The multi-dimensional matrix for consultation-liaison psychiatry (mMAX-LP).

OBJECTIVE: Consultation-liaison psychiatry (CLP) services are particularly susceptible to heterogeneity, developing haphazardly in response to local interests and perceived need. This hampers the generalisability of comparisons between services in terms of service models, resource requirements and outcome data. The objective of this paper therefore is to chronicle the development of a method to meaningfully describe, map and compare different CLP services. METHOD: A review of the literature was followed by multiple site visits in both New Zealand and England, and an extended process of consultation and feedback. RESULTS: Sixteen dimensions common to CLP services were extracted to create a multi-dimensional matrix (mMAX-LP) which had three broad clusters (structure, coverage and relationship with physical health services). The model was applied and discussed with the previously visited hospitals over the succeeding five years. Additionally, the matrix was tested, and its utility demonstrated during the planned reconfiguration of CLP services at a large teaching hospital in South Auckland, New Zealand by tracking the evolution of CLP services. CONCLUSIONS: mMAX-LP shows promise as a useful model for profiling and comparing CLP services; mapping their evolution over time; and sign-posting future service development.

Retrospective chart review to assess domains of quality of death (recognition of dying, appropriate limitations, symptom monitoring, anticipatory prescribing) of patients dying in the acute hospital under the care of a nephrology service with renal supportive care support over time.

AIM: To explore the quality of deaths in an acute hospital under a nephrology service at two teaching hospitals in Sydney with renal supportive care services over time. METHODS: Retrospective chart review of all deaths in the years 2004, 2009 and 2014 at St George Hospital (SGH) and in 2014 at the Concord Repatriation General Hospital. Domains assessed were recognition of dying, invasive interventions, symptom assessment, anticipatory prescribing, documentation of spiritual needs and bereavement information for families. End-of-life care plan (EOLCP) use was also evaluated at SGH. RESULTS: Over 90% of patients were recognized to be dying in all 3 years at SGH. Rates of interventions in the last week of life were low and did not differ across the 3 years. There was a significant increase in the prescription of anti-psychotic, anti-emetic and anti-cholinergic medication over the years at SGH. Use of EOLCP was significantly higher at SGH, and their use improved several quality domains. Of all deaths, 68% were referred to palliative care at SGH and 33% at Concord Repatriation General Hospital (not significant). Cessation of observations and non-essential medications and documentation of bereavement information given to families was low across both sites in all years, although this significantly improved when EOLCP were used. CONCLUSION: While acute teams are good at recognizing dying, they need support to care for dying patients. The use of EOLCP in acute services can facilitate improvements in caring for the dying. Renal supportive care services need time to become embedded in the culture of the acute hospital.

Improving Anaphylaxis Care: The Impact of a Clinical Pathway.

BACKGROUND: Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation. METHODS: In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision. RESULTS: The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand. CONCLUSIONS: By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.

Neonatal Jaundice: Improved Quality and Cost Savings After Implementation of a Standard Pathway.

OBJECTIVES: Seattle Children's Hospital sought to optimize the value equation for neonatal jaundice patients by creating a standard care pathway. METHODS: An evidence-based pathway for management of neonatal jaundice was created. This included multidisciplinary team assembly, comprehensive literature review, creation of a treatment algorithm and computer order sets, formulation of goals and metrics, roll-out of an education program for end users, and ongoing pathway improvement. The pathway was implemented on May 31, 2012. Quality metrics before and after implementation were compared. External data were used to analyze cost impacts. RESULTS: Significant improvements were achieved across multiple quality dimensions. Time to recovery decreased: mean length of stay was 1.30 days for 117 prepathway patients compared with 0.87 days for 69 postpathway patients (P < .001). Efficiency was enhanced: mean time to phototherapy initiation was 101.26 minutes for 14 prepathway patients compared with 54.67 minutes for 67 postpathway patients (P = .03). Care was less invasive: intravenous fluid orders were reduced from 80% to 44% (P < .001). Inpatient use was reduced: 66% of prepathway patients were admitted from the emergency department to inpatient care, compared with 50% of postpathway patients (P = .01). There was no increase in the readmission rate. These achievements translated to statistically significant cost reductions in total charges, as well as in the following categories: intravenous fluids, laboratory, room cost, and emergency department charges. CONCLUSIONS: An evidence-based standard care pathway for neonatal jaundice can significantly improve multiple dimensions of value, including reductions in cost and length of stay.

Effect of the 2014 Clinical and Laboratory Standards Institute urine-specific breakpoints on cefazolin susceptibility rates at a community teaching hospital.

BACKGROUND: Enterobacteriaceae, which include Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis, are identified as the infectious etiology in the majority of urinary tract infections (UTIs) in community hospitals across the United States. The minimum inhibitory concentration (MIC) is a useful tool when choosing an appropriate antibacterial agent. Recent changes to the 2014 Clinical and Laboratory Standards Institute (CLSI) guidelines included reporting a urine-specific cefazolin breakpoint for enterobacteriaceae (susceptible ≤16 mcg/mL). The purpose of this study was to determine the clinical and financial impact of implementing the 2014 CLSI urine-specific breakpoints for cefazolin in a community-based teaching hospital in the Southern U.S.A. METHODS: A retrospective review of patients hospitalized from January 1, 2010 through October 1, 2014 was performed. Patients that met inclusion criteria had a documented initial clinical isolate of E. coli, K. pneumoniae, or P. mirabilis from urine cultures during each year. Descriptive statistics and two-proportion test of hypothesis were used in the analysis to compare susceptibility rates before and after implementation of the updated CLSI breakpoints for cefazolin. RESULTS: A total of 190 clinical isolates from patients were included in the study. E. coli was the most common organism isolated (63.7%), followed by K. pneumoniae (22.1%), and P. mirabilis (14.2%). 86% of the included isolates were susceptible to cefazolin using the 2010 breakpoints. Implementation of the 2014 breakpoints did not significantly impact susceptibility results for E. coli, K. pneumoniae, or P. mirabilis. CONCLUSION: Modification of breakpoints did not significantly impact susceptibility rates of cefazolin. Substituting cefazolin may decrease the overall drug cost by 77.5%. More data is needed to correlate in vitro findings with clinical outcomes using cefazolin for UTIs.

Patterns of adherence to NICE glaucoma guidance in two different service delivery models.

PURPOSE: To assess adherence patterns to the UK National Institute of Health and Clinical Excellence (NICE) guidelines on glaucoma management (2009) in a tertiary referral centre shared care setting and in a district general hospital (DGH) setting. METHOD: We performed a retrospective case note analysis of 200 patients from two centres between January and June 2010. The two centres involved were a consultant-guided teaching hospital optometry-led shared care setting (setting 1) and a consultant-led DGH clinic setting (setting 2). The main outcome measures were compliance with eight of the main NICE guidelines on glaucoma diagnosis and management (2009). RESULTS: Both centres showed good adherence to the guidelines regarding the choice of initial treatment (96% vs 100%, settings 1 and 2, respectively) and arranging appropriate monitoring intervals (92% vs 86%). However, significant differences were seen when assessing whether an optic disc image was obtained at the initial visit (74% vs 10%), whether an appropriate initial assessment was performed (96% vs 58%), whether patients' review interval complied with the NICE guidance regardless of hospital cancellations (92% vs 66%), and whether concordance with medication was checked (88% vs 24%) (settings 1 and 2, respectively, P<0.01-Fisher's exact test). CONCLUSION: Our study provides evidence to suggest that a hospital-based shared care service with trained optometrists using assessment sheets compares favourably to non-specialist glaucoma care delivered by ophthalmologists.

Hospital competition and inpatient services efficiency in Taiwan: a longitudinal study.

There is no consistent evidence of the relationship between market competition and hospital efficiency. Some studies indicated that more competition led to a faster patient turnover rate, higher hospital costs, and lower hospital efficiency. Since the 1980s some studies found market competition could increase the efficiency of inpatient services. However, there were few studies testing the market competition during a hospital's earlier stages on its efficiency during later stages, or the dynamic of efficiency. In this study, we examined the effect of early-stage market competition on later-stage hospital efficiency in Taiwan, and we determine the efficiency change using longitudinal study design. The data for the analysis came from the annual national hospital survey of 1996 and 2001 provided by the Department of Health. There were 102 teaching hospital be analysed. The results show that no evidence supports the proposition that higher market competition would improve the efficiency of hospitals in delivering inpatient services in Taiwan. Importantly, neither was the inefficiency score nor the Malmquist productivity index of inpatient services associated with the level of hospital market competition, regardless of the adjustment for hospital characteristics. However, the results may be related with the hospital increasing beds investment behavior.

Changing Clostridium difficile infection testing and treatment trends at a large tertiary care teaching hospital.

OBJECTIVE: To assess changes in testing and treatment trends of CDI at a time when the Clostridium difficile hypervirulent strain was first identified. METHOD: A retrospective cohort study was performed. C. difficile cytotoxicity results were merged with pharmacy databases and changes in testing and treatment pattern over time were assessed. RESULTS: 6,613 tests for C. difficile were performed on 5,100 patients. Using least squares regression times series analysis, rates of testing increased by 0.63 +/- 0.31 tests per month (P = 0.05) although the number of positive tests did not increase significantly. Overall, metronidazole was the most commonly used drug (81.6%), followed by vancomycin (9.3%), rifaximin (8.4%), and nitazoxanide (0.70%). Use of rifaximin increased by 3.3 +/- 0.55 new prescriptions per month (Fig. 2; P < 0.01) while use of metronidazole increased by 5.0 +/- 2.8 new prescriptions per month and oral vancomycin increased by 0.4 +/- 0.7 new prescriptions per month; however these results were not statistically significant. For patients receiving rifaximin the drug was given as monotherapy (26.2%), in combination with oral vancomycin (24.2%), or in combination with metronidazole (49.7%). CONCLUSION: Increased rates of CDI testing and use of alternative therapies was observed at a time when the hypervirulent strain was first identified.

Achieving quality assurance standards in colposcopy practice: a teaching hospital experience.

OBJECTIVE: To assess the performance of the colposcopy service of the teaching hospitals of Cardiff and Vale Trust, University of Wales, Cardiff, South Wales, UK by determining if patients attending colposcopy clinic had been managed in accordance with the local departmental, regional and national (National Health Service Cervical Screening Programme) guidelines with the ultimate purpose of identifying areas for improvement in patients' care. METHODS: We retrospectively analysed the case notes of 426 women who attended the colposcopy clinic over a three-month period in 2005. RESULTS: This study has shown that five of the national standards have been achieved. These relate to availability of cytology report at the time of colposcopic assessment, recording of colposcopist's impression as to the nature of the cervical lesion, suitability of biopsy samples for histological analysis, primary haemorrhage as a complication of large loop excision of transformation zone treatment and inpatient admission following this treatment. However, other five unmet standards relate to recording of visibility of squamocolumnar junction, predictability of high-grade lesion, taking a biopsy from a high-grade lesion as suggested by smear, recording consent of treatment, and number of treatments performed as an outpatient. CONCLUSION: Our findings should lead to changes in the structure and functioning of the colposcopy clinic that would improve the detection of significant disease and the timeliness of diagnosis and the speed with which results are communicated.

Comparison of outcome measures for a traditional pediatric faculty service and nonfaculty hospitalist services in a community teaching hospital.

OBJECTIVE: Several studies have found decreased cost and length of stay for patients who are cared for by pediatric hospitalists compared with traditional faculty models. The objective of this study was to compare cost and length of stay between a faculty group and 2 separate hospitalist groups in a community teaching hospital. This study differs from previous ones in that both the traditional faculty and hospitalist models were in place simultaneously, and the traditional faculty group was employed by the hospital, whereas the hospitalist groups were in private practice. METHODS: A total of 1009 pediatric patients with any of the 11 most frequent diagnosis-related groups were analyzed according to the admitting physician group. Total direct costs and length of stay were computed for 3 separate groups (faculty group, hospitalist group 1, and hospitalist group 2). Linear regression models were used to compare total direct costs and length of stay among the groups. Each model accounted for age, severity index, and payer source. RESULTS: Age, severity index, and physician group were predictive in determining total direct costs and length of stay. There was no significant difference in patient age among the groups, but the faculty group had significantly increased severity indices compared with hospitalist groups 1 and 2 (1.6 +/- 0.7 vs 1.3 +/- 0.6 vs 1.4 +/- 0.6, mean +/- SD). The faculty group had statistically significantly lower total direct costs compared with hospitalist groups 1 and 2 (1781 dollars +/- 1449 dollars vs 1954 dollars +/- 1212 dollars vs 1964 dollars +/- 1495 dollars, mean +/- SD). The faculty group had shorter average length of stay compared with hospitalist groups 1 and 2 (2.6 +/- 2.0 vs 3.1 +/- 2.6 vs 2.9 +/- 2.3, mean +/- SD). The readmission rates among the groups were similar. CONCLUSIONS: Traditional faculty models can be as efficient in terms of total direct costs and length of stay as evolving hospitalist models. This study's results may be unique because the traditional faculty model was composed of general pediatricians instead of a blend of generalists and subspecialists. In addition, the traditional faculty physicians concentrated almost entirely on the care of inpatients while engaged in hospital care.

A decade on: has the use of integrated care pathways made a difference in Lanarkshire?

This article aimed to: (1) review the work carried out in Lanarkshire between 1996 and 1999 on a Scottish Executive funded project and (2) to discuss the situation from 1999 to 2006. (1) This 3-year project led to the successful development and implementation of over 100 integrated care pathways in an urban teaching hospital (Glasgow) and a district general hospital (Lanarkshire) and was the first in-depth study of integrated care pathways to be undertaken in Scotland. The main report on the project was produced in 1999 (Clinical Audit and Quality using Integrated Pathways of Care) and reported increased adherence to British Thoracic Society and Scottish Intercollegiate Guidelines Network guidelines and multiple best practice statements, and improved standards of documentation. The general findings were that process indicators were improved by integrated care pathway use and there was some suggestion of improved length of stay with no apparent effect on outcome. Evidence was found that integrated care pathways have made a difference for both patients and staff. (2) This provides an update of integrated care pathway development in a changing environment within NHS Lanarkshire and examines some of the key factors for success.

Hospital doctors and their schemas about appropriate prescribing.

OBJECTIVES: To investigate cognitive schemas and schema systems used by hospital doctors to influence prescribing, particularly in terms of making appropriate prescribing decisions, and to compare the numbers and content of schemas between doctors with different levels of experience. DESIGN: Qualitative interviews with a purposively selected sample. PARTICIPANTS AND SETTING: Seven pre-registration (PRHOs) and 5 senior house officers (SHOs) and 5 consultants from a range of medical specialties in a teaching hospital. RESULTS: The qualitative analysis of the themes and patterns explored during the interviews indicated that all doctors articulated schemas that influenced their behaviour. The junior doctors seemed to have simplistic schemas, with interdoctor agreement; the consultants appeared to have more sophisticated schemas, with greater individual variation. Those schemas adopted by the PRHOs (prescribing "novices") could be subsumed by, rather than contradicted by, those of the consultants (prescribing "experts"), with a transitional stage demonstrated by the SHOs. The most noticeable distinction was the greater emphasis by consultants on holistic patient care and what might be seen as their separate schemas for appropriate prescribing stemmed from that premise. In contrast, junior doctors appeared to have had a single schema that encompassed both prescribing generally and appropriate prescribing. CONCLUSIONS: Although the design of this study was cross-sectional rather than longitudinal, the findings suggest that the acquisition and adjustment of schemas and schema systems are significant factors in the professional development of the hospital doctor from novice through to expert. It could be hypothesised that house officers possess simpler schemas as a way of coping with their job demands, which evolve in complexity as they gain experience. However, the transitional stage found with the SHOs is critical during cognitive development, with implications for the training and support available to doctors throughout their professional careers.

Patient Safety Leadership WalkRounds.

BACKGROUND: In the WalkRounds concept, a core group, which includes the senior executives and/or vice presidents, conducts weekly visits to different areas of the hospital. The group, joined by one or two nurses in the area and other available staff, asks specific questions about adverse events or near misses and about the factors or systems issues that led to these events. ANALYSIS OF EVENTS: Events in the Walkrounds are entered into a database and classified according to the contributing factors. The data are aggregated by contributing factors and priority scores to highlight the root issues. The priority scores are used to determine QI pilots and make best use of limited resources. Executives are surveyed quarterly about actions they have taken as a direct result of WalkRounds and are asked what they have learned from the rounds. RESULTS: As of September 2002, 47 Patient Safety Leadership WalkRounds visited a total of 48 different areas of the hospital, with 432 individual comments. DISCUSSION: The WalkRounds require not only knowledgeable and invested senior leadership but also a well-organized support structure. Quality and safety personnel are needed to collect data and maintain a database of confidential information, evaluate the data from a systems approach, and delineate systems-based actions to improve care delivery. Comments of frontline clinicians and executives suggested that WalkRounds helps educate leadership and frontline staff in patient safety concepts and will lead to cultural changes, as manifested in more open discussion of adverse events and an improved rate of safety-based changes.

An inpatient diabetes QI program.

OBJECTIVE: The goal of this study was to establish a continuous quality improvement (CQI) program for diabetes which would identify patterns in the problems of care encountered by hospitalized patients with diabetes and improve the in-hospital process of diabetes care delivery. RESEARCH DESIGN AND METHODS: The laboratory information system in an acute and tertiary care 1,000-bed urban teaching hospital provided us on a daily basis with a list of patients on the medical service having blood glucose (BG) levels < 40mg/dl or > 450mg/dl and positive serum acetones. We performed concurrent implicit chart review when BG levels were hypoglycemic (< 40mg/dl) or hyperglycemic (> 450mg/dl on two occasions) or when diabetic ketoacidosis (DKA) was present (acetones were > 1+) using preset indicators for documentation and appropriate medical management. Data were expressed as the ratio of number of cases in compliance with the indicator over total number of cases identified. A test for trend in proportions was used to assess compliance with the indicators over time. RESULTS: Documentation of nursing unit-based capillary blood glucose (CBGM) and insulin infusion monitoring improved significantly over time (p < 0.001 for both). The medical management of hypoglycemia, hyperglycemia and DKA improved (p = 0.1) over the three-year period. Identification of recurrent multidisciplinary process problems in the management of DKA, intravenous insulin infusion constitution and delivery, CBGM determination in the setting of anemia, and recognition of clinical settings conducive to the development of hypo- and hyperglycemia were identified and addressed with standardization in documentation, an insulin infusion protocol, administrative rules, and staff education. CONCLUSIONS: Efforts to standardize specific clinical and documentation processes had a positive impact on the care of hospitalized patients with diabetes and resulted in an institutional effort to improve inpatient diabetes care with a CQI team.

Collaborating to reduce costs in invasive cardiology: the Partners Healthcare experience. Partners Healthcare Invasive Cardiology Team.

BACKGROUND: As part of the closely watched marriage between Brigham and Women's Hospital and Massachusetts General Hospital, the invasive cardiology team--cardiologists and other staff from the two organizations--began with monthly meetings; its mission is to reduce costs of cardiology services while maintaining or improving patient satisfaction and outcomes. IMPROVEMENT EFFORTS: Joint purchasing efforts have led to substantial price reductions for some supplies, such as pacemakers and balloon angioplasty. However, concern over quality drove cardiologists to choose newer, more expensive models of other supplies, such as implantible cardioverter-defibrillators. Also, the team is studying the actual costs savings that can be achieved by shifting patients undergoing cardiac catheterization to the outpatient setting. In addition, cardiologists recognized an opportunity to decrease length of stay and increase quality by removing the arterial sheath for uncomplicated percutaneous transluminal coronary angioplasty patients on the same day the procedure is performed. Each hospital is developing strategies for this change in procedure. In addition to these improvement efforts, the team is encouraging optimal use of contrast agents and increasing overall efficiency of laboratories. Team members are also sharing guidelines and critical pathways and developing strategies for evaluating new technologies. LESSONS LEARNED: The team has had little difficulty in achieving a collegial atmosphere and consensus around clinical issues and products once clinicians are face-to-face. Announcing bimonthly meetings may overcome meeting scheduling difficulties. The other major stumbling block has been the lack of detailed cost information.

Care of dying patients in hospital.

OBJECTIVE: To study the process of care of dying patients in general hospitals. DESIGN: Non-participant observer (MM) carried out regular periods of continuous comprehensive observation in wards where there were dying patients, recording the quantity and quality of care given. Observations were made in 1983. SETTING: 13 wards (six surgical, six medical, and one specialist unit) in four large teaching hospitals (bed capacity 504-796) in west of Scotland. SUBJECTS: 50 dying patients (29 female, 21 male) with mean age of 66 (range 40-89); 29 were dying from cancer and 21 from non-malignant disease. RESULTS: Final period of hospitalisation ranged from 6 hours to 24 weeks. More than half of all patients retained consciousness until shortly before death. Basic interventions to maintain patients' comfort were often not provided: oral hygiene was often poor, thirst remained unquenched, and little assistance was given to encourage eating. Contact between nurses and the dying patients was minimal; distancing and isolation of patients by most medical and nursing staff were evident; this isolation increased as death approached. CONCLUSIONS: Care of many of the dying patients observed in these hospitals was poor. We need to identify and implement practical steps to facilitate high quality care of the dying. Much can be learned from the hospice movement, but such knowledge and skills must be replicated in all settings.