[Integration of activities of regional hospitals and territorial medical institutions]

Medical and economic efficiency of regional therapeutic and prophylactic institutions is to develop in integration with therapeutic and prophylactic institutions of administrative territories of a subject of the federation, which necessitates modifications in the functions and organizational structure of organization and methodology departments of regional, central, and municipal hospitals.

Profile of a comprehensive psychiatric emergency program in a New York City municipal hospital

This paper profiles the services provided, and the patient population treated, in a busy inner city Comprehensive Psychiatric Emergency Program (CPEP) located in Elmhurst, Queens, New York City. For each CPEP component, including the emergency room, extended observation unit and crisis services two years of data are reviewed. A diagnostic profile of patients seen, description of services, patient referrals and dispositions are presented. The children and adolescents treated in the CPEP are described in more detail, focusing on the high frequency of violence to self or others seen in their presenting problems. The CPEP's role in providing comprehensive community based services is discussed.

Demands on obstetrical care in the urban environment: postpartal survey

In recent years, obstetrical management reflecting the individual needs of parturient women and newborn children has acquired an increasing significance. Today, the majority of obstetrical departments provide alternatives to traditional methods of delivery. The purpose of this study was to analyze the current obstetric situation as perceived by the women concerned. During the lying-in period spent in the care of the obstetrical department, 386 women were interviewed as to their birth experience. The questionnaire employed used a predominantly structured format. The present study examined a total of six of Vienna's municipal hospitals. The majority of women interviewed were satisfied with the standard of care provided by obstetricians and midwives. However, certain administrative and organizational aspects were subject to criticism, for example, shift changes among the medical staff as well as the presence of an excessive number of people during delivery were felt to detract from the intimate character of giving birth. In general, the standards of care provided by urban obstetrical departments as well as the experience of giving birth itself confirmed women's expectations. However, certain areas remain where improvements seem both desirable and feasible without requiring undue effort. Women who gave a positive assessment of their personal experience of delivery also tended to carry away a favorable impression of their stay in hospital as a whole.

[Creative activities in home care for terminally-ill cancer patients at a rural municipal hospital]

Karuizawa Hospital is a rural, small town municipal hospital with 60 beds, located in Nagano Prefecture in central Japan. The terminal stages of patients who were treated in our department of surgery but later died of cancer are reviewed. In the five year period extending from April, 1994 through March, 1999 sixty patients died from cancer. Of them, 34 people died in their own home and 26 in our hospital. The annual ratio of patients who died at home to those who died in the hospital are analyzed, as well as whether these ratios differed according to the location of the patient's cancer. The identity of the patients' main home caregiver was sought, as well as how many days the patients resided at home until they passed away, and how frequently doctors or nurses visited their home. Some of the doctors' attempts to gain informed consent are described. Based on the findings, the authors recommend an end to the practice of first revealing the name and details of a patient's disease to his/her family. It was also found that documented information is useful in order to promote smooth relationships among patients, family members, and the doctor.

Towards safer blood transfusion practice

The objective of this study was to determine the current state of transfusion practice at a large metropolitan hospital in South Australia, with a view to making recommendations to improve safety. Transfusion practice was monitored using a questionnaire and a concurrent audit design. Patients identified as having received a packed red blood cell transfusion in the previous 24 h, were selected by a random number generator. Questions included those about blood pack identification, documentation of the transfusion process, and patient observation. The results of this audit indicated that areas of documentation, primarily patient consent, blood pack administration times and patient monitoring required re-evaluation. Recommendations to improve practice were made based on these results. This is an ongoing service provided by the hospital, which has proven invaluable in identifying deficiencies in transfusion practice in order to improve patient care.

Security departments and employee assistance programs: an effective alliance against domestic violence

The authors discuss the collaboration of the Police and Security Department and the EAP at Massachusetts General Hospital to deal with domestic violence. Findings from a research study are presented.

[Substantiation of the choice of technical means in reduction of implementation costs of the project "Full automation of a central municipal hospital"]

A way of reducing the cost price of hospital automation is proposed. It is not necessary for it to update the whole equipment, but only a small part--the workstations used by programmers for their work, which support the stability of hospital automation; the working places of operators should be kept without modifications, but to allot them properties to inherit a potency and modernity of the purchased equipment; for this purpose they should be equipped with virtual machines copying properties of workstations being arrange in accordance with the pyramidal structure. A UNIX which represents a multi-user, multitask operational operative system providing an access on several pseudoterminals is simultaneously installed on the PENTIUM 100/133 workstation. A graphic terminal of the AMR "UnTerminal" firm (USA) is proposed for use as working places. Their advantage is that they have a special adapter connected directly to the bus of PC extension. Each user is allotted a video adapter, a keyboard controller, sequential and parallel interfaces for connection of the printer and manipulator. Each working place supports multitasking and it can be equipped with a printer, a "mouse" or modem. The image is transmitted on work places with a very high velocity-77 mehabits/sec that supports not only a text mode, but also VGA or SVGA graphics. Certainly, graphic terminals are more expensive than text terminals, but their capacities are similar to those of the main computer, here, the workstation. They may be located from the main computer at a distance of up to 75 meters or more and do not require adjustment during their installation.

Quality improvement in an integrated urban healthcare system: a necessary journey

Public hospitals and clinics in the United States provide health care for the needs of large numbers of people who are medically indigent, homeless, chronically mentally ill, and suffer medical and social disorders associated with poverty. These "safety-net" healthcare providers traditionally struggle with barriers to providing high-quality, patient-sensitive care, including decaying physical facilities, burdensome bureaucracies, underfunded capital equipment and construction programs, and complex, politically driven budgets and governance. However, these same institutions now must compete for their own Medicaid and Medicare clientele because the private sector is marketing to those patients. They also must continue to provide increasing services to growing numbers of uninsured patients. To accomplish this, these institutions must reinvent themselves as patient-focused, high-quality, cost-effective healthcare providers. The Denver Health system is the public safety-net provider for the city and county of Denver. This large public institution has instituted a multifaceted performance-improvement program. The program includes training employees for patient-focused service, implementing continuous quality-improvement practices, instituting clinical pathways, revising the preexisting ambulatory quality-management program, reengineering key aspects of ambulatory clinic services, and redesigning the hospital-based patient-care services. Major successes have been achieved in some initiatives, but not in all. Many key "lessons learned" may guide others.

Upstairs downstairs: vertical integration of a pediatric service

BACKGROUND

The combined effects of recent changes in health care financing and training priorities have compelled academic medical centers to develop innovative structures to maintain service commitments yet conform to health care marketplace demands. In 1992, a municipal hospital in the Bronx, New York, affiliated with a major academic medical center reorganized its pediatric service into a vertically integrated system of four interdependent practice teams that provided comprehensive care in the ambulatory as well as inpatient settings. One of the goals of the new system was to conserve inpatient resources.

OBJECTIVE

To describe the development of a new vertically integrated pediatric service at an inner-city municipal hospital and to test whether its adoption was associated with the use of fewer inpatient resources.

DESIGN

A descriptive analysis of the rationale, goals, implementation strategies, and structure of the vertically integrated pediatric service combined with a before-and-after comparison of in-hospital resource consumption.

METHODS

A before-and-after comparison was conducted for two periods: the period before vertical integration, from January 1989 to December 1991, and the period after the adoption of vertical integration, from July 1992 to December 1994. Four measures of inpatient resource use were compared after adjustment for case mix index: mean certified length of stay per case, mean number of radiologic tests per case, mean number of ancillary tests per case, and mean number of laboratory tests per case. Difference-in-differences-in-differences estimators were used to control for institution-wide trends throughout the time period and regional trends in inpatient pediatric practice occurring across institutions. Results. In 1992, the Department of Pediatrics at the Albert Einstein College of Medicine reorganized the pediatric service at Jacobi Medical Center, one of its principal municipal hospital affiliates, into a vertically integrated pediatric service that combines ambulatory and inpatient activities into four interdependent practice teams composed of attending pediatricians, allied health professionals, house officers, and social workers. The new vertically integrated service was designed to improve continuity of care for patients, provide a model of practice for professional trainees, conserve scarce resources, and create a clinical research infrastructure. The vertically integrated pediatric service augmented the role of attending pediatricians, extended the use of allied health professionals from the ambulatory to the inpatient sites, established interdisciplinary practice teams that unified the care of pediatric patients and their families, and used less inpatient resources. Controlling for trends within the study institution and trends in the practice of pediatrics across institutions throughout the time period, the vertical integration was associated with a decline in 0.6 days per case, the use of 0.62 fewer radiologic tests per case, 0.21 fewer ancillary tests per case, and 2.68 fewer laboratory tests per case.

CONCLUSIONS

We conclude that vertical integration of a pediatric service at an inner-city municipal hospital is achievable; conveys advantages of improved continuity of care, enhanced opportunities for primary care training, and increased participation of senior clinicians; and has the potential to conserve significant amounts of inpatient resources.

Caring for survivors of torture in an urban, municipal hospital

Survivors of torture can present with multiple health consequences, both physical and psychological, which can persist even years after the abuse. The authors developed a multidisciplinary program in the primary care medical clinic of an urban municipal hospital in New York City serving an ethnically diverse population to provide multidisciplinary care to survivors of torture and their families.

Privatization of a public hospital: a quality improvement strategy

Public hospitals face mounting challenges posed by the rise of managed care, increasing hospital competition, growing responsibilities in indigent care, and stagnant public sector revenues. Privatization exists as a viable strategy for reengineering the structure and operation of public hospitals to meet the new demands of quality and efficiency imposed by a rapidly changing health care environment.

US-Hungarian partnership: strengthening home care's stand

A partnership established between a US home care provider and a hospital in Hungary dedicated itself to reducing the length of hospital stays by strengthening home care in Vac, Hungary. With other similar ventures, the accomplishments of the partnership can be disseminated throughout other parts of Hungary and central and eastern Europe.

Surveying technologists: a novel method for establishing productivity standards in a clinical haematology laboratory

Personnel costs comprise the largest clinical laboratory expense. Yet standards to judge the productivity of personnel have not been established. A survey of the authors' own personnel was conducted to derive productivity standards in the Clinical Hematology Laboratory at the Massachusetts General Hospital, Boston, Massachusetts, USA. Technologists were asked how many white blood cell differentials they could perform in an eight-hour shift. Differential productivity was tracked before and after the survey. Of the respondents, 100 per cent failed to meet their own expectations of productivity. Nine technologists were tracked both before and after the survey was mailed and manifested a significant increase in productivity. These results suggest that technologists are objective in their assessment of their own productivity, that their opinions might be a resource for establishing productivity standards within the laboratory, and that such surveys may serve as motivational tools to augment productivity.

Directly observed therapy for tuberculosis: the Harlem Hospital experience, 1993

OBJECTIVES

A directly observed therapy program was established at Harlem Hospital, New York, NY, in 1993 to promote high tuberculosis treatment completion rates.

METHODS

The Harlem program used an on-site surrogate family model. Treatment completion rate, visit adherence rate, human immuno-deficiency virus seroprevalence, and time to sputum culture conversion were assessed.

RESULTS

Out of 145 enrolled patients with suspected and confirmed tuberculosis, 95 (92 confirmed and 3 suspected) continued treatment. The visit adherence rate was 91.1 +/- 7.9%, with one patient (1%) lost to follow-up.

CONCLUSION

High rates of treatment completion and visit adherence were achieved because of unique program characteristics. Thus, directly observed therapy is advocated as a means of ensuring treatment completion.