Challenges confronting rural hospitals accentuated during COVID-19

The Balanced Budget Act of 1997 created a designation for critical access hospitals(CAHs)to sustain care for people living in rural communities who lacked access to care due to hospital closures over the preceding decade.Twenty-five years later,1350 CAHs serve approximately 18% of the US population and a systematic policy evaluation has yet to be performed.This policy analysis serves to define challenges faced by CAHs through a literature review addressing the four major categories of payment,quality,access to capital,and workforce.Additionally,this analysis describes how current challenges to maintain sustainability of CAHs over time are accentuated by gaps in public health infrastructure and variability in individual health care plans exhibited during the COVID-19 pandemic.

Perception of Caesarean Section among Pregnant Women in a Rural Missionary Hospital

Introduction: Caesarean section is the delivery of a foetus through an incision made on the uterus. It is useful in situations where vaginal delivery is not feasible. Women in our setting usually see it as a reproductive failure and a sign of weakness. Our aim was to evaluate the perception of caesarean section among pregnant women attending antenatal clinic in a rural missionary hospital. Methodology: This was a cross-sectional study conducted at Mile 4 missionary hospital, Abakaliki among women attending routine antenatal clinic. Information was obtained from respondents with the aid of a questionnaire. Ethical clearance was obtained for the study. Data was analysed using the Statistical Package for Social Sciences (SPSS) version 21. Results: A total of 209 pregnant women participated in this study. Their age ranged from 14 to 43 with a mean age of 27 ± 5 years. One hundred and seventy two women (82.3%) have heard of caesarean section in the past. Eighteen (8.6%) have had caesarean section in the past while 5 were not willing to undergo the procedure again. Sixty (28.7%) are not willing to undergo caesarean section even when it is indicated. Conclusion: Despite awareness of caesarean section, women do not appear to have a positive attitude towards the procedure.

Control of Postpartum Haemorrhage with Uterine Balloon Tamponade Using Foley Catheter in a Rural Mission Hospital in Ebonyi State, Southeast Nigeria

Background: Postpartum haemorrhage is the leading cause of maternal deaths worldwide, the majority of which occur in low resource settings. Uterine atony is the commonest cause of postpartum haemorrhage. Uterine balloon tamponade (UBT) is an effective method of treating refractory postpartum haemorrhage. Aim: Commercial UBT devices are often not affordable and not readily available in rural settings. The aim of this paper is to report on three cases of postpartum haemorrhage successfully managed with uterine balloon tamponade using Foley catheters. Case Reports: We report on three patients with major obstetric haemorrhage from uterine atony who were successfully managed with uterine balloon tamponade using Foley’s urethral catheter. The first two patients had primary postpartum haemorrhage while the third patient had significant bleeding during the surgical evacuation of the uterus for a molar pregnancy. In each case, uterine bleeding was refractory to pharmacologic uterotonics. They all had uterine tamponade with a Foley catheter with the dramatic resolution of their bleeding. Conclusion: In well-selected patients, uterine balloon tamponade with Foley catheter is cheap, arrests bleeding and prevents clinical deterioration among women with refractory postpartum haemorrhage, especially in low resource settings where commercial balloon tamponade may not be available or affordable.

Non-communicable disease burden among inpatients at a rural district hospital in Malawi

Background The burden of non-communicable diseases(NCDs)is high in Malawi.However,resources and training for NCD care remain scarce,especially in rural hospitals.Current care for NCDs in the developing world focuses on the WHO’s traditional 4×4 set.However,we do not know the full burden of NCDs outside of that scope,like neurological disease,psychiatric illness,sickle cell disease,and trauma.The goal of this study was to understand the burden of NCDs among inpatients in a rural district hospital in Malawi.We broadened our definition of NCDs beyond the traditional 4×4 set of NCDs,and included neurological disease,psychiatric illness,sickle cell disease,and trauma.Methods We conducted a retrospective chart review of all inpatients who were admitted to the Neno District Hospital between January 2017 and October 2018.We broke patients down by age,date of admission,type,and number of NCD diagnoses,and HIV status,and constructed multivariate regression models for length of stay and in-hospital mortality.Results Of 2239 total visits,27.5%were patients with NCDs.Patients with NCDs were older(37.6 vs 19.7 years,p<0.001)and made up 40.2%of total hospital time.We also found two distinct populations of NCD patients.The first were patients 40 years and older with primary diagnoses of hypertension,heart failure,cancer,and stroke.The second were patients under 40 years old with primary diagnoses of mental health conditions,burns,epilepsy,and asthma.We also found significant trauma burden,accounting for 40%of all NCD visits.In multivariate analysis,carrying a medical NCD diagnosis was associated with longer length of stay(coefficient 5.2,p<0.001)and a higher risk of in-hospital mortality(OR 1.9,p=0.03).Burn patients also had significantly longer length of stay(coefficient 11.6,p<0.001).Conclusions There is a significant burden of NCDs in a rural hospital in Malawi,including those outside of the traditional 4×4 set.We also found high rates of NCDs in the younger population(under 40 years of age).Hospitals must be equipped with adequate resources and training to meet this burden of disease.

山区农村老年人急性心脑血管事件目击情境真实体验的质性研究

背景山区急救是我国基层紧急救援网络建设中的难点,山区农村老年人作为山区主要常住人口,心脑血管急症死亡率、致残率均处于高水平,了解该群体在心脑血管事件目击情境下真实体验是对山区急救素养研究的重要补充。目的剖析山区农村老年人在急性心脑血管事件目击情境下的真实体验,重点深入了解山区农村老年人急救素养水平,为基层公共卫生服务人员山区心脑血管疾病管理工作提供现实参考。方法采用目的抽样法,2024年1—2月选取在贵州省遵义山区的农村老年人为研究对象进行面对面、半结构式深入访谈,使用定向内容分析法,以知信行(KAP)理论为框架进行资料分析。结果共凝练出3个主题8个亚主题:(1)个体急救知识与技能:急救知识严重匮乏、信息甄别能力弱、信息支持需求存在。(2)紧急情况下施救信念与态度:对生命急救消极应对、对施救作用缺乏信心、施救顾虑较多。(3)突发情境中具体行为:病情反应力差、施救行为问题凸显。结论山区农村老年人在心脑血管急性事件目击情境中急救素养低、救治水平差、施救主动性不足等问题凸显,基层卫生服务组织应当注重提升该群体急性心脑血管疾病救治能力的相关工作。

涉农高校助推土壤保护工作路径新探究——以扬州大学土壤医院为例

乡村振兴战略是新发展阶段实现我国农业农村现代化的重大决策部署。虽然乡村振兴已经取得明显成效,但仍有一些方面的问题有待创新性解决。由于人为管理土壤肥力方式不当,导致次生盐渍化、土壤酸化、连作障碍等退化问题频发,给耕地土壤质量、农产品安全与质量保障造成严重威胁。但土壤问题综合性强、复杂多样,农民、农技人员专业素质不够、土壤修复成本过高,很大程度上限制着耕地保护计划实施。土壤医院以高校师生团队为平台,对障碍土壤开展调查与采样分析,综合立定土壤地力质量等级,确定土壤地力质量定量提升方法,结合目标作物产量推荐土壤-作物养分管理实施方案,并开展实验室模拟试验、校验和田间试验示范。该模式将农教学、产学研深度结合,把知识播撒在大地,把技术教给农民,可有效地促进各地农民增收、乡村振兴,值得涉农高校在全国范围内推广、应用。

Organizational commitment and turnover intention among rural nurses in the Philippines: Implications for nursing management

Objectives:The unrelenting migration trend of Filipino nurses to other countries has threatened the quality of patient care services in the country.This study explored the extent of nurses'organizational commitment and turnover intention in the Philippines.Furthermore,predictors of nurses'organizational commitment and turnover intention were identified.Methods:A cross-sectional research design was adopted for this study.Two hundred nurses from nine rural hospitals in the Central Philippines were asked to participate in the study and 166 nurses responded(an 83%response rate).Two standardized instruments were used:the Organizational Commitment Questionnaire and the Six-item Turnover Intention Inventory Scale.Results:Findings revealed that Philippine nurses were moderately committed(3.13±0.24)to and were undecided(2.42±0.67)whether or not to leave their organization.Nurses'age(P=0.006),gender,(t=-2.25,P=0.026),education(t=2.38,P<0.001),rank(t=4.38,P<0.001),and work experience(t=2.18,P=0.031)correlated significantly with organizational commitment,while nurses'age(P=0.028)and education(t=1.99,P=0.048)correlated significantly with turnover intention.An inverse relationship was identified between the organizational commitment and turnover intention(r=-0.22,P=0.005).Conclusion:The findings of this study highlight the need for formulation and implementation of interventions to promote life-long commitment in nurses and to reduce turnover rates.

Perceptions of Rural Emergency Department Providers regarding Telehealth-Based Care: Perceived Competency, Satisfaction with Care and Tele-ED Patient Disposition

Introduction: This study assesses rural providers’ perceptions of their ability to deliver high quality care via telehealth compared to usual care, and whether attending providers perceive that emergency department (ED) telehealth visits influence clinical reasoning in regard to patient disposition, specifically in tele-behavioral and tele-neurological cases. Methods: A cross-sectional survey was conducted of 134 ED providers (nurses [n = 126] and physicians [n = 8]) who were working in five Midwestern critical access hospitals (response rate 83%). Descriptive, correlational and stepwise regression analyses were employed to evaluate provider perceptions of 1) competency level in telehealth delivery, 2) patient health outcomes, 3) access to continuing education in telehealth, and 4) clinical influence of telehealth visit. Evaluation of preliminary set of N = 100 telehealth cases were assessed for influence of telehealth on clinical reasoning of attending physicians regarding patient disposition. Results: The majority (67%;n = 90) of participants had at least minimal experience with telehealth care delivery, with an average of 1 - 2 visits in teleneurology, and 3 - 4 visits in telebehavioral cases. Providers rated their overall mean competency level in telehealth care delivery as 3.01/5.00 based on a 5 point “novice (1) to expert” (5) scale. Mean scores for providers perceived competency level in 7 evidence-based sub-categories for telehealth care delivery were self-reported as relatively low to mid-range values, ranging from 2.64 - 3.57/5.00. Stepwise linear regression analysis of whether all providers “would recommend telehealth to their family and friends” revealed two predictors for model of best fit (n = 81;p 2 = 0.598): 1) their perceptions of telehealth experience compared to usual care;and 2) perceptions of patient health outcomes with telehealth compared to usual care. Providers rated “neutral” to “very unlikely” that they “would recommend telehealth to family and friends” (2.75/5.00;n = 122;91%). Attending physicians reported that for a majority of cases, telehealth visits influenced patient disposition and transfer decision-making (58.4%), and the influence of telehealth visits on patient disposition was statistically significantly higher for behavioral health cases (p Discussion: This study will be followed on to inform administrators/policy makers about 1) perceived level of competency of providers who implement tele-emergency care, 2) potential importance of telehealth equipment used and teamwork between rural providers and distant specialist, and 3) how use of telehealth may enhance ability of rural ED providers to improve quality of care. Perceived influence of telehealth on patient disposition is reported to be highest for telebehavioral patients. Healthcare educators need to place a priority on addressing provider competencies in telehealth through health professions degree programs and continuing education. Further research is needed to promote application and testing of evidence-based provider competencies in telehealth, and potentially relevant health communication models, to increase providers’ perceived efficacy and competency in telehealth care delivery, thus supporting high quality patient health outcomes.

医保制度整合背景下城乡居民住院服务利用差异的影响因素研究

目的测量医保制度整合后城乡居民住院服务利用差异值,分析城乡居民住院服务利用差异的主要影响因素及贡献程度。方法利用2018年中国健康与养老追踪数据,采用Oaxaca-Blinder分解法辅以Heckman两步法对城乡居民住院服务利用差异进行度量和分解。结果城乡居民住院服务利用的差异可分为禀赋效应和系数效应,其中禀赋效应占比53.2%,系数效应占比46.8%。禀赋效应中经济因素和医疗保险制度是造成城乡居民住院服务利用差异的主要因素,贡献率分别为26.6%和28.4%,系数效应即因城乡属性不同导致的城乡住院服务利用差异贡献率为46.8%。结论应在顶层设计和统筹方面进一步完善医疗保险制度,制定有利于农村经济弱势群体的补偿政策,充分发挥政府和市场的协同配合作用。

基于医保公平视野下不同级别公立医院老年骨质疏松性骨折住院费用对比分析

[目的]了解山西省公立医院老年骨质疏松性骨折患者的住院费用及不同医保类型住院费用的差别,为完善医保政策和合理控制医疗费用提供建议。[方法]选取山西省12个市区内10所三级医院和10所二级医院中符合调查要求的582例患者,由患者所在医院的骨科专职护士填写《患者出院结算费用明细表》,并运用秩和检验对其住院费用进行分析。[结果]二级医院与三级医院的总费用、手术费、检查费、化验费、护理费、医药费差异均有统计学意义(P<0.05);同一级别医院中不同医保类型患者统筹支付费用之间差异均无统计学意义(P>0.05);在三级医院中,城乡居民基本医疗保险患者的平均住院费用及自付费用、城镇职工基本医疗保险患者的自费费用均高于二级医院,差异有统计学意义(P<0.05)。[结论]我国医保政策整体效能良好,但仍需持续关注重点管控对象。

大病保险、医疗服务升级与农民健康

“健康中国2030”规划纲要明确了健康对经济社会发展的重要作用,在新型农村合作医疗制度未能显著改善农民健康的背景下,研究农民健康水平的提升机制具有重要意义。本文聚焦2012年8月开始试点实施的城乡居民大病保险制度,基于2011—2015年中国健康与养老追踪调查(CHARLS)数据,以样本所在城市是否试点实施农村大病保险作为依据构造“农村大病保险”参保变量,运用计量模型实证检验农村大病保险对农民健康的影响效应及机制。实证结果显示,试点农村大病保险使农民自评健康显著提高0.08个单位,并且在对健康水平和农村大病保险等变量进行重新调整的情形下,实证结果依然稳健。异质性分析结果显示,农村大病保险对低收入群体的健康促进作用更大,并且对社区内有医疗点的群体影响效果更为显著。机制分析结果显示,对于需住院群体而言,农村大病保险通过促进农民做出住院决策进而改善了健康;而对于住院群体,农村大病保险通过促进农民选择级别更高的县区级医院进而改善了健康。为进一步提高农民健康水平,应丰富农村大病保险的筹资主体,引入个人缴费和财政补贴,在扩大大病保险基金规模的前提下,进一步提升大病保险待遇水平;同时,应改善农村基层医疗资源分配,提高农民基层医疗服务可及性和服务水平。

农村院前急救的基层延伸:建设“村民-村医”自救互救环节

目的 在现有农村“院前急救-院内急救”急救体系下,提出新增建设“村民-村医”自救互救环节,延伸农村院前急救链,主要以村民与村医的角度深入探究建设困境,并多维度提出完善策略,为提升农村院前急救水平提供新思路。方法 走访我国5省市6地区,并对13名基层急救相关人员(村民、村医、村干部)开展质性访谈,深入调研建设“村民-村医”自救互救环节的困境和具体建议。结果 建设“村民-村医”自救互救环节存在困境:村民的急救素养有待提高,表现在急救意识、急救技能掌握等方面;乡村基层医疗机构的服务水平仍需加强,表现在急救能力、药物与设施配备等方面。结论 从人力资源、物质基础、信息宣传和法律保障4个角度入手,可为有效建设“村民-村医”自救互救环节提供助力,进一步完善农村院前急救体系。

基于农村地区现行院前急救科普方式的实践及思考

为实践现行院前急救科普方式,引领学生投身乡村振兴战略,并对现存问题作对策研究,在郴州市桂东县清竹村开展了实地科普活动。2023年7月,通过线上科普宣传,线下问卷调研、科普培训等形式,开展院前急救的科普工作。调查发现,村民在此次科普活动中的参与率仅为17%,村民对院前急救重要性的认知程度低,对院前急救知识的学习意愿不高,表明我国农村院前急救普及方式存在较大缺陷。建议我国加大对院前急救重要性的宣传力度,增强公民院前急救意识与能力;丰富村民获取急救知识的途径;制定规范化的培训体系,统一院前急救标准;重视对中小学学生及高校学生的院前急救培训,培养相关人才,加大派遣专业人员下乡科普的力度。

三甲医院“组团式”帮扶乡村振兴重点帮扶县人民医院成效提升实践研究

以珠海市人民医院“组团式”帮扶正安县人民医院为例,分享了三甲医院“组团式”帮扶国家乡村振兴重点帮扶县人民医院的具体做法和取得的成效:珠海市人民医院创新推出“七新体系”建设,通过发展新平台、管理新效能、帮扶新机制、人才新动力、技术新趋势、智慧新医疗和医院新文化等方面全方位各维度予以帮扶,有力提升受援医院业务量和医疗质量发展,强化了重点学科建设和临床科研实力,全面加强了县域急诊急救、慢病管理、肿瘤防治等体系建设,实现了多个指标从零到有的突破。总结了医疗对口帮扶工作的成功经验:应选派优质科学的帮扶团队、创新帮扶模式和方法、优化帮扶全流程管理机制和评价体系,需从优化资源配置、加强人才引进、注重可持续发展和强化机构之间交流合作等方面解决受援单位实际难题。

融入科普和思政的内分泌教学查房在县级医院中的应用

在我国大力推动“万名医师支援农村卫生工程”的背景下,作为三级教学医院的医务工作者深入农村卫生工作,结合内分泌疾病的特点,在援建过程中针对县级医院普遍缺乏规范化教学查房流程的现状,为提高医疗援建效率以探索符合县级医院的教学查房模式,并将爱党、爱国、爱伤护患的情怀深化融入日常的临床工作中等问题。通过典型案例的选取、思政元素的融入、将科普思维引入到教学查房之中,以达到展示规范化的教学查房流程并存留教案,延续教学效果。同时以科普相关的问题为授课讨论的切入点,提高授课讨论兴趣点,并提倡县级医师进行科普以普惠大众。最终将爱岗敬业、医患沟通、爱伤护患等思政理念潜移默化地传递给县级医师,县级医师工作者通过科普制作体现人文关怀、沟通协作等思政映射点,最终有效提高县级医院医师的医疗技术水平、人文情怀以及慢病防治水平。

基于“互联网+”的山东省某三级医院城乡医联体双向转诊模式实践探索

目的探索利用互联网技术实现城乡医联体内的双向转诊模式,优化城乡医联体内双向转诊路径。方法利用互联网、远程医疗等信息技术,依托互联网医院,构建区域线上双向转诊服务新模式。结果该模式运行以来,已完成33家医院入驻,转诊患者由612人次增至2393人次,双向转诊患者信息录入时间由5.0min缩减至1.0min,转诊数据统计分析时间由3.0min缩减至0.5min,提高了转诊效率和服务质量,有利于医联体单位之间区域协同发展。结论基于“互联网+”的城乡医联体双向转诊模式能够实现城乡医疗资源的优化配置和共享,提高医疗服务效率和质量,改善转诊患者就医体验。

农村地区综合医院诊治的自杀未遂病人的特征

目的 :我国每年至少有 2 0 0万人自杀未遂 ,但对其特征缺乏了解 ,因此难以建立并实施任何有效的干预及预防措施。为此 ,本研究着重了解主要服务于农村地区的综合医院自杀未遂病人的特征。方法 :由经过严格培训的调查员用自制调查表对 4所市县级综合医院留院观察的 3 2 6例自杀未遂病人及其家属进行调查 ,并由精神科主治医师做出精神科诊断 (以DSM -IV为诊断标准 ) ;每个案例需 2～ 3小时。结果 :被调查的自杀未遂者的特征如下 :平均年龄 3 2岁 (标准差 =13 ) ,76%为女性 ,75 %已婚 ,78%住在乡村 ,家庭经济状况与当地人经济状况相近 ;65 %自杀前发生夫妻吵架或不和 ;83 %服农药 ;77%的服毒者服用家里存放的物品 ;5 4%属于冲动性自杀 (自杀前考虑自杀的时间≤ 2小时 ) ;自杀当时 40 %患精神障碍 (以心境障碍为主 ) ,其中仅 3 0 %寻求过帮助、 16%看过精神科。结论 :与西方发达国家相比 ,国内农村地区自杀未遂者精神障碍的患病率显著低 ,自杀方式以服农药为主。因此 ,我国的自杀预防及干预措施不能从国外照搬 ,为了解决我国这一巨大的公共卫生问题 。

乡镇卫生机构人员稳定性分析

目的了解乡镇卫生机构人员的流动情况,为基层卫生人力的稳定发展提出政策建议。方法采用分层随机抽样的方法,于2011年5—7月在我国东、中、西部共抽取6个省/市,即北京、浙江、安徽、山西、云南、贵州,48个乡镇卫生院进行现场调查。采用自主设计的乡镇卫生机构流入、流出人员调查表,收集各乡镇卫生院在2007—2010年流入和流出人员的基本信息及其流动原因。结果 2007—2010年,6个省/市的48个乡镇卫生院共计流入卫生人员361名,流出人员187名。流入、流出人员中女性分别占67.0%（242/361）、51.9%（97/187）;流入人员中20~29岁占72.0%（260/361）,流出人员中20~29岁占24.6%（46/187）、30~39岁占39.0%（73/187）;流入、流出人员中医生分别占42.1%（152/361）、56.1%（105/187）;流入人员中无职称占52.4%（189/361）,流出人员中初级职称占63.1%（118/187）。福利待遇、生活环境、职业发展等因素是人员流失的主要原因。结论卫生人员流入总量大于流出总量,流动人员中女性多于男性,以20~39岁中青年为主,医生占到流动人员的半数,流入人员以无职称为主,但流出人员以初级职称为主。乡镇卫生院人员引进困难和流失问题并存,需要从人力管理的各个环节稳定队伍,保障农村基层卫生人力的稳定供给及职业的可持续发展,完善卫生人才流动机制,引导卫生人才合理流动。

基于数据包络分析的乡镇卫生院运行效率评价及分析

目的通过数据包络分析(data envelopment analysis,DEA)了解2011—2013年北京市H区乡镇卫生院的运行效率,为H区乡镇卫生院的资源配置提供合理化建议。方法本研究资料均来源于2013年11月—2014年2月,首都医科大学农村医患信任研究课题组在北京市H区卫生局配合下对北京市H区16所乡镇卫生院进行的普查。运用DEA投入导向的CCR和BCC模型计算乡镇卫生院的综合效率、技术效率及规模效率值;确定乡镇卫生院运行效率评价的投入指标和产出指标,分析其实际值与理想值的差异。结果 (1)综合效率:2011年16所乡镇卫生院中,有3所卫生院的综合效率=1,占18.8%;2012年有2所卫生院的综合效率=1,占12.5%;2013年有3所卫生院的综合效率=1,占18.8%。技术效率:2011—2012年16所乡镇卫生院中,均有8所卫生院的技术效率=1,占50.0%;2013年有9所卫生院的技术效率=1,占56.2%。规模效率:2011年16所乡镇卫生院中有3所卫生院的规模效率=1,占18.8%;2012年有2所卫生院的规模效率=1,占12.5%;2013年有3所卫生院的规模效率=1,占18.8%。(2)2013年非DEA有效的乡镇卫生院开放床位数实际值>目标值;卫生技术人员数实际值>目标值;固定资产总额实际值>目标值。结论 2011—2013年,北京市H区的16所乡镇卫生院运行效率较平稳,规模效率可能是制约总体效率的主要因素。乡镇卫生院存在开放病床数过多,卫生技术人员数量配置过剩,固定资产闲置的问题。建议乡镇卫生院:(1)根据自身服务能力和功能定位合理购置诊疗设备,促进医疗资源有效配置;(2)在人员配比上适当引进资质水平较高医务人员,鼓励医务人员参加技术课程培训和资格考试;(3)按实际情况酌情配置病床数,提高病床运用效率。

北京市某区村卫生室的人力资源现状及发展对策

目的深入了解北京市村卫生室人力资源现状及存在的问题。方法在北京市H区选取有代表性的乡/镇和村作为实地观察和访谈现场,对当地村医进行实地观察和个人深入访谈。结果研究发现乡村医生队伍存在着年龄老化、质量不高、补充不足等问题。结论在此基础上提出了村卫生室人力资源发展的对策,以期为探索农村卫生队伍建设,特别是村级医疗卫生队伍建设的可行之路,推动农村卫生事业的发展提供建议。