The management and control process in an Accident and Emergency (A/E) department of a District General Hospital is investigated and the functional relationship between the A/E department and the inpatient hospital service is discussed. Attention is focused on resource allocation and methods are proposed towards reconciling levels of service and resource utilisation. Within the framework of control problems inside the A/E department, a computerised patient record system has been designed and implemented, on an experimental basis, to allow easy access to patient-related information for performance evaluation. Established statistical techniques are employed to demonstrate how such information can be utilised in medium-term management activities in the A/E department and to provide a sound basis for defining areas where specific problems arise. A method is developed, which uses patient data to the extent that they are routinely available through the patient record system, for allocating physicians to weekly shifts in a way which takes account of the fixed number of physician hours per week; of physician preferences with regard to shifts; and of the patient assessment of the service provided. With regard to the role of the A/E department as an essential link between the community at large and the hospital service, a simulation model is developed for determining the number of beds in hospital inpatient departments on the basis of expected demand and according to a pre-specified set of measures of hospital efficiency. The measures used are the rapid admission of emergency patients; high occupancy rates; and short lengths of waiting lists. A further study on bed capacity planning concerns the contemplated development of an observation ward in the A/E department. Owing to the increased uncertainty in planning for prospective units, approximation is accepted for the sake of procedural simplicity and an analytic infinite server queueing model is employed to evaluate various numbers of beds for the unit interms of the average occupancy rates and of hourly and daily service levels.

<p> Access to primary health care services is a significant issue for many communities seeking to improve the health of their populations. This single case study describes the 12-year journey of 2 adjoining rural counties in 2 states towards meeting the primary and specialty care needs of the uninsured and underinsured population. Data were triangulated using historical documents, first-person interviews, and health utilization data. The community leadership moved through various models including a free clinic and a university-sponsored health center before finally establishing a federally qualified health center, which now serves 40,000 citizens in these counties. The site is now hosting new programs funded by research grants in alliance with area universities. Success is contributed to an unwavering desire to provide a medical home for the underinsured and underinsured, a shared vision, recognition that continued success was dependent on a funding source, recognition that practices and processes must be in place to assist with navigation for those in need of services to seek care at the appropriate venue, and a belief that the infrastructure built to provide care was sustainable. All participants recognized the importance of funding for sustainability. Positive social change has occurred from the emergence of a multidisciplinary center to serve the community&rsquo;s uninsured and underinsured, thus improving access to care, management of chronic conditions, and access to behavioral health professionals. Findings from this study may inform other communities faced with similar problems and can inform legislators of the importance of federally qualified health centers in the provision of health care to vulnerable populations.</p><p>

<p> The continuously growing readmission rates within 30-days of discharge point toward compromising quality outcomes such as fragmented health care. The purpose of this project was to compare the effectiveness of pre-intervention traditional interdisciplinary rounds (IR)/ progression of care rounds (POCR) members, in comparison to the intervention of modified IR/POCR members, by adding a disease-specific educator (DSE) member to the team, as measured by the 30-day unplanned readmissions rate in patients discharged from a single cardiology unit in Galveston, Texas. A comparison of 30-day unplanned readmissions during two different timeframes was performed using the planned readmission tool. The Iowa model of evidence-based practice and the model of collaborative care supported the project. A comparative quantitative methodology was used to analyze the data. The final sample consisted of 50 (<i>N</i> = 50) patients discharged during the pre-intervention and 53 (<i>N</i> = 53) during post-intervention. The data was analyzed using descriptive statistics and an unpaired t-test. The pre-intervention IR/POCR team members period 30-day readmissions were 7 compared to 3 during the post-intervention IR/POCR team members. The standard deviation of pre-intervention IR/POCR and post-intervention was 3.95980 and 2.12132 respectively. The results show a significant value of 0.106 (95% CI, -1.04243 to 5.04243). The implementation of the DSE to the IR/POCR team assisted in identifying and closing the gap associated with quality patient outcomes and reduced 30-day unplanned readmission rates. Further research is needed due to a limited practice site. </p><p>

<p> <b>Background:</b> Stroke is the leading cause of disability in the US, affecting approximately 795,000 persons annually. Stroke care is delivered across multiple settings from hyperacute care in a hospital through chronic stroke management in the community. Considerable advancements have been made in the delivery of hyperacute and acute stroke care. Science and practice gaps exist in providing stroke transitional care across multiple providers and settings once an individual is discharged from an in-patient care facility to home. </p><p> <b>Purpose:</b> Using a qualitative descriptive design, this study engaged and elicited descriptions from stroke survivors and caregivers affected by stroke to inform the refinement and tailoring of a stroke-specific model of transitional care. </p><p> <b>Sample:</b> A purposeful sample of 19 individuals affected by stroke and their caregivers was required to attain data saturation. Participants provided rich descriptions regarding the postacute stroke transition from an inpatient care facility to home. </p><p> <b>Methods:</b> The investigator conducted five focus group discussions using a semi-structured interview format to elicit participant descriptions of their stroke transitional care experience. Interviews were audio-recorded, transcribed, organized using Atlas.ti 8.1 software, and analyzed using the content analysis method. </p><p> <b>Findings:</b> Stroke transitional care is generally not provided, and a host of unmet survivor and caregiver needs persist. The findings of this study inform stroke-specific exemplars for essential transitional care components. Stroke-specific findings emerged from the data that could not be explained in the context of the transitional care model, such as self-determination and self-efficacy, transportation challenges, and neuropsychiatric management. There is considerable healthcare system passivity in delivering postacute and transitional stroke care, leaving stroke survivors and their caregivers feeling abandoned and marginalized. The findings from this dissertation study and the literature inform refined, stroke-specific components and a stroke transitional care model. </p><p> <b>Conclusion:</b> This dissertation study is the first of its kind to engage primary stakeholders in developing stroke-specific refinements to and exemplars of stroke transitional care components. Study findings describe an urgent need for <i>active</i> stroke transitional care delivery, discusses stroke-specific exemplars of core transitional care components, and identifies refinements for a stroke transitional care model. The findings of this study are innovative in describing a community stroke nurse-led transitional care model that &ldquo;reaches back&rdquo; to the hospital. The unique findings from this study can inform a community-centric, stroke-specific transitional care model that aligns with the American Heart Association/American Stroke Association&rsquo;s guidelines for adult stroke rehabilitation and recovery, from which community stroke nurse-led interventions can be developed and examined. </p><p>

<p> In response to climbing health care costs in the United States, many insurers and policy makers would like to eliminate waste in healthcare by steering spending toward the most cost-effective treatments. Obstacles to achieving this goal include identifying specific medical settings where overuse occurs, and then developing strategies to prevent overuse without harming patient welfare. My study examined childbirth, the number one reason for hospitalization in the US, where the overuse of medical resources primarily takes the form of nonmedically indicated cesarean deliveries. </p><p> The financial tools (physician payment differential and patient&rsquo;s cost sharing) and other tools (utilization management, physician profiling, and practice guidelines) of managed care insurance create varied incentives that could affect behaviors of physicians and patients. Using data from the MarketScan commercial database, I proved that in a fee-for-service setting, physician&rsquo;s financial incentives (physician payment differential) and patient&rsquo;s financial disincentive (patient&rsquo;s cost-sharing) affect treatment choices on childbirth delivery method, and other incentives from managed care insurance have little effect. My study also found that more restrictive nonfinancial tools in non-capitated HMOs which are expected to reduce the use of cesarean sections turn out to have little effect, while lower cost-sharing in non-capitated HMOs leads to more use of cesareans. It could provide two health policy implications: (1) health plans with generous benefits may need more restrictions and effective regulations aimed at cost control, and (2) raising patients cost-sharing may prove effective for managing medical expenses. Finally, a &ldquo;What if&rdquo; analysis sheds light on the likely effectiveness of various changes in managed care insurance design intended to reduce low-risk primary cesarean deliveries.</p><p>

<p>Abstract Palliative care (PC) is the comprehensive management of patients diagnosed with terminal illness. Care for PC patients focuses on relieving symptoms. The purpose of this study was to determine the difference between pretest and posttest scores on the Frommelt Attitude towards the Care of the Dying (FATCOD) and the Palliative Care Quiz for Nurses (PCQN) after an educational intervention to emergency department (ED) nurses. The framework for this project was Bandura?s social cognitive theory. The FATCOD was used to assess ED nurses? attitudes toward PC, and the PCQN was used to assess ED nurses? knowledge about PC prior to the educational program. The educational intervention was developed using evidence obtained from the literature review and guided by the PCQN. The program presented to the ED nurses covered the essentials of palliative care and the information and skills needed by the ED nurse caring for the PC patient. The FATCOD and the PCQN were then administered as a posttest. A total of 70 nurses from two ED units volunteered to take part in the project. Results of the PCQN pre- and posttest showed a significant difference (p < .05), and the FATCOD pre- and posttest showed no significant difference (p = .849). The results revealed that education significantly improved knowledge of PC for the ED nurses participating in the project. Attitudes about PC were not significantly changed after the education program. The project promotes positive social change by raising awareness of the need for PC educational opportunities for ED nurses. By improving PC in the ED, patients and their families may experience increased satisfaction with end-of-life care and improved quality of life.

<p> Ethical ED nurse leadership is faced with persisting challenges to delivering culturally competent care, which is crucial in reducing widespread racial healthcare disparities. Implicit biases are continually cited as key sources driving these inequities. However, research is lacking as how to effectively reduce implicit biases and increase health provider cultural competence. This quantitative, pretest-posttest project evaluated the efficacy of a cultural competency education by investigating if and to what extent the intervention decreased implicit biases and increased perceived cultural competence. Survey data were collected from a convenience sample of 36 ED nurse staff employed at a large urban medical center in California. Data included participant scores on the Race Implicit Association Test (IAT) and the Clinical Cultural Competence Questionnaire (CCCQ). Two-tailed paired samples <i>t</i>-test (CI = 95%; <i>p</i> &lt; .05) indicated that the overall CCCQ score change of 5.5 points was statistically significant (<i>p</i> = .001) and linked to Knowledge (<i>p</i> = .000) and Attitudes subscales (<i>p</i> = .012) improvement. Race IAT changes were not statistically significant. No correlation was found between Race IAT and CCCQ scores. One-way repeated ANOVAs were used to investigate demographic variable impacts on scoring with limited value. Overall cultural competence scores were poor and Race IAT scores differed substantially from prior findings. Based on project results, the education was promising, supporting a solid, theory-based platform for strategically optimizing cultural competence and reducing health disparities in the ED care setting.</p><p>

<p>This dissertation, composed of three manuscripts, provides a foundation for the evaluation of advancing sedation and excessive respiratory depression in terms of managing post-operative patient?s pain with opioids. The first manuscript provides a framework for the concept of sedation in terms of how it is assessed and applied to post-operative pain management. The second manuscript is a qualitative review of the literature regarding the assessment of opioid induced sedation and advancing respiratory depression in regards to managing patient?s pain. The third manuscript provides the dissertation study examining expert nurses? common meanings and shared practices with sedation in the context of postoperative pain management with opioids. Using Heidegger?s interpretive phenomenological methods, interviews with expert post-anesthetic care unit nurses were conducted to capture the missing practical knowledge behind the nursing gestalt approach to managing patient?s pain. The third manuscript is currently being prepared for submission to a journal focusing on pain management nursing. Further research studies are warranted.

<p> Duties performed by staff Registered Nurses (RNs), and Nurse Managers (NMs) require a different skill set to be effective. Nursing leadership is responsible for guiding staff RNs in providing quality, effective, and cost-efficient care. Incompetent leadership may lead to decreased retention and negative patient outcomes. Quality nursing leadership positively influences professional development of staff RNs and patient care. A literature review exposed a gap in leadership training that assists new NMs to function independently and efficiently. The purpose of this original basic qualitative study, which employed Husserl and Heidegger&rsquo;s approach of phenomenology, was to explore the experiences of staff RNs who transitioned into the NM role within the last five years and practice in either a small rural hospital or large urban medical center in southeastern North Carolina. Semi-structured interviews using open-ended questions were utilized to collect rich, contextual data until data saturation occurred. Open and axial coding of the data, documented in a code/theme frequency table, facilitated the discovery of central themes within the data including: the benefit of having performed managerial duties while in a staff RN role; leadership training to introduced a broader view of NM responsibilities and techniques needed to accomplish these duties; and a dedicated mentor who provided intimate guidance during the transition. The evidence from this study aligns with the published literature regarding the transition from a staff RN role into a NM role and supports making a proposal to the hospital&rsquo;s administration for a systems-oriented NM training opportunity such as a 90-day nursing leadership orientation that included formal classes on budgeting, common human resource management issues, and how to evaluate staff. This formalized training, in concert with one-on-one mentoring with experienced NM, would ensure a smoother transition from the staff RN role into the NM role and would produce more efficient, more satisfied nursing leadership professionals who are more inclined to stay with the organization that helped their career growth.</p><p>

abstract: This study aims to unearth monological and monocultural discourses buried under the power of the dominant biomedical model governing the HIV/AIDS debate. The study responds to an apparent consensus, rooted in Western biomedicine and its "standardizations of knowledge," in the production of the current HIV/AIDS discourse, especially in Sub-Saharan Africa. As a result, biomedicine has become the dominant actor (in) writing and rewriting discourse for the masses while marginalizing other forms of medical knowledge. Specifically, in its development, the Western biomedical model has arguably isolated the disease from its human host and the social experiences that facilitate the disease's transmission, placing it in the realm of laboratories and scientific experts and giving full ownership to Western medical discourse. Coupled with Western assumptions about African culture that reproduce a one-sided discourse informing the social construction of HIV/AIDS in Africa, this Western monopoly thus constrained the extent and efficacy of international prevention efforts. In this context, the goal for this study is not to demonize the West and biomedicine in general. Rather, this study seeks an alternative and less monolithic understanding currently absent in scientific discourses of HIV/AIDS that frequently elevates Western biomedicine over indigenous medicine; the Western expert over the local. The study takes into account the local voices of Sub-Saharan Africa and how the system has affected them, this study utilizes a Foucauldian approach to analyze discourse as a way to explore how certain ways of knowledge are formed in relation to power. This study also examines how certain knowlege is maintaned and reinforced within specific discourses. / Dissertation/Thesis / M.S. Biology 2014