Making health care safer: a critical analysis of patient safety practices.
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OBJECTIVES: Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety. SEARCH STRATEGY AND SELECTION CRITERIA: Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions. Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation. This process resulted in the identification of 79 practices for review. The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients. Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice. Pertinent studies were identified using various bibliographic databases (e.g., MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts. DATA COLLECTION AND ANALYSIS: Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature." For most practices, the project team required that the primary outcome consist of a clinical endpoint (i.e., some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality. This criterion was relaxed for some practices drawn from the non-health care literature. The evidence supporting each practice was summarized using a prospectively determined format. The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries. A separate ranking was developed for research priorities. MAIN RESULTS: Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery. Many patient safety practices drawn primarily from nonmedical fields (e.g., use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment. The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections. CONCLUSIONS: An evidence-based approach can help identify practices that are likely to improve patient safety. Such practices target a diverse array of safety problems. Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care. (+info)
Clinical and economic impact of new trends in glaucoma treatment.
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CONTEXT: Glaucoma is a chronic ophthalmic condition affecting approximately 15 million people. Several therapies are currently available (eg, beta-blockers, sympathomimetics, carbonic anhydrase inhibitors) but have side effects that may limit use. Over the last few years, new medications with improved efficacy and side-effect profiles have become available. This analysis evaluates 2 therapies, brimonidine and betaxolol, based on head-to-head clinical trial data to determine clinical consequences and their related expected costs. OBJECTIVE: To calculate comparative costs and the cost-effectiveness of brimonidine 0.2% and betaxolol 0.25% as first-line therapy for patients with primary open-angle glaucoma. DESIGN: Safety, efficacy, effectiveness, and quality-of-life data were collected in a multicenter, randomized, double-blind, head-to-head comparative effectiveness study, with a drug switch possibility. A disease-intervention model (decision tree) was developed with clinicians, academicians, and health economists. Components of care for each pathway in the model were identified and evaluated; their costs were applied at appropriate points throughout the tree. Expected outcomes and costs were computed and compared. PATIENTS: Participants were men (n = 76) and women (n = 112), 21 years of age or older, with newly diagnosed or currently untreated ocular hypertension or open-angle glaucoma. RESULTS: The clinical success rates of first-line brimonidine 0.2% and betaxolol 0.25% are 73.9% and 56.2%, respectively, as determined in a head-to-head comparative effectiveness trial. Total expected costs for patients receiving brimonidine and betaxolol as a primary therapy are $301.37 and $328.19, respectively, based on the model. Dividing costs by outcomes, the cost-effectiveness ratios for brimonidine and betaxolol are $407.81 ($301.37/0.739) and $583.97 ($328.19/0.562), respectively, representing the cost/unit outcome, or the cost to achieve clinical success. CONCLUSIONS: Brimonidine 0.2% is less costly and more cost-effective than betaxolol 0.25% when used as initial monotherapy with and without subsequent add-on therapies, including laser treatments and/or surgery, as needed. (+info)
The HCA National Disease Management Program for coronary disease detection and treatment in women.
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The diagnosis and treatment of heart disease in women continues to be one of the greatest challenges facing cardiovascular medicine today. Marked reductions in mortality rates during the past 2 decades did not result in improved outcomes for women. A major rate-limiting step to improving mortality rates for women is early diagnosis and initiation of effective lifesaving therapies for women. In 1999, HCA Healthcare Systems, Inc, Nashville, TN, initiated a coordinated effort among 208 hospitals in 26 states to improve the diagnosis of coronary disease and to target women who should receive aggressive risk factor modification and referral to cardiologists. We describe the initial phases of program development, including employee risk factor screening; citywide health risk assessment; nationwide educational programs for clinicians, staff, and consumers; and a dedicated outcomes assessment program for tracking women at risk for coronary disease. We believe that these efforts provide a venue for optimal care and improved outcomes for women served by HCA facilities. (+info)
The participation of pharmacists in a team to introduce a clinical pathway to laparoscopic cystectomy in obstetrics and gynecology.
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In the Department of Obstetrics and Gynecology at our hospital, a team of doctors, pharmacists, nurses, and other medical staff was established to prepare a clinical pathway for laparoscopic cystectomy. Various data on clinical charts including the use of drugs were collected from 57 patients by pharmacists and nurses. Based on the analysis of these data, hospitalization period, method of preoperative bowel preparation, time to initiation of food intake, duration of antibiotic administration, and time and content of pharmaceutical instructions to patients of dosage and administration were determined. Criteria for variances requiring the doctor's directions were determined for fever, wound pain, and vomiting. The clinical pathway established here allows of not only the efficient and uniform care of patients, but also the active exchange of opinions among members of the medical team. Moreover, most patients who replied to a questionnaire said that they were at ease during hospitalization because they had received detailed information about the clinical pathway including the use of drugs before surgery. Thus, the participation of pharmacists on a medical team that is introducing a clinical pathway is particularly important because the use of drugs and pharmaceutical care are an important part of good patient care. (+info)
Integrated care pathways for vascular surgery: an analysis of the first 18 months.
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OBJECTIVES: A review of the use of previously described integrated care pathways (ICPs) established for three elective vascular surgical procedures. DESIGN: A retrospective analysis of information gathered prospectively over an initial 18 month period of use of vascular surgical ICPs. SUBJECT: Patients admitted to a single vascular unit for "open" repair of abdominal aortic aneurysm (AAA), carotid endarterectomy, or femoropopliteal bypass grafting. METHODS: An analysis of variance data, length of stay, and costings after the use of ICPs, compared with previous clinical practice. RESULTS: Variance data were gathered for each of the three procedures. Variances of medication prescribing and delays in discharge were common to all procedures. In particular: (i) gastrointestinal complications were more specific to AAA repair and (ii) wound drains were removed a day later than originally proposed after femoropopliteal bypass. Overall, improved efficiency due to use of ICPs reduced the length of stay for all procedures, which was reflected in a potential cost saving of some 25%. CONCLUSION: There are clear benefits to the use of ICPs, resulting in more structured, efficient, and cost effective patient care. Recommended changes to current practice based on variance analysis will require continued audit to sustain this "evidence based" approach. (+info)
The effect of a critical pathway on patients' outcomes after carotid endarterectomy.
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BACKGROUND: In 1996, an integrated plan of care was implemented to improve quality of care for patients undergoing elective carotid endarterectomy. Goals were to reduce length of stay, costs, number of preoperative and intensive care unit admissions, and use of diagnostic procedures yet maintain good outcomes. OBJECTIVES: To determine whether use of the integrated plan of care met the goals. METHODS: Data on financial and process outcomes, use of angiographic diagnostic procedures, and demographics were retrieved from the hospital's database for all patients who had elective carotid endarterectomy without cerebral infarction. RESULTS: A total of 783 patients met inclusion criteria: 129 before implementation of the plan of care, 66 during the 6-month transition, and 588 after implementation. Preoperative angiography was done in 32% of patients before implementation, 11% during the transition, and 4% after implementation. Percentages of patients admitted to the intensive care unit were 77% before implementation, 24% during transition, and 9% after implementation. Mean lengths of stay were 2.93 days before implementation, 2.12 days during transition, and 1.68 days after implementation. Costs per case were $7798 before implementation, $5750 during transition, and $5387 after implementation. Analysis of variance revealed significant differences between groups in total length of stay (P = .001), preoperative length of stay (P<.001), and costs (P<.001). CONCLUSION: Use of the integrated plan of care reduced length of stay, costs, admissions to intensive care units, and use of cerebral angiography. Use of the plan improved resource utilization while maintaining quality of care. (+info)
Improving outcomes following penetrating colon wounds: application of a clinical pathway.
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INTRODUCTION: During World War II, failure to treat penetrating colon injuries with diversion could result in court martial. Based on this wartime experience, colostomy for civilian colon wounds became the standard of care for the next 4 decades. Previous work from our institution demonstrated that primary repair was the optimal management for nondestructive colon wounds. Optimal management of destructive wounds requiring resection remains controversial. To address this issue, we performed a study that demonstrated risk factors (pre or intraoperative transfusion requirement of more than 6 units of packed red blood cells, significant comorbid diseases) that were associated with a suture line failure rate of 14%, and of whom 33% died. Based on these outcomes, a clinical pathway for management of destructive colon wounds was developed. The results of the implementation of this pathway are the focus of this report. METHODS: Patients with penetrating colon injury were identified from the registry of a level I trauma center over a 5-year period. Records were reviewed for demographics, injury characteristics, and outcome. Patients with nondestructive injuries underwent primary repair. Patients with destructive wounds but no comorbidities or large transfusion requirement underwent resection and anastomosis, while patients with destructive wounds and significant medical illness or transfusion requirements of more than 6 units/blood received end colostomy. The current patients (CP) were compared to the previous study (PS) to determine the impact of the clinical pathway. Outcomes examined included colon related mortality and morbidity (suture line leak and abscess). RESULTS: Over a 5.5-year period, 231 patients had penetrating colon wounds. 209 survived more 24 hours and comprise the study population. Primary repair was performed on 153 (73%) patients, and 56 patients had destructive injuries (27%). Of these, 40 (71%) had resection and anastomosis and 16 (29%) had diversion. More destructive injuries were managed in the CP group (27% vs. 19%). Abscess rate was lower in the CP group (27% vs. 37%), as was suture line leak rate (7% vs. 14%). Colon related mortality in the CP group was 5% as compared with 12% in the PS group. CONCLUSIONS: The clinical pathway for destructive colon wound management has improved outcomes as measured by anastomotic leak rates and colon related mortality. The data demonstrated the need for colostomy in the face of shock and comorbidities. Institution of this pathway results in colostomy for only 7% of all colon wounds. (+info)
Combination antipsychotics: pros, cons, and questions.
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In prescription surveys, use of combination antipsychotics is common and is increasing, despite little supporting evidence. This article highlights potential problems with using combination antipsychotics, discusses paths to their maintenance use, and reviews the efficacy evidence. Paths to maintenance antipsychotic combinations include (1) failure or patient refusal of all reasonable monotherapies, (2) indefinite continuation of combinations initially intended to be brief, (3) trials of combinations in preference to reasonable monotherapy trials, and (4) addition of a second antipsychotic to counteract a problem (safety, tolerability, or adherence) arising during successful monotherapy. Virtually all of the evidence on combination antipsychotics is on augmentation of clozapine, with only one randomized controlled trial. Research on combination antipsychotics is sorely needed. Designing clinical trials is made difficult by the very large numbers of possible combinations and doses. It may be feasible to analyze existing data bases to identify combinations that appear particularly promising to investigate. (+info)