7. Since an estimated 29 new diabetics may be detected (when all screenees have been followed to diagnosis), the newly diagnosed may equal 0.48 percent of the total screened. Table II is the result of an extensive breakdown on all persons screened. Checking the figures, it is interesting to note that the percentage in any pair of columns (negative and positive compared) is always greater in the positive column. This would appear to support the current belief that a family history of diabetes, obesity, or a large baby are all related to the development of diabetes. Additional figures obtained through the same breakdown are as follows: 1. Total white females testing negative_-. - 3, 344 2,549 53 34 NOTE.-56.7 percent of the total number of screenees were females, whereas only 43.3 percent were males. Thus, 13.4 percent more females than males were tested. Since the number of colored persons screened per county was so low, I considered the data of no statistical value. Nevertheless, the numbers testing negative and positive are as follows: 1. Total nonwhite females testing negative_. 2. Total nonwhite males testing negative_-3. Total nonwhite females testing positive--4. Total nonwhite males testing positive-- 131300 As has been mentioned, few physicians returned their reports concerning diagnosis of positive screenees. Thus, no accurate breakdown could be presented with respect to the types of tests leading to diagnosis. As an estimate, I would judge that 90 percent of the followup tests were fasting blood sugars-approximately 10 percent received glucose-tolerance tests. I know of two cases where screenees were given the glucose-tolerance test with severe resultant reactions. These, fortunately, are the exception rather than the rule. FOLLOW UP ACTIVITIES If positive screenees failed to return to their physicians for diagnosis within 30 days after notification, followup proceedings were begun. To accomplish this, I visited the person's physician and asked permission to contact that screenee. If the local doctor favored my doing the followup, I urged this person to have further tests done. Some physicians, however, preferred to do their own followup. Throughout the survey, certain known diabetics were screened by mistake. These, if their results were negative, were considered candidates for home visits (with their doctor's permission). Again, it was my duty to see such persons, explain to them the meaning of a diabetes screening test, and remind them that a negative blood sugar should never tempt them to discontinue medical treatment. These visits, I believe, were a very essential phase of the diabetes program. I know of five such persons who felt the negative test report indicated they were no longer diabetics. Had these people been ignored, their disease might soon have been out of control. In addition, I followed up certain special cases. These included persons who listed no physician, those who listed a physician but reported to another, and one whose positive letter was missent. GLADWIN AND IONIA While the clinitron was set up in Newberry, 940 blood samples were sent to me for screening from the Gladwin, district No. 7 area. The results were forwarded to Dr. Sweet at Standish, therefore, I have no statistical breakdown on them. Approximately the last 600 blood samples (all from this area) gave negative test results. Since all previous screening was 1 to 2 percent positive, this would appear unrealistic. No good reason has been discovered; attempts at an explanation have been made. By doubling the amount of blood tested (i.e. using 0.2250 cc. of blood instead of 0.1125 cc.) all samples returned positive. This should rule out mechanical error. Perhaps, however, the problem arose due to faulty refrigeration. These samples had been refrigerated overnight, then were removed for 24 hours (for shipping) and were finally refrigerated another 10 days prior to testing. This explanation requires further testing. Finally, I operated the clinitron for 1 week (August 4 through 9) at the Ionia Fair, in Ionia, Mich. Here, over 1,100 blood samples were run with no difficulty. Again, I have no statistical breakdown on the results. COMMENTS A community diabetes program may be evaluated in terms of "yield,” “acceptability," and "cost." The Chippewa, Luce, and Mackinac screening program resulted in a fairly good yield at a fairly reasonable cost. But, in my opinion, acceptability left much to be desired. This factor covers acceptance by the individuals screened, by the local medical group, and the community itself. In certain areas, the physicians whom I visited expressed dislike for the diabetes program. Two physicians were totally uncooperative. Most of this antagonism, I believe, results from insufficient knowledge of the program, its aims, and its actual advantages to the physician. In spite of the fact that most physicians cooperated well and appreciated the program, the few who did not are enough to create a problem. These physicians, if possible, should be given further attention. The registration of screenees, I believe. is another aspect of the program which could be improved. These are my opinions based on observation and conversation with local health department personnel : 1. A permanent registrar, who understands fully how to complete the registration cards, would be of great value. Here are a few of my reasons for the suggestion: (a) Several registrars seemed to misunderstand the item "Diabetic history in the family?" taking it instead to refer to the person's history of his own disease. (b) The item "large" baby was apparently misunderstood by many. A newborn of 10 pounds or over was preselected as "large." But, several cards were marked "7 pounds" or "8 pounds" and the "yes" blank was checked. (c) Registrars were frequently poor judges of "obesity." In certain cases, the height-weight figures left no doubt that the screenee was obese, yet the card was checked "no." 2. If statistical breakdowns are to be carried out in the future, I believe the registration cards should be simplified. This could be done thus: place the person's name and address, along with his physician's name and address, along the top of the card. Then, place the remaining items in two columns, one at the left margin and the other at the right. Group sex, race, age, height, weight, and obesity in one column; "Known diabetic?" "Diabetic history in the family?" and "Mother of large baby?" in the another column. This is perhaps not the best answer to the problem, but I believe it would simplify tabulation. Finally, the letters to the doctors should read "the result of the test was above a preselected level of 160 mg percent" instead of "above what is usually considered normal." A few local doctors have called their health departments concerning this. One woman mentioned to me that her local physician was not notified how "high" the test was; thus, he refused to do any further tests without more detailed information. Aside from these negative comments, I consider the Chippewa, Luce, Mackinac screening program highly successful in that it brought many unrecognized diabetics to diagnosis and treatment. CONCLUSION My role as medical extern has been educational, stimulating, and enjoyable. Not only did I work on diabetes, but I was exposed to numerous additional phases of public health, its problems, and its important value to each member of any community. Educationally, I have become aware of some of the relationships among health departments and physicians. I now realize the benefits a physician may obtain from his health department, and how that health department is in turn assisted by a cooperating physician. Furthermore, various summer contacts have stimulated my interest in the art of medicine as such. Never before have I witnessed so thoroughly local doctors, their patients, and the associations between the two. I met both specialists and general practitioners; medical doctors and osteopaths. With regard to patients, I visited the rich and the poor; the well educated and the poorly educated. Speaking with various physicians gave me an opportunity to see textbook knowledge in action as I myself may some day be applying it. And, speaking with different patients helped me understand their difficulties, fears, and superstitions. With the close cooperation and able assistance of all health department personnel, most local physicians, and their receptionists, my externship has been most enjoyable. If all prospective doctors could share my experience, they too could observe that “public health is the science and the art of preventing disease, prolonging life, and promoting physical and mental health and efficiency through organized community efforts." Books: BIBLIOGRAPHY Cecil and Loeb, "Textbook of Medicine," W. B. Saunders Co., Philadelphia, London, 1955. Ham, Thomas Hale, "A Syllabus of Laboratory Examinations in Clinical Diagnosis," Harvard University, Cambridge, 1957. Robbins, Stanley L., "Textbook of Pathology," W. B. Saunders Co., Philadelphia, London, 1957. Bulletins : American Diabetes Association, Inc., "Detecting Diabetes Among Schoolchildren," New York, N.Y. Federal Security Agency, Public Health Service, "Diabetes," U.S. Government Printing Office, 1952. U.S. Department of Health, Education, and Welfare, Public Health Service, "Diabetes Program Guide," U.S. Government Printing Office, Washington, D.C., 1957. U.S. Department of Health, Education, and Welfare, "Taking Care of Diabetes," U.S. Government Printing Office, Washington, 1958. HISTORY-HOMES-FOR-THE-AGED PROGRAM OF THE GRAND RAPIDS, MICH., HEALTH DEPARTMENT FOREWORD The history of the development of regulatory measures relating to the licensing and inspection of homes for the aged represented in this report records only the major achievements and accomplishments in the program since its inception. Many other lesser but significant accomplishments that have contributed to the success of the program could not be practicably mentioned in this version of the historical record. Deserving appreciation for information and service to the program is hereby extended to Mrs. Mary Otterbein, R.N., director of public health nurses of the Grand Rapids Health Department through whose interest, active support, supervision and direction the program was initiated. Appreciation is also extended to Miss Hazel Henry, R.N., the first full-time institution inspector and Florence Gould, R.N., the present supervisor of the homes-for-the-aged program, both of whom greatly contributed to the present expanded and successful program. HISTORY The development of regulatory measures relating to the licensing and inspection of convalescent homes and homes for the aged in Grand Rapids dates back to 1939. The Michigan Department of Social Welfare, in 1939 passed the first statewide ordinance regulating the inspection and licensing of all homes "privately operated for a valuable consideration for four or more aged persons." However, following the passage of the ordinance, the local social welfare department in Grand Rapids was unable to provide an inspector to carry out the provisions of the ordinance. As a result of this shortage of personnel, the Grand Rapids Health Department was requested to assist with the inspection and licensing of existing homes in Grand Rapids. Responsibility for this inspection and the subsequent granting of licenses rested with the director of the nursing bureau in cooperation with the supervisor of hospitals of the State department of social welfare. It was soon discovered that many homes in operation at the time of license application failed to meet the minimum standards of the ordinance. Substandard conditions were most often observed in relation to food preparation and quality, general sanitation, and medical care. Every attempt was made to assist operators in meeting the minimum standards of the ordinance. Eventually, however, accomplishments in the form of an increased number of improve ments resulted through the cooperation of the director of nurses with the operators, the department of social welfare and with the helpful support of local newspapers. Further problems soon made it apparent that a full-time worker was needed in the program. In 1943 a full-time institution inspector was appointed and a city ordinance regulating convalescent homes was adopted. The ordinance provided for a license fee of $15 per patient which made possible the appointment of the first full-time institution inspector in Grand Rapids. However, the ordinance did not implement existing rules and regulations necessary to elevate standards of care or to improve the qualifications of staff personnel. Also revisions made at this time excluded homes being operated by charitable or eleemosynary organizations from the provisions of the ordinance. In 1946 the ordinance was revised to include recordkeeping as a prerequisite for licensing and the delegation of authority to the health officer to revoke a license for violation of the ordinance. During the next 10 years emphasis was placed in the folowing three major areas: 1. Improving the qualifications of personnel In cooperation with the Department of Vocational Education a 64-hour course of study was formulated for nonprofessional nursing personnel. The course emphasized the importance of nursing care for the aged. Successful completion of the course combined with sufficient supervised experience in a home enabled the nonprofessional nurse to take the State board examination necessary for licensure as a practical nurse. 2. Adoption of a uniform record system A complete personal history record sheet for individual patients was developed and adopted in cooperation with the operators of homes for the aged. The new form, similar to the one now in use, provided pertinent background information and contained a provision for the operator to legally assume responsibility in case of sudden emergency or death. Prior to the adoption of a uniform system of records, information on patients included only the name of the patient's physician and the rate of pay for care. 3. Improvement of food handling and food service Advice and consultation was offered to all operators regarding food purchasing and handling to insure maximum nutrition per food dollars. Assistance was given by a nutritionist from the Michigan Department of Health. 4. Revision and adoption of a new city ordinance Under the first city ordinance licensing convalescent homes, it was extremely difficult to improve basic minimum requirements. Therefore, in 1953, the present and more inclusive ordinance was revised and adopted. Major changes in the ordinance included: 1. Homes providing care for two or more persons would be required to secure license. Authority was given to the health officer to determine the health, welfare, and safety of persons receiving care in boarding homes, convalescent, and nursing homes. 2. License fees reduced from $15 to $5 per bed (with a minimum license fee of $10 and a maximum of $100). Supervision of the care of the aged and sick in licensed homes was established to be a function of the health department and as such the salary of the inspector deemed legitimate expenditure of public funds. 3. Floor space increased to a minimum of 60 square feet per bed. 4. Boarding homes for the aged required to secure license. 5. All church homes required to secure license. Routine inspection and licensing under the new ordinance involves an annual team inspection by representatives of the following department of the city. They are health, building, fire, electrical and plumbing. On approval by all departments the license application is approved by the director of public health or his deputy. The team inspection has worked out very well with fine cooperation among the team members. The responsibility of the position of inspector, now known as supervisor of homes for the aged as defined by the director of public health had the following objective: A. To assure the best possible care for the institutionalized person with: 1. Minimum of duplication of effort. 2. Minimum inconvenience to persons and guardians. 3. Maximum community involvement. 4. Maximum assumption of responsibility on part of operators. The method of accomplishment was to be through: 1. Cooperation in planning and working with the operators. 2. Placing the program in the division of environmental health. 3. Reporting on routine activities to the director of division of environmental health. 4. Understanding that the program is a joint responsibility of the division of administration, environmental health and nursing. 5. Working with lay groups and service clubs to create an interest in the entire problem of the aged and dependent. 6. Working with local and State agency representatives relative to referrals, responsibility, clearance, and other policy matters. 7. Conducting an inclusive program rather than selecting one area for specialization. The supervisor continued to implement the improvement programs initiated by the former inspector. Areas of major emphasis include: Nursing care (including qualified personnel), staff training, accident prevention, nutrition, food management, record keeping, inspection, and community-patient relationship and interest. The objectives of the director of public health are being accomplished. Some of these include: 1. Nursing care in 75 percent of the licensed homes is under the supervision of a registered or a licensed practical nurse. 2. All staff members of homes for the aged receive chest X-rays annually. 3. When feasible, chest X-rays of individual patients are requested before admission to a home for the aged. 4. Sputum examinations are done on patients having a suspicious cough when it is not possible to transport them for an X-ray. 5. Michigan Association of Nursing Home Owners and Michigan State University have set up a 5-year training program for personnel in homes for the aged. The areas of study are as follows: Patient care, food service operation, personnel, safety, socio-psychological aspects, physical operations, financial operations, public relations, and legal problems. 6. A uniform "nurses' notes" record is being used in the majority of the homes. 7. The monthly report of admissions and discharges which were begun in 1950 have been revised and are being used to secure monthly census counts. 8. In 1955 an accident reporting system was adopted. All accidents resulting in personal injury occurring in homes are reported within 24 hours. An investigation is made to see if another such accident can be prevented. 9. The health department nutritionist at the request of the supervisor offers consultation on food purchasing, inventory, and menu planning. Assistance is also given in relation to individual special diets. 43350-60-pt. 6 -21 |