Improving management of asthma: closing the loop or progressing along the audit spiral?
OBJECTIVE: To assess whether the management of asthma has improved from three consecutive surveys. DESIGN: Retrospective case note survey of acute asthma admissions in 1983 and 1989; case notes selected from 1985-6 survey of prospectively identified patients to include only patients with a final discharge code of asthma. SETTING: A large city teaching hospital. Patients--101 patients with acute asthma as the primary diagnosis in 1983; 85 in 1985-6; and 133 in 1989, 14 of whom were subsequently transferred elsewhere. MAIN MEASURES: Conformity with a checklist of important aspects of the process of asthma management including initial assessment, treatment, supervision, and discharge and review arrangements. RESULTS: All patient groups were similar in age, smoking habit, and stay in hospital and, as an objective guide to severity of asthma, had similar initial pulse rates. Major improvements occurred in management: by 1989, 119(90%) patients were treated with oral corticosteroids (69(68%), 67(79%) in 1983, 1985-6 respectively) and 109(82%) with oxygen (62(61%), 51(60%)) (both p < 0.001). 114(86%) had regular recording of peak flow measurements (53(52%), 54(64%); p < 0.001), and 103/119(86%) were discharged taking oral corticosteroids (66(65%), 63(74%); p < 0.01). Significantly fewer patients, however, had their regular inhaled corticosteroid treatment increased on discharge (38/119(32%) v 53(52%), 39(46%); p < 0.01), but more were receiving high dose inhaled treatment on admission. CONCLUSIONS: The management of asthma improved significantly, and the normal practice of doctors has changed in an area of practice with longstanding problems. (+info)
National audit of acute severe asthma in adults admitted to hospital. Standards of Care Committee, British Thoracic Society.
OBJECTIVE: To ascertain the standard of care for hospital management of acute severe asthma in adults. DESIGN: Questionnaire based retrospective multicentre survey of case records. SETTING: 36 hospitals (12 teaching and 24 district general hospitals) across England, Wales, and Scotland. PATIENTS: All patients admitted with acute severe asthma between 1 August and 30 September 1990 immediately before publication of national guidelines for asthma management. MAIN MEASURES: Main recommendations of guidelines for hospital management of acute severe asthma as performed by respiratory and non-respiratory physicians. RESULTS: 766 patients (median age 41 (range 16-94) years) were studied; 465 (63%) were female and 448 (61%) had had previous admissions for asthma. Deficiencies were evident for each aspect of care studied, and respiratory physicians performed better than non-respiratory physicians. 429 (56%) patients had had their treatment increased in the two weeks preceding the admission but only 237 (31%) were prescribed oral steroids. Initially 661/766 (86%) patients had peak expiratory flow measured and recorded but only 534 (70%) ever had arterial blood gas tensions assessed. 65 (8%) patients received no steroid treatment in the first 24 hours after admission. Variability of peak expiratory flow was measured before discharge in 597/759 (78%) patients, of whom 334 (56%) achieved good control (variability < 25%). 47 (6%) patients were discharged without oral or inhaled steroids; 182/743 (24%) had no planned outpatient follow up and 114 failed to attend, leaving 447 (60%) seen in clinic within two months. Only 57/629 (8%) patients were recorded as having a written management plan. CONCLUSIONS: The hospital management of a significant minority of patients deviates from recommended national standards and some deviations are potentially serious. Overall, respiratory physicians provide significantly better care than non-respiratory physicians. (+info)
Survey of non-invasive ventilation (NIPPV) in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) in the UK.
BACKGROUND: Non-invasive positive pressure ventilation (NIPPV) has been shown to be beneficial in the treatment of acute exacerbations of chronic obstructive pulmonary disease (COPD) complicated by respiratory failure. A survey was undertaken to assess the availability of NIPPV for the treatment of acute exacerbations of COPD and to determine how NIPPV is delivered in hospitals in the UK. METHODS: A questionnaire was sent to consultants with an interest in respiratory medicine from 268 of the hospitals found in the BTS directory. The questionnaire enquired about the hospital as well as the availability of NIPPV in the hospital. If NIPPV was available in the hospital, details of implementation, staffing and funding were determined. RESULTS: Replies to the questionnaire were received from 98.5% of consultants. NIPPV was available in 48% of hospitals, these hospitals tending to serve larger populations and to have more respiratory physicians than the hospitals where NIPPV was not available. There was considerable regional variation in the availability of NIPPV. In hospitals where NIPPV was not available the reason(s) were lack of consultant training in 53%, lack of other staff training in 63%, financial in 63%, and doubt about the benefit of NIPPV in 15% of cases. In those hospitals where NIPPV was available, clinical practice varied greatly: 68% of centres treated fewer than 20 patients a year with this form of treatment and 9% treated more than 60 patients a year. Although NIPPV was paid for completely from the trust equipment budget in 46 hospitals (41%), other money such as research or charitable funds were used at least partially in the other hospitals and NIPPV was financed solely from research or charitable funds in 41 hospitals (37%). CONCLUSIONS: Equipment for NIPPV is available in less than half of the acute hospitals in the UK. In those in which it is available it is generally underused. Lack of training and problems with funding are generally given for the failure to introduce NIPPV. (+info)
Audit of acute admissions of COPD: standards of care and management in the hospital setting.
Despite publication of several management guidelines for COPD, relatively little is known about standards of care in clinical practice. Data were collected on the management of 1400 cases of acute admission with Chronic Obstructive Pulmonary Disease in 38 UK hospitals to compare clinical practice against the recommended British Thoracic Society standards. Variation in the process of care between the different centres was analysed and a comparison of the management by respiratory specialists and nonrespiratory specialists made. There were large variations between centres for many of the variables studied. A forced expiratory volume in one second measurement was found in only 53% of cases. Of the investigations recommended in the acute management arterial blood gases were performed in 79% (interhospital range 40-100%) of admissions and oxygen was formally prescribed in only 64% (range 9-94%). Of those cases with acidosis and hypercapnia 35% had no further blood gas analysis and only 13% received ventilatory support. Long-term management was also deficient with 246 cases known to be severely hypoxic on admission yet two-thirds had no confirmation that oxygen levels had returned to levels above the requirements for long-term oxygen therapy. Only 30% of current smokers had cessation advice documented. To conclude, the median standards of care observed fell below those recommended by the guidelines. The lowest levels of performance were for patients not under the respiratory specialists, but specialists also have room for improvement. The substantial variation in the process of care between hospitals is strong evidence that it is possible for other centres with poorer performance to improve their levels of care. (+info)
Nebulized bronchodilator formulations: unit-dose or multi-dose?
BACKGROUND: Nosocomial infections linked to the use of multi-dose bronchodilator nebulizer formulations have been reported in the literature. OBJECTIVE: Survey American hospital respiratory therapy services to determine practice patterns, opinions, and awareness regarding unit-dose and multi-dose bronchodilator formulations. METHODS: A quota sample targeted 4 hospital size categories (0-100 beds, 101-200 beds, 201-400 beds, and > 400 beds) using a listing of general medical/surgical hospitals from the American Hospital Association. Hospitals were contacted via telephone to identify the director of respiratory therapy services, who was invited to complete a 29-item Web-based survey of their hospital practices and their opinions about and knowledge of issues with multi-dose and unit-dose bronchodilator formulations. RESULTS: One thousand forty-seven hospitals were recruited and 409 valid surveys were completed (completion rate 39%). The reported mean +/- SD percentage of unit-dose nebulizer treatments was 80.2 +/- 26.2%. Seventy-two percent (296) of respondents indicated having a policy and procedure manual that deals specifically with nebulized bronchodilator solutions, but only 107 reported having internal monitoring guidelines for compliance with those policies and procedures. Multi-dose bottles of bronchodilator concentrate were used with multiple patients in 77% of cases, and on average 9.7 +/- 8.5 patients were treated with the same multi-dose bottle. Eighty-one percent of respondents reported that treatments from multi-dose bottles are prepared at the bedside. The length of time a multi-dose bottle was kept (after being opened) ranged from 24 hours (8%) to 1 month (11%), and only 3% of respondents reported following manufacturers' recommendations. In the respondents' opinion the chief advantage of multi-dose was cost per dose (84%), and the chief advantage of unit-dose was less risk of contamination (92%). With other factors (therapist time, cost of saline diluent for multi-dose concentrate, dose-error, and contamination) considered, 73% thought that unit-dose vials were more cost-effective. Three hundred thirty-six respondents (82%) thought that a sterile, low-volume (0.5 mL) unit-dose vial of bronchodilator concentrate would be useful, and 249 (74%) of those 336 respondents indicated that such a formulation would replace multi-dose bottles. Only 56% of respondents knew about the evidence regarding the risk of contamination with multi-dose bottles. CONCLUSIONS: Multi-dose bottles of bronchodilator solution are used in approximately 20% of nebulizer treatments, and without strict adherence to infection control procedures they are a potential source of nosocomial infection. A sterile, low-volume unit-dose vial of bronchodilator concentrate would be a useful alternative to multi-dose concentrate for modifying doses or mixing drugs in nebulizer therapy. (+info)
Respiratory care management information systems.
Hospital-wide computerized information systems evolved from the need to capture patient information and perform billing and other financial functions. These systems, however, have fallen short of meeting the needs of respiratory care departments regarding work load assessment, productivity management, and the level of outcome reporting required to support programs such as patient-driven protocols. The respiratory care management information systems (RCMIS) of today offer many advantages over paper-based systems and hospital-wide computer systems. RCMIS are designed to facilitate functions specific to respiratory care, including assessing work demand, assigning and tracking resources, charting, billing, and reporting results. RCMIS incorporate mobile, point-of-care charting and are highly configurable to meet the specific needs of individual respiratory care departments. Important and substantial benefits can be realized with an RCMIS and mobile, wireless charting devices. The initial and ongoing costs of an RCMIS are justified by increased charge capture and reduced costs, by way of improved productivity and efficiency. It is not unusual to recover the total cost of an RCMIS within the first year of its operation. In addition, such systems can facilitate and monitor patient-care protocols and help to efficiently manage the vast amounts of information encountered during the practitioner's workday. Respiratory care departments that invest in RCMIS have an advantage in the provision of quality care and in reducing expenses. A centralized respiratory therapy department with an RCMIS is the most efficient and cost-effective way to monitor work demand and manage the hospital-wide allocation of respiratory care services. (+info)
Respiratory therapists' attitudes about participative decision making: relationship between managerial decision-making style and job satisfaction.
BACKGROUND: Studies of non-health-care work environments indicate that non-managerial employee job satisfaction is higher in companies that use participative (as opposed to autocratic) decision making. It has not been determined whether managerial decision-making style influences job satisfaction among respiratory therapists (RTs) and which managerial decision-making style RTs prefer. METHODS: We surveyed Nebraska RTs' attitudes regarding their job satisfaction, their perceptions of their managers' decision-making styles (autocratic, consultative, and/or delegative), and which decision-making style they would prefer their managers to use. We sought to determine whether there is a significant correlation between RTs' perceptions of their managers' decision-making styles and the RTs' job satisfaction. The study population was 792 licensed and practicing non-managerial RTs in Nebraska, from which we randomly selected 565 RTs to survey. The self-administered, descriptive survey used 2 Likert scales (one for decision-making style and one for job satisfaction) and inquired about 57 items. The survey was mailed on October 1, 1999. On October 28, 1999, we sent a second mailing to RTs who had not responded. RESULTS: We received 271 responses (response rate 47.9%). The respondents were generally satisfied with their jobs (mean +/- SD Minnesota Satisfaction Questionnaire score 73.46 +/- 11.63). The sub-scale scores ranged from 20 ("very dissatisfied") to 100 ("very satisfied"). The respondents did not want autocratic managerial decision making (mean +/- SD autocratic sub-scale score 4.29 +/- 0.60). Autocratic decision making was associated with lower job satisfaction (r = 0.49), whereas consultative and delegative decision making were associated with higher job satisfaction (r = -0.31 and -0.48, respectively). RTs who worked in departments that had < 25 RT employees reported higher job satisfaction than did RTs in larger departments (p = 0.029). CONCLUSIONS: Our survey data indicate that (1) RTs prefer delegative and consultative managerial decision making, (2) job satisfaction was highest in departments that had < 25 RTs in the department and in which the manager practiced participative decision making. These findings offer guidance for organizing optimal work environments for RTs. (+info)
Device and equipment evaluations.
Device evaluation, which is an essential skill set for the respiratory therapist, ranges from comparing manufacturer's specifications to comprehensive device testing, either with patients or on the bench. Good device evaluations help guide decisions about device selection, procedure development, and risk and failure analysis. Poor evaluations cost time and money and fail to return value. Manufacturer's specifications alone are poor criteria for device selection, because of how and why those specifications are created and the potential gap between the manufacturer's test methods and the complexity of clinical situations. Proper clinical evaluation of devices with patients requires extensive preparation and resource expenditure, and clinical evaluations may not allow isolating key variables to determine specifics of device performance. In vitro testing, using models to simulate discrete components of device/patient interface, is less expensive and easier to conduct. This article discusses the process of experiment design and model development for device and equipment evaluations. (+info)