Hospice shared-care saved medical expenditure and reduced the likelihood of intensive medical utilization among advanced cancer patients in Taiwan--a nationwide survey.

PURPOSE: Hospice shared care (HSC) is a new care model that has been adopted to treat inpatient advanced cancer patients in Taiwan since 2005. Our aim was to assess the effect of HSC on medical expenditure and the likelihood of intensive medical utilization by advanced cancer patients. METHODS: This is a nationwide retrospective study. HSC was defined as using "Hospice palliative care (HPC) teams to provide consultation and service to advanced cancer patients admitted in the nonhospice care ward." There were 120,481 deaths due to cancer between 2006 and 2008 in Taiwan. Patients receiving HSC were matched by propensity score to patients receiving usual care. Of the 120,481 cancer deaths, 12,137 paired subjects were matched. Medical expenditures for 1 year before death were assessed between groups using a database from the Bureau of National Health Insurance. Paired t and McNemar's tests were applied for comparing the medical expenditure and intensive medical utilization before death between paired groups. RESULTS: Compared to the non-HSC group, subjects receiving HSC had a lower average medical expenditure per person (US$3,939 vs. US$4,664; p<0.001). The HSC group had an adjusted net savings of US$557 (13.3%; p<0.001) in inpatient medical expenditure per person compared with the non-HSC group. Subjects that received different types of HPC had 15.4-44.9% less average medical expenditure per person and significantly lower likelihood of intensive medical utilization than those that did not receive HPC. CONCLUSIONS: HSC is associated with significant medical expenditure savings and reduced likelihood of intensive medical utilization. All types of HPC are associated with medical expenditure savings.

Successful mechanical ventilation weaning experiences at respiratory care centers.

A phenomenological qualitative study was conducted on the experiences of patients who had been successfully weaned from mechanical ventilation, including essential elements of the patient support system during the weaning process. In-depth interviews were conducted with 20 participants who had been recruited through purposive sampling from three respiratory care centers in Taiwan. The experiences of participants who had been successfully weaned from mechanical ventilation could be categorized into five themes, which were (a) dealing with the unfamiliar context presented by the weaning program, (b) experiencing various psychological responses and self-endurance ambiguity, (c) being tortured by helplessness, (d) wondering whether to continue or give up, (e) and release from self-breathing. Findings were intended to give nurses an increased understanding of patient experiences and help in raising their competence in managing patient emotional reactions that arise during the weaning process. As patient conditions gradually improve, nurses should assess the criteria for mechanical ventilation weaning and provide preparatory information and clarify patient questions to avoid potential negative responses during the process. Participants also reported that the professionalism of nurses and concern from family members were essential sources of support for successful weaning. Nurses can apply recommendations to develop effective patient support systems that encourage family members to accompany patients at critical times during the weaning process. Therefore, the results of this study may assist healthcare personnel to develop strategies to ensure successful weaning from mechanical ventilation.

Outcomes of continuing education in the care of children with asthma for pediatric healthcare providers.

In this study, the authors assessed the knowledge of healthcare providers regarding asthma care, examined the outcomes of continuing education for asthma care, and explored the relationships among demographic characteristics of the healthcare providers and the improvement in asthma care knowledge. Thirty-one pediatricians and 38 nurses in the pediatric units of a medical center completed a questionnaire before and after an asthma care program. Pediatricians and pediatric nurses provided correct answers to asthma care questions 84.45% and 61.97% of the time, respectively, before the program and 93.06% and 88.03% of the time, respectively, after the program, which was a significant improvement (p < .001). No significant correlations or differences were found between the changes in asthma care knowledge and the demographic characteristics of healthcare providers. Results from this study suggest that continuing education can improve the knowledge of asthma care among pediatric healthcare providers.

A comparison of MICU survival prediction using the logistic regression model and artificial neural network model.

Under the policy of restraint in medical expenditure and with the dual pressures of medical technology development and population aging, the critical care services will exert even greater pressure on the limited medical resources. Therefore, the objective of this study is to compare the abilities of two models, the Logistic Regression Model and the Neural Network Model, to predict the survival of critical care patients, in order to provide a more ethical and objective survival prediction system, as well as to promote more effective management of the resources of the medical intensive care unit (MICU). The two models use the Acute Physiology and Chronic Health Evaluation-II (APACHE-II) and Glasgow Coma Scale (GCS) scores of 1,496 patients stayed who in the MICU of a Taiwan medical center during January 2002-January 2004 to conduct the survival prediction. The study results show that the Neural Network Model has a better predictive ability than the Logistic Regression Model both with regard to the survivors (86.7%, n = 361) and with regard to the entire population of patients studied (74.7%, n = 498).

Predictors of sleep quality and successful weaning from mechanical ventilation among patients in respiratory care centers.

BACKGROUND: Poor quality of sleep may result in more problems for patients who undergo weaning from mechanical ventilation because it could result in disabled muscle relaxation and affect the function of the respiratory muscles. Few studies have specifically investigated what factors contributed to quality of sleep and weaning outcomes. PURPOSE: This study investigates the predictors of quality of sleep and successful weaning from mechanical ventilation in patients at respiratory care centers. METHODS: We used a cross-sectional design to recruit 94 patients who were in the process of weaning from ventilation at three respiratory care centers in a medical center in central Taiwan. A structured questionnaire was used to collect data. Disease severity during the first 24 hours after commencing the weaning process was assessed using the Acute Physiology and Chronic Health Evaluation II. Level of consciousness was evaluated using the Glasgow Coma Scale, and quality of sleep was measured using the Verran and Snyder-Halpern Sleep Scale. Stepwise multiple regression and logistic regression were used for multivariate analysis. RESULTS: Fifty-three (56.4%) of the 94 participants successfully completed the weaning process. Participants who successfully weaned within 72 hours were younger (p = .038), had a lower level of disease severity (p < .001), and had a better quality of sleep (p = .004) than their counterparts who failed to wean. Factors including disease severity (B = -1.32), current use of hypnotic drugs (B = -10.71), and having three-to-four coexisting chronic diseases (B = -9.91) contributed negatively to quality of sleep. Factors including level of consciousness (odds ratio [OR] = 1.64), quality of sleep (OR = 1.05), disease severity (OR = 0.81), and alcohol consumption history (OR = 0.21) were found to significantly impact weaning success. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: A strong relationship was identified between disease severity and quality of sleep. Both factors are significant predictors of successful weaning from mechanical ventilation. A better understanding of the related risk factors will help improve the care provided by nurses and medical personnel to patients undergoing the weaning process.

Evaluation of the blood volume effect on the diagnosis of bacteremia in automated blood culture systems.

BACKGROUND: Blood culture volume is the most important variable in detecting bacteremia and fungemia. However, the majority of hospitals in Taiwan do not meet the criteria for an ideal blood culture volume (8-10 mL per bottle, two bottles per set) during collection. METHODS: The object of this study is to initiate an educational program for healthcare workers to increase blood volume collection and to evaluate the relationship between blood volumes and bacteremia recovery rate for detecting bacteremia and fungemia effectively by using the BD BACTEC 9240 blood culture system. RESULTS: After education, the blood sample volume ≥5 mL group increased from 2.93% to 71.24%. For a total of 4,844 bottles, the relative improvement in recovery rate for detection has increased by 17.81% between the <5 mL group and the ≥5 mL group. The recovery rates for the low-volume (<3 mL), mid-volume (3-7 mL), high-volume (8-10 mL) and extreme high-volume (>10 mL) groups are 13.31%, 15.02%, 17.68%, and 14.96%, respectively. CONCLUSION: With good blood collection practice, our study found that blood volume obtained was in direct proportion to recovery rate for the detection of bacteremia and fungemia.

A well-designed online transfusion reaction reporting system improves the estimation of transfusion reaction incidence and quality of care in transfusion practice.

Recognizing and reporting a transfusion reaction is important in transfusion practice. However, the actual incidence of transfusion reactions is frequently underestimated. We designed an online transfusion reaction reporting system for nurses who take care of transfusion recipients. The common management before and after transfusion and the 18 most common transfusion reactions were itemized as tick boxes. We found the overall documented incidence of transfusion reaction increased dramatically, from 0.21% to 0.61% per unit of blood, after we started using an online reporting system. Overall, 94% (30/32) of nurses took only 1 week to become familiar with the new system, and 88% (28/32) considered the new system helpful in improving the quality of clinical transfusion care. By using an intranet connection, blood bank physicians can also identify patients who are having a reaction and provide appropriate recommendations immediately. A well-designed online reporting system may improve the ability to estimate the incidence of transfusion reactions and the quality of transfusion care.