Audit of thrombolysis initiated in an accident and emergency department.
Early thrombolytic therapy after acute myocardial infarction is important in reducing mortality. To evaluate a system for reducing in-hospital delays to thrombolysis pain to needle and door to needle times to thrombolysis were audited in a major accident and emergency (A and E) department of a district general hospital and its coronary care unit (CCU), situated about 5 km away. Baseline performance over six months was assessed retrospectively from notes of 43 consecutive patients (group 1) transferred to the CCU before receiving thrombolysis. Subsequently, selected patients (23) were allowed to receive thrombolysis in the A and E department before transfer to the CCU. The agent was administered by medical staff in the department after receiving oral confirmation of myocardial infarction from the admitting medical officer in the CCU on receipt of fax transmission of the electrocardiogram. A second prospective audit during six months from the start of the new procedure established time intervals in 23 patients eligible to receive thrombolysis in the A and E department (group 2b) and 30 ineligible patients who received thrombolysis in the CCU (group 2a). The groups did not differ significantly in case mix, pre-hospital delay, or transfer time to the CCU. In group 2b door to needle time and pain to needle time were reduced significantly (geometric mean 38 min v 121 min (group 2a) and 128 min (group 1); 141 min v 237 min (group 2a) and 242 min (group 1) respectively, both p < 0.0001). The incidence of adverse effects was not significantly different. Nine deaths occurred (six in group 1, three in group 2b), an in-hospital mortality of 9.9%. Thrombolysis can be safely instituted in the A and E department in selected patients, significantly reducing delay to treatment. (+info)
Turfing: patients in the balance.
OBJECTIVE: To examine the language of "turfing," a ubiquitous term applied to some transfers of patients between physicians, in order to reveal aspects of the ideology of internal medicine residency. SETTING: Academic internal medicine training program. MEASUREMENTS: Using direct observation and a focus group, we collected audiotapes of medical residents' discussions of turfing. These data were analyzed using interpretive and conversation analytic methods. The focus group was used both to validate and to further elaborate a schematic conceptual framework for turfing. MAIN RESULTS: The decision to call a patient "turfed" depends on the balance of the values of effectiveness of therapy, continuity of care, and power. For example, if the receiving physician cannot provide a more effective therapy than can the transferring physician, medical residents consider the transfer inappropriate, and call the patient a turf. With appropriate transfers, these residents see their service as honorable, but with turfs, residents talk about the irresponsibility of transferring physicians, burdens of service, abuse, and powerlessness. CONCLUSIONS: Internal medicine residents can feel angry and frustrated about receiving patients perceived to be rejected by other doctors, and powerless to prevent the transfer of those patients for whom they may have no effective treatment or continuous relationship. This study has implications for further exploration of how the relationships between physicians may uphold or conflict with the underlying moral tenets of the medical profession. (+info)
Planning for major incidents involving children by implementing a Delphi study.
This paper provides a practical approach to the difficult problem of planning for a major incident involving children. It offers guidance on how general principles resulting from an expert Delphi study can be implemented regionally and locally. All phases of the response are covered including preparation, management of the incident, delivery of medical support during the incident, and recovery and support. A check list for regional planners is provided. Supplementary equipment is discussed and action cards for key roles in the paediatric hospital response are shown. Particular emphasis is placed on management of the secondary-tertiary interface including the special roles of paediatric assessment teams and paediatric transfer teams. A paediatric primary triage algorithm is provided. The important role of local interpretation of guidance is emphasised. (+info)
Paying a premium: how patient complexity affects costs and profit margins.
OBJECTIVE AND BACKGROUND: Tertiary medical centers continue to be under extreme pressure to deliver high-complexity care, but paradoxically there is considerable pressure within these institutions to reduce their emphasis on tertiary care and refocus their efforts to develop a more community-like practice. The genesis of this pressure is the perceived profitability of routine surgical activity when compared with more complex care. The purpose of this study is to assess how the total cost and profit (loss) margin can vary for an entire trauma service. The authors also evaluate payments for specific trauma-related diagnostic-related groups (DRGs) and analyze how hospital margins were affected based on mortality outcome. MATERIALS AND METHODS: The authors analyzed the actual cost of all trauma discharges (n = 692) at their level I trauma center for fiscal year 1997. Data were obtained from the trauma registry and the hospital cost accounting system. Total cost was defined as the sum of the variable, fixed, and indirect costs associated with each patient. Margin was defined as expected payments minus total cost. The entire population and all DRGs with 10 or more patients were stratified based on survival outcome, Injury Severity Score, insurance status, and length of stay. The mean total costs for survivors and nonsurvivors within these various categories and their margins were evaluated. RESULTS: The profit margin on nonsurvivors was $5,898 greater than for survivors, even though the mean total cost for nonsurvivors was $28,821 greater. Within the fixed fee arrangement, approximately 44% of transfers had a negative margin. Both survivors and nonsurvivors become increasingly profitable out to 20 days and subsequently become unprofitable beyond 21 days, but nonsurvivors were more profitable than survivors. CONCLUSIONS: There is a wide variance in both the costs and margins within trauma-related DRGs. The DRG payment system disproportionately reimburses providers for nonsurvivors, even though on average they are more costly. Because payers are likely to engage in portfolio management, patients can be transferred between hospitals based on the contractual relationship between the payer and the provider. This payment system potentially allows payers to act strategically, sending relatively low-cost patients to hospitals where they use fee-for-service reimbursement and high-cost patients to hospitals where their reimbursement is contractually capped. Although specific to the authors' trauma center and its payer mix, these data demonstrate the profitability of maintaining a level I trauma center and preserving the mission of delivering care to the severely injured. (+info)
Regional dissemination of vancomycin-resistant enterococci resulting from interfacility transfer of colonized patients.
During early 1997, the Siouxland District Health Department (SDHD; Sioux City, IA) reported an increased incidence of vancomycin-resistant enterococcal (VRE) isolates at area health care facilities. To determine the prevalence and risk factors for colonization with VRE strains at 32 health care facilities in the SDHD region, a prevalence survey and case-control study were performed. Of 2266 patients and residents, 1934 (85%) participated, and 40 (2.1%) were positive for (gastrointestinal) VRE colonization. The prevalence of VRE isolates was significantly higher in acute care facilities (ACFs) than in long-term care facilities (LTCFs) (10/152 [6.6%] vs. 30/1782 [1.7%]; odds ratio [OR], 4.1; 95% confidence interval [CI], 1.8-9.0). LTCF case patients were significantly more likely than controls to have been inpatients at any ACF (19/30 vs. 12/66; OR, 8.0; 95% CI, 2.7-23.8). Of 40 VRE isolates, 34 (85%) were a related strain. The predominant strain was present in all 12 LTCFs that had at least 1 case patient in each facility. Soon after the introduction of VRE isolates into this region, dissemination to multiple LTCFs resulted from resident transfer from ACFs to LTCFs. (+info)
Remote telemedical interpretation of neonatal echocardiograms: impact on clinical management in a primary care setting.
OBJECTIVE: The purpose of this study was to evaluate the utility of telemedical echocardiographically assisted neonatal cardiovascular evaluation in a primary care setting. BACKGROUND: Neonates with congenital heart disease are frequently born far from pediatric subspecialty centers and can be clinically unstable at presentation. Recent advances in telecommunication technology have made it possible to transmit echocardiographic images over long distances. This technology may be beneficial to newborns with heart defects who are born in primary care centers. METHODS: A retrospective review of all telemedical echocardiograms obtained from neonates (aged 1 day to 30 days) was performed. A telemedical link was created using a T-1 transmission line and a standard voice telephone line between the Mayo Clinic, Rochester, Minnesota (pediatric cardiology site), and the Altru Clinic, Grand Forks, North Dakota (primary care site), which is a general pediatric practice 400 miles from Rochester. Neonates with possible cardiac disorders were identified by the general pediatricians, who then requested telemedical echocardiography. RESULTS: The 133 neonates had 161 T-1 echocardiograms. Median patient age was two days (range, one day to 29 days). One hundred thirty-two of 133 initial echocardiograms (99%) were obtained because of urgent indications. Transmitted images provided adequate diagnostic information in all patients. Seventy-nine neonates (59%) had a change in medical management or required cardiology follow-up. An immediate change in management occurred in 32 patients (24%), including seven in whom emergency transfer was either arranged or avoided. CONCLUSIONS: Telemedical echocardiography provides accurate diagnostic data in neonates. Rapid telediagnosis facilitates appropriate care of sick neonates with possible congenital heart disease in the primary care setting. Unnecessary long-distance transfers can be avoided with this technology. (+info)
Acute medical bed usage by nursing home residents.
An increasing number of elderly patients in nursing home care appears to be presenting to hospital for acute medical admission. A survey of acute hospital care was undertaken to establish accurately the number and character of such admissions. A total of 1300 acute medical beds was surveyed in Northern Ireland in June 1996 and January 1997 on a single day using a standardised proforma. Demographic details, diagnosis and length of admission were recorded. A total of 84 patients over the age of 65 (mean 79.5 years) admitted from nursing home care was identified in June 1996 and a total of 125 (mean 83.3 years) in January 1997. A total of 88 (70%) of admissions in 1997 were accompanied by a general practitioner's letter. The assessing doctor judged that 12 (9.6%) of admissions in 1997 could have had investigations and or treatment reasonably instituted in a nursing home. The proportion of acute medical beds occupied by nursing home residents was 6% in June 1996 rising to 10% in January 1997. The study accurately identifies the significant contribution of nursing home patients to acute medical admissions and the low proportion in whom admission was unnecessary. Closure of long stay hospital facilities should be accompanied by investment in community medical services and also reinvestment in acute hospital care for elderly people. (+info)
Hospital transfer for primary coronary angioplasty in high risk patients with acute myocardial infarction.
OBJECTIVE: To investigate the feasibility, safety, and associated time delays of interhospital transfer in patients with acute myocardial infarction for primary percutaneous transluminal coronary angioplasty (PTCA). DESIGN AND PATIENTS: Prospective observational study with group comparison in a single centre. 68 consecutive patients with acute myocardial infarction transferred for primary PTCA from other hospitals (group A) were compared with 78 patients admitted directly to the referral centre (group B). MAIN OUTCOME MEASURES: Patient groups were analysed with regard to baseline characteristics, time intervals from onset of chest pain to balloon angioplasty, hospital stay, and follow up outcome. RESULTS: Patients in group A presented with a higher rate of cardiogenic shock initially than patients in group B (25% v 6%, p = 0.01) and had been resuscitated more frequently before PTCA (22% v 5%, p = 0.01). No deaths or other serious complications occurred during interhospital transfer. Median transfer time was 63 (range 40-115) minutes for helicopter transport (median 42 (28-122) km, n = 14), and 50 (18-110) minutes by ground ambulance (median 8 (5-68) km, n = 54). The median time interval from the decision to perform coronary arteriography to balloon inflation was 96 (45-243) minutes in group A and 52 (17-214) minutes in group B (p = 0.0001). In transferred patients (group A) the transportation associated delay and the longer in-hospital median decision time (50 (10-1120) minutes in group A v 15 (0-210) minutes in group B, p = 0.002) concurred with a longer total period of ischaemia (239 (114-1307) minutes in group A v 182 (75-1025) minutes in group B, p = 0.02) since the beginning of chest pain. Success of PTCA (TIMI 3 flow in 95% of all patients), in-hospital mortality (7% v 9%, mortality for patients not in cardiogenic shock 0% v 4%), and follow up after median 235 days was similarly favourable in groups A and B, respectively. Only one hospital survivor (group A) died during follow up. CONCLUSION: Interhospital transport for primary PTCA in high risk patients with acute myocardial infarction is safe and feasible within a reasonable period of time. Short and medium term outcome is favourable. Optimising the decision process and transport logistics may further improve outcome by reducing the total time of ischaemia. (+info)