Challenges for routine health system data management in a large public programme to prevent mother-to-child HIV transmission in South Africa

Background

Recent changes to South Africa's prevention of mother-to-child transmission of HIV (PMTCT) guidelines have raised hope that the national goal of reducing perinatal HIV transmission rates to less than 5% can be attained. While programmatic efforts to reach this target are underway, obtaining complete and accurate data from clinical sites to track progress presents a major challenge. We assessed the completeness and accuracy of routine PMTCT data submitted to the district health information system (DHIS) in three districts of Kwazulu-Natal province, South Africa.

Methodology/Principal Findings

We surveyed the completeness and accuracy of data reported for six key PMTCT data elements between January and December 2007 from all 316 clinics and hospitals in three districts. Through visits to randomly selected sites, we reconstructed reports for the same six PMTCT data elements from clinic registers and assessed accuracy of the monthly reports previously submitted to the DHIS. Data elements were reported only 50.3% of the time and were “accurate” (i.e. within 10% of reconstructed values) 12.8% of the time. The data element “Antenatal Clients Tested for HIV” was the most accurate data element (i.e. consistent with the reconstructed value) 19.8% of the time, while “HIV PCR testing of baby born to HIV positive mother” was the least accurate with only 5.3% of clinics meeting the definition of accuracy.

Conclusions/Significance

Data collected and reported in the public health system across three large, high HIV-prevalence Districts was neither complete nor accurate enough to track process performance or outcomes for PMTCT care. Systematic data evaluation can determine the magnitude of the data reporting failure and guide site-specific improvements in data management. Solutions are currently being developed and tested to improve data quality.

The convenient myth of Thomas Szasz

Thomas Szasz's original critique of the concept of 'mental illness' is almost 50 years old. Over that half century Szasz has maintained a consistent campaign against the 'Therapeutic State', challenging the paternalism of coercive psychiatry and defending liberty and autonomy. Despite his widespread celebrity Szasz continues to be misread and misrepresented. In this paper we review some of Szasz's key ideas, in the light of Clarke's recent critique, setting this within the context of 'mental health nursing' and the problems in living affecting persons worldwide.

Mental health in an age of celebrity: the courage to care

Modern psychiatry, which once focused only on the containment and "cure" of madness, has evolved into a mental health industry, where almost every aspect of human life, may be cast as a "mental disorder". In Western countries, a narcissistic appetite for self-improvement and "well-being" has evolved over the past 50 years, mirroring the emergence of the celebrity culture. These developments appear linked to a fading of interest in the traditional concept of human caring, leading to a further marginalisation of people with serious "mental health problems" and to increased use of authoritarian forms of control and containment. In this paper, the idea of vocation in the field of mental health is explored. What exactly are we called to do as people-whether as professionals, friends or fellow travellers-when someone experiences a significant problem in human living?

Computer technology and the childhood immunization programme: an investigation of low uptake rates in Coventry Primary Care Trust

BACKGROUND

The childhood vaccination programme in Coventry Primary Care Trust (PCT) has resulted in consistently low uptake rates for a number of years. After an evaluation of operational processes, an examination of the data systems was performed.

METHODS

The under-reporting of vaccinations performed and methodology issues were investigated using data collected by the Child Health Information Department (CHID) and the Finance Department.

RESULTS

Data held by the Finance Department result in an uptake rate of between 0.79 and 1.92% higher than those held by the CHID. Locally, the Southwest Child Health (SWIFT) system, the programme used to calculate uptake rates by many of the PCTs across the country, excludes those children residing outside the boundary but registered within it. Coventry PCT's Cover of Vaccination Evaluated Rapidly (COVER) statistics are based on a subgroup of the responsible population.

CONCLUSIONS

The computer technology currently utilized by the NHS provides inaccurate statistics for the COVER programme. Systematic under-reporting to the CHID results in moderately lowered uptake rates. A programming anomaly in the SWIFT system has resulted in the collection of data based on a subgroup of the responsible population. This undermines the validity of the statistics collected and renders comparability of data between different PCTs, particularly those using different systems, difficult.

Sexual health education for people with mental health problems: what can we learn from the literature?

Research into sexual risk behaviour among people with 'severe' mental health problems suggested that they are likely to engage in high-risk sexual behaviour, for a number of reasons, putting them at risk of sexually transmitted diseases. The aim of this review is to describe approaches, content and outcomes of sexual health education programmes, developed and implemented for people with mental health problems. A literature review from 1980 to 2005 was carried out using the electronic databases CINAHL, PsycINFO, British Nursing Index, Pubmed and Medline, and the Cochrane library was also searched. The literature search was confined to papers written in English. The keywords 'sexuality', 'sexual health education', 'sexual health promotion', 'HIV', 'sexually transmitted disease' were combined with 'mental illness', 'chronic mental illness''severe mental illness''persistent mental illness''psychiatry', 'mental disorder', 'education interventions' and 'evaluation'. A vast amount of literature was recovered on sexual risk behaviour in people with severe mental health problems, and sexual dysfunction as a result of prescribed medication. As the focus of the review was on sexual health education, this literature was omitted. Although the literature on sexual health education for people experiencing mental health problems was sparse, 14 studies were located that either described or evaluated sexual health education programmes. Most sex education programmes focused on topics such as HIV and other sexually transmitted diseases, negotiating safe sex and skill development in condom use. Findings suggested that the people who attended benefited from sexual health education programmes, facilitated in a sensitive and supportive manner. Education tended to produce a reduction in sexual risk behaviour as opposed to complete cessation. Nevertheless, it is appropriate to consider integrating such education with service provision. The results of the review provide guidance to service providers and mental health nurses wishing to develop and evaluate sexual health education programmes for service users. Areas for future research are also identified.

Iatrogenic sexual dysfunction and the protective withholding of information: in whose best interest?

In recent years a growing body of evidence has highlighted the impact of neuroleptics and antidepressants on sexual function. Research from a service user's perspective suggested that service users are dissatisfied with the information that they received on drugs, and would like more education, in particular, on the side effects of medication that impact on sexual function. This paper reports some of the findings of a grounded theory study that explored how psychiatric nurses responded to issues of sexuality in practice. Emphasis within the paper is given to how nursing staff addressed the side effects of drugs that impact on sexual function. Findings suggested that nurse addressed the issue of prescribed medication and sexual function in practice, using a 'Veiling Sexualities Cycle', which had three subcategories: 'Hanging the Veil', 'Lifting the Veil' and 'Re-veiling'. In the light of contemporary mental health policy, findings from the study are discussed and recommendations for practice and education made.

Comparative effects of anastrozole, tamoxifen alone and in combination on plasma lipids and bone-derived resorption during neoadjuvant therapy in the impact trial

BACKGROUND

Estrogen has beneficial effects on lipid metabolism and bone preservation. The IMPACT trial evaluated neoadjuvant therapy with anastrozole or tamoxifen alone, or a combination. The comparative effects of these treatments on serum lipids and bone resorption were assessed.

PATIENTS AND METHODS

Non-fasting clotted blood samples were taken from 176 postmenopausal patients at baseline, 2 and 12 weeks for assessment of serum levels of estradiol, the bone resorption marker CTx and lipid profiles [total cholesterol (TC), high density lipoprotein cholesterol (HDL-C) and non-HDL cholesterol (N-HDL-C)].

RESULTS

After 12 weeks, tamoxifen was associated with a significant increase in HDL-C (26.5%), and a decrease in TC (6.5%) and N-HDL-C (12.3%). Anastrozole was associated with a significant increase in HDL-C (11.2%), and a non-significant increase in TC (2.9%) and N-HDL-C (3.4%), both of which were significantly different from tamoxifen. The combination was associated with a significant increase in HDL-C (9.4%), and a decrease in TC (10.9%) and N-HDL-C (13.9%). For tamoxifen and the combination, there were non-significant decreases in CTx compared with a significant increase (45.6%) with anastrozole. No correlation between serum estradiol and CTx was seen in any of the treatment groups.

CONCLUSION

Anastrozole did not have a detrimental effect on lipid profiles following 3 months of therapy. There was a significant increase in CTx with anastrozole in contrast to tamoxifen.

Observation: the original sin of mental health nursing?

The assessment and management of 'risk' has become a focal aspect of contemporary mental health practice. Given their proximal relationship with service users, nurses most often represent the 'front line' of risk management, typically expressed in hospital settings through the bureaucratic process of 'observation'. Much of the available 'evidence' is highly critical of this practice and service user researchers, in particular, have repeatedly called for alternatives. This paper reviews the historical and inter-professional dimensions of the practice of observation, contrasting this with mental health nursing's search over the past two decades, at least within the UK, for professional autonomy. Contemporary mental health nursing is trapped in an anachronistic relationship with psychiatric medicine. If nursing is to prosper, nurses must address the complex issues underlying this inter-professional relationship. The authors describe the development of 'bridging'--a radical alternative to observation practice, which represents a means of managing 'risk' and a way that nurses might develop their interpersonal relationships with people deemed to be at risk, thereby asserting the power of 'caring'.

Neuroleptic medication and sexuality: the forgotten aspect of education and care

Discussing issues of sexuality is a challenging and difficult issue for many health care workers. When it comes to sexuality and people with mental health problems there seems to be a dual taboo. Mental health nurses are ideal members of the health care team to talk to service users about issues as sensitive as sexuality and the side effects of medication that impact on sexual health. However, in both clinical practice and the nursing literature, the side effects of medications that impact on sexual function are often ignored and unspoken about. This paper examines the impact of both conventional and atypical neuroleptic medication on sexual function and discusses the probable causes of such effects. The possible reasons why health care professionals are reluctant to discuss side effects impacting on sexual health with service users are explored and emphasis is placed on the need for mental health nurses to respond to requests from service users for more education and discussion in the area of sexuality and sexual health.

A method for determining the rate of major limb amputations in battle casualties: experiences of a British Field Hospital in Iraq, 2003

INTRODUCTION

The majority of battle casualties undergoing surgery at 34 Field Hospital, the sole Coalition field hospital in Iraq during the conflict, sustained injuries to the extremities. To compare our experiences with those from previous conflicts, we report data on major limb amputations and propose a method for determining the rate of major limb amputation in a conflict setting.

PATIENTS AND METHODS

A retrospective review of battle casualties admitted to the hospital was carried out based on casualty records and operating theatre logbooks. Data were collected for the period 26 March and 8 May 2003, focusing on casualties undergoing surgery for battle-injured extremities during the conflict.

RESULTS

68 (55%) casualties underwent surgery for battle injuries to extremities. Six upper and eight lower limb amputations (proximal to carpals and tarsals) were carried out from a total of 87 battle-injured limbs that had surgery, giving an overall amputation rate of 16% (14/87).

CONCLUSIONS

In presenting our amputation rate of 16%, we highlight the lack of uniformity in describing 'amputation rates' between conflicts. A consistent method for quantifying amputations performed in a conflict setting could prove to be a useful tool.

The role of clinical examination in excluding vascular injury in haemodynamically stable patients with gunshot wounds to the neck. A prospective study of 59 patients

OBJECTIVE

To prospectively evaluate the safety and accuracy of physical examination in determining the management of stable patients with gunshot wounds to the neck.

DESIGN

Prospective study of 59 patients with gunshot wounds to the neck.

PATIENTS AND METHODS

Fifty-nine stable patients with gunshot wounds to the neck managed between December 2001 and August 2003. All patients had a physical examination and routine angiography according to a written protocol approved by the research ethics committee. The sensitivity, specificity, and predictive values of physical examination were assessed and compared with the angiographic findings.

RESULTS

Thirteen patients with positive findings on physical examination (history of bleeding, haematoma, minimal bleeding, thrill, bruit and pulse deficit) and 10 patients without clinical signs of vascular injury had vascular injury. A sensitivity of 57%, specificity 53%, positive predictive value 43% and negative predictive value of 67% were calculated for physical examination alone in detecting vascular injury.

CONCLUSION

Findings on physical examination are not good predictors of vascular injury in stable patients with gunshot wounds to the neck. Our findings question the validity of physical examination alone, as a safe and accurate assessment of patients with gunshot wounds to the neck. Arteriography or ultrasonography is needed to identify vascular injuries.

Randomised clinical trial of elective re-siting of intravenous cannulae

INTRODUCTION

Peripheral venous thrombophlebitis (PVT) represents a considerable source of iatrogenic morbidity, occurring in about 20% of hospital in-patients. The aim of this prospective randomised study was to investigate the effect of elective change of intravenous cannulae on the incidence of PVT in hospital in-patients.

PATIENTS AND METHODS

General medical and surgical inpatients requiring intravenous therapy were randomised into control (n = 26) or study (n = 21) groups. Cannulae in the control group were only removed if the site became painful, the cannula dislodged, or there were signs of PVT. Cannulae in the study group were changed electively every 48 h. All patients were examined daily for signs of PVT.

RESULTS

Peripheral venous thrombophlebitis developed in 11/26 patients in the control group and 1/21 patients in the study group (P = 0.003). Elective change of cannulae did not significantly increase the total number of cannulae sited (41 cannulae in the control group versus 43 in the study group).

CONCLUSIONS

Elective change of cannulae resulted in a significant reduction in the incidence of infusion phlebitis. The authors recommend that elective re-siting of intravenous cannulae becomes standard practice for all patients requiring intravenous therapy.

The Nurses' Global Assessment of Suicide Risk (NGASR): developing a tool for clinical practice

Contemporary and established literature indicates that people with mental health problems are at a higher risk of suicide than the general population. Because suicide is a multifaceted, complex phenomenon, risk assessment within the mental health care system requires a pluralistic, multidimensional and multiprofessional response. While assessment tools may provide useful guidance, especially guarding against complacency and over confidence, the fundamental basis of risk assessment must involve a thorough examination of the personal, interpersonal and social circumstances of each individual. Such thorough and rigorous assessments, the authors of this paper would add, require a degree of 'clinical judgement'. As a rule, inexperienced members of mental health care staff should not be charged with the responsibility of conducting suicide risk assessments without sound mentorship. However, with the right support and assessment tool, the novice practitioner might develop the kind of clinical judgement necessary for this critical task. Accordingly, this paper traces the development of the Nurses' Global Assessment of Suicide Risk (NGASR). It illustrates the practice development context out of which the need for the tool arose; it outlines the key evidence that underpins the construction of the tool and it is described. It is important to point out that as yet, no wide scale, quantitative validation of the tool has been conducted. Therefore, at this point, the tool should be treated with a degree of appropriate caution. Nevertheless, the preliminary attempts that have been made to 'validate' or 'rate' the tool in practice are included. While acknowledging that any risk assessment tool represents only one aspect of the necessarily broader assessment of risk, the NGASR appears to provide a useful template for the nursing assessment of suicide risk, especially for the novice.

Randomized clinical trial of multimodal optimization and standard perioperative surgical care

BACKGROUND

Multimodal optimization of surgical care has been associated with reduced hospital stay and improved physical function. The aim of this randomized trial was to compare multimodal optimization with standard care in patients undergoing colonic resection.

METHODS

Twenty-five patients requiring elective right or left hemicolectomy were randomized to receive a ten-point optimization programme (14 patients) or conventional care (11). The groups were similar in terms of age (64 versus 68 years), male : female sex ratio (6 : 8 versus 5 : 6) and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) score (both 26). Outcome measures were recorded before operation and on postoperative days 1, 7 and 30. They included hand grip strength, lung spirometry, and pain and fatigue scores. Further outcome measures included time to achieve a predetermined mobilization target, time to resumption of normal diet, and length of stay.

RESULTS

Optimization was associated with maintained grip strength, earlier mobilization (46 versus 69 h; P = 0.043), and significantly lower pain and fatigue scores. Patients in the optimization group tolerated a regular hospital diet significantly earlier than controls (48 versus 76 h; P < 0.001). Optimization significantly reduced the median length of hospital stay (3 versus 7 days; P = 0.002).

CONCLUSION

Optimization of surgical care significantly improved patients' physical and psychological function in the early postoperative period and facilitated early hospital discharge.

Finding solutions through empowerment: a preliminary study of a solution-orientated approach to nursing in acute psychiatric settings

Acute inpatient care is not a therapeutic milieu, perhaps owing to the lack of nursing skills. Solution-focused therapy (SFT) has been successful in US inpatient facilities in relation to both objective and subjective 'measures'. This paper reports a study of SFT in a UK context, with the aim of developing a user-friendly SFT training course and assessing its impact on both nurses and clients, via a multifaceted, triangulated data collection design. Nurses' knowledge and clinical performance were assessed, as was the client's perspective. There was a significant difference in nurses' SFT knowledge after training and strong evidence of the model being used in practice during the course of training, although nursing documentation was not fully completed. Eighty-three per cent of nurses said that they would continue using the model, and clients found the SFT approach helpful. The findings match the US experience of using SFT.

Considering the care of the suicidal client and the case for 'engagement and inspiring hope' or 'observations'

Psychiatric/mental health (P/MH) nursing has rightly been described as a 'broad church', and one that contains many contested matters and areas of differing opinion. One such contested matter is that of the appropriate care for the person who is at risk of suicide. Recent, albeit limited, debate of this issue has taken place, and the literature, such as it is, indicates two principal (though linked) positions. These can be summarized as the 'engagement and hope inspiration' position and the 'observations' position. Given the P/MH nurse's unique position in providing 24-hour, day-to-day care to suicidal clients and the growing problem of suicide within people who suffer from mental health problems, it is both necessary and perhaps timely to consider this debate in more detail. Accordingly, this paper considers the debate regarding care for suicidal mental health care clients. First, the paper briefly describes the historical policy context of care for the suicidal client. Next, it focuses on 'observations' and concludes that there is a range of well-established, empirically based problems or drawbacks to this approach. Following this, it focuses on 'engagement, inspiring hope' and points out the key processes of engagement: forming a relationship, a human-human connection, conveying acceptance and tolerance, and hearing and understanding. The value and importance of these most fundamental of interpersonal processes is described and alluded to throughout the limited research into care of the suicidal client. The paper then describes the range of criticisms that have been levelled at the engagement-inspiring hope approach and considers these criticisms in more detail. As a result of this detailed examination, the paper then reiterates the need to replace 'observations' with 'engagement-hope inspiration' as the principal approach to caring for suicidal mental health clients.

Judgement days: developing an evaluation for an innovative nursing model

This paper reports on the process and outcomes of the evaluation of an innovative nursing model (the Tidal Model). In relation to process, the study has been used to refine the methodology in terms of defining important variables to take as outcome measures to be analysed both descriptively and inferentially. In relation to outcomes, the pre-post-test design has generated significant findings in relation to improved patient care.

Tumour markers--magic or menace?

Breast cancer follow-up is aimed at the detection of metastatic disease at a stage when it can still be treated. Traditionally this has been done on a symptomatic basis confirmed by UICC criteria. By inference, tumour burden by this time is likely to be high, and therefore any therapy possibly less effective. Breast Serum Tumour Marker estimation, while disease volume is still low, has been shown in a District General Hospital setting to allow early treatment and monitor efficacy of therapy. A randomised multi-centre study is essential to determine whether these investigations are sensible and life-saving or costly and confusing.

Surgical repair of intercostal pulmonary hernia secondary to cough induced rib fracture

Intercostal pulmonary hernia, a protrusion of lung parenchyma with overlying pleural membranes through an abnormal defect in the thoracic cage, is an uncommon phenomenon. Rib fractures caused by coughing similarly represent an infrequently occurring clinical presentation. Pulmonary herniation through an intercostal defect caused by cough fractures has been described twice in the literature to our knowledge. We present a case of pulmonary herniation secondary to cough fracture in a chronic bronchitic, successfully treated by thoracotomy with application of the basic principles of hernia repair, and a discussion of the mechanisms of injury.

The use of 188Re to treat in-stent re-stenosis of coronary arteries

A pilot study has been conducted in which coronary arteries subject to re-stenosis after angioplasty and stenting have been irradiated following further angioplasty. The method of irradiation has been to use radioactive 188Re in an angioplasty balloon. This paper considers all aspects of the procedure including elution of the rhenium from a tungsten/rhenium generator, its concentration, dispensing and safe delivery to the patient using specially designed equipment to reduce staff doses and radioactive spills. In the pilot study of 28 lesions in 26 patients only 1 was recorded as having angiographic re-stenosis in the treated region at 6 months although 4 other patients had edge re-stenosis. This represents less than 18% re-stenosis in a population that would have been expected to exhibit at least 50% re-stenosis at 6 months. A total of 72 patients have been treated either in the pilot study or a subsequent trial. In only one case has a minor spill of radioactivity occurred and in no case has the balloon burst. Radiation doses to staff are approximately 20 microSv per procedure and are therefore not of serious consequence. It is concluded that this procedure is safe, feasible and effective in reducing in-stent re-stenosis.

The tidal model: developing a person-centered approach to psychiatric and mental health nursing

TOPIC

Overview of the theoretical and practical basis of a new model of psychiatric and mental health nursing practice.

PURPOSE

To illustrate the history of the development of the model and some of the processes that aim to re-empower the patient and develop genuinely collaborative approaches to care.

SOURCES

Literature review, author's research, and related clinical experience.

CONCLUSIONS

The Tidal Model provides a practice framework for the exploration of the patient's need for nursing and the provision of individually tailored care.

The Tidal Model: developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing

Nursing theories and nursing models have a low profile within psychiatric and mental health nursing in the United Kingdom. This paper describes the philosophical and theoretical background of the Tidal Model, which emerged from a 5-year study of the 'need for psychiatric nursing'. The Tidal Model extends and develops some of the traditional assumptions concerning the centrality of interpersonal relations within nursing practice. The model also integrates discrete processes for re-empowering the person who is disempowered by mental distress or psychiatric services or both. The paper reports briefly on the ongoing evaluation of the model in practice.

The management of penetrating neck injuries

In recent years, there has been a major increase in patients with penetrating injuries to the neck admitted to the Johannesburg Hospital. Pressure on resources led to increasing delays for surgery, and a policy of selective conservatism emerged. In common with other centers, mandatory exploration of all wounds that breach the platysma was found to be no longer necessary as it became clear that many penetrating wounds to the neck were best treated conservatively. A policy of blanket investigation of all nonoperated cases also matured toward selective investigation, directed by careful clinical examination. A retrospective study was made of all patients undergoing exploration for gunshot wounds or stabs to the neck at the Johannesburg Hospital Trauma Unit between 1994 and 1998. An overall mortality rate of 9% was mostly a reflection of severe, associated injuries. The evolution of the nonoperative management of cervical penetrating wounds is a good example of the validity of the concept of "selective conservatism." A distillation of the experience at a busy, urban trauma center is presented, with guidelines to manage these potentially lethal injuries.

Penetrating wounds of the torso

Penetrating trauma is on the increase as a result of interpersonal violence throughout the world. It is essential that military surgeons are familiar with such injuries and trained not only in the principles of their management, but also have first-hand operative experience before deployment in the field of conflict. More often than not, this experience is to be gained in the civilian urban setting in countries such as South Africa and the USA. The article addresses the first requirement--the principles of management--and outlines basic measures to enable those unfamiliar with penetrating wounds of the torso to make a reasonable and directed approach to dealing with these patients. It does not attempt to give definitive advice on specific injuries. It is organised according to anatomical regions, but emphasises that this is only in order to put shape to the article; penetrating injuries frequently having no respect for anatomical boundaries. Particular attention is drawn to difficult areas such as mediastinal injuries, and to modern concepts of 'damage control' surgery and the 'abdominal compartment syndrome'. The emphasis throughout is on how to get out of trouble and where particular danger spots may be anticipated. Reference will be made to the differences that may be expected within the military environment as opposed to the civilian setting, where rapid and (usually) safe evacuation to a well-equipped secure facility may not be possible. The article aims to raise the awareness of those involved in the care of patients with penetrating wounds of the torso that a methodical approach with a practised team of experienced individuals can salvage injuries which at first sight may seem terrifying or hopeless.

Working with the metaphor of life and death

The experience of being human is intangible. As a result, descriptions of human experience rely heavily on metaphor to convey something of that whole lived experience. By contrast, contemporary scientific narratives of the mind emphasise the form of human thought and emotion, over the content of people's experience, where constructive attempts are made to explain the experience of self, through metaphorical allusion. This paper considers the importance of metaphor as a vehicle for expressing and exploring selfhood. Examples from the psychiatric literature, as well as from the visual and literary arts, are used to reflect on the importance of metaphor in clarifying the meanings of the constructs of health and illness.

Damage control surgery--concepts and practice

The results of prolonged and extensive procedures in the critically injured are poor, even in experienced hands. The operating theatre is a hostile and physiologically unfavourable environment for the severely injured patient. Laparotomy for major trauma involves dissipation of heat and massive blood loss requiring replacement. The result is a vicious cycle of hypothermia, acidosis and coagulopathy leading to death from an irreversible physiological insult (62). The damage control concept places surgery as an integral part of the resuscitative process, rather than an end in itself, and recognises that outcomes after major trauma are determined by the physiological limits of the patient, rather than by efforts of anatomical restoration by the surgeon. All those involved in the care of wounded patients should be familiar with this concept and its surgical and logistical implications.

The required role of the psychiatric-mental health nurse in primary health-care: an augmented Delphi study

An augmented Delphi study was employed to elicit the perceptions of CPNs, GPs, social workers, managers of psychiatric nursing services and health service purchasers in England, on the role required of a psychiatric (mental health) nurse in primary health care. In the final stage of the study, users of mental health service were enlisted in a verification study of the emergent findings. A broad consensus emerged that a gap existed in mental health services in primary care. This was perceived as placing a large burden on GPs, which might be reduced by the appropriate development of community psychiatric-mental health nursing. The study suggested the possibilities for development of a 'mental health nurse consultant' role, which might augment the current CPN role, within which the nurse might offer not only direct patient care, but also support to members of the primary care team.