PubMed · 9727230
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M F Shore. 1997. Training the existing workforce.. https://doi.org/10.1023/a%3A1022292810632
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BACKGROUND: Treatment and follow-up policy for Barrett's oesophagus are dependent on the grade of dysplasia. However, sampling error of random biopsy protocols and subjectivity of pathological grading may hamper endoscopic surveillance. METHODS: The Amsterdam Comprehensive Cancer Center Barrett Advisory Committee (BAC) is a regional multidisciplinary consultative working-group, offering revision of pathology, revision of pathology plus additional endoscopic diagnostics, or referral for treatment. RESULTS: Between July 1998 and July 1999 30 patients were referred to the B.A.C for advice; eighteen patients were referred because of suspicion of high grade dysplasia. Reassessment of biopsies, including additional quantitative pathology, with or without additional endoscopic diagnostics, led to adjustment of the grading of dysplasia in 15 patients (50%). A suspicion of low grade dysplasia was rejected in nine out of ten cases. Adjustment of the original diagnosis often influenced further therapy or follow-up. CONCLUSIONS: reassessment of conventional pathology, quantitative pathology, and additional diagnostic procedures might improve the accuracy of diagnosis and staging of malignant degeneration of Barrett's oesophagus, although experience is still limited. The complexity of the management of these patients demands a specialised multidisciplinary approach. A Barrett Advisory Committee can offer valuable contributions to the treatment of patients with Barrett's oesophagus.
BACKGROUND: In 1995 The Johns Hopkins Hospital in Baltimore convened an interdisciplinary task force to evaluate sedation practices, create a comprehensive set of sedation guidelines, and evaluate patient safety outcomes following guideline implementation. METHODOLOGY: Baseline data were collected on all procedures in which sedation was administered by a nonanesthesiologist for a 6-month period, using scanning technology to automate data entry. Sedation practices were reviewed, and four critical events were examined: unresponsiveness, obstructed airway, airway placement, and cardiopulmonary resuscitation (CPR). In 1998 data collection procedures were repeated to evaluate the impact of the guidelines on sedation practices and patient safety outcomes. RESULTS: In 1995 sedation practices varied, and one or more critical events occurred in 45 (1.4%) of 3,255 procedures. Steps taken included development and dissemination of a clinical sedation guideline, including monitoring criteria to guide nonanesthesiologists, and evaluation planning. In 1998 sedation practices were more consistent. One or more critical events occurred in 50 (1.6%) of 3,134 procedures, representing a small increase in critical events from 1995. More events of unresponsiveness were identified, and no event required CPR. Although not statistically significant, this trend suggests that critical events were being identified earlier, preventing patients from progressing to a more serious event requiring CPR. Steps taken included further refinement of clinical practice guidelines and establishment of ongoing monitoring. CONCLUSIONS: Standardization of sedation practices is a complex and resource-intensive activity, requiring ongoing oversight and monitoring. Commitment from medical staff, nursing staff, and administration is essential to successful implementation of sedation guidelines.
Managed care poses a major threat to the future of clinical psychiatry in academic settings. High costs and an aversion to the business aspects of service delivery have left academic departments at a disadvantage in the marketplace. However, numerous departments have attempted to adapt to the current health care environment. On the basis of a review of these efforts, the authors identify the processes of change and seven models of change being employed to reengineer psychiatry within academic medical centers. The models are labeled transform, build, manage, buy, partner or affiliate, sell or lease, and consult. The authors discuss the strengths and weaknesses of these efforts and suggest three approaches to establishing the unique value of academic clinical services for purchasers and for the public. The first is to enhance productivity and clinical effectiveness through greater integration of clinical care, research, and training. The second is to take a leadership role in managing care, and the third is to advance the integration of behavioral health care with primary medical care and other specialties in the medical center.