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Biomedical subjects

M M Shabot

Publications and source records attributed to M M Shabot.

At least 19 recordsLinked to original sources
PubMed2003

Sociotechnical requirements analysis for clinical systems.

OBJECTIVE: We explore sociotechnical requirements by examining the use of a computerized patient record system in an intensive care unit of a U.S. hospital and present two sociotechnical requirements, awareness and coordination, embedded in the users' work. METHOD: The study is based on observation during seven months of the use of a computerized patient record system in a surgical intensive care unit. During that period semi-formal interviews, informal interviews were held. RESULTS AND CONCLUSIONS: A key step in the design of clinical systems is the development and analysis of requirements. However, traditional requirements analysis is based on a set of assumptions that break down in the highly collaborative, exception-filled clinical domain. Sociotechnical requirement analysis enabled the designers to gather a much richer description of the environment surrounding the computer system, highlighting awareness and coordination, embedded in the users' work.

Cooperative Behavior↗
PubMed2001

Nosocomial pneumonia is not prevented by protective contact isolation in the surgical intensive care unit.

Nosocomial pneumonia (NP) is the leading cause of death from hospital-acquired infection in intubated surgical intensive care unit (SICU) patients. To determine whether protective contact isolation would lower the incidence of NP in intubated patients we performed a prospective, randomized, and controlled study in two SICUs in a tertiary medical center. Over a period of 15 months two identical ten-bed SICUs alternated for 3-month periods between protective contact isolation (isolation group) and standard "universal precautions" (control group). In the isolation group all personnel and visitors donned disposable gowns and nonsterile gloves before entering an intubated patient's room; handwashing was required before entry and on leaving the room. In the control group caregivers utilized only "standard precautions" including handwashing and nonsterile gloves for intubated patients. Respiratory cultures were obtained 48 hours after SICU admission and every 48 hours thereafter until extubation, transfer to floor care, or death. Airway colonization (AC) occurred in 72.7 per cent of isolated patients and 69.0 per cent of control patients (P = 0.61). The incidence of NP was significantly higher in the isolation group (36.4%) compared with the control group (19.5%) (P = 0.02). There was no statistically significant difference between groups in days from SICU admission to AC, days to NP, and mortality. We conclude that protective contact isolation with gowns, gloves, and handwashing is not superior to gloves and handwashing alone in the prevention of AC and NP in SICU patients and may in fact be detrimental.

Adolescent↗
PubMed2001

Integrated web-based viewing and secure remote access to a clinical data repository and diverse clinical systems.

The advent of the World-Wide-Web protocols and client-server technology has made it easy to build low-cost, user-friendly, platform-independent graphical user interfaces to health information systems and to integrate the presentation of data from multiple systems. The authors describe a Web interface for a clinical data repository (CDR) that was moved from concept to production status in less than six months using a rapid prototyping approach, multi-disciplinary development team, and off-the-shelf hardware and software. The system has since been expanded to provide an integrated display of clinical data from nearly 20 disparate information systems.

Computer Graphics↗
PubMed2000

Wireless clinical alerts for physiologic, laboratory and medication data.

A fully interfaced clinical information system (CIS) contains physiologic, laboratory, blood gas, medication and other data that can be used as the information base for a comprehensive alerting system. Coupled with an event driven rules engine, a CIS can generate clinical alerts which may both prevent medical errors and assist caregivers in responding to critical events in a timely way. The authors have developed a clinical alerting system which delivers alerts and reminders to clinicians in real time via a alphanumeric display pagers. This paper will describe the system, the type and number of alerts generated, and the impact on clinical practice. A major issue remains in measuring the impact of wireless alerts on patient outcomes.

Algorithms↗
PubMed2000

Intensive care unit outcomes of surgical centenarians: the "oldest old" of the new millennium.

This study compared the severity of illness and outcomes of surgical intensive care unit (SICU) patients age 100 years or older with those of younger SICU patients. Severity of illness was measured with the Simplified Acute Physiology Score (SAPS) and the Quantified Therapeutic Intervention Scoring System (QTISS). Outcomes were evaluated with SICU length of stay (LOS), hospital LOS, SICU mortality, and hospital mortality. All patients admitted to an urban, tertiary-care SICU from August 1, 1986 to July 31, 1998 (12 years) were included. A total of 24,395 consecutive patients were evaluated of whom nine (0.037%) were age 100 or more. Complete outcome data were available for 13,773 patients who were divided into five groups on the basis of age: <70, 70 to 79, 80 to 89, 90 to 99, and 100 years and above. Nine centenarians were admitted to the SICU of whom one died in the SICU and another died in the hospital after SICU discharge (22.2% overall mortality). Centenarian patients had higher SAPS and QTISS on admission than patients in all other groups, although this difference was not significant because of the small number of centenarians. SICU and hospital LOS were not significantly longer for centenarians. Mortality in the SICU and hospital was significantly different across the age groups and rose with age. However, the modest 11.1 per cent SICU mortality rate in centenarians along with their LOS statistics indicate that these patients fare relatively well in surgical intensive care.

APACHE↗
PubMed2000

Secure remote access to a clinical data repository using a wireless personal digital assistant (PDA).

TCP/IP and World-Wide-Web (WWW) technology have become the universal standards for networking and delivery of information. Personal digital assistants (PDAs), cellular telephones, and alphanumeric pagers are rapidly converging on a single pocket device that will leverage wireless TCP/IP networks and WWW protocols and can be used to deliver clinical information and alerts anytime, anywhere. We describe a wireless interface to clinical information for physicians based on Palm Corp.'s Palm VII pocket computer, a wireless digital network, encrypted data transmission, secure web servers, and a clinical data repository (CDR).

Computer Security↗
PubMed2000

Technology architecture guidelines for a health care system.

Although the demand for use of information technology within the healthcare industry is intensifying, relatively little has been written about guidelines to optimize IT investments. A technology architecture is a set of guidelines for technology integration within an enterprise. The architecture is a critical tool in the effort to control information technology (IT) operating costs by constraining the number of technologies supported. A well-designed architecture is also an important aid to integrating disparate applications, data stores and networks. The authors led the development of a thorough, carefully designed technology architecture for a large and rapidly growing health care system. The purpose and design criteria are described, as well as the process for gaining consensus and disseminating the architecture. In addition, the processes for using, maintaining, and handling exceptions are described. The technology architecture is extremely valuable to health care organizations both in controlling costs and promoting integration.

Computer Systems↗
PubMed1999

Percutaneous dilatational tracheostomy: still a surgical procedure.

Although percutaneous dilatational tracheostomy (PDT) has been shown to be a cost-effective bedside alternative to open tracheostomy (OT), prior reports of the complications of the procedure are contradictory. Reported complications range from minor events to fatal ones, in varying percentages. This prospective study was designed to identify the type and severity of complications accompanying the introduction of PDT to a tertiary medical center. Surgical and medical intensive care unit (ICU) patients requiring elective tracheostomy were identified as appropriate for PDT using approved institutional criteria. All procedures were performed at an ICU bedside in the presence of a surgeon privileged to perform OT. Demographic data, procedural information, and patient outcome (including minor and major complications, length of stay, and survival) were collected. PDT was performed in 96 ICU patients, with complete data available for 95 patients. PDT was performed in an average of 13.1+/-1.0 minutes. Twenty-three major and minor complications occurred, including two perioperative deaths, in 15 patients (15.8%). A total of 37 PDT patients (38.9%) died in the hospital, indicative of the severity of illness of patients requiring tracheostomy. Based on the experience to date, Cedars-Sinai Medical Center (Los Angeles, CA) continues to require a surgeon privileged to perform OT to participate in all PDT procedures.

Aged↗
PubMed1999

A novel governance system for enterprise information services.

The authors created a novel system for governing the enterprise information services (IS) of a large health care system. The governance organization is comprised of key members of the attending medical staff, hospital and health system administration, and the IS department. A method for defining the requirements and business case for proposed new systems was developed for use by departments requesting new or expanded information services. A Technology Architecture Guideline document was developed and approved to provide a framework for supported hardware and software technologies. IS policies are approved by the main governance council. All project proposals are reviewed by specialized governance committees and, if approved, are launched for further development. Fully developed proposals are reviewed, approved and prioritized for funding by the governance council. This novel organization provides the methodology and structure for enlightened peer review and funding for well developed IS project proposals.

Academic Medical Centers↗
PubMed1998

Outcomes from abdominal aortic aneurysm resection: does surgical intensive care unit length of stay make a difference?

Recent studies indicate that surgical intensive care unit (SICU) length of stay (LOS) may be shortened without significantly compromising patient care. We tested the validity of that claim in patients following abdominal aortic aneurysm (AAA) resection, a group that traditionally mandated SICU care, to determine whether recent changes in care have affected outcomes. Severity of illness, utilization of SICU-specific resources, lengths of stay, and outcomes were measured in 295 consecutive AAA patients admitted to the SICU postoperatively over a 6-year period (1988-1994). Patient age ranged from 32 to 97 years (mean, 73.1 +/- 0.5) with 82 per cent males and 18 per cent females. There were 266 elective AAAs and 29 ruptured AAAs. Overall mortality was 5.8 per cent, including a 3.4 per cent mortality in elective AAA patients and 27.6 per cent mortality in the ruptured group. Patients with ruptured AAAs were 4.5 years older than were elective AAA patients, had higher severity of illness scores, and had longer SICU and hospital LOS. In the elective group, SICU LOS declined from 3.3 +/- 0.4 to 1.7 +/- 0.3 days over the study period, without a concomitant change in admission severity of illness, hospital LOS, or mortality. Severity of illness at the time of transfer from the SICU to floor care rose over 21 per cent during the study period. Over a 6-year period, SICU LOS was reduced by nearly 50 per cent in patients receiving elective AAA resections without affecting outcome, as measured by hospital LOS or mortality. Decreasing the SICU LOS was effected by transferring patients to floor care with a higher severity of illness. This change saved approximately $175,000 per year in SICU costs.

Adult↗
PubMed1998

Outcomes from nonemergent orthotopic liver transplantation: is postoperative care becoming routine?

The outcome of surgical intensive care unit (SICU) care after nonemergent orthotopic liver transplantation (OLTX) was evaluated in 168 consecutive patients over a 6-year period (1/90-12/95). Prospective data collected included age, first and last SICU day Simplified Acute Physiology Score and Quantitative Therapeutic Intervention System Score, SICU length of stay (LOS), and mortality. The patient population was 61 per cent male and 39 per cent female, with ages ranging from 20 to 75 years. A total of four patients died in the SICU, for a mortality of 2.4 per cent. Over the study period, SICU LOS decreased by 21 per cent, from 3.9 +/- 0.7 to 3.1 +/- 0.3 days (P < 0.05). Although no difference in admission severity of illness was observed over the study period, there was an increase in the intensity of intervention performed on admission to the SICU. Over the study period, there was no difference in severity of illness or intensity of intervention upon discharge to floor care. The decreased SICU LOS did not adversely affect patient mortality or severity of illness upon SICU discharge during the 6-year period. With intensified SICU intervention, nonemergent orthotopic liver transplantation patients can have a shorter SICU LOS without adverse effects on outcome.

Adult↗
PubMed1997

The effect of surgical ICU triage patterns on differing severity adjusted outcomes in France and the United States.

INTRODUCTION: Surgical patients treated in French intensive care units (ICU's) appear to have higher mortality rates than patients in the United States. We hypothesized that this may be due to the French practice of not transferring dying patients from the ICU. We wished to determine if the different mortality rates could be explained by transfer practices for dying patients or other factors such as severity of illness. METHODS: Flowsheet data for 6,787 consecutive surgical ICU (SICU) patients from our institution over a 31 month period was entered into an ICU Clinical Information System which calculated the Day 1 Simplified Acute Physiology Score (SAPS) for each patient upon admission to the SICU. SICU and overall hospital mortality data were matched with severity data and the complete data set was analyzed against results for 2,604 surgical patients in French ICU's. Since terminally ill patients in France are not transferred to floor care, we also compared the French ICU mortality rate with both our SICU mortality rate and combined SICU and surgical floor mortality rates. RESULTS: Our overall SICU mortality was 1.7% and our combined SICU and hospital mortality was 4.2%, while the French ICU mortality was 14.1%. The French ICU's had more patients with higher severity of illness as measured by SAPS. When the effects of ICU transfer practices and severity of illness were considered, there were no mortality differences seen among patients admitted to the different units after elective surgery. Significant differences in mortality were seen when patients admitted emergently were studied. CONCLUSIONS: The differences in severity adjusted ICU mortality between French ICU's and our SICU are explained by different triage practices for terminally ill patients following elective ICU admission. These triage differences do not fully explain the mortality differences seen among patients emergently admitted to the ICU. Other factors such as the presence of trauma, ICU staffing practices, patient mix or other unidentified factors may be responsible for the severity adjusted differences in mortality among emergency surgical ICU patients.

Emergency Service, Hospital↗
PubMed1997

The HP CareVue clinical information system.

The HP CareVue system is an object-oriented, client-server system optimized for critical care, inpatient and special care environments. It is a fully graphical system, highly visual in its mode of operation, which requires no commands to operate. Data review may be performed by clinical users without specific instructions. Several different kinds of interfaces are provided for the system. These allow it to be connected to most hospital data-producing systems, physiologic monitors and bedside devices, such as ventilators, urimeters and oximeters. Flowsheet charting, free text, structured notes, clinical pathways, configurable forms, medication administration records and many other types of displays and reports allow the system to function as a nearly complete Electronic Medical Record (EMR). The system is highly configurable by lead nurses, physicians or technicians without programming knowledge or experience. Configuration and linking of multiple CareVue systems is possible, including a complete testing environment for verification of charting changes before clinical activation. All CareVue data is exportable for purposes of electronic archiving, warehousing and real-time decision support.

Electronic Data Processing↗
PubMed1997

Surgical intensive care unit care after ovarian cancer surgery: an analysis of indications.

OBJECTIVE: Our purpose was to develop a profile of preoperative and perioperative characteristics that would enable gynecologic oncologists to identify those patients with ovarian cancer who would benefit most from postoperative surgical intensive care unit care and thereby optimize resource utilization and cost effectiveness. STUDY DESIGN: A retrospective analysis was performed of 85 patients admitted to the surgical intensive care unit after cytoreductive surgery between Jan. 1, 1989, and Dec. 31, 1993. Fifty-three patients admitted to the surgical intensive care unit for < 24 hours were compared with 32 patients admitted for > 24 hours. Five preoperative characteristics (age, American Society of Anaesthesiology classification, body mass index, albumin, primary versus recurrent disease) and six perioperative characteristics (estimated blood loss, ascites, surgical time, bowel resection, Swan-Ganz catheter, ventilator dependence) were compared across the two groups by univariate analysis and multivariate logistic regression analyses. RESULTS: All preoperative variables were similar across the two groups. Ascites volume and length of surgery were not significant, whereas estimated blood loss was significant in the univariate analysis but not in the logistic regression analysis. Three perioperative variables were found to be predictive of extended surgical intensive care unit care by logistic regression analysis: placement of a Swan-Ganz catheter (odds ratio 4.31, 95% confidence interval 1.13 to 16.4), bowel resection (odds ratio 13.0, 95% confidence interval 1.96 to 86.5), and ventilator dependence (excluded from logistic regression analysis for mathematic reasons). CONCLUSIONS: The patient's preoperative medical condition proved to be less important than how she fares during surgery. The patient most likely to benefit from surgical intensive care unit care had undergone bowel resection, required invasive hemodynamic monitoring, or was ventilator dependent postoperatively. This patient profile may prove to be a useful screening tool to optimize resource utilization and cost effectiveness, but it cannot replace clinical judgment.

Age Factors↗
PubMed1996

Telesurgery. Acceptability of compressed video for remote surgical proctoring.

OBJECTIVE: To determine the clinical acceptability of various levels of video compression for remote proctoring of laparoscopic surgical procedures. DESIGN: Observational, controlled study. SETTING: Community-based teaching hospital. PARTICIPANTS: Physician and nurse observers. INTERVENTIONS: Controlled surgical video scenes were subjected to various levels of data compression for digital transmission and display and shown to participant observers. MAIN OUTCOME MEASURES: Clinical acceptability of video scenes after application of video compression. RESULTS: Clinically acceptable video compression was achieved with a 1.25-megabit/second data rate, with the use of odd-screen 43.3:1 Joint Photographic Expert Group compression and a small screen for remote viewing. CONCLUSION: With proper video compression, remote proctoring of laparoscopic procedures may be performed with standard 1.5-megabit/second telecommunication data lines and services.

Adult↗
PubMed1996

Achieving measurable CQI results.

A West Coast institution realized that patients receiving blood transfusions did not always have their data documented in accordance with hospital policy. By measuring compliance and communicating the results back to staff, the expected outcome was that compliance with the policy would increase. In addition, this study expected to determine whether the existing policy was effective in detecting transfusion reactions.

Accreditation↗
PubMed1996

When is ICU care warranted after carotid endarterectomy? A three-year retrospective analysis.

The purpose was to determine the valid indications for Surgical Intensive Care Unit (SICU) admission after carotid endarterectomy (CEA). The indications for admission to the SICU after CEA were studied over a 3-year period (4/89-3/92). Absolute indications for ICU admission (AIA) included mechanical ventilation, a pulmonary artery catheter, and intravenous vasoactive or antiarrhythmic drug infusion. Patients were grouped according to presence of an AIA (Group A), absence of an AIA and a one day SICU length of stay (Group B), or absence of an AIA and a SICU length of stay > 1 day (Group C). A total of 305 patients were admitted to the SICU during the study. There were 55 patients in Group A. Of the 250 patients without an AIA, 239 were in Group B and 11 comprised Group C. Group A patients had a significantly higher severity of illness compared with Groups B and C (P < 0.05). Group B patients demonstrated no need for SICU care. Group C patients received ongoing SICU care due to postoperative neurological changes, arrhythmias, angina, incisional bleeding, vocal cord paresis, and unavailability of a ward room. None of these conditions was life-threatening, and only vocal cord paresis would have required SICU admission. Two patients in Group A died; no patients died in Group B or C. Only patients with an AIA, perioperative neurological changes, or early hemodynamic instability require SICU admission after CEA. An observation period in the recovery room allows for selection of nearly all patients who will eventually require SICU care.

Adult↗