Clinical performance and quality health care最新文献

{"title":"Surveillance of handwashing episodes in adult intensive-care units by measuring an index of soap and paper towel consumption.","authors":"M J Bittner,&nbsp;E C Rich","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To determine whether handwashing surveillance could be conducted by measurements of soap and towel consumption.</p><p><strong>Design and participants: </strong>In the medical intensive-care unit (MICU) of the Omaha Veterans' Affairs Medical Center, 10 4-hour day-time observation periods encompassing 409 handwashing episodes were scheduled in a 51-day period. In the surgical intensive-care unit (SICU), 7 4-hour periods encompassing 350 episodes were scheduled in a 49-day period. An observer measured paper towel height, towel weight, and soap weight at each sink. The observer also counted handwashing episodes and bed occupancy. Using handwashing episodes as a dependent variable, stepwise linear regression was performed with changes in towel height, towel weight, and soap weight as independent variables.</p><p><strong>Results: </strong>Mean handwashing episodes per hour per occupied bed were 2.39 +/- 0.80 (standard deviation) in the MICU and 2.83 +/- 0.72 in the SICU. Correlation r with handwashing episodes for MICU changes was 0.891 for towel height, 0.950 for towel weight, and 0.882 for soap weight. Corresponding correlations for the SICU were 0.881, 0.918, and 0.904. For both units, stepwise regression retained changes in the weight of towels and soap as independent variables (P < .0001), with R2 0.965 (MICU) and 0.981 (SICU).</p><p><strong>Conclusion: </strong>Because soap and towel consumption measurements are closely related to handwashing frequency and because these measurements are easy to obtain, they offer a means of handwashing surveillance that can be sustained indefinitely. This can facilitate feedback-based interventions to improve handwashing frequency.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 4","pages":"179-82"},"PeriodicalIF":0.0,"publicationDate":"1998-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21219528","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Utilizing national nosocomial infection surveillance system data to improve urinary tract infection rates in three intensive-care units.","authors":"D G Dumigan,&nbsp;C A Kohan,&nbsp;C R Reed,&nbsp;J F Jekel,&nbsp;M K Fikrig","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To reduce catheter-related urinary tract infection rates in three intensive-care units to at or below the National Nosocomial Infection Surveillance System pooled mean for similar units.</p><p><strong>Design: </strong>A nursing team, physician team, and laboratory team reviewed and revised protocols and procedures for better catheter management.</p><p><strong>Setting: </strong>A 500-bed community teaching hospital.</p><p><strong>Interventions: </strong>The teams developed medical indications for urinary catheter placement and criteria that allowed the registered nurse to remove a catheter without a physician's order when no longer medically necessary. They created a computer prompt to assure a urinalysis accompanied all urine cultures.</p><p><strong>Results: </strong>After introducing the new protocols, the incidence density of catheter-related urinary tract infections fell 17% in the surgical intensive-care unit, 29% in the medical intensive-care acute unit, and 45% in the coronary intensive-care acute unit. The registered nurses' compliance in removing the catheter per protocol was 88%. Physician ordering of a concomitant urinalysis with each urine culture achieved 93%.</p><p><strong>Conclusions: </strong>A multidisciplinary approach assisted in reducing catheter-associated urinary tract infections in three intensive-care units, although not to the extent desired. The teams are investigating preconnected and antimicrobial-coated catheters further.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 4","pages":"172-8"},"PeriodicalIF":0.0,"publicationDate":"1998-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21219526","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A quality management approach to optimizing delivery and administration of preoperative antibiotics.","authors":"L Welch,&nbsp;A C Teague,&nbsp;B A Knight,&nbsp;A Kenney,&nbsp;J E Hernandez","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To optimize the process for delivering and administering preoperative antibiotics in order to prevent potential adverse patient outcomes.</p><p><strong>Design: </strong>Using a multidisciplinary quality-improvement team, an evaluation of the preoperative medication order and delivery process was conducted. Charts were reviewed by selected time periods, with winter 1994 discharges for orthopedic surgeries (n = 97) and spring 1995 discharges for open heart procedures (n = 50) being used to arrive at baseline data (n = 147). A plan was devised to mainstream the medication-use process so that it would be standardized hospitalwide. A goal of administering preoperative antibiotics within 30 to 60 minutes prior to cut time was established. Following redesign and education, a repeat chart review of orthopedic surgeries (n = 33) and open heart procedures (n = 168) was conducted during April 1997 for discharges from the same diagnosis-related groups to total (n = 201).</p><p><strong>Setting: </strong>A nearly 1,000-bed tertiary referral center and teaching hospital with three separate campuses.</p><p><strong>Results: </strong>We identified multiple ordering mechanisms, multiple medication sources and delivery sites, multiple administration sites and administering personnel, and other logistical conflicts. Thirty-one percent of cases received antibiotics less than 30 minutes prior to start time, 39% between 30 to 60 minutes, and 30% greater than 60 minutes before start time. Following the multidisciplinary redesign and education, an increase from 39% to 61% receiving preoperative antibiotics between 30 to 60 minutes prior to surgery start time and a decrease from 31% to 18% receiving them in less than 30 minutes was documented. The percentage of patients receiving preoperative antibiotics in 60 minutes or less increased from 70% to 80%.</p><p><strong>Conclusion: </strong>A continuous quality-improvement approach that engages all departments involved in patient care is necessary to achieve meaningful change in complicated hospital processes.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 4","pages":"168-71"},"PeriodicalIF":0.0,"publicationDate":"1998-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21220340","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospitalk: an exploratory study to assess what is said and what is heard between physicians and nurses.","authors":"E Larson,&nbsp;H E Hamilton,&nbsp;K Mitchell,&nbsp;J Eisenberg","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>Collaboration and effective communication between healthcare professionals has been demonstrated to improve patient outcomes and job satisfaction. The purpose of this study was to examine physician and nurse communication in a hospital setting during a time of very rapid change.</p><p><strong>Data sources and study setting: </strong>Full-time attending internal medicine physicians (n = 5), registered nurses (n = 18), and medical residents (n = 12) working on two adult medical units in a 325-bed tertiary-care hospital in the mid-Atlantic region from fall 1996 to summer 1997.</p><p><strong>Study design: </strong>Descriptive survey and interview.</p><p><strong>Data collection methods: </strong>Each subject completed a written questionnaire, Physician-Nurse Communication Scale, and a structured interview with a trained social linguistics team.</p><p><strong>Principal findings: </strong>Physicians and nurses shared similar perceptions regarding their roles in communication processes, such as giving orders, asking for information, and asking for and giving opinions. They differed significantly in the perceptions of the physician and nurse roles in giving information, orienting, and providing education. Generally, physicians perceived that nurses initiated certain types of communication significantly less often than did nurses. Both groups expressed an interest in more interaction; nurses particularly expressed the need to be \"listened to\" or respected more. Nurses were significantly more likely to express the need to change interactions with house staff than with attending physicians (P = .02).</p><p><strong>Conclusions: </strong>Interactions between physicians and nurses are perceived differently by the two groups, leading to misunderstanding of motive and meaning. Recommendations are made to improve communication between these two professional groups.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 4","pages":"183-9"},"PeriodicalIF":0.0,"publicationDate":"1998-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21219525","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Preventable trauma deaths: evaluation by peer review and a guide for quality improvement. Emergency Medical Study Group for Quality.","authors":"K Takayanagi,&nbsp;K Koseki,&nbsp;T Aruga","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Background: </strong>The trauma-injury severity-score (TRISS) methodology was developed in the United States to calculate the probability of survival for trauma patients presenting for emergency care.</p><p><strong>Objective: </strong>We assessed the utility of using the TRISS methodology to identify preventable trauma deaths and compared the results to peer review using explicit standards.</p><p><strong>Methods: </strong>Explicit peer review standards were developed by a focus group. The validity of these standards was evaluated by comparing the results of peer review performed by two independent expert panels. All trauma cases admitted to 10 centers in Japan between April 1, 1994, and March 31, 1996, were evaluated using the TRISS methodology. Cases with an expected probability of survival of more than 0.5 were considered preventable. These cases were subjected to peer review. Patients who were dead on arrival were excluded from analysis.</p><p><strong>Results: </strong>Of 3,125 patients who were not dead on arrival, the TRISS methodology identified 2,525 as having a probability of survival greater than 0.5. In this group, 189 patients died; thus, 25.3% of all deaths were considered preventable by the TRISS method. Peer review found that only 11.2% of the deaths were preventable; thus, only 46.6% of preventable deaths identified by TRISS were confirmed by peer review. Agreement between the two expert peer review panels was very good (kappa = 0.62).</p><p><strong>Conclusion: </strong>TRISS can be used as a screening tool to identify potentially preventable trauma deaths. Peer review is appropriate to confirm preventability and to identify potential medical errors.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 4","pages":"163-7"},"PeriodicalIF":0.0,"publicationDate":"1998-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21220339","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Hawthorne strategy: implications for performance measurement and improvement.","authors":"T R Lied,&nbsp;V A Kazandjian","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The Hawthorne experiments are a backdrop for diverse studies assessing the impact of treatment and experimentation on human and organizational performance. The Hawthorne effect is used to describe the positive impact on behavior that sometimes occurs in a study or experiment as a result of the interest shown by the experimenter in humans who are being treated, studied, or observed. We propose that the Hawthorne effect can be viewed as an active construct to develop a coherent strategy for performance improvement. We propose a \"Hawthorne strategy\" that transcends the Hawthorne effect in that it offers an approach to improving performance indefinitely. This strategy uses external observations of performance to increase internal commitment to performance improvement. The focus of individual responsibility increases as does the perceived connection between individual efforts and external performance improvement. The sense of accountability is maintained by institutional recognition and periodic reinforcement of individual behaviors that contribute to performance improvement. A successful Hawthorne strategy encourages providers of care to be evaluators of their performance as individuals, as members of groups, and as members of institutions.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 4","pages":"201-4"},"PeriodicalIF":0.0,"publicationDate":"1998-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21219524","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections.","authors":"M A Gardam,&nbsp;B Amihod,&nbsp;P Orenstein,&nbsp;N Consolacion,&nbsp;M A Miller","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To assess the impact of the overutilization of indwelling urinary catheters in the emergency department on the development of nosocomial urinary tract infection.</p><p><strong>Design: </strong>Prospective cohort study.</p><p><strong>Setting: </strong>638-bed tertiary-care hospital.</p><p><strong>Patients: </strong>118 consecutive medical and surgical admissions from the emergency department collected over 3 weeks.</p><p><strong>Intervention: </strong>Catheterized patients were assessed. The completeness of documentation relating to catheter insertion and two outcomes were measured: asymptomatic bacteriuria and urinary tract infection.</p><p><strong>Results: </strong>24 (20.3%) had catheters inserted, of whom 12 (50%) were catheterized for justifiable indications. Positive urine cultures were found in 10 of the catheterized patients (42%), 5 of whom fulfilled the definition for catheter-associated urinary tract infection. Three of the five infections occurred in patients for whom catheterization was not justifiable. An order was written for catheter insertion in 62.5% of charts, while the rationale for catheterization was documented in 16.7%.</p><p><strong>Conclusions: </strong>Many nosocomial urinary tract infections are due to the inappropriate placement of indwelling urinary catheters in the emergency department. The prevention of these infections should begin with restricting catheterization to those patients for whom it is appropriate.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 3","pages":"99-102"},"PeriodicalIF":0.0,"publicationDate":"1998-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21054094","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Inappropriate antibiotic therapy in febrile cancer patients with bacteremia.","authors":"S Spanik,&nbsp;D West,&nbsp;P Pichna,&nbsp;J Novotny,&nbsp;J Dacok,&nbsp;M Mraz,&nbsp;B Chmelik,&nbsp;I Krupova,&nbsp;V Krcmery","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>The aim of the study was to assess the outcome of inappropriately treated cancer patients with documented bacteremia.</p><p><strong>Design/setting: </strong>95 cases of inappropriately treated bacteremias in febrile cancer patients in a tertiary-care center were analyzed and compared with a group of appropriately treated bacteremias to assess risk factors for inappropriate therapy and outcome.</p><p><strong>Results: </strong>Among 285 bacteremias, 95 (33.3%) were not treated appropriately, with 42 receiving the wrong antibiotics and 17 having too short a therapeutic course of appropriate antibiotics. In 13, therapy was delayed for more than 48 hours after the onset of fever. Twenty-three patients did not receive antibiotic therapy at all despite bacteremia. A group of 95 inappropriately treated bacteremias was compared to 190 appropriately treated bacteremias occurring in the same period. Microbiological cure after the initial course of therapy was achieved more often (76.8% vs 38.9%, P < .001) in the group of appropriately treated bacteremias in all cases and also in the subgroup of leukemic patients (P < .01). Overall and attributable mortality were significantly lower in patients who were treated appropriately. There was no difference in the number of antibiotics administered in appropriately versus inappropriately treated bacteremias. Cost of therapy between both groups was similar.</p><p><strong>Conclusions: </strong>Inappropriately treated bacteremic cancer patients had outcomes that were significantly worse than patients who were treated appropriately. The reasons for inappropriate therapy were selection of the wrong antimicrobials, too short a duration of therapy, delayed onset of therapy, or absence of antimicrobial therapy.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 3","pages":"109-13"},"PeriodicalIF":0.0,"publicationDate":"1998-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21054090","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Behind the physician licensure numbers: false impressions, retirement crisis, and migration.","authors":"V Olchanski,&nbsp;D W Marsland,&nbsp;L F Rossiter,&nbsp;R E Johnson","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>This communication examines the supply of primary-care physicians at the state level. It shows that the number of actively practicing physicians is considerably less than the number of licensed physicians; the age distribution of primary-care physicians has a bulge in the ages younger than 50, and this bulge may lead in the near future to an unexpected increase in physician attrition due to retirement; and, at the state level, migration may be playing the dominant role in determining the total supply of primary-care physicians.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 3","pages":"142-6"},"PeriodicalIF":0.0,"publicationDate":"1998-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21055231","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"E-mail medicine: dawn of a new era in physician-patient communication.","authors":"M D Nettleman,&nbsp;V Olchanski,&nbsp;J B Perlin","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Computer-based electronic mail has opened up new opportunities for physician-patient communication. In many ways, electronic communication is more convenient than either the telephone or the postal service. However, it is important to recognize the limitations of electronic mail. In this article, we review important issues and recommend minimal standards for physician-patient communication via electronic mail.</p>","PeriodicalId":79831,"journal":{"name":"Clinical performance and quality health care","volume":"6 3","pages":"138-41"},"PeriodicalIF":0.0,"publicationDate":"1998-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21054087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}