Does a 'direct' transfer protocol reduce time to coronary angiography for patients with non-ST-elevation acute coronary syndromes? A prospective observational study.

OBJECTIVE: National guidelines recommend 'early' coronary angiography within 96 h of presentation for patients with non-ST elevation acute coronary syndromes (NSTE-ACS). Most patients with NSTE-ACS present to their district general hospital (DGH), and await transfer to the regional cardiac centre for angiography. This care model has inherent time delays, and delivery of timely angiography is problematic. The objective of this study was to assess a novel clinical care pathway for the management of NSTE-ACS, known locally as the Heart Attack Centre-Extension or HAC-X, designed to rapidly identify patients with NSTE-ACS while in DGH emergency departments (ED) and facilitate transfer to the regional interventional centre for 'early' coronary angiography. METHODS: This was an observational study of 702 patients divided into two groups; 391 patients treated before the instigation of the HAC-X pathway (Pre-HAC-X), and 311 patients treated via the novel pathway (Post-HAC-X). Our primary study end point was time from ED admission to coronary angiography. We also assessed the length of hospital stay. RESULTS: Median time from ED admission to coronary angiography was 7.2 (IQR 5.1-10.2) days pre-HAC-X compared to 1.0 (IQR 0.7-2.0) day post-HAC-X (p<0.001). Median length of hospital stay was 3.0 (IQR 2.0-6.0) days post-HAC-X v 9.0 (IQR 6.0-14.0) days pre-HAC-X (p<0.0005). This equates to a reduction of six hospital bed days per NSTE-ACS admission. CONCLUSIONS: The introduction of this novel care pathway was associated with significant reductions in time to angiography and in total hospital bed occupancy for patients with NSTE-ACS.

Dopamine-D1 and delta-opioid receptors co-exist in rat striatal neurons.

Cocaine's enhancement of dopaminergic neurotransmission in the mesolimbic pathway plays a critical role in the initial reinforcing properties of this drug. However, other neurotransmitter systems are also integral to the addiction process. A large body of data indicates that opioids and dopamine together mediate emotional and reinforced behaviors. In support of this, cocaine-mediated increases in activation of dopamine D1 receptors (D1R) results in a desensitization of delta-opioid receptor (DOR) signaling through adenylyl cyclase (AC) in striatal neurons. To further define cellular mechanisms underlying this effect, the subcellular distribution of DOR and D1R was examined in the rat dorsolateral striatum. Dual immunoperoxidase/gold-silver detection combined with electron microscopy was used to identify DOR and D1R immunoreactivities in the same section of tissue. Semi-quantitative analysis revealed that a subset of dendritic cellular profiles exhibited both DOR and D1R immunoreactivities. Of 198 randomly sampled D1R immunoreactive profiles, 43% contained DOR. Similarly of 165 DOR-labeled cellular profiles, 52% contained D1R. The present data provide ultrastructural evidence for co-existence between DOR and D1R in striatal neurons, suggesting a possible mechanism whereby D1R modulation may alter DOR function.

The individualistic nature of healthcare: challenges for public policy.

Modern healthcare in America is thought to be strongly individualistic in nature in that it largely focuses on curative treatment of individuals instead of preventive medicine that would affect whole segments of the population. This article describes the terms individualism, entitlement, and respect for personal autonomy within the context of ethically sound public policy formation.

Recognizing the needs of the underserved in light of public health projects.

Healthy People 2000 grew out of the idea that positive changes could occur if Americans worked together toward certain goals. One of the most compelling lessons learned from the Healthy People 2000 initiative is that as a nation we can make dramatic progress in a relatively short period of time. Ten years later, Healthy People 2010 evolved from the underlying belief that the health of the individual is inseparable from the health of the community, and that the health of every community determines the overall health status of the nation. Healthy People 2010 challenges individuals, communities, and healthcare professionals to take specific steps to ensure that good health, as well as long life, is accessible to all Americans. Critics of public health projects such as Healthy People 2010 argue that these projects often fail to meet their goals because solutions are seen through the eyes of the dominant culture--that we have a tendency to disregard the lived experience of those we are trying to reach. This is the reason why a deeper cultural awareness is essential to public policy formation. The real challenge and opportunity for wound care clinicians are to recognize the thousands of alternative health and healing systems in the United States, each with a colorful and unique worldview. This article identifies public health projects that impact clinical care, defines what is meant by the term underserved, and describes the health practices of what are considered ethnically diverse groups.

Artificial intelligence: the clinician of the future.

Human beings have long been fascinated with the idea of artificial intelligence. This fascination is fueled by popular films such as Stanley Kubrick's 2001: A Space Odyssey and Stephen Spielberg's recent film, AI. However intriguing artificial intelligence may be, Hubert and Spencer Dreyfus contend that qualities exist that are uniquely human--the qualities thought to be inaccessible to the computer "mind." Patricia Benner further investigated the qualities that guide clinicians in making decisions and assessments that are not entirely evidence-based or grounded in scientific data. Perhaps it is the intuitive nature of the human being that separates us from the machine. The state of artificial intelligence is described herein, along with a discussion of computerized clinical decision-making and the role of the human being in these decisions.

Walking the HMO balance.

Fidelity is the ethical obligation to act in good faith to keep promises, fulfill agreements, and maintain relationships and fiduciary responsibilities. Consumers are increasingly interested in the balance between the fiscal viability of our current healthcare delivery system and the system's reason for existence--that is, to serve the health needs of clients. Escalating healthcare costs have driven many institutions and third party payors to examine service and payment practices. Some consumers and consumer rights groups contend that these evolving practices threaten the very essence of health and healthcare. The ethical obligation of fidelity, especially as it relates to the business model of healthcare, is examined. Threats to fidelity are reviewed, and the response to these threats by one consumer rights group is presented. A case study is included.

Pressure ulcers, outcomes, and the nursing shortage.

The incidence of pressure ulcers is dependent on a number of variables. This article argues that the current and upcoming nursing shortage will adversely influence the pressure ulcer-related goals of public policy initiatives that strive to reduce the humanistic and cost burden of certain chronic conditions. The current state of the nursing shortage is described herein, along with examples of legislation proposed to control for this crisis and a consideration of the just distribution of goods and services (e.g., pressure ulcer care). Also provided is the voice of a nurse profoundly affected by the situation--a consideration of real and perceived threats to care.

Justice and the right to a decent minimum of healthcare.

Throughout time, caring for those who were unable to provide for themselves was based on the virtues of charity, compassion, and benevolence rather than on the ethical principle of justice. In America, and other industrialized countries, the primary barrier to healthcare is the widespread lack of adequate insurance reimbursement. This raises questions about who should receive what share of the nation's scarce healthcare resources, irrespective of insurance status. This article argues that the debate about social justice has been driven by inequalities in access to healthcare and health insurance. This debate is fueled by dramatic increases in healthcare costs. Wound care clinicians are important stakeholders in this debate as they are likely to speak for the patient who has been literally or politically silenced because of age, chronic illness, or poverty.

Six-month depression relapse rates among women treated with acupuncture.

Conventional treatments for Major Depression, although reasonably effective, leave many without lasting relief. Alternative approaches would therefore be welcome for both short- and long-term treatment of depression. Thirty-eight women were randomized to one of three treatment conditions in a double-blind randomized controlled trial of acupuncture in depression. All participants eventually received eight weeks of acupuncture treatment specifically for depression. From among the 33 women who completed treatment, 26 (79%) were intertiewed at six-month follow-up. Relapse rates were comparable to those of established treatments, with four of the 17 women (24%) who achieved full remission at the conclusion of treatment experiencing a relapse six months later. Compared to other empirically validated treatments, acupuncture designed specifically to treat major depression produces results that are comparable in terms of rates of response and of relapse or recurrence. These results suggest a larger trial of acupuncture in the acute- and maintenance-phase treatment of depression is warranted.

Independent use of activity materials by the elderly in a residential setting.

A lottery was implemented to encourage the elderly clients of a residential home to use activity materials any time they wished, independently of staff intervention and the institutional routine of the home. During baseline, there were minimal levels of independent use of activity materials by residents. Various conditions were implemented but only the introduction of a l20 lottery prize brought about a significant increase in the frequency of independent use of activity materials. A follow-up suggested that the reinforcing properties of the activity materials themselves eventually maintained the target behavior.

Culture, health, and healing.

Americans are increasingly interested in and willing to participate in alternative or adjunctive healthcare, which is sometimes called complementary healthcare. Some believe this is because of wide-spread cultural diversity or an increasing awareness of options in health practice, while others contend it is a reaction to dissatisfaction with Western health practices. Diversity among cultures and subcultures has posed challenges for clinicians. This article addresses the impact of culture on health and healing, examining alternative health practices and their impact on chronic care, specifically chronic wound care.

Defining extraordinary care.

Criteria-based protocols are an ethically appropriate strategy to addressing issues such as allocation of scarce resources; however, protocols can conflict with the ethical ideal of respect for individual autonomy. This article illustrates the conflict that can occur between individual patient situations and standardized criteria-based protocols. Furthermore, ordinary care and treatment outlined in criteria-based protocols can become extraordinary in some cases. The case study presented illustrates why it is important to distinguish between ordinary and extraordinary care in some situations. The distinction between the two is described herein.

The ethical considerations of outcome research.

Escalating costs have led to the increasing interest in outcome research in all areas of industry. In healthcare, providers, payors, and consumers are making every effort to improve the quality of patient care while managing costs. Because the overriding issue of cost is driving much of outcome research, it is increasingly important to recognize the fragile balance that exists between cost and quality. In addition, clinicians face a number of other ethical and legal concerns such as confidentiality, informed consent, and the needs of the underserved. This column describes outcome research, along with ethical principles that influence this research.

Examining caregiver rights.

Lay caregivers increasingly are accepting responsibility for the care of loved ones in the home health setting. These caregivers are often not prepared emotionally or physically for such responsibility. The rights of caregivers are examined herein as they relate to the obligations of clinicians to ease the caregivers transition to their new and sometimes unexpected role.

Quality care among aging Americans.

The unique needs of many elderly Americans are often not heard. However, in the face of an ever-growing aging population, clinicians are more actively planning healthcare for older adults across practice settings. This article examines the home care needs of elderly patients who wish for care, but not aggressive, acute care. The author reviews bioethical considerations that apply to elderly individuals and groups and presents suggestions to promote quality care that is ethically sound. This article also describes clinicians' obligation to identify what quality care means to the very old person and explains the deficiency model of aging along with its impact on medical intervention.

Arguing for a dynamic quality in professional codes of ethics.

Many professional organizations and healthcare institutions have developed codes of ethics for a number of reasons. Unlike legal mandates, codes of ethics provide professionals with a framework for ethical behavior within their specific discipline. Professionals today face challenges because the necessary ethical debates cannot keep pace with the rapidly changing environment in which ethical dilemmas quickly emerge. This article describes components of codes of ethics, outlines the evolving nature of ethics, and argues for a dynamic quality in these codes as a way to provide timely, sensitive guidance for professional practice.

The ethics of advanced technology.

Clinicians are faced with the consequences of advanced technology in every aspect of their practice--from computerized documentation to local wound care treatments to clarifying information located by patients on the Internet. Americans are preoccupied with the promise of new and different technologies. The technological imperative describes the human drive to use technology once it becomes available simply because it is available. This raises a number of patient care issues--including ethical issues. Nonmaleficence and respect for personal autonomy are addressed in this ethical analysis of advanced technology. Opportunities for wound care clinicians are discussed herein.

Politics, public policy, and healthcare.

In many cases, justice is the ethical principle that drives decisions around politics, public policy, and healthcare. This article presents the ethical principle of justice as it relates to the equitable distribution of healthcare goods and services. The impact of politics, especially in a presidential election year, is discussed as it relates to agendas and alternatives for healthcare policy formation--specifically, as it directly and indirectly influences wound care and wound care delivery. Opportunities for wound care clinicians are presented.

Legalism and ethics in healthcare.

Legalism is the translation of moral problems into legal problems--the repression of moral debate for fear it will be translated into a legal mandate. Some assert that legalism interferes with the serious debate of significant moral issues, while others believe that it elevates moral judgments to moral standards. The purpose of this article is to describe legalism and its impact on ethical decision-making, particularly in the wound care setting.