Clinical triggers or rapid response teams: does the emperor need "new" clothes?

Essential to any rapid response system is certainty regarding its ability to provide an immediate and appropriate response to calls for help.

The need for organizational change in patient safety initiatives.

OBJECTIVES: This study describes a computer simulation model that has been developed to explore organizational changes required to improve patient safety based on a medication error reporting system. METHODS: Model parameters for the simulation model were estimated from data submitted to the MEDMARX medication error reporting system from 570 healthcare facilities in the U.S. The model's results were validated with data from the Pittsburgh Regional Healthcare Initiative consisting of 44 hospitals in Pennsylvania that have adopted the MEDMARX medication error reporting system. The model was used to examine the effects of organizational changes in response to the error reporting system. Four interventions were simulated involving the implementation of computerized physician order entry, decision support systems and a clinical pharmacist on hospital rounds. CONCLUSIONS: Results of the analysis indicate that improved patient safety requires more than clinical initiatives and voluntary reporting of errors. Organizational change is essential for significant improvements in patient safety. In order to be successful, these initiatives must be designed and implemented through organizational support structures and institutionalized through enhanced education, training, and implementation of information technology that improves work flow capabilities.

A cross-cultural comparison of critical care delivery: Japan and the United States.

OBJECTIVE: To compare the utilization and outcomes of critical care services in a cohort of hospitals in the United States and Japan. DESIGN: Prospective data collection on 5,107 patients and detailed organizational characteristics from each of the participating Japanese study hospitals between 1993 and 1995, with comparisons made to prospectively collected data on the 17,440 patients included in the US APACHE (acute physiology and chronic health evaluation) III database. SETTING: Twenty-two Japanese and 40 US hospitals. PATIENTS: Consecutive, unselected patients from medical, surgical, and mixed medical/surgical ICUs. MEASUREMENTS: Severity of illness, predicted risk of in-hospital death, and ICU and hospital length of stay (LOS) were assessed using APACHE III. Japanese ICU directors completed a detailed survey describing their units. MAIN RESULTS: US and Japanese ICUs have a similar array of modalities available for care. Only 1.0% (range, 0.56 to 2.7%) of beds in Japanese hospitals were designated as ICUs. The organization of the Japanese and US ICUs varied by hospital, but Japanese ICUs were more likely to be organized to care for heterogeneous diagnostic populations. Sample case-mix differences reflect different disease prevalence. ICU utilization for women is significantly lower (35.5% vs 44.8% of patients) and there were relatively fewer patients > or = 85 years old in the Japanese ICU cohort (1.2% vs 4.6%), despite a higher per capita rate of individuals > or = 85 years old in Japan. The utilization of ICUs for patients at low risk of death significantly less in Japan (10.2%) than in the United States (12.9%). The APACHE III score stratified patient risk. Overall mortality was similar in both national samples after accounting for differences in hospital LOS, utilizing a model that was highly discriminating (receiver operating characteristic, 0.87) when applied to the Japanese sample. The application of a US-based mortality model to a Japanese sample overestimated mortality across all but the highest (> 90%) deciles of risk. Significant variation in expected performance was noted between hospitals. Risk-adjusted ICU LOS was not significantly longer in Japan; however, total hospital stay was nearly twice that found in the US hospitals, reflecting differences in hospital utilization philosophies. CONCLUSIONS: Similar high-technology critical care is available in both countries. Variations in ICU utilization reflect differences in case-mix and bed availability. Japanese ICU utilization by gender reflects differences in disease prevalence, whereas differences in utilization by age may reflect differences in cultural norms regarding the limits of care. Such differences provide context from which to assess the delivery of care across international borders. Miscalibration of predictive models applied to international data samples highlight the impact that differences in resource use and local practice cultures have on outcomes. Models may require modification in order to account for these differences. Nevertheless, with large databases, it is possible to assess critical care delivery systems between countries accounting for differences in case-mix, severity of illness, and cultural normative standards facilitating the design and management such systems.

Age and the risk of in-hospital death: insights from a multihospital study of intensive care patients.

OBJECTIVES: To determine independent relationships between age and the risk of in-hospital death. DESIGN: Retrospective cohort study. SETTING: Thirty-eight intensive care units (ICUs) in 28 hospitals in a large Midwest metropolitan region. PARTICIPANTS: One hundred fifty-six thousand, one hundred thirty-six consecutive admissions to medical, surgical, neurological, and mixed medical/surgical ICUs between March 1, 1991, and March 31, 1997. MEASUREMENTS: In-hospital death rates were compared at successive 5-year age intervals, adjusting for gender, diagnosis, admission source, comorbidity, and acute physiology scores. Acute physiology scores were determined using a validated methodology based on abnormalities in 17 physiological measures collected during the first 24 hours of ICU admission. RESULTS: The adjusted odds of death increased with each 5-year age increment. For example, relative to patients younger than 35, adjusted odds of death in patients aged 40 to 44, 50 to 54, 60 to 64, 70 to 74, 80 to 84, and 90 and older were 1.51, 1.73, 2.38, 2.98, 3.86, and 4.74, respectively. In stratified analyses, age-related increases in the odds of death were somewhat higher in surgical than medical patients or patients with lower severity of illness at admission. Although acute physiology scores had excellent discrimination in all age groups, discrimination decreased with age (e.g., c-statistics of 0.928 and 0.835 in patients younger than 45 and 85 and older, respectively). CONCLUSION: Our findings demonstrate incremental increases in the risk of hospital death associated with age that was independent of severity of illness and other prognostic factors. Although the current results may be less biased by differences in treatment goals than studies of general hospitalized patients, the lower discrimination of physiology scores in older patients suggests that unmeasured factors (e.g., functional status, patient preferences for care, differences in physician practices) may be of greater prognostic importance in older than in younger patients.

Pittsburgh Regional Healthcare Initiative: a systems approach for achieving perfect patient care.

The Pittsburgh Regional Healthcare Initiative (PRHI) is an innovative model for health system change based on regionwide shared learning. By linking patient outcomes data with processes of care and sharing that information widely, PRHI supports measurable improvements in regionwide clinical practice and patient safety. In addition, through the redesign of problem solving at the front lines of care, PRHI helps health care organizations to evolve toward becoming sustainable systems of perfect patient care. This paper describes PRHI's design for change, reviews the progress and limitations of the shared learning model, and offers a set of broader policy considerations.

A new conceptual framework for ICU performance appraisal and improvement.

PURPOSE: This study examined the use of outcomes for the purposes of ICU evaluation and improvement. We reviewed the strengths and weaknesses of an outcomes-centered approach to intensive care unit (ICU) evaluation and present a more comprehensive conceptual framework for ICU evaluation and improvement. MATERIALS AND METHODS: Data was collected from 2 sources: (1) a structured review of the literature, with relevant articles identified using Medline, and (2) 85 semistructured interviews of health care professionals (eg, physicians) and health care administrators (eg, chief executive officer). The interviewees came from 4 institutions: a 900-bed East Coast teaching medical center, a 600-bed East Coast teaching medical center, a 590-bed East Coast teaching medical center, and a 435-bed West Coast private community hospital. A nonrandomized, purposeful sample was used. RESULTS: A conceptual framework for ICU evaluation is presented that identifies and defines 3 different types of variables: performance (eg, appropriateness of care, effectiveness of care), outcome (eg, resource use, mortality), and process (eg, timeliness of treatment, work environment). The framework emphasizes performance variables and the relationships between performance, outcome, and process of care variables, as a logical focus for ICU evaluation and improvement. CONCLUSIONS: Performance variables offer distinct advantages over outcome variables for ICU evaluation. Their use, however, will require additional development of current evaluation tools and methods. They provide the ability to identify the value an ICU adds to patient care in a hospital or to an episode of illness, and to evaluate integrated systems for providing care.

Guiding principles for physician reentry programs.

Physician reentry is defined by the American Medical Association (AMA) as: "A return to clinical practice in the discipline in which one has been trained or certified following an extended period of clinical inactivity not resulting from discipline or impairment." Physician reentry programs are creating an avenue for physicians who have left medicine in good standing to return to clinical practice. To date, however, programs have developed independently, with little coordination among them. If, as predicted, more physicians seek to reenter practice and more programs are developed in response, the need for information on program outcomes will grow. Valid assessment tools should be developed and shared across reentry programs to assess individual learner outcomes. This discussion paper sets forth Guiding Principles for Physician Reentry Programs as a step toward a more coordinated approach to physician reentry education and training. They serve as a reference for setting priorities and standards for action and, more specifically, offer a foundation from which programs can be planned, evaluated, and monitored. In addition to the guiding principles, an overview of physician reentry is provided including information on reentry physicians and physician reentry programs as well as a definition of physician reentry, reasons for taking leave and returning to clinical practice, and barriers physicians face as they seek to reenter clinical care.

Reporting trends in a regional medication error data-sharing system.

Inter-organizational systems for sharing data about medication errors have emerged as an important strategy for improving patient safety and are expected to encourage not only voluntary error reporting but also learning from errors. Yet, few studies have examined the hypothesized benefits of inter-organizational data sharing. The current study examined the developmental trends in information reported by hospitals participating in a regional reporting system for medication errors. A coalition of hospitals in southwestern Pennsylvania, under the auspices of the Pittsburgh Regional Healthcare Initiative (PRHI), implemented a voluntary system for quarterly sharing of information about medication errors. Over a 12-month period, 25 hospitals shared information about 17,000 medication errors. Using latent growth curve analysis, we examined longitudinal trends in the quarterly number of errors and associated corrective actions reported by each hospital. Controlling for size, teaching status, and JCAHO accreditation score, for the hospitals as a group, error reporting increased at a statistically significant rate over the four quarters. Moreover, despite significant baseline differences among hospitals, error reporting increased at similar rates across hospitals over subsequent quarters. In contrast, the reporting of corrective actions remained unchanged. However, the baseline levels of corrective actions reporting were significantly different across hospitals. Although data sharing systems promote error reporting, it is unclear whether they encourage corrective actions. If data sharing is intended to promote not just error reporting but also root-cause-analysis and process improvement, then the design of the reporting system should emphasize data about these processes as well as errors.

Medication errors resulting from computer entry by nonprescribers.

PURPOSE: The characteristics of medication errors associated with the use of computer order-entry systems by nonprescribers are discussed. METHODS: A retrospective analysis of records submitted to MEDMARX was conducted for the period from July 1, 2001, to December 31, 2005, to identify all computer-related medication errors made by nonprescribers. Quantitative analysis of the records included the severity of each error, the origin within the medication-use process, the type of error, principal causes, the location within the facility where the error was made, and the therapeutic drug classes frequently involved. Similar data from the University of Pittsburgh Medical Center (UPMC) were also analyzed and compared with the national data set. RESULTS: During the 4.5 years, 693 unique facilities submitted 90,001 medication error records that were the result of computer entry by nonprescribers. The national data set and the UPMC data had similar findings for error severity, error origin, and type of error but showed some differences in the rank ordering of error causes, location where the error occurred, and drug classes frequently associated with such errors. The percentage of harm associated with computer-entry errors was small for both the national data set and UPMC data (0.99% and 0.80%, respectively). Both data sets cited performance deficit as the leading cause of computer-entry errors, but large percentage differences were seen with other causes, including inaccurate or omitted transcription (30% versus 12.6%, respectively), documentation (19.5% versus 10.6%, respectively), and procedure or protocol not followed (21.7% versus 30.3%, respectively). Both data sets implicated the inpatient pharmacy department as the location where most computer-entry errors occurred (49.3% versus 69.0%, respectively). CONCLUSION: Analysis of the characteristics of medication errors associated with the use of computer-entry systems by non-prescribers from both MEDMARX and an individual health system database demonstrated that computer systems create new opportunities for errors to occur. Working closely with information technology personnel dedicated to assisting pharmacy departments and vendors, adequate training of pharmacy staff, and development of national standards for drug information displays in computer order-entry systems may help minimize such errors.

An advanced pharmacy practice experience in inpatient medication education.

OBJECTIVE: To describe a unique advanced pharmacy practice experience (APPE) in which pharmacy students provided medication education to hospitalized patients. DESIGN: Students were trained to independently assess patients' needs for education and identify drug-related problems. Students then provided medication education and performed medication therapy management under the supervision of clinical staff pharmacists. To assess the impact of the APPE, the number of hospitalized patients assessed and educated during the 3-month time period prior to student involvement was compared to the first 3 months of the APPE. ASSESSMENT: Student participation increased the number of patients receiving medication education and medication therapy management from the hospital pharmacy. At the end of the APPE, students reported that the experience positively affected their ability to impact patients' care and to critique their own learning and skills. CONCLUSION: The inpatient medication education APPE provided students the opportunity to be responsible and accountable for the provision of direct patient care. In addition, the APPE benefitted the hospital, the school of pharmacy, and, most importantly, the patients.

Paramedic intubation errors: isolated events or symptoms of larger problems?

Paramedics provide life-saving emergency medical care to patients in the out-of-hospital setting, but only selected emergency interventions have proved to be safe or effective. Endotracheal intubation (the insertion of an emergency breathing tube into the trachea) is an important and high-profile procedure performed by paramedics. In our study population, we found that errors occurred in 22 percent of intubation attempts, with a frequency of up to 40 percent in selected ambulance systems. These findings indicate frequent errors associated with this life-saving technique. These events might be emblematic of larger issues in the structure and delivery of out-of-hospital emergency care.

Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation.

BACKGROUND: Relationships between day of the week of admission to hospitals and hospital outcomes have been poorly studied. Intensive care units (ICUs) appear to be uniquely suited to examine such a question given the unpredictability of ICU admissions and the clinical instability of their patient populations. METHODS: This retrospective cohort study included 156,136 patients admitted to 38 ICUs in 28 hospitals in a large Midwestern metropolitan area during 1991 to 1997. Demographic and clinical data were collected from patients' medical records and used in multivariable risk-adjustment models that examined the risk for in-hospital death and ICU length of stay. RESULTS: The adjusted odds of in-hospital death were 9% higher (OR 1.09; 95% CI, 1.04-1.15; P <0.001) for weekend admissions (Saturday or Sunday) than in patients admitted midweek (Tuesday through Thursday). However, the adjusted odds of death were also higher (P <0.001) for patients admitted on Monday (OR 1.09) or Friday (OR 1.08). Findings were generally similar in analyses stratified by admission type (medical vs. surgical), hospital teaching status, and illness severity. Adjusted ICU length of stay was 4% longer (P <0.001) for weekend or Friday admissions, compared with midweek admissions. CONCLUSIONS: Patients admitted to an ICU on the weekend have a modestly higher risk for death and ICU length of stay. However, the similar risk for death in patients admitted on Friday and Monday suggests that "weekend effects" may be more related to unmeasured severity of illness and/or selection bias than to differences in quality of care.

Pennsylvania partners in pursuit of good health: building a shared-responsibility model for state health improvement.

Over the last decade, much attention has focused on the reorganization of the roles and functions of public health to improve the health of communities. The Pennsylvania State Health Improvement Plan (SHIP) offers one example of how national, state, and local components of the public health system can effectively integrate their strategies and resources to improve responsiveness to local public health needs. This article reviews the policy action and planning process used to develop a community partnership, shared-responsibility model and the strategies and implementation plans that have been adopted to achieve substantial, measurable improvement in community health status.

Identifying potentially ineffective care in a community hospital.

OBJECTIVES: To develop a formula to predict mortality for intensive care unit patients between day 5 in an intensive care unit and 100 days after hospital discharge from a community hospital. DESIGN: Retrospective 1-yr derivation study with validation on a subsequent year's intensive care unit population. SETTING: An 850-bed, not-for-profit community hospital with three adult intensive care units, including medical-surgical, cardiac-medical, and cardiac-surgical units. PATIENTS: The development patient set included 4045 consecutive adult admissions to the intensive care unit between July 1995 and June 1996. The validation sample consisted of 4084 admissions between July 1996 and June 1997. RESULTS: During the first year, 100-day posthospital discharge mortality was predicted by the combination Acute Physiology and Chronic Health Evaluation (APACHE) III predicted mortality on day 5 of >0.92 or the product of day 1 and day 5 APACHE predicted mortality of >0.40, with an increase in the APACHE predicted mortality from day 1 to day 5 of >0.10. Specificity in the development cohort was 0.99, sensitivity was 0.30, and positive predictive value was 0.95. The second-year validation study demonstrated a specificity, sensitivity, and positive predictive value of 0.98, 0.29, and 0.91, respectively, when applying the model to the validation sample. CONCLUSIONS: By using readily available APACHE III data, we were able to identify patients at high risk of dying between intensive care unit day 5 and 100 days after discharge. Although the low sensitivity limits the number of patients for whom death at 100 days is predicted, the high specificity and positive predictive value suggests this information may provide useful information for families and physicians. If these formulas can be validated in diverse institutional settings, decisions regarding short- and long-term outcomes may be improved by using objective survival predictions from two time points.