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(1/2766) The impact of a multidisciplinary approach on caring for ventilator-dependent patients.

OBJECTIVE: To determine the clinical and financial outcomes of a highly structured multidisciplinary care model for patients in an intensive care unit (ICU) who require prolonged mechanical ventilation. The structured model outcomes (protocol group) are compared with the preprotocol outcomes. DESIGN: Descriptive study with financial analysis. SETTING: A twelve-bed medical-surgical ICU in a non-teaching tertiary referral center in Ogden, Utah. STUDY PARTICIPANTS: During a 54 month period, 469 consecutive intensive care patients requiring mechanical ventilation for longer than 72 hours who did not meet exclusion criteria were studied. INTERVENTIONS: A multidisciplinary team was formed to coordinate the care of ventilator-dependent patients. Care was integrated by daily collaborative bedside rounds, monthly meetings, and implementation of numerous guidelines and protocols. Patients were followed from the time of ICU admission until the day of hospital discharge. MAIN OUTCOME MEASURES: Patients were assigned APACHE II scores on admission to the ICU, and were divided into eight diagnostic categories. ICU length of stay, hospital length of stay, costs, charges, reimbursement, and in-hospital mortality were measured. RESULTS: Mortality in the preprotocol and protocol group, after adjustment for APACHE II scores, remained statistically unchanged (21-23%). After we implemented the new care model, we demonstrated significant decreases in the mean survivor's ICU length of stay (19.8 days to 14.7 days, P= 0.001), hospital length of stay (34.6 days to 25.9 days, P=0.001), charges (US$102500 to US$78500, P=0.001), and costs (US$71900 to US$58000, P=0.001). CONCLUSIONS: Implementation of a structured multidisciplinary care model to care for a heterogeneous population of ventilator-dependent ICU patients was associated with significant reductions in ICU and hospital lengths of stay, charges, and costs. Mortality rates were unaffected.  (+info)

(2/2766) Solving stubborn-wound problem could save millions, team says.

Why do some wounds refuse to heal? A team in London, Ont., is attempting to determine the cellular and molecular clues that could lead to better treatment of recalcitrant wounds.  (+info)

(3/2766) Ward pharmacy: a foundation for prescribing audit?

OBJECTIVES: To determine the extent and nature of prescription monitoring incidents by hospital pharmacists and to derive a performance indicator to allow prescription monitoring to be compared among hospitals in North West Thames region. DESIGN: Survey of all self recorded prescription monitoring incidents for one week in June 1990. SETTING: All (31) acute hospitals in the region with pharmacy departments on site, covering 10,337 beds. SUBJECTS: 210 pharmacists. MAIN MEASURES: Number of prescription monitoring incidents recorded, their nature, and outcome; a performance indicator of prescription monitoring (incidents/100 beds/week) and its variation according to specialty and site. RESULTS: 3273 prescription monitoring incidents were recorded (median 89 per hospital, range 3-301), the most common being related to the dose and frequency of administration of the drug (933 incidents, 29%). These incidents led to alterations of prescriptions on 1611 occasions; the pharmacist's advice was rejected on 81. The greatest number of prescription monitoring incidents/100 beds/week by specialty was recorded for intensive therapy units (median 75); the medians for medicine and surgery were 32 and 21 respectively. This performance indicator varied 20-fold when analysed by site, values ranging from 3.6 to 82.1 (median 29.8). CONCLUSIONS: Hospital pharmacists play a large part in monitoring and improving prescribing, and most of their interventions are related to the basics of prescribing. They therefore have a role in medical audit, working with clinicians to identify prescribing problems, and to set standards and monitor practice. A performance indicator of prescription monitoring incidents/100 beds/week allows comparison of pharmacists' activities among sites and may be a valuable tool in auditing them.  (+info)

(4/2766) Paediatric home care in Tower Hamlets: a working partnership with parents.

OBJECTIVES: To describe the first two years of a paediatric home care service. DESIGN: Observational cross sectional study, 1989-91. SETTING: One inner London health district. PATIENTS: 611 children referred to the service; 50 children selected from those referred during the first year, whose parents were interviewed and whose general practitioners were invited to complete a questionnaire. MAIN MEASURES: Description and costs of service; views of parents and general practitioners of selected sample of children. RESULTS: In its second year the team received 303 referrals and made 4004 visits at a salary cost of 98000 pounds, an average of 323 pounds/referral and 24 pounds/visit. This represented a referral rate of 3.2% (258/7939) of inpatient episodes from the main referring hospital between 1 December 1989 and 30 November 1990. Of all referrals to the service, 343(56%) came from hospital inpatient wards. The service was used by disadvantaged and ethnic minority families. The children's parents (in 28(61%) families) and the home care team did a wide range of nursing tasks in the home. Parents of 47(94%) children sampled agreed to be interviewed, and those of 43(91%) found the service useful; guidance and support were most commonly appreciated (33, 70%). Parents of 25(53%) children said that hospital stay or attendance had been reduced or avoided. Parents and general practitioners disagreed on clinical responsibility in 10 children, and communication was a problem for some general practitioners. CONCLUSIONS: The service enabled children to receive advanced nursing care at home. Clinical responsibility should be agreed between parents and professionals at referral.  (+info)

(5/2766) Diabetes care.

Providing good quality diabetes care is complex but achievable. Many aspects of the care do not require high tech medicine but, rather, good organisation. Diabetes is a costly disease, consuming 1500 pounds per diabetic patient per year versus 500 pounds on average for a non-diabetic member of the population in health service costs. Investment now in good quality diabetes care is sound: patients will benefit from a better quality of life associated with a reduced incidence of the complications of diabetes and the direct costs to the health service in treating these complications and the indirect costs to employers will be reduced. Physical and clinical assessments--measurements of blood glucose and glycosylated haemoglobin concentrations, weight, and blood pressure and assessment of eyes, kidneys, feet, and heart--are clearly important, but quality must include consideration of people and their reactions to life and diabetes--a lifelong entanglement--for which much more support should be provided.  (+info)

(6/2766) The dangers of managerial perversion: quality assurance in primary health care.

The promotion of primary health care (PHC) at the Alma Ata conference has been followed by a variety of managerial initiatives in support of the development of PHC. One of the more promising vehicles has been the implementation of quality assurance mechanisms. This paper reviews recent examples of this genre and argues that the thrust of both primary health care and quality assurance are in danger of being distorted by a rather antiquated approach to management.  (+info)

(7/2766) Understanding adverse events: human factors.

(1) Human rather than technical failures now represent the greatest threat to complex and potentially hazardous systems. This includes healthcare systems. (2) Managing the human risks will never be 100% effective. Human fallibility can be moderated, but it cannot be eliminated. (3) Different error types have different underlying mechanisms, occur in different parts of the organisation, and require different methods of risk management. The basic distinctions are between: Slips, lapses, trips, and fumbles (execution failures) and mistakes (planning or problem solving failures). Mistakes are divided into rule based mistakes and knowledge based mistakes. Errors (information-handling problems) and violations (motivational problems) Active versus latent failures. Active failures are committed by those in direct contact with the patient, latent failures arise in organisational and managerial spheres and their adverse effects may take a long time to become evident. (4) Safety significant errors occur at all levels of the system, not just at the sharp end. Decisions made in the upper echelons of the organisation create the conditions in the workplace that subsequently promote individual errors and violations. Latent failures are present long before an accident and are hence prime candidates for principled risk management. (5) Measures that involve sanctions and exhortations (that is, moralistic measures directed to those at the sharp end) have only very limited effectiveness, especially so in the case of highly trained professionals. (6) Human factors problems are a product of a chain of causes in which the individual psychological factors (that is, momentary inattention, forgetting, etc) are the last and least manageable links. Attentional "capture" (preoccupation or distraction) is a necessary condition for the commission of slips and lapses. Yet, its occurrence is almost impossible to predict or control effectively. The same is true of the factors associated with forgetting. States of mind contributing to error are thus extremely difficult to manage; they can happen to the best of people at any time. (7) People do not act in isolation. Their behaviour is shaped by circumstances. The same is true for errors and violations. The likelihood of an unsafe act being committed is heavily influenced by the nature of the task and by the local workplace conditions. These, in turn, are the product of "upstream" organisational factors. Great gains in safety can ve achieved through relatively small modifications of equipment and workplaces. (8) Automation and increasing advanced equipment do not cure human factors problems, they merely relocate them. In contrast, training people to work effectively in teams costs little, but has achieved significant enhancements of human performance in aviation. (9) Effective risk management depends critically on a confidential and preferable anonymous incident monitoring system that records the individual, task, situational, and organisational factors associated with incidents and near misses. (10) Effective risk management means the simultaneous and targeted deployment of limited remedial resources at different levels of the system: the individual or team, the task, the situation, and the organisation as a whole.  (+info)

(8/2766) How patients perceive the role of hospital chaplains: a preliminary exploration.

OBJECTIVE: An exploratory study of the attitudes of hospital patients to the service provided by hospital chaplains. DESIGN: Questionnaire study of hospital inpatients in December 1992. SETTING: One large teaching hospital in London. PATIENTS: 180 hospital inpatients in 14 different general wards, 168 (93%) of whom agreed to take part. MAIN MEASURES: Attitudes to chaplains and their role contained in 12 questions developed during a pilot study on hospital inpatients (16) and staff (14) and their relation to patients' age, sex, length of hospital stay, and religious beliefs, according to Kendall rank order correlations. RESULTS: Of 168(93%) respondents, 72(43%) were women; mean age of patients was 63.1 (SD 16.8) years. Forty five (27%) were inpatients of three days or less and 22(13%) for one month or more. 136(81%) were Christian; 17(10%) atheist, agnostic, or had no religion; and 15(9%) were of other religions. In general, patients showed positive attitudes towards the role of hospital chaplains and to the services they provided. The correlation analysis showed that there was a significant tendency for older patients, those who had been inpatients for longer, and those with religious beliefs to be more sympathetic to the role of hospital chaplains. CONCLUSIONS: Hospital chaplains provide a service which is appreciated by patients. This study provides a simple instrument for assessing patients' attitudes to chaplains.  (+info)