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PubMed2004

Critical care medicine as a distinct product line with substantial financial profitability: the role of business planning.

OBJECTIVE: As academic health centers face increasing financial pressures, they have adopted a more businesslike approach to planning, particularly for discrete "product" or clinical service lines. Since critical care typically has been viewed as a service provided by a hospital, and not a product line, business plans have not historically been developed to expand and promote critical care. The major focus when examining the finances of critical care has been cost reduction, not business development. We hypothesized that a critical care business plan can be developed and analyzed like other more typical product lines and that such a critical care product line can be profitable for an institution. DESIGN: In-depth analysis of critical care including business planning for critical care services. SETTING: Regional academic health center in southern New Jersey. SUBJECTS: None. INTERVENTIONS: As part of an overall business planning process directed by the Board of Trustees, the critical care product line was identified by isolating revenue, expenses, and profitability associated with critical care patients. MEASUREMENTS AND MAIN RESULTS: We were able to identify the major sources ("value chain") of critical care patients: the emergency room, patients who are admitted for other problems but spend time in a critical care unit, and patients transferred to our intensive care units from other hospitals. The greatest opportunity to expand the product line comes from increasing the referrals from other hospitals. A methodology was developed to identify the revenue and expenses associated with critical care, based on the analysis of past experience. With this model, we were able to demonstrate a positive contribution margin of dollar 7 million per year related to patients transferred to the institution primarily for critical care services. This can be seen as the profit related to the product line segment of critical care. There was an additional positive contribution margin of dollar 5.8 million attributed to the critical care portion of the hospital stay of patients admitted primarily through other product lines or the emergency room. This can be seen as the profit related to the "hospital service" segment of critical care. This represented a total contribution margin of dollar 12.8 million, approximately 24% of the institution's entire contribution margin. This information was subsequently used to develop strategic plans to promote this product line. CONCLUSIONS: We were able to define the critical care product line, and we were able to demonstrate profitability through an analysis of revenue and expenses related to critical care services. Our experience suggests that the concept of critical care as a product line, in addition to a hospital service, may lead to a useful analysis of this new discipline. This plan provided a rational foundation for development of the operating and capital budgets for the health system.

Academic Medical Centers↗
PubMed2001

Modeling a medical environment: an ontology for integrated medical informatics design.

Modern medical environments have seen an increase in technological complexity and pressures of handling more patients with fewer resources, resulting in higher demands on medical practitioners. Medical informatics designers will have to focus on the problem of organizing medical information more effectively to enable practitioners to cope with these challenges. This article addresses this research problem for the particular area of medical problem solving in patient care. First, we describe a traditional modeling approach for medical reasoning used as a basis for developing some decision support systems. We argue these models may be faithful to what is known about biomedical knowledge, but they have limitations for human problem solving, especially in unanticipated situations. Second, we present an ontological framework, known as the abstraction hierarchy (Rasmussen, IEEE Trans. Man. Cybernetics 15 (1985) 234-243), for integrating patient representations that are faithful to existing biomedical knowledge and that are consistent with what is known about human problem solving. Through an example of a critical event in the operating room, we reveal how this framework can support medical problem solving in unanticipated situations. Third, we show how to use these representations as a frame of reference for mapping medical roles, responsibilities, sensors, and controls in an operating room context. Finally, we provide some insight for medical informatics designers in using this framework to design novel training programs and human-computer displays.

Decision Support Techniques↗
PubMed1998

A study of patterns and prevention of blood exposures in OR personnel.

The authors conducted a surveillance study of occupational blood exposures in the ORs at six hospitals to identify risk patterns and prevention strategies. For 15 months, trained circulating nurses recorded OR staff members' exposures during all surgical procedures using a modified version of the Exposure Prevention Information Network surveillance system. It was discovered that a high proportion of percutaneous injuries were potentially preventable if safer devices had been used, and the authors estimate that use of blunt suture needles alone could reduce injuries by 30%. Increased use of barrier precautions is indicated to prevent mucocutaneous blood exposures. Health care workers' eyes were identified in the study as being the most vulnerable location for serious blood exposures.

Blood-Borne Pathogens↗
PubMed1985

Portable ultrasound examinations in intensive care units.

The portability of modern real-time ultrasound units has led to a marked increase in the demand for examinations in medical, surgical, and pediatric intensive care units, the pediatric nursery, and the operating room. The results of all portable ultrasound examinations in the medical and surgical intensive care units at the Massachusetts General Hospital over a four-month period were analyzed to determine the efficacy of such studies. Of 48 examinations, portable sonograms were useful in 90 per cent, found new, clinically important information in 17 per cent, and led to misleading information in 4 per cent. Portable ultrasound examinations are valuable clinically and are probably cost effective.

Boston↗
PubMed1991

The use of X-terminals as clinical workstations.

The Medical Computer Facility at the Fox Chase Cancer Center has installed X-terminals in patient examination rooms and at nursing stations for clinical data access by physicians and nurses. The X-terminals are connected to UNIX operating system RISC processors via Ethernet. The RISC processors communicate with databases on a minicomputer cluster. Simultaneous presentation of textual (e.g., pathology and radiology reports) and graphical (e.g., clinical laboratory results) clinical data is provided under X-Windows. CT and MRI images can also be displayed in windows. Our experiences implementing X-terminal clinical workstations in a production environment will be discussed.

Cancer Care Facilities↗
PubMed1994

Integrated patient-centered computing: operations optimization for the 21st century.

Over the last few years, health care providers have increasingly recognized that health care is an information business. In fact, the restructuring now being contemplated by many in the context of reform cannot be done without proper information management support. The unfortunate concentration of the health care industry over the last 20 years on administrative and financial data capture has obscured the fact that the important focus should be on patient care and health care operations information. Information on patient care has, unfortunately, largely been relegated to the paper chart and other ad hoc pieces of paper. New systems should focus on health care operations optimization, with specific design features to address failings in the paper system. To be successful, such systems must be integrated and patient centered. This is especially clear in the new enterprise-based world of health care delivery, where patients are the only common factor among venues. Health record professionals, the primary caretakers of patient care information, should be deeply involved in helping institutions move to this new world.

Continuity of Patient Care↗
PubMed1995

Histopathological and cytopathological correlations of percutaneous testis biopsy and open testis biopsy in infertile men.

A testis biopsy is used to assess quantitatively testicular spermatogenesis in infertile patients. Recently, several reports have used less invasive, percutaneous methods to obtain testis tissue. Percutaneous testis biopsies and touch imprints, immediately followed by open testis biopsies, were performed on 24 testes (19 patients) to ascertain whether they could provide the same histological information as an open biopsy. The technique of percutaneous testis biopsy using a core biopsy system is described. Comparison of the percutaneous and open biopsy histological diagnoses revealed a 95% correlation. The percutaneous method using 1 pass through the testis failed to provide adequate tissue in 2 of 24 patients. Touch imprints obtained by the percutaneous method also provided a 95% correlation compared with the open method (2 of 24 touch imprints were lost during processing and, thus, were not evaluated). Percutaneous testis biopsies and touch imprints provide adequate tissue for histological and cytological evaluation, with excellent correlation with biopsies obtained by the traditional open methods. Percutaneous testis biopsy and touch imprint may be performed in an office setting, thus obviating the need to perform an open biopsy in the operating room.

Adult↗
PubMed1999

An approach for access differentiation design in medical distributed applications built on databases.

A formalized "top to bottom" design approach was described in [1] for distributed applications built on databases, which were considered as a medium between virtual and real user environments for a specific medical application. Merging different components within a unified distributed application posits new essential problems for software. Particularly protection tools, which are sufficient separately, become deficient during the integration due to specific additional links and relationships not considered formerly. E.g., it is impossible to protect a shared object in the virtual operating room using only DBMS protection tools, if the object is stored as a record in DB tables. The solution of the problem should be found only within the more general application framework. Appropriate tools are absent or unavailable. The present paper suggests a detailed outline of a design and testing toolset for access differentiation systems (ADS) in distributed medical applications which use databases. The appropriate formal model as well as tools for its mapping to a DMBS are suggested. Remote users connected via global networks are considered too.

Computer Communication Networks↗
PubMed2005

Inhalation anesthesiology and volatile liquid anesthetics: focus on isoflurane, desflurane, and sevoflurane.

Clinical pharmacists rarely are involved in the selection and dosing of anesthetic agents. However, when practicing evidence-based medicine in a cost-conscious health care system, optimizing drug therapy is imperative in all areas. Thus, we provide general information on anesthesiology, including the different types of breathing systems and the components of anesthesia machines. Modern inhalation anesthetics that are predominantly used in clinical practice include one gas--nitrous oxide--and new volatile liquid agents--isoflurane, desflurane, and sevoflurane. Desflurane and sevoflurane are the low-soluble inhalation anesthetics, and they offer some clinical advantages over isoflurane, such as fast induction and faster recovery with long procedures. However, efficient use of isoflurane can match the speed of induction and recovery of the other agents in certain cases. In addition, the patient characteristics, duration and type of procedure, type of breathing system, and efficiency in monitoring must be considered when selecting the most optimal therapy for each patient. Maximizing the clinical advantages of these agents while minimizing the waste of an institution's operating room and pharmacy budget requires an understanding of the characteristics, pharmacokinetics, and pharmacodynamics of these anesthetic agents and the collaborated effort from both the anesthesia and pharmacy departments. An anesthetic agent algorithm is provided as a sample decision-process tree for selecting among isoflurane, desflurane, and sevoflurane.

Anesthesia, Inhalation↗
PubMed1999

Diagnostic laparoscopy outside of the operating room.

Laparoscopy is increasingly being used as a diagnostic technique to characterize intraperitoneal processes. This technique can be highly informative when applied in settings such as the intensive care unit, the emergency room, the trauma bay, and the office. Diagnostic laparoscopy is an excellent method to evaluate intraperitoneal processes and should be part of the general surgeon's armamentarium of skills. In this paper, the technique of diagnostic laparoscopy and its role outside of the operating room setting is reviewed. Diagnostic laparoscopy is also compared with other diagnostic modalities.

Contraindications↗
PubMed1988

Anesthesiology update: the preanesthetic evaluation.

Ideal anesthetic management consists of the preanesthetic attainment of a state in which a diagnostic or therapeutic procedure or surgical operation can be performed with as little physiologic and psychologic trauma as possible, and the likelihood of a speedy and uneventful postoperative course is enhanced. Significant impairment of cardiovascular, respiratory, renal and other organ system functions is common in patients facing surgery. Thus, it is imperative that preoperative evaluation be complete. Signs of congestive heart failure, myocardial ischemia or infarction or both, hypertension, electrolyte abnormalities, and cardiac arrhythmias should be aggressively sought and treated before surgery. In addition, before the induction of anesthesia, information must be obtained about the specific associated pathologies (cardiac and otherwise), drugs being used to treat these conditions, and the adequacy of the current therapies. The preoperative evaluation does not begin with the anesthesiologist's visit, but with the evaluation and care given by the primary physician. A team approach is advisable in complex cases. Appropriate consultations, including that of the anesthesiologist, should be made in a timely fashion. Except in emergency situations, the temptation to send incompletely evaluated and treated patients to the operating room should be resisted. Good preoperative preparation will improve the chances for a successful outcome.

Cardiovascular Diseases↗
PubMed2006

Evaluation of operating room suite efficiency in the Veterans Health Administration system by using data-envelopment analysis.

BACKGROUND: Operating room (OR) activity transcends single ratios such as cases/room, but weighting multiple inputs and outputs may be arbitrary. Data-envelopment analysis (DEA) is a novel technique by which each facility is analyzed by the weightings that optimize its score. METHODS: We performed DEA analysis of 23 Veterans Health Administration annual OR activity; 87,180 cases were performed, 24 publications generated, and 560 trainee-years of education delivered, in 168 ORs over 166,377 hours by 1,384 full-time equivalents of surgical and anesthesia providers and 523 nonproviders. RESULTS: Varying analyzed parameters produced similar efficiency rankings, with individual differences suggesting possible inefficiencies. We characterized returns to scale for efficient sites, suggesting whether patient flow might be efficiently further increased through these sites. We matched inefficient sites to similar efficient sites for comparison and suggested resource alterations to increase efficiency. CONCLUSIONS: Broader DEA application might characterize OR efficiency more informatively than conventional single-ratio rank ordering.

Anesthesiology↗
PubMed2006

A common body of care: the ethics and politics of teamwork in the operating theater are inseparable.

In the operating theater, the micro-politics of practice, such as interpersonal communications, are central to patient safety and are intimately tied with values as well as knowledge and skills. Team communication is a shared and distributed work activity. In an era of "professionalism," that must now encompass "interprofessionalism," a virtue ethics framework is often invoked to inform practice choices, with reference to phronesis or practical wisdom. However, such a framework is typically cast in individualistic terms as a character trait, rather than in terms of a distributed quality that may be constituted through intentionally collaborative practice, or is an emerging property of a complex, adaptive system. A virtue ethics approach is a necessary but not sufficient condition for a collaborative bioethics within the operating theater. There is also an ecological imperative-the patient's entry into the household (oikos) of the operating theater invokes the need for "hospitality" as a form of ethical practice.

Bioethics↗
PubMed2006

Adverse events detected by clinical surveillance on an obstetric service.

OBJECTIVE: Adverse events are adverse patient outcomes resulting from medical care. We performed this study to estimate the rate of adverse events and potential adverse events-errors that have a high likelihood of causing patient harm-occurring during obstetric care. METHODS: This was a prospective cohort study of an obstetric unit in a teaching hospital. We included patients admitted consecutively to the hospital. A trained observer monitored patients for 72 triggers, which were predefined occurrences deemed likely to indicate an actual or potential adverse event. When a trigger occurred, the observer captured information describing it. A five-person multidisciplinary team, including the observer, three physicians, and a hospital risk manager, judged whether the trigger represented an adverse event or potential adverse event. Adverse events were further characterized as preventable. RESULTS: The cohort included 425 patients; 47% were in active labor. We identified 110 triggers. Nine were considered adverse events (risk 2%, 95% confidence interval [CI] 1-4%, rate 0.8 events per 100 patient days), and six were preventable (risk 1%, 95% CI 0-3%, rate 0.5 events per 100 patient days). The remaining triggers included 14 potential adverse events (risk 3%, 95% CI 2-5%, rate 1.3 events per 100 patient days). No adverse event resulted in permanent disability or death. Adverse events and potential adverse events were most commonly "system" problems, such as unavailable staff or operating rooms, or poor fetal outcomes, such as trauma to the newborn. CONCLUSION: Serious adverse events occur infrequently on an obstetric service. However, important quality problems are common and should be targeted for improvement. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2000

Involvement of the hippocampus and associative parietal cortex in the use of proximal and distal landmarks for navigation.

Rats with dorsal hippocampus or associative parietal cortex (APC) lesions and sham-operated controls were trained on variants of the Morris water maze navigation task. In the 'proximal landmark condition', the rats had to localize the hidden platform solely on the basis of three salient object landmarks placed directly in the swimming pool. In the 'distal landmark condition', rats could rely only on distal landmarks (room cues) to locate the platform. In the 'beacon condition', the platform location was signaled by a salient cue directly attached to it. Rats with hippocampal lesions were impaired in the distal and to a less extent in the proximal landmark condition whereas rats with parietal lesions were impaired only in the proximal landmark condition. None of the lesioned groups was impaired in the beacon condition. These results suggest that the processing of information related to proximal, distal landmarks or associated beacon are mediated by different neural systems. The hippocampus would contribute to both proximal and distal landmark processing whereas the APC would be involved in the processing of proximal landmarks only. Navigation relying on a cued-platform would not require participation of the hippocampus nor the APC. Assuming that the processing of proximal landmarks heavily depends on the integration of visuospatial and idiothetic information, these results are consistent with the hypothesis that the APC plays a role in the combination of multiple sensory information and contributes to the formation of an allocentric spatial representation.

Animals↗
PubMed1999

Microsurgery costs and outcome.

Reliable information on cost and value in microsurgery is not readily available in the literature. Driving factors for cost, determinants of complications, and cost-reduction strategies have not been elucidated in this population, despite such progress in other areas of medicine. Clearly, the time-consuming and costly nature of this endeavor demands that appropriate indications and patient management be delineated; to operate proactively in this cost-conscious time, financial and outcome determinations are critical. One hundred seven consecutive free-tissue transfers performed from 1991 to 1994 by a single microsurgeon were studied. Retrospective chart review for clinical parameters was combined with analysis of hospital costs and professional charges. Operating room and anesthesia costs were based on a microcost analysis of actual operating room time, materials, labor, and overhead. Other patient level costs were generated by Transition 1, a hospital cost-accounting system. The following issues were addressed: (1) flap survival; (2) total costs and length of stay for all free flaps; (3) payments received from various insurers; (4) breakdown of operating room costs by labor, supplies, and overhead; (5) breakdown of inpatient costs by category; (6) additional costs of complications and takebacks; (7) factors associated with complications and flap takebacks; and (8) cost-reduction strategies. Mean free flap operating room costs (exclusive of professional fees) ranged among case types from $4439 to $6856 and were primarily a function of operating room times. Elective patient cases lasted a mean 440 minutes. There was a large disparity in reimbursement: private insurers covered hospital costs (not charges) completely, whereas Medicare paid 79 percent and Medicaid only 64 percent. Length of stay, operative procedures, and complications had the greatest influence on inpatient costs in this group of free flap patients. Potential cost savings as a result of possible practice changes (e.g., shortening intensive care unit stays and avoiding staged operations) can be predicted. This analysis has caused a revision in these institutions' practice patterns and lays the foundation for planned outcome studies in this population.

Adult↗
PubMed1984

Closed-circuit and high-flow systems: examining alternatives.

The nonrebreathing system has been with us since Morton demonstrated the administration of diethyl ether in 1846. Its current popularity is evidenced by the extensive use of the Bain system. The greatest advantage, its history of patient safety, is related to the circuit's simplicity and the knowledge that the delivered concentration equals the inhaled concentration. Most disadvantages of the nonrebreathing system are related to the required high delivery rates: operating room and environmental pollution, necessity of scavenging gases, cost of agents, energy loss through no-return operating room ventilation, inhalation of dry gases, and the inability of the anesthesiologist to quantitate patient uptake of oxygen and inhaled anesthetics. Partial rebreathing systems reduce the disadvantages related to high delivery flow rates but, owing to the required rebreathing, do not permit the anesthesiologist to know the inhaled anesthetic concentration. A carbon dioxide absorber is necessary. It is still impossible to quantitate uptake by the patient, and it is difficult to conclude that any real net advantage results from the use of partial rebreathing systems. When modern-day technology provides the practitioner with an appropriate anesthesia machine, it is likely that closed-circuit anesthesia will become the method of choice for anesthesia delivery. Although the economic, ecologic, and physiologic advantages of this system are important, its greatest asset is the ability to monitor important respiratory and cardiovascular variables in patients noninvasively. Important information provided to the anesthesiologist by the patient during closed-circuit anesthesia is lost through the pop-off valve when high-flow systems are used. During closed-circuit anesthesia the gas machine itself becomes a monitor. Practicing anesthesiologists will embrace closed-circuit anesthesia practice when-and if-they are convinced that it provides an opportunity for better and more efficient patient care than other systems.

Anesthesia, Inhalation↗
PubMed1996

Cadaver organ donation and moral distress: a staff nurse's perspective.

Current advancements in medical science, such as the progress seen in the area of organ transplantation, brings with it many ethical dilemmas for which there are no precedents. Obtaining informed consent for cadaver organ donation requires perioperative nurses to confront the moral responsibility that they have to their patients, their patients' families, and to the nursing profession as a whole. The perioperative nurse must question his or her own moral and cultural beliefs, face their own fears of death, and confront societal misconceptions about brain death. This evolution is emotionally demanding and often stresses one's support systems. However, with self-discovery and education, it can also be very rewarding.

Attitude of Health Personnel↗