ID: mdl-31170337

RESUMEN

SUMMARY: According to the latest WHO guidelines, the ICD-ICF joint use currently represents the most agreed method to portray a patient's Care Pathway during a hospitalization. On this note, ICS Maugeri carried out an internal project aiming to identify the ICF codes that better describe the rehabilitation pathways in its Italian Institutes. 2 main goals so far have been achieved: 1. To re-conceptualize the Care Pathways thought the lenses of the ICD-ICF frameworks; 2. To link, whenever possible and by means of the WHO-ICF linking rules, each pertinent ICF code to the most appropriate assessment method, harmonizing its outputs to the 0-4 ICF Likert scale. The current project represents a first attempt towards the creation of a standard functioning assessment methodology to be implemented in rehabilitation settings. Despite being referred to the Maugeri group only, the ICD-ICF procedure described could hopefully be extended to other settings, representing a support for health information technologies.


Asunto(s)
Vías Clínicas/organización & administración , Hospitalización , Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud , Evaluación de la Discapacidad , Humanos , Clasificación Internacional de Enfermedades , Italia
7.
G Ital Med Lav Ergon ; 41(2): 105-111, 2019 05.
Artículo en Italiano | MEDLINE | ID: mdl-31170338

RESUMEN

SUMMARY: Due to epidemiological and social changes related to the increase in the average life expectancy, hospital users are characterized by elderly chronic and comorbid patients who require recurrent hospitalizations often with disability outcomes. In this framework, an innovative clinical and management hospitalization model is the adequate answer to systematically promote the patient independence. Main features are interdisciplinary and integrated care pathways facing both disease and disability biologically and functionally diagnosed by ICD and ICF. The definition, personalization of pathways/protocols and outcome evaluation represent the foundations of this new model for patient care. The digitalization of hospital clinical data and medical knowledge make the model feasible and fitting the recent WHO guideline: recommendations on digital interventions for health system strengthening.


Asunto(s)
Vías Clínicas/organización & administración , Hospitalización/estadística & datos numéricos , Rehabilitación/organización & administración , Anciano , Personas con Discapacidad , Humanos , Clasificación Internacional de Enfermedades , Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud , Modelos Organizacionales
8.
G Ital Med Lav Ergon ; 41(2): 112-116, 2019 05.
Artículo en Italiano | MEDLINE | ID: mdl-31170339

RESUMEN

SUMMARY: One of the main aims of Healthcare Information Technology is the safe and efficient management of significant amounts of clinical data. Now more than ever, such goal requires the creation of common semantics to ontologically organize knowledge enclosed in databases. By means of the application of the WHO ICD-ICF frameworks, the ensemble of rehabilitative activities lead in all the Maugeri institutes in Italy, has been formally standardized to create a Nomenclator, with the aim to: a) support clinicians in the definition of the individualized Care Pathway; b) program, optimize and maximize patient's rehabilitation activities, according to clinical and organizational requirements; c) qualitatively and quantitatively report the daily health-care professionals' workflows; d) provide a structured and detailed medical record meeting appropriateness requirements. In this regard, the application of the ICD-ICF framework as a baseline ontology, paves the path to an ongoing tracking of the rehabilitation processes, leading to a more accurate description of patient's functioning profile. The upcoming challenge for rehabilitation is the ultimate overcoming of a solely epidemiological perspective, in order to embrace a holistic approach, fostered by ontologically-based information technologies.


Asunto(s)
Vías Clínicas/organización & administración , Tecnología de la Información , Rehabilitación/organización & administración , Evaluación de la Discapacidad , Personal de Salud/organización & administración , Humanos , Clasificación Internacional de Enfermedades , Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud , Italia , Flujo de Trabajo
9.
J Surg Res ; 242: 276-285, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31125841

RESUMEN

BACKGROUND: Although Enhanced Recovery after Surgery (ERAS) pathways are becoming the standard of care in microvascular breast reconstruction, evidence supporting their use is limited or based on small sample sizes. We hypothesized that improvements in postoperative outcomes would persist when examining the largest cohort of patients undergoing abdominal-based microvascular breast reconstruction, to date. MATERIALS AND METHODS: Data were retrospectively reviewed for 276 consecutive patients who underwent abdominal-based free flap breast reconstruction before and after ERAS implementation (pre-ERAS, n = 138 patients; post-ERAS, n = 138 patients). Primary outcomes were postoperative opioid use measured in oral morphine equivalents (OMEs), median hospital length of stay (LOS) in days, and incidence of postoperative complications. RESULTS: Postoperative opioid requirements were significantly lower in the post-ERAS cohort compared with the pre-ERAS cohort (57.3 OME, [interquartile range 20.0-115.5] versus 297.3 OME [interquartile range 138.6-437.7], P < 0.0001). There was no significant difference in hospital LOS when controlling for variables that differed between the groups. In addition, there were no differences in the rate of postoperative complications, return to operating room, or readmission after ERAS pathway implementation. CONCLUSIONS: ERAS improves specific aspects of recovery for patients undergoing microvascular breast reconstruction, most notably postoperative opioid use. Patient selection and a shift toward less invasive procedures may explain a nonsignificant impact on hospital LOS.


Asunto(s)
Vías Clínicas/organización & administración , Colgajos Tisulares Libres/trasplante , Mamoplastia/métodos , Complicaciones Posoperatorias/prevención & control , Pared Abdominal/cirugía , Adulto , Femenino , Colgajos Tisulares Libres/efectos adversos , Implementación de Plan de Salud , Humanos , Incidencia , Tiempo de Internación , Mamoplastia/efectos adversos , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Evaluación de Programas y Proyectos de Salud , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento
10.
BMC Musculoskelet Disord ; 20(1): 186, 2019 May 01.
Artículo en Inglés | MEDLINE | ID: mdl-31043169

RESUMEN

BACKGROUND: A model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment. METHODS: Nurse-assessed patients with MSD (N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results. RESULTS: The group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 €, the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis. CONCLUSION: From the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02218749 . Registered August 18, 2014.


Asunto(s)
Análisis Costo-Beneficio/estadística & datos numéricos , Enfermedades Musculoesqueléticas/terapia , Atención Primaria de Salud/economía , Triaje/economía , Adolescente , Adulto , Anciano , Vías Clínicas/economía , Vías Clínicas/organización & administración , Femenino , Estudios de Seguimiento , Médicos Generales/economía , Médicos Generales/estadística & datos numéricos , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Musculoesqueléticas/diagnóstico , Enfermedades Musculoesqueléticas/psicología , Enfermeras y Enfermeros/economía , Enfermeras y Enfermeros/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Fisioterapeutas/economía , Fisioterapeutas/estadística & datos numéricos , Atención Primaria de Salud/organización & administración , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Suecia , Resultado del Tratamiento , Triaje/estadística & datos numéricos , Adulto Joven
12.
J Health Organ Manag ; 33(3): 323-338, 2019 May 20.
Artículo en Inglés | MEDLINE | ID: mdl-31122119

RESUMEN

PURPOSE: The purpose of this paper is to define a clinical pathway for total joint replacement (TJR) surgery, estimate the effect of delays between steps of the pathway on wait time for surgery and to identify factors contributing to more efficient operations and challenges to their implementation. DESIGN/METHODOLOGY/APPROACH: This is a case study with a mixed methods approach. The authors conducted interviews with hospital staff. Data collected in the interviews and through on-site observation were analyzed to map the TJR process and identify the steps of the care pathway. The authors extracted and analyzed data (time stamps) from 60 hospital patient records for each step in the pathway and ran a regression on the duration of the whole trajectory. FINDINGS: There were wide variations in the delays observed between the seven steps identified. The delay between Step 1 and Step 2 was the only significant variable in predicting the total wait time to surgery. In one hospital, one delay explained 50 percent of the variation. There was misalignment between findings from the qualitative data in terms of strategies implemented to increase efficiency of the clinical pathway to the quantitative data on delays between the steps. RESEARCH LIMITATIONS/IMPLICATIONS: The study identified the clinical pathway from the consultation with an orthopaedic surgeon to the surgery. However, it did not go beyond the surgery. Future research could investigate the relationship between specific processes and delays between steps of the process and patient outcomes, including length of stay, mobilization and functionality in activities of daily living, as well as potential complications from surgery, readmission and the services required after the patient was discharged. PRACTICAL IMPLICATIONS: Wait times can be addressed by implementing strategies at the health system level or at the organizational level. The authors found and discuss areas where there could be efficiency gains for health care organizations. SOCIAL IMPLICATIONS: Stakeholders in care processes are diverse and they each have their preferences in how they practice (in the case of providers) and how they perceive and wish to respond adequately to patients' needs in contexts that have different norms and approaches. The approach in this study enables a better understanding of the processes, the organizational culture and how these may affect each other. ORIGINALITY/VALUE: Our mixed methods enabled a process mapping and the identification of factors that significantly affected the efficiency of the TJR surgery process. It combines methods from process engineering with health services and management research. To some extent, this study demonstrates that although managers can define and enforce processes, organizational culture and practices are harder to influence.


Asunto(s)
Vías Clínicas/organización & administración , Eficiencia Organizacional , Artroplastia de Reemplazo , Procedimientos Quirúrgicos Electivos/métodos , Humanos , Listas de Espera
18.
J Gastrointestin Liver Dis ; 28(1): 83-88, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30851176

RESUMEN

BACKGROUND AND AIMS: In 2009, the Danish Government instituted "Fast Track Clinical Pathways" (FTCP) to accelerate diagnosis and treatment of cancers including hepatocellular carcinoma (HCC). We examined how the implementation of FTCP affected the time from referral to diagnosis and treatment as well as the patient survival. METHODS: 309 consecutive patients with suspected HCC were included, 79 referred during the period 2007-2008 (before FTCP) and 230 during 2009-2011. Of those, 271 (88%) were diagnosed with HCC and 161 (60%) had cirrhosis, in most cases caused by alcohol. RESULTS: The time from referral to the first visit was reduced from a mean 16.4 (11.5) to 5.4 (6) days (p<0.001) and the time from the first visit to the Multidisciplinary Tumour Conference (MDT) treatment decision from 34.9 (27.9) to 16.1 (14.4) days (p<0.001). The total time from referral to treatment was reduced from 53.2 (37.9) to 35.9 (23.1) days (p<0.001). There was a weak trend of improved survival after FTCP: 231 (147-368) vs. 293 (227-396) days (p=0.11). CONCLUSIONS: The implementation of FTCP reduced the total time from referral to treatment by three weeks; however, without significant effects on overall mortality. While shortened waiting time is a comfort for the patient, it remains to be elucidated whether it will change the prognosis.


Asunto(s)
Carcinoma Hepatocelular/terapia , Vías Clínicas/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Detección Precóz del Cáncer/métodos , Neoplasias Hepáticas/terapia , Derivación y Consulta/organización & administración , Tiempo de Tratamiento/organización & administración , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/mortalidad , Toma de Decisiones Clínicas , Dinamarca , Eficiencia Organizacional , Femenino , Humanos , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/mortalidad , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Evaluación de Programas y Proyectos de Salud , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Listas de Espera , Adulto Joven
19.
J Clin Nurs ; 28(11-12): 2214-2224, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-30786078

RESUMEN

AIM: To explore patients' and healthcare professionals' experiences of patients' surgical pathways in a perioperative setting. BACKGROUND: Elective surgical pathways have improved over the past decades due to fast-track programmes, but patients desire more personalised and coordinated care and treatment. There is little knowledge of how healthcare professionals' collaboration and communication affect patients' pathways. DESIGN: The overall framework was complex intervention method. A phenomenological-hermeneutic approach was used for data analyses. COREQ checklist was used as a guideline to secure accurate and complete reporting of the study. METHODS: Field observations (120 hr) and semi-structured interviews (24 patients) were undertaken during 2016-2017. Healthcare professionals involved in the pathways were interviewed: (a) 13 single interviews and (b) 13 focus group interviews (37 healthcare professionals) were conducted. The Consolidated Criteria for Reporting Qualitative Research checklist was used. RESULTS: Patients asked for individualised information adapted to their life and illness experiences. Furthermore, healthcare professionals need access to a quick overview of individual patients and their perioperative pathway in the electronic patient journal (EPJ). Agreements made with patients did not always reach the right receiver, there was poor interpersonal communication and the complex teamwork between many healthcare professionals made pathways incoherent and uncoordinated. Healthcare professionals who had the time to talk about other subjects than the disease with smiles and good humour gave patients a feeling of security. CONCLUSION: Patients wanted to be treated as individuals, but often they received standard treatment. Healthcare professionals had the intention of treating patients individually, but the EPJ and information provided to patients were not easy to access. RELEVANCE TO CLINICAL PRACTICE: Visible information about the patient's whole pathway could improve healthcare professionals' care and treatment. In addition, systematic feedback from patients' could make it possible to adjust information, care and treatment to achieve a more coherent pathway. Particular attention needs to be paid to how electronic healthcare systems can underpin relational coordination in pathways.


Asunto(s)
Actitud del Personal de Salud , Vías Clínicas/organización & administración , Personal de Salud/psicología , Atención Dirigida al Paciente/normas , Atención Perioperativa/métodos , Femenino , Grupos Focales , Conocimientos, Actitudes y Práctica en Salud , Humanos , Relaciones Interpersonales , Masculino , Atención Perioperativa/psicología , Investigación Cualitativa
20.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 31(1): 102-107, 2019 Jan.
Artículo en Chino | MEDLINE | ID: mdl-30707878

RESUMEN

OBJECTIVE: To explore the effective strategies of clinical pathway construction in intensive care unit (ICU). METHODS: From January 2016 to July 2018, 1 488 patients were discharged from ICU of Liuzhou Worker's Hospital of Guangxi Zhuang Autonomous Region. The pilot project of "postoperative monitoring of heart disease" with simpler route and less variation was selected first, and then the pilot project was promoted to "post-operative monitoring" after its success. The implementation of the clinical pathway was divided into three stages: the first stage, January 2016 to May 2017, for the pilot phase, a total of 87 patients were enrolled in the clinical pathway trial; the second stage, June 2017 to December 2017, surgical ICU "postoperative monitoring of heart disease" was put into the pathway 111 times; the third stage, January 2018 to July 2018, surgical ICU "postoperative monitoring of heart disease" was entered in the path 116 times; comprehensive ICU "postoperative care" was put into the path 96 times. After carefully analyzed the reasons and sum up the experience, internet+medical treatment (Liuzhou Worker's Hospital became the fifth deep partner of Tencent Inc in the internet+medical field, and carried out the plan and practice of "WeChat wisdom hospital 3.0" in 2017) was used, four aspects of connection, payment, security and ecological cooperation were upgraded, and the construction of 6 level of electronic medical record (EMR) was accelerated. At the same time, through diagnosis related groups system (DRGs), the concept of evidence-based medicine, quality management and continuous improvement as the leading factor, and combined with the construction status of hospital information system (HIS) and EMR system, step by step implementation and design of information management platform for clinical pathway were formulated. The completion rate of clinical pathway, average length of hospital stay, average cost, cure rate and improvement rate were the main observation parameters. RESULTS: In the first stage, none of the 87 patients who entered the clinical pathway completed the clinical pathway. In the second stage, the completion rate of surgical ICU clinical pathway was increased from 33.33% in June 2017 to 94.44% in December 2017, and up to 100% in October 2017, and the average completion rate from January to July 2018 was 94.00%. The completion rate of ICU clinical pathway was increased from 81.82% in January 2008 to 92.86% in July 2008. There was a significant difference in the overall clinical pathway completion rate from 2016 to 2018 (χ2 = 204.300, P = 0.000). After the effective implementation of clinical pathway in June 2017, the length of hospital stay of patients was significantly shortened as compared with that before implementation (days: 2.96±0.43 vs. 6.66±0.75, P < 0.01), and the daily cost was significantly reduced (Yuan: 3 550.92±755.51 vs. 6 171.48±377.29, P < 0.01). The average length of hospital stay was shortened by about 3.84 days (P < 0.01), and the average daily cost was reduced by about 2 108.39 Yuan (P < 0.01) after the implementation of clinical pathway by surgical ICU "postoperative monitoring of heart disease" as compared with those before implementation. The average length of hospital stay was shortened by about 2.98 days (P < 0.01) and the average daily cost was reduced by 5 094.13 Yuan (P < 0.01) after the implementation of clinical pathway by comprehensive ICU "post-operative monitoring" as compared with those before implementation. At the same time, the cure rate was increased from 1.16% (7/603) to 42.26% (105/227), and the improvement rate was decreased from 94.36% (569/603) to 52.86% (120/227, both P < 0.01) after the implementation of surgical ICU clinical pathway, but there was no significant difference in the cure rate or the improvement rate after the implementation of comprehensive ICU [2.77% (33/1 193) vs. 2.22% (2/90), 79.21% (945/1 193) vs. 97.78% (88/90), both P > 0.05]. CONCLUSIONS: Application of clinical pathway to control ICU quality and guide diagnosis and treatment, more refined diagnosis and treatment schemes including clinical guidelines, average length of stay, average cost of hospitalization, cost-efficiency ratio and so on were completed, which confirmed that the improvement of clinical pathway management strategy originated from clinical were needed. Informatization, intellectualization, standardization and effective control of medical cost of clinical pathway could improve medical quality and accurate management. The integration of ICU clinical pathway construction and HIS could promote the development of digital hospitals.


Asunto(s)
Vías Clínicas/organización & administración , Sistemas de Información en Hospital/organización & administración , Unidades de Cuidados Intensivos/organización & administración , China , Humanos , Proyectos Piloto
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