Predicting discharge diagnoses using a computerized preadmission screening tool

The authors integrated into an existing hospital information system a preadmission screening system, intended to reduce payment denials and reimbursement shortfalls that result from improperly classifying the billing status of patients. They report the results of efforts to validate the expert system upon which the preadmission screening system is based.

Continuous quality improvement applied to medical care: experiences at LDS hospital

At LDS Hospital the authors are implementing continuous quality improvement (CQI), a systems-analytic approach to quality management in industry, as an approach to quality management in medical domains. Their approach consists of 1) choosing a process to be improved, 2) assembling a team of expert clinicians that understands the process and the outcomes, 3) determining key steps in the process and expected outcomes, 4) collecting data that measure the key process steps and outcomes, and 5) feeding back the data to the practitioners. CQI theory states that the practitioners will use the information and their own best intentions to improve the manner in which they provide care. The authors have developed statistical tools that display the data and distinguish between random and assignable variation.

The impact of the HELP computer system on the LDS Hospital paper medical record

This study sought to answer the question: What percentage of an LDS Hospital patient's chart is contained in the HELP system? Using the number of pages in the record as the criteria, the answer is about 26 percent overall, but between 35 percent and 40 percent for patients in nursing divisions where computerized nurse charting is used. Although this fraction is likely to rise in the near future, the critical factor driving computerization is the desire for data usable in computerized decision making rather than the need to computerize the entire chart per se. The medical record at LDS Hospital will probably be a hybrid of computerized and paper data for some time to come.

In vivo regulation of Zif268 messenger RNA expression by 17 beta-estradiol in the rat uterus

Administration of 17 beta-estradiol (E2) induces a mitogenic response in the rat uterus. Previous studies have shown that this effect involves the transient activation of c-fos and c-myc expression, followed by significant increases in both DNA synthesis and cell proliferation. Zif268 is a zinc finger-containing, DNA-binding transcription factor that has been implicated in the regulation of cell growth and development and has been shown to be coregulated with c-fos in a number of systems. To determine whether Zif268 is also a target for estrogen regulation, we measured the effects of E2 on Zif268 mRNA expression in the uterus of the ovariectomized rat. In this report we demonstrate that although low levels of Zif268 mRNA expression are detectable in the uteri from ovariectomized control rats, treatment with E2 (4, 40, or 400 micrograms/kg BW) induces a rapid and transient 45- to 50-fold increase in the level of Zif268 mRNA 2 h after E2 treatment. The elevated levels of Zif268 mRNA returned to basal 6 h after hormone treatment. Lower doses of E2 (0.004, 0.04, and 0.4 micrograms/kg) had little or no effect on Zif268 mRNA expression, while higher doses of E2 (4-400 micrograms/kg) resulted in maximal increases in Zif268 expression. Dexamethasone, 5 alpha-dihydrotestosterone, and progesterone had no effect on uterine Zif268 mRNA expression, and the induction of Zif268 by E2 was abolished by pretreating the animals with the RNA synthesis inhibitor actinomycin-D. In addition, stimulation of Zif268 mRNA expression was observed with the short-acting estrogen estriol, suggesting that the response may be specific for estrogenic steroids.(ABSTRACT TRUNCATED AT 250 WORDS)

In vivo regulation of parathyroid hormone-related peptide messenger ribonucleic acid in the rat uterus by 17 beta-estradiol

During pregnancy, elevated levels of PTH-related peptide (PTHrP) persist in the myometrium of the rat uterus. Near term, intrauterine occupancy is correlated with high levels of PTHrP messenger RNA in the gravid horn of the unilaterally pregnant uterus. In nongravid tissue from these same animals the presence of smaller yet significant elevations of PTHrP mRNA suggests that the PTHrP gene also may be regulated by humoral factor(s). To test this hypothesis, we assessed the action of 17 beta-estradiol (E2) on the expression of the PTHrP gene in the uterus of the ovariectomized rat. While low levels of PTHrP mRNA are detected in uteri from ovariectomized rats, a single dose of E2 (4, 40, or 400 micrograms/kg body weight) stimulated a 6- to 8-fold increase in the levels of PTHrP mRNA in the uterus at approximately 2 h after E2 treatment. This increase was transient with levels gradually declining to pretreatment (basal) levels within 24 h. Other steroid hormones tested, including dihydrotestosterone, dexamethasone, and progesterone, failed to stimulate this response. The increase of PTHrP mRNA accumulation required a dose greater than 0.4 micrograms/kg. The magnitude and duration of PTHrP mRNA accumulation were very similar when doses of 40 or 400 micrograms/kg were used. In addition, the stimulation of the PTHrP gene by E2 is neither age dependent nor specific to the rat and is, in part, under transcriptional control. Together, these data indicate that in vivo E2 regulates the levels of PTHrP mRNA in the rat uterus and support a role for E2 in the increased expression of PTHrP mRNA in early gestational tissue, as well as in the nongravid horn of the unilaterally pregnant uterus.

Development of a computerized adverse drug event monitor

Adverse events during drug therapy are receiving renewed attention. Some adverse drug events (ADEs) are identified only after the widespread clinical use of a drug. The Food and Drug Administration advocates post-marketing surveillance systems to provide early warnings of previously undetected ADEs. The identification of ADEs by U.S. hospitals is now required by the Joint Commission on Accreditation of Healthcare Organizations. We developed a series of computer programs and data files on the HELP System to help identify ADEs. The HELP System monitors laboratory test results, drug orders, and data entered through a computerized ADE reporting program. A nurse or pharmacist verifies computer alerts of possible ADEs. The computerized system identified 401 ADEs during the first year of use compared to 9 by voluntary reporting methods during the previous year (p less than 0.001). This paper describes the development and early use of the computerized ADE surveillance system.

Assessing the effectiveness of a computerized blood order "consultation" system

To optimize blood ordering and accurately assess transfusion practice, in 1987, an "on line" computerized, knowledge-based, blood order critiquing system was integrated into the HELP Hospital Information System (HIS) at LDS Hospital. Evaluations of the computerized ordering system demonstrated its benefits and limitations on transfusion practice. Based on this experience, a second generation blood ordering system using a consultation mode was developed. A pilot test of this blood order consultant system, using historical data in the HELP system's database, was performed. This pilot test demonstrated that the consultation system provided accurate recommendations for red blood cell (RBC) and platelet orders. Comparing the appropriateness of blood orders with the recommendations made by the director of the blood bank, the orders recommended by the computer "consultant" agreed 95.5% of the time. The computer consultation system also recommended fewer RBC units for transfusion. Preliminary results obtained using the consultant approach suggest that we may be able to simplify blood ordering practice and also reduce the number of units of blood products ordered. Based on these findings we are now preparing to compare the "critiquing" and "consultation" approaches using a clinical trial.

Real time data acquisition: experience with the Medical Information Bus (MIB)

Care of the acutely ill patient requires rapid acquisition, recording and communications of data. In the modern hospital it is not unusual for a patient to be connected to several monitoring and recording devices simultaneously. Each of these devices is typically made by a different manufacturer who may specialize in one sort of measurement, for example, pulse oximetry. Most of the modern monitoring and recording devices are micro-processor based and have communications capabilities. Unfortunately, there is no operable standard communications technology available from all devices. In addition different clinical staff (physicians, nurses, or respiratory therapists) may be responsible for collecting data. As a result there is a need to develop methods, standards, and strategies for timely and automatic collection of data from these monitoring and recording devices. We report on more than 5 years of clinical experience of automated ICU data collection using a prototype of the Medical Information Bus (MIB).

Computer-critiqued blood ordering using the HELP system

Recently the medical risk of blood transfusions has emphasized the need to improve the safe use of blood products. For the past 2 1/2 years at LDS Hospital we have used the HELP computer system to assist and critique ordering of blood products "on-line" by physicians and nurses. This report details the computer methods used to order blood products and to critique the appropriateness of those orders. Physicians personally enter the orders for more than 45% of the blood products using computer terminals, whereas 7% are from physician standing orders. Nurses enter the remaining orders from written orders (26%), verbal orders (14%), and phone orders (8%). There were 3396 blood orders for 1043 patients generated by 273 physicians during the fourth quarter of 1989. Each order is justified at the time it is entered by selecting from a menu of physician-approved criteria. The criteria are linked to supportive data in the data base, i.e., laboratory results and clinical data. The computer verified that 82% of these orders met criteria. Quality Assurance nurses verified the remaining 18%. Of these 18% only one in eight required manual chart review. After computer and Quality Assurance review, only eight (0.24%) of the orders were found to be true exceptions to established criteria. Physicians and nurses have accepted the computerized critiquing system. Through use of the computer we provide "on-line" critiquing and improve the use of scarce blood product resources.

Somatization tendencies and ability to detect internal body cues

39 subjects performed a task in which they were required to detect the presence of a resistive load during the inhalation phase of breathing. Subjects were also measured on somatization tendencies, using the SCL-90-R test. A signal-detection analysis indicated an inverse relationship between ability to detect the resistive load during breathing and somatization score. Results are discussed relative to possible ramifications for somatoform disorders.

A computerized laboratory alerting system

A computerized laboratory alerting system (CLAS) has been developed as part of an ongoing effort to improve the quality of care at LDS Hospital. The system identifies potentially life-threatening conditions on the basis of laboratory findings and then generates appropriate warnings and transmits them to clinicians. Use of the system has led to a significant increase in the proportion of patients in life-threatening situations who have received appropriate care (50.8% before implementation vs. 62.5% afterward, P less than 0.05). Among patients with hypokalemia, falling potassium levels, hyperkalemia, hypokalemia during treatment with digoxin, hyponatremia, falling sodium levels, hypernatremia, hypoglycemia, or hyperglycemia, the average length of time spent in the life-threatening situation has decreased from 30.4 to 15.7 hours (P less than 0.05) and the average length of stay has decreased from 14.6 to 8.8 days (P less than 0.05). There has been little change in the proportion of patients with findings indicating metabolic acidosis who have received appropriate care (32.3 vs. 34.6%). We conclude that CLAS has an important role in patient care at our hospital.

Clinical evaluation of computer-based respiratory care algorithms

A collection of computer-based respiratory care algorithms were implemented as a prototype computer-based patient advice system (COMPAS) within the existing HELP hospital information system. Detailed medical logic recommended ventilator adjustments for 5 different modes of ventilation: assist/control (A/C), intermittent mandatory ventilation (IMV), continuous positive airway pressure (CPAP), pressure controlled inverted ratio ventilation (PC-IRV), and extracorporeal carbon dioxide removal (ECCO2R). Suggestions for adjusting the mode of ventilation, fraction of inspired oxygen (FiO2), positive end-expiratory pressure (PEEP), peak inspiratory pressure, and several other therapeutic measures related to the treatment of severe arterial hypoxemia in adult respiratory distress syndrome (ARDS) patients were automatically presented to the clinical staff via bedside computer terminals. COMPAS was clinically evaluated for 624 hours of patient care on the first 5 ARDS patients in a randomized clinical trial. The clinical staff carried out 84% (320/379) of the computerized therapy suggestions. In response to a questionnaire distributed to clinical users of the system, 86% judged the system to be potentially valuable. Through implementation of COMPAS, a computer-based ventilatory therapy advice system, we have laid the groundwork for standardization of ventilator management of arterial hypoxemia in critically ill ARDS patients.

Cardiac self-perception in obese and normal persons

Cardiac self-perception was measured in obese and normal weight subjects. Subjects had to judge whether a tone was coincident with their own heartbeat or slightly mismatched. A signal-detection analysis was used to measure sensory sensitivity to the heartbeat separate from nonsensory, response-bias factors. Subjects were able to perform the heartbeat-detection task, with an average sensory sensitivity d' of .58. No significant differences in sensory sensitivity were found between obese and normal-weight subjects, nor were any sex differences noted. Measurement of response bias (Ln beta) indicated that obese subjects had a significantly more lax response criterion than normal-weight subjects. Results are discussed in terms of Schachter's (1971) internality-externality theory of obesity and ramifications for weight control are discussed.

Reducing the duration of prophylactic antibiotic use through computer monitoring of surgical patients

The use of antibiotic prophylaxis for unnecessarily prolonged periods after surgical procedures can contribute to increased health care costs and adverse drug reactions as well as the development of antibiotic-resistant infections. Hospitals are under economic pressures to develop methods to control the excessive use of these drugs. We expanded the capabilities of our hospital information system to monitor the duration of surgical antibiotic prophylaxis. For six months during one year we used the computer system to monitor antibiotics received by every surgical patient and to identify patients receiving antibiotic prophylaxis longer than was deemed necessary according to generally accepted guidelines. For six months in the following year we used the system to monitor and identify the same types of patients and clinical pharmacists placed antibiotic "stop orders" in the charts of the patients identified by the computer. Surgical patients received an average of 19 doses of antibiotics in the first year compared with 13 doses in the second year (p less than 0.001). The average cost of antibiotics received more than 48 hours after the operation was $42 less per patient in year 2 than in year 1, resulting in a potential cost savings of $44,562 in six months. The computer system was found to be an efficient tool for monitoring all antibiotics given to surgical patients and identifying patients receiving antibiotic prophylaxis longer than necessary. Clinical use of this system appears to have resulted in improved usage of antibiotic prophylaxis.

Performance evaluation of contemporary spirometers

A comprehensive evaluation of 62 spirometers from 37 different sources was performed using a two-part protocol: calibrated syringe, and dynamic waveform testing. All testing was done with ambient air. Calibrated syringe testing examined the ability of the spirometers to accurately measure the output of a 3 L calibrating syringe under varying conditions. The accuracy, FVC volume linearity, and stability of each spirometer was determined from these data. All but five of 42 spirometers accurately measured a 3 L calibrating syringe to within +/- 3 percent. Dynamic waveform testing consisted of introducing 24 standard waveforms into the spirometer from a computer-controlled air pump. The values of FVC, FEV1, and FEF25-75% were compared to the actual values for each waveform to determine a performance rating. Only 35 (56.5 percent) of the spirometers performed acceptably when measuring the 24 standard waveforms. Nine (14.5 percent) were marginal and 18 (29.0 percent) were unacceptable. Fifty-nine (95 percent) of the 62 spirometers were computerized. Software errors were found in 25 percent of the computerized systems evaluated. Although using a 3 L syringe for quality control purposes is essential, simple testing of spirometers with a 3 L calibrating syringe for validation purposes was inadequate to assess spirometer performance when compared to dynamic waveform testing. Dynamic waveform testing is essential to accurately measure and validate acceptability of spirometer system performance.

Medical impact analysis for the space station

Since the Space Station Health Maintenance Facility can house only a relatively limited quantity of supplies and equipment, the decisions about what should be included must be based on documented research. In this study, Space Station medical care priorities were determined by a medical impact analysis of two analog populations, U.S. Army and U.S. Navy personnel. Diseases and injuries in the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) were ranked, using a Medical Impact Score (MIS) combining modified incidence rate and a function of disease outcome. The validity of the analysis method was tested by measuring rank order correlation between the two analog populations. Despite virtually identical age and sex distributions, Army and Navy incidence rates differed significantly for half of the ICD-9-CM categories, p less than 0.05. Disability rates differed for 76%, p less than 0.05. Nevertheless, Army and Navy MIS rank orders for categories and sections were not significantly different, p less than 0.001. In critical ways, the Space Station will be a safer environment than Earth. Cardiac events, musculoskeletal injuries, affective psychoses, and renal calculi were among the highest scoring categories.

Therapeutic antibiotic monitoring: surveillance using a computerized expert system

STUDY OBJECTIVE

To develop and evaluate a computerized system to monitor therapeutic antibiotics in a hospital setting.

MATERIAL AND METHODS

From November 1986 through October 1987, we prospectively monitored 1,632 hospitalized patients who had 2,157 microbiology specimens sent for culture and sensitivity testing. During the study period, computer algorithms were used to identify patients whose antibiotic therapy was inappropriate in relation to microbiology culture and sensitivity data. When inconsistencies occurred between antibiotic therapy and in vitro sensitivity data, computer algorithms generated therapeutic antibiotic monitor (TAM) alerts. A clinical pharmacist then notified the attending physician of the alert.

RESULTS

Antibiotic therapy was identified by the computer as inappropriate in 696 instances (32%). After we eliminated false-positive alerts, 420 evaluable TAM alerts remained. Physicians responded to the TAM alerts by either changing or starting antimicrobial therapy in 125 cases (30%). Moreover, physicians were previously unaware of the relevant susceptibility test results in 49% of the alerts.

CONCLUSION

Computer-assisted monitoring is an efficient and promising method to identify and correct errors in antimicrobial prescribing and to assure the appropriate use of therapeutic antibiotics.

Development of a computerized laboratory alerting system

Using the capabilities of the HELP medical information system at LDS Hospital, a Computerized Laboratory Alerting System (CLAS) was developed. CLAS monitors and alerts for the presence of life-threatening conditions in hospitalized patients which are indicated by laboratory test results. Alerts are posted on computer terminals on the hospital's nursing divisions, where they are reviewed and acknowledged by hospital staff so that appropriate treatment can be rapidly instituted. CLAS was evaluated to determine its effectiveness in relaying alerts to the clinical staff, and improvements were made to develop an effective user interface. Initial average alert response times on nursing divisions ranged from 5.1 to 58.2 hr. The average alert response time dropped to 3.6 hr when alert review was integrated with laboratory result review, and to 0.1 hr after installation of a flashing light to notify hospital staff of the presence of new alerts.

Computerizing the intensive care unit: current status and future directions

Computers are serving intensive care patients by simplifying and improving the accuracy of data acquisition, facilitating communications, storing and organizing patient records, and providing expert suggestions. The future will bring many changes in the way nurses practice in intensive care. The computer should be considered an evolutionary tool to help effect these changes.

Subjective equality and just noticeable differences in body-size judgments by obese persons

Body-size estimates by obese and normal-weight subjects were compared using two different procedures with a TV-video methodology. In the continuous method subjects adjusted an image larger or smaller until they judged a correct TV-image had been achieved. In the second procedure the method of constant stimuli was used wherein values corresponding to the point of subjective equality (PSE) and difference threshold (DL) were determined. No differences between obese and normal-weight subjects were obtained with these procedures. On the continuous task subjects slightly underestimated body size and were more accurate on descending trials where they adjusted the size of the image downwards. With the second procedure, an average PSE of -.62% was obtained, with an average DL = 7.27%. Different PSE values were obtained when subjects were judging whether their image was distorted too wide or too thin. Data from the two procedures are compared and ramifications for the study of body size are discussed.

Computerized management of patient care in a complex, controlled clinical trial in the intensive care unit

Acute respiratory distress syndrome (ARDS) is often not responsive to conventional supportive therapy and the mortality rate may exceed 90%. A new form of supportive care, extracorporeal carbon dioxide removal (ECCO2R), has shown a dramatic increase in survival (48%). A controlled clinical trial of the new ECCO2R therapy versus conventional continuous positive pressure ventilation (CPPV) is being initiated. Detailed care protocols have been developed by 'expert' critical care physicians for the management of patients. Using a blackboard control architecture, the protocols have been implemented on an existing hospital information system and will direct patient care and help manage the controlled clinical trial. Therapeutic instructions are automatically generated by the computer from data input by physicians, nurses, respiratory therapists, and the laboratory. Preliminary results show that the computerized protocol system can direct therapy for acutely ill patients.