Challenges Of Implementing Evidence Based Practice Nursing Essay

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With growth in research, there has been great changed experienced in the healthcare setting. The new environment in provision of healthcare has been modeled to cope with the ever changing nature of diseases and social life. New medical practitioners are facing great challenges as they transit from class to evidence based practices, which define new trend in nursing. Evidence-based practices environment is poising great challenges not only to new nurses but also to experienced nurse (Melynk, 2002). The new practice require nurses to apply clinical evidence to clients situations through the use of clinical judgment and considering the client values ant eh resources available in the healthcare system. The practice environment for nurses has greatly changed with the changing and increased focus on the evidence-based practice. Evidence based practice can be defined as well calculated, conscious and explicit employment of current evidence in the decision making process when providing care to individual patients. Evidence-based practice (EBP) is therefore understood to be a decision making approach through which clinicians tend to use best evidence available and also consult with patients to come up with best care option which suits the conditions of the patient (Ferguson and Day, 2007). In nursing, this approach has been emphasized but there is a great focus on participation of the client, the clinical judgment, and the resources available in the healthcare system. In the current environment where healthcare system is becoming more cost conscious, healthcare practitioners have to make rational decision. However, there are many challenges that are facing the implementation of this system especially for the new nurses who have not gained enough experience.

In light of the growing importance of evidence-based practice in healthcare provision, this paper looks into the importance of the evidence based practices in the new healthcare market. The paper will also focus on the challenges that have been encountered in strive to adapt evidence based practice.

Significance of evidence based practiced

Evidence-based practice has greatly changed the landscape of healthcare provision. It has made it possible for health care providers to use the best practices that have been greatly research in details while handling their patients. Evidence-based practice puts the client value at the center of the health care practices making sure that clients have a contribution to their healthcare. This is in the sense that EBP ensure that client values and practices are considered while providing healthcare (Ferguson and Day, 2007). This creates a patient-centered healthcare system in which patient preference, needs and values acts as guide to all clinical decision made by healthcare providers.

Clinical judgment is at the center of provision of healthcare. It is a critical aspect in EBP which is used to health nurses and other healthcare practitioners to make the best appropriate clinical decision that will result to least health effects on the patient. EBP decision making process need to be based on rational technical knowledge, best identified and researched practices, and patient contribution (Gerrish et al., 2007). EBP assist medical care practitioners to make the most appropriate clinical decision that takes care of all the above aspects. Therefore evidence-based practice is all about assisting healthcare providers to give the utmost best care that will assist patients to recover in the shortest time possible. It creates a consultative and involving process in which nurses make decision based on the best practice and client contribution.

Challenges of implementing evidence based practice

There have been reports of substantial improvement in health outcome for patients who are treated through evidence based practices. Well designed studies have shown that improved patient outcomes are more likely to be realized when nurses use research evidence in handling patients. However, there are many impediments which have made it difficult to implement EBP in healthcare settings especially for novice medical practitioners. There are many nurses who are struggling to implement EBP in their practice due to a number of reasons. There are eight factors that have been cited as impediments in implementation of EBP.

One of the greatest challenges facing implementation of EBP is lack of knowledge on use of evidence based practices. It has been shown that most nurses do not have enough knowledge to integrate research findings in their practices. Research findings shows that there is little evidence that shows that most nurses, especially novice nurses have knowledge on the implementation of EBP in their practices (Paramonczynk, 2005). A study by Bonner and Sandon (2008) that sought to examine the knowledge, attitude and nurses use of research found out that there was variance in EBP knowledge among nurse. The study concluded that in order to overcome knowledge barrier, nurses need to have specific research education, leadership and enabling work environment to effectively implement EBP in their practices.

The second factor that has been identified as a barrier to implementation of EBP is misperception and negative attitudes on research and evidence based practices. Most nurses have a negative attitude towards research and do not understand what entails EBP. This problem has persisted especially in old nurses due to fear of change of what can be identified as ‘practice culture’. It is a fear for change. However, a study by Bonner and Sandon (2008) found out that senior nurses were likely to have positive attitude towards research and implementation of EBP compared to younger nurses. In this study, only 44% of the nurses showed positive view of research and willingness to undertake extensive research.

The third factor inhibiting implementation of EBP is lack of knowledge on how to carry out search and appraise best practices (Tagney and Haines, 2009, p. 488). There has been identified problem on the knowledge of nurses on how to carry out research. It has been identified that three factors which determine nurse utilization of research include individual characteristics of nurse, characteristics of the organizations, and environmental characteristics. Most nurses are not well equipped to carry out research which leads to effective practice of EBP (Bonner and Sandon, 2008). In Bonner and Sandon (2008), it was found out that while 58.9% of the participants had gone through a research unit in their study, only a dismal 14.5% showed a good understanding of research design and only 10.8% understood statistics and date interpretation (p. 340). In this study, 36.3% identified lacks of skills as a barrier to implementation of EBP.

The fourth factor that has inhibited EBP is the overload of nursing work that leaves them with no time to carry out research (Tagney and Haines, 2009, p. 488). With increased shortage in nursing and in other areas of medical care, workload has become a major problem not only in implementation of EBP but also in provision of general healthcare. In a study by Bonner and Sandon (2008) lack of enough time to carry out the study, which emanates from work overload was identified as the third highest barrier (44.9%) after resources (55.2%) and support from peers (49.7%). With overload of works, nurses have not time to carry out research.

The fifth factor is constraints within the organization. For one to carry out extensive research there must be resources. There has to be adequate nursing journals, books, internet, and other resources with credible research findings. In Bonner and Sandon (2008) study, 55.2% identified resource constraint as one of the barriers to implementation of EBP which ranks it higher above all other constraints.

The sixth barrier is contradictory patients’ expectations. For example there are some patients who may demand to be given antibiotics for upper respiratory infection which may not be indicated in their physician’s prescription. Most patients who come to seek healthcare services come with preconceived ideas about the prescription they will received which has been contributed by wide scale dissemination of inaccurate medical information. Most nurses therefore feel they are not doing the right thing or simply avoid creating scenes with patients and hence restrain from implementing EBP.

The seventh factor is the fear for one to have different practice from what other nurses or medical peers are practicing which directly emanates from organizational culture (Tagney and Haines, 2009, p. 488). Most nurses have found out when they join a health care facility, there is culture of care that has been carried over. Nurses will therefore fear implementation EBP as it may deviate from the normal practices. Therefore lack of support from peers, as was demonstrated in Bonner and Sandon (2008) study is the second largest barrier identified by 29.7% of the nurse.

The eighth and last factor is large amount of information that can be found in nursing journals and books which sometimes may be confusing to practitioners. There is a large amount of information from different research findings and some of the information has been found to be inaccurate and hence confusing to most nurses. Nurses therefore find it difficult to identify the correct information to use in EBP.

Identify 3 tools from the CMS Web site that are helpful in meeting the requirements for Medicare reimbursement set forth by CMS.

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Identify 3 tools from the CMS Web site that are helpful in meeting the requirements for Medicare reimbursement set forth by CMS.

Paper , Order, or Assignment Requirements

For this assignment, write a 2-3 page report that you will deliver to Mr. Magone on how the new Centers for Medicare and Medicaid Services (CMS) initiatives and regulations will impact the organization’s revenue structure. In your presentation, address the following questions:
• Why did CMS become more involved in the reimbursement component of health care? How does CMS’s involvement impact the reimbursement model for Healing Hands Hospital and other health care organizations? If CMS reimbursement regulations for Medicare and Medicaid change, does it follow that other insurance providers change their policies on reimbursement?
• What tools can be implemented to ensure organizations such as Healing Hands Hospital and physician practices are meeting the policies and procedures set forth by CMS?
• Identify 3 tools from the CMS Web site that are helpful in meeting the requirements for Medicare reimbursement set forth by CMS.

Framework for Speech Enhancement and Recognition

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A Generalized Framework for Speech Enhancement and Recognition with Special Focus On Patients with Speech Disorders



Literature Review

Kumara Sharma et.al. have proposed Harmonics-to-Noise Ratio and Critical-Band Energy Spectrum of speech as Acoustic Indicators of Laryngeal and Voice Pathology [8]. Acoustic analysis of speech signals is a noninvasive technique that has been proved to be an effective tool for the objective support of vocal and voice disease screening. In the present study acoustic analysis of sustained vowels is considered. A simple

k

-means nearest neighbor classifier is designed to test the efficacy of a harmonics-to-noise ratio (HNR) measure and the critical-band energy spectrum of the voiced speech signal as tools for the detection of laryngeal pathologies [12]. It groups the given voice signal sample into pathologic and normal. The voiced speech signal is decomposed into harmonic and noise components using an iterative signal extrapolation algorithm. The HNRs at four different frequency bands are estimated and used as features. Voiced speech is also filtered with 21 critical-band pass filters that mimic the human auditory neurons. Normalized energies of these filter outputs are used as another set of features. The HNR and the critical-band energy spectrum can be used to correlate laryngeal pathology and voice alteration, using previously classified voice samples. This method could be an additional acoustic indicator that supplements the clinical diagnostic features for voice evaluation [42].

Cepstral-based estimation is used to provide a baseline estimate of the noise level in the logarithmic spectrum for voiced speech. A theoretical description of Cepstral processing of voiced speech containing aspiration noise, together with supporting empirical data, is provided in order to illustrate the nature of the noise baseline estimation process. Taking the Fourier transform of the liftered (filtered in the Cepstral domain) cepstrum produces a noise baseline estimate. It is shown that Fourier transforming the low-pass liftered cepstrum is comparable to applying a moving average (MA) filter to the logarithmic spectrum and hence the baseline receives contributions from the glottal source excited vocal tract and the noise excited vocal tract[43]. Because the estimation process resembles the action of a MA filter, the resulting noise baseline is determined by the harmonic resolution as determined by the temporal analysis window length and the glottal source spectral tilt. On selecting an appropriate temporal analysis window length the estimated baseline is shown to lie halfway between the glottal excited vocal tract and the noise excited vocal tract. This information is employed in a new harmonics-to-noise (HNR) estimation technique, which is shown to provide accurate HNR estimates when tested on synthetically generated voice signals. HNR is defined as the ratio between the energy of the periodic component to the energy of the aperiodic component in the signal. As such it is sensitive to all forms of waveform aperiodicity [8],[12]. It only specifically reflects a signal to aspiration noise ratio when other aperiodicities in the signal are comparatively low. Validation of a HNR method requires testing the technique against synthesis data with a priori knowledge of the HNR.

Time-domain methods that require individual period detection for HNR estimation can be problematic because of the difficulty in estimating the period markers for pathological voiced speech. Frequency domain methods encounter the problem of estimating noise at harmonic locations .Cepstral techniques have been introduced to supply noise estimates at all frequency locations in the spectrum (the Cepstral processing removes the harmonics from the spectrum).It is shown that the cepstrum-based noise baseline estimation process is comparable to applying a moving average MA filter to the power spectrum and hence the baseline receives contributions from the glottal source excited vocal tract and the noise excited vocal tract. Two important issues need to be considered with respect to HNR estimation for sustained vowel phonation when inferring glottal noise levels: HNR is a global indicator of voice periodicity.HNR is indirectly related to the noise level of the glottal source .HNR provides a global estimate of signal periodicity. Hence a low value of HNR can arise from any form of aperiodicity, for example, from aspiration noise, jitter, shimmer, nonstationarity of the vocal tract, or other waveform anomalies [43].

Daryush Mehta has discussed about Aspiration Noise during Phonation: Synthesis, Analysis, and Pitch-Scale Modification. The current study investigates the synthesis and analysis of aspiration noise in synthesized and spoken vowels. Based on the linear source-filter model of speech production, author has implemented a vowel synthesizer in which the aspiration noise source is temporally modulated by the periodic source waveform. Modulations in the noise source waveform and their synchronism with the periodic source are shown to be salient for natural-sounding vowel synthesis. The accurate estimation of the aspiration noise component that contains energy across the frequency spectrum and temporal characteristics due to modulations in the noise source was a challenging task for the author. Spectral harmonic/noise component analysis of spoken vowels shows evidence of noise modulations with peaks in the estimated noise source component synchronous with both the open phase of the periodic source and with time instants of glottal closure [39].

Due to natural modulations in the aspiration noise source, author has developed an alternate approach to the speech signal processing with the aim of accurate pitch-scale modification. The proposed strategy takes a dual processing approach, in which the periodic and noise components of the speech signal are separately analyzed, modified, and re-synthesized. The periodic component is modified using our implementation of time-domain pitch-synchronous overlap-add, and the noise component is handled by modifying characteristics of its source waveform. Author has modeled an inherent coupling between the original periodic and aspiration noise sources; the modification algorithm is designed to preserve the synchronism between temporal modulations of the two sources [44]. The reconstructed modified signal is perceived to be natural-sounding and generally reduces artifacts. Arpit Mathur et.al. have discussed about the significance of parametric spectral ratio methods in detection and recognition of whispered speech [45].


Other References

Kaladhar developed confusion matrix which is a matrix for a two-class classifier, contains information about actual and predicted classifications done by a classification system. The accuracy obtained by training the probabilistic neural network using Parkinson disease dataset got 100% as positives, predictions that an instance is positive, using WEKA 3 and Matlab v7. The data explored in this research was obtained from the Oxford Parkinson’s Disease Detection Dataset. Data mining is the process of extracting patterns from data. Data mining is an important tool to transform this data into information. Authors present results with accuracy obtained by training the probabilistic neural network using the above dataset [46]. Xiao Li et.al. proposed a technique to reduce the likelihood computation in ASR systems that use continuous density HMMs. Based on the nature of dynamic features and the numerical properties of Gaussian mixture distributions, the observation likelihood computation is approximated to achieve a speedup. Although the technique does not show appreciable benefit in an isolated word task, it yields significant improvements in continuous speech recognition. For example, 50% of the computation can be saved on the TIMIT database with only a negligible degradation in system performance [47].

Authors analyze the case with only static features and their deltas and focus on achieving computational saving by partially computing the observation probability in a Gaussian component. It ignores computing the dynamic-feature part of an observation vector when its static-feature part already falls in the tail of a Gaussian. This technique doesn’t require a complicated training procedure and brings almost no overhead to the decoding process. It is effective on both isolated word and connected word speech tasks, but works especially well on connected word recognition with high-dimensional dynamic features [47]. Elisabeth Ahlsén has discussed different types of communication disorders. In case of Global aphasia there is nil or almost no linguistic communication. In case of Broca’s aphasia there is slow, effortful speech, telegram style, word finding problems known as anomia, relatively good comprehension. In case of Wernicke’s aphasia there is fluent verbose speech, word finding difficulties known as anomia, substitutions of words and sounds, impaired comprehension. In case of Anomic aphasia there are only word finding problems [49].

Kristen Jacobson explains about auditory and language processing disorders as follows

.

There are three general levels that speech sounds travel through while we are “listening”. The first level refers to the reception of sounds that occurs within our ears. A person who is diagnosed with a hearing impairment has difficulties perceiving sounds at this level. This problem is not referred to as a processing disorder. Central auditory processing disorders (CAPD) refer to difficulties discriminating, identifying and retaining sounds after the ears have heard the sounds. Individuals who experience difficulties attaching meaning to sound groups that form words, sentences and stories are often diagnosed with language processing disorders. They may also experience similar difficulties processing and organizing language for meaning during reading. Similar sounding words are often confused and some individuals may experience sensitivity to specific sounds. Reduced recognition of stress patterns and word boundaries within sentences is often present, especially during rapid speech or listening without visual cues. At times, only parts of messages are received accurately, so that messages and directions often appear incomplete. Specific language processing deficits are often reflected in delayed responses, the need to rehearse statements, and/or the need for frequent reviews while learning new information [50].

There are various types of speech disorders in children described as follows.

Articulation: There is difficulty in the production of individual or sequenced sounds. The speakers exhibit substitutions, omissions, additions, and distortions of syllables or words. The Motor or Neurogenic speech disorders result into speech difficulties and affect the planning, coordination, timing, and execution of speech movements. Apraxia of speech is neurogenic motor speech disorder affecting the planning of speech. There is difficulty with the voluntary, purposeful movement of speech .The causes are stroke, tumor, head injury, and developmental disorders. The speakers can produce individual sounds but cannot produce them in longer words or sentences. Voice disorders affect pitch, duration, intensity, resonance, and vocal quality parameters. Fluency disorders produce interruptions in the flow of speaking. It is also known as stuttering. It means frequent repetition and/or prolongation of words or sounds [51].

Treatment of children with Speech Oral Placement Disorders (OPD)s needs various types of speech oral placement therapy (OPT) .Children with speech OPDs may have typical or a typical oral structures. The key to the definition of OPD lies in the child’s ability or inability to imitate auditory-visual stimuli and follow verbal oral placement instructions. Children with OPD cannot imitate targeted speech sounds using auditory and visual stimuli .They also cannot follow specific instructions to produce targeted speech sounds [52].

Thomas Dubuisson et.al. described an analysis system aiming at discriminating between normal and pathological voices. Based on the normal and pathological samples included the

MEEI

database, it has been found that using two features (spectral decrease and first spectral tristimuli in the Bark scale). Music Information Retrieval (

MIR

) aims at extracting information from music in order to build classification system of music. Temporal Domain features are Energy, mean, standard deviation. Spectral features are spectral Delta, Spectral Mean Value, Spectral Standard Deviation, Spectral Center of Gravity known as spectral centroid, Spectral Moments. The first four moments of the power spectrum M

1

, M

2

, M

3

, M

4

. M

3

is used to compute the skewness defining the orientation of the PSD around its first moment. If it is positive, the PSD is more oriented to the right and to the left if is negative. The skewness is computed as Skewness = M

3

/(M

2

)3/2 . The fourth moment is used to compute the kurtosis defining the acuity of the PSD around its first moment. A Gaussian distribution is having a kurtosis equal to 3, a distribution with a higher kurtosis is more acute than a Gaussian one while a distribution with a lower kurtosis is more flat than a Gaussian distribution. The kurtosis is computed as

Kurtosis = M

4

/(M

2

)2. The Soft Phonation Index is defined for the (0–1000 Hz) and (0–8000 Hz) frequency bands [54]. Behnaz Ghoraani et.al. proposed a novel methodology for automatic pattern classification of pathological voices. The main contribution of this paper is extraction of meaningful and unique features using Adaptive time-frequency distribution (TFD) and nonnegative matrix factorization (NMF). The proposed method extracts meaningful and unique features from the joint TFD of the speech, and automatically identifies and measures the abnormality of the signal. The proposed method is applied on the Massachusetts Eye and Ear Infirmary (MEEI) voice disorders database. As a matter of fact from the TFD of abnormal speech it is evident that there are more transients in the abnormal signals, and the formants in pathological speech are more spread and are less structured [55].

Corinne Fredouille et.al. have addressed voice disorder assessment. The goal of this methodology is to bring a better understanding of acoustic phenomena related to dysphonia. The automatic system was validated on dysphonic corpus (80) female voices. These observations led to a manual analysis of unvoiced plosives, which highlighted a lengthening of VOT according to the dysphonia severity validated by a preliminary statistical analysis. The feature vectors issued from this analysis, at a 10 millisecond rate, are finally normalized to fit a 0-mean and 1-variance distribution. The LFSC/MFSC computation is done by using the (GPL) SPRO toolkit. Finally, the feature vectors can be augmented by adding dynamic information representing the way these vectors vary in time. Here, first and second derivatives of static coefficients are considered (also named Δ and ΔΔ coefficients) resulting in 72 coefficients [56].

Younggwan Kim et.al. discussed the role of the statistical model-based voice activity detector (SMVAD) to detect speech regions from input signals using the statistical models of noise and noisy speech. The LRT-based decision rule may cause detection errors because of statistical properties of noise and speech signals[57].

Wiqas Ghai et.al. described automatic speech recognition system as comprised of modules Speech Signal acquisition ,Feature extraction, using MFCC is done . Acoustic Modeling is done for expected phonetics of the hypothesis word/sentence. For generating mapping between the basic speech units such as phones, tri-phones & syllables, a rigorous training is carried. During training, a pattern representative for the features of a class using one or more patterns corresponding to speech sounds of the same class. Language & Lexical Modeling is done with the help of Text Corpus, Pronunciation Dictionary and Language Model [59].

Lucas Leon Oller presents analysis of voice signals for the Harmonics-to-Noise crossover frequency .The harmonics-to-noise ratio (HNR) has been used to assess the behavior of the vocal fold closure. The objective is to find a particular harmonics-to-noise crossover frequency (HNF) where the harmonic components of the voice drop below the noise floor, and use it as an indicator of the vocal fold insufficiency. . As the range used for the calculation of the cepstrum approaches the lowest octaves, the growth of the rahmonics should accelerate at some point, the range is going to contain harmonics that are above the noise floor level, and then the energy of the rahmonics will start to faster. That point would be the harmonics-to-noise crossover frequency [60]. Daryl Ning has developed an Isolated Word Recognition System in MATLAB. A robust speech-recognition system combines accuracy of identification with the ability to filter out noise and adapt to other acoustic conditions, such as the speaker’s speech rate and accent. It requires detailed knowledge of signal processing and statistical modeling [61].


Phonetic Concepts

Daniel Jurafsky et.al. presented a case study of Star trek where robots converse with humans in natural Dialogue system with language conversational agents. Various components that make up modern conversational agents, including language input and language output dialogue ,automatic speech recognition, natural language understanding ,response planning , speech synthesis systems and the goal of machine translation which leads to automatic translation of a document from one language to another is explained here [62].

Steven Pruett describes speech as the motor act of communicating by articulating verbal expression and Language as the knowledge of a symbol system used for interpersonal communication. Mary Planchart has explained four domains of language namely Phonology, Grammar , Morphology ,Syntax , and Pragmatics [63], [64].

Eric J. Hunter has presented a case study of a 5 year old healthy male child. He has analyzed comparison of the child’s fundamental frequencies in structured elicited vocalizations versus unstructured natural vocalizations. The child also wore a National Center for Voice and Speech voice dosimeter, a device that collects voice data over the course of an entire day, during all activities for 34 hours over 4 days. It was observed that the child’s long-term F

0

distribution is not normal. If this distribution is consistent in long-term, unstructured natural vocalization patterns of children, statistical mean would not be a valid measure. Author has suggested mode and median as two parameters which convey more accurate information about typical F

0

usage [65].

Evaluate the importance of monitoring the effect of technology on workflow.McGonigle, D., & Mastrian, K. G. (2015).

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Evaluate the importance of monitoring the effect of technology on workflow.McGonigle, D., & Mastrian, K. G. (2015).

 

Consider a clinical process or task that you perform on a frequent basis. Do you do it the same every time? Why do you proceed the way you do? Habit? Protocol? Each day nurses complete certain tasks that are considered routine, but have you ever stopped to reflect on why things are done the way they are? Perhaps you have noticed areas where there is a duplication of efforts or an inefficient use of time. Other tasks might pass seamlessly from person to person. In order to design the most efficient flow of work through an organization, it is useful to understand workflow and the ways it can be structured for the most optimal use of time and resources.he implementation of a new technology can dramatically affect the workflow of an organization. Newly implemented technologies can initially limit the productivity of users as they adjust to their new tools. Such implementations tend to be so significant that they often require workflows to be redesigned in order to achieve improvements in safety and patient outcomes. However, before workflows can be redesigned, they must first be analyzed. This analysis includes each step in completing a certain process. Some systems duplicate efforts or contain unnecessary steps that waste time and money and could even jeopardize patient health care. By reviewing and modifying the workflow, you enable greater productivity. This drive to implement new technologies has elevated the demand for nurses who can perform workflow analysis.
In this Discussion you explore resources that have been designed to help guide you through the process of workflow assessment.
To prepare:
Take a few minutes and peruse the information found in the article Workflow Assessment for Health IT Toolkit listed in this weeks Learning Resources.
As you check out the information located on the different tabs, identify key concepts that you could use to improve a workflow in your own organization and consider how you could use them.
Go the Research tab and identify and read one article that is of interest to you and relates to your specialty area.Post a summary of three different concepts you found in Workflow Assessment for Health IT Toolkit that would help in redesigning a workflow in the organization in which you work (or one with which you are familiar) and describe how you would apply them. Next, summarize the article you selected and assess how you could use the information to improve workflow within your organization. Finally, evaluate the importance of monitoring the effect of technology on workflow.McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.
Chapter 14, Nursing Informatics: Improving Workflow and Meaningful Use
Huser, V., Rasmussen, L. V., Oberg, R., & Starren, J. B. (2011). Implementation of workflow engine technology to deliver basic clinical decision support functionality. BMC Medical Research Methodology, 11(1), 4361.
https://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit

Analyze and discuss the relationship between quality and cost in Healthcare Health care costs in the United States continue to increase.

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Analyze and discuss the relationship between quality and cost in Healthcare
Health care costs in the United States continue to increase.

Analyze and discuss the relationship between quality and cost in Healthcare
Health care costs in the United States continue to increase. Despite the high cost of care for health care in the United States, quality indicators and outcomes lag behind other countries when compared to certain dimensions of performance.

For this assignment, analyze and discuss the relationship between quality and cost in health care in the United States, and research and identify how the Patient Protection and Affordable Care Act (PPACA) attempts to reduce costs and improve quality. Based on your research of the PPACA, provide an argument for whether the PPACA has been a success in reducing costs and improving quality.

Note: Use APA style to cite at least 5 scholarly sources from the last 5 years. 5-6 pages, excluding cover page, abstract page, and reference page.

:As a current or aspiring healthcare manager and as a result of taking this course how will you prepare your organization to face the major trends and changes taking place in medicine today?

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:As a current or aspiring healthcare manager and as a result of taking this course how will you prepare your organization to face the major trends and changes taking place in medicine today?

As a current or aspiring healthcare manager and as a result of taking this course how will you prepare your organization to face the major trends and changes taking place in medicine today?

Allopathic and the Complementary Approaches to Medicine

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HND Complementary Therapies

Image 1, (Collinge, 2008)

Contents


Introduction


History of Medicine and Healing


Herbalism


Chinese


Hippocrates


Different approaches between Allopathic and Complementary Therapies


Allopathic


Complementary


Common Ground


Disadvantages of Integration


Existing Models


Conclusion


Bibliography


References


Introduction

This report describes models and theories of healing.  The history of medicine and healing is discussed relating to Allopathic and the Complementary approaches and common ground between both.  Also included is where the different models exist and a brief description of the research findings.


History of Medicine and Healing


Herbalism

Herbalism is the study and use of plants used for medicinal purposes to treat many different ailments.  Different cultures use plants from traditions passed down from their ancestors and through observations realised that plants can have a positive effect on someone displaying ill health.

The first recording of herbs being used as medicine dates back 5000 years in Iraq where archaeologist had been found thyme and caraway on a clay bed which was used in healing the sick.


Chinese

Chinese herbalism also dates back 5000 years and is widely used in Chinese medicine in the present day.   The Chinese emperor Chi’en Nung wrote a book called Pen Tsao which contained over 300 herbs such as Chinese ephedra, the herb from which Western scientists have derived the drug ephedrine used to treat obesity.


Hippocrates

Hippocrates was born on the island of Kos, Greece around 460 BC. He became regarded as the founder of medicine and he based his medical practices on observing and studying the human body. He held the belief that illness had a physical and a logical explanation.  Hippocrates findings and recordings of medicinal recipes reveal treatments and curatives used by the early ancient Greeks and are still practiced within allopathic care today.

According to the

World Health Organisation

(WHO), 80 percent of the population of some Asian and African countries presently use herbal medicine in a majority of their  health care. The reason being pharmaceuticals are really expensive and most of these countries are poverty stricken so cannot afford modern day medicines.   This compared to herbal medicines which can be grown abundantly in a more natural way for a fraction of the cost on their doorstep.

Most of the modern day medicines are derived from herbal, natural plants which are used in many ancient traditional cultures and are still used in this day and age such as

Many of the

pharmaceuticals

currently available today  have a long history of use as herbal remedies, including


  • Opium

    , – an analgesic that is chemically processed to make heroine and morphine.

  • Aspirin

    ,- used to treat pain, fever and inflammation within the body.

  • Digitalis

    – is used to treat heart conditions.

  • Quinine

    – used in the treatment of malaria and also for restless leg syndrome.

(Patwardhan, B. 2005)


Different approaches between Allopathic and Complementary Therapies


Allopathic


Negative


Positive

Use of pharmaceutical drugs which may be harmful to other organs in the body.

Waiting time on appointment.

Limited appointment time allocated.

Unfamiliar GP.

Symptoms are only addressed not the cause on initial appointment.

Waiting time for referral to specialist.

Patient relies on GP for their overall health and take no responsibility of their own.

Long term use of drugs can cause dependency and/or addiction.

Drugs can cause other symptoms or damage to other organs in the body.

Emergency treatment.

Treatment of infection.

Scans and Xrays can show internal issues of the body.

Specialist care when illness or disease is in the later stages.


Complementary


Negative


Positive

Usually a long appointment

Treatment can take a long time to work

Can be costly

Not available long term on the NHS.

Not regulated.

Therapist spends time with client to get to know them

Non invasive

Patient takes own responsibility for  own lifestyle.

Treats the body as a whole, mentally, physically and emotionally


Common Ground

Common ground for Allopathic and Complementary therapies include

  • Both are aiming to give the patient relief from the symptoms displayed.
  • Agreements between both on protocols used.
  • Patient satisfaction and commitment from both sides.
  • An understanding of how both health models work and how they can work together..
  • How patients expectations are met such as complementary therapies during cancer treatments.


Disadvantages of Integration

Some disadvantages of integration of complementary therapies into allopathic health care may include:

  • Lack of knowledge of various complementary therapies and what they involve.
  • Not knowing the referral process.
  • No scientific evidence so may be a bit skeptical about complementary therapies.
  • The patient might not see results immediately, so may end treatment too soon.
  • May experience a healing crisis so patient may think symptoms are worsening so will end treatment.
  • Beliefs of patient may discourage them from accepting complementary treatments.
  • Not all complementary therapy treatments are suitable for some conditions so this could be disappointing for the patient.


Existing Models

‘The Centre’ at Gartnavel Hospital in the west end of Glasgow offers people an integrated health service for those who suffer from long term chronic pain, physical tiredness and mental health issues relating to anxiety the help to combat these issues through a holistic approach to the body. Referrals are made from all health care professionals in exactly the same way as all other hospitals and clinics. Normally your GP will refer you, but you may be referred from another hospital specialist. All patients are offered an appointment within nine weeks of the referral letter being received. The main aim is to promote and enhance wellbeing through self-care, self-regulation and self-healing.  Patients are seen in an Outpatient Clinic by either a doctor or an advanced specialist nurse practitioner whose purpose is to achieve a comprehensive and holistic understanding of your illness, and the impact it has on your daily life. The integrative care plan involves a co-ordinated mix of health and wellness coaching with advice and information. It also includes the teaching of health-making practices and technique interventions which are intended to facilitate greater vitality, resilience and growth in the person who presents with the illness. These practices and therapies may include:

  • Mindfulness Based Cognitive Therapy,
  • Heart math,
  • Counselling,
  • Art and Music Therapy,
  • Physiotherapy
  • Therapeutic Massage
  • Acupuncture,
  • Homeopathy,
  • Mistletoe Therapy,
  • Relaxation,
  • Stress Management,
  • Yoga and Tai Chi.

Glastonbury Health Centre (GHC) is another model who offers an integrated complementary medicine service joining their NHS General Practice with five mainstream complementary therapies.

The GHC aim is to improve the health and wellbeing of their patients,  who are chronically ill with many different conditions.

They claim that the cost of the complementary therapies service is covered by the savings they make in medication costs and referrals so this means it is working out to be more financially viable.


GHC


was established in 1992 and consists of a three GP practice with 4,500 patients and funded




by Somerset Trust for Integrated Health.




The aims of the Trust are to support the integration of effective complementary medicine in Primary Care.




This is achieved by:











– subsidising access to complementary medicine,











– researching the impact of integrated complementary medicine,











– establishing links and disseminating information to other providers, and











– lobbying the NHS to support integrated complementary medicine.




(


Cherion, n.d)

GHC provide 3 hours of treatment which are usually broke down into  4-6 separate  appointments and  include:

  • Acupuncture,
  • Herbal medicine
  • Homoeopathy
  • Massage Therapy
  • Osteopathy.

According to Green Medicine This choice of therapies were chosen as they as they consist of 70% of complementary medicine consultations in the UK, and they are the most-validated specialities with accredited professional standards. Osteopathic practice is now subject to registration by the General Osteopathic Council.  (Cherion, n.d).


Conclusion

On completion of this report, I now have a better understanding of how complementary therapies can be integrated into other areas and not just as a pamper session.  I have read many articles when researching this report relating to complementary therapies and modern day health care and found the evidence that both can really work well together.  I also found that integration is becoming more and more popular and hope that in the near future, patients can make a personal choice of how their health conditions are treated.  My aims for my future is to work within the NHS sector either in palliative care or with addictions, and I think this unit will stand me in good stead for reaching the qualifications standard needed to access this area of employment. Overall I have enjoyed researching this subject and learned lots to help me further my future education within complementary therapies.


Bibliography


References

        Cherion. (n.d).

Complementary Medicines in Public Health Foundation .

Available: http://www.greenmedicine.co.uk/Integratedhealth/ih-links.html. Last accessed 14th October 2018.

  • Patwardhan, B. (2005).

    Traditional Medicine: Modern Approach for Affordable Global Health.

    Available: www.who.int/intellectualproperty/studies/B.Patwardhan2.pdf. Last accessed 14th October 2018.
  • Image1, front cover,

    https://www.google.co.uk/search?rlz=1C1GCEB_enGB819&biw=1600&bih=758&tbm=isch&sa=1&ei=LKnFW5voDKnGgAaNobCAAQ&q=integration+of+health+complementary+and+allopathic&oq=integration+of+health+complementary+and+allopathic&gs_l=img.3…107751.116810.0.118710.29.29.0.0.0.0.124.2815.18j11.29.0….0…1c.1.64.img..0.2.226…0i24k1.0.tnjcMAkPqic#imgrc=yLfhpP1qbvu7gM:. (2018). Viewed 14



    th



    October 2018.


A description of the foodborne hazards that have occurred within the healthcare organization that have caused it to become noncompliant

/in /by

A description of the foodborne hazards that have occurred within the healthcare organization that have caused it to become noncompliant

You have just been hired as a compliance officer for your healthcare organization, and you have discovered that the food services department of the organization is not in compliance with state food safety regulations for healthcare organizations. The board of directors has requested a report from you and your team that contains an outline of the issues that have been occurring within the food services department that have caused it to become noncompliant, a plan to bring the department into compliance, and a description of how you and your team plan to maintain the department’s compliance in the future.

Your report should cover the following topics:

a description of the foodborne hazards that have occurred within the healthcare organization that have caused it to become noncompliant,
why it is important for patient recovery that the food service department maintain food safety and become complaint with state regulations,
the key elements of your compliance plan, and
the importance of internal audits and project management in the creation, implementation, and maintenance of the compliance plan.

Remembering Maslow’s “Hierarchy of Needs, Self-Actualization sits alone atop of the needs pyramid (behind physiological, safety, social, and esteem needs). Maslow described self-actualization as “What a man can be, he must be”.

/in /by

Remembering Maslow’s “Hierarchy of Needs, Self-Actualization sits alone atop of the needs pyramid (behind physiological, safety, social, and esteem needs). Maslow described self-actualization as “What a man can be, he must be”.

 

PASSION: Why am I here?

I am here because of my vested interest and enthusiasm to care and offer and helping and healing hands to the sick and needy. My innate and high degree of compassion and caring toward other human beings, is what drives my desire to truly make a difference. I stay in the nursing profession to make a difference. I am not only passionate about taking care of other human beings and making a difference in their patients’ lives, but strive to make a difference in their facilities, communities, government, and professional organizations.

Remembering Maslow’s “Hierarchy of Needs, Self-Actualization sits alone atop of the needs pyramid (behind physiological, safety, social, and esteem needs). Maslow described self-actualization as “What a man can be, he must be”. This level of need pertains not only to what my full potential is, but realizing that potential. I become a nurse because I wanted to accomplish a higher degree of education and skill in order to attain self-actualization. I stay in the profession to continue my education and continue to excel in skill and knowledge base in an effort to gain self-actualization which would strengthen my confidence and render efficient care for patients and families.

MOTIVATION: What moves me to act?

The smiles, the positive remarks and satisfaction expressed from families and staff gives me that inner fulfillment and personal achievement. This , I get after caring for somebody in best way I could makes me feel rewarded and a desire to go back and do more . I can go home knowing that I have fulfilled my reason for being a nurse for that very day which is, making a difference in someone’s life.

I always try to remember if that patient was me or a love one, I would like the people involve to render safe and efficient care. I know sometimes we just cannot be there no matter how much we want but if I can be there as much as possible I feel I am doing the best I can.

My Effective goal setting is also a source of motivation for me. My goal is to render safe and efficient care. I try to hold confidence and believe in the ability to reach those goals, for the attainment will lead to a successful career.

INSPIRATION: What keeps me in motion?

I enjoy most about being a nurse is the opportunity to comfort and offer a helping hand to others during stressful times. Most inspiring to me is patient and their families expressing positive words and expressions that are recognized and appreciated, throughout the day and in my career this far. It definitely might have been an impact I made on the patient.

I enjoy the opportunity to make a difference in a patient’s life. Whether it’s through teaching, providing care or supporting a family. Each aspect of care allows me to give personally of myself and feel rewarded at the end of the day, knowing I made a difference. I anticipate that my inspiration to becoming and outstanding nurse who positively affect patients, practice, and profession.

LOYALTY: Whom do I serve?

Nurses come from a culture of caring, characterized by concern and consideration for the whole person. Nurses recognize that patients are more than a set of symptoms that need to be treated; they look at the physical, spiritual, emotional, and psychosocial needs of the individual. What this ultimately means for patients is that nurses will listen to them, advocate for them, and provide the information they need to make informed decisions—and then support them in those decisions. With increased customer satisfaction comes the likelihood of customer loyalty. Nursing plays a tremendous role in customer loyalty. Patients will change pharmacies, medications, and payers, but don’t mess with their nurse! They are loyal to the nurse because he or she offers a personal and therapeutic touch. No one spends more time interacting with the patient than the nurse.

Investigation of Thyroid Emergencies

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Unit 1


Thyroid Emergencies


Authors:

  • Dr. Khalid Khatib
  • Dr. Subhal Dixit


1.0 Objectives

After reading this unit, you will be able to:

  • Enumerate thyroid diseases which will land the patient in the intensive care unit;
  • Describe the clinical features, investigation and treatment of throid storm;
  • Describe the clinical features, investigation and treatment of hypothyroid coma; and
  • Describe the clinical features, investigation and treatment of obstructive symptoms due to goiter.


1.1 Introduction

Thyroid emergencies comprise a miniscule fraction of patients with thyroid dysfunction, who land up hospitalized in the intensive care unit (ICU) as a consequence of their abnormal thyroid physiology or anatomy. As these conditions are infrequently encountered in the ICU, a proper understanding of the hormonal pathophysiology and varied clinical features will lead to appropriate and timely institution of hormonal and supportive treatment, ultimately rendering survival benefit to the patient. The following conditions constitute thyroid emergencies: i) thyroid storm, ii) hypothyroid coma, and iii) massive goiter causing compression of the airways and large blood vessels.


1.2 Thyroid Storm

It is also known as thyroid crisis or thyrotoxic crisis and is an extreme physiological condition due to thyroid hormone excess. A very severe, life threatening and decompensated form of thyrotoxicosis, it is rare (seen in 1-2% of patients admitted for thyrotoxicosis); but mortality rates approach 10-20%. Thyroid storm may be seen even in patients who have not been diagnosed with hyperthyroidism. The male to female ratio is 1:3.

Causes: i) Grave’s disease, ìi) Toxic multinodular goiter, iii) Solitary nodular goitre iv) Subacute thyroiditis v) Postpartum thyroiditis, vi) Thyrotoxicosis factitia, vii) Metastatic thyroid malignancy.

Whatever the etiology of hyperthyroidism, its conversion to thyroid storm requires the addition of precipitating factors.

Precipitating factors: i) Infection, ii) Trauma, iii) Surgery- of the thyroid gland or non-thyroidal, iv)Acute myocardial infarction or Acute coronary syndrome, v) Pregnancy, labor, complicated delivery vi) Burns vii) Medical illnesses- congestive heart failure, diabetic ketoacidosis, cerebrovascular accident, pulmonary thromboembolism, sepsis, viii) Stress- emotional ix) Abrupt interruption of thyroid drug therapy, x) Administration of iodine compounds or radioiodine (I

131

or I

123

), xi) Others- chemotherapy for leukemia, radiation therapy to neck malignancies, aspirin overdose, organophosphate poisoning, exercise, status epilepticus and drugs (tyrosine kinase inhibitors, lithium, biological agents like interleukin 2 and interferon).

Clinical features: i) Central Nervous System- apathy, agitation, delirium, confusion, paranoia, and coma. ii) Cardiovascular System- congestive heart failure, tachyarrhythmia (atrial fibrillation, supraventricular tachycardia, ventricular tachycardia and ventricular fibrillation,) sinus tachycardia, dilated cardiomyopathy, high cardiac output state, and pulmonary hypertension. iii) Gastrointestinal tract- vomiting, diarrhoea, jaundice, diffuse abdominal pain occasionally presenting as acute abdomen. iv) Respiratory system- dyspnea, tachypnea and acute respiratory failure. v) Thermoregulation- fever, hyperthermia and diaphoresis. vi) Nutrition- weight loss. vii) Renal- proteinuria, acute renal failure.viii) Electrolyte disturbances- hypercalcemia, ketoacidosis, lactic acidosis. viii) Hematology- leucocytosis, hypercoagulable state leading to thromboembolism.

Some elderly patients may have very few signs of hyperthyroidism and present with stupor, apathy, coma, and congestive heart failure (apathetic thyroid storm).

Diagnosis: i) It usually needs to be based on clinical judgment and treatment started even before laboratory results are available. A semiquantative scale developed by Burch and Wartofsky can be used to definitively identify patients with thyroid storm. ii) Thyroid function tests(TFT): TFTs reveal increase in free T3 and free T4 while TSH will be very low (even undetectable). iii) Other laboratory investigations: Serum bilirubin, transaminases, blood glucose levels may be increased while potassium and total cholesterol may be decreased.

Treatment:

Principles of treatment: i) Treat the hyperthyroid state. ii) Prevent the effects of circulating T3 and T4. iii) Treat the multiorgan dysfunction. iv) Treat the precipitating cause.

i) Treat the hyperthyroid state:

1) Prevent new thyroid hormone synthesis (Thionamides) 2) Prevent new thyroid hormone release (Thionamides) 3) Prevent conversion of circulating T4 to T3 ( steroids, lithium, high dose iodine and iodinated contrast medium)

Thionamides: Propylthiouracil, Carbimazole, Methimazole are used in the treatment of hyperthyroid state.

Propylthiouracil (PTU): a) Dose: Loading dose- 500-1000 mg followed by a maintenance dose of 250 mg every 4-6 hours. b) It additionally prevents peripheral conversion of T4 to T3. c) It is given either orally (if patient is conscious and able to swallow) or through the nasogastric tube or rectally. d) Onset of action is rapid. e) PTU has potential for hepatotoxicity. f) Hence it is preferred now only in pregnancy, where other thionamides cannot be used.

Methimazole or Carbimazole: a) Dose: 20-30 mg every 4-6 hours may even go up to 60-80 mg every 4-6 hours. b) They are preferred over PTU unless the patient is pregnant. c) They can be given orally, through the nasogastric tube, rectally, or even intravenously.

Steroids: a) Hydrocortisone is used in the dose of 100 mg intravenously or intramuscularly every 6 hours and continued till the condition of the patient improves completely. b) If Dexamethasone is used, the dose is 2 mg intravenously every 6 hours. c) Doses of both the drugs need to be tapered appropriately before they are stopped.

Lithium: a) Dose: 1200 mg per day in 3-4 divided doses. b) Lithium is used if thionamides are contraindicated and patient is allergic to iodine. c) Serum lithium levels are monitored to prevent toxicity.

High dose Iodine: a) Lugol’s iodine or potassium iodide solution is used. b) Dose: 0.3 ml or 10 drops of Lugol’s iodine diluted to 50 ml every 8 hours, orally or through the nasogastric tube. c) Its action is due to the Wolff-Chaikoff effect leading to the suppression of thyroid hormone release and peripheral conversion of T4 to T3. d) It should be administered at least one hour after administration of thionamide drugs. e) Sodium iodide may be used intravenously (dose- 500-1000 mg), but it is not easily available as a sterile solution.

Iodinated contrast solution: 0.5-1 gm every 12 hours.

Cholestyramine at a dose of 4gm, 2-4 times a day orally, reduces enterohepatic circulation of thyroid hormones. In refractory cases, plasma exchange, peritoneal dialysis or hemofiltration may be used to reduce the circulating thyroid hormones.

ii) Prevent the effects of circulating T3 and T4:

Beta blockers: 1) They block the hyperadrenergic effects of the excessive thyroid hormones. 2) They can be used if there are no contraindications to their use (history of asthma, COPD or congestive heart failure). 3) They must be used with continous cardiac monitoring. 4) Propranolol is used most commonly at the dose of 60-80 mg, three times a day, orally or through the nasogastric tube. It may also be used intravenously at the dose of 10 mg; at the rate of 0.5-1 mg per minute till heart rate is less than 100 per minute and then continued orally as above. 5) If propranol is contraindicated, cardioselective betablockers (metoprolol, atenolol), calcium channel blockers or digoxin may be used. 6) Esmolol, an ultra short acting beta blocker, is preferred by some, as an intravenous infusion of 50-100 mcg/kg/min with a loading dose of 250-500 mcg/kg.

iii) Treat the multiorgan dysfunction:

1) Manage the patient in intensive care unit. 2) Take care of ABC (airway, breathing, and circulation). 3) Respiratory support with oxygen therapy or mechanical ventilation (noninvasive or invasive) as required. 4) Resuscitation and hemodynamic support- Intravenous infusions to correct fluid and electrolyte disturbances. 5) Antipyretics- cooling mattresses and cold sponging are used along with paracetamol to reduce the raised temperature. Salicylates are avoided as they reduce thyroid hormone binding to thyroglobulin and may in fact worsen thyroid storm. 6) Treat hypertension. 7) Treat delirium and agitation by sedation with haloperidol and benzodiazepines. 8) Provide nutritional support with adequate dextrose infusions and vitamin (especially thiamine) supplementation. 9) Treat the tachyarrythmias with antiarrythmic drugs if patient is hemo- dynamically stable or by electrical cardioversion if unstable. Treat congestive heart failure with diuretics and ACE inhibitors.

iv) Treat the precipitating cause:

1) Search and treat the focus of infection. 2) Use broad spectrum antibiotics on empiric basis as appropriate. 3) Send urine and blood cultures. 4) Treat trauma, diabetic ketoacidosis, myocardial infarction and other precipitating factors as per usual principles.

Once thyroid storm has been treated the hyperthyroid state should be treated definitively with antithyroid drugs, radioiodine or thyroidectomy.


1.3 Hypothyroid coma

It is also known as myxedema coma or myxedematous coma and is due to very severe, untreated hypothyroidism manifesting with reduced temperature and altered mental status. It is an emergency to be treated in an ICU and has high mortality, but fortunately it is rare. Typically the patient is an elderly female with history of hypothyroidism with or without adequate treatment, who may have stopped treatment, or may have suffered an intercurrent stressful situation (infection). Occasionally coma may be the first presentation of hypothyroidism. Rarely hypothyroid coma may be seen in young females, some of whom may be pregnant.

Precipitating factors: i) Burns, ii) Trauma, iii) Surgery, iv) Severe infection- pulmonary or urinary tract infection, sepsis, v) Low ambient temperature, vi) Cardiac diseases- myocardial infarction, congestive heart failure, vii) Cerebrovascular accident viii) Labour, ix) Anesthesia x) Drugs- neuroleptics, sedatives (benzodiazepines), xi) Intake of large amounts of liquids, xii) Seizures, xiii) Gastrointestinal bleeding.

Some of the common causes of hypothyroidism are: i) Chronic autoimmune thyroiditis, ii) Thyroidectomy (total or partial), iii) Graves disease treated with radioiodine, iv) Secondary hypothyroidism- hypopituitarism, v) Drugs- amiodarone, lithium.

Clinical features: i) Hypothermia- is usually severe with temperature approximately 26.7

0

C (80

0

F). Rarely, temperature may even reach 21

0

C. In some cases, temperature may be normal in the presence of infection. ii) Altered mental status- may present as disorientation, depression, paranoia, hallucination, cerebellar signs, amnesia, disturbed memory, abnormal EEG findings, seizures, status epilepticus, stupor, obtundation or coma. iii) Cardiovascular system- abnormalities present as bradycardia, prolonged QT interval, varying degrees of AV block, ventricular arrhythmias (torsades de pointes), pericardial effusion, reduced cardiac output or shock. iv) Respiratory system- disturbances present as hypoventilation and hypercarbia or respiratory failure requiring mechanical ventilation. v) Renal and electrolyte disturbances- manifests as hyponatremia, edema, retention of urine or rarely renal failure. vi) Gastrointestinal- manifestations are constipation, paralytic ileus, ascites, gastroparesis, and gastrointestinal bleeding. vii) Hematological- problems are coagulopathy due to vonWillebrand syndrome and reduction of coagulation factors, DIC (disseminated intravascular coagulation), granulocytopenia and microcytic or macrocytic anemia. viii) General- manifestations of hypothyroidism like macroglossia, ptosis, generalized skin swelling or cool dry skin, periorbital edema, obesity and depressed deep tendon reflexes.

Diagnosis: i) It should be suspected clinically. ii) TSH is raised in most cases. It may rarely be normal in pituitary causes of hypothyroidism. Severe systemic illness and drugs (inotropes, steroids) used to treat the associated systemic illness will cause blunting of the TSH elevation. iii) T3 and T4 levels are low. iv) Hyponatremia, hypoglycemia, hypoxia, respiratory acidosis, hypercapnia, hypercholesterolemia and elevated LDH and serum creatinine kinase levels may be present.

Treatment:

Principles of treatment: i) Thyroid hormone supplementation. ii) Steroids. iii) Correction of fluid and electrolyte disturbances. iv) Treatment of precipitating cause.

i) Thyroid hormone supplementation: a) Supplementation with L-thyroxine with or without addition of liothyronine. b) Therapy is preferably intravenous. c) There is no consensus on the best therapeutic regime. d) Dose of L-thyroxine- High dose (300-400mcg on day 1 and then 50-100 mcg/day on subsequent days) is preferred by some. Though tolerated by young patients, it may cause sudden cardiac death in the elderly. Hence a lower dose is preferred (100mcg on day 1 and then 50-100mcg on subsequent days). e) Liothyronine- at a dose of 10-25 mcg (bolus), intravenously and then 10 mcg intravenously every 4 hours for the first 24 hours and every 6 hours over the next 48 hours and then oral therapy with L-thyroxine (50-100 mcg daily), as feasible. Initial therapy with liothyronine may be preferred, as it has better bioavailability and peripheral conversion of T4 to T3 is impaired in hypothyroid coma. Care should be taken during liothyronine therapy as excess T3 may increase mortality. f) Combined T4+T3 approach: to avoid above complications, a combined approach with L-thyroxine and liothyronine is advised as shown in Table no. 1.

Table No. 1 Combined L-thyroxine and liothyronine therapy

Dose

L-thyroxine

Liothyronine

Initial

250 mcg i.v./orally/NGT

10 mcg i.v.

Over 24 hours

10 mcg i.v., 8-12 hourly

After 24 hours

100 mcg i.v./orally/NGT

Continue above dose

After 48 hours

50-100 mcg i.v./orally/NGT

Continue above dose

After 72 hours

Maintenance therapy with L-throxine (50-100 mcg orally/ NGT)

ii) Steroids: a) Hydrocortisone at a dose of 50-100 mg intravenously every 6 hours, is preferred. b) It is required to treat the associated adrenal insufficiency.

iii) Correction of associated fluid, electrolyte and other disturbances: a) Maintain airway and provide mechanical ventilation if necessary. b) Hyponatremia- is a frequent occurrence and needs correction by restricting water intake or by intravenous infusion of isotonic saline (if serum sodium is less than 120). If hyponatremia is more severe, infusion of 3% NS is used very carefully. Occasionally, Conivaptan may be used in patients with euvolemic or hypervolemic hyponatremia. c) Hypothermia- is treated with passive and gradual heating with blankets and air warmers.

iv) Treatment of precipitating cause: a) Appropriate antibiotics (broad- spectrum) are started for bacterial infections. b) Diuretics are used to treat volume overload and pulmonary edema. c) Intravenous glucose is used in the presence of hypoglycemia d) Inotropes are used if shock is present while digoxin is used with care for congestive heart failure.


1.4 Airway and vascular obstruction due to goitre

Gross enlargement of the thyroid gland, especially substernal and intrathoracic extension, causes compression of the airway and the great vessels at the thoracic inlet. Sometimes massive hemorrhage inside a thyroid nodule, malignant thyroid disease, metastasis to thyroid gland and Reiter’s thyroiditis may cause compressive symptoms.

Symptoms and signs: i) Dyspnea- usually chronic with acute or subacute exacerbations, ii) Stridor, dysphonia, iii) Dysphagia, choking, iv) Fullness and pressure in neck, v) Superior vena cava syndrome- causing facial edema, cyanosis and venous engorgement of face and arms, vi) Esophageal varices, vii) Phrenic or laryngeal nerve paralysis, viii) Horner’s syndrome, ix) Chylothorax, and x) Sleep apnea.

Treatment: a) Continous positive airway pressure (CPAP) application or intubation and mechanical ventilation for maintaining patency of the airways and to treat respiratory distress. b) In a few cases where intubation is not possible, emergency tracheostomy may be required. c) Surgery to relieve the obstruction in the form of thyroidectomy and associated sternotomy, if required. d) Radioiodine and percutaneous laser ablation may be preferred in some patients.


1.5 Let us sum it up

Thyroid storm occurs in hyperthyroid patients in the presence of precipitating circumstances leading to a hyperadrenergic condition which is fatal unless treated with care. It is treated with thionamides, beta blockers and correction of abnormal organ function.

Hypothyroid coma usually presents in the winter months, in elderly females, in the presence of a precipitating cause. The patient has profound hypothermia and altered mental status or coma. It is treated with supplementation of thyroid hormones and treatment of the associated multiorgan dysfunction.

Obstruction of the airway and blood vessels in the neck by an enlarged thyroid gland is very rare.