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PubMedDate not supplied

PACS--clinical experience at UCLA.

Implementation of picture archiving communication systems (PACS) at UCLA began with the evaluation of the systems in Pediatric Radiology, one of the 11 sections of the Department and the Coronary Care Unit, one of the 14 ICU's in the Hospital. We have now completed PACS development for all CT's and MR's which allows communication between a newly developed outpatient facility, the hospital, and the remote research facility in addition to Pediatric Radiology and the Coronary Care Unit. The following are some of the advantages of PACS from a clinical standpoint: (a) Conferences with clinicians have been more effective by spending more time on each case, but less total time for each conference; (b) Clinicians are satisfied with PACS at the remote site, but it is clear that the radiologists' interpretation must accompany the images; (c) PACS allows for the development of interactive teaching of the students; (d) PACS allows for a new method of radiology practice by analyzing the image and providing a more comprehensive, quantitative consultation, otherwise not possible with analog systems.

Ambulatory Care Information Systems↗
PubMedDate not supplied

Communication and teamwork in patient care: how much can we learn from aviation?

OBJECTIVE: To identify evidence on the role of assertiveness and teamwork and the application of aviation industry techniques to improve patient safety for inpatient obstetric care. DATA SOURCES: Studies limited to research with humans in English language retrieved from CINAHL, PubMed, Social Science Abstracts, and Social Sciences Citation Index, and references from reviewed articles. STUDY SELECTION: A total of 13 studies were reviewed, including 5 studies of teamwork, communication, and safety attitudes in aviation; 2 studies comparing these factors in aviation and health care; and 6 studies of assertive behavior and decision making by nurses. Studies lacking methodological rigor or focusing on medication errors and deviant behavior were excluded. DATA SYNTHESIS: Pilot attitudes regarding interpersonal interaction on the flight deck predicted effective performance and were amenable to behavior-based training to improve team performance. Nursing knowledge was inconsistently accessed in decision making. Findings regarding nurse assertiveness were mixed. CONCLUSIONS: Adaptation of training concepts and safety methods from other fields will have limited impact on perinatal safety without an examination of the contextual experiences of nurses and other health care providers in working to prevent patient harm.

Accidents, Aviation↗
PubMed2003

Use of and attitudes toward complementary and alternative medicine among family practice patients in small rural Illinois communities.

CONTEXT: Complementary and alternative medicine (CAM) use continues to increase in the United States. Data on rural patients' use and extent of integration of CAM with conventional medicine are lacking, although this is a population often associated with use of "folk remedies" and self-care strategies. PURPOSE: To examine rural primary care patients' attitudes toward and use of CAM. METHODS: A total of 176 surveys (70% response rate) were returned by patients at 5 geographically dispersed, rural Illinois family practice clinics to examine rural patients' use of, attitudes toward, and experiences with alternative medicine and providers. FINDINGS: Nearly two thirds of patients reported use of alternative medicine. Therapies most often used were vitamins/megavitamins, chiropractic, relaxation, and prayer/faith healing. Rural patients with more medical problems and a higher level of education were more likely to use alternative techniques. Three fifths of the patients felt that their doctor should discuss alternative medicine and therapies with them. CONCLUSIONS: Physician understanding and communication regarding CAM may be especially important in rural areas, where access to care is more limited and where there is greater reliance on the primary care physician as a "gatekeeper" for patient health.

Adult↗
PubMed2005

Aneurysmal rupture without subarachnoid hemorrhage: case series and literature review.

OBJECTIVE: Although an aneurysmal rupture typically presents on computed tomographic (CT) imaging as only subarachnoid hemorrhage (SAH), it may be associated with intraparenchymal hemorrhage (IPH), intraventricular hemorrhage (IVH), or subdural hemorrhage. On rare occasions, however, an aneurysmal rupture may present with IPH or IVH without SAH. METHODS: The Division of Cerebrovascular Neurosurgery at The Johns Hopkins Medical Institutions maintains a prospective database of all patients treated for intracranial aneurysms at this institution since 1991. Using this database, we identified patients with ruptured aneurysms who presented with IPH or IVH in the absence of SAH on CT imaging. RESULTS: Eight hundred twenty-two patients with radiographically documented ruptured aneurysms were admitted from January 1991 through June 2004. Of these, nine patients presented with IPH only, three with IPH and IVH, and one with IVH only, for a total of 13 cases. There were seven posterior communicating artery, four middle cerebral artery, one basilar apex, and one posterior cerebral artery aneurysms. The incidence of aneurysmal rupture with IPH and/or IVH without SAH is 1.6% CONCLUSION: Initial presentation of a ruptured aneurysm without SAH is rare and may have a multifactorial cause attributable to the timing of CT imaging, physiological parameters, or location of the aneurysm. Patients presenting with a head CT scan revealing IPH in the temporal lobe or with IVH should be considered for an urgent workup of a ruptured aneurysm, even in the absence of diffuse SAH.

Adolescent↗
PubMedDate not supplied

Postoperative mental status in elderly hip surgery patients.

PURPOSE: To determine if elderly patients undergoing hip surgery became delirious postoperatively and, if so, whether age and/or time of day were related to delirium. DESIGN: Repeated measures. SAMPLE: A convenience sample of 70 hip surgery patients 60 years of age and older at a large Midwestern teaching hospital were studied. Patients were excluded who were unconscious, unable to hear, see, and/or verbally communicate in English. Patients were also excluded who had a known history of dementia, Alzheimer's dementia, addiction to alcohol and/or sedative hypnotics, functional psychosis, or any other psychiatric diagnosis. Of the 70 patients, 37 were female and 33 were male. Mean age of the patients was 72.9 years (S.D. = 8.13). Patients were placed into one of three groups: Group 1--age 60 to 69 years (n = 25); Group 2--age 70 to 79 years (n = 25); or Group 3--80 years and older (n = 20). The most common procedure for all groups was total hip replacement (n = 48). METHOD: Data were collected primarily by both objective and subjective assessment of the patients. Both the Folstein's Mini Mental Status Exam (MMSE) and the NEECHAM Confusion Tool were used to collect data. Chart reviews provided additional data. Patients were assessed preoperatively to obtain baseline assessment and screen out patients with preexisting confusion. Assessments were then done once in the morning and once in the evening for 5 days following surgery. MAIN RESEARCH CLASSIFICATIONS: Delirium, sundowning, sundown syndrome. FINDINGS: The MMSE and NEECHAM were found to be highly correlated: Morning NEECHAM vs morning MMSE (Correlation Coefficient = .6515; p = .000), evening NEECHAM vs evening MMSE (Correlation Coefficient = .8301; p = .000). A test of repeated measures was used to examine the data. The Within factor was time, the Between factor was age, and the interaction effect was age by time of day. Dependent variables were total NEECHAM scores and total MMSE scores, in addition to total scores of these tests' subsections. An alpha level of .05 was used for all statistical tests. Age had a significant main effect on the NEECHAM (F = 7.44; p = .001) and MMSE (F = 6.04; p = .004). Time did not have a significant effect on either the MMSE (F = .00; p = .953) or the NEECHAM (F = .43; p = .513). There was no statistically significant interaction between age and time of day (NEECHAM, F = .97, p = .384 and MMSE (F = .19, p = .826). No subjects were assessed as demented per the MMSE. Only 12 episodes of acute confusion were noted using the NEECHAM. CONCLUSION: Patients in this population rarely, if ever, became confused. The older the individual, the more likely he/she was to have confusion. Time of day was neither significant in development of delirium nor on mental status assessment scores in this population. IMPLICATIONS FOR NURSING RESEARCH: Current research literature notes that 10% to 50% of elderly postoperative patients experience delirium. Patients who have had femoral neck fractures can experience delirium three times more than patients having nonorthopaedic surgery. This study found that delirium in hip surgery patients is rare. A study of the more subtle components of delirium such as attention and memory might reveal less obvious changes in mental status following surgery. Type of orthopaedic surgery also might impact incidence of delirium. A comparative study between elderly total knee and total hip replacement patients would be interesting. Studying patients who have emergency hip surgery related to fracture in comparison to patients having elective hip surgery for degenerative conditions might identify other etiologies for delirium following hip surgery. Fatigue rather than time of day might be studied to observe whether it has a significant impact on mental status or delirium scores.

Aged↗
PubMed1996

[Speech rehabilitation following total laryngectomy with tracheo-esophageal puncture].

Speech rehabilitation after total laryngectomy has often been neglected, and traditional methods of esophageal voice production are frequently unsuccessful or disappointing. The development of the tracheoesophageal puncture (TEP) technique and the valved voice prosthesis by Singer and Blom in 1979 offered patients an alternative method for laryngeal speech rehabilitation. This technique is now used successfully in an increasing number of patients after total laryngectomy. We present our experience with TEP since 1988 in 8 men and 1 woman, aged 50-86 years, who had adequate follow-up. In 5, primary TEP was performed at the same time as the total laryngectomy; in 4, secondary puncture was performed 12-18 months after primary surgery. 1 had serious operative complications, 2 had minor complications, 1 had long-term problems which necessitated discontinuing use of the prosthesis, while 8 achieved satisfactory voice use and could communicate effectively. We hope that further experience with TEP in Israel will confirm its effectiveness for speech rehabilitation after total laryngectomy.

Aged↗
PubMedDate not supplied

A threshold limit theorem for a multitype epidemic model.

The asymptotic final size distribution of a multitype Martin-Löf process, a discrete-time SIR model for the spread of an infectious disease in a closed multitype population, is derived for the case of large total population size. When all subgroups are of comparable size and the infection pattern is irreducible, a threshold behavior is obtained, and the asymptomatic distributions for small and large outbreaks can be found. As an important corollary we get a threshold limit theorem for a class of continuous-time SIR models with several types.

Communicable Diseases↗
PubMed2006

Communication skills in psychiatry residents-- how do they handle patient concerns? An application of sequence analysis to interviews with simulated patients.

BACKGROUND: The main focus of the training of psychiatrists is on diagnosis and treatment based on the traditional doctor-centered approach to the psychiatric interview. Less attention is given to the correct handling of patients' emotional concerns, which is crucial for the patient-physician relationship, but also for improving diagnostic and treatment decisions. The aim of this study is to assess psychiatrists' responses to patients' concerns and worries. METHOD: 118 consultations, conducted by 10 residents in psychiatry with 20 simulated patients, have been coded using the Verona Psychiatric Interview Classification System. Lag1 sequential analysis and a multinomial logit regression analysis were performed to investigate the relationship between patients' expressions of concern and psychiatrists' subsequent interventions in terms of patient-centered skills. RESULTS: Compared to doctor-centered interventions, all patients' expressions of concern increased the probability of passive listening (odds ratios between 2.4 and 4.2). They also increased the occurrence of emotion focusing interventions (odds ratios between 3.3 and 1.7), which however remained rare (4% of residents' total responses). A small although significant increase in the likelihood of active listening expressions was observed as a response to two types of patient expressions of concern: statements of feelings (odds ratio 1.4) and expression of opinions regarding problematic psychosocial issues (odds ratio of 1.7). CONCLUSIONS: Young psychiatrists are good passive listeners but need to improve active listening skills which, together with emotion focusing skills, should be a major learning target in psychiatry. These patient-centered interviewing skills should integrate those traditionally used for attributing ICD-10 and/or DSM-IV categories.

Adult↗
PubMed2006

Return to work after two years of total disability: a case report.

BACKGROUND: Little is specifically written regarding the details of clinical interventions with workers with chronic spinal pain. Specifically, the individual thought process behind the management of an injured worker is not often discussed except in clinical conferences or discussions with other clinicians. It is well known that once an injured worker is disabled from work for 2 years, successful return is unlikely. We thought it would be informative to illustrate the clinical approach we took with this case because of the history of long term pain and disability. METHODS: This paper describes the conservative management of a patient who was disabled from work for 2 years, using an integrated approach including chiropractic manipulation, pain education, restricted duty and clear communications among all parties involved. RESULTS: After 15 weeks, the patient returned to her previous occupation as a nurse, first part time, and subsequently full time. CONCLUSION: This report is provided to illustrate a systematic approach diagnosis and treatment to assist this injured workers return to work. This case illustrates that even after 2 years successful return to work can be achieved.

Adult↗
PubMedDate not supplied

[Surgical treatment of interatrial septal defect].

On the basis of the authors' experience acquired between 1956 and 1973 (a total of 401 cases with inter-atrial communications and 234 cases of ostium secundum that have been operated by them), data are presented concerning the diagnostic means, the indications and the contra-indications of the surgical treatment, as well as the attitude to be adopted towards the associated lesions.

Adolescent↗
PubMed2004

Practical effects of educating nurses on the Natural Death Act.

BACKGROUND: The aim of this study was to investigate a nursing staff's knowledge of the Natural Death Act before and after an educational intervention. PATIENTS AND METHODS: This was a quasi-experimental designed study. Questionnaires were sent to 135 nurses in a medical center who volunteered to participate in the educational program. Demographic data and knowledge of the Natural Death Act were collected. The return rate was 85.37% (n=105). The educational program lasted for 6 h and included five subjects: hospice-palliative care, Natural Death Act, how to face suffering patients, nursing for agonized patients, and communicating with families. The program was a combination of lectures, case discussions, evaluation of individuals' values, and attitudes toward patient death. MAIN RESULTS: At baseline, the average total score in the 18-item questionnaire on the Natural Death Act was 12.96, with a range of 5-18. After the educational intervention, the average total score increased from 12.9 correct answers to 17.04 (of 18). The average increase was 4.08 points, a statistically significant difference. CONCLUSIONS: A provision of appropriate training for medical professionals appears to be a useful educational strategy, and this result shows that the Natural Death Act should be included in nursing school educational program. In the future, more effort should be made to fulfill patients' expectations and to follow medical ethics guidelines.

Adult↗
PubMed2004

Using human extra-cortical local field potentials to control a switch.

Individuals with profound paralysis and mutism require a communication channel. Traditional assistive technology devices eventually fail, especially in the case of amyotrophic lateral sclerosis (ALS) subjects who gradually become totally locked-in. A direct brain-to-computer interface that provides switch functions can provide a direct communication channel to the external world. Electroencephalographic (EEG) signals recorded from scalp electrodes are significantly degraded due to skull and scalp attenuation and ambient noise. The present system using conductive skull screws allows more reliable access to cortical local field potentials (LFPs) without entering the brain itself. We describe an almost locked-in human subject with ALS who activated a switch using online time domain detection techniques. Frequency domain analysis of his LFP activity demonstrates this to be an alternative method of detecting switch activation intentions. With this brain communicator system it is reasonable to expect that locked-in, but cognitively intact, humans will always be able to communicate.

Amyotrophic Lateral Sclerosis↗
PubMed2004

Impact of MyCareTeam for poorly controlled diabetes mellitus.

OBJECTIVE: Web-based diabetes management can be used to provide frequent interactions between patients and providers and thus result in improved glycemic control. METHODS: In a single-center, prospective feasibility study, 16 poorly controlled patients with either type 1 or 2 diabetes mellitus were enrolled to assess the impact of using MyCareTeam, a web-based diabetes management application, for diabetes management. Patients were asked to transfer their blood glucose data electronically, maintain exercise logs, and communicate with their provider via MyCareTeam. The provider gave clinical interventions to optimize blood glucose control and provided feedback via MyCareTeam. Diabetes, nutrition, and exercise information was also available via MyCareTeam. RESULTS: A significant reduction of over 2.22% points in hemoglobin A1C was seen for the total patient population. Differences between moderate/heavy users (n = 8) versus light/never users (n = 8) of MyCareTeam were evaluated for intergroup differences based upon utilization. Moderate/heavy users had a significant 6-month A1C reduction of 3.15 percentage points compared with a reduction of 1.28 percentage points in light/never users. Other secondary end points were improved as well, including systolic blood pressure, diastolic blood pressure, total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides. However, as expected, body mass index levels increased because of aggressive diabetes management with insulin therapy. CONCLUSIONS: These results demonstrate a significant treatment effect from the MyCareTeam application. A larger randomized control trial is under way at the Boston Veterans Administration Healthcare System. If these results are confirmed as expected, then web-based diabetes management may prove to be the link to achieving target American Diabetes Association glycemic goals in patients with poorly controlled diabetes.

Blood Glucose↗
PubMed2004

Applied strategies for improving patient safety: a comprehensive process to improve care in rural and frontier communities.

CONTEXT: Medical errors and patient safety have gained increasing attention throughout all areas of medical care. Understanding patient safety in rural settings is crucial for improving care in rural communities. PURPOSE: To describe a system to decrease medical errors and improve care in rural and frontier primary care offices. METHODS: Applied Strategies for Improving Patient Safety (ASIPS) was a demonstration project designed to collect and analyze medical error reports and use these reports to develop and implement interventions aimed at decreasing errors. ASIPS participants were clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). This paper describes ASIPS in HPRN. FINDINGS: Fourteen HPRN practices with a total of 150 clinicians and staff have participated in ASIPS. Participants have submitted 128 reports. Diagnostic tests were involved in 26% of events; medication errors appeared in 20% of events. Communication errors were reported in 72%. Two learning groups developed "Principles for Process Improvement" for medication errors and diagnostic testing errors. Several safety "alerts" were issued to improve care, and 2 interventions were implemented to decrease errors. CONCLUSIONS: A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in rural primary care settings. Information from reports can be used to identify processes that can be improved.

Colorado↗
PubMed2006

A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability.

BACKGROUND: Breakdown in communication among members of the healthcare team threatens the effective delivery of health services, and raises the risk of errors and adverse events. AIM: To describe the process of developing an authentic, theory-based evaluation instrument that measures communication among members of the operating room team by documenting communication failures. METHODS: 25 procedures were viewed by 3 observers observing in pairs, and records of events on each communication failure observed were independently completed by each observer. Each record included the type and outcome of the failure (both selected from a checklist of options), as well as the time of occurrence and a description of the event. For each observer, records of events were compiled to create a profile for the procedure. RESULTS: At the level of identifying events in the procedure, mean inter-rater agreement was low (mean agreement across pairs 47.3%). However, inter-rater reliability regarding the total number of communication failures per procedure was reasonable (mean ICC across pairs 0.72). When observers recorded the same event, a strong concordance about the type of communication failure represented by the event was found. DISCUSSION: Reasonable inter-rater reliability was shown by the instrument in assessing the relative rate of communication failures displayed per procedure. The difficulties in identifying and interpreting individual communication events reflect the delicate balance between increased subtlety and increased error. Complex team communication does not readily reduce to mere observation of events; some level of interpretation is required to meaningfully account for communicative exchanges. Although such observer interpretation improves the subtlety and validity of the instrument, it necessarily introduces error, reducing reliability. Although we continue to work towards increasing the instrument's sensitivity at the level of individual categories, this study suggests that the instrument could be used to measure the effect of team communication intervention on overall failure rates at the level of procedure.

Academic Medical Centers↗
PubMed2004

A three-part intervention to change the use of hormone replacement therapy in response to new evidence.

BACKGROUND: Slow adaptation of new information by providers may result in suboptimal care. OBJECTIVE: To evaluate changes in prescriptions for combination hormone replacement therapy (HRT) after a multicomponent intervention to deliver new information to patients and providers. DESIGN: Quasi-experimental study with multiple baselines. SETTING: Veterans Affairs Tennessee Valley Healthcare System (VA-TVHS). PATIENTS: Female veterans age 50 to 79 years who had a prescription filled at the VA-TVHS for combination HRT between 1 January 2002 and 1 July 2002. MEASUREMENTS: Discontinuation of HRT. INTERVENTION: A 3-part intervention consisted of 1) notifying patients who were using combination HRT of the results of the Women's Health Initiative study (patient education component), 2) sending all providers an e-mail with the Women's Health Initiative study results (provider education component), and 3) placing an electronic alert in each eligible patient's chart (provider care component). The alert asked providers to reevaluate the need for combination HRT. The intervention was implemented at different VA-TVHS sites in a stepwise fashion to differentiate intervention effect from media effect. Study follow-up continued through 31 December 2002. RESULTS: The total rate of discontinuation of combination HRT was 70.3% in 2002. The proportion of discontinuation from time of media release until intervention was 23.3%. After initiation of the intervention, an additional 43% of the original cohort discontinued use of HRT; this percentage represents a 59% relative decrease in HRT use among patients. After adjustment for time, the discontinuation rate per day was 4.9 times higher after the multifacted intervention than after the media release (95% CI, 1.8 to 13.1). LIMITATIONS: A true control group is lacking. CONCLUSION: A multifaceted approach in an integrated health care system with standardized methods of communication is an effective way to implement patient-centered, effective, and timely care with changing medical knowledge.

Aged↗
PubMed2004

Variations in neurodegenerative disease across the UK: findings from the national study of Progressive Intellectual and Neurological Deterioration (PIND).

AIMS: To identify any UK children with variant Creutzfeldt-Jakob disease (vCJD) and obtain information about the causes of progressive intellectual and neurological deterioration (PIND) and the geographical distribution of cases. METHODS: The PIND Study uses the monthly surveillance card that is sent to all UK paediatricians by the British Paediatric Surveillance Unit. Case details are obtained from the reporting paediatricians by telephone interview, site visit, or self completion of a questionnaire. A paediatric neurology expert group then classifies the anonymised cases. The Communicable Disease Surveillance Centre (CDSC) provides mapping support. RESULTS: After five years and five months of surveillance, 1400 children had been reported. In the UK the majority of PIND cases had a confirmed diagnosis (comprising 99 different conditions); 505 "no cases" and 97 "outstanding" cases were excluded. A total of 798 PIND cases were included as follows: 577 with a confirmed underlying diagnosis; six with definite or probable vCJD, 51 who had undiagnosed PIND but were not thought to have vCJD, and 164 cases who were still under investigation. In some districts there were unexpectedly high numbers of PIND cases with a heterogeneous mixture of underlying diagnoses. In the five districts with the largest numbers of resident cases the majority not only came from a particular ethnic group but also had high reported rates of consanguinity. CONCLUSIONS: In districts with large numbers of PIND cases there are major resource implications. These children and their families have complex problems and they need access to diagnostic facilities and appropriate service provision.

Adolescent↗
PubMedDate not supplied

[The quality of medical records: a retrospective study in Lazio Region, Italy].

INTRODUCTION: Medical records have an important role in the communication among different care providers and in forensic medicine. In Italy, information on completeness and correctness of medical records is scanty, whereas future hospital accreditation could take into account their quality as a proxy of good medical practice. PURPOSE: We performed a retrospective study in order to assess the quality of medical records in the Lazio region. METHODS: From all 37009 hospital discharges for five different diseases in 123 hospitals (acute myocardial infarction (AMI), coronary artery bypass surgery, pneumonia, cerebrovascular disorders, breast surgery), registered in the Regional Hospital Information System, we selected a random sample of 2022 (5.5% of the total). Ten physicians, previously trained, reviewed the relative medical charts and filled in "ad hoc" questionnaires. RESULTS: A total of 1960 (97% of the target) charts were reviewed. Organization and structure of data recording strongly varied. Important differences were found across the diseases for various items: presence of anamnesis 98.1% (range: from 95.6% for breast surgery to 100% for AMI); presence of physical examination 92.7% (range: from 88.1% for breast surgery to 98.5% for AMI), completeness of the daily medical records was good in 70.8% (range: from 34.2% for pneumonia to 93.9% for cerebrovascular disorders). Variability among different type of hospitals was also observed, being teaching hospitals and some private hospitals more accurate. CONCLUSIONS: Quality of medical records tended to vary across different type of hospitals and different diseases. Actions for improving the quality should be undertaken as a priority. Efforts have to be done in restructuring charts, creating guidelines and training caregivers. The development and application of computer based health information systems should help solving these problems.

Hospitals↗