Hydrophobic Inorganic Oxide Pigments via Polymethylhydrosiloxane Grafting: Dispersion in Aqueous Solution at Extraordinarily High Solids Concentrations.

Building on the recent demonstration of aqueous-dispersible hydrophobic pigments that retain their surface hydrophobicity even after drying, we demonstrate the synthesis of surface-modified Ti-Pure R-706 (denoted R706) titanium dioxide-based pigments, consisting of a thin (one to three monolayers) grafted polymethylhydrosiloxane (PMHS) coating, which (i) are hydrophobic in the dry state according to capillary rise and dynamic vapor sorption measurements and (ii) form stable aqueous dispersions at solid contents exceeding 75 wt % (43 vol %), without added dispersant, displaying similar rheology to R706 native oxide pigments at 70 wt % (37 vol %) consisting of an optimal amount of conventional polyanionic dispersant (0.3 wt % on pigment basis). The surface-modified pigments have been characterized via 29Si and 13C cross-polarization/magic angle spinning solid-state NMR spectroscopy; infrared spectroscopy; thermogravimetric and elemental analyses; and ζ potential measurements. On the basis of these data, the stability of the surface-modified PMHS-R706 aqueous dispersions is attributed to steric effects, as a result of grafted PMHS strands on the R706 surface, and depends on the chaotropic nature of the base used during PMHS condensation to the pigment/polysiloxane interface. The lack of water wettability of the surface-modified oxide particles in their dry state translates to improved water-barrier properties in coatings produced with these surface-modified pigment particles. The synthetic approach appears general as demonstrated by its application to various inorganic-oxide pigment particles.

Are Evidence-based Practices Associated With Effective Prevention of Hospital-acquired Pressure Ulcers in US Academic Medical Centers?

BACKGROUND: In 2008, the Centers for Medicare and Medicaid Services (CMS) established nonpayment policies resulting from costliness of hospital-acquired pressure ulcers (HAPUs) to hospitals. This prompted hospitals to adopt quality improvement (QI) interventions that increase use of evidence-based practices (EBPs) for HAPU prevention. OBJECTIVE: To evaluate the longitudinal impact of CMS policy and QI adoption on HAPU rates. MATERIALS AND METHODS: We characterized longitudinal adoption of 25 QI interventions that support EBPs through hospital leadership, staff, information technology, and performance and improvement. Quarterly counts of HAPU incidence and inpatient characteristics were collected from 55 University HealthSystem Consortium hospitals between 2007 and 2012. Mixed-effects regression models tested the longitudinal association of CMS policy, HAPU coding, and QI on HAPU rates. The models assumed level-2 random intercepts and random effects for CMS policy and EBP implementation to account for between-hospital variability in HAPU incidence. RESULTS: Controlling for all 25 QI interventions, specific updates to EBPs for HAPU prevention had a significant, though modest reduction on HAPU rates (-1.86 cases/quarter; P=0.002) and the effect of CMS nonpayment policy on HAPU prevention was much greater (-11.32 cases/quarter; P<0.001). CONCLUSIONS: HAPU rates were significantly lower after changes in CMS reimbursement. Reductions are associated with hospital-wide implementation of EBPs for HAPU prevention. Given that administrative data were used, it remains unknown whether these improvements were due to changes in coding or improved quality of care.

Comparative effectiveness of quality improvement interventions for pressure ulcer prevention in academic medical centers in the United States.

BACKGROUND: Prevention of pressure ulcers, one of the hospital-acquired conditions (HACs) targeted by the 2008 nonpayment policy of the Centers for Medicare & Medicaid Services (CMS), is a critical issue. This study was conducted to determine the comparative effectiveness of quality improvement (QI) interventions associated with reduced hospital-acquired pressure ulcer (HAPU) rates. METHODS: In an quasi-experimental design, interrupted time series analyses were conducted to determine the correlation between HAPU incidence rates and adoption of QI interventions. Among University HealthSystem Consortium hospitals, 55 academic medical centers were surveyed from September 2007 through February 2012 for adoption patterns of QI interventions for pressure ulcer prevention, and hospital-level data for 5,208 pressure ulcer cases were analyzed. Between- and within-hospital reduction significance was tested with t-tests post-CMS policy intervention. RESULTS: Fifty-three (96%) of the 55 hospitals used QI interventions for pressure ulcer prevention. The effect size analysis identified five effective interventions that each reduced pressure ulcer rates by greater than 1 case per 1,000 patient discharges per quarter: leadership initiatives, visual tools, pressure ulcer staging, skin care, and patient nutrition. The greatest reductions in rates occurred earlier in the adoption process (p<.05). CONCLUSIONS: Five QI interventions had clinically meaningful associations with reduced stage III and IV HAPU incidence rates in 55 academic medical centers. These QI interventions can be used in support of an evidence-based prevention protocol for pressure ulcers. Hospitals can not only use these findings from this study as part of a QI bundle for preventing HAPUs.

Hospital-Acquired Pressure Ulcers at Academic Medical Centers in the United States, 2008-2012: Tracking Changes Since the CMS Nonpayment Policy.

BACKGROUND: In 2007, the Centers for Medicare & Medicaid Services (CMS) announced its intention to no longer reimburse hospitals for costs associated with hospital-acquired pressure ulcers (HAPUs) and a list of other hospital-acquired conditions (HACs), which was followed by enactment of the nonpayment policy in October 2008. This study was conducted to define changes in HAPU incidence and variance since 2008. METHODS: In a retrospective observational study, HAPU cases were identified at 210 University HealthSystem Consortium (UHC) academic medical centers in the United States. HAPU incidence rates were calculated as a ratio of HAPU cases to the total number of UHC inpatients between the first quarter of 2008 and the second quarter of 2012. HAPU cases were defined by multiple criteria: not present on admission (POA); coded for stage III or IV pressure ulcers; and a length of stay greater than four days. RESULTS: Among the UHC hospitals between 2008 and June 2012, 10,386 HAPU cases were identified among 4.08 million inpatients. The HAPU incidence rate decreased significantly from 11.8 cases per 1,000 inpatients in 2008 to 0.8 cases per 1,000 in 2012 (p < .001; 95% confidence interval: 8.39-8.56). Among HAPU cases were trends of more elderly patients, greater case-mix index, and more surgical cases. The analysis of covariance model identified CMS non-payment policy as a significant covariate of changing trends in HAPU incidence rates. CONCLUSIONS: HAPU incidence rates decreased significantly among 210 UHC AMCs after the enactment of the CMS nonpayment policy. The hospitals appeared to be reacting efficiently to economic policy incentives by improving prevention efforts.

Increased Adoption of Quality Improvement Interventions to Implement Evidence-Based Practices for Pressure Ulcer Prevention in U.S. Academic Medical Centers.

OBJECTIVE: In 2008, the U.S. Centers for Medicare and Medicaid Services enacted a nonpayment policy for stage III and IV hospital-acquired pressure ulcers (HAPUs), which incentivized hospitals to improve prevention efforts. In response, hospitals looked for ways to support implementation of evidence-based practices for HAPU prevention, such as adoption of quality improvement (QI) interventions. The objective of this study was to quantify adoption patterns of QI interventions for supporting evidence-based practices for HAPU prevention. METHODS: This study surveyed wound care specialists working at hospitals within the University HealthSystem Consortium. A questionnaire was used to retrospectively describe QI adoption patterns according to 25 HAPU-specific QI interventions into four domains: leadership, staff, information technology (IT), and performance and improvement. Respondents indicated QI interventions implemented between 2007 and 2012 to the nearest quarter and year. Descriptive statistics defined patterns of QI adoption. A t-test and statistical process control chart established statistically significant increase in adoption following nonpayment policy enactment in October 2008. Increase are described in terms of scope (number of QI domains employed) and scale (number of QI interventions within domains). RESULTS: Fifty-three of the 55 hospitals surveyed reported implementing QI interventions for HAPU prevention. Leadership interventions were most frequent, increasing in scope from 40% to 63% between 2008 and 2012; "annual programs to promote pressure ulcer prevention" showed the greatest increase in scale. Staff interventions increased in scope from 32% to 53%; "frequent consult driven huddles" showed the greatest increase in scale. IT interventions increased in scope from 31% to 55%. Performance and improvement interventions increased in scope from 18% to 40%, with "new skin care products . . ." increasing the most. LINKING EVIDENCE TO ACTION: Academic medical centers increased adoption of QI interventions following changes in nonpayment policy. These QI interventions supported adherence to implementation of pressure ulcer prevention protocols. Changes in payment policies for prevention are effective in QI efforts.

A framework of quality improvement interventions to implement evidence-based practices for pressure ulcer prevention.

PURPOSE: To enhance the learner's competence with knowledge about a framework of quality improvement (QI) interventions to implement evidence-based practices for pressure ulcer (PrU) prevention. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Summarize the process of creating and initiating the best-practice framework of QI for PrU prevention.2. Identify the domains and QI interventions for the best-practice framework of QI for PrU prevention. Pressure ulcer (PrU) prevention is a priority issue in US hospitals. The National Pressure Ulcer Advisory Panel endorses an evidence-based practice (EBP) protocol to help prevent PrUs. Effective implementation of EBPs requires systematic change of existing care units. Quality improvement interventions offer a mechanism of change to existing structures in order to effectively implement EBPs for PrU prevention. The best-practice framework developed by Nelson et al is a useful model of quality improvement interventions that targets process improvement in 4 domains: leadership, staff, information and information technology, and performance and improvement. At 2 academic medical centers, the best-practice framework was shown to physicians, nurses, and health services researchers. Their insight was used to modify the best-practice framework as a reference tool for quality improvement interventions in PrU prevention. The revised framework includes 25 elements across 4 domains. Many of these elements support EBPs for PrU prevention, such as updates in PrU staging and risk assessment. The best-practice framework offers a reference point to initiating a bundle of quality improvement interventions in support of EBPs. Hospitals and clinicians tasked with quality improvement efforts can use this framework to problem-solve PrU prevention and other critical issues.

Countrywide monitoring of absorbed dose rate in air due to outdoor natural gamma radiation in India.

The Indian Environmental Radiation Monitoring Network continuously monitors, throughout India, the absorbed dose rate in air due to outdoor natural gamma radiation, by using Geiger-Mueller detector-based standalone environmental radiation monitors. The network consists of 546 monitors spread across 91 monitoring locations distributed all over the country. In this paper, the countrywide long-term monitoring results are summarised. The measured mean dose rate of the monitoring locations followed a log-normal distribution and ranged from 50 to 535 nGy.h-1 with a median value of 91 nGy.h-1. Due to outdoor natural gamma radiation, the average annual effective dose was estimated to be 0.11 mSv.y-1.

Generation of map on natural environmental background absorbed dose rate in India.

A systematic mapping of natural absorbed dose rate was carried out to assess the existing exposure situation in India. The mammoth nationwide survey covered the entire terrestrial region of the country comprising of 45127 sampling grids (grid size 36 km2) with more than 100,000 data points. The data was processed using Geographic Information System. This study is based on established national and international approaches to provide linkage with conventional geochemical mapping of soil. Majority (93%) of the absorbed dose rate data was collected using handheld radiation survey meters and remaining were measured using environmental Thermo Luminescent Dosimeters. The mean absorbed dose rate of the entire country including several mineralized regions, was found to be 96 ± 21 nGy/h. The median, Geometric Mean and Geometric Standard Deviation values of absorbed dose rate were 94, 94 and 1.2 nGy/h, respectively. Among the High Background Radiation Areas of the country, absorbed dose rate varied from 700 to 9562 nGy/h in Karunagappally area of Kollam district, Kerala. The absorbed dose rate in the present nationwide study is comparable with the global database.

Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis.

BACKGROUND: In October 2008, Centers for Medicare and Medicaid Services discontinued reimbursement for hospital-acquired pressure ulcers (HAPUs), thus placing stress on hospitals to prevent incidence of this costly condition. OBJECTIVE: To evaluate whether prevention methods are cost-effective compared with standard care in the management of HAPUs. RESEARCH DESIGN AND SUBJECTS: A semi-Markov model simulated the admission of patients to an acute care hospital from the time of admission through 1 year using the societal perspective. The model simulated health states that could potentially lead to an HAPU through either the practice of "prevention" or "standard care." Univariate sensitivity analyses, threshold analyses, and Bayesian multivariate probabilistic sensitivity analysis using 10,000 Monte Carlo simulations were conducted. MEASURES: Cost per quality-adjusted life-years (QALYs) gained for the prevention of HAPUs. RESULTS: Prevention was cost saving and resulted in greater expected effectiveness compared with the standard care approach per hospitalization. The expected cost of prevention was $7276.35, and the expected effectiveness was 11.241 QALYs. The expected cost for standard care was $10,053.95, and the expected effectiveness was 9.342 QALYs. The multivariate probabilistic sensitivity analysis showed that prevention resulted in cost savings in 99.99% of the simulations. The threshold cost of prevention was $821.53 per day per person, whereas the cost of prevention was estimated to be $54.66 per day per person. CONCLUSION: This study suggests that it is more cost effective to pay for prevention of HAPUs compared with standard care. Continuous preventive care of HAPUs in acutely ill patients could potentially reduce incidence and prevalence, as well as lead to lower expenditures.

Protocol for sampling and analysis of food and agricultural produces consequent to a nuclear accident in India.

Nuclear accidents, despite having an extremely low probability of occurrence, could cause uncontrolled release of radioactive elements (fission and activation products) into the environment, and may ultimately lead to contamination of food products. Such a scenario requires extraordinary measures for control of food, which might be contaminated to a level not suitable for human consumption. Agricultural products (which include grain crops, vegetable, fruits, dairy, meat, eggs and poultry) pass through a series of local, district and state level markets to finally reach consumers. An effective intervention at different stages of distribution by targeted sampling and analysis of suspected (contaminated) foodstuffs will substantially reduce the chances of contaminated food to reach the public. At the same time, it will also ensure food security of the people without imposing unreasonable restrictions in market flow. This can also help in getting the farmers adequately compensated. This paper presents a protocol for sampling and analysis suitable for India, considering the diversity with respect to climate, soil type, land use, crop pattern, population density, etc. The paper also provides an estimate of infrastructure requirement to carry out environmental monitoring following the emergency with respect to human resources and instruments. The paper proposes to use the national web portal for collection of data pertaining to crop pattern, land use and market flow. A web-based decision support system (Web-DSS) on a GIS platform, for sampling, analysis and display of data online would enhance the transparency of decision being taken and enable the administrators to effectively monitor the work flow, details of sample collection, analysis and effective use of human and other resources.

Comparison of concomitant therapy versus standard triple-drug therapy for eradication of Helicobacter pylori infection: A prospective open-label randomized controlled trial.

INTRODUCTION: Resistance to commonly used antibiotics against Helicobacter pylori (H. pylori) is increasing rapidly leading to lower success of traditional triple therapy to eradicate H. pylori infection. So, search for a new regimen as the first-line therapy of H. pylori infection is needed. AIM: In this study, we compared the efficacy of 14-day concomitant therapy and 14-day triple therapy for the eradication of H. pylori infection. METHOD: In this open-labeled prospective trial, patients with H. pylori infection were randomized to concomitant therapy (pantoprazole 80 mg, amoxicillin 2000 mg, clarithromycin 1000 mg, and metronidazole 1000 mg daily in divided doses) and triple therapy (pantoprazole 80 mg, amoxicillin 2000 mg, and clarithromycin 1000 mg daily in divided doses). Duration of treatment was 14 days. Gastric biopsy was done 10-12 weeks after completion of therapy to confirm H. pylori eradication. RESULT: The eradication rate achieved with the concomitant therapy was significantly greater than that obtained with the triple therapy. Per-protocol eradication rates of concomitant and triple therapy were 77% and 58.3% (p = 0.028), respectively. Intention-to-treat eradication rates of concomitant and triple therapy were 70.1% and 49.3% (p = 0.013), respectively. Both the treatment regimens were well tolerated. CONCLUSION: Although the rate of eradication of H. pylori infection with  concomitant therapy was higher than that with triple therapy, the rate of concomitant therapy was still less than expected.

Wettability Reversal of Hydrophobic Pigment Particles Comprising Nanoscale Organosilane Shells: Concentrated Aqueous Dispersions and Corrosion-Resistant Waterborne Coatings.

We demonstrate the synthesis of polysiloxane-modified inorganic-oxide nanoparticles comprising a TiO2-based pigment (Ti-Pure R-706), which undergo drastic wettability reversal from a hydrophilic wet state to a hydrophobic state upon drying. Furthermore, the dry hydrophobic pigment particles can be reversibly converted back to a hydrophilic form by the application of high shear aqueous milling. Our synthetic approach involves first condensing the cross-linking monomer CH3Si(OH)3 onto the surface of Ti-Pure R-706 at pH 9.5 ± 0.2 in an aqueous suspension. After drying this surface-modified material in the presence of a polyanionic dispersant so as to preserve the primary particle size via dynamic light scattering, it is trimethylsilyl-capped with (CH3)3SiOH, which consumes some residual Si-OH functionalities, and washed to remove all dispersant and excess reagents. Transmission electron microscopy demonstrates a ∼6 nm polysiloxane coating uniformly surrounding the surface of the pigment particle. A 70 wt % (37 vol %) concentrated aqueous slurry of the hydrophobically modified pigment particles prepared in the absence of dispersant exhibits rheological characteristics that are nearly the same as an aqueous dispersion of native unmodified hydrophilic Ti-Pure R-706 comprising an optimal amount of the organic anionic dispersant. It is also possible to synthesize dispersions without the use of an added surfactant and/or dispersant at even higher solid concentrations of up to 75 wt % (43 vol %) in water, conditions at which even the hydrophilic native Ti-Pure R-706 oxide pigment yields a gel-like paste in the absence of a dispersant. Films prepared by drying an aqueous suspension of these pigment particles exhibited a hydrophobic contact angle of ∼125°. When acrylic-based waterborne coatings were prepared comprising these surface-modified Ti Pure R-706 pigments, they showed excellent corrosion protection of a mild steel substrate. These data point to a wettability reversal in which the particles change from hydrophobic to hydrophilic upon high-shear aqueous milling and vice versa upon drying. 29Si CP/MAS NMR spectroscopy highlights the importance of flexibility of the polysiloxane coating for achieving this wettability reversal, a result that emphasizes the importance of surface reconstruction.

Comparing Three Methods for Reducing Psychotropic Use in Older Demented Spanish Care Home Residents.

BACKGROUND/OBJECTIVE: In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use. DESIGN: Retrospective, propensity score-matched, controlled, patient-level observational analysis. SETTING: A total of 45 nursing homes in Spain. PARTICIPANTS: A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score-matched controls. INTERVENTION: Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid. MEASUREMENTS: At 2 and 4 weeks following intervention: change from baseline drug class-specific milligram-equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use. RESULTS: Within each intervention/drug-class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class-specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%-32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%-28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%-33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%-38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%-33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%-43.5%) reduction in anxiolytic MEDDs. Intervention-associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints. CONCLUSION: We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.

Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis.

OBJECTIVE: Hospital-acquired pressure injuries are localised skin injuries that cause significant mortality and are costly. Nursing best practices prevent pressure injuries, including time-consuming, complex tasks that lack payment incentives. The Braden Scale is an evidence-based stratification tool nurses use daily to assess pressure-injury risk. Our objective was to analyse the cost-utility of performing repeated risk-assessment for pressure-injury prevention in all patients or high-risk groups. DESIGN: Cost-utility analysis using Markov modelling from US societal and healthcare sector perspectives within a 1-year time horizon. SETTING: Patient-level longitudinal data on 34 787 encounters from an academic hospital electronic health record (EHR) between 2011 and 2014, including daily Braden scores. Supervised machine learning simulated age-adjusted transition probabilities between risk levels and pressure injuries. PARTICIPANTS: Hospitalised adults with Braden scores classified into five risk levels: very high risk (6-9), high risk (10-11), moderate risk (12-14), at-risk (15-18), minimal risk (19-23). INTERVENTIONS: Standard care, repeated risk assessment in all risk levels or only repeated risk assessment in high-risk strata based on machine-learning simulations. MAIN OUTCOME MEASURES: Costs (2016 $US) of pressure-injury treatment and prevention, and quality-adjusted life years (QALYs) related to pressure injuries were weighted by transition probabilities to calculate the incremental cost-effectiveness ratio (ICER) at $100 000/QALY willingness-to-pay. Univariate and probabilistic sensitivity analyses tested model uncertainty. RESULTS: Simulating prevention for all patients yielded greater QALYs at higher cost from societal and healthcare sector perspectives, equating to ICERs of $2000/QALY and $2142/QALY, respectively. Risk-stratified follow-up in patients with Braden scores <15 dominated standard care. Prevention for all patients was cost-effective in >99% of probabilistic simulations. CONCLUSION: Our analysis using EHR data maintains that pressure-injury prevention for all inpatients is cost-effective. Hospitals should invest in nursing compliance with international prevention guidelines.

How do healthcare professionals working in accountable care organisations understand patient activation and engagement? Qualitative interviews across two time points.

OBJECTIVE: If patient engagement is the new 'blockbuster drug' why are we not seeing spectacular effects? Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organisations (ACO). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown. We assessed the use and understanding of patient engagement approaches among frontline clinicians and managers at ACO-affiliated practices. DESIGN: Qualitative study; 103 in-depth, semi-structured interviews. PARTICIPANTS: Sixty clinicians and eight managers were interviewed at two established ACOs. APPROACH: We interviewed healthcare professionals about their awareness, attitudes, understanding and experiences of implementing three key approaches to patient engagement and activation: 1) goal-setting, 2) motivational interviewing and 3) shared decision making. Of the 60 clinicians, 33 were interviewed twice leading to 93 clinician interviews. Of the 8 managers, 2 were interviewed twice leading to 10 manager interviews. We used a thematic analysis approach to the data. KEY RESULTS: Interviewees recognised the term 'patient activation and engagement' and had favourable attitudes about the utility of the associated skills. However, in-depth probing revealed that although interviewees reported that they used these patient activation and engagement approaches, they have limited understanding of these approaches. CONCLUSIONS: Without understanding the concept of patient activation and the associated approaches of shared decision making and motivational interviewing, effective implementation in routine care seems like a distant goal. Clinical teams in the ACO model would benefit from specificity defining key terms pertaining to the principles of patient activation and engagement. Measuring the degree of understanding with reward that are better-aligned for behaviour change will minimise the notion that these techniques are already being used and help fulfil the potential of patient-centred care.

Using clinical data to predict high-cost performance coding issues associated with pressure ulcers: a multilevel cohort model.

OBJECTIVE: Hospital-acquired pressure ulcers (HAPUs) have a mortality rate of 11.6%, are costly to treat, and result in Medicare reimbursement penalties. Medicare codes HAPUs according to Agency for Healthcare Research and Quality Patient-Safety Indicator 3 (PSI-03), but they are sometimes inappropriately coded. The objective is to use electronic health records to predict pressure ulcers and to identify coding issues leading to penalties. MATERIALS AND METHODS: We evaluated all hospitalized patient electronic medical records at an academic medical center data repository between 2011 and 2014. These data contained patient encounter level demographic variables, diagnoses, prescription drugs, and provider orders. HAPUs were defined by PSI-03: stages III, IV, or unstageable pressure ulcers not present on admission as a secondary diagnosis, excluding cases of paralysis. Random forests reduced data dimensionality. Multilevel logistic regression of patient encounters evaluated associations between covariates and HAPU incidence. RESULTS: The approach produced a sample population of 21 153 patients with 1549 PSI-03 cases. The greatest odds ratio (OR) of HAPU incidence was among patients diagnosed with spinal cord injury (ICD-9 907.2: OR = 14.3; P < .001), and 71% of spinal cord injuries were not properly coded for paralysis, leading to a PSI-03 flag. Other high ORs included bed confinement (ICD-9 V49.84: OR = 3.1, P < .001) and provider-ordered pre-albumin lab (OR = 2.5, P < .001). DISCUSSION: This analysis identifies spinal cord injuries as high risk for HAPUs and as being often inappropriately coded without paralysis, leading to PSI-03 flags. The resulting statistical model can be tested to predict HAPUs during hospitalization. CONCLUSION: Inappropriate coding of conditions leads to poor hospital performance measures and Medicare reimbursement penalties.

Building information for systematic improvement of the prevention of hospital-acquired pressure ulcers with statistical process control charts and regression.

OBJECTIVES: To demonstrate complementary results of regression and statistical process control (SPC) chart analyses for hospital-acquired pressure ulcers (HAPUs), and identify possible links between changes and opportunities for improvement between hospital microsystems and macrosystems. METHODS: Ordinary least squares and panel data regression of retrospective hospital billing data, and SPC charts of prospective patient records for a US tertiary-care facility (2004-2007). A prospective cohort of hospital inpatients at risk for HAPUs was the study population. RESULTS: There were 337 HAPU incidences hospital wide among 43 844 inpatients. A probit regression model predicted the correlation of age, gender and length of stay on HAPU incidence (pseudo R(2)=0.096). Panel data analysis determined that for each additional day in the hospital, there was a 0.28% increase in the likelihood of HAPU incidence. A p-chart of HAPU incidence showed a mean incidence rate of 1.17% remaining in statistical control. A t-chart showed the average time between events for the last 25 HAPUs was 13.25 days. There was one 57-day period between two incidences during the observation period. A p-chart addressing Braden scale assessments showed that 40.5% of all patients were risk stratified for HAPUs upon admission. CONCLUSION: SPC charts complement standard regression analysis. SPC amplifies patient outcomes at the microsystem level and is useful for guiding quality improvement. Macrosystems should monitor effective quality improvement initiatives in microsystems and aid the spread of successful initiatives to other microsystems, followed by system-wide analysis with regression. Although HAPU incidence in this study is below the national mean, there is still room to improve HAPU incidence in this hospital setting since 0% incidence is theoretically achievable. Further assessment of pressure ulcer incidence could illustrate improvement in the quality of care and prevent HAPUs.

Distribution, enrichment and principal component analysis for possible sources of naturally occurring and anthropogenic radionuclides in the agricultural soil of Punjab state, India.

Enrichment factor (EF) of elements including geo-accumulation indices for soil quality and principal component analysis (PCA) were used to identify the contributions of the origin of sources in the studied area. Results of (40)K, (137)Cs, (238)U and (232)Th including their decay series isotopes in the agricultural soil of Mansa and Bathinda districts in the state of Punjab were presented and discussed. The measured mean radioactivity concentrations for (238)U, (232)Th and (40)K in the agricultural soil of the studied area differed from nationwide average crustal abundances by 51, 17 and 43 %, respectively. The sequence of the EFs of radionuclides in soil from the greatest to the least was found to be (238)U > (40)K > (226)Ra > (137)Cs > (232)Th > (228)Ra. Even though the enrichment of naturally occurring radionuclides was found to be higher, they remained to be in I(geo) class of '0', indicating that the soil is uncontaminated with respect to these radionuclides. Among non-metals, N showed the highest EF and belonged to I(geo) class of '2', indicating that soil is moderately contaminated due to intrusion of fertiliser. The resulting data set of elemental contents in soil was also interpreted by PCA, which facilitates identification of the different groups of correlated elements. The levels of the (40)K, (238)U and (232)Th radionuclides showed a significant positive correlation with each other, suggesting a similar origin of their geochemical sources and identical behaviour during transport in the soil system.