A Multicenter, Cross-Sectional Quality Improvement Project: The Perioperative Implementation of a Hypertension Protocol by Anesthesiologists.

BACKGROUND: Hypertension is a common risk factor for cardiovascular morbidity and mortality, with a high prevalence in patients presenting for elective surgery. In limited resource environments, patients have poor access to primary care physicians, limiting the efficacy of lifestyle modification for the management of hypertension. In these circumstances, the perioperative period presents a unique opportunity for diagnosis and initiation and/or modification of pharmacotherapy of hypertension. Anesthesiologists are ideally placed to lead this aspect of perioperative medicine. The study objective was for anesthesiologists to identify patients at the preoperative visit with previously undiagnosed or poorly controlled chronic hypertension and follow a simple management algorithm. METHODS: In collaboration with expert physicians, we designed and implemented an algorithm for the diagnosis and management of chronic hypertension. This was a multicenter, cross-sectional quality improvement project in 7 hospitals in the Western Cape, South Africa. On the day before scheduled elective surgery, adult in-patients had 2 sets of blood pressure (BP) readings taken, one by nurses and the other by anesthesiologists, using a noninvasive automated BP device. These were averaged on an electronic database, to diagnose hypertension. Patients with normal BP or well-controlled hypertension required no further management. Those with borderline BP received educational pamphlets. Patients with stage 1 or 2 hypertension were managed with medication according to the algorithm, starting 1 day postoperatively, and provided with educational pamphlets. Patients with stage 3 disease had their surgery postponed and were referred to a physician. The primary outcome was adherence by the anesthesiologist to the algorithm in the diagnosis and management of hypertension. An 80% adherence rate was considered successful implementation. The secondary outcome was the adherence to the algorithm at discharge. RESULTS: Two hundred ninety-eight patients were screened for hypertension. One hundred six patients were eligible for the quality improvement project. Thirty-seven (34.9%) had borderline BP readings, 43 (40.6%) had stage 1, 22 (20.8%) stage 2, and 4 (3.8%) stage 3 hypertension, respectively. The adherence rate by the anesthesiologist in initiating treatment according to the algorithm was 89 of 106 (84.0%; 95% confidence interval [CI, 77.0-91.0). There was full adherence to the algorithm in 59 of 106 (55.5%; 95% CI, 46.2-65.1) at the time of discharge from hospital. CONCLUSIONS: Anesthesiologists successfully implemented a quality improvement project for diagnosis and management of hypertension in the perioperative period. This has the potential to reduce the public health burden of hypertension in limited resource environments. Successful ongoing prescription and follow-up requires cooperation within a multidisciplinary team.

Assessing systemic barriers to permanency achievement for children in out-of-home care: development of the child permanency barriers scale.

State and local child welfare agencies are engaged in multiple efforts to enact systems change to improve outcomes, particularly in regard to achievement of child permanency. The Child and Family Services Review process, conducted by the Administration Children and Families, requires states to implement program improvement plans designed to improve outcomes for which they are not meeting national standards. However, a tool has not been demonstrated as useful in assessing the barriers to achievement of permanency across the out-of-home service continuum, from recruitment of families to placement stability. This article reports on the development and refinement of such a tool in one Midwestern state. The Child Permanency Barriers Scale has four factors: kinship, placement and matching, adequate services and resources, and communication and collaboration. Implications for use in state-specific and multisystem assessment and system reform are discussed.

University faculty perceptions of the health risks related to cigarettes and smokeless tobacco.

INTRODUCTION AND AIMS: It is now widely understood by tobacco research and policy experts that smokeless tobacco (ST) use confers significantly less risk than smoking, but no studies have assessed tobacco risk perceptions in highly educated populations. The purpose of this study was to explore the perception of risks related to smoking and ST use among full-time faculty on two campuses at the University of Louisville. DESIGN AND METHODS: In October 2007, a survey that quantified risk perceptions of cigarette smoking and ST use with respect to four health domains (general health, heart attack/stroke, all cancer, oral cancer) was sent to 1610 full-time faculty at the Belknap and the Health Sciences Center (HSC) campuses of the University of Louisville, and 597 (37%) returned a completed survey. RESULTS: Overall, cigarettes were considered as high risk for all health domains by large majorities (75-97%). Except for heart attack/stroke, ST was also considered as high risk by the majority of faculty (69-87%), and at least half perceived cigarettes and ST to be equally harmful across all domains. HSC faculty had somewhat more accurate risk perceptions than Belknap faculty for ST, but both groups overestimated the risks, especially for oral cancer. DISCUSSION AND CONCLUSIONS: This study found that the risks of ST use are overestimated and conflated to that of cigarettes among highly educated professionals, demonstrating the need for better education about the risks of tobacco use and for communication of accurate information by health organisations and agencies.

Interprofessional ambulatory primary care practice-based educational program.

Although interprofessional teamwork and collaboration are considered key elements for improving patient outcomes, there are few reports of controlled studies involving interprofessional training of health care learners in the ambulatory primary care setting. We describe an educational program for teams of nurse practitioners, family medicine residents and social work students to work together at clinical sites in the delivery of longitudinal care in primary care ambulatory clinics. Year 1 was a planning year. Program evaluation completed at the end of the second curriculum (Year 3) indicated that the changes the team made at the end of the first curriculum (Year 2) resulted in increased appreciation of the training program, greater perception of value of care delivered by interprofessional teams among team learners as compared to non-team learners, and team learner self assessment of improved team skills including working with other professionals, resolving conflict, and integrating prevention and health promotion into health care. Team learners demonstrated an increased awareness of the limits of their own profession's approach to team care. We conclude that interprofessional ambulatory clinical training in primary care where learners work together providing care to patients can contribute to fostering both positive learner attitudes toward interprofessional work and development of team skills.

Orthopedic trauma from recreational all-terrain vehicle use in central Kentucky: a 6-year review.

BACKGROUND: All-terrain vehicle (ATV) crashes and injuries have become an increasing concern for the medical community. After the expiration of federal guidelines in 1998, the United States Consumer Product Safety Commission has tracked an increasing incidence of usage and injury. This retrospective review of data from a Level I trauma center presents ATV crash-related injury prevalence, type, and location sustained in central Kentucky and compares the data with previous reports. METHODS: Patient demographics, helmet and alcohol use, insurance type, injury type and location, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, Functional Independence Measure (FIM), duration of hospital stay, days in an intensive care unit (ICU), internal disposition, and discharge destination were analyzed among individuals who had sustained ATV crash-related injuries between January 1998 and December 2003. RESULTS: Patients were primarily male (85.4%), white (98%), resided in a rural county (85.1%), and relied on commercial insurance (36.2%) or self-pay (31.4%) for medical expenses. Alcohol use before injury was documented for 25% and 85.5% were not wearing a helmet. Rollover was the primary ATV crash mechanism (63.3%) and 52.1% of patients lost consciousness. Of 707 total injuries, 319 (45.1%) were fractures or dislocations with the spine (26%), ribs (24.1%), clavicle (6%), radius-ulna (5.3%), and tibia-fibula (4.7%) being the most common locations. Admitted patients were hospitalized for 8.1+/-12.7 days (range=0-127 days), 42% were transferred to the standard care ward, 28.2% spent 8.4+/-7.7 days (range=1-34 days) in the ICU, and 18.6% were taken directly to the operating room. At discharge 78.2% of patients went home, 12.8% were transferred to a rehabilitation facility, 4.8% died, and 3.2% were transferred to another hospital. Patients who never lost consciousness or who were discharged to home had lower ISSs and greater composite and component GCS and FIM scores. CONCLUSION: Almost half of all patients sustained one fracture or joint dislocation with the spine being the most prevalent location. Injury severity, the low number referred to rehabilitation facilities, and predominantly rural residence locations suggests that many may not be accessing needed healthcare services. Prospective longitudinal outcome studies are needed to assess patient functional independence, quality of life, and health care system effectiveness.