Student Number : 9600048X - MSc (Med) research report - Faculty of Health Sciences / Disorders of the thyroid gland are amongst the most common endocrine disorders. The diagnosis of thyroid disease consists of a history and clinical examination, followed by specific confirmatory investigations. These investigations are an important diagnostic component in thyroid disease and are amongst the most common investigations ordered in clinical laboratories. Although these tests are relatively inexpensive individually, they account for a disproportionately large amount of health care expenditure for diagnostic testing. Appropriate laboratory investigation is critical to establish the diagnosis and cause of thyroid disease in the most costeffective way. Discovery Health released a set of evidence-based guidelines in order to educate the clinician with regard to the selection of thyroid function tests. According to these guidelines a TSH (Thyroid Stimulating Hormone) test is the investigation of choice in suspected thyroid disease. This study is a retrospective investigation that compares the difference in ordering patterns of laboratory investigations by clinicians before and after the publication of the guidelines. Two data sets were generated from the data bank of Discovery Health. The first data set (I) was based on records compiled before March 2003 whereas the second data set (II) was based on records compiled from April 2003. Following use of the exclusion and inclusion criteria the sample size totaled 73 850 cases. An analysis was made with regard to the requesting frequency of specific tests. This study will focus solely on the appropriateness of thyroid function tests ordered. It is beyond the scope of this study to attach a specific clinical diagnosis to the results. The thyroid function tests requested before the publication of the evidence-based guidelines were often requested without careful thought and consideration on the part of the clinician. Some of the combination tests ordered (Free T3 and Free T4) are not advocated as an initial investigation in the evaluation of thyroid function and waste funds in this instance. The ordering of inappropriate thyroid function tests often leads to the depletion of funds available to a patient within the financial year. The results revealed that after publication of the guidelines there was an increase in the requesting frequency of TSH as a first line investigation, as well as Free T4 while a decrease in requests for Free T3 was noted. The publication of evidence-based guidelines as a guide to requesting the correct thyroid function tests in order to diagnose suspected thyroid disease appears to have impacted in increasing awareness amongst clinicians with regard to the tests required to diagnose and monitor thyroid disease.

Orientador: Angelo Zanaga Trape / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-10-11T13:41:31Z (GMT). No. of bitstreams: 1 Selmi_GiulianadaFontouraRodrigues_M.pdf: 2858376 bytes, checksum: 82dd080d277979caa8e7cc939d01d5c0 (MD5) Previous issue date: 2013 / Resumo: Dentre os inúmeros produtos químicos atualmente existentes, podemos citar os praguicidas, produtos largamente utilizados na agricultura e que apresentam um significante potencial de exposição, especialmente de trabalhadores rurais, que tem o manuseio desses produtos como função rotineira. Neste contexto é importante ressaltar a necessidade de ações de prevenção de agravos à saúde do trabalhador, assim como avaliar as margens de segurança durante o preparo, o carregamento e a aplicação de praguicidas. Estas ações podem ser viabilizadas através da realização do processo de avaliação do risco, processo amplamente utilizado e que possibilita estimar o risco de determinado produto frente a condições específicas de exposição, contribuindo para a geração de informações que conduzem à adequada tomada de decisões regulatórias e que visam à proteção da saúde humana. A avaliação do risco é composta pelas etapas de identificação do perigo, avaliação dose-resposta, avaliação da exposição e caracterização do risco, sendo que este projeto trata especificamente da etapa de avaliação da exposição, na qual é realizada a estimativa ou quantificação de uma substância frente a um cenário específico de exposição. A exposição pode ser estimada através dos modelos preditivos ou através da condução dos estudos de monitoramento ocupacional em campo. Para este último, os protocolos internacionais que orientam sua condução propõem a utilização de diferentes metodologias, não havendo uma padronização na condução do estudo em campo, sendo esta, portanto, uma das principais limitações relacionadas ao processo de estimativa da exposição dérmica. Assim, o objetivo desse trabalho foi realizar uma avaliação das etapas que compõem um estudo em campo, proporcionando como resultado final a elaboração de um guia que contempla as principais etapas e orientações para a adequada condução deste tipo de estudo. Este trabalho foi desenvolvido através da análise de três estudos de campo atual e conduzido no Brasil, assim como na análise dos protocolos internacionais que tratam do assunto, da EPA e da OECD. Além da elaboração do guia, concluiu-se que, o método do corpo total é a metodologia de dosimetria passiva mais adequada para a quantificação da exposição dérmica de trabalhadores rurais. Para as demais partes do corpo, sugere-se a utilização de luvas impermeáveis e lavagem das mãos como dosímetros externos e internos das mãos, touca árabe para a região da cabeça, limpeza com água e sabão para a face e pescoço e a amostragem das meias para a quantificação da exposição dos pés. Espera-se que o guia proposto evidencie a necessidade de ações que contribuam para o desenvolvimento de uma metodologia única de quantificação da exposição dérmica / Abstract: Pesticides are amongst the most widely used chemical products currently available on the market. Their use in agriculture can present a significant exposure risk, especially to the rural workers whose daily routines involve constant exposure to these substances. It is therefore vital to try to minimize any potentially detrimental impacts on the health of the personnel involved, as well as to determine the levels of safety during the preparation, loading, and application of pesticides. Risk assessment analysis is a procedure that is widely used to estimate the risk of a given substance under specified exposure conditions, generating information that can be used in regulatory mechanisms designed to protect human health. The risk assessment comprises several stages: hazard identification, dose-response assessment, exposure assessment and risk characterization. The present work concerns the exposure stage, and considers the estimation or quantification of exposure to a substance under defined circumstances. Exposure can be estimated either using predictive models or by occupational monitoring in the field. In the latter case, different international protocols have been proposed, without any standardization of the procedures to be followed in field studies; this is one of the main limitations in relation to estimates of dermal exposure. The objective of the present work was therefore to evaluate the different stages of a field study, in order to produce a guide outlining the procedures to be followed in this type of investigation. To this end, three recent field studies undertaken in Brazil were used, together with an analysis of the relevant international USEPA and OECD protocols. In addition to the guide, it was concluded that the whole body approach was the most suitable passive dosimetry technique for quantification of the dermal exposure of rural workers. For specific parts of the body, the use of impermeable gloves and hand washing are proposed as external and internal dosimeters for the hands, an arab cap for the head region, washing with soap and water for the face and neck, and sampling of the socks for quantification of exposure of the feet. It is hoped that the proposed guide demonstrates the need for actions that could contribute to the development of a unified methodology for quantification of dermal exposure / Mestrado / Epidemiologia / Mestra em Saúde Coletiva

Discharge instructions provided to patients discharged from the emergency department (ED) are often provided in a way that is neither clear nor concise. Patients are often discharged home without a clear understanding of their diagnosis, medications, reasons to return to the ED, follow-up instructions, or how to manage their care at home during their illness. Therefore, a guideline needed to be developed in order to help the ED staff provide clear and concise discharge instructions to patients discharged from the ED. The Ace Star Model of Knowledge Transformation was the foundation for the development of the evidence-based guideline. A formative group of 7 individuals was created to critique the initial draft of the guideline, and a final version of the guideline was then distributed to 10 medical professionals to aid in the approval and determination of the quality of the guideline. The data analysis from the formative group questionnaire, and the appraisal of guidelines for research and evaluation tool led to the recommendations for a guideline on the delivery of evidence-based discharge instructions. This project has implications for social change in practice by (a) increasing the awareness among medical professionals about the importance of their communication style on patient discharge and (b) allowing for more efficient communication to occur between them and their patients. The use of an evidence-based practice guideline for providing discharge instructions to patients discharged from the ED will allow improved quality of care to patients, efficient communication between the healthcare providers and patients, a positive impact for social change in practice, and a consistent and reliable method for patients to understand their discharge instructions in a way that is clear and concise.

Colorectal cancer is the 3rd leading cause of cancer-related deaths. Early screening provides the best prospects for preventing the morbidity and mortality associated with the disease. Nurses have the duty to promote health and prevent diseases. However, low rates of colorectal cancer screening continue to be reported, especially among African Americans who continue to suffer disproportionately from the disease. There is a need for a culturally-sensitive clinical practice guideline that nurses can use to educate patients appropriately on colorectal cancer. The practice focused question for this project was designed to explore whether a culturally-sensitive clinical practice guideline to increase colorectal cancer screening among African Americans could be developed using best practices. The health belief model informed the background, development, and implementation of this project. Evidence from peer-reviewed nursing literature was synthesized in a literature review matrix and then used to develop a clinical practice guideline to increase colorectal cancer screening. It is anticipated that this guideline will improve nursing practice by equipping nurses with the knowledge and skill to provide culturally-sensitive education on colorectal cancer and screening. Through the patient education and enhanced nursing practice stipulated in the clinical practice guideline, health care providers may work to eliminate disparities in colorectal cancer screening among African Americans.

Recovering from a cardiac surgery procedure and the transition to home can be an overwhelming experience for patients and caregivers. A tertiary care hospital's cardiothoracic surgery department suspended a nurse-practitioner-coordinated transitional care program in the 1st quarter of 2016. Following this decision, the readmission rate increased from its previous rate of 15.6% in quarter 1 to 20% in quarter 3. The purpose of this scholarly project was to develop a clinical practice guideline (CPG) that can bridge the gap in the transitional care process. The transitional care model informed the design of the project. A draft guideline was distributed to 5 stakeholders from the inpatient cardiac surgery care team for initial review. After initial review and revisions an edited version was then distributed to 5 additional stakeholders. Those stakeholders provided an assessment utilizing the AGREE II tool to assess the 6 domains of scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application and editorial independence, and overall quality. Four domains indicated a high level of agreement (96%-100%) and 2 domains indicated a response of < 76% for domains related to rigor and organizational resources. The overall guideline assessment of the quality of the CPG received a score of 96%, with a recommendation to adopt the guideline. Advanced practice nurses will utilize this guideline to provide a systematic process in bridging gaps in care for the transition of the cardiac surgery patient population from hospital to home. Social change will be promoted through improved patient management by using evidence-based transitional care, decreased readmissions, and improved health outcomes for the cardiac surgical population.

SAMMANFATTNING Sjuksköterskan tillämpar omvårdnadsprocessen genom att observera, värdera, prioritera, dokumentera och vid behov åtgärda och hantera förändringar i allmäntillståndet, samt motverka komplikationer i samband med sjukdom, vård och behandling. Andningsfrekvens (AF) är den vitalparameter som först förändras och signalerar en förändring i allmäntillståndet. Vid de flesta hjärtstopp på sjukhus finns tecken till försämring hos patienten redan några timmar eller upp till ett dygn före.  Syftet var att undersöka sjuksköterskans inställning och följsamhet till att mäta och bedöma AF hos akuta sjuka patienter, för att tidigt upptäcka en försämring i patientens hälsotillstånd. Genom en litteraturstudie framkom fyra teman. Rutiners betydelse, sjuksköterskans inställning till AF och varför den inte mättes, värdet av förändringsarbete samt möjliga arbetssätt för att undvika vårdskador. Rutiner för mätning av AF, olika poängsystem och mätmallar för bedömning av vitalparametrar, påverkade antalet mätningar och registreringar av AF. Den enskilda sjuksköterskans inställning inverkade på mätningen och bedömningen av AF. Flera anledningar till varför AF inte mättes fanns. Studier visade att förändringsarbete och implementering av nya arbetssätt var ett komplext område, insatser krävdes inom flera områden på olika nivåer. Vårdskador och plötslig oväntad död minskade när nya rutiner och arbetssätt kombinerades med utbildning, uppföljning och återkoppling till personalen. AF är en viktig vitalparameter. Används inte den kunskapen för att hitta patienter på väg att försämras, riskerar patienterna att drabbas av vårdskador. Ett utbildningsbehov finns, den senaste forskningen har påvisat att rätt genomförd implementering av övervakningsrutiner och förändrat arbetssätt kan ge ett bra utfall i minskat antal vårdskador och oförutsedd död. / ABSTRACT The nurse applies the nursing process by observing, evaluating, prioritising, documenting and when necessary manage changes in the condition of the patient, and to prevent complications associated with disease, care and treatment. Respiratory Rate (RR) is the vital sign that first changes and signals changes in a patient’s condition. In most cardiac arrests there are signs of deterioration of the patient a few hours up to a day before the event.    The aim of this study was to investigate the nurse´s attitude and adherence to measure and assess RR in acutely ill patients, for an early detection of deterioration in the patient's state of health. Through a literature study four themes were emerged. The importance of guidelines, the nurses' attitude and why the RR was not measured, the value of change of management and possible ways to avoid injuries. Guidelines for the measurement of RR, different scoring systems and observations charts for the assessment of vital signs all affected the measuring and scorings of RR. The individual nurse's attitude affected the measurement and assessment of RR. Several reasons why RR was not measured were found. The studies showed that the process of change and implementation of new ways of working is a complex, and efforts were needed in several areas and at different levels. Care injuries and sudden unexpected deaths decreased when new routines and working procedures were combined with training, monitoring and feedback to the staff.   Research shows that RR is an important vital sign. If this knowledge is not used to find patients about to deteriorate, these patients risk suffering from permanent health effects. There is a need for significant training in this area and recent research has shown that a correct implementation of the procedures provide a good outcome in a decreased number of medical injuries and unexpected death

Introduction: The aim of this study was to assess the patient, practice and practice management related factors contributing to non-adherence of type 2 diabetes mellitus clinical practice guideline in Estonia.Methods: Descriptive postal survey using a self-administered questionnaire. Results: Of the 354 doctors who received the questionnaire 46% (n=163) responded. 76% of them have type 2 diabetes guidelines. Low awareness of diabetes and its complications among patients as well as their low motivation to change their lifestyle were considered to be the biggest difficulties in managing individual patients. In addition to the most often listed problems, non-compliance with medical regimen, patients’ financial problems and their non-attendance were mentioned. The greatest health care systems related barriers to practices providing desirable care wereinadequate number of patients` educational materials, the lack of special diabetes education for nurses and underfunding. The patient related issues were regarded as problems in 96% of the cases and health care system related factors were mentioned in 79% of the cases. / <p>ISBN 91-7997-114-8</p>

The outsourcing of non–core Information and Communication Technology services in the ICT industry has been successfully conducted for many years based on various models and frameworks. Client organisations embark on this for many reasons including cost savings, access to specialised skills and access to global resources to name but a few. This study identified and evaluated the management of outsource agreements between client organisations and suppliers with specific focus on creating an understanding of those factors that has a direct impact on the success of outsource agreements. The primary objective of the research study was to provide a comprehensive management guideline for client organisations embarking on outsource initiatives or planning to renew existing agreements. The secondary objective was to assist service providers with guidance on pitfalls and issues experienced in the management of such agreements and to highlight the lessons learned from the industry at large. The research was conducted by means of a literature study and empirical study. The literature study included background information on outsourcing, outsourcing theories as well as outsource management frameworks. Furthermore, it addressed lessons learned and issues and pitfalls to avoid by service providers. The literature review formed the basis for creating an understanding of those factors that has a direct impact on the success of outsource agreements. Based on the evaluation of the empirical study, it was concluded that client organisations that are planning to embark on the outsourcing or renewal of services need to follow a management framework with a full lifecycle in order to ensure success. The top issues that suppliers need to address are to ensure that a climate of trust exists between them and the client; they need to be as transparent as possible and ensure that they carry extensive business knowledge of the client being serviced. / Thesis (M.B.A.)--North-West University, Potchefstroom Campus, 2012.

Objective: To explore adult cancer symptom management by home care nurses. Scoping review: A scoping review was conducted to describe interventions used by nurses for cancer symptom management in the home care setting. Five included studies revealed that home care nursing contributed to positive client- and system-level outcomes. Study: A mixed-methods descriptive study explored usability of a set of 13 cancer treatment-related symptom management protocols for nurses in the home care setting. Thirty-eight nurses in home care participated. Qualitative and quantitative data indicated the protocols were highly usable. Several barriers suggested they would be better used as resources to support and train nurses rather than documentation tools. Conclusions: Few studies have evaluated interventions for cancer symptom management by home care nurses. This set of protocols was well-received, but further research is required to determine their effectiveness and interventions for implementing with home care nurses providing cancer symptom management.

The outsourcing of non–core Information and Communication Technology services in the ICT industry has been successfully conducted for many years based on various models and frameworks. Client organisations embark on this for many reasons including cost savings, access to specialised skills and access to global resources to name but a few. This study identified and evaluated the management of outsource agreements between client organisations and suppliers with specific focus on creating an understanding of those factors that has a direct impact on the success of outsource agreements. The primary objective of the research study was to provide a comprehensive management guideline for client organisations embarking on outsource initiatives or planning to renew existing agreements. The secondary objective was to assist service providers with guidance on pitfalls and issues experienced in the management of such agreements and to highlight the lessons learned from the industry at large. The research was conducted by means of a literature study and empirical study. The literature study included background information on outsourcing, outsourcing theories as well as outsource management frameworks. Furthermore, it addressed lessons learned and issues and pitfalls to avoid by service providers. The literature review formed the basis for creating an understanding of those factors that has a direct impact on the success of outsource agreements. Based on the evaluation of the empirical study, it was concluded that client organisations that are planning to embark on the outsourcing or renewal of services need to follow a management framework with a full lifecycle in order to ensure success. The top issues that suppliers need to address are to ensure that a climate of trust exists between them and the client; they need to be as transparent as possible and ensure that they carry extensive business knowledge of the client being serviced. / Thesis (M.B.A.)--North-West University, Potchefstroom Campus, 2012.