Quality management in a multi-hospital system: a single standard of care.
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Concurrent Review↗
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Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
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Monitoring the care of the ventilator-dependent patient.
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Adult↗
Patient flow management.
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Admitting Department, Hospital↗
A rural hospital's use of software to determine accurate Medicare reimbursement levels.
This article details how a software program has helped a hospital collect more Medicare payments for which it was eligible than it previously had collected. The software simplifies the process of selecting complications by reminding the user when no complications have yet been entered, by determining whether each item entered qualifies as a complication, and by suggesting other possibilities. In many instances, these complications are possibilities that a person performing manual coding might not consider.
Concurrent Review↗
Path-based patient care should build quality into the process.
Clinical paths can help caregivers "do the right thing the first time" for the individual patient. They also can help to continually improve the system of providing care for future patients. By comparing what should be happening (according to the clinical path) with what actually is happening, the healthcare team can design an effective plan for patient care. By gathering data about the patient care experience, the healthcare team can redesign care for future patients. This article describes important concurrent and retrospective activities of path-based patient care and the ways in which healthcare providers are using clinical paths to improve patient outcomes.
Cholecystectomy↗
Controlled clinical evaluation of BACTEC Plus Aerobic/F and BacT/Alert Aerobic FAN bottles for detection of bloodstream infections.
A total of 7,190 blood culture sets were obtained from adult patients with a suspected bloodstream infection. A 20-ml sample of blood was distributed equally between the aerobic FAN bottle which was monitored in the BacT/Alert system and a Plus Aerobic/F bottle which was monitored in the BACTEC 9240 system. A total of 988 positive cultures were obtained from 483 patients; however, only 453 positive cultures from 173 patients met the criteria for volume ( > or = ml per bottle) and clinical significance on the basis of concurrent case review required for data analysis. There were 25 and 68 false positives from the FAN and Plus Aerobic/F bottles, respectively. There were no statistically significant differences between systems in the number of positive cultures or septic episodes by species; however, the total number of Enterobacteriaceae and Pseudomonas aeruginosa isolates combined was significantly greater in the FAN bottle (P = 0.04). Detection times did not differ significantly between systems for positive cultures; however, episodes of Staphylococcus aureus bacteremia were detected significantly more rapidly from the FAN bottle (P = 0.005). There was no significant difference between systems in the detection of bloodstream infections in patients receiving antibiotics at the time of blood culture.
Adult↗
Use of hospital beds: a cohort study of admissions to a provincial teaching hospital.
An instrument was developed to study the use of hospital beds and discharge arrangements of a cohort of 847 admissions to the John Radcliffe Hospital, Oxford, for a three week period during February-March 1986. For only 38% of bed days were patients considered to have medical, nursing, or life support reasons for requiring a provincial teaching hospital bed. The requirements for a bed in the hospital decreased with the patient's age and length of stay in hospital. For only a tenth of patients was the general practitioner concerned in discussions with hospital staff about the patient's discharge and less than one third of patients had been given more than 24 hours' notice of discharge. Several features might increase the proportion of bed days that are occupied by patients with positive reasons for being in hospital. Among these are an increased frequency of ward rounds by consultants, or delegating discharge decisions by consultants to other staff; providing diagnostic related protocols for planning the length of stay in hospital; planned discharges; and providing liaison nurses to help with communication with primary care staff.
Bed Occupancy↗
Enrollment in the Health Alliance Plan HMO is not an independent risk factor for coronary artery bypass graft surgery.
BACKGROUND: Henry Ford Hospital is the sole provider of cardiac surgical services for the Health Alliance Plan, a health maintenance organization (HMO) that presently serves 450,000 enrollees. METHODS AND RESULTS: To determine the effect of managed care referral patterns on the outcome of coronary artery bypass graft (CABG) surgery, we retrospectively reviewed two concurrent groups of patients, 569 HMO patients and 225 patients with free-for-service (FFS) insurance, who had undergone isolated primary CABG surgery between January 1, 1990 and January 31, 1994. The 605 patients with Medicare operated on during the same time frame were excluded to obviate age bias. Age, sex, use of cardiac medications, history of prior percutaneous transluminal coronary angioplasty or thrombolytic therapy, history of recent and remote myocardial infarction, extent of coronary disease, presence of preexisting comorbid conditions, and incidence of unstable clinical syndromes and left ventricular dysfunction (ejection fraction < 40%) were comparable for both groups. In hospital mortality (HMO group, 1.9%; FFS group, 2.2%), mean ICU stay (HMO, 2.6 +/- 0.3 days; FFS, 2.3 +/- 0.3 days), and total hospital length of stay (HMO, 9.8 +/- 0.8 days; FFS, 8.6 +/- 0.6 days) were likewise similar. CONCLUSIONS: These data refute the notion that the gate-keeper mentality often associated with managed-care health insurance vehicles results in delayed referral of patients with coronary artery disease and results in suboptimal outcome.
Coronary Artery Bypass↗
Chance, concurrence, and clustering. Analysis of reviewers' recommendations on 1,000 submissions to the Journal of Clinical Investigation.
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Manuscripts, Medical as Topic↗
Criteria for hospital admission.
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Adult↗
Interim hospital order--a regional secure unit experience.
The Mental Health Act, 1983, provides certain new provisions for the disposal of mentally disordered offenders, including the Interim Hospital Order. This Order allows the appropriateness of an eventual Hospital Order to be assessed. However, there is a wide variation in the use of the Interim Hospital Order. This paper examines the use of this Order in the Trent Regional Secure Unit, where it seems to have been used principally to assess the treatability of patients under the category of psychopathic disorder.
Commitment of Persons with Psychiatric Disorders↗
A multifaceted approach to managed mental health care.
While many HMOs and insurance companies have contracted with outside managed mental health firms to control mental health utilization, ConnectiCare, an IPA Model HMO with nearly 100,000 members, manages its own mental health utilization with a multifaceted approach. How the system has evolved and preliminary results are presented to illustrate how an HMO can manage its own mental health care program while using local providers.
Concurrent Review↗
Identifying physicians and patterns generating unnecessary in-hospital days. An exploratory stage of developing an institution-specific physician-focused utilization effort.
A focused, concurrent utilization review effort identified the existence of a large number of unnecessary hospital days remaining even after a highly successful utilization review effort. Within a group of physicians identified as having the highest acuteness adjusted average lengths of stay, 38.3% of their patient's hospital days were unnecessary, with 83% of those days being within physician control. Observation, diagnostic undertakings or therapeutic efforts that were unnecessary or appropriate for the outpatient setting represented 81.3% of the unnecessary days. A future utilization study will compare the practice patterns among physicians in the same department in order to define future goals and develop necessary corrective actions that will be acceptable to the medical staff.
Boston↗
Utilization of pulmonary function tests by primary care internists in a community hospital.
OBJECTIVE: A quality assurance effort to evaluate the use of pulmonary function tests by primary care physicians. Specifically, to examine the patient's understanding of the test, the types of tests physicians order, and the appropriateness of the ordered tests for answering questions posed by physicians. DESIGN: Concurrent chart review, clinical interviews, and patient interviews. SETTING: Community teaching hospital. PATIENTS: 101 consecutive inpatients and outpatients, referred to the Pulmonary Function Laboratory over a consecutive 5-month period. MEASUREMENTS: Interview of the patient by a pulmonary technician. Interview of the primary care physician by a pulmonary physician. Interview, where applicable, with the house staff. Final assessment by a pulmonary physician. MAIN RESULTS: 64% of the patients understood the purpose of the test and 49% of the patients felt there was some potential benefit to be derived from participating in the testing. Sixty-five percent of the physicians ordered specific tests on their patients. Seventy-two percent of physicians planned on using the data obtained from testing to formulate treatment decisions. Fifty percent of the interviewed physicians said they were using the results for decisions regarding further diagnostic evaluation and/or treatment. The reviewing pulmonary physician considered that 31% of the pulmonary function tests ordered were appropriate for the goals defined by the requesting physician. Sixty-eight percent of the ordered tests could have had some aspects of ordering improved, and 1% of the testing was unnecessary. CONCLUSIONS: 1) There is a need to increase patient understanding of the indications and potential benefits of participating in pulmonary function testing. 2) When physicians-in-training are involved in the process of requesting pulmonary function tests, greater staff-level supervision and involvement should be present. 3) There is a need to increase physician knowledge regarding the appropriate pulmonary function tests that should be requested for specific clinical questions and situations. 4) The requesting form for pulmonary function testing may serve to remind and educate the physician, while documenting the indications for the testing and the physician's efforts. 5) Quality assurance/utilization-review efforts can be combined with educational efforts that could result in a diminution of the deficiencies.
Adult↗
Pharmacoepidemiology of bleeding events after use of r-alteplase or streptokinase in acute myocardial infarction.
OBJECTIVE: To determine in nonresearch, general medical practice conditions the comparative incidence and types of bleeding complications after the use of streptokinase (SK) and r-alteplase (recombinant tissue plasminogen activator, rt-PA) to treat acute myocardial infarction (AMI). DESIGN: Retrospective medical record review of concurrently treated patients (96-hour observation posttreatment) in 32 participating hospitals in the US. MAIN OUTCOME MEASURES: The medical record description of all bleeding events regarding the body site affected, changes in hemoglobin concentrations, blood products administered, and clinical outcome (permanent sequelae or death). Bleeding severity was determined by defined criteria. CONTROL DATA: Comorbidity and concomitant medications (e.g., aspirin, heparin, warfarin) likely to predispose or contribute to bleeding events were analyzed. DATA ANALYSIS: Logistic regression analysis. RESULTS: Data from 419 patients who received rt-PA and 207 who received SK were evaluated. In the 96-hour period after initiation of thrombolytic therapy, 30.5 and 31.9 percent of rt-PA and SK patients, respectively, experienced one or more bleeding events (crude risk ratio [CRR] = 1.04; 95 percent confidence interval [CI] 0.91-1.14; p = 0.73). In the first 24-hour period, 21.5 percent of rt-PA and 15.9 percent of SK patients experienced bleeding events (CRR = 0.74; 95 percent CI 0.42-1.15; p = 0.08). The leading types of bleeding and percents of all patients affected were: perivascular access site (18.4 percent), gastrointestinal (6.4 percent), skin/soft tissue/muscle (5.0 percent), urinary (3.4 percent), pulmonary (2.2 percent), systemic (1.9 percent), and oral (1.4 percent). Intracranial bleeding occurred in 4 rt-PA and 2 SK patients; 4 of these patients died. Events deemed clinically significant occurred in 15 rt-PA and 9 SK patients (3.8 percent of all patients). Ten patients likely died from these events, 6 within the first 24 hours. Three rt-PA patients and 1 who received SK (0.6 percent) died of cerebrovascular events within the first 24 hours. After controlling for demographic factors and therapeutic variables, using logistic regression analyses, no thrombolytic-related differences were found in the incidence or severity of bleeding following use of the two thrombolytics. CONCLUSIONS: These clinical data do not support a theoretical advantage of rt-PA to cause less bleeding propensity than SK.
Hemorrhage↗
Impact of pharmaceutical sales representatives on physician antibiotic prescribing.
This study revealed a significant impact on physician prescribing practices by PSRs, based on the results of evaluations of each agent's average number of new prescriptions per month, number of grams dispensed per month, and dollar values of those prescriptions. Comparisons of these data to regional, national, and world trends revealed no correlation.
Advertising↗
Albumin audit results and guidelines for use. University Medical Center, Tucson, Arizona.
OBJECTIVE: To identify patients receiving albumin, develop guidelines for albumin use, and examine distribution and billing procedures. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: All patients received albumin in a four-week period. Patients were identified concurrently using intensive care unit surveys and the pharmacy computer system, and retrospectively using billing statements. Data were analyzed from 73 of 79 patients (92.4 percent); 6 (7.6 percent) had no record of albumin being ordered or administered. Pediatric patient data were used only in the financial calculations. DATA COLLECTION: Demographics and albumin dosages were recorded for all patients. Prescribing service and indications for use were recorded in adults. Albumin administered was compared with the amount billed to each patient. MAIN RESULTS: Sixty adult patients aged 14-91 y (median 62) received 1-69 units (median 4 units [1 unit = 12.5 g albumin]) and 470 total units. Surgical services prescribed albumin in 73 percent and medical services in 27 percent of the patients. Common indications for albumin included volume expansion (65 percent), as intraoperative fluid (13 percent), and to increase urine output (10 percent). The pharmacy computer system identified 63 percent of the patients. Of these, 13 percent were not billed for albumin they received. Examinations of patient billing statements found that up to $17,740 a year (15 percent) of albumin administered is not billed. The floor-stock distribution system used in the intensive care units contributed to most errors. CONCLUSIONS: Recommendations addressing the problems identified in this audit were made to the pharmacy, medical, nursing, and billing departments. Guidelines for albumin use were formulated and approved by the hospital's pharmacy and therapeutics committee.
Albumins↗
Drug interaction: omeprazole and phenprocoumon.
BACKGROUND: Oral anticoagulants like the coumarin derivatives are characterised by a particularly narrow therapeutic range. Any interfering co-medication can pose a challenge to establishing a stable anticoagulant dosage regimen and thus present a serious risk for the patient. Here we describe two cases of patients on anticoagulant therapy that suggest possible drug interactions between phenprocoumon and the proton pump inhibitor omeprazole. RESULTS: In both patients, the International Normalised Ratio (INR) increased beyond the therapeutic range after they were given omeprazole for the treatment of gastrointestinal symptoms. The INR returned to therapeutic levels after the phenprocoumon dose was reduced (Case 1) and omeprazole discontinued (Case 2). CONCLUSIONS: The increased anticoagulant activity of phenprocoumon observed in the two described cases and the known interaction potential of omeprazole suggest that the clearance of phenprocoumon may have been reduced due to competitive inhibition of its degradation by omeprazole. Drug interactions may be one of the reasons for the difficulties encountered with some patients in establishing a stable anticoagulant therapy. Physicians should carefully review any concurrently used medication and if possible opt for drugs with a low interaction potential.
Aged↗