Can admission notes be improved by using preprinted assessment sheets?
(1/18)
Inpatient medical notes often fail to record important details of patient history and findings on clinical examination. To overcome problems with content and legibility of notes we introduced preprinted notes for the admission of children to this hospital. The quality of the information recorded for 100 children whose admissions were clerked with the preprinted notes was compared with that recorded for 100 whose admissions were recorded with the traditional notes. All case notes were selected randomly and retrospectively from traditional notes written from April to October 1993 and from preprinted notes written from October 1993 to April 1994. The quality of information was assessed according to the presence or absence of 25 agreed core clinical details and the number of words per clerking. In admissions recorded with the preprinted notes the mean number of core clinical details present was significantly higher than those recorded with traditional notes (24.0 v 17.6, p < 0.00001). Admissions recorded with the preprinted notes were also significantly shorter (mean 144 words v 184 words, p < 0.0001). The authors conclude that information about children admitted to hospital is both more complete and more succinct when recorded using preprinted admission sheets. (+info)
The Sheffield experiment: the effects of centralising accident and emergency services in a large urban setting.
(2/18)
OBJECTIVES: To assess the effects of centralisation of accident and emergency (A&E) services in a large urban setting. The end points were the quality of patient care judged by time to see a doctor or nurse practitioner, time to admission and the cost of the A&E service as a whole. METHODS: Sheffield is a large industrial city with a population of 471000. In 1994 Sheffield health authority took a decision to centralise a number of services including the A&E services. This study presents data collected over a three year period before, during and after the centralisation of adult A&E services from two sites to one site and the centralisation of children's A&E services to a separate site. A minor injury unit was also established along with an emergency admissions unit. The study used information from the A&E departments' computer system and routinely available financial data. RESULTS: There has been a small decrease in the number of new patient attendances using the Sheffield A&E system. Most patients go to the correct department. The numbers of acute admissions through the adult A&E have doubled. Measures of process efficiency show some improvement in times to admission. There has been measurable deterioration in the time to be seen for minor injuries in the A&E departments. This is partly offset by the very good waiting time to be seen in the minor injuries unit. The costs of providing the service within Sheffield have increased. CONCLUSION: Centralisation of A&E services in Sheffield has led to concentration of the most ill patients in a single adult department and separate paediatric A&E department. Despite a greatly increased number of admissions at the adult site this change has not resulted in increased waiting times for admission because of the transfer of adequate beds to support the changes. There has however been a deterioration in the time to see a clinician, especially in the A&E departments. The waiting times at the minor injury unit are very short. (+info)
Improving the quality of the admission process in a French psychiatric hospital: impact on the expertise of the professional team.
(3/18)
INTRODUCTION: A 20-month quality improvement project was undertaken in order to improve the patient admission process at a 350-bed French public psychiatric hospital. In addition to improving the quality of patient admissions, the project was expected to increase the expertise of quality improvement team members. METHODS: The project team consisted of two physicians, three heads of nursing, one senior manager, one member of the admissions staff and one secretary. A pharmacist acted as internal facilitator. The team used problem-solving methodology to identify and correct any shortcomings in the existing admission process. Validated data were collected before and after implementation of corrective actions. The team was trained to become more effective on the basis of a published how-to manual for building an effective work team. Team effectiveness was compared before and after the project. RESULTS: Changes in relevant variables were as follows: (i) patients going through the admissions department (40% after corrective action, versus 20% before); (ii) no delay in admission formalities for patients entering hospital by long-standing arrangement (100% versus 20%); and (iii) no delay in admission formalities for patients whose hospitalisation was not predetermined but foreseen (45% versus 0%). The expertise of team members improved in terms of the four tested items: meeting customers' needs and expectations (P< 2 x 10(-6)); contribution of the team to the internal quality improvement strategy (P< 0.01); understanding of the methodology (P< 0.04) and accountability (P< 2 x 10(-5)). Improvements in adherence to the mission statement were also observed. A total of 728 hours were spent on project management. DISCUSSION: Objective improvements were achieved; in particular, the team was shown to have become more effective. The extent to which the lessons learned here can be extrapolated may depend on the openness to change of members of other project teams. CONCLUSION: This project demonstrated that it is possible to put theory into action and thereby make progress. In order to advance further, a second quality improvement project is planned. (+info)
Booked inpatient admissions and hospital capacity: mathematical modelling study.
(4/18)
OBJECTIVES: To investigate the variability of patients' length of stay in intensive care after cardiac surgery. To investigate potential interactions between such variability, booked admissions, and capacity requirements. DESIGN: Mathematical modelling study using routinely collected data. SETTING: A cardiac surgery department. SOURCE OF DATA: Hospital records of 7014 people entering intensive care after cardiac surgery. MAIN OUTCOME MEASURES: Length of stay in intensive care; capacity requirements of an intensive care unit for a hypothetical booked admission system. RESULTS: Although the vast majority of patients (89.5%) had a length of stay in intensive care of < or = 48 hours, there was considerable overall variability and the distribution of stays has a lengthy tail. A mathematical model of the operation of a hypothetical booking system indicates that such variability has a considerable impact on intensive care capacity requirements, indicating that a high degree of reserve capacity is required to avoid high rates of operation cancellation because of unavailability of suitable postoperative care. CONCLUSION: Despite the considerable enthusiasm for booked admissions systems, queuing theory suggests that caution is required when considering such systems for inpatient admissions. Such systems may well result in frequent operational difficulties if there is a high degree of variability in length of stay and where reserve capacity is limited. Both of these are common in the NHS. (+info)
How evidence based are therapeutic decisions taken on a medical admissions unit?
(5/18)
OBJECTIVES: To audit the proportion of drug treatments started on a medical admissions unit that is justified by published evidence, and the proportion for which no justification could be found. METHODS: Retrospective review of randomly selected case notes to identify drug treatments started and the problem(s) for which they were prescribed, followed by literature searches. RESULTS: A total of 132 treatment-problem pairs were found, comprising 85 unique treatment-problem pairs. An evidence base was found in support of 78 of the treatments started (59.1%). A further 41 treatment-problem pairs could be argued to be reasonable practice (sometimes included in guidelines), even though no published trial data support them. Ninety per cent of drug treatments started on the medical admissions unit have either an evidence base or are accepted practice. CONCLUSIONS: Regular audit of this nature could be carried out on units admitting acute medical patients. Similar audits in internal medicine have delivered consistent results (50%-60%); there is a baseline level against which units can compare themselves. Clinical audit is an integral feature of clinical governance; all wards admitting acute medial patients could conduct similar audits on a random sample of patients. (+info)
Post-endoscopy checklist reduces length of stay for non-variceal upper gastrointestinal bleeding.
(6/18)
OBJECTIVE: To examine the effect of improved gastroenterologist-to-admitting service communication on hospital stay for upper gastrointestinal bleeding. HYPOTHESIS: a detailed checklist addressing factors relevant to discharge planning would shorten hospital stay, when added to the procedure report. DESIGN: Pre-post intervention design, recording balance measures (potential confounders). SETTING: A Canadian university hospital. STUDY PARTICIPANTS: Intermittent 5- to 7-day batches of consecutive emergency patients presenting with non-variceal upper gastrointestinal bleeding as their primary problem. The durations of the background and intervention periods were 3 months (beginning 9 June 2003) and 4 weeks (beginning 8 September 2003), respectively. INTERVENTION: The gastrointestinal bleeding Quality Improvement and Health Information multidisciplinary team (quality improvement personnel; emergency physicians, hospitalists, gastroenterologists, in-patient and endoscopy nurses) developed a one-page checklist, outlining detailed recommendations (3-Ds-diet, drugs, discharge plan) to append to the procedure report. MAIN OUTCOME MEASURES: Difference in median length of hospital stay was the primary endpoint. As balance measures, demographics, bleeding severity, comorbidities, readmission rates, and various benchmark times were recorded prospectively. RESULTS: Thirty-nine patients met the criteria in the background period (4 months, intermittently sampled), and 22 in the intervention period (4 weeks, continuously sampled). There were no significant baseline differences. Median in-patient stay was 7.0 (95% interquartile range 2-24) versus 3.5 (95% interquartile range 1-12) days for the background and intervention periods, respectively (P = 0.003). This remained significant when outliers (stay > 10 days) were removed (P = 0.02). CONCLUSION: A checklist, with very specific recommendations to the admitting service, significantly reduced hospital stay for non-variceal gastrointestinal bleeding. (+info)
The anatomy of decision support during inpatient care provider order entry (CPOE): empirical observations from a decade of CPOE experience at Vanderbilt.
(7/18)
The authors describe a pragmatic approach to the introduction of clinical decision support at the point of care, based on a decade of experience in developing and evolving Vanderbilt's inpatient "WizOrder" care provider order entry (CPOE) system. The inpatient care setting provides a unique opportunity to interject CPOE-based decision support features that restructure clinical workflows, deliver focused relevant educational materials, and influence how care is delivered to patients. From their empirical observations, the authors have developed a generic model for decision support within inpatient CPOE systems. They believe that the model's utility extends beyond Vanderbilt, because it is based on characteristics of end-user workflows and on decision support considerations that are common to a variety of inpatient settings and CPOE systems. The specific approach to implementing a given clinical decision support feature within a CPOE system should involve evaluation along three axes: what type of intervention to create (for which the authors describe 4 general categories); when to introduce the intervention into the user's workflow (for which the authors present 7 categories), and how disruptive, during use of the system, the intervention might be to end-users' workflows (for which the authors describe 6 categories). Framing decision support in this manner may help both developers and clinical end-users plan future alterations to their systems when needs for new decision support features arise. (+info)
Exploring if day and time of admission is associated with average length of stay among inpatients from a tertiary hospital in Singapore: an analytic study based on routine admission data.
(8/18)
BACKGROUND: It has been postulated that patients admitted on weekends or after office hours may experience delays in clinical management and consequently have longer length of stay (LOS). We investigated if day and time of admission is associated with LOS in Tan Tock Seng Hospital (TTSH), a 1,400 bed acute care tertiary hospital serving the central and northern regions of Singapore. METHODS: This was a historical cohort study based on all admissions from TTSH from 1st September 2003 to 31st August 2004. Data was extracted from routinely available computerized hospital information systems for analysis by episode of care. LOS for each episode of care was log-transformed before analysis, and a multivariate linear regression model was used to study if sex, age group, type of admission, admission source, day of week admitted, admission on a public holiday or eve of public holiday, admission on a weekend and admission time were associated with an increased LOS. RESULTS: In the multivariate analysis, sex, age group, type of admission, source of admission, admission on the eve of public holiday and weekends and time of day admitted were independently and significantly associated with LOS. Patients admitted on Friday, Saturday or Sunday stayed on average 0.3 days longer than those admitted on weekdays, after adjusting for potential confounders; those admitted on the eve of public holidays, and those admitted in the afternoons and after office hours also had a longer LOS (differences of 0.71, 1.14 and 0.65 days respectively). CONCLUSION: Cases admitted over a weekend, eve of holiday, in the afternoons, and after office hours, do have an increased LOS. Further research is needed to identify processes contributing to the above phenomenon. (+info)