The Chief Complaint

Advanced age is a well-recognized risk factor for adverse outcomes after trauma. A substantial body of literature, much of it cited within this article, demonstrates increased morbidity and mortality in geriatric trauma patients compared with their younger counterparts. Whether this outcome difference is because of the decreased physiologic reserve that accompanies aging, a higher incidence of preexisting medical conditions in the geriatric patient, or other factors yet to be identified remains unclear. It is clear, however, that good outcomes can be achieved in this patient population when appropriately aggressive trauma care is directed toward geriatric patients with survivable injuries. Implicit in the above statement is the need to identify, as soon as possible after injury, those patients who will benefit from aggressive resuscitation, timely injury management, and posttrauma rehabilitation. It is equally important, however, to limit these intensive and expensive treatment modalities to patients whose injuries are not only survivable but also compatible with an acceptable quality of life. Our purpose in developing this guideline was to provide the trauma practitioner with some evidence-based recommendations that could be used to guide decision-making in the care of the geriatric trauma patient. We began this process by first developing a series of questions, the answers to which we hoped could be supported by the existing scientific literature. The initial set of questions were as follows: 1. Is age itself a marker of increased morbidity/ mortality? If so, what age should be used? 2. Is age instead a surrogate for increased preexisting conditions (PECs)? If so, which premorbid conditions are particularly predictive of poor outcomes? 3. Should age itself be a criterion for triage from the field directly to a trauma center, regardless of Glasgow Coma Scale (GCS) score, Trauma Score (TS), and so forth? If so, what age should be used? 4. Do trauma centers have better outcomes with geriatric trauma than nontrauma centers? 5. Are there specific injuries, scores (e.g., Injury Severity Score [ISS], TS, GCS score), or PEC/age combinations in geriatric trauma patients that are so unlikely to be survivable that a nonaggressive approach from the outset could be justified? 6. What resuscitation end-points should be used for the geriatric trauma patient? 7. Should all geriatric trauma patients receive invasive hemodynamic monitoring? If so, what specific types of monitoring should be used? If not, which geriatric patients benefit from invasive monitoring? Unfortunately, after examining the available literature, it is clear that evidence-based responses to all of the questions raised above are not possible. As the evidentiary tables demonstrate, there are few, if any, prospective, randomized, controlled trials that definitively address any of the above issues. Second, there is a lack of uniformity as to a specific age criterion for geriatric trauma. As shown in the evidentiary tables, geriatric trauma is variously defined in the literature as age greater than or equal to 55, 60, 65, 70, 75, and even 80 years of age. There is even literature support for increased mortality from trauma beginning at age 45! Furthermore, because age is a continuous variable, and not a dichotomous one, adverse outcomes associated with geriatric trauma are likely to increase in a continuous fashion with age as opposed to a stepwise leap as a given patient reaches a specific age. Third, there is no concise definition of a geriatric trauma patient. In some studies, all patients over a given age are included, whereas in others, patients with penetrating injuries, burns, and minor injuries, such as slip-and-falls, are excluded. Some studies include all patients regardless of hemodynamic instability or injury severity, whereas others impose strict entrance criteria or exclude patients who do not survive for a predetermined period of time after admission. Such lack of uniformity regarding inclusion criteria makes it Submitted for publication October 3, 2001. Accepted for publication September 16, 2002. Copyright © 2003 by Lippincott Williams & Wilkins, Inc. From the Carolinas Medical Center (D.G.J.), Charlotte, North Carolina, Trauma Service, Bronson Hospital (B.R.P.), Kalamazoo, and Trauma Burn Center, University of Michigan Health System (W.W.), Ann Arbor, Michigan, New York Hospital–Cornell Medical Center (P.S.B.), New York, New York, Robert Wood Johnson Medical School (J.S.H.), New Brunswick, New Jersey, Mt. Sinai Hospital (M.R.H.), Chicago, Illinois, Morehouse School of Medicine (K.E.S.), Atlanta, Georgia, and R Adams Cowley Shock Trauma Center, University of Maryland Medical Center (T.M.S.), Baltimore, Maryland. Address for reprints: David G. Jacobs, MD, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232; email: djacobs@carolinas.org.

PurposeTo explore patients’, caregivers’, and health professionals’ perspectives on barriers and challenges to accessing, commencing and completing cancer therapy, with a focus on geriatric patients and the impacts of comorbidities and rurality.Patients and MethodsA qualitative sub-study using focus group discussions was conducted in a regional cancer center and one of its outreach clinics in rural New South Wales, Australia. Five discussions with three distinct cohorts were undertaken, including: 1) geriatric cancer patients (two discussions); 2) caregivers (two discussions); and 3) health professionals (one discussion). Each focus group comprised eight to ten participants. A question guide was used to elicit participants’ experiences of receiving/providing cancer care and support during cancer treatment in a rural setting. Iterative thematic analysis was undertaken, with transcripts coded using NVivo software.ResultsParticipants identified travel to larger regional centers and/or metropolitan areas and related arrangements as primary challenges to accessing diagnostic tests, surgeries, some treatments, and follow-up tests. Financial stress, and a lack of knowledge regarding available support services and mechanisms, was also a key issue for most patients and caregivers. Differences in availability of specific testing equipment, such as PET-CT, further complicated patients’ and caregivers’ experience of seeking diagnosis and management of cancer. While all interview cohorts identified positive rapport between clinicians and patients as a key characteristic of their experience of cancer management in rural and regional areas, difficulty in retaining clinical staff and related staffing levels at some health services were understood to negatively impact patients’ and caregivers’ experiences.ConclusionOverall, the study highlights the effects of geographical, social, and informational isolation on patients’ and caregivers’ experience of cancer diagnosis and management, and suggests several implications for further research and practice improvement.

Overview of the Geriatrics Curriculum In recent years, we have developed and strengthened the geriatrics curriculum through a deliberate process of specifying learning outcomes, identifying existing geriatrics content, designing and implementing new learning activities and resources, and assessing students’ geriatrics-related knowledge, skills, and attitudes. Further, recent changes in the curriculum governance structure ensure ongoing assessment and improvement of the geriatrics curriculum. The geriatrics curriculum now is fully integrated in required courses across all four years of the curriculum, providing a coherent and comprehensive program that prepares students to care effectively and compassionately for older adults. A unique feature of our curriculum is its focus on preparing students to improve the health of the state’s population, which includes a growing number of citizens over the age of 65. Approximately 40% of clinical teaching takes place in communities throughout the state, where students learn about caring for diverse populations in a variety of communities and health care settings. Curriculum Management and Governance Structure (see Figure 1)FIGURE 1. Governance StructureIn January 2002, the Curriculum Management and Policy Committee (CMPC) was established as the central body responsible for curriculum management and governance. The CMPC is chaired by the executive associate dean for medical education, who reports to the dean, and its members are the co-chairs of the three course directors’ committees and the associate deans for admission, student affairs, and educational development. The following committees report to and advise the CMPC and are the avenue by which the geriatrics curriculum has been integrated in the overall curriculum: Three course directors’ committees, one each for the first and second year, and one for the third and fourth years combined, are responsible for overseeing, coordinating, and improving the individual courses and overall curriculum for each year. The co-chairs of these committees are appointed by the executive associate dean for medical education. Each committee is composed of all of the course directors for the respective year(s). Ex-officio members include staff from the Office of Medical Education and student representatives. The director of the Program on Aging, as a second-year course director, is a member of that committee and also attends the first-, third- and fourth-year committee meetings. The Curriculum Advisory Board convenes quarterly to serve as a forum for all constituencies and stakeholders involved with the educational program for the MD degree, to share ideas about the curriculum, and discuss current practice, concerns, and plans. The director of the Program on Aging is a member of this committee. Two additional committees report to the CMPC and have supported the development of the geriatrics curriculum: The Faculty Advisory Committee on Educational Technology advises the executive associate dean for medical education on matters regarding effective selection and use of educational technology and information systems. Much of the computer-assisted geriatrics instruction has been facilitated by this group. The Whitehead Curriculum Committee, an arm of the Whitehead Medical Society (the student government), works to improve individual courses and the overall curriculum and serves as the liaison among students, student government, and the Curriculum Management and Policy Committee. Each year the two second-year students who are elected co-vice presidents for curriculum of the Whitehead Medical Society serve as co-chairs of the committee, which is composed of student representatives from each class, the co-chairs of the course directors’ committees, the executive associate dean for medical education, and the associate deans for student affairs and educational development. Whitehead representatives attend meetings of the course directors’ committees and Curriculum Advisory Board. The new governance structure has permitted organizational and administrative flexibility to manage and coordinate the curriculum and to react to a rapidly changing academic medical center environment to facilitate change if and when it is deemed necessary. The strengthening of the geriatrics curriculum has been and continues to be a critical focus. In addition to the overall curriculum governance structure of the medical school, the Geriatrics Curriculum Committee (GCC), centered in the Program on Aging, serves as a major force in the development of the geriatrics curriculum. The seven-member interdisciplinary GCC, chaired by the director of the Program on Aging, was created to remedy gaps in the geriatrics curriculum. The group’s accomplishments include: development of a comprehensive syllabus outlining geriatrics learning objectives and content that all medical students should master prior to graduation; thiswas done through surveying practicing physicians to determine the skills needed to work effectively with elders in the community and following guidelines from the American Geriatrics Society (“Areas of Basic Competency for the Care of Older Patients for Medical and Osteopathic Schools,” 1998); evaluation of existing geriatrics content and learning activities to assess where and how well these topics are taught in the curriculum; and implementation of educationally sound methods to address geriatrics components that may not be fully incorporated into the medical curriculum. Plans developed by the GCC are shared with the three course directors’ committees and the Curriculum Advisory Board via the Program on Aging representative. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change The John A. Hartford Foundation grant received through the AAMC in June 2000 provided the resources that allowed us to strengthen and build the geriatrics curriculum across all four years, expand our outreach to students interested in geriatrics medicine, and document those areas in the curriculum where geriatrics knowledge and skills were inadequate or lacking. Specifically, our goals were to increase (1) the exposure of all students to core geriatrics content to help ensure a sound knowledge base for practice, (2) the number of opportunities for student exposure to older adults to support empathic practice, based upon an appreciation of normal and successful aging as well as its challenges, and (3) educational experiences to engage students in applying their knowledge and skills to solve complex problems in geriatrics medicine. These efforts were well received by faculty and students and resulted in increased visibility throughout the School of Medicine and increased awareness of the importance of geriatric medicine as an inherent component of core competencies. Both before and midway through the grant period, institutional involvement in curriculum change permitted even greater achievements in enhancing the geriatrics program. Prior to this, the Program on Aging had limited opportunities to make formal recommendations regarding medical school curriculum design and content, with virtually no active, authoritative role in the decision-making process. In 1999, the large and unwieldy First- and Second-Year Course Directors’ Committee was divided in two, so that each committee could focus exclusively on a single year’s curriculum. This promoted more intense and focused work on analyzing the curriculum and determining ways to strengthen it. In 2001, the dean appointed the Leadership Task Force on the Outcomes of the Medical School Curriculum, composed of nine department chairs representing both basic and clinical sciences. This committee was charged with describing the core competencies (learning objectives) to be achieved by graduating medical students and with revising the curriculum governance structure to promote efficient and effective decision making. The subsequent establishment of a set of core competencies and the reconfiguration of the governance structure (described above) resulted in major curriculum changes, with significant implications for expanding the depth and breath of geriatrics content throughout the four-year curriculum. The Second-Year Course Directors’ Committee transformed the second-year curriculum from separate courses generated by each department into integrated block courses focusing on organ systems. The committee also established both an introductory and a capstone block to begin and end the year, with each of these blocks using case-based learning with a strong geriatrics focus. Theme for the Geriatrics Curriculum The teaching mission of the Division of Geriatric Medicine and the Program on Aging is to build the capacity of UNC to prepare health care providers at all levels for evidence-based, outcomes-oriented health care for older adults and ultimately, to improve or preserve their level of function and quality of life. The major theme for the geriatrics dimension of the UNC medical school curriculum is twofold, to ensure (1) that the geriatrics curriculum is a recognizable and integral component throughout all four years of the medical curriculum; and (2) that students, faculty, and administrators recognize that the mastery of geriatrics competencies is most effectively achieved within an interdisciplinary system of care delivery that recognizes the interdependence of education; research; primary, subspecialty, and ancillary care; and public policy and regulation. The questions that must be addressed for each curricular activity are “How does this intervention affect the student’s acquisition of identifiable geriatric core competencies?” and “How does this intervention increase the student’s understanding and implementation of interdisciplinary team skills?” An additional theme is the commitment to recognize and encourage those students who have a particular interest in geriatrics and the potential to be leaders in the field, regardless of their subspecialty interest. Learning Outcomes for the Geriatrics Curriculum After completion of the enhanced four-year geriatrics curriculum, students will be able to describe age-related physiological changes, differentiate between normal aging and disease processes, demonstrate the problem-solving ability necessary to provide care to older persons, exhibit the professional qualities of integrity, compassion, thoroughness, responsibility, and commitment to caring for older persons, identify political, financial, and social factors that affect delivery of care, and recognize their own potential and that of their patients for subscribing to aging stereotypes. Special Programs Community partnerships Community partnerships play an essential role in fulfilling the university’s commitment to prepare professionals to meet the health care needs of North Carolina’s citizens. The Program on Aging facilitates student involvement in two partnerships that offer a variety of opportunities for work with older adults across the spectrum of geriatrics issues: The Program on Aging enjoys a strong and longstanding relationship with the North Carolina Area Health Education Centers (AHEC) program, a nationally recognized model for interdisciplinary education and training of health care providers. Several regional AHECs collaborate with us on innovative projects to ensure that there are community clinical training sites with well-qualified preceptors available to teach geriatrics knowledge and clinical skills. The Education for Lifelong Service (ELS) Program provides students with community service opportunities, complemented by a curriculum designed to foster leadership skills in service delivery. ELS has responsibility for the newly established Office of Community Service and sponsors courses on the care of underserved and vulnerable populations, including activities that emphasize services to older adults. Program on Aging representatives participate on the ELS leadership team. Standardized geriatric patients The UNC School of Medicine Standardized Patient (SP) Program, administered by the Office of Educational Development, gives students opportunities to practice communication and diagnostic and examination skills before they encounter patients in the actual clinical setting. In addition, the program provides a mechanism to assess these same skills in a standardized format. The program maintains an active database of SPs, including those who are suitable for presentation of geriatric illnesses and situations. Simulated case presentations using geriatric standardized patients are frequently requested for classroom learning, most notably in the first- and second-year Introduction to Clinical Medicine course, in second- year integrated cases, and as part of the fourth-year Clinical Performance Examination, which students must pass in order to graduate. Faculty development The Office of Educational Development provides several faculty development programs and activities in which geriatrics faculty participate and that help to strengthen the geriatrics curriculum. The Expert Preceptor Program, designed for practitioners in community-based clinical settings, is available in an online, interactive format known as the Expert Preceptor Interactive Curriculum. This is a self-paced program comprising modules that can be used individually as information resources or collectively as a complete curriculum. Each module focuses on a skill related to clinical teaching in the community practice setting or on strategies for teaching contemporary health issues. The Teaching Scholars Program is a year-long series of monthly seminars designed to promote expertise and scholarship in medical education for fellows and faculty. In addition, participants choose a specific area of educational interest to pursue in depth and present their results to colleagues at a symposium at the conclusion of the program. Completion of the program confers recognition as a scholar in medical education, and graduates are targeted for positions of leadership in the curriculum. Each year, ten teaching scholars are chosen from faculty nominated by their department chairs, with at least one participant from the Program on Aging. The Excellence in Teaching Series consists of monthly seminars and workshops focused on innovative approaches that enhance learning and instruction in medical education. These sessions provide a forum for participants to discuss practical approaches that facilitate and maximize student learning. The series is designed for faculty and residents who have responsibility for teaching in the classroom, lab, and/or clinical setting. Consultations on teaching and curriculum development issues are provided for individuals or groups of faculty as needed. Faculty and staff from the Office of Educational Development work closely with the Program on Aging to provide ongoing support for efforts to enhance the geriatrics curriculum. Student interest group The UNC Student Chapter of the American Geriatrics Society is a student-led organization for physicians-in-training who have an interest in geriatrics medicine regardless of intended area of specialty. The group focuses on ways to enhance the visibility of geriatrics issues at the UNC School of Medicine and to provide educational programs on geriatric medicine. For those students specifically interested in careers in geriatrics, the chapter seeks to develop leadership skills in geriatrics medicine by sponsoring interdisciplinary educational programs, encouraging research participation, and creating geriatrics-related community service opportunities. The leaders of this student group have initiated a one-hour orientation to geriatric patient care for first year students prior to their community week experience. (See the discussion of “Students’ Clinical Experiences” below.) Palliative care and end-of-life issues In the first year, the required Medicine and Society course provides multiple opportunities for exploration of the social aspects of aging in our society and in politics, as well as the economic factors affecting geriatrics health care. Students discuss various medical-ethical issues found most often among the elderly, e.g., palliative care and end-of-life decisions. In the second year, up to 20 students may select the seminar entitled The Good Death or the Good Fight: Ethnical, Legal, and Policy Issues in Medical Choices as their required humanities and social sciences seminar. A fourth-year elective course sponsored by the Department of Medicine specifically addresses palliative care and end-of-life issues. Palliative Medicine is a six semester-hour, interdisciplinary course taught by faculty from the Departments of Medicine (including a certified geriatrician) and Psychiatry; the Schools of Social Work, Pharmacy, and Nursing; and the Hospital Chaplaincy Office. Resulting Pedagogical Changes Program on Aging faculty promote the importance of teaching methods that encourage students’ active engagement in learning processes that are both self-directed and collaborative. One approach that has proven particularly effective is a merger of evidence-based and problem-based methods. Students are given a clinical vignette in which a patient presents with symptoms and complaints (a problem-based case). Students work in teams to define the problem and set priorities for self-directed (evidence-based) study. This approach is especially appropriate where students must understand the unique and complex presentation of common illnesses among older adults. Specific curricular enhancements include: The Introduction to Clinical Medicine course for first-year students (ICM-1), which devotes time for more in-depth presentations of topics that traditionally have not been an inherent component of the medical curriculum. When these “special topics” were introduced into the curriculum in 1998, geriatrics medicine was included as a three-hour roundtable discussion. Today, the day-long seminar on aging is a firmly established component of ICM-1. Through the AAMC-Hartford program, we further developed this activity to include a lecture and exercise on ageism and aging stereotypes. Strengthened geriatrics content in the following targeted first- and second-year courses: Psychiatry, Gross Anatomy, Immunology, Cardiovascular System, and Respiratory System. The success of this collaborative effort with individual course directors led to an invitation to participate in the design and implementation of the new second-year integrated curriculum. Other regularly scheduled, geriatrics-specific teaching opportunities for required first- and second-year courses. These include geriatrics assessment interviews with standardized patients, a polypharmacy component for the pharmacy course, a geriatrics problem-based case that addresses end-of-life issues, and geriatrics case exercises; they were developed for use in the new introductory and capstone block courses in the second-year curriculum. An interactive, Web-based geriatrics case exercise for the first-year Introduction to Clinical Medicine (ICM) course, which was developed, integrated, and titled “Meet Mrs. Jefferson.” A problem-based case, “Robert Waters,” was developed for the second-year ICM course. A “patient bank” of geriatric subjects for student interviews for the required first-year Medicine and Society course. Students are assigned two patients to interview in teams (two to three students per team). The assignment required recruitment of a significant number of patient-volunteers. Geriatricians from the Program on Aging assisted with recruitment, providing an additional opportunity to ensure a geriatrics component in course content. Additions of geriatrics content to the third-year family medicine, internal medicine, psychiatry, and obstetrics - gynecology (See “Students’ Clinical in below.) of the required fourth-year care to include two additional care geriatrics These two sites are in communities with the growing populations in the In addition to the required courses and activities the Program on Aging sponsors the following elective For years, the Program on Aging has sponsored a elective course, known as designed to provide first- and second-year students with clinical care of older patients in and care and opportunities for The Program the by groups of students to an geriatrics to make to older patients and to patients over an Geriatric Education Consultations provide a forum for students to with a master geriatrics clinical team to community-based sites for interdisciplinary with practitioners regarding complex geriatric patient issues. Students who are based in the community are often in with patients or family members and responsibility for case presentations and on geriatrics are through the Departments of Medicine and including in in Geriatric Health and and An to of Technology The School of Medicine that all first-year medical students a and that are specifically to ensure that all students have and to all resources needed for the medical school curriculum. Each student has a at or assigned and each lecture has as resources are and begin with the course that serve as the for course The first-year course students how to and research and build The Educational Technology provides faculty and staff with and to for curricular course directors with and provide expertise necessary to teaching resources to the classroom, the lab, and the clinical setting. This strong learning environment our commitment to evidence-based practice and learning, as in Pedagogical of the ways in which technology the geriatrics curriculum include use of an geriatrics case-based exercise in the Introduction to Clinical Medicine course, and providing students with the appropriate information resources needed to complete the case-based in the introductory and capstone block courses in the second year. Clinical in Geriatrics One and Two the first two years of the medical curriculum focus on students a in the basic the Introduction to Clinical Medicine course provides clinical experiences as Students are introduced to basic clinical skills on in sessions with faculty In addition, they in community-based care Students learn the complete and in the of a approach to care. Both in the classroom and their clinical in the students are to the spectrum of care, from to The Student Chapter of the American Geriatrics Society has initiated a one-hour week seminar for first-year students focusing on basic care issues common to older the internal medicine at least one of the required patient must focus on a patient or the obstetrics and gynecology each student is required to complete two of and two of and attend of and two of which address issues often in geriatric patients, e.g., and Students are responsible for case one of which must be of a patient age or The Geriatric and Management on the service is one of six students can choose to meet the This geriatrics clinical is available for six the academic year and can six students per Through the students learn clinical skills in the of among geriatric geriatrics content the family medicine among overall at least of patients by students are age or and on geriatrics issues are throughout the The required care has two newly established geriatrics-specific sites where students have clinical preceptors who are certified In the academic year students received geriatrics clinical training at these provide additional opportunities for fourth-year students to complete clinical geriatric One is a where the student is assigned to a variety of clinical to work with certified The second is a where the student works with a certified geriatrics to provide comprehensive and for specifically assigned In both the students are to focus on a specific area of interest. The and An clinical examination is used to assess students in the Introduction to Clinical Medicine course, faculty to and how well students specific clinical skills and Students through a series of patient For each the student is to a and a faculty the student’s using a assessment Standardized geriatrics patients are included in this of geriatrics content that is in the courses and is by including appropriate on the various and In with the and Course Directors’ Committee, the Office of Educational Development the Clinical Performance a assessment required of all fourth-year to patient in North the a patient that and medical problems most frequently in care in this geriatrics one to one third of the The is designed to ensure that relationship and communication skills, examination skills, skills, and management and assessment skills are across to Students a that provides a of each case, for each case, overall and skill In with the students are given a case-based geriatrics developed by the Program on Aging. For both the and the the Program on Aging works with the Office of Educational Development to ensure that core geriatrics competencies are included in the to the Program a of the success we have in geriatrics needs to the we are now with the for ongoing faculty teaching time and significant staff and expand our educational programs in all we must engage new faculty as well as who can a geriatrics component to the training they offer in their respective The success of the John A. grant has the for a comprehensive approach to geriatrics education. must to new ways to address the needs of at to assess the of new and to rapidly new information and methods to our Outcomes The recent of the second-year curriculum from courses to integrated blocks us an opportunity to more fully develop the geriatrics curriculum. The provides an for case-based learning the AAMC-Hartford had given new to geriatrics content, we were able to for additional case-based geriatrics The introductory block with a evidence-based case using a geriatric The case provided an opportunity to demonstrate how diagnostic information is used in patient care, to emphasize the of geriatrics care, and to students’ awareness regarding the of health care issues by this rapidly growing of the The capstone block focuses on two patient cases, one of which an Both are designed to multiple aspects of medical care that were addressed in Students work in groups to the including and and The of the curriculum governance system allowed for more Program on Aging involvement in curriculum Through committee the Program on Aging continues to new and from faculty to in and implementing geriatrics teaching resources and of The Program on Aging has achieved an level of visibility and within the School of Medicine and throughout all the and programs in the UNC Division of Health is a relationship with the Office of Medical Education and with individual course a commitment to ensure that geriatrics content and an integral component of required courses. available between 2000 and the staff time needed to collaborate with course directors and offer geriatrics-specific classroom and learning the two years, these course have and the Program on Aging has on all course directors’ committees and in curriculum design and The by the AAMC-Hartford allowed us to for additional from the is us both further expand the medical student curriculum and also build educational programs for and faculty, including community-based For further at

A key limiting factor in the scale up and sustainability of HIV care and treatment programmes is the global shortage of trained health care workers. This paper discusses why it is important to move beyond conceptualising health care workers simply as 'inputs' in the delivery of HIV treatment and care, and to also consider their roles as partners and agents in the process of health care. It suggests a framework for thinking about their roles and responses in HIV care, considers the current evidence base, and concludes by identifying key areas for future research on health care workers' responses in HIV treatment and care in low and middle income settings.

The chief complaint is a patient's self-reported primary reason for presenting for medical care. The clinical utility and analytical importance of recording chief complaints have been widely accepted in highly developed emergency care systems, but this practice is far from universal in global emergency care, especially in limited-resource areas. It is precisely in these settings, however, that the use of chief complaints may have particular benefit. Chief complaints may be used to quantify, analyze, and plan for emergency care and provide valuable information on acute care needs where there are crucial data gaps. Globally, much work has been done to establish local practices around chief complaint collection and use, but no standards have been established and little work has been done to identify minimum effective sets of chief complaints that may be used in limited-resource settings. As part of the Academic Emergency Medicine consensus conference, "Global Health and Emergency Care: A Research Agenda," the breakout group on data management identified the lack of research on emergency chief complaints globally-especially in low-income countries where the highest proportion of the world's population resides-as a major gap in global emergency care research. This article reviews global research on emergency chief complaints in high-income countries with developed emergency care systems and sets forth an agenda for future research on chief complaints in limited-resource settings.

Moving from awareness to action on preventing patient exposure to toxic environmental chemicals

ObjectiveTo evaluate current practices and standards of evaluation and treatment of childhood febrile illness in Southern Province, Zambia.MethodsFrom November to December 2013, we conducted a cross-sectional survey of facilities and health workers and we observed the health workers’ interactions with febrile children and their caregivers. The facility survey recorded level of staffing, health services provided by the facility, availability and adequacy of medical equipment, availability of basic drugs and supplies and availability of treatment charts and guidelines. The health worker survey assessed respondents’ training, length of service, access to national guidelines and job aids for managing illnesses, and their practice and knowledge on management of neonatal and child illnesses. We also conducted exit interviews with caregivers to collect information on demographic characteristics, chief complaints, counselling and drug dispensing practices.FindingsThis study included 24 health facilities, 53 health workers and 161 children presenting with fever. Facilities were insufficiently staffed, stocked and equipped to adequately manage childhood fever. Children most commonly presented with upper respiratory tract infections (46%; 69), diarrhoea (31%; 27) and malaria (10%; 16). Health workers insufficiently evaluated children for danger signs, and less than half (47%; 9/19) of children with pneumonia received appropriate antibiotic treatment. Only 57% (92/161) were tested for malaria using either rapid diagnostic tests or microscopy.ConclusionVarious health system challenges resulted in a substantial proportion of children receiving insufficient management and treatment of febrile illness. Interventions are needed including strengthening the availability of commodities and improving diagnosis and treatment of febrile illness.

This chapter sets the stage for better understanding of the responses to a therapy in dementia, particularly those psychological factors related to the placebo effect. The crucial point here is that the three steps ‘feeling sick’, ‘seeking relief’, ‘meeting the therapist’, are all modified, or totally absent, in the demented patient. In fact, different types of dementia may lead to changes in the perception of some symptoms, first and foremost pain. As to ‘seeking relief’, the demented patient does not have a purposive behavioural repertoire that is aimed at seeking a doctor for relieving his own symptoms, thus the demented patient does not have expectations of positive therapeutic outcomes. Similarly, in ‘meeting the therapist’ the cognitively impaired patient cannot interact with health professionals, thus the interaction is based only on the doctor’s inference of the symptoms through observation.

The future of health professions education: Emerging trends in the United States.

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

To assess the rate and determinants of sharp injuries during the previous 6 months among health care workers at first-level care facilities in two districts of Pakistan. Cross-sectional survey at public, general practitioners and non-licensed private practitioners selected through stratified random sampling. At each facility, we interviewed a prescriber and a dispenser/injection provider about knowledge of bloodborne pathogens transmission and preventive practices, risk perception, and use of precautions and sharp injuries received during the previous 6 months. Multivariable Poisson regression was used to assess the factors associated with the number of sharp injuries. Fifty-four percentage of the 233 workers had at least one injury during the previous 6 months. The overall rate of sharp injuries per person per year was 3.7; among non-physician prescribers (9%), it was 4.3; among dispensers (69%), it was 3.7, and among physicians (18%), it was 2.1. In the multivariable model, work experience, risk perception and type of health care worker were significantly associated with receiving sharp injuries during the previous 6 months. In the model including dispensers only, a higher knowledge score was associated with fewer sharp injuries, while perceived severity of disease and lack of professional qualification were associated with more. Sharp injuries are common in Pakistan. Better knowledge about modes of bloodborne pathogen transmission and professional qualification may reduce their incidence.

Geriatric trauma is expected to increase due to the lifestyle and activity of the aging population and will be among the major future challenges in health care. Therefore, the aim of this study was to investigate differences between polytraumatized geriatric and non-geriatric patients regarding mortality, length-of-stay and complications with a matched pair analysis. We included patients older than 17 years with an Injury Severity Score (ISS) of 16 or more admitted to our level 1 trauma center between January 2008 and December 2015. The cohort was stratified into two groups (age < 70 and ≥ 70 years). One-to-one matching was performed based on gender, ISS, mechanism of injury (penetrating/blunt), Glasgow coma scale (GCS), base excess, and the presence of coagulopathy (international normalized ratio (INR) ≥ 1.4). Outcome was compared using the paired t-test and McNemar-test. A total of 1457 patients were identified. There were 1022 male (70%) and 435 female patients. Three hundred and sixty-four patients (24%) were older than 70 years. Matching resulted in 57 pairs. Mortality as well as length-of-stay were comparable between geriatric and non-geriatric polytraumatized patients. Complication rate (34% vs. 56%, p = 0.031) was significantly higher in geriatric patients. This indicates the possibility of similar outcomes in geriatric polytraumatized patients receiving optimal care.

Transmission of infection from non-isolated patients with COVID-19 to healthcare workers

BackgroundTechnology, including information and communication technology (ICT), plays a significant role in the quality of health services. However, its application in elderly health services is still lacking. The aim of this study was to determine the knowledge of, attitudes toward, and practices of cell phone and mobile application use for elderly health care among Indonesian health care workers.MethodsThis was a cross-sectional study conducted with health care workers in Jakarta, Indonesia. The potential subjects were contacted through instant messenger application and/or through conventional short message service or telephone calls from August through November 2020.ResultsThere were 134 subjects. All the subjects had used various health applications to assist with their daily work, including telemedicine (64.2%), guidelines (60.4%), and medical calculators (46.3%). However, 96.3% of the subjects were not aware of the existence of a health application for geriatric assessment. Furthermore, 98.5% of subjects thought that it is important to use ICT to manage geriatric patients, and 94.8% felt that comprehensive geriatric assessment (CGA) in digital form would help them manage geriatric patients better. Nevertheless, 35.10% of subjects had never applied CGA to their geriatric patients.ConclusionsThe current health care system has begun to enter a period of using ICT in performing health services for geriatric patients. Nevertheless, only a few Indonesian health care workers were aware of or were using the geriatric mobile application. It is essential to improve the dissemination of geriatric health care and e-health literacy among them to improve the quality of elderly health care.

BackgroundDocumentation of test results for latent tuberculosis (TB) infection is important for health care workers and students before they begin work. A negative result provides a baseline for comparison with future tests. A positive result affords a potential opportunity for treatment of latent infection when appropriate. We sought to evaluate the yield of the referral process for positive baseline tuberculin tests, among persons beginning health care work or studies.MethodsRetrospective cohort study. We reviewed the charts of all new health care students and workers referred to the Montreal Chest Institute in 2006 for positive baseline tuberculin skin tests (≥10 mm). Health care workers and students evaluated for reasons other than positive baseline test results were excluded.Results630 health care students and workers were evaluated. 546 (87%) were foreign-born, and 443 (70%) reported previous Bacille Calmette-Guérin (BCG) vaccination. 420 (67%) were discharged after their first evaluation without further treatment. 210 (33%) were recommended treatment for latent TB infection, of whom 165 (79%) began it; of these, 115 (70%) completed adequate treatment with isoniazid or rifampin. Treatment discontinuation or interruption occurred in a third of treated subjects, and most often reflected loss to follow-up, or abdominal discomfort. No worker or student had active TB.ConclusionsOnly a small proportion of health care workers and students with positive baseline tuberculin tests were eligible for, and completed treatment for latent TB infection. We discuss recommendations for improving the referral process, so as to better target workers and students who require specialist evaluation and treatment for latent TB infection. Treatment adherence also needs improvement.