Study on the compliance willingness and influencing factors of doctors′ clinical pathway compliance in DRG pilot hospitals / 中华医院管理杂志

Objective:To study the influencing factors of doctors′ compliance intention towards clinical pathways at diagnosis-related groups(DRG) pilot hospitals, as a reference in advancing the development of critical pathways management and the transition of DRG payment methods from pilot exploration to actual payment.Methods:With purposive sampling method, an online questionnaire survey was conducted on doctors at 4 tertiary hospitals involved in the DRG pilot in Wuhan from December 2020 to February 2021. The questionnaire covered doctors′ basic personal information, identification degree of three dimensions based on the theory of planned behavior, as well as their past compliance behavior and compliance willingness of clinical pathways. The influence of different factors on doctors′ clinical path compliance intention was analyzed by Kruskal-Wallis test and Wilcoxon signed-rank test, and the ordered multi-class logistic regression analysis was used in multivariate analysis.Results:335 valid questionnaires were obtained, of which 205(61.2%) doctors had high willingness to follow clinical pathways. Such factors as degree of attention to peer doctors′ attitudes towards clinical pathways( OR=16.44), sufficient understanding of the documents( OR=14.91), the adaptation between information systems and clinical pathways( OR=12.54), sufficient learning resources( OR=9.42), and high enrollment rate of their patients in charge in the past six months( OR=5.77), could positively affect the doctors′ willingness to follow clinical pathways. The high enrollment completion rate of patients cared by doctors in the past six months( OR=0.09) and the high mutation rate caused by medical prescriptions( OR=0.00) negatively affected doctors′ compliance intention towards clinical pathway. Conclusions:Most doctors at DRG pilot hospitals had high willingness to comply with the clinical pathways. The main factors affecting their willingness to follow the clinical pathway include, previous relevant work experience, the attitude of peer doctors, and support resources. To increase doctors′ compliance willingness towards clinical pathway, it is necessary to speed up the DRG payment process, adopt a flexible management model, enhance the sense of participation of doctors, and ensure adequate support vesources.

Análisis de los resultados de un programa de calidad en cuidados paliativos para los últimos días de vida. Diez años de experiencia / Analysis of the results of a palliative care quality program for the last days of life: ten years of experience

Las secuencias integradas de cuidado para últimos días de vida proponen estándares de calidad para optimizar la atención de pacientes y familias. Se implementó el Programa Asistencial Multidisciplinario Pallium (PAMPA ©) basado en estándares del International Collaborative for Best Care for the Dying Person en cuatro fases: inducción, implementación, diseminación y sustentabilidad, en cinco centros de salud en Argentina, entre 2008 y 2018. Se incluyeron 1237 pacientes adultos en situación de últimos días de vida, en seguimiento por equipos de cuidados paliativos entrenados en el PAMPA ©. Se efectuó una auditoría antes y después de la ejecución del programa, aún en curso. El rango de medianas de permanencia en los cinco centros desde el inicio de la secuencia hasta el fallecimiento fue de 16 a 178 horas. Se compararon objetivos de cuidado: control de síntomas, comunicación, necesidades multidimensionales, hidratación y nutrición, documentación de intervenciones y cuidados post mortem. El análisis conjunto mostró una mejoría del número de registros (p = 0.001). La comunicación del plan de cuidados con el paciente no mostró diferencias (p = 0.173). Se realizó capacitación y supervisión permanente a los equipos profesionales de quienes se registraron percepciones de la implementación. Los principales emergentes de este análisis cualitativo fueron: actitudes ante el programa, aportes fundamentales, fortalezas, debilidades y definición subjetiva del programa, reconocimiento de las singularidades culturales institucionales y su influencia en el cuidado. El PAMPA © demostró la factibilidad de un modelo de atención para pacientes y familias en final de vida, basado en estándares de calidad internacionales

The integrated care pathways for the last days of life propose quality standards optimizing the care of patients and families. The Pallium Multidisciplinary Assistance Program (PAMPA ©) was implemented based on standards of the International Collaborative for Best Care for the Dying Person in 4 phases: induction, implementation, dissemination and sustainability, in five health centers in Argentina, between 2008 and 2018. A total of 1237 adult patients in the last days of life were included and cared for by palliative care teams trained in PAMPA ©. An audit was conducted before and after the implementation of the Program, which is still going on. The median range of follow up into five centers from the beginning of the pathway until death varied from 16 to 178 hours. Care goals were compared: symptom control, communication, multidimensional needs, hydration and nutrition, documentation of interventions and post-mortem care. The overall analysis showed an improvement in the number of records (p = 0.001). The goal of communication on care plan to the patient showed no difference (p = 0.173). Continuous training, support and permanent teams' supervision were carried out and perceptions and impact of the implementation were registered. The main emerging items of the qualitative analysis were attitudes towards the program, fundamental contributions, strengths, weaknesses and subjective definition of the program, recognition of institutional cultural singularities and its influence on care. PAMPA © demonstrated its feasibility as a model of end of life care for patients and families, based on international quality standards

Dez anos de experiência. Resumo: As sequências integradas de cuidado para últimos dias de vida propõem padrões de qualidade para otimizar a atenção de pacientes e famílias. Implementou-se o Programa Assistencial Multidisciplinar Pallium (PAMPA ©) baseado em parâmetros do International Collaborative for Best Care for the Dying Person em quatro fases: indução, implementação, disseminação e sustentabilidade, em cinco centros de saúde na Argentina, entre 2008 e 2018. Se incluíram 1237 pacientes adultos em situação terminal, assistidos por equipes de cuidados paliativos treinadas no PAMPA ©. Fez-se uma auditoria antes e despois da execução do programa, que ainda está sendo desenvolvido. A média de permanência nos cinco centros desde o início da sequência até a morte deu entre 16 a 178 horas. Conferiram-se objetivos de cuidado: controle de sintomas, comunicação, necessidades multidimensionais, hidratação e nutrição, documentação de intervenções e cuidados post mortem.A análise conjunta tem evidenciado uma melhora do número de registros (p = 0.001). A comunicação do regime de cuidados com o paciente não mostrou diferenças (p = 0.173). Realizou-se capacitação e supervisão permanente às equipes profissionais e se registraram as percepções da implementação.Desta análise qualitativa surgiram notadamente: atitudes em fase do programa, contribuições fundamentais, fortalezas, fraquezas e definição subjetiva do programa, reconhecimento das singularidades culturais institucionais e sua influência no cuidado. O PAMPA © demonstrou a factibilidade de um modelo de atendimento para pacientes e famílias em estado terminal, baseado em padrões de qualidade internacionais

Application of WPBL + CBL teaching combined with clinical pathways in dermatological nursing teaching / 中华医学教育探索杂志

Objective:To explore the application of web problem-based learning (WPBL) + case-based learning (CBL) combined with clinical pathways in dermatological nursing teaching.Methods:A total of 120 nurses who practiced in the dermatology department of The First Affiliated Hospital of Air Force Medical University from July 2018 to June 2020 were selected as the research objects. According to the nurse practice period, they were divided into a control group and a study group, with 60 people in each group. The control group used traditional teaching, and the study group used WPBL+CBL combined with clinical pathways for teaching. After the teaching, the two groups of practical nurses were assessed for their theoretical and clinical operational abilities, and the comprehensive abilities of the two groups of practical nurses and their satisfaction with teaching were assessed through questionnaire surveys. SPSS 22.0 was used for t test and χ2 test. Results:The theoretical and clinical performance assessment results of the study group were better than those of the control group, and the difference was statistically significant ( P<0.001). The research group was better than the control group in assessment of improving clinical operation ability, independent problem-solving ability, cultivating teamwork ability, improving self-learning ability, improving ability of presenting and analyzing problems, improving comprehensive analysis ability, cultivating clinical thinking ability and comprehensive ability, with statistical significance ( P<0.001). The satisfaction rate of the trainee nurses in the study group was 93.33%, and the satisfaction rate of the trainee nurses in the control group was 31.67%, with statistically significant differences. Conclusion:WPBL+CBL combined with clinical pathways teaching can significantly improve the theoretical and clinical operation ability of dermatology practice nurses, and improve their comprehensive ability and clinical teaching satisfaction rate, which is worthy of application and promotion in clinical nursing teaching.

Implementación de vías clínicas multidisciplinarias en una institución de salud de alta complejidad

Clinical pathways or structured multidisciplinary care plans are a tool to standardize clinical practice. The aim of this article is to describe and propose a methodology for the development of clinical pathways in a highly complex health institution. We used the guidelines of the European Quality of Care Pathway, which are based on a 4-stage model: definition and diagnosis, development, implementation and continuity. To make this process operational, we incorporated the project management methodology (PMO). The implemented methodology contemplates the generation of an institutional governance structure responsible for the coordination of the project and the prioritization of the clinical processes to be standardized. The implementation of each clinical pathway was carried out in four steps, namely team generation, development, planning and implementation, and continuous improvement. With this methodology, 23 clinical pathways were developed between 2014 and 2018. Their implementation significantly reduced hospitalization days and their variability, optimized the use of resources and standardized clinical records. The standardization of clinical processes allowed the development of new skills such as the generation of clinical projects, an institutional methodology for managing change and sustainability through cycles of continuous improvement.

Algoritmo para el diagnóstico de pacientes con trastornos del neurodesarrollo y sospecha de un síndrome genético / Algorithm for the diagnosis of patients with neurodevelopmental disorders and suspicion of a genetic syndrome

El amplio espectro de aberraciones cromosómicas observable en los trastornos del neurodesarrollo no siempre puede ser caracterizado por análisis cromosómico. El objetivo del trabajo fue determinar la etiología genética de estos trastornos en pacientes con afecciones neurológicas congénitas y sospecha clínica de un síndrome genético, aplicando un algoritmo de estudio clínico-molecular. En 71 de 111 niños analizados, se hallaron aberraciones submicroscópicas asociadas a síndromes de microdeleción-microduplicación: DiGeorge (22 casos), Prader-Willi (26 casos), Angelman (2 casos), Williams-Beuren (17 casos), Smith-Magenis (1 caso), Miller-Dieker (1 caso) y síndrome cri du chat (1 caso). Adicionalmente, se detectó una inserción desbalanceada de novo de la región 17p12p11.2, en el punto 5p13.1, en un niño de tres años. La utilización del método clínico unido a técnicas moleculares, como hibridación fluorescente in situ, ha permitido, en la mayoría de los casos, el diagnóstico certero de pacientes y/o familias con trastornos del neurodesarrollo.

The wide range of chromosome aberrations seen in neurodevelopmental disorders may not always be characterized by means of a chromosome analysis. The objective of this study was to determine the genetic etiology of these disorders in patients with congenital neurological conditions and clinical suspicion of a genetic disorder using a clinical and molecular testing algorithm. Among 111 studied children, 71 showed submicroscopic chromosome aberrations associated with microdeletion/microduplication syndromes: DiGeorge (22 cases), Prader-Willi (26 cases), Angelman (2 cases), Williams-Beuren (17 cases), Smith-Magenis (1 case), Miller-Dieker (1 case), and cri du chat syndrome (1 case). Additionally, a de novo trisomy 17p12p11.2 due to an unbalanced insertion into 5p13.1 was identified in a 3-year-old child. In most cases, the use of a clinical method together with molecular techniques, such as fluorescence in situ hybridization, has allowed to make an accurate diagnosis in patients and/or families with neurodevelopmental disorders.

Análisis de los resultados de un programa de calidad en cuidados paliativos para los óltimos días de vida: Diez aóos de experiencia / Analysis of the results of a palliative care quality program for the last days of life. Ten years of experience

Las secuencias integradas de cuidado para ó;ºltimos días de vida proponen estándares de calidad para optimizar la atenció;n de pacientes y familias. Se implementó; el Programa Asistencial Multidisciplinario Pallium (PAMPA©) basado en estándares del International Collaborative for Best Care for the Dying Person en cuatro fases: inducció;n, implementació;n, diseminació;n y sustentabilidad, en cinco centros de salud en Argentina, entre 2008 y 2018. Se incluyeron 1237 pacientes adultos en situació;n de ó;ºltimos días de vida, en seguimiento por equipos de cuidados paliativos entrenados en el PAMPA©. Se efectuó; una auditoría antes y despuó;©s de la ejecució;n del programa, aó;ºn en curso. El rango de medianas de permanencia en los cinco centros desde el inicio de la secuencia hasta el fallecimiento fue de 16 a 178 horas. Se compararon objetivos de cuidado: control de síntomas, comunicació;n, necesidades multidimensionales, hidratació;n y nutrició;n, documentació;n de intervenciones y cuidados post mortem. El análisis conjunto mostró; una mejoría del nó;ºmero de registros (p = 0.001). La comunicació;n del plan de cuidados con el paciente no mostró; diferencias (p = 0.173). Se realizó; capacitació;n y supervisió;n permanente a los equipos profesionales de quienes se registraron percepciones de la implementació;n. Los principales emergentes de este análisis cualitativo fueron: actitudes ante el programa, aportes fundamentales, fortalezas, debilidades y definició;n subjetiva del programa, reconocimiento de las singularidades culturales institucionales y su influencia en el cuidado. El PAMPA© demostró; la factibilidad de un modelo de atenció;n para pacientes y familias en final de vida, basado en estándares de calidad internacionales.

The integrated care pathways for the last days of life propose quality standards optimizing the care of patients and families. The Pallium Multidisciplinary Assistance Program (PAMPA©) was implemented based on standards of the International Collaborative for Best Care for the Dying Person in 4 phases: induction, implementation, dissemination and sustainability, in five health centres in Argentina, between 2008 and 2018. A total of 1237 adult patients in the last days of life were included and cared for by palliative care teams trained in PAMPA©. An audit was conducted before and after the implementation of the Program, which is still going on. The median range of follow up into five centres from the beginning of the pathway until death varied from 16 to 178 hours. Care goals were compared: symptom control, communication, multidimensional needs, hydration and nutrition, documentation of interventions and post-mortem care. The overall analysis showed an improvement in the number of records (p = 0.001). The goal of communication on care plan to the patient showed no difference (p = 0.173). Continuous training, support and permanent teams supervision were carried out and perceptions and impact of the implementation were registered. The main emerging items of the qualitative analysis were: attitudes towards the program, fundamental contributions, strengths, weaknesses and subjective definition of the program, recognition of institutional cultural singularities and its influence on care. PAMPA© demonstrated its feasibility as a model of end of life care for patients and families, based on international quality standards.

Study of arborizing clinical pathway in pediatric intussusceptions and appendicitis / 中华医院管理杂志

Objective@#To evaluate the feasibility and efficacy of a self-made arborizing clinical pathway(ACP)in acute pediatric intussusceptions and appendicitis.@*Methods@#Based on the clinical pathway(CP)-node concept, an ACP electronic template with some CP branches for dealing with significant variations was made, using a doctor-advices package in the CP program of the Clinical Information System in our hospital.From February 2018 through January 2019, children inpatients diagnosed with acute intussusceptions at our hospital accepted the ACP or the conventional CP management respectively according to parity of admitted order.@*Results@#426 children diagnosed with intussusceptions and 612 children diagnosed with appendicitis were included. After excluding some unqualified samples, 216 intussusception and 302 appendicitis children were enrolled in the observation group respectively which was subject to the ACP, 210 and 310 in the control group subject to the conventional CP. There were no significant differences between the observation and control groups in both diseases about patient demographics and therapeutic approach. The CP implementation-quality differences between the two groups in both diseases were observed and compared. Significant differences were found between the two groups in both diseases about CP completion rate(97.2% versus 90.5% and 97.7% versus 90.1%), the rate of outside-CP doctor′s orders((4.6±1.3)% versus (19.3±5.3)%and(6.1±1.7)%versus (20.3±5.1)%), the hospitalized period((2.7±0.3)d versus (3.2±0.4)d and(5.6±0.4)d versus (6.2±0.5)d), the hospitalization costs and the satisfaction rate.@*Conclusions@#ACP belongs to one of compound CPs, is appropriate to use in these solitary diseases with significant variations. ACP can deal with the CP problem of significant variations rooted in the diseases or treatments, thus contributing to promotion and application of CP.

Key factors affecting the implementation of clinical pathways: a systematic review / 中华医院管理杂志

Objective@#To systematically review the barriers and facilitators affecting the implementation of clinical pathways for the clinical pathways.@*Methods@#PubMed, Embase, CNKI, CBM, Wanfang, Cvip databases were searched to collect articles about clinical pathways implementation barriers and facilitators from inception to January 4th, 2019. The tool of confidence in the evidence from reviews of qualitative research(CERQual)was used to grade the confidence of each study.@*Results@#A total of 43 articles from 12 countries were included.There were 8 main categories and 31 subcategories of the barriers about clinical pathways, including content of the clinical pathways, negative outcomes of clinical pathways, physicians knowledge, physicians attitude, resource availability, implementation of activities, patients factors and social factors. The first three barriers of high confidence were lacking of time, capital, equipment, staff and other resources(15 articles, 34.9%), increasing workload(14 articles, 32.6%), unrecognizing pathways(12 articles, 27.9%). There were 6 main categories and 28 subcategories of the facilitators about clinical pathways, including pathways content related, physician related, resource factor and implementation activity. The first three facilitators of high confidence were communication, education and training(25 articles, 58.1%), supporting from managers and colleagues(21 articles, 48.8%)and establishing a clinical pathway facilitation committee(17 articles, 39.5%).@*Conclusions@#The successful implementation of clinical pathways connects with its development process, aftereffect evaluation and feedback. It will be implemented effectively only by the completely and environmentally acceptable pathways design, adequate resources, effective organizational activities, continuous audit, evaluation and feedback and physicians active cooperation.

Study of arborizing clinical pathway in pediatric intussusceptions and appendicitis / 中华医院管理杂志

Objective To evaluate the feasibility and efficacy of a self-made arborizing clinical pathway( ACP ) in acute pediatric intussusceptions and appendicitis. Methods Based on the clinical pathway(CP)-node concept, an ACP electronic template with some CP branches for dealing with significant variations was made, using a doctor-advices package in the CP program of the Clinical Information System in our hospital. From February 2018 through January 2019, children inpatients diagnosed with acute intussusceptions at our hospital accepted the ACP or the conventional CP management respectively according to parity of admitted order. Results 426 children diagnosed with intussusceptions and 612 children diagnosed with appendicitis were included. After excluding some unqualified samples, 216 intussusception and 302 appendicitis children were enrolled in the observation group respectively which was subject to the ACP, 210 and 310 in the control group subject to the conventional CP. There were no significant differences between the observation and control groups in both diseases about patient demographics and therapeutic approach. The CP implementation-quality differences between the two groups in both diseases were observed and compared. Significant differences were found between the two groups in both diseases about CP completion rate(97.2% versus 90.5% and 97.7% versus 90.1% ), the rate of outside-CP doctor′s orders ((4.6 ± 1.3)% versus (19.3 ± 5.3)% and ( 6.1 ± 1.7 )% versus (20.3 ± 5.1 )% ), the hospitalized period((2.7 ± 0.3)d versus (3.2 ± 0.4)d and(5.6 ± 0.4) d versus (6.2 ± 0.5) d), the hospitalization costs and the satisfaction rate.Conclusions ACP belongs to one of compound CPs, is appropriate to use in these solitary diseases with significant variations. ACP can deal with the CP problem of significant variations rooted in the diseases or treatments, thus contributing to promotion and application of CP.

Key factors affecting the implementation of clinical pathways: a systematic review / 中华医院管理杂志

Objective To systematically review the barriers and facilitators affecting the implementation of clinical pathways for the clinical pathways.Methods PubMed, Embase, CNKI, CBM, Wanfang, Cvip databases were searched to collect articles about clinical pathways implementation barriers and facilitators from inception to January 4th, 2019. The tool of confidence in the evidence from reviews of qualitative research ( CERQual) was used to grade the confidence of each study. Results A total of 43 articles from 12 countries were included.There were 8 main categories and 31 subcategories of the barriers about clinical pathways, including content of the clinical pathways, negative outcomes of clinical pathways, physicians knowledge, physicians attitude, resource availability, implementation of activities, patients factors and social factors. The first three barriers of high confidence were lacking of time, capital, equipment, staff and other resources (15 articles, 34.9% ), increasing workload (14 articles, 32.6% ), unrecognizing pathways(12 articles, 27.9% ). There were 6 main categories and 28 subcategories of the facilitators about clinical pathways, including pathways content related, physician related, resource factor and implementation activity. The first three facilitators of high confidence were communication, education and training(25 articles, 58.1% ), supporting from managers and colleagues ( 21 articles, 48.8% ) and establishing a clinical pathway facilitation committee(17 articles, 39.5% ).Conclusions The successful implementation of clinical pathways connects with its development process, aftereffect evaluation and feedback. It will be implemented effectively only by the completely and environmentally acceptable pathways design, adequate resources, effective organizational activities, continuous audit, evaluation and feedback and physicians active cooperation.

Management practice and thinking of different DRGs grouped patients in clinical pathway / 中华医院管理杂志

Objective To analysis the clinical pathway management efficiency under different DRG groups, for a basis for further optimizing clinical pathway management. Methods The retrospective analysis method was used to compare the average length of stay, sub-average costs, and drug proportions of patients with different DRGs in the same clinical pathway. Shapiro-Wilk was used to detect the normality of the samples, t test was used to analyze measurement data conformed to the normal distribution, non-parametric test was used to analyze the abnormal distribution data, and enumeration data was detected by using chi-square test. Results For patients with a clinical pathway of bronchial pneumonia, patients with severe complications and concomitant symptoms had no significant difference in mean hospitalization and sub-costs, regardless of whether they completed or entered the clinical pathway ( P >0.05). For the other two DRG patients, the difference between the average length of stay, sub-average costs, and the proportion of medications for patients who completed the clinical pathway and withdrew from or did not complete the clinical pathway was significant(P<0.05). In the severe surgical group, the length of stay and average cost for patients who completed the clinical pathway were lower than those who exited or did not enter the clinical pathway(P<0.05). Conclusions Patients with different severity of DRGs should be cautious when they are enrolled in the clinical pathway.

A Análise de Trajetórias Assistenciais como Metodologia de Integração Ensino-Serviço na Saúde / The Analysis of Critical Pathways as a Tool for Integrating Teaching and Service in Health

RESUMO A integração ensino-serviço é considerada pelo Ministério da Saúde (MS) uma importante estratégia para a formação de profissionais que atendam aos princípios e diretrizes do Sistema Único de Saúde (SUS). Este artigo descreve um relato de experiência acerca da promoção de integração entre estudantes de Medicina e uma equipe Estratégia Saúde da Família (ESF). A partir das Visitas Domiciliares (VD) às famílias acompanhadas pelos estudantes, elaborou-se o desenho de trajetórias assistenciais que posteriormente foram discutidas com os profissionais da ESF. As trajetórias evidenciaram o agravo de doenças crônicas, o mix público-privado na utilização dos serviços de saúde e a busca de atendimento apenas quando surgem os sintomas. A equipe de saúde confirmou as dificuldades relatadas pelos usuários em relação ao atendimento especializado, ao acesso a procedimentos cirúrgicos e à realização de alguns exames. Por outro lado, os profissionais também relataram cuidados que não apareceram nas trajetórias informadas pelo usuário, como a realização de consultas médicas na ESF e atendimento realizado pela equipe de enfermagem. Observou-se que muitos usuários percebem a atenção primária (AP) como uma extensão do atendimento emergencial, não compreendendo as atribuições desse nível de atenção. Esta situação, somada à dificuldade da equipe na realização da promoção em saúde e de VD, contribui para a frustração dos trabalhadores da ESF. Esta análise permitiu aos estudantes identificar tanto as dificuldades do usuário no acesso à saúde como as da equipe para promover a integralidade do cuidado. Além disso, verificou-se certo distanciamento entre o preconizado pelas políticas públicas e os processos de trabalho, apesar dos esforços dos trabalhadores para atender às necessidades dos usuários, evidenciando também as falhas na gestão e na rede de atenção à saúde. Constatou-se a importância desta metodologia para a formação interprofissional em saúde, visto que promove a análise de situações encontradas no cotidiano de uma equipe de saúde.

ABSTRACT The integration of teaching and service is considered by Ministry of Health and Education as an important strategy for training professionals, according to the principles and guidelines of the Unified Health System (Sistema Único de Saúde - SUS). This article reports on an experience of integration between medical students and a Family Health Strategy (FHS) team, carried out based on the analysis and discussion of users' clinical pathways. The clinical pathways were designed based on Home Visits (HV) to families who had been followed up by the students. These clinical pathways were then discussed with the professionals of the FHS. The pathways evidenced a worsening of chronic diseases, the use of a mixture of public and private health services, and the search for care only when symptoms appear. The health team confirmed the difficulties reported by the users in relation to specialized care, access to surgical procedures, and the performance of some diagnostic tests. On the other hand, the professionals also reported care that is not known to the users, such as obtaining medical consultations in the FHS and the care given by the nursing team. It was observed that many users perceive Primary Care (PC) as an extension of Emergency Care, and do not understand level-of-care assignments. This situation, together with the difficulty of the team in promoting health and home visits, contributes to the frustration of the FHS workers. This analysis enabled the students to identify the difficulties of users in accessing health, and the difficulties of the FHS team in promoting comprehensiveness of healthcare. In addition, there was a certain distance between public policies and work processes, despite the health workers' efforts to meet the needs of users, also showing failures in health care management and network. The importance of this method for inter-professional training in health was apparent, as it promotes an analysis of situations encountered in the daily life of the health team.

Reconstruction and practice of key nodes in the clinical pathway information system / 中华医院管理杂志

Xiangya Hospital of Central South University has reconstructed its key nodes of the clinical pathway information system in order to promote efficient and extensive implementation of the clinical pathway. Its methods include introduction of new classification of clinical pathways, enriched contents of clinical pathway forms, and design of such concepts as "Standard stage date", "Big category of drugs","Grouping prescriptions" and "Concreted mutation".

Evaluation of early outcomes of enhanced recovery after surgery for laparoscopic radical cystectomy / 中华泌尿外科杂志

Objective To explore the perioperative outcomes and safety of enhanced recovery after surgery (ERAS) in laparoscopic radical cystectomy (LRC).Methods We retrospectively evaluated outcome of 10 LRC patients on ERAS protocol from May 2017 to October 2017,and 39 LRC patients on conventional recovery after surgery(CRAS) protocol from July 2015 to November 2016.There were (60.9 ±11.4) years and (63.7 ± 12.1) years in ERAS group and CRAS group respectively(P =0.514);(25.5 ±2.7) kg/m2 and (24.4 ± 3.6) kg/m2 with body mass index (P =0.375).Both of the median of charlson comorbidity index (P =0.931) and American Society of Anesthesiologists score (P =0.254) were 2 There was no statistical significance between the two groups for type of urinary diversion and preoperative laboratory studies (P ＞ 0.05).Patients' perioperative outcomes,early (30-day) complications and postoperative readmission rate were compared.Results The ERAS group had less intraoperative crystalloid infusion [(950.0 ± 474.3) ml vs.(1 797.4 ± 448.1) ml,P ＜ 0.001],faster removed gastric tube (0 d vs.4 d,P ＜0.001),and shorter passing flatus time [(1.6 ± 0.8) d vs.(2.9 ± 1.4) d,P =0.006] than the CRAS group;however,no difference was found in terms of intraoperative colliod infusion [(1 110.0 ± 331.5)ml vs.(1 117.9 ± 397.9) ml,P =0.954].No patients from either group required conversion to open surgery.There was no significant difference between the two groups for operative time (P =0.311),estimated blood loss (P =0.073),drain days (P =0.681),postoperative hospital stay (P =0.509),overall blood transfusion (P =1.000),intensive care unit stay (P =1.000) and tumor characteristics (pathological stage,histology,nodes removed,positive nodes,lymph node-positive patients,positive surgical margins).The 30-day postoperative complications were documented in 5 (50％)and 23 (59％)patients in groups ERAS and CRAS (P =0.878),respectively.And the most common complication were minor complications (Clavien-Dindo grade 1 and 2) in both groups (100.0％ vs.86.9％,P =0.729).The 30-day readmission rate was 20.0％ (2 patients) in ERAS group and 10.3％ (4 patients) in CRAS group with no statistical significance(P =0.588).Conclusions Our ERAS protocol expedited bowel function recovery after RC and urinary diversion without increasing in 30-day complications compared with CRAS.The key of implement ERAS pathway is to explore and develop their own protocol conformed to their medical treatment enviroment.

The Effects of Clinical Pathway of Nursing on Pulmonary Function Index and Complications in Patients with COPD / 昆明医科大学学报

Objective To explore the effects of clinical pathways of nursing on pulmonary function index and complication in patients with COPD. Methods From October 2015 to June 2017, 94 patients with COPD were divided into two groups according to the order of admission and the nursing method: 47 patients undergoing routine nursing care and 47 patients receiving clinical pathways of nursing. We compared the incidence of complications, lung function, satisfaction, sense of comfort, anxiety, average hospitalization, health knowledge score and hours of ventilator use between the observation group and the control group. Results The incidence of complications in the observation group was significantly lower than that in the control group (P＜0.05) . The lung function index of the observation group was better than that of the control group, but the difference was not statistically significant (P＞0.05) . In the observation group, the satisfaction, the sense of comfort and the health knowledge score were higher.The anxiety degree was lower and the average hospital stay and hours of ventilator use were shorter compared to the control group (P＜0.05) . Conclusion The clinical pathways of nursing are used to reduce the incidence of complications, to improve the lung function index, the nursing satisfaction, sense of comfort and health knowledge score,and to reduce the average length of hospital stay, anxiety and hours of ventilator use in patients with COPD care.

Pilot single-centre cross-sectional study to determine emergency physicians' knowledge and management of sports concussion: an experience from Singapore

<p><b>INTRODUCTION</b>Sports concussion remains challenging to manage despite changes to policy and practice since the 2012 International Consensus Conference on Concussion in Sport. Emergency physicians (EPs) are usually the first line of medical care for athletes in amateur and youth collision sports. This single-centre cross-sectional study aimed to establish EPs' understanding and management of concussion in Singapore.</p><p><b>METHODS</b>An anonymised, 17-item online questionnaire was sent to EPs requesting for information on their clinical experience, training, exposure to concussion cases in the emergency department (ED) and assessed knowledge of the condition.</p><p><b>RESULTS</b>Out of 65 EPs, 52 (80%) responded, 25 (48.1%) of whom were medical officers. Over 90% had not received formal training in concussion management, and 73.1% regularly assessed concussion. 40 (76.9%) EPs recognised that loss of consciousness was not essential for diagnosis and only 24 (46.2%) knew the most common symptom. 26 (50.0%) incorrectly reported that they would perform brain imaging. Among those who indicated onward referral, 29 (55.8%) would refer concussed patients to neurosurgery. There were no significant differences between clinical grade or training in concussion and positive responses for definition, imaging modality or most common symptom of concussion.</p><p><b>CONCLUSION</b>Concussion is a common presentation to EDs in Singapore. However, understanding of the condition, its clinical diagnosis, investigation and onward management is limited. Although EPs reported training in concussion, it is likely to be insufficient. Commencing relevant education programmes for undergraduate and postgraduate medical students may enable progressive acquisition of knowledge and thereby improve patient management in the future.</p>

Effect evaluation of clinical pathway application in inpatients with chronic severe hepatitis B / 重庆医学

Objective To evaluate the effect of clinical pathway(CP) application in inpatients with chronic severe hepatitis B (CSHB).Methods treated from October 2014 to May 2016A total of 182 inpatients with CSHB in the infectious department of a grade A class 3 hospital of Chongqing City were selected and divided into the CP group and non-CP group(NCP).The CP group accepted the standardized treatment strictly according to the procedure set by the CP information system,while the NCP group was implemented the traditional treatment methods.The hospital stay,total hospitalization cost,drug expenses,examination cost,laboratory testing cost,comprehensive medical services and medical material cost were evaluated in the two groups.The master rate of disease knowledge,satisfaction,rate of timely taking medication and outpatient follow-up rate after discharge were investigated and evaluated.Results Compared with the NCP group,the hospital stay length,hospitalization total cost,medication cost,examination cost and laboratory testing cost in the CP group were significantly lower than those in the NCP group(P＜0.05);the patient satisfaction (100.0 ％) and master rate of disease knowledge (97.3 ％) were higher than 96.2 ％ and 92.4 ％ in the NCP group.The rate of regularly taking medication and outpatient follow-up rate after discharge all were 98.7％ in the CP group,which were higher than 95.3 ％ and 92.5％ in the NCP group,and the differences were statistically significant (P＜0.05).Conclusion Implementing CP in the patients with CSHB can obviously shorten the hospitalization days,decreases the hospitalization cost,and improves the patient satisfaction and compliance.

Effect evaluation of clinical pathway application in inpatients with chronic severe hepatitis B / 重庆医学

Objective To evaluate the effect of clinical pathway(CP) application in inpatients with chronic severe hepatitis B (CSHB).Methods treated from October 2014 to May 2016A total of 182 inpatients with CSHB in the infectious department of a grade A class 3 hospital of Chongqing City were selected and divided into the CP group and non-CP group(NCP).The CP group accepted the standardized treatment strictly according to the procedure set by the CP information system,while the NCP group was implemented the traditional treatment methods.The hospital stay,total hospitalization cost,drug expenses,examination cost,laboratory testing cost,comprehensive medical services and medical material cost were evaluated in the two groups.The master rate of disease knowledge,satisfaction,rate of timely taking medication and outpatient follow-up rate after discharge were investigated and evaluated.Results Compared with the NCP group,the hospital stay length,hospitalization total cost,medication cost,examination cost and laboratory testing cost in the CP group were significantly lower than those in the NCP group(P＜0.05);the patient satisfaction (100.0 ％) and master rate of disease knowledge (97.3 ％) were higher than 96.2 ％ and 92.4 ％ in the NCP group.The rate of regularly taking medication and outpatient follow-up rate after discharge all were 98.7％ in the CP group,which were higher than 95.3 ％ and 92.5％ in the NCP group,and the differences were statistically significant (P＜0.05).Conclusion Implementing CP in the patients with CSHB can obviously shorten the hospitalization days,decreases the hospitalization cost,and improves the patient satisfaction and compliance.

Study on influence of clinical pathway management on physician diagnosis and treatment behaviors / 重庆医学

Objective To observe the influence of the clinical pathway management intervention on medical service behaviors.Methods The clinical cases data in a grade A class 3 hospital of Zhangjiakou City,Hebei Province during 2011-2013 were retrospectively analyzed.The influence of implementing the clinical pathway management on the diagnosis results,medical records writing quality,clinical medication,operation,hospitalization time,medical costs,assisted examination items selection were observed and analyzed.Results The admission and discharge diagnosis coincidence rate and preoperative and postoperative diagnostic coincidence rate of 3 diseases entities in the two groups were 100%,the difference had no statistical significance (P>0.05);the medical record grade-A rate in the implementing clinical pathway group was significantly higher than that in the non-implementing clinical pathway group,the medical record grade-B rate was significantly lower than that in the non-implementing clinical pathway group,the difference was statistically significant (P0.05);the average hospitalization time,total costs,drug costs,laboratory fee and examination fee in the implementing clinical pathway group were lower than those in the non-implementing clinical pathway group,the difference was statistically significant (P<0.05);the operation fee,healthy material fee and nursing fee had no statistically significant difference was statistically significant(P<0.05).Conclusion Implementing the clinical pathway can standardize the doctor′s diagnosis and treatment behaviors and makes the medical work to develop to be more favorable for patients.