8,599 research outputs found
Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED).
BackgroundRecurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population.Methods/designIn this single-blind randomized controlled trial, 516 adults (โฅ40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care.DiscussionIf this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings.Trial registrationClinicalTrials.gov Identifier NCT01763203
์ถฉ์์ผ ์์ฆ ์ฒญ์๋ ๋ฐ ์ ์ ์ฑ์ธ์์ 2-mSv CT์ ๊ธฐ์กด ์ ๋ CT์ ๋ฏผ๊ฐ๋ ๋ฐ ํน์ด๋: LOCAT์ ์ฌํ ํ์๊ทธ๋ฃน ๋ถ์
ํ์๋
ผ๋ฌธ(๋ฐ์ฌ)--์์ธ๋ํ๊ต ๋ํ์ :์ตํฉ๊ณผํ๊ธฐ์ ๋ํ์ ์ตํฉ๊ณผํ๋ถ,2019. 8. ์ด๊ฒฝํธ.Introduction: To explore heterogeneity across patient or hospital characteristics in the diagnostic sensitivity and specificity of 2-mSv CT relative to conventional-dose CT (CDCT) in adolescents and young adults with suspected appendicitis.
Methods: We used the per-protocol analysis set of a large randomized controlled noninferiority trial conducted between Dec 2013, and Aug 2016, comparing 2-mSv CT and CDCT (typically 7 mSv). The data included 2,773 patients (median age [interquartile range], 28 [21โ35] years) and 160 radiologists from 20 hospitals. We tested for heterogeneity in sensitivity and specificity for the diagnosis of appendicitis across predefined subgroups by patient sex, body size, clinical risk scores for appendicitis, time of CT examination (i.e., working hours [typically 08:00โ17:00 of working days] vs. after hours), CT machines, radiologists experience, previous site experience in 2-mSv CT, and site practice volume. We drew forest plots and tested for additive or multiplicative treatment-by-subgroup interaction on sensitivity and specificity.
Results: The 95% CIs for the between-group differences, particularly for sensitivity, were wide due to small sizes (< 200) for the subgroups of extreme body sizes, high clinical risk score for appendicitis, newer CT machines, hospital with prior experience in 2-mSv CT, and hospitals with small appendectomy volume. Otherwise, the 95% CIs in most subgroups contained the previously reported overall between-group differences as well as null hypothesis value (i.e., 0). There was no significant additive or multiplicative interaction for either sensitivity or specificity.
Conclusions: We found no notable subgroup heterogeneity, which implies that 2-mSv CT can replace CDCT in diverse populations. Further studies are needed for the populations for which our subgroups were small.์๋ก : ๋ณธ ์ฐ๊ตฌ๋ ์ถฉ์์ผ ์์ฆ ์ฒญ์๋
๋ฐ ์ ์ ์ฑ์ธ์์ ๊ธฐ์กด CT์ ๋น๊ตํ์ฌ 2-mSv CT์ ์ง๋จ ๋ฏผ๊ฐ๋ ๋ฐ ํน์ด๋์์ ํ์ ๋๋ ๋ณ์์ ํน์ฑ์ ๋ฐ๋ฅธ ์ด์ง์ฑ์ด ์๋์ง๋ฅผ ํ์ํ๋ ์ฐ๊ตฌ์.
๋ฐฉ๋ฒ: ๋ณธ ์ฐ๊ตฌ๋ 2013๋
12์์์ 2016๋
8์ ์ฌ์ด์ 15โ44์ธ์ ํ์์์ 2-mSv CT์ ๊ธฐ์กด ์ ๋ CT (์ผ๋ฐ์ ์ผ๋ก 7 mSv)๋ฅผ ๋น๊ตํ ๋๊ท๋ชจ ๋น์ด๋ฑ์ฑ ๋ฌด์์๋ฐฐ์ ์์์ํ์ ํ๋กํ ์ฝ ๋ณ ๋ถ์์ธํธ๋ฅผ ์ฌ์ฉํจ. ๋ณธ ์ฐ๊ตฌ์๋ 20๊ฐ ๋ณ์์์ 2,773๋ช
์ ํ์ (์ค์๊ฐ ์ฐ๋ น [์ฌ๋ถ์์ ๋ฒ์], 28 [21โ35]์ธ)๊ฐ ํฌํจ๋์์ผ๋ฉฐ, 160๋ช
์ ํ๋
์๊ฐ ์ฐธ์ฌํจ. ํ์์ ์ฑ๋ณ, ์ ์ฒด ํฌ๊ธฐ, ์ถฉ์์ผ์ ๋ํ ์์ ์ํ ์ ์, CT ๊ฒ์ฌ์๊ฐ (์ผ๊ณผ์๊ฐ [๊ทผ๋ฌด์ผ ๊ธฐ์ค ์ค์ 8์๋ถํฐ ์คํ5์] ๋๋ ์ผ๊ณผ์๊ฐ ์ดํ), CT ์ฅ๋น, ํ๋
์์ ๊ฒฝํ์ ๋, 2-mSv CT์ ๋ํ ์ด์ ๊ฒฝํ ์ฌ๋ถ, ๊ทธ๋ฆฌ๊ณ ๋ณ์์ ์์๊ท๋ชจ ๋ฑ์ ์ฌ์ ์ ์๋ ํ์ ๊ทธ๋ฃน์์ ์ถฉ์์ผ ์ง๋จ์ ์ํ ๋ฏผ๊ฐ๋ ๋ฐ ํน์ด๋์ ์ด์ง์ฑ์ ํ
์คํธํจ. ๋ ๊ตฐ์ ์ฐจ์ด๋ฅผ ์ฒ๊ทธ๋ฆผ์ผ๋ก ์ ์ํ๊ณ , ๋ฏผ๊ฐ๋์ ํน์ด๋์ ๋ํ ๋ง์
๋ฐ ๊ณฑ์
์ํธ์์ฉ์ ํ
์คํธํจ.
๊ฒฐ๊ณผ: ๋ง์ด ๋ ์ฌํ๊ฑฐ๋ ๋ฑ๋ฑํ ๊ฒฝ์ฐ, ์ถฉ์์ผ ์ผ์ฆ ๋ฐ์ ์ ์๊ฐ ๋์ ๊ฒฝ์ฐ, ์ต์ CT ๊ธฐ๊ธฐ๋ฅผ ์ฌ์ฉํ ๊ฒฝ์ฐ, 2-mSV CT ์ ์ด์ ๊ฒฝํ์ด ์๋ ๋ณ์, ๊ทธ๋ฆฌ๊ณ ์ถฉ์์ ์ ์ ๊ท๋ชจ๊ฐ ์์ ๋ณ์์ ๊ฒฝ์ฐ ๋ฑ ํน์ ํ์ ๊ทธ๋ฃน์ ์์ ํฌ๊ธฐ (< 200)๋ก ์ธํด ๋ฏผ๊ฐ๋์ ๋ํ 95 % ์ ๋ขฐ๊ตฌ๊ฐ์ด ๋์์. ๊ทธ ์ธ, ๋๋ถ๋ถ์ ํ์ ๊ทธ๋ฃน์์ ๊ทธ๋ฃน ๊ฐ ์ฐจ์ด์ ๋ํ 95 % ์ ๋ขฐ๊ตฌ๊ฐ์ ์ด์ ๋ณด๊ณ ๋ ์ ์ฒด ๊ทธ๋ฃน ๊ฐ ์ฐจ์ด ๋ฐ ๊ท๋ฌด ๊ฐ์ค ๊ฐ (์ฆ, 0)์ ํฌํจํ์์. 2-mSv CT ๊ตฐ๊ณผ ๊ธฐ์กด ์ ๋ CT ๊ตฐ ๊ฐ์ ๋ฏผ๊ฐ๋ ๋ฐ ํน์ด๋์์ ๋ง์
๋๋ ๊ณฑ์
์ํธ์์ฉ์ ๋ณด์ด๋ ํ์ ๊ทธ๋ฃน์ ์์์.
๊ฒฐ๋ก : ์ถฉ์์ผ ์์ฆ ์ฒญ์๋
๊ณผ ์ ์ ์ฑ์ธ์์ 2-mSv CT์ ๊ธฐ์กด ์ ๋ CT ๊ฐ์ ๋ฏผ๊ฐ๋์ ํน์ด๋์์ ์ด์ง์ฑ์ ๋ณด์ด๋ ํ์๊ทธ๋ฃน์ ์์์. ์ด๋ 2-mSv CT๊ฐ ๋ค์ํ ์ง๋จ์์ ๊ธฐ์กด ์ ๋ CT๋ฅผ ๋์ฒดํ ์ ์์์ ์๋ฏธํจ. ๋ค๋ง, ๋ณธ ์ฐ๊ตฌ์์ ์์ ํฌ๊ธฐ๋ฅผ ๊ฐ์ง ์ผ๋ถ ํ์ ๊ทธ๋ฃน์ ๋ํด์๋ ์ถ๊ฐ์ ์ธ ์ฐ๊ตฌ๊ฐ ํ์ํจ.INTRODUCTION 1
Motivations of LOCAT 1
Purposes of LOCAT 3
Motivations of Dissertation Research 4
Purposes of Dissertation Research 5
BACKGROUND 7
Epidemiology of Appendicitis and CT utilization 7
Imaging Utilization 7
Popularity of CT 8
CT Radiation 9
Radiation Dose Level 10
Typical Radiation Dose for Multi-purpose Abdomen CT 10
Typical Radiation Dose for Appendiceal CT 11
Low Doses Explored in Research Settings 12
Carcinogenic Risk Associated with CT Radiation 12
Controversy 13
ALARA Principle 14
Efficacy and Effectiveness of LDCT Compared to CDCT 15
Clinical Outcome 19
Diagnostic Performance 20
Inter-observer Agreement 21
Differentiation between Complicated vs. Uncomplicated Appendicitis 22
Image Quality 24
Visualization of the Appendix 24
Alternative Diagnoses 25
Step-wise Multimodal Diagnostic Approach Incorporating LDCT 27
Patient Subgroups Less Benefited from LDCT 27
Selective Utilization of LDCT 29
Additional Imaging Test(s) Following LDCT 30
Imaging Techniques for LDCT for Suspected Appendicitis 31
Intravenous Contrast Enhancement 31
Contrast-enhancement Phase 31
Enteric Contrast 32
Anatomical Coverage 32
Tube Current 33
Tube Potential 34
Iterative Reconstruction 34
Image Reconstruction Thickness 35
Coronal Reformation 35
Sliding-Slab Averaging Technique 36
Image Interpretation and Reporting for LDCT 37
Diagnostic Criteria for Appendicitis 37
Structured Reporting 38
Other Practical Issues in Implementing LDCT 39
Dedicated Protocol for Appendiceal CT 40
Education for Referring Physicians and Surgeons 41
Education for Radiologists 42
Dose Calibration and Monitoring 43
MATERIALS AND METHODS 47
Study Overview 47
Practice Setting 48
Pre-registration Procedures 48
Study Organization and Site Recruitment 49
Site Activation 50
Patients 51
Eligibility Criteria 54
Clinical Suspicion for Appendicitis 55
The Need for CT Examination 55
Generalizability 56
Representativeness of Study Sample 57
Withdrawal Criteria 58
Randomization 58
Index Test 59
CT Image Acquisition and Archiving 66
Radiation Doses 69
Record of Modulated Radiation Dose 71
Target Median DLP Values for the 2-mSv CT and CDCT groups 71
Calibration of Radiation Doses 72
Estimation of Carcinogenic Risk Associated with CT Examination 74
Image Interpretation 75
Radiologists and CT Reports 76
Radiologist Training 78
Considerations Regarding Technical Advantages over Previous Studies 79
Image Submission 80
Co-intervention 81
Additional Imaging 82
General Treatment Guidelines 82
Follow-up 84
Endpoints in LOCAT 85
Primary Endpoint 86
Secondary Endpoints 86
Considerations for NAR and APR 89
Changes in Endpoints 89
Reference Standards 91
Overview of Reference Standards 91
Definition of Acute Appendicitis 92
Mild or Early Acute Appendicitis 92
Appendiceal Diverticulitis 93
Cases of Delayed Appendectomy 93
Periappendicitis 93
Definition of Appendiceal Perforation 94
Reporting AEs 95
Definition of AE 96
Definition of SAE 97
AE Characteristics 97
Grade 98
Expected/Unexpected AEs 98
Attribution 98
Individual Symptoms vs. Single Diagnosis 99
Who Should Report AEs 99
How to Report AEs 99
Follow-up for AEs 100
Ethical Considerations 100
Ethics and Responsibility 100
Informed Consent Form 101
Data Security and Participant Confidentiality 101
Early Stopping Rules in LOCAT 101
Data Management 102
Case Report Forms 103
Monitoring Participant Accrual 103
Monitoring Data Quality 103
Data and Safety Monitoring Board 105
Statistical Analysis 105
Considerations for Primary Endpoint 105
Analysis Plans 107
Sample Size 108
Sample Size Considerations 108
Final Sample Size 110
Rationale for the Noninferiority Margin 111
Reported NARs Following Preoperative CT 111
Reported NARs in Patients Without Preoperative CT 112
Sample Size Considerations on APR 113
Subgroup Analyses for APR and NAR 114
Subgroup Analyses for Diagnostic Performance 116
RESULTS 119
Patient Characteristics 119
Overall Diagnostic Performance 123
Subgroups of Limited Comparison 123
Between-group Differences for Subgroups 123
Heterogeneity 131
DISCUSSION 132
CONCLUSION 139
REFERENCES 140
APPENDIX 164
Abstract in Korean 176Docto
Medical Error Disclosure: โSorryโ Works and Education Works!
Patient safety and medical errors have emerged as global concerns and error disclosure has been established as standards of practice in many countries. Disclosure of medical errors to patients and their families is an important part of patient-centred medical care and is essential to maintaining trust. However, physicians still hesitate to disclose errors to patients despite their belief that errors should be disclosed. Multiple barriers such as fear of medical lawsuits and punishment, fear of damaging their professional reputation, and diminished patient trust inhibit error disclosure. These barriers as well as lack of training or education programs addressing error disclosure contribute to a low estimated disclosure rate in real situations. Nowadays, the importance of patient safety education including error disclosure is emphasized and related research is increasing. In this paper, we will discuss the background of medical error disclosure and studies on education programs related to error disclosure. In this regard, we will examine the content and methods currently being taught, discuss the effects or outcomes of such education programs and obstacles or difficulties in implementing them. Finally, the direction of future error disclosure education, support systems, and education strategies will also be covered.prohibitio
Factors Related to Korean Nurses' Willingness to Report Suspected Elder Abuse
SummaryPurposeThis study aimed to describe Korean nurses' willingness to report suspected elder abuse and examine its related factors.MethodsA descriptive correlational design was used. A convenience sample of 365 nurses from a hospital completed our questionnaires. Stepwise logistic regression analysis was performed to examine predictors of willingness to report.ResultsSixty-eight nurses (18.6%) were not willing to report suspected elder abuse. In the stepwise logistic regression analysis, fewer years in clinical work, a higher level of knowledge on elder abuse law, and the perception of more severe abuse were found to be significant predictors of willingness to report elder abuse.ConclusionAs the Welfare of the Aged Act included a clause on mandated reporters, nurses' role in intervening in elder abuse cases has become more critical. In order to increase nurses' reporting, education on elder abuse should be provided to all nurses, and support programs should be designed for nurses to effectively involve them in reporting elder abuse
Patients Safety Culture: A Baseline Assessment Of Nurses\u27 Perceptions In A Saudi Arabia Hospital
ABSTRACT
PATIENT SAFETY CULTURE: A BASELINE ASSESSMENT OF NURSES\u27 PERCEPTIONS IN A SAUDI ARABIA HOSPITAL
by
AHMAD E. ABOSHAIQAH
May 2010
Advisor: Dr. Stephen J. Cavanagh
Major: Nursing
Degree: Doctor of Philosophy
Patient safety (the avoidance and prevention of patient injuries or adverse events resulting from the processes of health care delivery) has become a major academic and public concern in healthcare. In order to promote and sustain a culture of safety in a healthcare organization, healthcare professionals stress the need to understand both individual and system contributions to error events. However, in Saudi Arabia, little is known about nurses\u27 perceptions of patient safety culture.
The purpose of this research is to identify the systems factors that Registered Nurses (RNs) perceive as contributing to a culture of patient safety and to study the effects these perceptions have on nurses\u27 participation and engagement in the patient safety culture at King Fahad Medical City (KFMC), Saudi Arabia. King\u27s conceptual system was utilized as the theoretical framework for this study.
This study used a quantitative research methodology with a descriptive/correlation design. The sample of this study was registered RNs at KFMC, Saudi Arabia. The Hospital Survey on Patient Safety Culture (HSOPSC) instrument was used to measure perceptions of nurses on patient safety culture.
Copies of the surveys were distributed to 600 RNs. A total of 500 questionnaires were returned. Among these returned questionnaires, 55 were excluded because they had missing responses on more than one complete section of the questionnaire. The total response rate for this study was 83%.
Overall, 52% of the nurses positively perceived patient safety culture at KFMC, which is considered an opportunity for improvement according to AHRQ\u27s definition of areas needing improvement. Nurses responded most positively to two dimensions, hospital management support for patient safety and organizational learning. Nurses responded most negatively to the dimensions of hospital handoffs and transitions, communication openness, non-punitive response to error, and supervisor/manager expectations and actions promoting patient safety.
There were significant differences between nurses\u27 perceptions of patient safety culture and gender, age, years of experience, Arabic vs. non-Arabic speaking, and length of shift; but astonishingly, for level of education, the results were not significantly correlated to any of the HSOPSC dimensions.
Findings from this study provide a description of the current status of patient safety at King Fahad Medical City from the nurses\u27 perspective. The findings will not only provide a baseline from which to work, but they will help raise safety awareness throughout the organization and identify areas most in need of improvement. Findings will lead to the development of interventions to improve patient safety in Saudi Arabia hospitals
Hospital Safety Climate Assessment toward Attitudeโs Nurses Based on Sammerโs Model Case study: An academic General and A specialized Hospital in Tehran (Iran)
Safety climate has become an important issue in organizational safety management of health systems. The aim of this applied study was assessment safety climate in general and specialized academic hospitals based on Sammerโs model, to introduce a model with the specific framework to assess climate safety in Iranian hospitals, moreover, to reduce medical errors and incidents, also to increase patient safety.
This model consists of seven dimensions: leadership, teamwork, evidence-based practices, communication, learning, justice and patient-centeredness. So a descriptive โcomparative study was undertaken through a methodology including 3 phases. Data were collected by a modified questionnaire based on the Hospital Survey on Patient Safety Culture (HSOPSC) from 217 nurses and an In-depth interview with 52 nurses in both hospitals.
According to the results in the general hospital, leadership, patient-centeredness and learning was recognized as the most effective factors, however, in the specialized hospital, the most important factors were patient-centeredness and justice.
Seven dimensions of Sammerโs model are effective in safety climate assessment, but they are not enough to assess safety climate Iranian hospitals. Adding other factors such as safety and standardized hospital building space, the safety of equipment, physical factors in the workplace, Social and culture factors and terms and conditions governing the hospital settings can help to complete the model and provide an integrated and more consistent one to take an effective step in assessing overall hospital safety climate
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