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PubMed2003

Evaluation of the appropriate use of albumin in adult and pediatric patients.

The appropriateness of albumin use and baseline albumin usage patterns were studied. Institutional practice patterns regarding the use of albumin were compared to criteria established by an independent expert panel. Fifty-three institutions, all of which were members of VHA or the University Health-System Consortium, participated in the evaluation. Investigators collected data over an eight-week period from the medical records, pharmacy records, and hospital billing data of adult (18 years of age or older) and pediatric (age 1-17 years) patients for whom albumin was prescribed. Data collected included patient-specific information, the prescribing physician's specialty area, patient location (level of care) when albumin was prescribed, primary reasons for prescribing albumin, and details of albumin use. Data were collected for 1649 adult and 23 pediatric patients. Albumin was prescribed inappropriately in 57.8% and appropriately in 28.2% of adults; appropriateness of use was unknown in 14% of the patients reviewed. The most common indication for albumin use was hypotension/hypovolemia (23.9%), followed by bypass-pump priming (16.3%), intradialytic blood pressure support (9.6%), and serum albumin values less than 2 g/dL (8.6%). Albumin was prescribed inappropriately 100% of the time when used for intradialytic blood pressure support, low serum albumin values, and acute respiratory distress syndrome. The most appropriate use of albumin occurred in patients with postsurgical hypotension and hypovolemia (67.8%), nephrotic syndrome (79.3%), non-hemorrhagic shock (44.3%), hemorrhagic shock (51.9%), and cirrhosis and paracentesis (31.3%). Albumin was inappropriately prescribed for 57.8% of adult patients and 52.2% of pediatric patients. The mean number of total grams used by patients receiving albumin appropriately was similar to those patients inappropriately receiving albumin.

Adolescent↗

PubMedDate not supplied

[The indirect immunofluorescence reaction in the laboratory diagnosis of ixodid tick-borne borreliosis].

Serological verification of ixodid tick-borne borrelioses (TBB) is carried out in Russia by using IFA with the standard antigen prepared from the strain Ip-21 B. afzelii by the Laboratory of Infection Vectors, Gamaleya Research Institute of Epidemiology and Microbiology, Russian Academy of Medical Sciences. This study is under way at approximately 50 research and practical institutions that are situated in 30 large administrative territories of the country. The nIFA data on 371 sera from 214 patients with TBB and 229 sera from controls who had other infections have been analyzed. Changes in the proportion antibody sera, mean geometrical and cut-off antibody titers in patients with TBB were compared with those in the controls. The values of seroconversion were analyzed in relation to the time lasted after the onset, the first serum collection, and an interval of reexamination. The specific results of tested of the coded sera were obtained during the international interlaboratory blind experiment. It is concluded that nIFA yields results that are suitable for TBB verification.

Acute Disease↗

PubMed2006

[Evaluation of the off-site preanaesthetic consult in Lorraine].

OBJECTIVES: To evaluate the results of Off Site preanaesthetic consult in Lorraine and to draw up a method for these pre-operative visits. STUDY DESIGN: Two surveys of the Lorraine-regional practice (from both the anaesthetists and surgeons from Lorraine) and one survey of patient satisfaction. PATIENTS AND METHOD: Questionnaires were sent by mail to all anaesthetists (n=270) and surgeons (n=339) in the Lorraine region. In the immediate postoperative period, specific questionnaires were sent by mail to selected patient groups (n=73 in each group), one group having and the other (control) not having Off Site preanaesthetic consult. RESULTS: Anaesthetists' survey: 48.4% of interviewed anaesthetists belonged to the pre-anaesthetic consult network. 81.2% of these anaesthetists performed Off Site pre-anaesthetic consult. The main recognized advantages were patient comfort (89.6%) and cost effectiveness (57.3%). 26.1% of anaesthetists who did not participate to the network were strongly opposed to this practice, while 60.9% were prepared to enter the network. Surgeons' survey: 15.6% of surgeons were not satisfied that anaesthetists in their institutions practiced the Off Site pre-anaesthetic consult. Patients' survey: no difference in satisfaction towards the quality of information delivered during the consultation (anaesthetic technique, analgesia and evaluation of the perioperative risk) nor in terms of perioperative anxiety. The average transportation distance spared by Off Site preanaesthetic Consult was 98 miles. CONCLUSION: Off Site preanaesthetic consult may have real benefits in terms of, patient satisfaction, comfort and cost-effectiveness. In the Lorraine region, a majority of anaesthetists has experience with this practice.

Anesthesiology↗

PubMed1999

The impact of new technology on a clinical practice.

The use of xenograft stentless tissue valves has increased because of excellent hemodynamics and availability. This article describes the impact of the incorporation of this new technology into a single institutional practice over time. A time span for continual usage of the new stentless Freestyle valve was divided into four distinct chronological groups and evaluated. Data on 266 consecutive patients receiving the Freestyle prosthesis were analyzed with regard to demographics, degree of illness, complexity of surgery, and outcomes to discover any distinct changes over time with respect to experience and acquired confidence and surgical expertise. Findings among the four groups were compared using Student's t-test. The only change in patient demographics was younger age (mean age decreased from 70 to 62 years). The number of procedures rose steadily, and the degree of illness increased as noted in the increase between groups in the percentage of patients with comorbidities (from 45% to 92%). The complexity of surgery score steadily increased (from 1.9 to 2.5); however, the mean cross-clamp time did not change. The surgical mortality rate for the entire study was 3.4%. In group 1, the mortality was 7.5% but decreased rapidly and remained steady throughout the rest of the study. The use of the Freestyle stentless conduit in a single practice over time shows a distinct learning curve. With experience, valves are placed in younger, sicker patients who require more complex surgery. Surgical outcomes and efficiency improve with acquired surgical expertise.

Adult↗

PubMed1985

Trial of labor in the patient with a prior cesarean birth.

The increasing incidence of cesarean birth has become quite controversial. The practice of delivering virtually all women with a prior cesarean section by repeat cesarean section is open to debate. In a large institutional practice, with rapid availability of all support services, selective attempts to deliver women vaginally, after a prior cesarean section, is appealing. A prospective 1-year study on all patients with a prior cesarean delivery commenced July 1, 1982. There were 1209 patients, of whom 751 (62%) underwent a trial of labor and 614 (82%) achieved vaginal delivery. There was no maternal mortality or perinatal mortality attributed to the trial of labor process. Oxytocin usage occurred in 38% of this population. The incidence of uterine rupture and scar dehiscence was similar in the various study subgroups. The overall group of women undergoing a trial of labor had significantly fewer postpartum complications and shorter hospital stays.

Adult↗

PubMedDate not supplied

Nursing education and healthcare reform.

What and how we teach, how we learn, and how we practice nursing are fundamentally changing. Perspectives on Assessment invites dialogue on assessment's central role in the paradigm shifts currently occurring in nursing education and nursing practice. Programs of assessment in educational and practice institutions offer the opportunity for continuous feedback on the quality and effectiveness of our efforts to prepare nurses who are competent to practice in a healthcare environment that is continuously changing and increasingly community based. The assessment process itself offers the opportunity for us to engage in an ongoing conversation about our progress with these two paradigm changes.

Curriculum↗

PubMedDate not supplied

Assessing competency for community-focused nursing practice.

Clinical Competence↗

PubMed2001

Champions for evidence-based practice: a critical role for advanced practice nurses.

Evidence-based practice is emerging as a widely accepted paradigm for contemporary professional nursing practice. Institutions and providers of healthcare services are adopting this framework to guide the structure, process, and outcomes of patient care delivery. Advanced practice nurses are ideally prepared and positioned within healthcare delivery systems to champion the integration of this practice as a model for evidence-based patient care. This article highlights opportunities and suggests strategies for advanced practice nurses to serve as catalysts for optimizing patient care through evidence-based practice.

Evidence-Based Medicine↗

PubMedDate not supplied

Quality improvement in an integrated urban healthcare system: a necessary journey.

Public hospitals and clinics in the United States provide health care for the needs of large numbers of people who are medically indigent, homeless, chronically mentally ill, and suffer medical and social disorders associated with poverty. These "safety-net" healthcare providers traditionally struggle with barriers to providing high-quality, patient-sensitive care, including decaying physical facilities, burdensome bureaucracies, underfunded capital equipment and construction programs, and complex, politically driven budgets and governance. However, these same institutions now must compete for their own Medicaid and Medicare clientele because the private sector is marketing to those patients. They also must continue to provide increasing services to growing numbers of uninsured patients. To accomplish this, these institutions must reinvent themselves as patient-focused, high-quality, cost-effective healthcare providers. The Denver Health system is the public safety-net provider for the city and county of Denver. This large public institution has instituted a multifaceted performance-improvement program. The program includes training employees for patient-focused service, implementing continuous quality-improvement practices, instituting clinical pathways, revising the preexisting ambulatory quality-management program, reengineering key aspects of ambulatory clinic services, and redesigning the hospital-based patient-care services. Major successes have been achieved in some initiatives, but not in all. Many key "lessons learned" may guide others.

Ambulatory Care↗

PubMed2003

Clinical research in family medicine: quantity and quality of published articles.

BACKGROUND AND OBJECTIVES: Publication of clinical research in peer-reviewed journals is an important measure of scholarly productivity. This study determined the quantity and quality of original clinical research published by family physicians. METHODS: We surveyed clinical research papers published in the year 2000 in four leading family medicine research journals and research originating in a family practice institution but published in 16 non-family medicine journals. All were selected on the basis of relevance to family physicians and "impact factor." The relevance and validity of papers was assessed using previously established criteria. RESULTS: The survey of family medicine journals revealed a total of 170 original research articles. Ninety eight were from academic family practice programs, and the remaining 72 were from other medical specialties or health care institutions. Most of the papers were cross-sectional surveys. There were seven qualitative studies, six randomized controlled trials, and no systematic reviews from family practice programs in these journals. Eight of the articles were from practice-based research networks. A total of 79 articles were considered relevant or highly relevant, and 22 of these were also considered valid (Patient-oriented Evidence That Matters or POEMs). The survey of 16 non-family medicine journals revealed 37 clinical research papers: 16 surveys, nine prospective cohort studies, seven randomized controlled trials, three systematic reviews/meta-analysis, one qualitative study, and one case-control study. There were nine "highly relevant" papers--seven could be classified as POEMs. CONCLUSIONS: Most clinical family medicine research uses less-rigorous study designs, such as the cross-sectional survey. The majority of papers do not meet established criteria for relevance and validity. There are no standards or comparable studies to compare these results to prior years or to other disciplines.

Cross-Sectional Studies↗

PubMed2004

Practice variation in perioperative antibiotic use in Japan.

OBJECTIVE: Under the fee-for-service system, the overuse and misuse of perioperative antibiotics have become serious concerns in Japan. The objective of the present study is to investigate practice variations of perioperative antimicrobial prophylaxis between and within hospitals, and to identify any opportunities for improvement. METHODS: We polled 319 surgeons in six specialties employed by 11 teaching hospitals in Japan. We developed questionnaires with vignettes, asking physicians about their practice of antimicrobial prophylaxis in six surgical procedures (gastrectomy, hysterectomy, cataract surgery, clipping of cerebral aneurysm, hip fracture surgery, and coronary artery bypass graft) and utilization of institutional clinical pathways. RESULTS: Average durations of prophylaxis varied by procedure, from 1.6 days for cataract surgery to 5.8 days for clipping surgery. Variation was also observed between institutions for the same procedure, e.g. institutional averages for the duration of prophylaxis for gastrectomy ranged from 2.3 to 7 days. Large intra-institutional variation in prophylaxis duration and inconsistent use of clinical pathways were observed in the cases of gastrectomy, hip fracture surgery, and clipping surgery. At one hospital, 20% of physicians performing gastrectomy indicated the use of an institutional clinical pathway, and prophylaxis duration ranged from 3 to 6 days. For cataract surgery and hysterectomy, clinical pathways were universally applied and intra-institutional practice variation was small, yet prophylaxis duration varied widely between hospitals and third-generation cephalosporins were used extensively. Average length of prophylaxis for hysterectomy ranged from 1.8 to 6 days and 43% of respondents prescribed third-generation cephalosporins. CONCLUSIONS: In Japan, perioperative antimicrobial prophylaxis lacks standardization. Efforts to strengthen an evidence-based approach to antimicrobial prophylaxis need to be made a priority at both the national and institutional levels.

Antibiotic Prophylaxis↗

PubMed1999

Current practices regarding newborn intracranial haemorrhage and obstetrical care and mode of delivery of pregnant haemophilia carriers: a survey of obstetricians, neonatologists and haematologists in the United States, on behalf of the National Hemophilia Foundation's Medical and Scientific Advisory Council.

We undertook this survey to determine institutional practices of obstetricians, neonatologists and haematologists regarding care of pregnant haemophilia carriers and newborns with haemophilia and intracranial haemorrhage (ICH). Our purpose was also to determine whether institutions had written guidelines to manage such patients. Questionnaires were sent to 1000 obstetricians and through the Haemophilia Treatment Centres (HTC) to 180 paediatric haematologists and 180 neonatologists, each representing an institution. Twenty-three per cent of obstetricians, 22% of neonatologists and 16% of paediatric haematologists returned completed surveys. Over 94% of the respondents had no written guidelines for management of pregnant haemophilia carriers or their newborns or for neurologic assessment of newborns. For known haemophilia carriers, 57% of the obstetricians routinely preferred vaginal delivery and 11% preferred caesarean section. Availability of perinatal services influenced prenatal management (P < 0.05). In term newborns with documented ICH, only 23% of neonatologists would evaluate for haemophilia, whereas in pre-term newborns with ICH, this number dropped even further to 3%. For all newborns with haemophilia, 40% preferred routine administration of clotting factor concentrates (CFC) immediately following birth to offset the trauma of delivery and 89% of paediatric haematologists favoured early prophylaxis with CFC. Guidelines are needed for management of pregnant haemophilia carriers as well as newborns with haemophilia. Physicians need to be made aware that ICH may be a presenting sign of haemophilia in both term as well as pre-term newborns, so that appropriate therapy can be instituted early in the event of a bleed.

Adult↗

PubMedDate not supplied

Current therapy in the management of heterotopic ossification of the elbow: a review with case studies.

Heterotopic ossification, or the appearance of ectopic bone in para-articular soft tissues after surgery, immobilization, or trauma, complicates the surgical and physiatric management of injured joints. The chief symptoms of heterotopic ossification are joint and muscle pain and a compromised range of motion. Current therapies for prevention or treatment of heterotopic ossification include surgery, physical therapy, radiation therapy, and medical management. Unlike heterotopic ossification of the hip, heterotopic ossification of the elbow has not been extensively investigated, leaving its optimal management ill-defined. To remedy this deficiency, we review risk factors, clinical anatomy, physical findings, proposed mechanisms, and current practice for treatment and prevention of heterotopic ossification. We then consider and draw conclusions from four cases of elbow injury treated at our institutions (three complicated by heterotopic ossification) in which treatment included surgery, radiation therapy, physical therapy, and medical therapy. We summarize our institutional practices and conclude with a call for a randomized clinical trial to better define optimal management of heterotopic ossification of the elbow.

Adult↗

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↗

PubMed2000

[Pain management and nursing care--results of a review of the literature].

Especially for patients with chronic conditions, the ability to cope with the experience of illness in their daily lives is essential for the quality of life. An analysis of the international literature, of German nursing textbooks and journals was carried out to determine the dissemination of the state of the art of pain management. International research findings indicate a wide gap between the state of the art and pain management practice. Multidisciplinary role model programs where nurses play a major role as change agents have proved to be an effective strategy to change the institutional practice of pain management. In Germany, pain therapy as a medical discipline as well as academic courses in nursing were only institutionalized in the last decade. As a consequence pain research and therapy remained the domain of medicine and psychology up to now. Enhancing knowledge and educative skills of nurses will not only promote the quality of care. It is a key concept of professionalization in nursing.

Analgesics↗

PubMed2004

The mentally ill and social exclusion: a critical examination of the use of seclusion from the patient's perspective.

Nurses in psychiatric settings have an important role to play in the application of seclusion, a measure that continues to be a frequently used intervention for the management of disturbing patient behaviours. Albeit a controversial measure, isolating patients remains a common institutional practice that has received widespread attention from a political, ethical, legal, and clinical standpoint. Although there is an abundance of scientific work on the subject, few studies have examined the experience of patients being confined. In order to improve the quality of nursing care surrounding this measure it appeared essential to obtain data on patients' perspectives, information deemed valuable in orienting nursing interventions. This qualitative study, guided by a phenomenological research design, aimed at describing and gaining a better understanding of patients with a severe and persistent psychiatric disorder who were placed in a seclusion room while hospitalized on a closed psychiatric unit. Using a semi-structured, non-directive interview format, a total of six patients participated in this study. Content analysis of participants' narratives yielded three main themes that appeared to be central to their experience of seclusion: their experience of seclusion on an emotional level, their perception of this intervention, and how they coped during their stay in the seclusion room. Major findings emerging from this nursing study centred on the following dimensions: patients' perceptions of seclusion as a punitive measure and a modality for social control and, the experience of seclusion serving as an intensification of already existing feelings of exclusion, rejection, abandonment, and isolation. In addition the findings also suggest that it is not seclusion per se that impacts on their negative perception and negative emotional experience but rather the lack of nurse-patient contact during the seclusion experience. Furthermore, whether patients coped by regressing, acting out, or taking on a more compliant stance, they appeared to be motivated by a need to connect with staff. This points to the importance of the relational aspects of nursing care when applying this restrictive measure. A need for modifying the institutional culture surrounding seclusion and transforming nursing practices are discussed as are future research endeavours.

Adaptation, Psychological↗

PubMedDate not supplied

Perspectives on assessment. Continuing the conversation.

Throughout this series, emphasis has been placed on positioning assessment centrally to the process of community-based nursing education and practice reform. Developing an ongoing program of assessment at the local level, in both educational and practice institutions, serves as a frame for the necessary conversations we must be having with each other. How are we doing in our effort to prepare nurses to practice in an environment where the only constant seems to be change? This article, the last in the series, addresses ways to structure our conversations into a program of assessment. It also suggests community stakeholders who might be included in our assessment conversations, as well as alternative assessment methods worthy of consideration.

Curriculum↗

PubMed2001

Industrial-waste management in developing countries: the case of Lebanon.

This paper presents a critical assessment of the existing Lebanese industrial sector, namely the current status and classification of industrial establishments based on a comparative synthesis and analysis of recent nationwide surveys and studies pertaining to industrial-waste management. Characterisation of solid and liquid industrial wastes generated, including hazardous wastes, is presented together with current and projected waste loads, recycling opportunities, and export/import practices. Institutional capacity and needs pertaining to the enforcement of relevant environmental legislation, staffing and resources, monitoring schemes, and public participation are critically evaluated. Finally, realistic options for industrial-waste management in the context of country-specific institutional economic and technical limitations are outlined. The industrial sector in Lebanon consists of small-scale industries (84% employ less than 10 persons), primarily involved in light manufacturing (96%). These industries which are distributed among 41 ill-defined zones and deficient in appropriate physical infrastructure, generate solid, liquid, and hazardous waste estimated at 346,730 tons/year, 20,169,600 m3/year and between 3000 to 15,000 tons/year, respectively. Although the growth of this sector contributes significantly to the socio-economic development of the country (industry accounts for 17% of the gross domestic product), in the absence of a comprehensive environmental management plan, this expansion may not be sustained into the coming millennium. The anticipated expansion will inevitably amplify adverse environmental impacts associated with industrial activities due to rising waste volumes and improper waste handling and disposal practices. These impacts are further aggravated by a deficient institutional framework, a lack of adequate environmental laws, and lax enforcement of regulations governing industrial-waste management.

Environmental Pollution↗