A case control study to improve accuracy of an electronic fall prevention toolkit.

Patient falls are a serious and commonly report adverse event in hospitals. In 2009, our team conducted the first randomized control trial of a health information technology-based intervention that significantly reduced falls in acute care hospitals. However, some patients on intervention units with access to the electronic toolkit fell. The purpose of this case control study was to use data mining and modeling techniques to identify the factors associated with falls in hospitalized patients when the toolkit was in place. Our ultimate aim was to apply our findings to improve the toolkit logic and to generate practice recommendations. The results of our evaluation suggest that the fall prevention toolkit logic is accurate but strategies are needed to improve adherence with the fall prevention intervention recommendations generated by the electronic toolkit.

Nerve-sparing technique and urinary control after robot-assisted laparoscopic prostatectomy.

OBJECTIVES: To characterize determinants of 4-, 12-, and 24-month urinary control after robot-assisted laparoscopic prostatectomy (RALP). METHODS: Adjusted comparative study using prospectively collected, patient self-reported urinary control for 602 consecutive RALPs. Urinary control defined as: (1) EPIC urinary function (UF) scored from 0 to 100 and (2) continence (zero pads per day). RESULTS: Both UF (62.8 vs. 42.4, P<0.001) and continence rates (47.2 vs. 26.7%, P=0.043) were better for bilateral nerve-sparing (BNS) vs. non-nerve-sparing (NNS) at 4 months, but only UF scores were significantly better at 12- (80.9 vs. 70.7, P=0.014) and 24-month (89.2 vs. 77.4, P=0.024) post-RALP. No difference in positive margin rates was observed. In multivariate analysis, older age (parameter estimate -0.42, 95% CI -0.80 to -0.04) and increasing gland volume (-0.13, CI -0.26 to -0.01) resulted in lower UF scores at 4 months, while higher pre-operative UF (0.25, CI 0.05-0.46), bladder neck-sparing technique (10.1, CI 3.79-16.35), BNS (19.1, CI 9.37-28.82), and unilateral nerve-sparing (19.00, CI 7.88-30.11) resulted in higher UF scores at 4 months. At 12 months, higher pre-operative UF (0.24, CI 0.083-0.40) and BNS (9.54, CI 1.92-17.16) resulted in higher UF scores. At 24 months, higher pre-operative UF (0.20, CI 0.06-0.33), bladder neck-sparing technique (7.80, CI 3.48-12.10), and BNS (7.86, CI 1.04-14.68) resulted in higher UF scores. CONCLUSIONS: BNS, bladder neck-sparing technique, and higher pre-operative UF score result in improved 24-month urinary control after RALP.

Anatomic bladder neck preservation during robotic-assisted laparoscopic radical prostatectomy: description of technique and outcomes.

BACKGROUND: Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted despite a daunting learning curve with bladder neck dissection as a challenging step for newcomers. OBJECTIVE: To describe an anatomic, reproducible technique of bladder neck preservation (BNP) and associated perioperative and long-term outcomes. DESIGN, SETTINGS, AND PARTICIPANTS: From September 2005 to May 2009, data from 619 consecutive RALP were prospectively collected and compared on the basis of bladder neck dissection technique with 348 BNP and 271 standard technique (ST). SURGICAL PROCEDURE: RALP with BNP. MEASUREMENTS: Tumor characteristics, perioperative complications, and post-operative urinary control were evaluated at 4, 12 and 24 months using (1) the Expanded Prostate Cancer Index (EPIC) urinary function scale scored from 0-100; and (2) continence defined as zero pads per day. RESULTS AND LIMITATIONS: Mean age for BNP versus ST was 57.1±6.6 yr versus 58.9±6.7 yr (p=0.033), while complication rates did not vary significantly by technique. Estimated blood loss was 183.7±95.8 ml versus 224.6±108 ml (p=0.938) in men who underwent BNP versus ST. The overall positive margin rate was 12.8%, which did not differ at the prostate base for BNP versus ST (1.4% vs. 2.2%, p=0.547). Mean urinary function scores for BNP versus ST at 4, 12, and 24 mo were 64.6 versus 57.2 (p=0.037), 80.6 versus 79.0 (p=0.495), and 94.1 versus 86.8 (p<0.001). Similarly, BNP versus ST continence rates at 4, 12, and 24 mo were 65.6% versus 26.5% (p<0.001), 86.4% versus 81.4% (p=0.303), and 100% versus 96.1% (p=0.308). CONCLUSIONS: BNP versus ST is associated with quicker recovery of urinary function and similar cancer control.

The costs and savings associated with prevention of adverse events by critical care nurses.

PURPOSE: The aim of the study was to determine the costs and savings associated with prevention of adverse events (AEs) by critical care nurses. MATERIALS AND METHODS: We performed a secondary analysis of data from 2 coronary care unit (CCU) studies that determined the incremental cost of AEs and the rate of near misses recovered by nurses during weekday, daytime shifts. For this study, we determined the nurse staffing costs and savings by averting AEs. Physicians judged the likelihood that observed near misses would have resulted in actual AEs if not initially intercepted. A sensitivity analysis was performed on the savings from preventing AEs and the costs of different nurse staffing ratios and experience levels. RESULTS: We observed 66 recovered near misses during 308 observation hours, with 34 (51.5%) judged to likely have reached and harmed the patient resulting in an AE if not intercepted. The annual incidence of prevented AEs extrapolated to 2296 events. Savings from prevented AEs ranged from $2.2 million to $13.2 million. Nurse staffing costs for the same time frame was $1.36 million. CONCLUSIONS: Although CCU nursing staffing costs are significant, the potential savings associated with preventing AEs is far greater. Further research is needed to identify the optimal nurse staffing ratios.

Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients.

PURPOSE: Rates of serious medication errors in three pediatric inpatient units (intensive care, general medical, and general surgical) were measured before and after introduction of unit-based clinical pharmacists. METHODS: Error rates on the study units and similar patient care units in the same hospital that served as controls were determined during six- to eight-week baseline periods and three-month periods after the introduction of unit-based clinical pharmacists (full-time in the intensive care unit [ICU] and mornings only on the general units). Nurses trained by the investigators reviewed medication orders, medication administration records, and patient charts daily to detect errors, near misses, and adverse drug events (ADEs) and determine whether near misses were intercepted. Two physicians independently reviewed and rated all data collected by the nurses. Serious medication errors were defined as preventable ADEs and nonintercepted near misses. RESULTS: The baseline rates of serious medication errors per 1000 patient days were 29 for the ICU, 8 for the general medical unit, and 7 for the general surgical unit. With unit-based clinical pharmacists, the ICU rate dropped to 6 per 1000 patient days. In the general care units, there was no reduction from baseline in the rates of serious medication errors. CONCLUSION: A full-time unit-based clinical pharmacist substantially decreased the rate of serious medication errors in a pediatric ICU, but a part-time pharmacist was not as effective in decreasing errors in pediatric general care units.

Costs of adverse events in intensive care units.

CONTEXT: Iatrogenic injuries are very common in critically ill adults. However, the financial implications of these events are incompletely understood. OBJECTIVE: To determine the costs of adverse events in patients in the medical intensive care unit and in the cardiac intensive care unit. DESIGN, SETTING, AND PATIENTS: We performed a matched case-control analysis on data collected during a prospective 1-yr observation study (July 2002 to June 2003) of medical intensive care unit and cardiac intensive care unit patients at an academic, tertiary care urban hospital. A total of 108 cases were matched with 375 controls in our study. MAIN OUTCOME MEASURES: Costs of care and lengths of stay were determined from hospital billing systems for patients in the medical and cardiac intensive care units. We then determined the incremental costs and lengths of stay for patients with adverse events compared with patients without events while in the intensive care unit. Costs were truncated for patients with a second adverse event on a subsequent day during the intensive care unit stay. RESULTS: For 56 medical intensive care unit patients, the cost of an adverse event was $3,961 (p = .010) and the increase in length of stay was 0.77 days (p = .048). This extrapolated to annual costs of $853,000 for adverse events in the medical intensive care unit. Similarly, for 52 cardiac intensive care unit patients, the cost of an adverse event was $3,857 (p = .023), corresponding to $630,000 in annual costs. On average, patients with events in the cardiac intensive care unit had an increase of 1.08 days in length of stay (p = .003). CONCLUSIONS: Patients who require intensive care are especially at risk for adverse events, and the associated costs with such events are substantial. The costs of adverse events may justify further investment in prevention strategies.

Health care expenditures associated with overweight and obesity among US adults: importance of age and race.

OBJECTIVES: We estimated health care expenditures associated with overweight and obesity and examined the influence of age, race, and gender. METHODS: Using 1998 Medical Expenditure Panel Survey data, we employed 2-stage modeling to estimate annual health care expenditures associated with high body mass index (BMI) and examine interactions between demographic factors and BMI. RESULTS: Overall, the mean per capita annual health care expenditure (converted to December 2003 dollars) was $3338 before adjustment. While the adjusted expenditure was $2127 (90% confidence interval [CI]=$1927, $2362) for a typical normal-weight White woman aged 35 to 44 years, expenditures were $2358 (90% CI=$2128, $2604) for women with BMIs of 25 to 29.9 kg/m(2), $2873 (90% CI=$2530, $3236) for women with BMIs of 30 to 34.9 kg/m(2), $3058 (90% CI=$2529, $3630) for women with BMIs of 35 to 39.9 kg/m(2), and $3506 (90% CI=$2912, $4228) for women with BMIs of 40 kg/m(2) or higher. Expenditures related to higher BMI rose dramatically among White and older adults but not among Blacks or those younger than 35 years. We found no interaction between BMI and gender. CONCLUSIONS: Health care costs associated with overweight and obesity are substantial and vary according to race and age.