Use of patient flow analysis to improve patient visit efficiency by decreasing wait time in a primary care-based disease management programs for anticoagulation and chronic pain: a quality improvement study

BACKGROUND: Patients with chronic conditions require frequent care visits. Problems can arise during several parts of the patient visit that decrease efficiency, making it difficult to effectively care for high volumes of patients. The purpose of the study is to test a method to improve patient visit efficiency. METHODS: We used Patient Flow Analysis to identify inefficiencies in the patient visit, suggest areas for improvement, and test the effectiveness of clinic interventions. RESULTS: At baseline, the mean visit time for 93 anticoagulation clinic patient visits was 84 minutes (+/- 50 minutes) and the mean visit time for 25 chronic pain clinic patient visits was 65 minutes (+/- 21 minutes). Based on these data, we identified specific areas of inefficiency and developed interventions to decrease the mean time of the patient visit. After interventions, follow-up data found the mean visit time was reduced to 59 minutes (+/-25 minutes) for the anticoagulation clinic, a time decrease of 25 minutes (t-test 39%; p < 0.001). Mean visit time for the chronic pain clinic was reduced to 43 minutes (+/- 14 minutes) a time decrease of 22 minutes (t-test 34 %; p < 0.001). CONCLUSION: Patient Flow Analysis is an effective technique to identify inefficiencies in the patient visit and efficiently collect patient flow data. Once inefficiencies are identified they can be improved through brief interventions

Criteria for clinical audit of women friendly care and providers' perception in Malawi

Background There are two dimensions of quality of maternity care, namely quality of health outcomes and quality as perceived by clients. The feasibility of using clinical audit to assess and improve the quality of maternity care as perceived by women was studied in Malawi. Objective We sought to (a) establish standards for women friendly care and (b) explore attitudinal barriers which could impede the proper implementation of clinical audit. Methods We used evidence from Malawi national guidelines and World Health Organisation manuals to establish local standards for women friendly care in three districts. We equally conducted a survey of health care providers to explore their attitudes towards criterion based audit. Results The standards addressed different aspects of care given to women in maternity units, namely (i) reception, (ii) attitudes towards women, (iii) respect for culture, (iv) respect for women, (v) waiting time, (vi) enabling environment, (vii) provision of information, (viii) individualised care, (ix) provision of skilled attendance at birth and emergency obstetric care, (x) confidentiality, and (xi) proper management of patient information. The health providers in Malawi generally held a favourable attitude towards clinical audit: 100.0% (54/54) agreed that criterion based audit will improve the quality of care and 92.6% believed that clinical audit is a good educational tool. However, there are concerns that criterion based audit would create a feeling of blame among providers (35.2%), and that manager would use clinical audit to identify and punish providers who fail to meet standards (27.8%). Conclusion Developing standards of maternity care that are acceptable to, and valued by, women requires consideration of both the research evidence and cultural values. Clinical audit is acceptable to health professionals in Malawi although there are concerns about its negative implications to the providers

Psychopathic traits and offender characteristics – a nationwide consecutive sample of homicidal male adolescents

<p>Abstract</p> <p>Background</p> <p>The aim of the study was to evaluate psychopathy-like personality traits in a nationwide consecutive sample of adolescent male homicide offenders and to compare the findings with those of a randomly sampled adult male homicide offender group. A further aim was to investigate associations between psychopathic traits and offender and offence characteristics in adolescent homicides.</p> <p>Methods</p> <p>Forensic psychiatric examination reports and crime reports of all 15 to19- year- old male Finnish offenders who had been subjected to a forensic psychiatric examination and convicted for a homicide during 1995–2004 were collected (n = 57). A random sample of 57 adult male homicide offenders was selected as a comparison group. Offence and offender characteristics were collected from the files and a file-based assessment of psychopathic traits was performed using the Hare Psychopathy Checklist-Revised (PCL-R) by trained raters.</p> <p>Results</p> <p>No significant differences existed between the adolescents and adults in PCL-R total scores, factor 2 (social deviance) scores, or in facets 3 (lifestyle) and 4 (antisocial). Adults scored significantly higher on factor 1 (interpersonal/affective) and facets 1 (interpersonal) and 2 (affective). The adolescent group was divided into two subgroups according to PCL-R total scores. One in five homicidal male adolescents met criteria for psychopathic personality using a PCL-R total score of 26 or higher. These boys significantly more often had a crime history before the index homicide, more frequently used excessive violence during the index homicide, more rarely lived with both parents until 16 years of age, had more institutional or foster home placements in childhood, had more school difficulties, more often had received special education, and, more often had contact with mental health services prior to age 18 years than boys scoring low on the PCL-R. They also more often had parental criminal history as well as homicide history of parents or near relatives than the group scoring low on the PCL-R.</p> <p>Conclusion</p> <p>Homicidal boys behaved as antisocially as the homicidal adults. The adults, however, showed more both affective and interpersonal features of psychopathy. Homicidal adolescents with psychopathy-like personality character form a special subgroup among other homicidal youngsters. Recognizing their characteristics, especially in life course development, would facilitate effective prevention and intervention efforts.</p

Understanding acute ankle ligamentous sprain injury in sports

This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. For extrinsic risk factors to ankle sprain injury, prescribing orthosis decreases the risk while increased exercise intensity in soccer raises the risk. For intrinsic factors, a foot size with increased width, an increased ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance could increase the ankle sprain injury risk. Players with a previous sprain history, players wearing shoes with air cells, players who do not stretch before exercising, players with inferior single leg balance, and overweight players are 4.9, 4.3, 2.6, 2.4 and 3.9 times more likely to sustain an ankle sprain injury. The aetiology of most ankle sprain injuries is incorrect foot positioning at landing – a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (60–90 ms). The failure supination or inversion torque is about 41–45 Nm to cause ligamentous rupture in simulated spraining tests on cadaver. A previous case report revealed that the ankle joint reached 48 degrees inversion and 10 degrees internal rotation during an accidental grade I ankle ligamentous sprain injury during a dynamic cutting trial in laboratory. Diagnosis techniques and grading systems vary, but the management of ankle ligamentous sprain injury is mainly conservative. Immobilization should not be used as it results in joint stiffness, muscle atrophy and loss of proprioception. Traditional Chinese medicine such as herbs, massage and acupuncture were well applied in China in managing sports injuries, and was reported to be effective in relieving pain, reducing swelling and edema, and restoring normal ankle function. Finally, the best practice of sports medicine would be to prevent the injury. Different previous approaches, including designing prophylactice devices, introducing functional interventions, as well as change of games rules were highlighted. This paper allows the readers to catch up with the previous researches on ankle sprain injury, and facilitate the future research idea on sport-related ankle sprain injury