The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole-Community Approach to Reducing Mortality From Active Violent Incidents.

Active violent incidents are dynamic and challenging situations that can produce a significant amount of preventable deaths. Lessons learned from the military?s experience in Afghanistan and Iraq through the Committee on Tactical Combat Casualty Care and the 75th Ranger Regiment?s Ranger First Responder Program have helped create the Committee for Tactical Emergency Casualty Care (C-TECC) to address the uniqueness of similar wounding patterns and to end preventable deaths. We propose a whole-community approach to active violent incidents, using the C-TECC Trauma Chain of Survival and a tiered approach for training and responsibilities: the first care provider, nonmedical professional first responders, medical first responders, and physicians and trauma surgeons. The different tiers are critical early links in the Chain of Survival and this approach will have a significant impact on active violent incidents.

Transición del paciente con diabetes tipo 1 desde la Unidad de Diabetes pediátrica a la Unidad de Diabetes de adultos / Transition of adolescents with type 1 diabetes from paediatric to adult Health Care

La transición de los pacientes pediátricos con diabetes tipo 1 (DM1) a Unidades de adultos puede conllevar efectos adversos para la salud de los pacientes si no se hace de forma adecuada. El paso tiene lugar durante la adolescencia, periodo especialmente crítico de la vida caracterizado por cambios específicos tanto psicológicos como fisiológicos, durante el que se incrementa el riesgo de aparición y progresión de las complicaciones crónicas así como de los ingresos relacionados con la DM1. Coincidiendo con el cambio de equipo médico se han objetivado pérdidas en el seguimiento de los pacientes y un empeoramiento en su grado de control metabólico que debemos intentar evitar. Se precisan programas planificados, progresivos y estructurados que incluyan la participación del individuo, de la familia y del servicio de salud para que la transición sea lo más favorable posible. El momento óptimo para hacer el cambio de equipo sanitario es cuando el paciente tenga madurez suficiente para ser casi autónomo en el tratamiento de la DM1, situación que en la mayoría de las personas no se alcanza antes de los 16-18 años. La coordinación entre los profesionales de pediatría y de adultos, la educación grupal, el uso de tecnologías y el abordaje psicosocial favorecen la adherencia y el seguimiento en esta fase de transición. Tras la valoración de las recomendaciones de las Sociedades Científicas Internacionales se propone un modelo de transición consensuado entre las Sociedad Española de Diabetes y la Sociedad Española de Endocrinología Pediátrica

The transition of adolescents with type 1 diabetes mellitus (T1DM) from paediatric health care to adult health care has been recognized as an important and difficult process, with a high risk of interruption of care and associated with poor glycaemic control. Transition to adult units takes place during adolescence in an especially critical period of life with changes, both in psychological and physiological aspects that increase the risk of onset and progression of chronic complications related to T1DM.Adverse outcomes that may affect the health of these patients can appear if transition is not done properly. Previous studies have shown that planned and structured transition programs are required, including the participation of the individual, the family, and the health service. The best time to make the transition is when they are mature enough to be almost capable of managing their T1DM. The majority of patients do not reach this stage before the age of 16-18 years. There should be coordination between professionals of paediatric and adult health care in the planning of this transition. Group education programs, the use of new technologies, and the approach to psychosocial aspects are suggested in order to improve adherence and followup during this period. After assessing the recommendations of some International Scientific Societies, the Spanish Society of Diabetes and the Spanish Society for Pediatric Endocrinology propose following a planned transition model

[Progressive Patient Care Model and its application into hospital organization: a narrative review]. / Progressive Patient Care e organizzazione ospedaliera per intensità di cure: revisione narrativa della letteratura.

Aim of this article is to review the literature about the Progressive Patient Care Model, in particular its conceptual and practical characteristics, its implementation and effects on the current health care organization. Was conducted by an integrative-narrative literature review. The Progressive Patient Care is a model which aims at group patients according to their complexity in order to place patients in the most appropriate care setting. The original model consists on five care levels: intensive care, intermediate care, self-care, long term care, home care.In Italy the above mentioned model can be considered as a contextualization of Progressive Patient Care in the light of similarities both in terms of model purposes and care levels classification. The organization for intensive care levels is an opportunity for Italian healthcare facilities to reach continuity of care. This model emphazises care processes looking to patients' needs rather than a division according to criteria of specialties.

Intermediate care for homeless people: results of a pilot project.

A year-long, nurse-led intermediate care pilot project was undertaken at a 120-bed homeless hostel in south London to improve healthcare outcomes among the clients involved, and to reduce emergency department (ED) attendance, ambulance call outs and use of acute care services. By the end of the year, the number of ED and hospital admissions had dropped significantly. The project was recognised by the Department of Health in 2010 as an example of innovative practice in work with 'at-risk' groups, and was awarded the 2011 Nursing Standard Community Nursing Award. This article considers reasons for the success of the project and the lessons that can be learned from it.

Pediatric mass critical care in a pandemic.

OBJECTIVES: Previous simulation studies suggest that temporary pediatric mass critical care approaches would accommodate plausible hypothetical sudden-impact public health emergencies. However, the utility of sustained pediatric mass critical care responses in prolonged pandemics has not been evaluated. The objective of this study was to compare the ability of a typical region to serve pediatric intensive care unit needs in hypothetical pandemics, with and without mass critical care responses sufficient to triple usual pediatric intensive care unit capacity. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS: The Monte Carlo simulation method was used to model responses to hypothetical pandemics on the basis of national historical evidence regarding pediatric intensive care unit admission and length of stay in pandemic and nonpandemic circumstances. Assuming all ages are affected equally, federal guidelines call for plans to serve moderate and severe pandemics requiring pediatric intensive care unit care for 457 and 5,277 infants and children per million of the population, respectively. MEASUREMENTS AND MAIN RESULTS: A moderate pandemic would exceed ordinary surge capacity on 13% of pandemic season days but would always be accommodated by mass critical care approaches. In a severe pandemic, ordinary surge methods would accommodate all the patients on only 32% of pandemic season days and would accommodate 39% of needed patient days. Mass critical care approaches would accommodate all the patients on 82% of the days and would accommodate 64% of all patient days. CONCLUSION: Mass critical care approaches would be essential to extend care to the majority of infants and children in a severe pandemic. However, some patients needing critical care still could not be accommodated, requiring consideration of rationing.

Internación por cuidados progresivos: propuesta metodológica para su implementación en un hospital general de agudos / Progressive patient care

Implementar un sistema de cuidados progresivos y atención interdisciplinaria en los hospitales generales del subsector público representa un desafío para el sistema de atención de la salud. El modelo, ya presente en un importante número de establecimientos del subsector privado y de la seguridad social, ubica a los pacientes en sectores de internación según sus necesidades de cuidado y dependencia, y no según las especialidades médicas tradicionales. En el presente artículo se presenta el marco conceptual y una propuesta metodológica para su efectiva implementación en un hospital público venciendo las naturales resistencias al cambio.

Implementation of progressive care patients and interdisciplinary care models in General Hospitals has been challengin for Public Health Care Sistems. The model actualy present in some Social Security and Private Hospitals place the patients in areas or units on the basis of their needs for care as deter­minated by the degree of illnes rather than on the basis of a medical specialty. This article describes the models theory and how it is posible to implement in a Public General Hospital despite of the natural resistence to change.

Strategies for transitioning to adult care for youth with Lennox-Gastaut syndrome and related disorders.

Transition is the process of preparing children with chronic illness and their families for the adult health care system. In patients with Lennox-Gastaut syndrome (LGS) and related disorders, the process of transition is complicated by the presence of intellectual handicap, treatment-resistant epilepsy, and behavioral issues. Patients who are not successfully transitioned to adult care may end up without specialty care, may not receive satisfactory adult services, may lack adequate follow-up and access to newer therapies, and may lack appropriate management of comorbid conditions. Several family related and clinician-related barriers can inhibit the transition process. Transition strategies that maximize each patient's ability to achieve his or her potential and optimize self-sufficiency may lead to better social outcomes. Adolescent clinics that include members of the pediatric and adult neurology teams may help ensure a smooth transition to adult care, although studies are needed to objectively establish the best model. Results are reported from a survey of 133 symposium attendees on the topic of practice characteristics and issues related to transitioning care. Results suggested a great deal of dissatisfaction about the process of transition, especially for patients with intellectual handicap. We provide suggestions for developing a transition program, including identifying a willing adult service, adapting a multidisciplinary approach, addressing legal and psychosocial issues, and celebrating rites of passage.

Rehospitalization from skilled nursing facilities: implications for policy.

(1) Between 2000 and 2006, rehospitalizations within 30 days following discharge to a skilled nursing facility increased by 29 percent. (2) Initial site of residence prior to a hospitalization affects the likelihood of a rehospitalization. (3) There is a significant variation across states in the rate of rehospitalizations following discharge to a skilled nursing facility.

[Integrated care for patients with advanced chronic obstructive pulmonary disease]. / Zintegrowana opieka medyczna u chorych na zaawansowana przewlekla obturacyjna chorobe pluc.

Chronic obstructive pulmonary disease (COPD) is the third cause of mortality and disability (assessed by DALY) among patients above 60 year old. Severe and very severe COPD (FEV(1) = equal or less than 50% and 30% of expected value, respectively) is estimated at 20% of all COPD patients. Advanced COPD usually leads to physical and mental deterioration, the patients often manage with the problems caused by the disease and other comorbidities poorly. This leads to increased risk of COPD exacerbations and further deterioration of the patient's status, increased costs of medical care and eventually increased risk of death. Current organization of medical care for those patients does not provide adequate health and social support for them. However, it seems that introducing an integrated approach proposed by World Health Organization, could improve the situation of advanced COPD patients. In Poland, this kind of care has been provided in advanced cancer patients throughout stationary palliative care units and hospices during the last several years. This experience should be helpful in integrating actions of general practitioners and specialized nurses, as well as providing access for the specialists' consultations according to the individual needs of the patients. It should also allow for broad cooperation with auxiliary staff, such as social workers, medical assistants and volunteers, as well as psychologists and clergymen (especially in the terminal phase of the disease).

Improving geriatric transitional care through inter-professional care teams.

OBJECTIVES: The aim of this study was to examine the impact of the use of an inter-professional care team on patient length of stay and payer charges in a geriatric transitional care unit. METHODS: An analysis of de-identified administrative records for transitional care patients for the 12-month period (2003-2004) cared for by the inter-professional team (n = 163) and cared for by traditional single provider care model (n = 176) was carried out. We conducted logistic regression on length of stay and charges controlling for patient demographics and acuity levels. RESULTS: The inter-professional care team patients had significantly shorter lengths of stay, fewer patient days and lower total charges. Patient diagnosis and acuity were similar across groups. CONCLUSION: This study provides empirical evidence of the impact of an inter-professional care model in providing cost-effective transitional care in a nursing home setting. Evidence of shorter lengths of stay, shorter patient days and lower charges suggests benefit in the development and financing of inter-professional care teams for transitional care services.

The role of mental health staff in intermediate care.

Intermediate care enables older people to have access to a range of intermediate care services at home or in designated settings. This article outlines developments in health and social policy since the inception of intermediate care and then presents three case studies that explore the positive contribution that mental health staff have made to an intermediate care team in south west England.

Self-esteem in patients treated for anorexia nervosa.

Anorexia nervosa (AN) mainly affects girls or women between 13 and 45 years of age. According to previous studies, one of the reasons for the desire to be thin is low self-esteem. The purpose of the study was to examine the self-esteem of 38 female patients with AN between 16 and 25 years of age, before and after 3 months of treatment at a specialist ward for eating disorders in Göteborg, Sweden. A quantitative pre- and post-assessment based on two self-rating questionnaires, the Rosenberg Self-Esteem Scale (RSE-S) and three subscales (weight phobia, body dissatisfaction, and ineffectiveness) of Eating Disorder Inventory-2 (EDI-2), together with body mass index (BMI), were used in the study, which was conducted between June 2005 and March 2008. The results reveal that self-esteem, BMI, weight phobia, and body dissatisfaction improved significantly between pre- and post-treatment. The RSE-S and EDI-2 ineffectiveness correlate highly with one another, which lends support to convergent validity, and the internal consistency was high for both the RSE-S and EDI-2 ineffectiveness. The results indicate that the treatment was effective, as both patients' self-esteem and BMI increased after completed treatment, which was the primary goal of the treatment at this ward. Future studies should focus on follow up and the way self-esteem manifests itself at different points in time within an individual.

Home hospitalization unit: an alternative to standard inpatient hospitalization from the emergency department.

OBJECTIVE: To assess the characteristics of the patients admitted to a home hospitalization unit (HHU) after a first emergency department (ED) visit. METHODS: This was a descriptive, retrospective study. The setting of the study was the ED of a 500-bed teaching hospital, which treats 125 000 emergency visits per year. HHU admits patients from the ED when hospitalization is imminent. Participants were all patients attending our ED from 1 January 2005 to 31 December 2005 and finally admitted to HHU. Variables were age, sex, diagnostic, mean length of stay, and readmission rate. RESULTS: A cohort composed of 250 patients admitted to HHU directly from the ED was identified. Mean age was 75 years. One hundred and fifty-eight were males (63%). The most common diagnoses were acute exacerbation of chronic obstructive pulmonary disease (127 of 250 patients, 50.8%), acute exacerbation of chronic heart failure (32 of 250 patients, 12.8%), pneumonia (24 of 250 patients, 9.6%), urinary tract infection (20 of 250 patients, 8%), and leg deep venous thrombosis (14 of 250 patients, 5.6%). Mean length of stay was 8 days. Readmission rate was 9%. CONCLUSION: A HHU proved to be effective and safe for acutely ill individuals who required hospitalization.

Standardization of change-of-shift report.

This article describes a clinical nurse-led initiative that changed the traditional group shift report in the conference room to a combination of a written report with a nurse-to-nurse verbal exchange at the patient's bedside. The new process resulted in less time spent in shift report, financial savings from reduced overtime, and a decrease in the number of patient falls and call lights during change of shift.

Staff nurses' experiences of a change in the care delivery model: a qualitative analysis.

This qualitative study describes the staff nurses' perspective of change in the care delivery model and skill mix in an intermediate care unit. Data were collected in interviews in focus groups with the registered nurses affected by the change. Two major themes emerged: (1) autonomy and control and (2) interdependence. The nurses emphasized an increased satisfaction (self and patient) with this model. This study confirmed that autonomy, control, connection with the patient, and peer and interdisciplinary support and respect are important for the staff nurse. These findings reinforced the value of involving the staff members in change and the importance of giving voice to their perspective through qualitative research.