Support of quality and business goals by an ambulatory automated medical record system in Kaiser Permanente of Ohio. (57/8935)

Kaiser Permanente of Ohio has developed a Medical Automated Record System (MARS) to address the business and clinical needs of the organization. The system is currently used by 220 physicians and 110 allied health personnel. To support the quality initiatives of the organization, the system has been programmed to generate reminders, at the moment of care, on compliance with clinical guidelines. This article details examples of compliance improvements with guidelines for the use of aspirin in coronary artery disease, use of influenza vaccinations in members older than 64 years of age, and stratification of asthmatic patients into severity levels; it also summarizes other quality improvements. MARS provides a data stream for electronic billing, which saves the organization the cost of manual billing. In addition, this system reduces operating costs, in particular the number of staff needed to deliver charts and the cost of printing forms. Cost-benefit analysis demonstrates that the system can produce savings in excess of maintenance costs.  (+info)

A risk management audit: are we complying with the national guidelines for sedation by non-anaesthetists? (58/8935)

OBJECTIVES: To assess the effect of a preprinted form in ensuring an improved and sustained quality of documentation of clinical data in compliance with the national guidelines for sedation by non-anaesthetists. DESIGN: The process of retrospective case note audit was used to identify areas of poor performance, reiterate national guidelines, introduce a post-sedation advice sheet, and demonstrate improvement. SETTING: Emergency Department, Musgrove Park Hospital, Taunton. SUBJECTS: Forty seven patients requiring sedation for relocation of a dislocated shoulder or manipulation of a Colles' fracture between July and October 1996 and July and October 1997. MAIN OUTCOME MEASURES: Evidence that the following items had been documented: consent for procedure, risk assessment, monitored observations, prophylactic use of supplementary oxygen, and discharging patients with printed advice. Case note review was performed before (n = 23) and after (n = 24) the introduction of a sedation audit form. Notes were analysed for the above outcome measures. The monitored observations analysed included: pulse oximetry, respiratory rate, pulse rate, blood pressure, electrocardiography, and conscious level. RESULTS: Use of the form significantly improved documentation of most parameters measured. CONCLUSIONS: Introduction of the form, together with staff education, resulted in enhanced documentation of data and improved conformity with national guidelines. A risk management approach to preempting critical incidents following sedation, can be adopted in this area of emergency medicine.  (+info)

Flexible sigmoidoscopy: screening for colorectal cancer. (59/8935)

Flexible sigmoidoscopy is an important screening procedure because of its ability to detect early changes in the distal colon. The 60-cm flexible sigmoidoscope provides excellent visualization with minimal discomfort to patients. Successful sigmoidoscopy requires adequate patient preparation, proper equipment and an experienced examiner who can recognize both normal and abnormal findings. Complications arising from sigmoidoscopy are rare, but patients may experience some cramping, gas or watery stools. Screening and primary preventive measures, including regular exercise and increased dietary fiber intake, can lower the morbidity and mortality associated with colorectal cancer.  (+info)

General practitioner prescribing of antibiotics for asthma. (60/8935)

Although asthma management guidelines in New Zealand do not advise prescribing antibiotics, almost a quarter of asthma consultations result in a prescription for antibiotics. This study, as part of a repeat audit of asthma care at an after-hours medical centre, describes general practitioners' perspectives on prescribing antibiotics to patients presenting with asthma. The results show that GPs have tended to overestimate the risk of bacterial infection in such patients.  (+info)

Reducing antibiotics for respiratory tract symptoms in primary care: consolidating 'why' and considering 'how'. (61/8935)

We summarize recently published evidence showing that antibiotic treatment offers little or no benefit to most patients presenting with sore throats, acute otitis media, maxillary sinusitis, and acute bronchitis. Despite this research, the prescription of antibiotics for respiratory tract conditions is rising in Britain. This wastes money, encourages people to consult for self-limiting conditions, and causes bacteria to become resistant to antimicrobials. Ways of changing present practice are underresearched. Enhanced consulting skills, guidelines and monitoring strategies, patient education, and anti-inflammatory drugs for recurrent and chronic sufferers all hold promise.  (+info)

Barriers between guidelines and improved patient care: an analysis of AHCPR's Unstable Angina Clinical Practice Guideline. Agency for Health Care Policy and Research. (62/8935)

OBJECTIVES: To describe common barriers that limit the effect of guidelines on patient care, with emphasis on recommendations for triage in the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Clinical Practice Guideline. DATA SOURCES: Previously reported results from a prospective clinical study of 10,785 patients presenting to the emergency department (ED) with symptoms suggestive of acute cardiac ischemia. STUDY DESIGN: Design is an analysis of the AHCPR guideline with regard to recognized barriers in guideline implementation. Presentation of hypothetical scenarios to ED physicians was used to determine interrater reliability in applying the guideline to assess risk and to make triage decisions. PRINCIPAL FINDINGS: The AHCPR guideline's triage recommendations demonstrate (1) poor interobserver reliability in interpretation by ED physicians; (2) limited applicability of recommendations for outpatient management (applies to 6 percent of patients presenting to the ED with unstable angina); (3) incomplete specifications of exceptions that may require deviation from guideline recommendations; (4) unexpected effects on medical care by significantly increasing the demand for limited intensive care beds; and (5) unknown effects on patient outcomes. In addition, analysis of the guideline highlights the need to address organizational barriers, such as administrative policies that conflict with guideline recommendations and the need to adapt the guideline to conform to local systems of care. CONCLUSIONS: Careful analysis of guideline attributes, projected effect on medical care, and organizational factors reveal several barriers to successful guideline implementation that should be addressed in the design of future guideline-based interventions.  (+info)

Clinical practice guidelines in end-stage renal disease: a strategy for implementation. (63/8935)

Clinical practice guidelines (CPGs) for end-stage renal failure (ESRD) were recently published, and represent a comprehensive review of available literature and the considered judgment of experts in ESRD. To prioritize and implement these guidelines, the evidence underlying each guideline should be ranked and the attributes of each should be defined. Strategies to improve practice patterns should be tested. Focused information for each high priority guideline should be disseminated, including a synopsis and assessment of the underlying evidence, the evidence model used to develop that guideline, and suggested strategies for CPG implementation. Clinical performance measures should be developed and used to measure current practice, and the success of changing practice patterns on clinical outcomes. Individual practitioners and dialysis facilities should be encouraged to utilize continuous quality improvement techniques to put the guidelines into effect. Local implementation should proceed at the same time as a national project to convert high priority CPGs into clinical performance measures proceeds. Patients and patient care organizations should participate in this process, and professional organizations must make a strong commitment to educate clinicians in the methodology of CPG and performance measure development and the techniques of continuous quality improvement. Health care regulators should understand that CPGs are not standards, but are statements that assist practitioners and patients in making decisions.  (+info)

Impact of new guidelines on physicians' ordering of preoperative tests. (64/8935)

OBJECTIVE: To compare the number of preoperative tests ordered for elective ambulatory surgery patients during the 2 years before and the 2 years after the establishment of new hospital testing guidelines. MEASUREMENTS: The patterns of preoperative testing by surgeons and a medical consultant during the 2 years before and the 2 years after the establishment of new guidelines at one orthopedic hospital were reviewed. All tests ordered preoperatively were determined by review of medical records. Preoperative medical histories, physical examinations, and comorbidities were obtained according to a protocol by the medical consultant (author). Perioperative complications were determined by review of intraoperative and postoperative events, which also were recorded according to a protocol. MAIN RESULTS: A total of 640 patients were enrolled, 361 before and 279 after the new guidelines. The mean number of tests decreased from 8.0 before to 5.6 after the new guidelines ( p =.0001) and the percentage decrease for individual tests varied from 23% to 44%. Except for patients with more comorbidity and patients receiving general anesthesia, there were decreases across all patient groups. In multivariate analyses only time of surgery (before or after new guidelines), age, and type of surgery remained statistically significant ( p =.0001 for all comparisons). Despite decreases in surgeons' ordering of tests, the medical consultant did not order more tests after the new guidelines ( p =.60) The majority of patients had no untoward events intraoperatively and postoperatively throughout the study period, with only 6% overall requiring admission to the hospital after surgery, mainly for reasons not related to abnormal tests. Savings from charges totaled $34,000 for the patients in the study. CONCLUSIONS: Although there was variable compliance among physicians, new hospital guidelines were effective in reducing preoperative testing and did not result in increases in untoward perioperative events or in test ordering by the medical consultant.  (+info)