Omring

ObjectivesSome nursing home residents opt to forgo hospital admission in case of a suspected hip fracture due to the poor prognosis. However, outcomes in these patients are unknown and hamper advance care planning and expectation management. This study assesses treatment satisfaction and quality of life in nursing home residents with a suspected hip fracture and a do-not-hospitalize directive.MethodsA prospective case series study was conducted in three nursing home organizations in The Netherlands. The primary outcome was the treatment satisfaction according to proxies and caregivers. Secondary outcomes were EuroQoL-5D-5L utility score, Qualidem scores, pain and opiate administration, adverse events, mortality, and quality of dying (Quality of Dying and Death Questionnaire).ResultsTwenty patients, with a median age of 87 years, were included. The treatment satisfaction as rated by proxies and caregivers was high (median numeric rating scale of 9 [P25-P75 8-10] and 9 [P25-P75 8-9], respectively). The life expectancy was short (median of 5 days [P25-P75 3-6]) with a 14-day mortality rate of 100%. The overall quality of the death was "good to almost perfect" in 77% of the patients (n = 10/13) and "intermediate" in 23% (n = 3/13). Symptom control was rated as "good to almost perfect" in 70% of patients. Four adverse events occurred in three patients (15%).ConclusionsThis study showed that nonoperative management of suspected proximal femoral fractures in nursing home patients that opted to forgo hospital admission, results in high treatment satisfaction, high quality of dying with good symptom control, and predictable short-term mortality rates.

In dit hoofdstuk bespreken wij een achttal casussen uit de praktijk van de bedrijfsarts. Deze wordt daarbij telkens voor een lastige keuze geplaatst. Kwesties die worden belicht zijn de bescherming van cliënten tegen verhoogde gezondheidsrisico’s, de grenzen van het beroepsgeheim bij het weigeren van voorgeschreven medicatie, ‘onmogelijke situaties’, bescherming van de persoonlijke levenssfeer, verplicht opleggen van een leefstijlinterventie om arbeidsgeschiktheid en duurzame inzetbaarheid te behouden, en het recht om vrijgesteld te worden van betaalde arbeid bij een naderend levenseinde. Voor het nemen van een beslissing is het essentieel te beginnen met het duiden van de argumenten als beginselargumenten of gevolgargumenten. Bij de bespreking hanteren wij de methode Morele Oordeelsvorming. Elke bespreking bestaat uit vijf onderdelen: Inleiding – Casus – De zeven stappen – Bespreking – Leervragen.

Dit hoofdstuk biedt een overzicht van de gedachtegang die het boek draagt. In de openingscasus wordt een verzekeringsarts met een lastig probleem geconfronteerd: een cliënt met een ernstige ziekte en een beperkte levensverwachting. Deze casus is de aanloop naar een beschouwing over de beroepsethiek voor de arts voor arbeid en gezondheid. Dat moet een steunende, reflectieve, responsieve, vertrouwenwekkende en verantwoordelijke beroepsethiek zijn. Beroepsethiek begint met morele twijfel. Wanneer is een handeling of beslissing moreel juist? Om die vraag te beantwoorden hebben we zowel een methode als een maatstaf nodig. Een moreel oordeel moet berusten op een goede methode van moreel onderzoek. We werpen een blik op de geschiedenis van de ethiek sedert de Verlichting. De arts voor arbeid en gezondheid van vandaag staat in een indrukwekkende traditie. Gerechtigheid en recht vormen de brug tussen de pioniers van toen en de huidige praktijk. De arts voor arbeid en gezondheid is het alledaagse gezicht van de sociale rechtsstaat. Hij wordt dan ook wel aangeduid als street level bureaucrat.

Abstract In the third era of quality assurance in health care, innovation is no longer the exclusive focus area of the individual medical professional dedicated to optimizing patient care nor is it achieved by design thinking by the health delivery organization aiming for economic sustainability. Change platform in the third era is the community of professionals, committed to providing the best possible care within the limits of organizational logic. We aim to clarify the conditions for sustainable quality improvement in health delivery organizations and in doing so to provide a means of improving initial feasibility assessment by identifying critical factors in the cooperation between different parties. We designed a model representing the sources of influence on the process of decision making regarding the selection of innovations and choosing the most effective implementation strategy. These sources are: aspects of legitimacy, core values and change readiness. We tested this model on a project, aimed at improving the efficiency of the OR in a Dutch University Clinic. The example project failed to deliver the projected outcome because of non-disclosed conflicting interpretations of core values and an implicit controversial status shift between medical professionals and OR management. This confirms the explaining power of our model. Successful implementation of quality innovation in health care depends (among other things) on addressing the challenges of differing concepts of legitimacy, conflicting core values and varying change readiness between social systems in complex organizations. Installing a QIC as such does not meet these challenges.

This chapter explores how design of a single organization can improve larger ecosystem functioning. An underlying assumption was that a hospital organization model based on sociotechnical system principles would in fact enable enhanced forms of cooperation and coordination between eco-system actors both within the hospital and in its relationship with actors external to the hospital. The chapter describes how the merger of two University Hospitals and their physical move into one new building was used as an ideal opportunity for building the organizational conditions necessary for enhanced collaboration and coordination among key ecosystem actors both within the hospital (i.e., the staff, clinicians and administrators) and in the relationships between the hospital and its external partners—i.e. General Practitioners connected to the hospital and other independent healthcare providers. Internally a customized version of the sociotechnical systems design approach created cross-functional, high performance teams. To improve cross organizational relationships, rather than using the usual institutional cooperation agreements between the Board of the Hospital, the Boards of the Associations of Regional/local GPs and other care providers these actors were involved in designing the modes of cooperation between the hospital teams and their connections with the world outside the hospital. Internally, the self-managing multi-disciplinary teams turned out to be very flexible and very effective in developing their ‘own’ networks both within the hospital and with the General Practitioners and other independent healthcare practitioners in the region. Additional outcomes of this redesign process included delivery of very high quality patient care and also a very flexible organization and a good quality of working life for all people working in the hospital. An important conclusion is that in order to be an effective participant in an integrated healthcare ecosystem, an organization must itself be designed as a flexible cooperative network of relatively independent multi-disciplinary units, serving a specific group of patients.

In this research, numerical simulations are used to analyze the mean free path distribution of a (highly) rarefied gas hosted in a constant temperature model cylinder. In the Knudsen regime, gas–gas collisions do not occur and molecular transport can be fully attributed to gas–wall collisions. It is commonly accepted that the mean free path probability distribution then becomes highly nontrivial. Therefore, we propose to analyze this function in terms of its first two moments. We show numerically that both the first and second moments of the path distribution are important in describing the transport of a rarefied gas. In case of the Smoluchowski thermostat, a thermal wall mechanism for the cylindrically shaped pore, the obtained values can be compared with the results that follow from kinetic gas theory.

In dit hoofdstuk ga ik in op de vraag wat dokters in ziekenhuizen verdienen. Dat is niet hetzelfde als antwoord te geven op de vraag wat dokters eigenlijk waard zijn. De meest waardevolle zaken in het leven hebben vaak een bijzonder lage prijs. Zonder water kunnen we niet leven, maar de prijs ervan valt in het niet bij de prijs van een diamant.

The 194 samples of forage were of 6 groups; grass or other forage dried, fresh or ensiled. Workers from 5 institutes analysed some of the samples by their usual methods, 10 methods altogether. Digestibility estimated with sheep was regressed on the other results and correlation coefficients and residual standard deviations were calculated; those were closer for groups of forages than for all forages together. The least accurate predictor of digestibility in vivo was crude fibre content, which is much used in the Netherlands. The best method for each fodder group was the method of Tilley and Terry (NAR 34, 156) as modified by Koelen, Kemmink and Dijkstra (De bepaling van de voederwaarde van ruwvoeders met behulp van de in vitroverteerbaarheid. Internal Report, Institute for Animal Feeding and Nutrition Research 'Hoorn' (1969), No. 27, available in English). It took least work but required sheep rumen fluid. For all groups together, the cell-wall constituents method of Gaillard and Nijkamp (NAR 38, 8034) was better for 54 samples but the residual standard deviation was higher than within groups; it required more labour, but not rumen fluid. (Abstract retrieved from CAB Abstracts by CABI’s permission)