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Even within the same However generic 160mg kamagra super visa, reliance on costs as a sole outcome may result health care system generic 160 mg kamagra super amex,effectiveness may vary between exper- in programs that improve health care delivery but do not imental and practice conditions and may diminish with benefit patients directly buy 160mg kamagra super with mastercard. In other health outcomes should not be forgotten as an important words 160mg kamagra super free shipping, health services delivery innovations may be effec- goal of these interventions purchase 160 mg kamagra super with amex. Finally, many programs have tive for a time and then no longer retain the same value begun adopting more of a systems approach to providing when the entire health care system and reimbursement care that also includes the community and patient as well system change. One approach has been to utilize geronto- management as a major philosophic tenet and practical logic nurse practitioners who are based at senior centers approach (e. In the best cases, there is partner- agement plan emphasizes physical activity and chronic ship with community agencies and resources to provide illness self-management, including attending a 7-week complementary education and services. Although the intervention did not demonstrate An important caveat in interpreting these new CGA- functional or health status benefits, total hospital days like interventions is that their effectiveness may be were reduced. Variations in health care delivery and have high predicted health care utilization is the Chronic 200 D. Reuben Care Clinics developed at Group Health Cooperative of reduction in new cases of delirium and hospitalized Puget Sound. In one ran- A major trend in the management of chronic illness has domized clinical trial, significant benefits on health, func- been disease management in which health care delivery tional status, or costs could not be demonstrated at 24 has been focused around a single disease (target condi- months. Another comprehensive care model that uses an These programs adopt the assessment and intervention interdisciplinary team of health professionals is the Co- approach of CGA, frequently using an interdisciplinary operative Health Care Clinics developed at Kaiser- team. The prototype condition has been congestive heart Permanente, Colorado, and widely replicated elsewhere. A multidisciplinary program (geriatrics car- This model of care focuses on older persons who have at diologist, nurse, dietitian, and social worker) for elderly least one of four chronic conditions (heart, lung, or joint patients with heart failure who were at risk for readmis- disease, or diabetes) and high outpatient utilization. At the end of these 90-min sessions, 30 min are set prehensive discharge planning and home follow-up has aside for brief one-on-one visits with the physician, if been developed and tested. In a randomized clinical trial, such care was criteria, a program of comprehensive discharge planning associated with increased visits and calls to nurses but (including multidimensional assessment), and home fewer emergency room and subspecialist visits and fewer follow-up with advanced practice nurses who visited the hospitalizations. Although there were no differences patients at least every other day during the hospitaliza- in health and functional status measures, participants tion and at least twice during the 4 weeks following dis- were more satisfied with their care and the overall costs charge; these visits were supplemented by telephone of care were less. In a randomized clinical trial, this intervention was associated with reduced hospital readmissions and costs (both reduced by approximately 50%). In-Hospital Settings Several interventions have incorporated CGA principles Case/Care Management into hospital care of older persons. Acute care of the elderly (ACE) units have been developed and widely Case management has been defined as a process designed replicated. The care of elderly patients in these units to allocate services appropriately and organize them effi- focuses on environmental changes, patient-centered care, ciently. The initial into fee-for service Medicare where it has traditionally randomized clinical trial of these units demonstrated been excluded as a benefit. However, the practice of their effectiveness in reducing functional decline and dis- case management varies considerably in terms of types charge to nursing homes among unselected older hospi- of health care professionals and their responsibilities. Similar to CGA, case management vir- tify hospitalized older persons who are at risk for func- tually always begins with some method of screening to tional and cognitive decline and intervene regardless identify high-risk older persons (case selection). Following intervention includes geriatric assessment and interdis- identification, the roles of case managers differ, though ciplinary involvement as needed, as well as specific inter- components frequently including problem identification, ventions to address the multiple dimensions of geriatric planning, coordinating or implementation, monitoring, syndromes. Comprehensive Geriatric Assessment and Systems Approaches to Geriatric Care 201 work, there is considerable variation especially with implement in independent provider models despite the respect to caseload, how services are provided (e. Logistic and reimbursement face to face versus on the telephone), assessment, and difficulties usually preclude such innovation. In to be guided by the following principles: randomized clinical trials and pre–post studies, case man- • Comprehensive provision of preventive services agement has had variable success in providing health or (including lifestyle modification) and basic and functional status benefits or reducing costs. In an Italian episodic care for older persons who have few health study of persons who were already receiving conven- care needs. These services will likely be provided as tional home health services, case management in con- inexpensively as possible, using community educa- junction with a geriatric evaluation unit resulted in tional and preventive care resources and trained health improved physical function, less cognitive decline, and 31,32 care providers who are mostly not physicians. Another trial of nurse case managers assigned to frail • Systematic identification of older persons who have older persons discharged from a hospital emergency more extensive health care needs and design of department failed to demonstrate health or economic systems to meet such needs on an ongoing basis. Such benefits and resulted in higher readmission rates to 34 care is likely to be best provided by teams of health emergency departments. A social work model of case care providers, but such teams must reflect more effi- management for health maintenance organization enrol- cient care rather than simply more care. Communica- lees at high risk of using health care services heavily tion among teams will be increasingly electronic.

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Volatile anesthetic tissues set the groundwork for thiopental to become agents can produce a complete anesthetic state buy kamagra super 160 mg low cost, but their use the standard drug for induction of anesthesia buy kamagra super 160mg overnight delivery. GABA centration of an agent at which 50% of subjects no longer is the principal inhibitory neurotransmitter found in produce purposeful movement in response to a skin inci- mammalian central nervous systems discount 160mg kamagra super fast delivery. Anesthesia can be maintained with any of these enhance and mimic the action of GABA on the ion channels buy kamagra super 160 mg on line. Relatively lower concen- trations are usually employed in combination with other codynamics and pharmacokinetics of thiopental suggest agents in a standard general anesthetic discount kamagra super 160mg line. Halothane has that the principal effect is based on a reduction of volume been associated with hepatitis and is rarely used in adult of distribution in the elderly, resulting in a higher con- patients. Anesthetic requirements decrease progressively centration of the drug at the effect site for any given dose. It appears that the elderly brain is Sedative Hypnotic Agents not more sensitive to the effects to thiopental. A more Induction of anesthesia is most commonly undertaken complete description of the pharmacology of barbitu- rates in the elderly is provided by Shafer. Nonetheless, it does possess some poten- venous anesthetic, one that has become very popular for tial to create the same adverse psychologic effects found the induction and maintenance (by continuous infusion) with other phencyclidines. The exact mechanism of with respiratory and cardiovascular disorders represent action of propofol has not been completely elucidated. The drug is used There is evidence that is acts through activation of the with some frequency for sedation of children outside the GABAA b1-subunit, as well as by inhibition of the N- operating room and for dressing changes in settings such methyl-d-aspartate (NMDA) subtype of the glutamate as burn units. It has a apnea, and rarely thrombophlebitis of the vein where the faster onset of action. Apnea is very common, with an inci- zolam the benzodiazepine of choice for most anesthetic dence similar to thiopental or methohexital; however, the use. Awakening times following a benzodiazepine Propofol has been used for sedation during surgical induction are much longer than for either thiopental or procedures and in the ICU for sedation during mechani- propofol, and thus benzodiazepines are rarely used for cal ventilation. As an adjunct to general and recovery occurs rapidly on termination of the infu- anesthesia, benzodiazepines provide better amnesia than sion, regardless of the duration of infusion. Elderly patients require lower doses of rates must be markedly reduced in elderly and sicker midazolam than younger patients. Its pro- decreased from an average of 10 mg for a 20-year-old perties include minimal respiratory depression, cerebral patient to 2. Reports that the drug can temporarily inhibit steroid synthesis and hence decrease adrenal activity,21,22 along with a side effect profile that includes myoclonus, pain on injection, and high incidence of nausea and vomiting, tremendously decreased the enthusiasm for this drug. Increasing age is associated with a smaller initial volume of distri- bution and decreased clearance of etomidate. Although phencyclidine, the prototype of this class of drugs was a promising anesthetic agent, it was associated with an unacceptably high incidence of psychologic effects, including hallucinations and delirium. Phencyclidine is currently available only for illicit recreational use ("angel dust"). Ketamine (Ketalar) was released for clinical use in humans in 1970 and is still Figure 21. The influence of age on the intravenous dose of used for a variety of clinical circumstances. Ketamine is midazolam required to produce sedation in 800 patients unique among the injectable hypnotic agents because it undergoing endoscopic procedures. Anesthesia for the Geriatric Patient 233 Anecdotal evidence suggests that some elderly patients manifest a paradoxic reaction to benzodi- azepines, becoming agitated rather than sedated. Flumazenil is the only available competitive antagonist for the benzodiazepine receptor. When administered to patients who have benzodi- azepine-induced CNS depression, flumazenil produces rapid and dependable reversal of unconsciousness, respi- ratory depression, sedation, amnesia, and psychomotor dysfunction. It should be emphasized that flumazenil is rarely used by experienced anesthesiologists, who greatly prefer to titrate the initial drug effect carefully rather than depend on functional antagonism. Repeated doses of flumazenil may be necessary because the effect of the initial benzodiazepine is likely to last longer than that of flumazenil and resedation may easily occur. Opioids The opioids are those endogenous and exogenous sub- stances that bind to the opiate receptors. The influence of age and weight on remifentanil downside is respiratory depression. The bolus dose should be reduced by 50% in elderly Pain perception is altered with aging, but this does not patients, and the infusion rate should be reduced by two-thirds.

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The local data were limited in part because low back pain metrics were not established until later in the demonstration discount 160mg kamagra super free shipping. Other factors also contributed to limited monitoring by the sites generic 160mg kamagra super overnight delivery, including competing demands for the implementation team members’ time discount kamagra super 160mg free shipping, mixed reactions by providers and clinic staff to using the guideline order kamagra super 160 mg on line, and lack of mandates from MTF commands cheap 160 mg kamagra super free shipping. Effects of the demonstration on care for low back pain patients were limited during the first year the sites worked with the practice guide- line, and effects that were found were for patterns of service delivery rather than for prescribing of pain medications. The only overall ef- fect for the demonstration was a decline in physical therapy referrals during the demonstration period. The decline in numbers of follow- up primary care visits in the last quarter of the demonstration may be an early sign of a trend, but additional data for later months would be needed to verify such a trend was real. Despite not finding overall effects, effects were observed from the encounter data that were specific to individual sites and consistent with their implementation strategies. The strongest of these were the Site A strategy to use back classes to reduce use of physical therapy, which was observed in the data as declines in physical therapy referrals; and the Site D strategy to establish the physical medicine clinic as gatekeeper and reduce inappropriate specialty referrals, which were observed in the data as 96 Evaluation of the Low Back Pain Practice Guideline Implementation shifts of referrals to the physical medicine clinic from other special- ties. The implications of these evaluation findings for ongoing implemen- tation of practice guidelines in AMEDD are considered in Chapter Seven. Chapter Seven LESSONS FROM THE LOW BACK PAIN DEMONSTRATION This first demonstration to field test methods for implementation of clinical practice guidelines yielded rich information and insights even as it struggled to achieve lasting new practices. Despite disap- pointing results in terms of the effects on treatment of acute low back pain, the demonstration contributed to improvements in methods for subsequent guideline demonstrations, and ultimately, for imple- mentation of the low back pain guideline in all Army health facilities as of the spring of 2000. In this chapter, we synthesize the factors influencing the successes and limitations of the low back pain guideline demonstration. We begin by examining how well the demonstration performed on the six critical success factors presented in the beginning of this report and reintroduced throughout, and we assess how this performance contributed to the demonstration results. Then we identify a number of issues for the MTFs that emerged from the demonstration that are likely to affect other MTF guideline implementation efforts. Finally, we discuss implications for MEDCOM with respect to approaches and methods as it moves forward with implementation of a number of DoD/VA practice guidelines in the Army health system. PERFORMANCE ON SIX CRITICAL SUCCESS FACTORS Research on practice guideline implementation has documented that a commitment to the implementation process, including use of multiple interventions, is required to achieve desired changes to 97 98 Evaluation of the Low Back Pain Practice Guideline Implementation clinical practices. Below are the six critical success factors that are es- sential for making lasting changes in the MTFs’ clinical and adminis- trative processes. We discuss here the extent to which this demon- stration realized these success factors, and we consider their effects on progress in implementing practice improvements. This demonstration provides a meaningful ex- ample of how leadership commitment can affect the ability to achieve practice improvements. The regional leadership endorsed the demonstration strongly, but local commanders exhibited mixed levels of commitment, and changes in command eroded this support yet further over time. Given that this was the first demonstration in a new MEDCOM initiative, it is understandable that it might be met with mixed reactions due to concerns regard- ing the initiative’s effects on MTF workloads and costs. Further, many providers, including physicians in leadership roles, have instinctive negative reactions to practice guidelines as "cookbook medicine," which indeed we heard in our evaluation. Unfortu- nately, passive or "wait and see" positions by command teams can become a self-fulfilling prophecy leading to failure because im- plementation teams are not given the motivation and support they need to change clinic procedures and mobilize providers and staff to accept the new practices. We believe these dynamics con- tributed to the limited results of the low back pain guideline demonstration. The demonstration did not perform well in the area of monitoring, in part because this was the first demonstration and it began very quickly as the DoD/VA practice guideline was being completed. The guideline expert panel did not select the key metrics for systemwide monitoring until well into the demonstration period. Further, MEDCOM did not have the resources early in this demonstration to establish a monitor- ing system at the corporate level. Without structured guidance from the corporate level, the sites varied widely in their approach to monitoring. One of the sites was quite aggressive in tracking utilization, but the other sites did not routinely monitor many measures. Some sites performed chart reviews to assess compli- ance with checking for red-flag conditions and documentation of Lessons from the Low Back Pain Demonstration 99 care, but these reviews were one-time events that were not estab- lished as regular monitoring mechanisms.

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Osmotic stool act on the VC and may be quite effective with fewer softeners generic kamagra super 160mg visa, such as lactulose buy kamagra super 160mg with mastercard, and milk of magnesia may be potential side effects cheap 160mg kamagra super. Corticosteroids are also potent effective in maintaining bowel function for patients at antiemetics 160 mg kamagra super fast delivery. A bowel regimen should be identi- Remediable causes of nausea or vomiting such as fied for all patients and followed routinely buy 160 mg kamagra super amex. Patients who peptic disease and obstipation should be identified and develop constipation should be treated with saline, or treated (Table 26. Doses of H2 blockers should be mineral oil retention, or tap water enemas as needed to halved in the elderly, as they may precipitate delirium. Bowel stimulants can be used once inhibitors [omeprazole (Prilosec), lansoprazole (Pre- any lower GI tract obstruction is resolved. Patients often vacid), and others] are the most potent agents respond to regularly scheduled glycerin or bisacodyl sup- for decreasing gastric acid secretion and do not alter positories (1–4 per rectum), after breakfast, daily. Bowel Management Diarrhea Constipation results in a myriad of other symptoms, Although less common than constipation, diarrhea can including urinary retention, nausea and vomiting, de- be a particularly distressing symptom in dying patients, lirium, and, if severe, intestinal perforation. When possible, the eti- mobility and bed rest predispose to constipation, so a ology of the diarrhea should be clarified, and processes bowel regimen should be initiated as patients become amenable to treatment, such as Clostridium difficile less mobile. Constipation occurs uniformly with opioid colitis, or fecal impaction, should be treated aggressively. Type of agent Medication Dose Onset Comments Stimulant/ contact agents Senna 1–3 tabs p. Care Near the End of Life 307 First-line therapy for diarrhea should be Kaolin-pectin be weighed against the discomfort of frequent move- 60 mL p. Loperamide (Imodium) is preferable to Infectious Processes diphenoxylate-atropine (Lomotil) combination, as the latter has greater potential for systemic and CNS toxicity. Fever may be suppressed by round-the-clock acetaminophen orally or per rectum, moistened swabs or artificial saliva) and lips (with petro- latum or lip balm). Even when the patient is unrespon- or with cooling techniques such as bathing with cool sive, the mouth should be cleaned and moistened at water. When a decision is made to give antibiotics, a broad-spectrum oral antibiotic or once-daily injection regular intervals for patient comfort and to lessen family distress. Other symptoms such as dyspnea associated with pneumonia, or dysuria and urinary frequency associated with urinary tract infection, Urinary Symptoms should be addressed to relieve physical distress. Urinary incontinence, dysuria, and frequency can be par- ticularly disturbing symptoms for patients, especially if Bereavement mobility is impaired. For symptoms Anticipatory grieving, or sadness about the expected of incontinence and frequency, a postvoid residual (PVR) death, should be acknowledged and support offered to volume should be documented. Communication before than 150 mL, an indwelling catheter should be left in death between the patient and friends and family is place or intermittent catheterization performed regu- important when possible. Indwelling catheters may be used for easing care- family members need to understand that death is likely, giver burden or avoiding moving patients with severe have adequate time to process that information, and pain; however, they are associated with urinary tract spend time with each other. Information about what to infections in all patients in whom they are in place for expect as disease progresses and death approaches may more than about 1 week. When retention may respond to bethanechol (Urecholine) 5 to death seems imminent, the patient and family should be 10 mg bid to tid. In the absence of elevated PVR, toltero- advised and given the opportunity to "say good-bye. Dysuria can sometimes be reduced with a caregiver team should participate in bereavement ac- bladder anesthetic, such as pyridium 100 to 200 mg p. Women with atrophic changes of the urethral meatus adequate for the family to know that the physician and external genitalia may have improved bladder func- recognizes their sense of loss. Some physicians maintain tion and reduction in irritative symptoms with small tickler files to call or to send a note to the patient’s family amounts of topical estrogen cream applied to the urethral on the anniversary of the patient’s death. Skin Care Skin should be kept clean and dry and decubitus ulcers prevented, particularly in cachectic or malnourished Conclusion patients. Prophylaxis includes avoiding friction, reducing prolonged pressure by turning every 2 h, or using an air Care near the end of life focuses on optimizing quality or water mattress when patients become bedbound; of life for the patient and their family and minimizing however, in some situations, these interventions need to symptoms. Death Foretold: Prophecy and Prognosis The process of caring for patients near the end of life in Medical Care. Chicago: University of Chicago Press; should be learned by all health providers and improved 1999. Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying: A Report by the Hastings Center. Center for Disease Control and Prevention, Bloomington: Indiana University Press; 1987.

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