Radiation dose to staff from medical X-ray scatter in the orthopaedic theatre

PURPOSE

Given the growing demand for intraoperative imaging, there is increased concern for radiation dose for orthopaedic surgical staff. This study sought to determine the distribution of scatter radiation from fluoroscopic imaging in the orthopaedic surgical environment, with particular emphasis on the positions of personnel and the type of orthopaedic surgery performed.

METHODS

A radiation survey detector was deployed at various angles and distances around an anthropomorphic phantom. The scatter dose rate in microsieverts per hour (µSv/h) was recorded using consistent exposure parameters for five common surgical procedures. A C-arm unit produced radiation for the hip arthroscopy, hip replacement and knee simulations, whilst a mini C-arm unit produced fluoroscopy for the foot and hand simulations.

RESULTS

Readings were tabulated, and coloured heatmaps were generated from scatter measurements for each of the five procedures. Positions corresponding to the typical location of the surgical staff (surgeon, surgical assistant, anaesthetist, instrument (scrub) nurse, circulation (scout) nurse and anaesthetic nurse) were superimposed on heatmaps. The surgeon's proximity to the radiation source meant this position experienced the greatest amount of radiation in all five surgical procedures. Mini C-arm doses were considered low in all procedures for positions, with and without lead protection.

CONCLUSION

This investigation demonstrated the distribution of scattered radiation dose experienced at different positions within the orthopaedic surgical theatre. It reinforces the importance of staff increasing their distance from the primary beam where possible, reducing exposure time and increasing shielding with lead protection.

Aminoglycoside Dosing and Volume of Distribution in Critically Ill Surgery Patients

Background: At a tertiary referral and Level I trauma center, current institutional guidelines suggest initial aminoglycoside doses of gentamicin or tobramycin 4 mg/kg and amikacin 16 mg/kg for patients admitted to surgical intensive care units (SICUs) with suspected gram-negative infection. The objective of this study was to evaluate initial aminoglycoside dosing and peak serum drug concentrations in critically ill surgery patients to characterize the aminoglycoside volume of distribution (V_d) and determine an optimal standardized dosing strategy. Methods: This retrospective, observational, single-center study included adult SICU patients who received an aminoglycoside for additional gram-negative coverage. Descriptive statistics were used to evaluate the patient population, aminoglycoside dosing, and V_d. Multivariable linear regression was applied to determine variables associated with greater aminoglycoside V_d. The mortality rate was compared in patients who achieved adequate initial peak concentrations versus those who did not. Results: One hundred seventeen patients received an aminoglycoside in the SICUs, of whom 58 had an appropriately timed peak concentration measurement. The mean Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score was 27.8 ± 8.9. The V_d in patients receiving gentamicin, tobramycin, and amikacin was 0.49 ± 0.10, 0.41 ± 0.09, and 0.53 ± 0.13 L/kg, respectively. Together, the mean aminoglycoside V_d was 0.50 ± 0.12 L/kg. Gentamicin or tobramycin 5 mg/kg achieved goal peak concentrations in 24 patients (63.2%), and amikacin 20 mg/kg achieved the desired concentrations in nine patients (50.0%). Net fluid status, Body Mass Index, and vasopressor use were not predictive of V_d. There was no difference in the in-hospital mortality rate in patients who achieved adequate peak concentrations versus those who did not (26.8% versus 26.7%; p = 0.99). Conclusion: High aminoglycoside doses are needed in critically ill surgery patients to achieve adequate initial peak concentrations because of the high V_d. Goal peak concentrations were optimized at doses of gentamicin or tobramycin 5 mg/kg, and amikacin 20 mg/kg.

Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture

Background

The context of the study is the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture (HSOPSC). The purpose of the study is to analyze how different elements of patient safety culture are associated with clinical handoffs and perceptions of patient safety.

Methods

The study was performed with hierarchical multiple linear regression on data from the 2010 Survey. We examine the statistical relationships between perceptions of handoffs and transitions practices, patient safety culture, and patient safety. We statistically controlled for the systematic effects of hospital size, type, ownership, and staffing levels on perceptions of patient safety.

Results

The main findings were that the effective handoff of information, responsibility, and accountability were necessary to positive perceptions of patient safety. Feedback and communication about errors were positively related to the transfer of patient information; teamwork within units and the frequency of events reported were positively related to the transfer of personal responsibility during shift changes; and teamwork across units was positively related to the unit transfers of accountability for patients.

Conclusions

In summary, staff views on the behavioral dimensions of handoffs influenced their perceptions of the hospital’s level of patient safety. Given the known psychological links between perception, attitude, and behavior, a potential implication is that better patient safety can be achieved by a tight focus on improving handoffs through training and monitoring.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1502-7) contains supplementary material, which is available to authorized users.

Critical Care Implications of the Affordable Care Act

OBJECTIVES

To provide an overview of key elements of the Affordable Care Act. To evaluate ways in which the Affordable Care Act will likely impact the practice of critical care medicine. To describe strategies that may help health systems and providers effectively adapt to changes brought about by the Affordable Care Act.

DATA SOURCES AND SYNTHESIS

Data sources for this concise review include search results from the PubMed and Embase databases, as well as sources relevant to public policy such as the text of the Patient Protection and Affordable Care Act and reports of the Congressional Budget Office. As all of the Affordable Care Act's provisions will not be fully implemented until 2019, we also drew upon cost, population, and utilization projections, as well as the experience of existing state-based healthcare reforms.

CONCLUSIONS

The Affordable Care Act represents the furthest reaching regulatory changes in the U.S. healthcare system since the 1965 Medicare and Medicaid provisions of the Social Security Act. The Affordable Care Act aims to expand health insurance coverage to millions of Americans and place an emphasis on quality and cost-effectiveness of care. From models which link pay and performance to those which center on episodic care, the Affordable Care Act outlines sweeping changes to health systems, reimbursement structures, and the delivery of critical care. Staffing models that include daily rounding by an intensivist, palliative care integration, and expansion of the role of telemedicine in areas where intensivists are inaccessible are potential strategies that may improve quality and profitability of ICU care in the post-Affordable Care Act era.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 2, Practice Facilitation

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, practice facilitation, which is a common strategy in primary care to help practices develop capacity and infrastructure to support their ability to improve patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe practice facilitation, its terminology, and other important information about the intervention. We encourage leaders and researchers to consider and build on this guideline as they plan, implement, evaluate, and report practice facilitation efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of practice facilitation.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 3, Educational Meetings

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, educational meetings, which is a common intervention in health professions' education. An educational meeting is an opportunity for clinicians to assemble to discuss and apply important information relevant to patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe proper educational meeting terminology and other important information about the intervention. We encourage leaders and researchers to consider and to build on this guideline as they plan, implement, evaluate, and report educational meeting efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of educational meetings.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 4, Interprofessional Education

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, interprofessional education (IPE), which is a common intervention in health professions education. IPE is an opportunity for individuals of multiple professions to interact to learn together, to break down professional silos, and to achieve interprofessional learning outcomes in the service of high-value patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe IPE, its terminology, and other important information about the intervention. We encourage leaders and researchers to consider and to build on this guideline as they plan, implement, evaluate, and report IPE efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of IPE.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 1, Performance Measurement and Feedback

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, performance measurement and feedback, which is a common intervention in health professions education. In the form of a summary report, performance measurement and feedback is an opportunity for clinicians to view data about the care they provide compared with some standard and often with peer and benchmark comparisons. Based on a review of recent evidence and a facilitated discussion with the US and Canadian experts, we describe proper terminology for performance measurement and feedback and other important information about the intervention. We encourage leaders and researchers to consider and build on this guideline as they plan, implement, evaluate, and report efforts with performance measurement and feedback. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of performance measurement and feedback.

Commentary: CME and its role in the academic medical center: increasing integration, adding value

Continuing medical education (CME), as it is currently structured, funded, and institutionalized, plays a marginal role in the academic medical center (AMC). In contrast, several models of more effective, integrated CME exist, and these enable the AMC to better achieve its potential in education, research, and health care delivery. Examples of such models are presented, emphasizing quality and performance improvement; regional, national, and public outreach; faculty and staff development; and research and scholarly activity. Although there are many reasons to maintain the status quo of CME programs, there are offsetting forces for change to be found in accreditation processes, movements toward maintenance of certification and licensure, and the need for the AMC to achieve higher quality standards. These models may offer a view of the potential of academic CME to be a major vehicle for the effective integration in quality, regional, and faculty development arenas, and as a scholarly and outcomes-oriented pursuit. Sitting at the right table and sufficiently integrated, CME holds real potential to help the AMC meet its multiple goals and missions.

The science of continuing medical education: terms, tools, and gaps: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines

BACKGROUND

By its synthesis of a selected portion of the continuing medical education (CME) literature, the evidence-based practice center (EPC) review discovered several major issues in primary study design and in the systematic review process of CME studies. Through this process, the review speaks to the need for clarity in designing, reporting and synthesizing CME trials and provides an opportunity to advance the research agenda in this field.

METHODS

The evidence-based guideline (EBG) committee reviewed the methods section of the EPC report and these guidelines in detail, commenting on the search and review process and on the nature of the primary literature and the definitions used within it, comparing these to other published standardized measures.

RESULTS

Although the EBG committee noted much strength in the EPC review, limitations of the primary literature and the review methodology were identified and defined. These strengths and limitations hold implications for further research in this area.

CONCLUSIONS

Noting these limitations and in order to move the field forward, the EBG committee proposes a standard nomenclature of terms in common use in CME; a more rigorous process of searching, distilling, and synthesizing the primary literature in this area; and a common format on which to base the development and description of future trials of CME interventions.

The reported validity and reliability of methods for evaluating continuing medical education: a systematic review

PURPOSE

To appraise the reported validity and reliability of evaluation methods used in high-quality trials of continuing medical education (CME).

METHOD

The authors conducted a systematic review (1981 to February 2006) by hand-searching key journals and searching electronic databases. Eligible articles studied CME effectiveness using randomized controlled trials or historic/concurrent comparison designs, were conducted in the United States or Canada, were written in English, and involved at least 15 physicians. Sequential double review was conducted for data abstraction, using a traditional approach to validity and reliability.

RESULTS

Of 136 eligible articles, 47 (34.6%) reported the validity or reliability of at least one evaluation method, for a total of 62 methods; 31 methods were drawn from previous sources. The most common targeted outcome was practice behavior (21 methods). Validity was reported for 31 evaluation methods, including content (16), concurrent criterion (8), predictive criterion (1), and construct (5) validity. Reliability was reported for 44 evaluation methods, including internal consistency (20), interrater (16), intrarater (2), equivalence (4), and test-retest (5) reliability. When reported, statistical tests yielded modest evidence of validity and reliability. Translated to the contemporary classification approach, our data indicate that reporting about internal structure validity exceeded reporting about other categories of validity evidence.

CONCLUSIONS

The evidence for CME effectiveness is limited by weaknesses in the reported validity and reliability of evaluation methods. Educators should devote more attention to the development and reporting of high-quality CME evaluation methods and to emerging guidelines for establishing the validity of CME evaluation methods.

The organization of intensive care unit physician services*

OBJECTIVE

To describe the organization of physician services in intensivist-staffed intensive care units (ICU) reporting that they meet vs. do not meet the Leapfrog Physician Staffing standard, and to describe ICU directors' perceptions of the quality of care in their unit.

DESIGN

Hospitals that were asked to participate in the 2001 and 2002 Leapfrog surveys regarding implementation of the ICU Physician Staffing standard were sampled. Survey instruments were developed and used to determine organizational characteristics, status regarding implementing and meeting the standard, financing of physician staffing, and perceptions of clinical performance.

SUBJECTS

ICU directors.

MEASUREMENTS AND MAIN RESULTS

Intensivists staffed ICUs in 100% of hospitals meeting the standard, and in 59% not meeting the standard. Mean percentage of patients visited on rounds by intensivists in ICUs who met (80 +/- 14.58) vs. did not meet (57.5 +/- 23.20) the standard showed no statistical difference, Wilcoxon rank-sum test = -1.99, p = .065. Only 25% (three of 12) of intensivists in ICUs meeting the standard had authority to write patient orders on all patients, compared to 65% (11 of 17) in ICUs not meeting the standard. Intensivists were present at least 8 hrs/day in 83% (ten of 12) of ICUs meeting and 18% (three of 17) of ICUs not meeting the standard. Provision of medical liability insurance for physicians occurred in 58% (seven of 12) of ICUs meeting and 25% (four of 16) of ICUs not meeting the standard (p = .003). ICU directors rated quality of ICU care as excellent in 70% of ICUs meeting and 35% of ICUs not meeting the standard.

CONCLUSIONS

ICUs now classify themselves as meeting or not meeting the ICU Physician Staffing standard. Yet, there is wide variation in organizational characteristics among ICUs meeting the standard, and between those meeting and not meeting the standard. The criteria defined by the Leapfrog Group for meeting the ICU Physician Staffing standard must be clearly defined if hospitals are to meet the standard.

Developing Quality Measures for Sepsis Care in the ICU

BACKGROUND

Sepsis is associated with increased morbidity, mortality, and costs of care. Although several therapies improve outcomes in patients with sepsis, rigorously developed measures to evaluate quality of sepsis care in the intensive care unit (ICU) are lacking.

METHODS

To select an initial set of candidate measures, in 2003-2004 an interdisciplinary panel reviewed the literature and used a modified nominal group technique to identify interventions that improve outcomes of patients with sepsis in the ICU. Design specifications or explicit definitions for each candidate measure were developed.

RESULTS

Ten potential measures were identified: vancomycin administration, time to vancomycin initiation, broad-spectrum antibiotic administration, time to broad-spectrum antibiotic initiation, blood culture collection, steroid administration, corticotropin stimulation test administration, activated protein C eligibility assessment, activated protein C administration, and vancomycin discontinuation.

DISCUSSION

The identification of potential measures of quality of care for patients with sepsis can help caregivers to focus on evidence-based interventions that improve mortality and to evaluate their current performance. Further work is needed to evaluate the feasibility and validity of the measures.

Herbal medicine and anesthesia

Complementary and alternative medicine is one of the fastest growing areas in health care. Many patients worldwide utilize these additional health care strategies in conjunction with standard medical therapies. Unfortunately little is understood about many of the interactions that can occur and as many as 50% of the patients do not inform their health care providers about these complementary and alternative therapies. The interactions that are most important in the perioperative period include sympathomimetic, sedative, and coagulopathic effects. Given the overall paucity of information regarding herbal medicines and their potential pertinent perioperative implications this domain requires a significant amount of further study and in my opinion would be fertile ground for federally funded requested projects.

Intensive care unit errors: detection and reporting to improve outcomes

Most efforts to identify and investigate errors in medicine have focused on active failures and general provider behaviors. We believe that the greatest improvements in error identification and management in the intensive care unit will be achieved by focusing on the intensive care unit's organizational characteristics. The results of three recent studies suggest that differences in intensive care unit organizational characteristics are significantly related to variation in the risk-adjusted morbidity and mortality. Physicians must assume greater leadership in creation of these safe systems for intensive care patients. We encourage the creation of multi-institutional communities to work collaboratively to advance patient safety in high-risk environments like the intensive care unit.

Toward learning from patient safety reporting systems

PURPOSE

To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety.

MATERIALS AND METHODS

Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm.

RESULTS

Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm.

CONCLUSIONS

The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.

Economic stress and misaligned incentives in critical care medicine in the United States

OBJECTIVES

This review will provide an overview of issues with economic ramifications intrinsic to the management of intensive care resources and identify some of the external pressures that ultimately influence the provision of intensive care services.

DESIGN

A review of the current literature was performed.

RESULTS

Economic stress is a reality of the management of intensive care resources. The nature of critical care medicine as a technologically heavy, labor intensive, high-cost, limited resource, combined with a projected increase in demand in an era of cost containment, presents an array of challenges.

CONCLUSIONS

It is in the best interest of the care of our patients that critical care providers increase awareness of the many factors influencing our practice economically. It is through such understanding that challenges can be met, solutions can be found, and the quality of intensive care can be improved in a financially sustainable environment.

Association between venous thromboembolism and perioperative allogeneic transfusion

HYPOTHESIS

Perioperative allogeneic blood product transfusion would be associated with venous thromboembolic complications in surgical patients.

DESIGN

Observational study using a state discharge database.

SETTING

Nonfederal acute care hospitals in Maryland performing colorectal cancer resections between January 1, 1994, and December 31, 2000.

PATIENTS

We obtained data on 14 014 adult patients having a primary diagnosis code for colorectal cancer and a primary procedure code for colorectal resection.

MAIN OUTCOME MEASURES

The primary outcome variable was a discharge diagnosis of venous thromboembolism (VTE).

RESULTS

Venous thromboembolism occurred in 1% of patients and was associated with an adjusted 3.8-fold increase in mortality (odds ratio, 3.8; 95% confidence interval, 2.1-6.8), a 61% increase in mean hospital length of stay, and a 72% increase in mean total hospital charges. Risk factors for VTE after adjustment included transfusion, female sex, age 80 years or older, moderate to severe liver disease vs no liver disease, admission through the emergency department, and low annual surgeon case volume. Transfusion was associated with an increase in the odds of developing VTE in women (odds ratio, 1.8; 95% confidence interval, 1.2-2.6) but not in men (odds ratio, 0.9; 95% confidence interval, 0.5-1.9). In the absence of transfusion, female compared with male sex was not associated with an increased risk of VTE (odds ratio, 1.2; 95% confidence interval, 0.8-1.7).

CONCLUSIONS

In this large observational study of patients undergoing colorectal cancer resection, perioperative allogeneic blood transfusion was associated with an increased risk of VTE in women but not in men. Given the substantial morbidity and mortality associated with VTE and the implication that this finding has for postoperative management in women, this association must be confirmed in independent studies.

Measuring clinical information technology in the ICU setting: application in a quality improvement collaborative

OBJECTIVE

Few instruments are available to measure the performance of intensive care unit (ICU) clinical information systems. Our objectives were: 1) to develop a survey-based metric that assesses the automation and usability of an ICU's clinical information system; 2) to determine whether higher scores on this instrument correlate with improved outcomes in a multi-institution quality improvement collaborative.

DESIGN

This is a cross-sectional study of the medical directors of 19 Michigan ICUs participating in a state-wide quality improvement collaborative designed to reduce the rate of catheter-related blood stream infections (CRBSI). Respondents completed a survey assessing their ICU's information systems.

MEASUREMENTS

The mean of 54 summed items on this instrument yields the clinical information technology (CIT) index, a global measure of the ICU's information system performance on a 100 point scale. The dependent variable in this study was the rate of CRBSI after the implementation of several evidence-based recommendations. A multivariable linear regression analysis was used to examine the relationship between the CIT score and the post-intervention CRBSI rates after adjustment for the pre-intervention rate.

RESULTS

In this cross-sectional analysis, we found that a 10 point increase in the CIT score is associated with 4.6 fewer catheter related infections per 1,000 central line days for ICUs who participate in the quality improvement intervention for 1 year (95% CI: 1.0 to 8.0).

CONCLUSIONS

This study presents a new instrument to examine ICU information system effectiveness. The results suggest that the presence of more sophisticated information systems was associated with greater reductions in the bloodstream infection rate.

Impact of the Leapfrog Group's intensive care unit physician staffing standard

PURPOSE

The aim of this study was to describe hospital efforts to meet the Leapfrog Group's intensive care unit (ICU) physician staffing (IPS) standard; compare adopters and committers with resisters relative to perceived benefits, barriers and motivating factors; and examine implementation strategies.

MATERIALS AND METHODS

Chief medical officers (CMO) and ICU directors at hospitals in 6 US regions were surveyed between August 2003 and January 2004. Hospital classifications were based on level of IPS implementation pioneer (met before IPS), adopter (met after IPS by 2002 Leapfrog survey), committer (not met but committed to December 2004 implementation), and resister (refused to adopt IPS). Meeting IPS included intensivist staffing, 8 hours/day 7 days/week; sole patient care in ICU; 95% pager response time </=5 minutes; and physicians certified in critical care.

RESULTS

Forty-three (80%) CMOs and 42 (78%) ICU directors were interviewed. Adopters (100%), committers (80%), and resisters (45%) employed intensivists; 1 adopter (14%) met all criteria for standard. Main motivators for implementation were "quality of patient care" for CMO (79%) and ICU director (71%) adopter/committers. Incentives to implement were increasing intensivist authority (90% committers) and intensivist salary support (80% committers and 70% adopters). Main resister barriers were implementation costs (61% CMOs) and medical staff controversy (55% ICU directors).

CONCLUSION

Most hospitals-including half of those who publicly resisted the standard-made attempts to change physician staffing in their ICUs, based on the criteria outlined by the Leapfrog Group. Major barriers that need addressing are implementation costs and convincing hospital organizations and medical staff regarding the benefits of adopting the standard.

Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study

PURPOSE

The aim of this study is to determine if patient safety incidents and the system-related factors contributing to them systematically differ for medical versus surgical patients in intensive care units.

MATERIALS AND METHODS

We conducted a multicenter prospective study of 646 incidents involving adult medical patients and 707 incidents involving adult surgical patients that were reported to an anonymous patient safety registry over a 2-year period. We compared incident characteristics, patient harm, and associated system factors for medical versus surgical patients.

RESULTS

The proportion of safety incidents reported for medical versus surgical patients differed for only 3 of 11 categories: equipment/devices (14% vs 19%; P = .02), "line, tube, or drain" events (8% vs 13%; P = .001), and computerized physician order entry (13% vs 6%; P < or = .001). The type of patient harm associated with incidents also did not differ. System factors were similar for medical versus surgical patients, with training and teamwork being the most important factors in both groups.

CONCLUSIONS

Medical and surgical patients in the intensive care unit experience very similar types of safety incidents with similar associated patient harm and system factors. Common initiatives to improve patient safety for medical and surgical patients should be undertaken with a specific focus on improving training and teamwork among the intensive care team.

Effectiveness of continuing medical education

OBJECTIVES

Despite the broad range of continuing medical education (CME) offerings aimed at educating practicing physicians through the provision of up-to-date clinical information, physicians commonly overuse, under-use, and misuse therapeutic and diagnostic interventions. It has been suggested that the ineffective nature of CME either accounts for the discrepancy between evidence and practice or at a minimum contributes to this gap. Understanding what CME tools and techniques are most effective in disseminating and retaining medical knowledge is critical to improving CME and thus diminishing the gap between evidence and practice. The purpose of this review was to comprehensively and systematically synthesize evidence regarding the effectiveness of CME and differing instructional designs in terms of knowledge, attitudes, skills, practice behavior, and clinical practice outcomes.

REVIEW METHODS

We formulated specific questions with input from external experts and representatives of the Agency for Healthcare Research and Quality (AHRQ) and the American College of Chest Physicians (ACCP) which nominated this topic. We systematically searched the literature using specific eligibility criteria, hand searching of selected journals, and electronic databases including: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Abstracts of Reviews of Effects (DARE), PsycINFO, and the Educational Resource Information Center (ERIC). Two independent reviewers conducted title scans, abstract reviews, and then full article reviews to identify eligible articles. Each eligible article underwent double review for data abstraction and assessment of study quality.

RESULTS

Of the 68,000 citations identified by literature searching, 136 articles and 9 systematic reviews ultimately met our eligibility criteria. The overall quality of the literature was low and consequently firm conclusions were not possible. Despite this, the literature overall supported the concept that CME was effective, at least to some degree, in achieving and maintaining the objectives studied, including knowledge (22 of 28 studies), attitudes (22 of 26), skills (12 of 15), practice behavior (61 of 105), and clinical practice outcomes (14 of 33). Common themes included that live media was more effective than print, multimedia was more effective than single media interventions, and multiple exposures were more effective than a single exposure. The number of articles that addressed internal and/or external characteristics of CME activities was too small and the studies too heterogeneous to determine if any of these are crucial for CME success. Evidence was limited on the reliability and validity of the tools that have been used to assess CME effectiveness. Based on previous reviews, the evidence indicates that simulation methods in medical education are effective in the dissemination of psychomotor and procedural skills.

CONCLUSIONS

Despite the low quality of the evidence, CME appears to be effective at the acquisition and retention of knowledge, attitudes, skills, behaviors and clinical outcomes. More research is needed to determine with any degree of certainty which types of media, techniques, and exposure volumes as well as what internal and external audience characteristics are associated with improvements in outcomes.

Clinical and economic outcomes of hospital acquired pneumonia in intra-abdominal surgery patients

OBJECTIVE

To measure the clinical and economic impact of postoperative hospital-acquired pneumonia (HAP) and to identify risk factors for the development of HAP.

SUMMARY BACKGROUND DATA

Although postoperative HAP is recognized to be an major risk associated with surgery, little is known about the overall outcomes of patients whose hospital stay is complicated by HAP following surgery.

METHODS

We studied 618,495 patients who underwent an intra-abdominal operation from the National Inpatient Sample database over a 1-year period (January 2000 to December 2000) using CPT codes and discharge diagnoses identified by the Clinical Classification Software. Data collected included demographic characteristics, type of operation, in-hospital mortality, discharge disposition, length of stay, and hospital charges.

RESULTS

Of the 13,292 patients with HAP following intra-abdominal surgery, 1421 died prior to discharge (mortality = 10.7%) compared with 7217 deaths in the control group of patients without HAP following intra-abdominal surgery (mortality = 1.2%) (P < 0.001). HAP was independently associated with a 4.13-fold (95% confidence interval = 3.94-4.34) increase in risk to be discharged to a skilled nursing facility. The mean length of hospital stay for intra-abdominal patients who developed HAP was significantly greater compared with intra-abdominal surgery patients who did not develop HAP (17.10 days versus 6.07 days, P < 0.001). After adjusting for patient characteristics, HAP was independently associated with a 75% (28,160.95 dollars; 95% confidence interval, 27,543.76 dollars - 28,778.13 dollars) mean increase in total hospital charges.

CONCLUSIONS

Given the high incidence and significant impact of HAP on patient outcomes, early preventive strategies and interventions to reduce HAP should be a priority.

Unsustainable growth rate: physician perspective

OBJECTIVE

To describe the sustainable growth rate history and calculations and why the present approach is not sustainable.

BACKGROUND

The sustainable growth rate was created to help control the growth rate in healthcare expenditures. Presently, it is responsible, at least in part, for reductions in physician payment. Two components of the sustainable growth rate make it unsustainable in its present form. These components are 1) the inability to go back and correct for values based on the wrong assumptions and 2) the inclusion of drug-related costs into the sustainable growth rate.

DISCUSSION

Few physicians have a full grasp of how their payment is structured from a mechanistic standpoint. A significant component of determining physician payment is established by the relative value unit, and how these are derived has been discussed in another article in this supplement. Once the relative value unit has been established, it is multiplied by the established conversion factor. A major component of the conversion factor is the sustainable growth rate. This article attempts to explain how the sustainable growth rate came into being, how it is calculated, and how it is flawed and contributing to decreasing physician payments. A few possible remedies are discussed, and the potential ramifications of those remedies on the physician community and the premiums of Medicare patients are examined.

Evaluation and management codes: from current procedural terminology through relative update commission to Center for Medicare and Medicaid Services

BACKGROUND

Physicians should have a working knowledge of the process by which patient care codes are created and subsequently assigned values. The Society of Critical Care Medicine has representatives on the national committees that focus on code creation and definition and on assignment of relative value units. In addition, a better understanding of documentation requirements and the audit process will facilitate improved compliance and minimize liability.

DISCUSSION

The authors discuss the current procedural terminology (CPT) process for defining care codes and the relative update commission (RUC) process for assigning values to those codes, with each code assigned a separate value in three separate categories. Steps for managing any concern or dispute about billing, denials, or an audit are subsequently addressed. Tenets of proper documentation are discussed, and some future developments are identified that are likely to affect critical care.

CONCLUSION

Knowledge of the procedures by which care codes are defined and valued is necessary for using these codes properly, as well as for addressing needs unmet by existing codes. Preventing audits is the best approach to proper coding and billing, and documentation is key.

Patient-safety and quality initiatives in the intensive-care unit

PURPOSE OF REVIEW

Patient safety has become the primary focus of health-care improvement in the last few years as an increasing body of evidence emphasizes the magnitude of harm posed to patients by medical errors. The intensive-care unit, by virtue of the high technology aggressive level of care the unit provides, has been identified as a significant source of patient harm. Consequently, the intensive-care unit also represents a tremendous opportunity to study and implement patient-safety initiatives, as significant improvements can be realized in this environment.

RECENT FINDINGS

Several broad areas of successful patient-safety initiatives have been reported over the recent past including implementation of Comprehensive Unit-based Safety Programs, introduction of communication tools (for example daily goal sheets), application of care bundles (that is mechanical ventilation or sepsis), as well as team approaches that can eradicate catheter-related bloodstream infections. Specific interventions are gaining supportive evidence and widespread acceptance for their ability to reduce harm including tight glucose control and ultrasonography for reducing central-line placement complications. Recent data also demonstrate the value of an intensivist as the team leader for the critically ill within the intensive-care unit and potentially with rapid-response teams.

SUMMARY

Many patient safety and quality-of-care initiatives that have broad application to all areas of medical care have been successfully developed in the intensive-care unit. The intensive-care unit appears to be a fertile ground for the development of safety initiatives.

Intensive care unit physician staffing: Financial modeling of the Leapfrog standard*

OBJECTIVE

To evaluate from a hospital's perspective the costs and savings, over a 1-yr period, of implementing The Leapfrog Group's Intensive Care Unit Physician Staffing (IPS) standard compared with the existing standard of nonintensivist staffing in adult intensive care units.

DESIGN

Using published data, we developed a financial model of costs and savings for 6-, 12- and 18-bed intensive care units using conservative estimates for all variables. Sensitivity analyses, including a best-case and worst-case scenario, were performed to evaluate the impact of changing assumptions on the outcome of the model.

SETTING

Nonrural hospitals in the United States.

PATIENTS

All adult intensive care unit patients.

INTERVENTIONS

The IPS standard requires that intensive care units have a dedicated intensivist present during daytime hours. Outside of these hours, an intensivist must be immediately available by pager, and a physician or "physician extender" must be in the hospital and able to immediately reach intensive care unit patients.

MEASUREMENTS AND MAIN RESULTS

Cost savings ranged from $510,000 to $3.3 million for 6- to 18-bed intensive care units. The best-case scenario demonstrated savings of $4.2-13 million. Under the worst-case scenario, there was a net cost of $890,000 to $1.3 million.

CONCLUSIONS

Financial modeling of implementation of the IPS standard using conservative assumptions demonstrated cost savings to hospitals. Only under worst-case scenario assumptions did intensivist staffing result in additional cost to hospitals. These economic findings must be interpreted in the context of significant reductions in patient morbidity and mortality rates also associated with intensivist staffing. Given the magnitude of its clinical and financial impact, hospital leaders should be asking "how to" rather than "whether to" implement The Leapfrog Group's ICU Physician Staffing standard.

Integrating the Intensive Care Unit Safety Reporting System with Existing Incident Reporting Systems

BACKGROUND

Voluntary incident reporting systems that identify risks can be integrated into existing hospital reporting systems and can improve patient safety.

FINDINGS

A voluntary and anonymous Web-based intensive care unit safety reporting system (ICUSRS) was implemented in a cohort of intensive care units (ICUs). The reporting system was integrated into hospitals' reporting systems after the adverse event reporting structures were investigated. Reporting systems were classified as mandatory or voluntary and internal or external; the extent of formal training was identified and the trajectory of completed adverse events in the exisiting systems were tracked. Information from reported incidents was sent back monthly to the hospital ICUs through case discussions and a quarterly newsletter.

RESULTS

All seven hospitals had internal reporting systems and two also used external reporting systems. In general, the majority of incident reports were completed by registered nurses and were reported to the nursing chain of command. Many of the sites had little knowledge or understanding of their existing reporting systems.

CONCLUSION

Voluntary external reporting systems such as the ICUSRS hold promise for improving patient safety.

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit

OBJECTIVE

To analyze the system factors related to "line, tube, and drain" (LTD) incidents in the intensive care unit (ICU).

DESIGN

Voluntary, anonymous Web-based patient safety reporting system.

SETTING

Eighteen ICUs in the United States.

PATIENTS

Incidents reported by ICU staff members during a 12-month period ending June 2003.

INTERVENTIONS

None.

MEASUREMENTS

Characteristics of the incidents (defined as events that could/did cause harm), patients, and patient harm were described. Separate multivariable logistic regression analyses of contributing, limiting, and preventive system factors for LTD vs. non-LTD incidents were reported.

MAIN RESULTS

Of the 114 reported LTD incidents, >60% were considered preventable. One patient death was attributed to an LTD incident. Of patients experiencing LTD incidents, 56% sustained physical injury, and 23% had an anticipated increased hospital stay. Factors contributing to LTD incidents included occurrence in the operating room (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.25-9.83), occurrence on a holiday (OR, 3.65; 95% CI, 1.12-11.9), patient medical complexity (OR, 3.68; 95% CI, 2.28-5.92), and age of 1-9 yrs (OR, 7.95; 95% CI, 3.29-19.2). Factors related to team communication were less likely to limit LTD incidents (OR, 0.28; 95% CI, 0.11-0.68), while clinician knowledge and skills helped prevent LTD incidents (OR, 1.80; 95% CI, 1.09-2.97).

CONCLUSIONS

Patients are harmed by preventable LTD incidents. Relative to non-LTD events, these incidents occur more frequently during holidays and in medically complex patients and children. Focusing on these contributing factors and clinician knowledge and skills is important for reducing and preventing these hazardous events.

Number needed to treat and cost of recombinant human erythropoietin to avoid one transfusion-related adverse event in critically ill patients

OBJECTIVE

To calculate the absolute risk reduction of transfusion-related adverse events, the number of patients needed to treat, and cost to avoid one transfusion-related adverse event by using erythropoietin in critically ill patients

DESIGN

Number needed to treat with sensitivity analysis.

SETTING

Teaching hospital.

PATIENTS

Hypothetical cohort of critically ill patients who were candidates to receive erythropoietin.

INTERVENTIONS

Using vs. not using erythropoietin to reduce the need for packed red blood cell transfusions.

MEASUREMENTS AND MAIN RESULTS

We used published estimates of known transfusion risks: transfusion-related acute lung injury, transfusion-related errors, hepatitis B and C, human immunodeficiency virus, human T-cell lymphotropic virus, and bacterial contamination, stratified by severity. Based on the estimated risk and frequency of transfusions with and without erythropoietin, we calculated the absolute risk reduction of transfusion-related adverse events, the number needed to treat, and cost to avoid one transfusion-related adverse event by using erythropoietin. The estimated incidence of transfusion-related adverse event was 318 permillion units transfused for all transfusion-related adverse events, 58 per million for serious transfusion-related adverse events, and 21 per million for likely fatal transfusion-related adverse events. The routine use of erythropoietin resulted in an absolute risk reduction of 191 per million for all transfusion-related adverse events, 35 per million for serious transfusion-related adverse events, and 12 per million for likely fatal transfusion-related adverse events. The number needed to treat was 5,246 to avoid one transfusion-related adverse event, 28,785 to avoid a serious transfusion-related adverse event, and 81,000 for a likely fatal transfusion-related adverse event. The total cost was $4,700,000 to avoid one transfusion-related adverse event, $25,600,000 to avoid one serious transfusion-related adverse event, and $71,800,000 to avoid a likely fatal transfusion-related adverse event. The magnitude of these results withstood extensive sensitivity analysis.

CONCLUSIONS

From the perspective of avoidance of adverse events, erythropoietin does not appear to be an efficient use of limited resources for routine use in critically ill patients.

Creating the web-based intensive care unit safety reporting system

In an effort to improve patient safety, researchers at the Johns Hopkins University designed and implemented a comprehensive Web-based Intensive Care Unit Safety Reporting System (ICUSRS). The ICUSRS collects data about adverse events and near misses from all staff in the ICU. This report reflects data on 854 reports from 18 diverse ICUs across the United States. Reporting is voluntary, and data collected is confidential, with patient, provider, and reporter information deidentified. Preliminary data include system factors reported, degree of patient harm, reporting times, and evaluations of the system. Qualitative and quantitative data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter.

Do intensivists in ICU improve outcome?

Despite considerable investment of resources, there remains wide variation in organization of Intensive Care Units (ICUs). One key domain is the physician staffing. In particular, does staffing with physicians trained in critical care (intensivists) improve clinical outcomes? The rationale for improved outcome with intensivist staffing is that physicians who have the skills to treat critically ill patients, and who are immediately available to detect and treat problems, may prevent or attenuate morbidity and mortality. Intensivist staffing may also yield benefits through a leadership role at the intensive care unit organizational level. The improved sense of continuity and close attendance to patients may also bolster improved patient and family satisfaction. Intensivist-led or intensivist-staffed ICUs may also realize decreased resource use because these physicians may be better at reducing inappropriate admissions, preventing complications that prolong length of stay, and recognizing opportunities for prompt discharge.

Platelet gene polymorphisms and cardiac risk assessment in vascular surgical patients

BACKGROUND

Current perioperative cardiac risk assessment tools use historic and surgical factors to stratify patient risk. Polymorphisms in platelet glycoprotein (GP) IIIa and GPIbalpha are associated with myocardial ischemic risk in nonsurgical settings, but their relation to perioperative ischemia is unclear. The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors.

METHODS

One hundred ninety-six patients who underwent infrainguinal, abdominal aortic, or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia. Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIbalpha. Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis.

RESULTS

Sixty-five patients (33%) experienced one or more ischemic endpoints (2% death, 5% myocardial infarction, 20% troponin+, 22% electrocardiogram+). The Pro33 (adjusted odds ratio [OR], 2.4 [95% confidence interval, 1.2-6.2]) and Met145 (OR 3.4 [1.4-9.3]) genotypes were independent predictors of composite ischemic outcome by multivariate regression, as were diabetes mellitus (OR 4.0 [1.7-12.5]), abdominal aortic surgery (OR 4.1 [1.7-14.4]), and thoracoabdominal aortic surgery (OR 6.4 [2.7-23.8]). The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 13.5, P < 0.001) of an ischemia prediction model. The derived risk assessment tool had a receiver operator characteristic curve of 0.73 (0.65-0.81) compared with 0.64 (0.57-0.74) for a model excluding genetic factors (P = 0.04). A significant relation between the GPIbalpha polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint.

CONCLUSIONS

Platelet polymorphisms are independent risk factors for postoperative myocardial ischemia and improve a risk prediction model when added to historic and surgical risk factors.

Eliminating catheter-related bloodstream infections in the intensive care unit

OBJECTIVE

To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs).

DESIGN

Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU.

SETTING

The Johns Hopkins Hospital.

PATIENTS

All patients with a central venous catheter in the ICU.

INTERVENTION

To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed.

MEASUREMENT

The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion.

MAIN RESULTS

Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU.

CONCLUSIONS

Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.