Biomedical subjects
Publications and source records attributed to Sanjay Saint.
This new department will provide innovative ideas for meeting the Joint Commission's National Patient Safety Goals as implemented in various health care settings.
BACKGROUND: A patient experienced a wrongful surgical resection, specifically, a radical retropubic prostatectomy because of a false-positive pathology report. FINDINGS FROM THE ROOT CAUSE ANALYSIS (RCA): The RCA team identified three antecedent events that contributed to this medical error: (1) a second (concurring) pathologist did not provide a written opinion, (2) a single pathologist who reviewed and signed the final report, and (3) a pathologist who did not review the case and reconfirm the diagnosis immediately prior to the surgical resection. RECOMMENDATIONS: The RCA team recommended that the concurring pathologist write his or her diagnostic findings on the referral form, two pathologists review and sign the final typed report, and a pathologist rereview the slides on the business day prior to a surgical resection. Because the prostate specific antigen (PSA) value can be helpful in select cases of prostate cancer, the team recommended the PSA value be referenced when reviewing prostate specimens obtained through fine-needle biopsy. TRACKING COMPLIANCE: Because a wrongful surgical resection is a rare event, emphasis was placed on measuring compliance with distinct elements that were part of the revised procedure. During a 12-month span, practitioners demonstrated sustained compliance to the enhanced process for analyzing and reporting results.
BACKGROUND: Indwelling urinary catheters are placed in up to 25% of hospitalized patients and are a leading cause of hospital-acquired infection. Duration of catheterization is the dominant risk factor for hospital-acquired urinary tract infection. Physicians are often unaware that their patients have a urinary catheter, and these "forgotten" catheters are frequently unnecessary. METHODS: A controlled trial, using a pretest-posttest design, was conducted on four hospital wards at an academic medical center. A simple written reminder was designed to aid the hospitalized patient's team in remembering that the patient had a urinary catheter. Two of the four wards were assigned to the intervention group, and two served as controls. A research nurse monitored the urethral catheter status of each patient daily. RESULTS: A total of 5,678 subjects were evaluated. After adjusting for age, sex, and length of stay, the average proportion of time patients were catheterized increased by 15.1% in the control group but decreased by 7.6% in the intervention group in the intention-to-treat analysis (p = .007). There was no significant difference in urethral recatheterizations between intervention and control groups. The hospital cost savings provided by the intervention offset the necessary costs of this nurse-based intervention. CONCLUSIORN: In the approximately 90% of U.S. hospitals currently without computerized order-entry systems, a written reminder should be considered as one method for improving the safety of hospitalized patients.
The impact of the new resident work-hours rules on all aspects of patient care and education must be considered. While physician fatigue has taken center stage as the primary motivation behind this movement, the effect of these rules on the continuity of care for hospitalized patients needs to be critically analyzed from the perspectives of patients, physicians, and the health care system. The authors describe a conceptual framework that places continuity at the center and then considers the benefits and drawbacks of preserving continuity from the perspectives of the major stakeholders. They describe the categories of outcomes related to residents' fatigue and sleep deprivation that have been studied. Only a few studies have addressed patient outcomes, while most address resident outcomes. The authors discuss some of the possible solutions, including night float and the British system of shift work, and suggest that these solutions have different effects on each group of stakeholders, including both intended and unintended benefits and harms. Finally, the research agenda that arises from this framework is described. It includes taking into account multiple perspectives, identifying important outcomes, and considering unintended consequences. Using this framework, medical educators may better evaluate previous studies and consider remaining questions.
BACKGROUND: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in critically ill patients. The clinical and economic consequences of VAP are unclear, with a broad range of values reported in the literature OBJECTIVE: To perform a systematic review to determine the incidence of VAP and its attributable mortality rate, length of stay, and costs. DATA SOURCE: Computerized PUBMED and MEDLINE search supplemented by manual searches for relevant articles, limited to articles published after 1990. STUDY SELECTION: English-language observational studies and randomized trials that provided data on the incidence of VAP were included. Matched cohort studies were included for calculation of attributable mortality rate and length of stay. DATA EXTRACTION: Data were extracted on patient population, diagnostic criteria for VAP, incidence, outcome, type of intensive care unit, and study design. DATA SYNTHESIS: The cumulative incidence of VAP was calculated by combining the results of several studies using standard formulas for combining proportions, in which the weighted average and variance are calculated. Results from studies comparing intensive care unit and hospital mortality due to VAP, additional length of stay, and additional days of mechanical ventilation were pooled using a random effects model, with assessment of heterogeneity. RESULTS: Our findings indicate a) between 10% and 20% of patients receiving >48 hrs of mechanical ventilation will develop VAP; b) critically ill patients who develop VAP appear to be twice as likely to die compared with similar patients without VAP (pooled odds ratio, 2.03; 95% confidence interval, 1.16-3.56); c) patients with VAP have significantly longer intensive care unit lengths of stay (mean = 6.10 days; 95% confidence interval, 5.32-6.87 days); and d) patients who develop VAP incur > or = USD $10,019 in additional hospital costs. CONCLUSIONS: Ventilator-associated pneumonia occurs in a considerable proportion of patients undergoing mechanical ventilation and is associated with substantial morbidity, a two-fold mortality rate, and excess cost. Given these findings, strategies that effectively prevent VAP are urgently needed.
OBJECTIVES: To examine the extent to which elderly individuals use various skilled care facilities after coronary artery bypass grafting (CABG). DESIGN: Retrospective cohort study. SETTING: State of Michigan from 1997 to 1998. PARTICIPANTS: Residents aged 65 and older enrolled in Medicare who underwent CABG. MEASUREMENTS: Cumulative incidence of admission within 100 days of hospital discharge, relative risk (RR) of admission, readmission or extended stay at a skilled care facility, and length of stay in a skilled care facility. RESULTS: Fifty percent of patients aged 80 and older used a skilled care facility after CABG, with most requiring admission to a skilled nursing facility (SNF) or readmission to an acute-care hospital within 100 days after discharge. Patients aged 80 and older had a significantly higher risk of admission to a SNF (adjusted RR=3.3, 95% confidence interval (CI)=2.8-4.0) than did those aged 65 to 69, as did patients aged 75 to 79 (adjusted RR=2.2, 95% CI=1.8-2.6) and those aged 70 to 74 (adjusted RR=1.5, 95% CI=1.3-1.8). The length of time spent in skilled care facilities significantly increased with age (mean days=13.3 for aged 65-69, 16.9 for 70-74, 19.6 for 75-79, and 22.9 for 80 and older; P<.001). CONCLUSION: Older patients are more likely to be admitted to a SNF, be readmitted to an acute-care hospital, and have longer institutional stays after CABG. When balancing the risks and benefits of CABG, physicians, patients, families, and policy-makers need to carefully consider the likelihood of follow-up institutional care in elderly patients.
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PURPOSE: Clinical trials evaluating acetylcysteine for the prevention of contrast-related nephropathy have reported mixed results. Although previous meta-analyses have concluded that acetylcysteine is beneficial, the recent availability of additional trials calls for reassessment of current evidence. METHODS: We performed a computerized search to identify relevant published and unpublished randomized clinical trials that evaluated acetylcysteine for the prevention of contrast-related nephropathy. Abstracted data from each trial included assessments of clinical outcomes, trial quality, and additional characteristics. The primary outcome of interest was the incidence of nephropathy after contrast administration. Data were combined using random-effects models with the performance of standard tests to assess for heterogeneity and publication bias. Subgroup analyses were also performed. RESULTS: Twenty trials involving 2195 patients met our inclusion criteria. Trials varied in patient demographic characteristics, inclusion criteria, dosing regimens, and trial quality. The summary risk ratio for contrast-related nephropathy was 0.73 (95% confidence interval: 0.52 to 1.0; P = 0.08), a nonsignificant trend towards benefit in patients treated with acetylcysteine. This effect varied, however, across the 20 trials (test of heterogeneity, P = 0.04). Although higher-quality trials demonstrated a stronger benefit for acetylcysteine in general, few reported important elements of study design, such as concealment of allocation, placebo-controls, or double-blinding. Heterogeneity was unexplained by subgroup analyses. CONCLUSION: Acetylcysteine may reduce the incidence of contrast-related nephropathy, but this finding is reported inconsistently across currently available trials. High-quality, large clinical trials are needed before acetylcysteine use in this indication can be recommended universally.
BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) mandated new work hours rules for all residency programs in July 2003. PURPOSE: To critically evaluate the evidence that adhering to the ACGME standards will improve patient safety. DATA SOURCES: Searches of electronic databases (MEDLINE, EMBASE, PREMEDLINE, and Current Contents) and other methods to identify the English-language literature for studies on resident work hours for the years 1966 to 2004. STUDY SELECTION: Studies that assessed a system change designed to counteract the effects of work hours, fatigue, or sleep deprivation and that included an outcome related to patient safety were included. Seven studies met these criteria. DATA EXTRACTION: Two investigators abstracted data from all included studies by using a standard data abstraction form; each study was rated according to established criteria to assess study design quality. DATA SYNTHESIS: Interventions used were float systems, other cross-coverage systems, or unspecified schedule changes. Outcomes included mortality, adverse events, and medication errors. The results suggest that introducing such interventions has an unclear effect on selected patient safety indicators. Specifically, some indicators (such as mortality) may not change after interventions, while other indicators may improve or worsen. LIMITATIONS: This analysis is limited by the study designs of the included studies, the diversity of interventions in the studies, and the possibility of publication bias favoring studies that demonstrated statistically significant differences. CONCLUSION: Evidence on patient safety is insufficient to inform the process of reducing resident work hours.
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BACKGROUND: We performed a cost-effectiveness analysis to determine the effect of maximal sterile barriers (MSBs) on reducing central venous catheter (CVC)--related infections. Use of MSBs when placing CVCs may reduce the risk of infections but is more cumbersome, time-consuming, and expensive than other techniques. METHODS: We developed a decision analytic model in which a patient could have a CVC placed with either an MSB or a less stringent technique. We calculated total direct medical costs and the incidences of catheter-related bloodstream infections, catheter colonization, and death. RESULTS: Use of MSBs lowered costs (from 621 dollars to 369 dollars per catheter insertion) and decreased the incidences of catheter-related bloodstream infections (from 5.3% to 2.8%), catheter colonization with local infection (from 5.5% to 2.9%) and death (from 0.8% to 0.4%). MSBs improved patient safety throughout all sensitivity analyses. CONCLUSIONS: Use of MSBs during CVC insertion likely lowers medical costs and decreases the incidences of catheter colonization, catheter-related bloodstream infections, and death. Cost savings were found over a wide range of clinical and economic assumptions, suggesting that MSBs should be routinely used when CVCs are inserted.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.