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PubMed2004

Utilization of comprehensive geriatric assessment in cancer patients.

A growing and diverse aging population, recent advances in research on aging and cancer, and the fact that a disproportional burden of cancer still occurs in people aged 65 years and older have generated great interest in delivering better cancer care for older adults. This is particularly true as more survivors of cancer live to experience cancer as a chronic disease. Cancer and its treatment precipitate classic geriatric syndromes such as falls, malnutrition, delirium, and urinary incontinence. Comprehensive Geriatric Assessment (CGA), by taking all patient's needs into account and by incorporating patient's wishes for the level of aggressiveness of treatment, offers a model of integrating medical care with social support services. It holds the promise of controlling health care costs while improving quality of care by providing a better match of services to patient needs. Three decades after the CGA was initially developed in England, oncologists have begun taking notice on the potential benefits that CGA might bring to the field of geriatric oncology. This article describes the utilization of the CGA in cancer patients with an eye toward promoting interdisciplinary care for older cancer patients. To set an initial context, a search of computerized databases took place, using "comprehensive geriatric assessment" and "cancer" as keywords. A selection of literature from between 1980 and 2003 was reviewed. Additional articles were identified through the bibliography of relevant articles.

Aged↗
PubMed1996

Surveillance of vascular incisions: outcomes a four-year unit-based quality-improvement program.

In a health care climate that emphasizes improving patient outcomes as well as reducing costs of care, the quality improvement process can be an effective tool to identify changes in practice that affect both of these factors in positive directions. Nursing staff members on our vascular surgical ward recognized incisional healing as critical to both cost of care and outcome. Infections and non-healing vascular incisions were problems that resulted in lengthy hospitalizations, the use of expensive antibiotics, and many read missions. Beginning in fiscal year 1992, nurses began monitoring incisional healing in vascular patients as part of the unit-based quality-improvement program. For 3 years nurses collected and analyzed data related to incisional healing in patients with postoperative groin, leg, and amputation incisions. They communicated with interdisciplinary colleagues about ways to improve outcomes and identified and implemented changes in practice that resulted in improvements. A formalized research program is underway to increase knowledge related to incisional healing and factor that affect healing in this specialty population.

Hospital Units↗
PubMed1994

The option to withdraw from chronic dialysis treatment.

This multidisciplinary discussion focuses on the case of a young diabetic woman who chose to stop chronic hemodialysis during a long and complicated illness. The perspective presented here include an academic lawyer's view of such medical decisions; a hospital chaplain's view of the religious framework for end-of-life situations; a clinical psychiatrist's considerations when consulted to evaluate patients in such straits; a transplant nurse's view of the opportunities for personal interaction that such clinical situations present; and a renal social worker's approach to chronic illness, advance directives, and death in the dialysis patient population. The discussion is intended to address objectively some important issues associated with death in this population, aimed at increasing our willingness to discuss these issues more openly with patients and with our colleagues.

Adult↗
PubMed2003

An overview of lung cancer.

Small cell lung cancer remains a devastating disease. A reduction in its impact will most likely come in the immediate future from smoking cessation programs. Because it is a rapidly growing disease, it seems unlikely that screening programs will have a significant impact on its curability. New chemotherapeutic agents with greater activity in this disease are desperately needed. Biologic agents such as the anti-idiotypic antibody BEC2 when combined with BCG may offer some hope to those with minimal residual disease after standard chemotherapy and radiation. Finally, an improved understanding of the biology of small cell cancer may ultimately provide the necessary clues to more effective treatment.

Female↗
PubMed2005

Interdisciplinary research and education at the biology-engineering-computer science interface: a perspective.

Progress in the life sciences, including genome sequencing and high-throughput experimentation, offers an opportunity for understanding biology and medicine from a systems perspective. This 'new view', which complements the more traditional component-based approach, involves the integration of biological research with approaches from engineering disciplines and computer science. The result is more than a new set of technologies. Rather, it promises a fundamental reconceptualization of the life sciences based on the development of quantitative and predictive models to describe crucial processes. To achieve this change, learning communities are being formed at the interface of the life sciences, engineering and computer science. Through these communities, research and education will be integrated across disciplines and the challenges associated with multidisciplinary team-based science will be addressed.

Biological Science Disciplines↗
PubMed2005

Brain arteriovenous malformations in adults.

Arteriovenous malformations of the brain (AMB) can cause stroke when they rupture. Epidemiological and imaging research has found that about 50% of patients with AMB present with haemorrhage, and the other 50% either present with non-focal symptoms, such as headache, seizure, or focal neurological deficit, or have no symptoms and the lesion is found during unrelated investigations. Treatment for arteriovenous malformations aims to prevent and resolve haemorrhage and is a growing interdisciplinary challenge. Although treatment uses enormous resources, there have been few studies on the risk-benefit ratios for treatment of unruptured AMB and the best approaches.

Adult↗
PubMed2003

Characteristics of physician leaders working to improve the quality of care in acute myocardial infarction.

BACKGROUND: The influence of physician leaders on their colleagues in local medical communities has been recognized for several decades. However, the literature indicates that little is known about the specific characteristics of physician leaders involved in improving quality in today's hospital environment. A taxonomy of the characteristics of the physician quality leader from the perspective of physicians and nonphysicians was developed. SUBJECTS AND METHODS: Information about physician leaders working to improve acute myocardial infarction (AMI) was gathered from in-depth interviews with 45 key physicians and nursing, quality management, and administrative staff at eight hospitals. Data were analyzed using the constant comparative method of qualitative data analysis. RESULTS: The physician leader characteristics were described in four main categories: personal commitment, professional credibility, quality improvement behaviors and skills, and institutional linkages. Each physician leader possessed different combinations of the characteristics from the four categories, revealing the complexity of the physician leader role. CONCLUSION: Understanding the key characteristics of physician leaders is a critical step in helping hospitals choose and develop physician leaders who can effectively bring about meaningful quality improvement.

Adrenergic beta-Antagonists↗
PubMed2003

Microsystems in health care: Part 5. How leaders are leading.

BACKGROUND: Leading and leadership by formal and informal leaders goes on at all levels of microsystems--the essential building blocks of all health systems--and between them. It goes on between microsystems and other levels of the systems in health care. This series on high-performing clinical microsystems is based on interviews and site visits to 20 clinical microsystems in the United States. This fifth article in the series describes how leaders contribute to the performance of those microsystems. ANALYSIS OF INTERVIEWS: Interviews of leaders and staff members offer a rich understanding of the three core processes of leading. Building knowledge requires many behaviors of leaders and has many manifestations as leaders seek to build knowledge about the structure, processes, and patterns of work in their clinical microsystems. Taking action covers many different behaviors--making things happen, executing plans, making good on intentions. It focuses action on the way people are hired and developed and involves the way the work gets done. Reviewing and reflecting provides insight as to how the microsystem's patterns, processes, and structure enable the desired work to get done; what success looks like; and what will be next after that "success" is created. CONCLUSION: The focus on the processes of leading is intended to enable more people to develop into leaders and more people to share the roles of leading.

Canada↗
PubMed2004

Which strategies facilitate improvement in quality of care for elderly hospitalized pneumonia patients?

BACKGROUND: A retrospective cohort study was conducted to elucidate which hospital-based quality improvement (QI) strategies are most effective in facilitating improvement in care for patients with community-acquired pneumonia. METHODS: In 1999 telephone interviews were conducted with 29 acute care hospitals in Connecticut regarding their use of QI strategies for 1,234 patients at baseline and 1,081 patients at follow-up. RESULTS: Hospital-based QI strategies were grouped into two domains of implementation approach (epidemiologic and social influence). Hospitals scoring a 4 in either the epidemiologic or social influence approach (versus a score of < or = 3) experienced a greater-than-average increase in percentage of patients with blood culture collection within 24 hours of hospital presentation. Hospitals applying all four social influence QI strategies showed a greater-than-average increase in delivery of antibiotics within 8 hours of patients' hospital arrival when compared with all the other hospitals combined. DISCUSSION: The finding that an increased proportion of patients receiving antibiotics within 8 hours and blood cultures within 24 hours of hospital arrival when the greatest numbers of hospital-based QI strategies were implemented in suggestive of a possible "dose effect" of QI.

Aged↗
PubMed2006

Recovery from medical errors: the critical care nursing safety net.

BACKGROUND: Safety initiatives have primarily focused on physicians despite the fact that nurses provide the majority of direct inpatient care. Patient surveillance and preventing errors from harming patients represent essential nursing responsibilities but have received relatively little study. METHODS: The study was conducted between July 2003 and July 2004 in a 10-bed academic coronary care unit. Direct observation of nursing care and solicited and institutional incident reports were used to find potential incidents. Two physician reviewers rated incidents as to the presence, preventability, and potential severity of harm of errors and associated factors. RESULTS: Overall data were collected for 147 days, including 150 hours of direct observation. One hundred forty-two recovered medical errors were found, including 61% (86/142) during direct observations. Most errors (69%; 98/142) were intercepted before reaching the patients. Errors that reached patients included 13% that were mitigated before resulting in harm and 18% that were ameliorated before more severe harm could occur. DISCUSSION: Protecting patients from the potentially dangerous consequences of medical errors is one of the many ways critical care nurses improve patient safety. Interventions designed to increase the ability of nurses to recover and promptly report errors have the potential to improve patient outcomes.

Academic Medical Centers↗
PubMed2006

Diabetes-related foot care at 10 Veterans Affairs medical centers: must do's associated with successful microsystems.

BACKGROUND: Well-coordinated interdisciplinary preventive foot care has been reported to significantly reduce diabetes-related foot ulcers, amputations, and hospitalization. However, the contribution of the specific components leading to these "successes" is not fully characterized. The microsystem conceptual framework was adapted to foot care to determine which of the microsystem success characteristics were associated with decreased major lower-limb amputation rates at 10 Veterans Affairs (VA) medical centers. METHODS: Two-day site visits were conducted using standardized interviews at the 10 VA medical centers. RESULTS: Six "must do's" for foot care in microsystems were correlated at > or = (-.30) with amputation rates: (1) addressing all foot care needs, (2) appropriate referrals, (3) ease in recruiting staff, (4) confidence in staff, (5) available stand alone specialized diabetic foot care services, and (6) providers attending diabetic foot care education in the past three years. Using multiple linear regression, the sum of these items described 59% of the variance (p = 0.006). DISCUSSION: Clinicians and managers may want to include the must-do's in system modifications to improve foot care for people with diabetes. Many of the sites displayed exemplary features in foot care, such as providing a formal orientation to the foot care clinics.

Amputation, Surgical↗