Maji: a new tool to prevent overhydration of children receiving intravenous fluid therapy in low-resource settings

We designed and evaluated the accuracy and usability of a device to regulate the volume of fluid dispensed during intravenous drip therapy. The mechanical system was developed in response to a pressing need articulated by clinicians in pediatric wards throughout sub-Saharan Africa, who require a tool to prevent overhydration in children receiving intravenous fluid in settings that lack burettes or electronic infusion pumps. The device is compatible with most intravenous bags and limits the volume dispensed to a preset amount that can be adjusted in 50 mL increments. Laboratory accuracy over a range of clinically-relevant flow rates, initial bag volumes, and target volumes was within 12.0 mL of the target volume. The ease of use is "excellent," with a mean system usability score of 84.4 out of 100. Use of the device limits the volume of fluid dispensed during intravenous therapy and could potentially reduce the morbidity and mortality associated with overhydration in children receiving intravenous therapy.

Rural hospitals and the adoption of managed care strategies

This research examined the performance of rural hospitals engaged in different levels of managed care activities and identified factors related to performance and competition that affected rural hospitals' likelihood of pursuing managed care as a strategy. The sample studied consisted of 139 rural hospitals in Iowa and Nebraska. Results showed that a relatively high percentage of hospitals were engaged in managed care activities, mainly through contractual arrangements. The study found that high competition in the marketplace increased the likelihood of hospitals pursuing managed care strategies, while high demand markets had a negative association with the likelihood of pursuing a managed care strategy. No significant relationship was detected between poor performance and pursuing a managed care strategy.

Organizational culture, continuous quality improvement, and medication administration error reporting

This study explores the relationships among measures of nurses' perceptions of organizational culture, continuous quality improvement (CQI) implementation, and medication administration error (MAE) reporting. Hospital-based nurses were surveyed using measures of organizational culture and CQI implementation. These data were combined with previously collected data on perceptions of MAE reporting. A group-oriented culture had a significant positive correlation with CQI implementation, whereas hierarchical and rational culture types were negatively correlated with CQI implementation. Higher barriers to reporting MAE were associated with lower perceived reporting rates. A group-oriented culture and a greater extent of CQI implementation were positively (but not significantly) associated with the estimated overall percentage of MAEs reported. We conclude that health care organizations have implemented CQI programs, yet barriers remain relative to MAE reporting. There is a need to assess the reliability, validity, and completeness of key quality assessment and risk management data.

Epidemiology of occupational injuries and illnesses in a university population: a focus on age and gender differences

BACKGROUND

Occupational injuries and illnesses are a major preventable public health problem.

METHODS

This study evaluated the incidence, nature, and cause of awarded workers' compensation claims for a large state university and teaching hospital. Rates and types of injury were compared across age and gender.

RESULTS

Rates of injury varied over twofold with age, with those 16-25 having the lowest rates of injury and those 36-45 having the highest rates. Claims rates were 1.36-fold higher for women than men. Women had higher rates for injury resulting from lifting, falling, noxious exposures, repetitive motion, and carpal tunnel syndrome. Similarly women had significantly higher rates of claims for pain, sprains, bruises, burns, concussion, and inhalation injury; with lower rates of cuts, ligament injury, and jammed joints.

CONCLUSIONS

These group differences suggest the need to examine age and gender job distributions and relevant ergonomic and environmental causative factors.

The Dose of Case Management Interventions

Case management programs need to be evaluated for outcomes achievement and efficient use of resources. As a provider intervention, case management is interactional and situational. Little is known about how to measure the actual dose delivered in order to assess quality and manage outcomes. Case management is interdisciplinary, has identifiable dimensions, and serves as a practical example of conceptualizing and measuring the dosage of a provider's intervention. The basic elements of the dosage of an intervention are amount, frequency, duration, and breadth. A three-dimensional model illustrates dosage of case management.

Iowa Case Management for rural drug abuse. Preliminary results

The Iowa Case Management Project (ICMP) was developed to evaluate the effectiveness of a comprehensive, solution-focused model of case management with rural clients in drug abuse treatment. For this preliminary report, 483 clients who were admitted to residential or outpatient treatment at a local facility volunteered to participate and were randomly assigned to one of four research conditions. Clients in three of the conditions received Iowa Case Management (ICM), while clients in the fourth condition received standard treatment services and served as the control group. Clients were assessed regarding psychosocial characteristics at intake and three additional times during the subsequent 12 months.

Health status and health professional visits in a rural area

Visits to physicians (MDs), physician assistants (PAs) or nurse practitioners (NPs) by residents of a rural county in the upper-middle west of the United States were analysed in this study. A telephone survey yielded 250 responses. The dependent variable was the natural logarithm of the number of times the respondent had seen a health professional (MD, PA or NP) in the past two years. Predisposing, enabling and medical need variables were tested as potential predictors of visits. Self-rated health status, being unable to perform usual activities, and feeling upset or 'down in the dumps' proved to be important predictors, as was having a usual source of care. Health insurance coverage and family income was not, however. Unexpectedly, smokers also reported more visits. The implications for policy and future research are discussed.

Physician visits in a farming-dependent county

Physician visits in a farming-dependent county in the upper-Midwest were studied using a mail questionnaire. A 16 percent random sample of households yielded 426 surveys (60 percent response rate). The dependent variable was the natural log (plus one) of the number of times the respondent had seen a physician in the prior 12 months. Predisposing, enabling, and medical need variables were tested as potential predictors of medical care usage. Self-rated health status proved to be an important predictor, as was a history of hospitalization and being married. However, health insurance coverage and family income were not associated with increased physician visits. Implications for modifying the conceptual model employed to analyze medical care utilization in similar populations are discussed.

An exploratory analysis of market-based, physician-organization arrangements

The growth of physician-organization arrangements (e.g., PHOs, MSOs) by physician specialty groups and delivery organizations is widely acknowledged. Yet, little is known about these new organizational forms. This paper presents a descriptive analysis of physician-organization arrangements (POAs) using survey data obtained from 79 organizations. The analysis examines the extent to which healthcare delivery organizations are engaged in the development of POAs, the number of physicians involved in POAs, and the decision-making control and strategies associated with POAs. These attributes are examined for the sample as a whole and relative to the institutional and market conditions facing study participants. Results are discussed in terms of their implications for health services managers.

Mission-driven marketing: a rural example

Marketing receives little attention in the academic healthcare management literature, possibly because it is associated with pursuit of profit rather than community benefit. However, a marketing perspective can be applied to the pursuit of the traditional missions of healthcare delivery organizations. Mission-oriented market selection criteria could include characteristics such as relevance to mission, underserved or vulnerable population status, resistance to care, limited resources, and low accessibility. A survey conducted in a rural county is used to demonstrate ways that underserved market segments can be identified and targeted. In the market surveyed, men used less medical care than women; depressed people and those with low levels of education used less medical care than people without these characteristics. Consumers were more likely to defer care because of cost if they lacked health insurance coverage, were female, were under age 55, had fair health status, were depressed, and were chronically ill. Marketing strategies worthy of consideration relate to price (e.g., free care, coupons and sales for eligible individuals), distribution (e.g., visiting nurses, malls and fairs, occupational medicine programs), product (e.g., satisfaction, waiting time, attractiveness, assertive follow-up), and promotion (education about insurance benefits, facilitating development of regular sources of care, health education).

Understanding why medication administration errors may not be reported

Because the identification and reporting of medication administration errors (MAE) is a nonautomated and voluntary process, it is important to understand potential barriers to MAE reporting. This paper describes and analyzes a survey instrument designed to assist in evaluating the relative importance of 15 different potential MAE-reporting barriers. Based on the responses of over 1300 nurses and a confirmatory LISREL analysis, the 15 potential barriers are combined into 4 subscales: Disagreement Over Error, Reporting Effort, Fear, and Administrative Response. The psychometric properties of this instrument and descriptive profiles are presented. Specific suggestions for enhancing MAE reporting are discussed.

Understanding and comparing differences in reported medication administration error rates

The prevention of medication administration errors (MAEs) represents a central focus of hospitals' quality improvement and risk management initiatives. Because the identification and reporting of MAEs is a nonautomated and voluntary process, it is essential to understand the extent to which errors may not be reported. This study reports the results of 2 multihospital surveys in which over 1300 staff nurses in each survey estimated the extent to which various types of nonintravenous (non-i.v.) and intravenous (i.v.)-related MAEs are actually being reported on their nursing units. Overall, respondents estimated that about 60% of MAEs are actually being reported. Considerable differences in estimated rates of MAE reporting were found between staff and supervisors working on the same patient care units. A simulation based on actual and perceived rates of MAE reporting is presented to estimate the range of errors not being reported. Implications regarding the reliability, validity, and completeness of MAEs actually being reported are discussed.

A multisite study of nurse staffing and patient occurrences

Restructuring of nursing care models has led to more "non-professional" caregivers, sometimes called unlicensed assistive personnel (UAPs) who provide more of the basic delegable direct patient care activities in collaboration with RNs. The purpose of this study, wherein data were collected from 39 units in 11 hospitals, was to determine the relationship between different levels of nurse staffing and patient outcomes (adverse occurrences). Using and tracking the same indicators of patient quality outcomes over a significant time period in different institutions with similar patient groups would greatly enhance the usefulness of such data. Among the more surprising findings in this study was the "non-linear" relationship between the proportion of RNs in the staff mix and MAEs. As the proportion of RNs on a unit increased from 50% to 85% "the rate of MAEs declined, but as the RN proportion increased from 85% to 100% the rate of MAEs increased." Further investigations are needed to explain this finding.

Reinke's edema: phonatory mechanisms and management strategies

Reinke's edema (RE) has been associated typically with smoking and sometimes with vocal abuse, but aspects of the pathophysiology of RE remain unclear. To gain new insights into phonatory mechanisms associated with RE pathophysiology, we used an integrated battery of objective vocal function tests to analyze 20 patients (19 women) who underwent phonomicrosurgical resection. Preoperative stroboscopic examinations demonstrated that the superficial lamina propria is distended primarily on the superior vocal fold surface. Acoustically, these individuals have an abnormally low average speaking fundamental frequency (123 Hz), and they generate abnormally high average subglottal pressures (9.7 cm H2O). The presence of elevated aerodynamic driving pressures reflects difficulties in producing vocal fold vibration that are most likely the result of mass loading associated with RE, and possibly vocal hyperfunction. Furthermore, it is hypothesized that in the environment of chronic glottal mucositis secondary to smoking and reflux, the cephalad force on the vocal folds by the subglottal driving pressure contributes to the superior distention of the superficial lamina propria. Surgical reduction of the volume of the superficial lamina propria resulted in a significant elevation in fundamental frequency (154 Hz) and improvement in perturbation measures. In almost all instances, both the clinician and the patient perceived the voice as improved. However, these patients continued to generate elevated subglottal pressure (probably a sign of persistent hyperfunction) that was accompanied by visually observed supraglottal strain despite the normal-sized vocal folds. This finding suggests that persistent hyperfunctional vocal behaviors may contribute to postsurgical RE recurrence if therapeutic strategies are not instituted to modify such behavior.

Organizational approaches to integrated health care delivery: a taxonomic analysis of physician-organization arrangements

Integrated health care organizations depend fundamentally on bringing organizations and physicians into closer alignment. Little empirical research has been conducted on the organizational mechanisms by which such alignment is attempted. This study employed primary data from 79 hospitals and health care systems to identify current approaches to aligning the strategic and economic interests of organizations and physicians. An empirical classification of both unbundled and structured physician-organization arrangements (POAs) resulted in 5 distinct strategic configurations. These configurations were differentiated by key contextual factors that shape patterns of development and operation of POAs. Particularly salient among these were managed care penetration, organization size, locus of control, and organization strategy. Results of the taxonomic analysis underscore the facts that most delivery organizations employ multifaceted rather than single approaches to physician integration and that these approaches are endemic to particular environmental and organizations conditions.

Institutional security indicator report: a management tool to bridge the communications gap

This article discusses a system developed by the Security Department of Hillcrest Hospital, to measure and report the level of security-related problems in the institution. This "Institutional Security Indicator Report" is one of the components of a Management Information System which is designed to measure workload and its effect on the utilization of personnel, level of quality, and other information which provides managers with sound qualitative, quantitative and financial data.