Trichloroacetic Acid Ingestion: Self-Harm Attempt.

OBJECTIVE: Trichloroacetic acid (TCAA), or trichloroethanoic acid, is a chemical analogue of acetic acid where three methyl group hydrogen atoms are replaced by chlorine. TCAAs are also abbreviated and referred to as TCAs, causing confusion with the psychiatric antidepressant drug class, especially among patients. TCAAs exist in dermatological treatments such as chemical peels or wart chemoablation medication. TCAA ingestion or overdose can cause gastric irritation symptoms including vomiting, diarrhea, or lassitude. This symptomatology is less severe than TCA overdose, where symptoms may include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion, seizures, rapid heart rate, and cardiac arrest. Owing to the vast difference in symptoms, the need for clinical intervention differs greatly. While overdose of either in a self-harm attempt can warrant psychiatric hospital admission, the risk of death in TCAA ingestion is far less. CASE REPORT: A patient ingested TCAA in the form of a commercially available dermatological chemical peel as a self-harm attempt, thinking that it was a more injurious TCA. CONCLUSION: Awareness among physicians, particularly psychiatrists, regarding this relatively obscure chemical compound (TCAA) and its use by suicidal patients mistakenly believing it to be a substance that can be significantly more lethal (TCA), is imperative.

Predictive value of dobutamine echocardiography just before noncardiac vascular surgery.

This study prospectively evaluated 75 consecutive patients (mean age 69 +/- 9 years) undergoing major vascular surgery to test the hypothesis that dobutamine stress echocardiography can be used to predict perioperative cardiac events. A positive test was defined as a new or worsening wall motion abnormality in at least 2 of 18 wall segments. Up to 40 micrograms/kg/min of dobutamine was administered. All readings were done by physicians unaware of the patients' symptoms and electrocardiographic response. In addition, physicians caring for the patients were unaware of the test result. End points of the study were unstable angina with documented electrocardiographic changes, nonfatal myocardial infarction or cardiac death. The perioperative ischemic event rate was 7% (5 of 75 patients). Three patients developed unstable angina and 2 sustained nonfatal myocardial infarctions. All of these patients had positive results on dobutamine stress echocardiography (sensitivity 100%). However, 22 patients who also had positive results on dobutamine stress echocardiography did not have perioperative events (specificity 69%). The corresponding positive predictive value was 19%. None of the 48 patients who had negative results on dobutamine stress echocardiography had events (negative predictive value 100%). In conclusion, dobutamine stress echocardiography can be used to predict perioperative events with great sensitivity, but its positive predictive value in this patient population in low, likely due to the low incidence of perioperative events in patients with known coronary artery disease and the imperfect specificity of dobutamine stress echocardiography in identifying significant coronary stenosis. Dobutamine stress echocardiography is most useful in this setting when negative, because it predicts safety from complications with confidence.

A performance-based incentive program for influenza immunization in the elderly.

Our objective was to implement and evaluate performance-based reimbursement for influenza immunization of the elderly in physician offices. We performed a community-based quasi-experiment with historic and concurrent comparisons, using primary care physician offices in Monroe County, New York. Participants in the intervention group included 53 primary care physicians admitting to one hospital, and the comparison group included 82 primary care physicians admitting to other hospitals. All physicians participated in a Medicare-sponsored demonstration to increase influenza immunization rates, and, during the 1990-1991 immunization season, used a target-based poster to track immunization rates. Physicians in the intervention group were enrolled in a performance-based financial incentive program that rewarded immunization rates above 70%. A survey concerning influenza immunization practices and opinions was sent to all physicians. The average physician-specific immunization rate in the incentive group was 73.1% versus 55.7% in the comparison practices (P < .001). Eligibility for incentives, practice size, sex of physician, medical specialty, reminder postcards, and practice populations including medically indigent patients were associated with immunization level. Controlling for the above variables, we completed a regression analysis showing that eligibility for the incentive was still significant (P = .003). The survey responses were not predictive of performance or significantly different between the two groups, except for the negative influence of sending postcards. This study in a community setting suggests that linking reimbursement to performance may be a successful strategy to increase influenza immunization levels for the elderly.

Introduction to human health and illness: a series of patient-centered conferences based on the biopsychosocial model.

In 1985, to increase the curricular presence of the biopsychosocial model of medical education, the University of Rochester School of Medicine and Dentistry introduced a series of whole-class, patient-centered conferences for all first- and second-year medical students. From 1985 through the spring of 1999, these sessions, called Introduction to Human Health and Illness (IHHI), were offered as a stand-alone course every Friday in the first two years of medical school; beginning in the fall of 1999, the sessions were integrated into other first- and second-year courses. With real patients present, these conferences focus on the relationships among biological, behavioral/psychological, and social factors in health and illness. Some of the sessions also explore the impact of physician behaviors on patients and their health and the roles of other professionals in patient care. The authors describe the creation and implementation of the IHHI course, organization, format, and faculty for the IHHI sessions, the opportunities the sessions provide for active student learning and interaction with patients, and their multidisciplinary content. Descriptions of specific sessions and a summary of the program's strengths, limitations, and opportunities for the future are also presented.

Treatment and control of hypertension as preventive therapy.

Hypertension increases the incidence of adverse cardiovascular events such as stroke, heart failure, and coronary artery disease. Studies have shown that treatment of even mild hypertension can reduce the occurrence of these adverse cardiovascular events--particularly stroke, congestive heart failure, and progression to more severe hypertension. Patients with newly diagnosed hypertension can be treated pharmacologically with thiazide-type diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, or calcium channel blockers. Nonpharmacologic therapy such as weight reduction can also play an important role in treatment. Additional study is needed to identify optimal drug treatment regimens and to clarify the association between treatment of hypertension and the occurrence of adverse effects from ischemic heart disease.

Diagnostic strategies and test algorithms in liver disease.

As clinicians evaluate patients, they first develop problem lists based on the history, physical examination, and basic laboratory studies. Synthesis and analysis result in a differential diagnosis with associated disease probabilities. Experienced clinicians then selectively use diagnostic tests to rule in or rule out these possibilities. For example, in a patient presenting with jaundice, anorexia, fever, and abdominal pain, the relative increases of the serum aminotransferase activity and the serum alkaline phosphatase will help to guide the subsequent evaluation. If the aminotransferase activity is markedly increase, then the subsequent evaluation will be targeted toward identifying an etiology for hepatocellular injury. In contrast, if the alkaline phosphatase is markedly increased, then the evaluation would be targeted toward identifying an etiology for obstructive jaundice. This paper reviews clinical decision making, discusses characteristics of diagnostic tests, and presents examples of how basic clinical information can guide the use of the laboratory in evaluating patients with suspected liver disease.

Quality of care during a community-wide experiment in prospective payment to hospitals.

To determine whether a community-wide experiment in hospital prospective payment adversely affected quality of care, availability and outcomes of care were studied in Rochester, NY from 1980 to 1984. During this 5-year period, prospective payment contained hospital expenditures in a community that was already below the national average in health-care costs. Access to necessary care was maintained, and there were increased admissions for management of maternal illness and acute myocardial infarction. Rates of inpatient elective surgery declined. Outcomes of care remained stable, including neonatal deaths, ischemic heart disease deaths, deaths from five selected surgical conditions, and rates of adverse outcomes from sentinel medical and surgical conditions. These results indicated that prospective payment programs in which incentives to decrease marginal or unneeded care are linked with a community-wide effort to plan for the delivery of services can be financially and clinically successful.

Innovations in patient care: changing clinical practice and improving quality.

BACKGROUND: In the traditional hospital organization, administrators supply the resources while physicians determine their use. Given this dichotomy, a partnership between clinicians and hospital management is essential for efforts to enhance the quality of care while controlling costs. To foster this partnership, in 1986 the University of Rochester's Strong Memorial Hospital developed its Innovations in Patient Care (IPC) program, which several other medical centers have duplicated. CURRENT STATUS AND LOGISTICS: Hospital operating revenues of approximately $175,000 per year are provided to both fund proposals and support core IPC staff. Clinical staff submit proposals to study innovations to promote higher quality care and/or the efficient and appropriate use of diagnostic and therapeutic services. Many of the 77 projects funded to date have led to important changes in clinical practice. CASE STUDIES: One study, whose principal investigator was assistant director of emergency medicine, showed that structured, condition-specific (for example, asthma, pharyngitis, lacerations, and isolated closed-head injury) quicksheets improved documentation of clinical findings, resource use, and clinical practice. A study organized by the leadership of surgical nursing revealed that a nursing case management model led to reductions in patient length of stay and increases in nurse satisfaction. Another study, designed by a fellow in neonatalogy, developed and tested guidelines for the use of head ultrasounds in screening very-low-birthweight infants for intraventricular hemorrhage. CONCLUSIONS: IPC programs, which integrate well with initiatives in total quality management, can be effectively used to change clinical practice and improve the quality and efficiency of patient care.

Levels and causes of stress among residents.

Medical and dental residents at the University of Rochester Medical Center were surveyed to measure stress and its causes. Their stress, as measured by the brief symptom inventory, showed levels slightly above those of an adult comparison group. The average levels of stress decreased with the residents' advancing levels of training. Comparison of the top quartile with the lowest quartile of scores of everyday stress showed significantly elevated stress for rotations in the emergency room, greater frequency of being on call, and lesser amount of sleep. The residents' reports showed that the bleakest three days of residency tended to occur in the first year and during intensive care rotations. Stress during these bleakest times was significantly higher than everyday levels. The residents described the major causes of distress during bleakest times as lack of sleep, inadequate support from senior professionals, large patient load, and competition from peers. "High quality" teaching rounds, a night-float system, and sick leave were felt by the residents to lessen stress. To cope with the stress, the residents reported they talked to others, tried to see humor in the situation, or slept.

Predicting the need for hospitalization of ambulatory patients with pneumonia.

OBJECTIVE: To develop clinical guidelines to identify patients with pneumonia who might be safely treated as outpatients. DESIGN: Retrospective chart review to derive guidelines, with subsequent prospective validation. SETTING: Initial review completed for patients seen in the emergency room (ER) of a university hospital and a community-based internal medicine practice. Validation conducted in the ERs of a university hospital and a community teaching hospital. PATIENTS/PARTICIPANTS: Individuals aged 16 years and older presenting with newly diagnosed pneumonia. Follow-up obtained through mail or telephone contact and chart review. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the initial retrospective review, 141 pneumonia patients without obvious reasons for hospital admission were identified and then classified as hospitalization necessary or unnecessary. Of these patients, 33 were classified as requiring admission. Multivariate analysis identified five variables that differentiated low-risk from high-risk study patients. These variables (and their relative weights) were: serious comorbid illness (3 points); preexisting lung disease (2 points); multilobar lung involvement by the disease by chest x-ray (2 points); observed or likely aspiration (2 points); and symptom duration of less than 7 or greater than 28 days (1 point). Risk scores were calculated using these variables. Patients with low scores (0-2 points) rarely had complications, and only one of 53 such patients (2%) was judged to require hospitalization. In contrast, patients with high scores (greater than or equal to 6 points) had frequent complications and 20 of 29 (69%) were felt to need hospitalization. Similar results were found during the validation phase. CONCLUSIONS: Clinical findings appear to help distinguish patients who need admission for treatment of pneumonia from those who do not. If validated in other settings, the clinical utility of these guidelines in assisting decision making about hospitalization should be determined.

The necessary length of hospital stay for chronic pulmonary disease.

OBJECTIVE: --To determine the necessary length of stay for patients admitted to the hospital with an exacerbation of chronic pulmonary disease and to compare this with the length of stay assigned by the diagnosis related group system. DESIGN: --A cohort of patients were followed up prospectively after hospital admission to determine when complications, critical incidents, and the need for monitoring occurred. The medically derived necessary lengths of stay were statistically compared with the lengths of stay assigned by the diagnosis related group. Clinical factors were used to predict long vs short necessary lengths of stay. SETTING: --Two acute care hospitals: one was the principal and the other a major community teaching hospital. PATIENTS: --A consecutive sample of 83 patients who were 45 years of age or older and who required admission for treatment of chronic pulmonary disease. MAIN OUTCOME MEASURES: --The occurrence and time of complications, critical interventions, and monitoring. RESULTS: --After 6 days in the hospital, 90% of patients were free of complications or the need for monitoring. However, 16 days elapsed before 90% of patients had been discharged from the hospital. The length of stay that was considered necessary for care averaged 6.9 days; the actual mean length of stay was 8.7 days. The correlation between each patient's ideal length of stay and the length of stay assigned by the diagnosis related group was low and was not statistically significant. Three clinical variables at the time of admission (high PCO2 levels, symptoms that were present for more than 1 day, and antibiotic treatment) were associated with the need for longer hospital stays. CONCLUSIONS: --The medically required length of stay for patients with an exacerbation of chronic pulmonary disease was between 6 and 7 days, on average. This length of stay, which was based on clinical events, differs from the length of stay that was calculated as a statistical norm by the diagnosis related group system. Clinical characteristics may help to identify patients who require a longer length of stay.

Reporting tools for clinical quality improvement.

To support clinical quality improvement (QI), effective quality analysis tools are essential. New strategies that we have incorporated into our routine assessment activities include comparative screening, clinical process benchmarking tables, and run charts for key quality indicators. To target areas for improvement, we use comparative screening. We have access to clinical data for 11 comparable medical centers. Currently, these data are used to identify our ranking relative to the others for mortality, readmission, and length of stay. Diagnosis-related groups and ICD-9-CM clusters serve as clinical groupings with defined minimal case volume requirements to ensure meaningful comparisons. These comparative reports permit our clinical leaders and hospital administrators to focus QI activities. Clinical process benchmarking involves peer-to-peer interfacility communication to identify those factors that create outstanding clinical performance. We successfully have used this tool to support process improvement in cardiac-surgery, administration of patient controlled analgesia, and respiratory therapy. Interdisciplinary QI teams identify the key investigative questions. Team members then contact their counterparts at similar facilities, which differ from our hospital in quality, based on empirical evidence or through comparative screening. The information that is obtained is collated in a tabular format, along with our own information, to permit easy identification of key clinical processes associated with better outcomes. Key quality and utilization goals at our hospital include reducing unplanned readmissions by 10%, achieving a 5% lower average length of stay, and not exceeding Health Care Financing Administration expected mortality rates in any clinical area.(ABSTRACT TRUNCATED AT 250 WORDS)