Treatment of patients with pulmonary embolism entirely in Hospital in the Home. (65/151)

BACKGROUND: Low molecular weight heparin (LMWH) has revolutionised the management of venous thromboembolism (VTE). An important feature of the use of LMWH is the ability to manage acute VTE in the home. This study examined the outcomes of patients with pulmonary embolism (PE) who were transferred to Hospital in the Home (HIH) within 24 hours of presentation for treatment with LMWH. METHODS: The authors reviewed records of all patients with PE who presented to two major hospitals in Melbourne (Victoria) and who were transferred to HIH for treatment with LMWH within 24 hours of presentation. The main outcome measures were length of stay, unexpected staff callouts, unexpected returns to hospital, recurrent embolism, bleeding, and death. RESULTS: Twenty-one patients were included in the study over 5 years, with a mean age of 56 years. Patients spent a mean of 9 hours in hospital before transfer and spent a mean of 6 nights in HIH. One patient required an unexpected staff callout. There were no unexpected returns to hospital. No patient deaths or instances of major bleeding were recorded. Three patients developed minor bleeding. DISCUSSION: Despite the long study period, this is a small cohort of patients and no control group is offered. However, all eligible patients were included in the study. With appropriate risk assessment and medical model of HIH, it might be safe to treat low risk patients with PE in HIH for their entire hospital stay.  (+info)

Do supervised weekly exercise programs maintain functional exercise capacity and quality of life, twelve months after pulmonary rehabilitation in COPD? (66/151)

BACKGROUND: Pulmonary rehabilitation programs have been shown to increase functional exercise capacity and quality of life in COPD patients. However, following the completion of pulmonary rehabilitation the benefits begin to decline unless the program is of longer duration or ongoing maintenance exercise is followed. Therefore, the aim of this study is to determine if supervised, weekly, hospital-based exercise compared to home exercise will maintain the benefits gained from an eight-week pulmonary rehabilitation program in COPD subjects to twelve months. METHODS: Following completion of an eight-week pulmonary rehabilitation program, COPD subjects will be recruited and randomised (using concealed allocation in numbered envelopes) into either the maintenance exercise group (supervised, weekly, hospital-based exercise) or the control group (unsupervised home exercise) and followed for twelve months. Measurements will be taken at baseline (post an eight-week pulmonary rehabilitation program), three, six and twelve months. The exercise measurements will include two six-minute walk tests, two incremental shuttle walk tests, and two endurance shuttle walk tests. Oxygen saturation, heart rate and dyspnoea will be monitored during all these tests. Quality of life will be measured using the St George's Respiratory Questionnaire and the Hospital Anxiety and Depression Scale. Participants will be excluded if they require supplemental oxygen or have neurological or musculoskeletal co-morbidities that will prevent them from exercising independently. DISCUSSION: Pulmonary rehabilitation plays an important part in the management of COPD and the results from this study will help determine if supervised, weekly, hospital-based exercise can successfully maintain functional exercise capacity and quality of life following an eight-week pulmonary rehabilitation program in COPD subjects in Australia.  (+info)

Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway. (67/151)

BACKGROUND: Care pathways can be complex, often involving multiple care providers and as such are recognised as containing multiple opportunities for error. Prospective hazard analysis methods may be useful for evaluating care provided across primary and secondary care pathway boundaries. These methods take into account the views of users (staff and patients) when determining where potential hazards may lie. The aim of this study is to evaluate the feasibility of prospective hazard analysis methods when assessing quality and safety in care pathways that lie across primary and secondary care boundaries. METHODS: Development of a process map of the care pathway for patients entering into a Chronic Obstructive Pulmonary Disease (COPD) supported discharge programme. Triangulation of information from: care process mapping, semi-structured interviews with COPD patients, semi-structured interviews with COPD staff, two round modified Delphi study and review of prioritised quality and safety challenges by health care staff. RESULTS: Interview themes emerged under the headings of quality of care and patient safety. Quality and safety concerns were mostly raised in relation to communication, for example, communication with other hospital teams. The three highest ranked safety concerns from the modified Delphi review were: difficulties in accessing hospital records, information transfer to primary care and failure to communicate medication changes to primary care. CONCLUSION: This study has demonstrated the feasibility of using mixed methods to review the quality and safety of care in a care pathway. By using multiple research methods it was possible to get a clear picture of service quality variations and also to demonstrate which points in the care pathway had real potential for patient safety incidents or system failures to occur. By using these methods to analyse one condition specific care pathway it was possible to uncover a number of hospital level problems. A number of safety challenges were systems related; these were therefore difficult to improve at care team level. Study results were used by National Health Service (NHS) stakeholders to implement solutions to problems identified in the review.  (+info)

Patient, informal caregiver and care provider acceptance of a hospital in the home program in Ontario, Canada. (68/151)

BACKGROUND: Hospital in the home programs have been implemented in several countries and have been shown to be safe substitutions (alternatives) to in-patient hospitalization. These programs may offer a solution to the increasing demands made on tertiary care facilities and to surge capacity. We investigated the acceptance of this type of care provision with nurse practitioners as the designated principal home care providers in a family medicine program in a large Canadian urban setting. METHODS: Patients requiring hospitalization to the family medicine service ward, for any diagnosis, who met selection criteria, were invited to enter the hospital in the home program as an alternative to admission. Participants in the hospital in the home program, their caregivers, and the physicians responsible for their care were surveyed about their perceptions of the program. Nurse practitioners, who provided care, were surveyed and interviewed. RESULTS: Ten percent (104) of admissions to the ward were screened, and 37 patients participated in 44 home hospital admissions. Twenty nine patient, 17 caregiver and 38 provider surveys were completed. Most patients (88%-100%) and caregivers (92%-100%) reported high satisfaction levels with various aspects of health service delivery. However, a significant proportion in both groups stated that they would select to be treated in-hospital should the need arise again. This was usually due to fears about the safety of the program. Physicians (98%-100%) and nurse practitioners also rated the program highly. The program had virtually no negative impact on the physician workload. However nurse practitioners felt that the program did not utilize their full expertise. CONCLUSION: Provision of hospital level care in the home is well received by patients, their caregivers and health care providers. As a new program, investment in patient education about program safety may be necessary to ensure its long term success. A small proportion of hospital admissions were screened for this program. Appropriate dissemination of program information to family physicians should help buy-in and participation. Nurse practitioners' skills may not be optimally utilized in this setting.  (+info)

The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient adherence. (69/151)

OBJECTIVES: To evaluate the relative effectiveness and cost-effectiveness of a home-based programme of cardiac rehabilitation using the Heart Manual, with centre-based programmes. It also sought to explore the reasons for non-adherence to cardiac rehabilitation programmes. DESIGN: An individually randomised trial, with minimisation for age, gender, ethnicity, initial diagnosis and hospital of recruitment. Participants were followed up after 6, 12 and 24 months by questionnaire and clinical assessment. Individual semistructured interviews were undertaken in the homes of a purposive sample of patients who did not adhere to their allocated programme, and focus groups were undertaken with groups of patients who adhered to the programmes. SETTING: Four hospitals in predominantly inner-city, multi-ethnic, socio-economically deprived areas of the West Midlands in England, for 2 years from 1 February 2002. PARTICIPANTS: A total of 525 patients who had experienced a myocardial infarction (MI) or coronary revascularisation within the previous 12 weeks. INTERVENTIONS: All the rehabilitation programmes included exercise, relaxation, education and lifestyle counselling. All patients were seen by a cardiac rehabilitation nurse prior to hospital discharge and provided with information about their condition and counselling about risk factor modification. The four centre-based programmes varied in length from nine sessions at weekly intervals of education, relaxation and circuit training to 24 individualised sessions over 12 weeks of mainly walking, fixed cycling and rowing with group-based education. The home-based programme consisted of an appropriate version of the Heart Manual, home visits and telephone contact. The Heart Manual was introduced to patients on an individual basis, either in hospital or on a home visit. Home visits by a nurse took place at approximately 1, 6 and 12 weeks after recruitment, with a telephone call at 3 weeks. At the final visit, patients were encouraged to maintain their lifestyle changes and to continue with their exercise programme. Where needed, follow-up was made by a rehabilitation nurse who spoke Punjabi. An audiotape of an abridged version of the Heart Manual in Punjabi accompanied the manual for patients with a limited command of English. MAIN OUTCOME MEASURES: Primary outcomes were smoking cessation, blood pressure, total and high-density lipoprotein cholesterol, exercise capacity measured by the incremental shuttle walking test and psychological status measured by the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes included self-reported diet, physical activity, cardiac symptoms and quality of life. Health service resource use and costs of rehabilitation programmes from health service and societal perspectives were also measured. Adherence to the physical activity element of the rehabilitation programmes was measured by questionnaire 6, 9 and 12 weeks. RESULTS: No clinically or statistically significant differences were found in any of the primary or secondary outcome measures between the home- and centre-based groups. Significant improvements in total cholesterol, smoking prevalence, the HADS anxiety score, self-reported physical activity and diet were seen in both arms between baseline and the 6-month follow-up. Five or more contacts with a cardiac rehabilitation nurse were received by 96% of home-based participants, whereas only 56% of centre-based participants attended this many rehabilitation classes. The direct rehabilitation costs to the health service were significantly higher for the home-based programme (mean cost 198 pounds versus 157 pounds for the centre-based programme), but when patient costs were included the mean cost of the centre-based arm rose to 182 pounds. Patients' reasons for not taking up or adhering to cardiac rehabilitation were multifactorial and very individual. Other health problems limited some patients' ability to exercise. Most non-adherers found some aspects of their cardiac rehabilitation programme helpful. Many had adapted advice on rehabilitation and were continuing to exercise in other ways and had made lifestyle changes, particularly to their diet. The home-based patients' lack of motivation to exercise on their own at home was a major factor in non-adherence. The focus groups revealed little diversity of views among patients from each programme. Patients in the hospital programme enjoyed the camaraderie of group exercise and the home-based patients valued the wealth of information and advice in the Heart Manual. CONCLUSIONS: A home-based cardiac rehabilitation programme for low- to moderate-risk patients does not produce inferior outcomes compared with the traditional centre-based programmes. With the level of home visiting in this trial, the home-based programme was more costly to the health service, but with the difference in costs borne by patients attending centre-based programmes. Different reasons were given by home and hospital cardiac rehabilitation patients for not taking up or adhering to cardiac rehabilitation, with home-based patients often citing a lack of motivation to exercise at home. Social characteristics, individual patient needs and the location of cardiac rehabilitation programmes need to be taken into account in programme design to maximise participation. Research is recommended into cardiac rehabilitation in patients from ethnic minority groups; measurement tools to assess physical activity and dietary change; evaluating the Heart Manual in patients who decline centre-based cardiac rehabilitation; the implementation of home-based programmes in the UK; and strategies that sustain physical activity in the long term.  (+info)

Perspectives from a home based neonatal care program in Brazil's Single Health System. (70/151)

This study aimed to report aspects of how mothers undertake home care of their infants while the latter are kept in a neonatal home care program. It was based on a qualitative approach and institutional analysis related to the gender category was used as theoretical reference frameworks. Data collection was carried out through semistructured interviews with eleven mothers after discharge from the program. Discourse analysis showed that the mothers assessed this form of care as essential, innovative and positive. It is thus considered an effective intervention from a child-integrated-care perspective, since interference of the team in the everyday lives of these women and their children encompassed not only the clinical aspect but affected other dimensions of their lives. It established a partnership with them and helped the mothers to build greater autonomy in caring for their children. However, there is a need for interinstitutional space, which will create the potential for basic health care actions.  (+info)

Immediate and early discharge for patients with exacerbations of chronic obstructive pulmonary disease: is there a role in "real life"? (71/151)

An exacerbation of chronic obstructive pulmonary disease (COPD) is the most common respiratory condition necessitating admission to hospital. Many of these are relatively mild in nature and as a consequence, there is increasing interest in immediate and early discharge of patients with nonsevere exacerbations. Following initial assessment, "hospital at home" or "assisted discharge" schemes enable suitable patients with COPD to be discharged into the community earlier than normally anticipated. The putative implication is that substantial financial savings can be made in addition to increasing the availability of in-patient beds, without compromising patient care or satisfaction. We highlight the current literature which has evaluated the role of hospital at home and assisted discharge schemes and discuss our own "real life" service operating in a large teaching hospital in Scotland.  (+info)

A 15-year audit of home parenteral nutrition provision at the John Radcliffe Hospital, Oxford. (72/151)

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