Monday, 18 March 2019

Child care: a nursing perspective

Alba Brugués



Do all professionals working in primary care develop their professional skills adequately? My answer is no, and I believe that the paediatric service of primary care is one of the services in which there is more room to rethink the model of care. To make it easier, I will explain the model of childhood health (this is how I like to express it) that we have been developing for some years at the Can Bou Health Center (CASAP). A model that is gradually becoming known and extended to other primary care centres and which has been presented to national and European congresses and has received great interest on the part of managers and experts in paediatrics and who, at the moment, is offering specific training for those who want to a change orientation of the care of children and their families in primary care.

In the first place, two basic conceptual pillars must be highlighted:
  1. In the nursing profession, the basic training axis is based on the promotion of health and the prevention of disease. When we talk about the Healthy Child Program, it’s obvious that the professional best prepared for this activity is the nurse.
  2. In organizations where professionals develop their skills to the fullest, they are more motivated and have more capacity for resolution at a team and organizational level; a model described by Clayton Christensen in his article: “Disruptions of Health Care Professions".
With these two premises I will expose some of the cores of the model change:

1. The nurse as a health reference consolidates for the paediatric population, especially oriented to the promotion of health and the prevention of diseases, in which the paediatrician and the family doctor become consultants in those cases where the nurse determines it.

2. The paediatrician and the family doctor allocate more space in their agendas to devote time to the diagnosis and treatment of children who require it. Specific queries have been created for childhood asthma, cryotherapy, dermatoscopy and allergies.

3. Own support material has been developed:

a) Infant Nurse Care Guide. A document created by the CASAP paediatric team that aims to support the activity carried out by the nurses during the follow-up and development visits of the child, in which the following values ​​are appreciated:
  • Family care based on the model of Virginia Henderson fourteen needs.
  • The physical examination by means of a colour facilitator (semaphore); in green colour, it’s determined which physical signs explored are normal for age or don’t require supplementary studies; in yellow, what physical signs are pathological or potentially pathological and have to be checked with the doctor or monitored in future reviews, and, in red, what will have to be assessed with the doctor and immediately referred to the specialized service for diagnosis.
  • The warning signs of psychomotor development that must be taken into account according to age from the Llevant table.
  • Immunizations.
  • The prescriptions and recommendations that must be delivered to the patient.

b) Guide to nursing interventions in health problems. Infancy, in which situations or demands of health problems in children have been prioritized. In this guide we have identified eighteen situations of possible autonomous resolution by the nurse and seventeen possible emergency interventions in which the resolution will be shared with the doctor.

At the same time, an exclusive agenda has been created for the demand management of nurses from 5:00 to 8:00 p.m.

4. Community health programs and group activities provided in the agendas have been increased regularly and periodically.

a) Welcome to the newborn. It’s a type of group visit during the first month of the baby's life in which experiences and knowledge are shared with a dozen families, a nurse and an educator from the municipal nursery school.
b) Group visit of six months. It’s a visit also in group format that eliminates the individual visit of the six months. In this session, two nurses give health education related to age-specific changes. The session is developed interactively and at the end an individualized physical examination is carried out.
c) Newborn space. Every two weeks a nurse participates in a session with a group of parents in the municipal nursery school, together with the educator, to discuss health education issues and share doubts and experiences of newborns and their families.
d) Breastfeeding support group. Group consultation and open one day a week.
e) Young consultation. Talks and exhibitions at the demand of those interested in the centre of young people in the city regarding issues related to drugs, sexuality, self-esteem, etc.
f) Health and School Program, at the request of several social networks and with their support, unilateral information is given and the possibility of consulting in a private environment is offered, apart from the on-demand interventions in the schools.

5. The promotion of research facilitates that the most motivated professionals can devote working time to research.

Diagram of the evolution of the model, from where we started to where we are now:



However, although the population is very satisfied with this service, it should be evaluated frequently if this approach which is very directed towards self-care, achieves the expected results and we can definitely turn the program around to get more autonomous adults and avoid dependent children and families being chronically healthy.

Monday, 11 March 2019

24/7 virtual visits: also in medicine?

Elena Torrente



A few days before Christmas, I went to London. It was freezing cold and the heavy snow made it difficult to access the big city. In Piccadilly Circus, the street musicians resisted the low temperatures and the Christmas lights adorned the city. When I took the subway, I was surprised by an advertisement: "An NHS family doctor visits you for free 24 hours a day, 7 days a week."

The Babylon Company has reached an agreement with the NHS to offer video consultation services. Citizens can download the application and request a visit with an NHS doctor 24 hours a day, with a response time of about two hours. According to the program website, face-to-face visits can also be scheduled if necessary and prescriptions are sent to the pharmacy of the user's choice. The family doctors attending the video consultations are from the NHS and have about ten years of experience.

Monday, 4 March 2019

Share the decisions table: one more step in the patient's experience

Mònica Almiñana



During the past Christmas holidays, many of us have shared a table with family and friends. Can you imagine if we did it with our patients to decide how we should evaluate their diseases?

That is what the Karolinska Hospital in Stockholm (Sweden) effectively proposes: a whole revolution in the way of understanding the care process. For those who don’t know, the Karolinska is one of the largest and most innovative university hospitals in Europe. It serves a total of 1.5 million patients per year, with a newly built infrastructure that houses 1,600 beds and employs 15,800 people.

Wednesday, 27 February 2019

The Titanic orchestra

Salvador Casado



This week the Minister of Health convened an urgent meeting to address the problem of Spanish Primary Care which, like every winter, does not cease to accumulate headlines. Surely she had to listen to objective data that speak of the structural deterioration of the same, the progressive overload of care, the lack of resources and the delicate situation of professionals. Surely they taught her the numbers that indicate how it is increasingly difficult to find family doctors, fleeing abroad from the garbage contracts offered. The graphs indicate that in a few years a high percentage of the most veteran doctors will retire. In addition the population pyramids indicate that there will be more and more complex chronic patients...

It should not be easy to be responsible for a constitutional right such as health care when the structure of transfers of health services to the Autonomous Communities has been from the beginning an epitome of lack of coordination, political commodification and duplication of expenditure (multiplied information systems, non-centralized purchases of medicines, technology and  external services among other things). And of course, what others have not fixed, I am not going to fix...

Monday, 25 February 2019

Improving health takes a lot more than exercising, dieting and quitting smoking

Josep Vidal-Alaball


In 2014, Ryan Meili, a Canadian family doctor, wrote a provocative article criticizing the health promotion policies implemented since the 1970s in most developed countries. With the title "Improving our health is about more than diet, smoking and exercise", Meili reviewed the determinants of a population’s health.

As is known, among the elements that determine  population’s health, health care is the least important when compared to the weight of social factors such as, for example, income and distribution, education, housing, employment or the social support available to the individual. Although the importance of these factors is evident, and although study after study has shown the differences in health caused by social inequalities, health policies continue to be largely committed (and budgetary priorities demonstrate this) by allocating available resources to improve health care of the population, often forgetting the other factors that are also determinants.

Monday, 18 February 2019

Who is responsible for providing quality and safe care?

Mª Luisa de la Puente



Chris Ham and Don Berwick argued that the teams of professionals who care for patients are mainly responsible for providing quality care and safety, placing managers and regulators second.

The health managers’ role is to manage the means of communication, training, resources and the time critical requirements to enable the functioning and constant improvement of the care and safety requirements. They cannot achieve this it if they are not focused on what is happening in the front line and making this their main priority.

While managers have the responsibility to add value to clinical teams surrounding them with the resources necessary for continuous efficiency and safety improvement, the clinical leaders must connect with the managers and the professionals and focus on  detecting the organisational factors that may leave room for improvement and work in the reordering them and in innovation to carry these out. According to this view, the new definition of professionalism assumes that those professionals who work in the first line, with the support of others, must accept the responsibility to identify and remove the obstacles that may get in the way of a high quality of care. Similar recommendations have been proposed by others like Bohmer since 2010, but the authors insist on this fact, given the practical difficulty to carry them out. 

Monday, 11 February 2019

Medical Schools: reductionism versus empiricism








Competitive eagerness has reached the medical faculties and now produce batches of new doctors with a higher scientific preparation, priorities arranged by factor of impact, a competitiveness for research funds and, to a lesser extent, clinical practice. Young doctors know that in order to fight for the most coveted places they must show a resume full of publications, while the clinical skills, although present, will not be the differential element. What is observed, then, is that the educational reforms driven by academic success.