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At least 793 records · Page 44Linked to original sources
PubMed2002

Positive predictive value of a point-of-care testing strategy on first-draw specimens for the emergency department-based detection of acute coronary syndromes.

CONTEXT: The rapid and accurate diagnosis of the etiology of chest pain is of central importance in the triage of patients presenting to emergency departments. The "first-draw" sensitivity of serum cardiac markers is known to be low on initial presentation; however, less is understood regarding the predictive value of a positive test in this situation. OBJECTIVE: To determine the ability of a critical pathway combining medical history and physical examination, electrocardiographic findings, point-of-care testing, and central laboratory data to accurately predict the presence of acute coronary ischemia. METHODS: We investigated the positive predictive value of a testing algorithm for first-draw specimens in clinical practice, combining a qualitative, point-of-care, triple-screen testing panel for cardiac markers, including myoglobin, creatine kinase-MB, and cardiac troponin I, with confirmation of the rapid assay in the central hospital laboratory by quantitative assays for creatine kinase-MB and cardiac troponin T. RESULTS: While a positive result on any of the individual cardiac markers of the point-of-care test had a positive predictive value for the acute coronary syndrome of only 36% (creatine kinase-MB, 41%; myoglobin, 36%; and troponin I, 65%), the positive predictive value for the diagnosis of acute coronary syndrome increased to 76% if all 3 point-of-care markers were simultaneously positive. The positive predictive value for acute coronary syndrome for a positive confirmatory result in the hospital laboratory for either creatine kinase-MB or cardiac troponin T was 61%. Among those patients with a positive marker on both the point-of-care test and the laboratory test, a careful retrospective review of the clinical history (with exclusion of patients with nonischemic cardiac pathologies and renal insufficiency) increased the positive predictive value of this algorithm to 98%. CONCLUSIONS: Our data suggest that qualitative, point-of-care, triple-screen cardiac marker testing of patients with chest pain at initial presentation may exhibit relatively low positive predictive values. Positive predictive value can be significantly improved by rapid confirmation in the hospital laboratory and careful review of clinical findings.

Chest Pain↗
PubMed1999

The impact of hospitalists on medical education and the academic health system.

Hospitalism as a career option is likely to reinforce the emphasis of traditional medical residency programs on inpatient care; may become an alternative area of emphasis in many subspecialty fellowship programs; and may even generate its own specific types of advanced training and certification. In the academic setting, subspecialists and their trainees are concerned that hospitalists may request fewer consultations, which could adversely affect subspecialists and the education of both fellows and residents. However, the focus and expertise of hospitalists is likely to improve inpatient education for students and residents and is appealing because it has the potential to improve the quality of inpatient care. Perhaps the major effect of the hospitalist movement on academic centers will be the creation of a cadre of physicians committed to critical pathways; clinical guidelines; quality assurance; risk management; clinical re-engineering; and the use of the inpatient service as a laboratory for developing, evaluating, and implementing initiatives to improve patient care. Although any fundamental change in the organization of clinical services brings with it the risk that essential components of the current system will be jeopardized, the hospitalist movement may have great benefits if it can develop safeguards to ensure seamless patient care and the appropriate use of subspecialty expertise.

Academic Medical Centers↗
PubMed1999

Hospital restructuring and the changing nature of the physical therapist's role.

BACKGROUND AND PURPOSE: This study was conducted to identify role behavior changes of acute care physical therapists and changes in the organizational and professional context of hospitals following restructuring. METHODS: A Delphi technique, which involved a panel of 100 randomly selected acute care physical therapy managers, was used as the research design for this study. Responses from rounds 1 and 2 were synthesized and organized into exhaustive and mutually exclusive categories for round 3. Data obtained from round 3 were used to develop a comprehensive perspective on the changes that have occurred. RESULTS: Changed role behaviors in patient care and professional interaction, including increased emphasis on evaluation, planning, teaching, supervising, and collaboration, appeared to be extensions of unchanged role behaviors. Reported changes in the structural and professional context of physical therapy services included using critical pathways to guide care, providing services system-wide, and using educational activities and meetings to maintain a sense of community. The importance of professionalism to physical therapists' work was identified and related to specific role behavior changes. CONCLUSION AND DISCUSSION: The changing role of physical therapists in acute care hospitals includes an increased emphasis on higher-level skills in patient care and professional interaction and the continuing importance of professionalism.

Adult↗
PubMed1993

Managing quality--the strategy for survival.

Everywhere I go today, health care management is saying all the latest words--total quality management, continuous quality improvement, benchmarking, critical pathways--but most are doing the same old stuff. Saying it and doing it are quite different. What has worked in the past will not be good enough for the future. Making the change is not optional, it is the price of admission to the marketplace.

Managed Care Programs↗
PubMed1994

The integrated inpatient management model's clinical management information system.

The rising cost of health care has increased the call for cost control. The pressing need to control cost, coupled with the increase in managed care and prospective payment, has placed new urgency on administrators and clinicians to work collaboratively in providing efficient and effective care. We have developed the Integrated Inpatient Management Model (IIMM) to assist in this collaborative effort. We describe the IIMM's clinical information system that provides decision support to both administrators and clinicians. This clinical information system is the information backbone for the development and monitoring of practice guidelines or critical pathways. An integrated information system of this type is essential if hospitals are to prosper during the next decade.

Ancillary Services, Hospital↗
PubMed1994

Hospitals' newest challenge: designing in quality.

The job of producing high-quality products is even more difficult for health care providers than it is for those in manufacturing, where the quality movement began. As a part of the service industry, health care providers are in the position of producing products and delivering services at the moment of sale. Our task is to improve the quality of all of these simultaneous and interrelated processes. Traditionally, health care providers have made efforts to improve their products and services without realizing the impact that could be made by also improving resources, processes, and outcomes. This article is an overview of the new direction we have been taking: Retrospective review. Critical pathways. Building quality into all areas (resources, processes, products and services, and outcomes). Focused study of outcomes). We foresee a further evolution that will lead to exciting new methods for understanding and delivering high-quality care.

Clinical Protocols↗
PubMed1995

Regionalization: Canadian-style integrated networks. A case study.

Developing a successful integrated network requires senior management to scrutinize and apportion available resources--technologies, beds, personnel and so forth--on a regional basis. Regionalization--the Canadian version of integrated networks--increasingly came to be seen as the answer that would work, and in New Brunswick the broadest efforts have been made. Fifty-one hospital and health center boards across the province were dissolved, and health services in the province were apportioned into seven regional hospital corporations, with an eighth encompassing the entire province. At Region 3 Hospital Corporation, a strategic planning exercise helped management identify resources. New information systems were put in place to provide resource utilization information for designating facilities for the level of care they would provide, as well as to provide feedback to physicians and develop critical pathways. Support services were consolidated. Budget reductions caused the curtailment of new service plans, but also increased cooperation among clinicians and non-clinical managers. Layoffs created worker bumping throughout the system to accommodate union seniority rules. Nearly three years into regionalization, most people in New Brunswick say they are satisfied with the healthcare they receive.

Communication↗
PubMed1997

Continuum care is built on provider relationships.

One of the biggest obstacles to creating truly seamless continuity of care is the difficulty of creating an effective feedback loop from home health care agencies to hospital case managers. The problem is complicated by the number of home health agencies to which most hospitals refer, and by lack of external incentives. Case managers at Children's Hospital of Pittsburgh attempt to get around the feedback problem by communicating with the families of patients receiving high-tech home care, such as infusion therapy. Experts advise that it's easier to establish policies for sharing information and case management tools such as critical pathways when you enter into formal partnerships with high-volume home care agencies.

Case Management↗
PubMed1994

Reducing orthopedic implant costs. A physician-driven approach at Mt. Sinai Medical Center, Cleveland.

Faced with the closing of its service, the Orthopaedics Department at Mt. Sinai Medical Center, working with Materials Management, began a program to become profitable. Through standardization, appropriate utilization, pre-planning of cases and the development of critical pathways, the service has realized about 40% savings in materials and dropped their average product costs to $2,700 per joint and reduced length of stay by five to six days. The keys have been physician input from the start, teamwork and continuous training.

Clinical Protocols↗
PubMedDate not supplied

Clinical patient information capture: the Columbia/HCA cancer care database experience.

Development of a cancer care database and interpretation of its contents will provide extensive information about a set of patients with a particular disease. By defining disease by stage, its associated costs of diagnosis, treatment and long term follow-up, patient outcomes and self-reported satisfaction and quality of life, a foundation for disease management evolves. Utilizing documented experience over the continuum of cancer care provides a stronger foundation for standards of care and critical pathway development as well as enhancing risk sharing capabilities in providing care for a set of cancer patients. Extensive data collection and analysis has been identified as the key to successful disease management. With the Columbia/HCA Cancer Care Database and future strategic initiatives, the development of an oncology disease management approach is aggressively moving forward.

Benchmarking↗
PubMed1998

Measuring and improving quality using information systems.

Information systems (IS) are increasingly important for measuring and improving quality. In this paper, we describe our integrated delivery system's plan for and experiences with measuring and improving quality using IS. Our approach is that for quality measurement to be practical, it must be integrated with the routine provision of care, and whenever possible should be done using IS. Thus, at one hospital, we now perform almost all quality measurement using IS. However, IS are not only useful for measuring care, but represent powerful tools for improving care using decision support. Specific areas in which IS has already been particularly effective include reducing the unnecessary use of laboratory testing, reporting important abnormalities to key providers rapidly, adverse drug event detection and prevention, initiatives to reduce the costs of drugs, and making critical pathways available to providers. The next wave of effort will be to promote widespread use of computerized guidelines, which is likely to prove more challenging. However, the advent of managed care in the U.S. has produced strong incentives to provide high quality care at low cost, and our perspective is that only with better IS than exist today will this be possible on a widespread basis. Such systems make feasible implementation of care improvement and cost reduction initiatives on a scale which could not previously be considered.

Decision Making, Computer-Assisted↗
PubMedDate not supplied

Physician-centered management guidelines.

The "Fortune 500 Most Admired" companies fully understand the irreverent premise "the customer comes second" and that there is a direct correlation between a satisfied work force and productivity, service quality, and, ultimately, organizational success. If health care organizations hope to recruit and retain the quality workforce upon which their core competency depends, they must develop a vision strategic plan, organizational structure, and managerial style that acknowledges the vital and central role of physicians in the delivery of care. This article outlines a conceptual framework for effective physician management, a "critical pathway," that will enable health care organizations to add their name to the list of "most admired." The nine principles described in this article are based on a more respectful and solicitous treatment of physicians and their more central directing role in organizational change. They would permit the transformation of health care into a system that both preserves the virtues of the physician-patient relationship and meets the demand for quality and cost-effectiveness.

Efficiency, Organizational↗
PubMed1999

Trauma nursing: an advanced practice case study.

Trauma is the leading cause of death in people less than 40 years of age. Blunt or penetrating trauma injuries may be a result of gunshot wounds, stabbings, head injuries,burns, falls or motor vehicle collisions. Unlike other patients entering the health care system, trauma victims have no time for hospital preparation. The physiologic and psychosocial complications resulting directly from the traumatic incident provide response patterns not typical of other patients. Further to this unpredictability, the trauma patient usually sustains multiple system injuries, making it difficult to design critical pathways in care plans. The complexity is heightened by the patient's unique perception of the traumatic event, which can be even more important than the physical injury in determining the ultimate impact of the trauma.

Adaptation, Psychological↗
PubMed1999

What you can do to optimize your hospital's reimbursement.

By paying attention to how coding is performed and documented, case managers can make significant impact on the hospital's bottom line by helping optimize reimbursement and reduce the number of claims denials. Coding is a particularly important consideration when you're examining data in terms of your case mix index. If coding data aren't accurate, then the strategies you use to improve efficiency and effectiveness might be directed inappropriately. Worse yet, if your case mix index appears to be too high, federal investigators could target your hospital for an upcoding investigation. Pay particular attention to coding issues when designing critical pathways and other performance improvement efforts. Eliminating an apparently unnecessary test may cut costs slightly, but it also may prevent your hospital from validating a high-paying diagnosis.

Case Management↗
PubMedDate not supplied

Anesthetic implications of laparoscopic surgery.

Minimally invasive therapy aims to minimize the trauma of any interventional process but still achieve a satisfactory therapeutic result. The development of "critical pathways," rapid mobilization and early feeding have contributed towards the goal of shorter hospital stay. This concept has been extended to include laparoscopic cholecystectomy and hernia repair. Reports have been published confirming the safety of same day discharge for the majority of patients. However, we would caution against overenthusiastic ambulatory laparoscopic cholecystectomy on the rational but unproven assumption that early discharge will lead to occasional delays in diagnosis and management of postoperative complications. Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiologic changes associated with patient positioning and pneumoperitoneum creation. General anesthesia and controlled ventilation comprise the accepted anesthetic technique to reduce the increase in PaCO2. Investigators have recently documented the cardiorespiratory compromise associated with upper abdominal laparoscopic surgery, and particular emphasis is placed on careful perioperative monitoring of ASA III-IV patients during insufflation. Setting limits on the inflationary pressure is advised in these patients. Anesthesiologists must maintain a high index of suspicion for complications such as gas embolism, extraperitoneal insufflation and surgical emphysema, pneumothorax and pneumomediastinum. Postoperative nausea and vomiting are among the most common and distressing symptoms after laparoscopic surgery. A highly potent and selective 5-HT3 receptor antagonist, ondansetron, has proven to be an effective oral and IV prophylaxis against postoperative emesis in preliminary studies. Opioids remain an important component of the anesthesia technique, although the introduction of newer potent NSAIDs may diminish their use. A preoperative multimodal analgesic regimen involving skin infiltration with local anesthesia. NSAIDs to attenuate peripheral pain and opioids for central pain may reduce postoperative discomfort and expedite patient recovery/discharge. There is no conclusive evidence to demonstrate clinically significant effects of nitrous oxide on surgical conditions during laparoscopic cholecystectomy or on the incidence of postoperative emesis. Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gallbladder disease.

Anesthesia↗
PubMed1999

Using information systems to improve practice.

Information systems are becoming a key tool for improving and measuring practice. They can improve care by providing decision support during routine care, by making important information more readily accessible, by pointing out redundancies, by suggesting alternatives, and by making guidelines accessible. Key domains, which are particularly amenable to such decision support, include drug prescribing, test ordering and implementation of critical pathways. In addition to their role in quality improvement, information systems can accomplish most quality measurement if key data are captured in coded form during the provision of routine care. These changes can help close the gap between knowledge and practice and promise to make the practice of evidence-based medicine a reality.

Decision Support Systems, Clinical↗
PubMed2000

[Use of bone densitometry in the framework of prevention and therapy of osteoporosis. Example of a systematic evaluation (health technology assessment)].

There is an ongoing controversy concerning the use of bone density measurements within therapeutic and preventive strategies of osteoporosis. Since there are no randomized controlled trials evaluating the effectiveness of bone density measurement with subsequent therapy we used a "critical pathway" model to determine possible benefit of tertiary, secondary and primary preventive strategies utilizing bone density measurement. In a first step data for fracture risk in each group are extracted from the literature. The second step outlines possible benefit from therapeutic studies. It may be estimated that in groups of patients with prevalent fractures use of bone density measurement and therapy according to bone density values may reduce fracture rates up to 30%. Bone density measurements performed with secondary preventive intent, however will probably lead to a reduction of fracture rates markedly below 10%. A set of risk factors that allows identification of a high risk group that may benefit from bone density measurement and subsequent therapy to a relevant extent remains to be developed. Primary preventive strategies do not require bone density measurements.

Absorptiometry, Photon↗
PubMed2001

A gene hypermethylation profile of human cancer.

We are in an era where the potential exists for deriving comprehensive profiles of DNA alterations characterizing each form of human cancer. Such profiles would provide invaluable insight into mechanisms underlying the evolution of each tumor type and will provide molecular markers, which could radically improve cancer detection. To date, no one type of DNA change has been defined which accomplishes this purpose. Herein, by using a candidate gene approach, we show that one category of DNA alteration, aberrant methylation of gene promoter regions, can enormously contribute to the above goals. We have now analyzed a series of promoter hypermethylation changes in 12 genes (p16(INK4a), p15(INK4b), p14(ARF), p73, APC,(5) BRCA1, hMLH1, GSTP1, MGMT, CDH1, TIMP3, and DAPK), each rigorously characterized for association with abnormal gene silencing in cancer, in DNA from over 600 primary tumor samples representing 15 major tumor types. The genes play known important roles in processes encompassing tumor suppression, cell cycle regulation, apoptosis, DNA repair, and metastastic potential. A unique profile of promoter hypermethylation exists for each human cancer in which some gene changes are shared and others are cancer-type specific. The hypermethylation of the genes occurs independently to the extent that a panel of three to four markers defines an abnormality in 70-90% of each cancer type. Our results provide an unusual view of the pervasiveness of DNA alterations, in this case an epigenetic change, in human cancer and a powerful set of markers to outline the disruption of critical pathways in tumorigenesis and for derivation of sensitive molecular detection strategies for virtually every human tumor type.

DNA Methylation↗