Toyota production system quality improvement initiative improves perioperative antibiotic therapy.

OBJECTIVE: To assess the role of a Toyota production system (TPS) quality improvement (QI) intervention on appropriateness of perioperative antibiotic therapy and in length of hospital stay (LOS) among surgical patients. STUDY DESIGN: Pre-post quasi-experimental study using local and national retrospective cohorts. METHODS: We used TPS methods to implement a multifaceted intervention to reduce nosocomial methicillin-resistant Staphylococcus aureus infections on a Veterans Affairs surgical unit, which led to a QI intervention targeting appropriate perioperative antibiotic prophylaxis. Appropriate perioperative antibiotic therapy was defined as selection of the recommended antibiotic agents for a duration not exceeding 24 hours from the time of the operation. The local computerized medical record system was used to identify patients undergoing the 25 most common surgical procedures and to examine changes in appropriate antibiotic therapy and LOS over time. RESULTS: Overall, 2550 surgical admissions were identified from the local computerized medical records. The proportion of surgical admissions receiving appropriate perioperative antibiotics was significantly higher (P <.01) in 2004 after initiation of the TPS intervention (44.0%) compared with the previous 4 years (range, 23.4%-29.8%) primarily because of improvements in compliance with antibiotic therapy duration rather than appropriate antibiotic selection. There was no statistically significant decrease in LOS over time. CONCLUSION: The use of TPS methods resulted in a QI intervention that was associated with an increase in appropriate perioperative antibiotic therapy among surgical patients, without affecting LOS.

Causes and risk factors for rehospitalization of patients hospitalized with community-acquired pneumonia.

BACKGROUND: Rehospitalization after inpatient treatment of community-acquired pneumonia occurs in one-tenth of all hospitalizations, but the clinical circumstances surrounding readmission to the hospital have not been well studied. The objective of this study was to identify the causes and risk factors for rehospitalization of inpatients with community-acquired pneumonia. METHODS: This project was performed as part of a randomized, multicenter, controlled trial of the implementation of practice guidelines to reduce the duration of intravenous antibiotic therapy and duration of hospitalization for patients who have received a clinical and radiographic diagnosis of pneumonia. The trial was conducted at 7 hospitals in Pittsburgh, Pennsylvania, from February 1998 through March 1999. The primary outcome for these analyses was rehospitalization within 30 days after the index hospitalization. Two physicians independently assigned the cause of rehospitalization as pneumonia related, comorbidity related, or both; consensus was reached for all assignments. Patient demographic characteristics and clinical factors independently associated with rehospitalization were identified using multiple logistic regression analysis. RESULTS: Of the 577 patients discharged after hospitalization for community-acquired pneumonia, 70 (12%) were rehospitalized within 30 days. The median time to rehospitalization was 8 days (interquartile range, 4-13 days). Overall, 52 rehospitalizations (74%) were comorbidity related, and 14 (20%) were pneumonia related. The most frequent comorbid conditions responsible for rehospitalization were cardiovascular (n = 19), pulmonary (n = 6) and neurological (n = 6) in origin. Less than a high school education (odds ratio, 2.0; 95% confidence interval, 1.1-3.4), unemployment (odds ratio, 3.7; 95% confidence interval, 1.1-12.3), coronary artery disease (odds ratio, 2.7; 95% confidence interval, 1.5-4.7), and chronic obstructive pulmonary disease (odds ratio, 2.3; 95% confidence interval, 1.3-4.1) were independently associated with rehospitalization. CONCLUSIONS: The majority of rehospitalizations following pneumonia are comorbidity related and are the result of underlying cardiopulmonary and/or neurologic diseases. Careful attention to the clinical stability of patients with these coexisting conditions at and following hospital discharge may decrease the frequency of rehospitalization of patients with community-acquired pneumonia.

Validation of a model to predict adverse outcomes in patients with pulmonary embolism.

AIMS: To validate a model for quantifying the prognosis of patients with pulmonary embolism (PE). The model was previously derived from 10 534 US patients. METHODS AND RESULTS: We validated the model in 367 patients prospectively diagnosed with PE at 117 European emergency departments. We used baseline data for the model's 11 prognostic variables to stratify patients into five risk classes (I-V). We compared 90-day mortality within each risk class and the area under the receiver operating characteristic curve between the validation and the original derivation samples. We also assessed the rate of recurrent venous thrombo-embolism and major bleeding within each risk class. Mortality was 0% in Risk Class I, 1.0% in Class II, 3.1% in Class III, 10.4% in Class IV, and 24.4% in Class V and did not differ between the validation and the original derivation samples. The area under the curve was larger in the validation sample (0.87 vs. 0.78, P=0.01). No patients in Classes I and II developed recurrent thrombo-embolism or major bleeding. CONCLUSION: The model accurately stratifies patients with PE into categories of increasing risk of mortality and other relevant complications. Patients in Risk Classes I and II are at low risk of adverse outcomes and are potential candidates for outpatient treatment.

Developmental changes in the phenomenology of depression in girls compared to boys from childhood onward.

BACKGROUND: Although it is well documented that teenage girls are at increased risk for depression, little is known about the importance of sex and development subsequent to onset of depression. In this article, we therefore report on sex differences in the developmental phenomenology of depression in a clinical sample. METHODS: Longitudinal analyses were used to examine changes in the risk of depression, patterns of comorbid diagnoses, and depressive symptoms from ages 8-13 years up to young adulthood (age 21) among 87 patients. RESULTS: Girls and boys were at similar risk for recurrent depression during follow-up. As girls got older, they had higher rates of comorbid eating disorders and lower rates of externalizing and substance use disorders than did boys; high risk periods for comorbid conditions also differed by sex. Comorbid disorders were usually contemporaneous with depression among girls but not among boys, and comorbidity patterns were influenced by age at depression onset. Girls with earlier (compared to later) onset depression were at lower risk for nonaffective disorders; boys evidenced the opposite pattern and were at particularly high risk for substance use disorders. There also were sex differences in developmental symptom patterns. LIMITATIONS: Results based on this initially clinically referred sample may not generalize to youths in other settings. CONCLUSIONS: Among depressed youths, sex-associated developmental trajectories in comorbid disorders and depressive symptoms have implications for intervention. Such information may help identify optimal timing of efforts to reduce the risk of or to treat comorbid disorders, and help select developmentally appropriate target symptoms for girls versus boys.