ENT one day surgery: critical analysis with the HFMEA method.

OBJECTIVES: Research shows that 51.4% of adverse events in hospitals occur in surgery and that 3-22% of surgical patients experience adverse events. The risk may be even higher when turnover is high and when patients are children, as is often the case in ear, nose and throat surgery. This quality project therefore started in response to requests from physicians in two hospitals in the Flemish part of Belgium. The aim of this study is to use the Healthcare Failure Mode & Effect Analysis method to evaluate the process flow for ear, nose and throat patients, and to redesign the process to enhance patient safety. METHODOLOGY: In two One Day Clinics, processes were prospectively analysed using the Healthcare Failure Mode & Effect Analysis method. RESULTS: Similar potential failures were reported in both hospitals. The major failure mode was linked to the absence of an active identity check throughout the process. The process was therefore redesigned by implementing a surgical safety checklist and an active identity check protocol. Although the Healthcare Failure Mode & Effect Analysis is a time-consuming method, this systematic approach by a multidisciplinary team has been found to be useful in detecting failure modes that need immediate safety responses. The involvement of all disciplines and an open safety culture during the procedure were the most important conditions. CONCLUSIONS: The Healthcare Failure Mode & Effect Analysis is a useful instrument for detecting the failure modes in this care process.

Establishing the relationship between nurse staffing and hospital mortality using a clustered discrete-time logistic model.

Studies based on aggregated hospital outcome data have established that there is a relationship between nurse staffing and adverse events. However, this result could not be confirmed in Belgium where 96 per cent of the variability of nurse staffing levels over nursing units (belonging to different hospitals) is explained by within-hospital variability. To better appreciate the possible impact of nurse staffing levels on adverse events, we propose a multilevel approach reflecting the complex nature of the data. In particular we suggest a clustered discrete-time logistic model that captures the risks associated with a given unit in the patient's trajectory through the hospital. The model also allows for nurse staffing levels to affect the current and subsequent nursing unit (carry-over effect). In the model 'time' is represented by the sequential number of the nursing unit that the patient is passing through. The model incorporates hospital and nursing unit random effects to express that patients treated in the same hospital and taken care of by nurses of the same unit share a common environment. In this study we used Belgian national administrative databases for the year 2003 to assess the relationship between nurse staffing levels and nurse education variables with in-hospital mortality. The analysis was restricted to elective cardiac surgery patients. Lower nursing unit staffing levels in the general nursing units were associated with high in-hospital mortality in units past the traditional cardiac surgery nursing units.

[Guidelines for clinical practice]. / Richtlijnen voor de klinische praktijk.

Clinical practice guidelines are systematically developed statements that are intended to support medical decision making in well-defined clinical situations. Essentially, their object is to reduce the variability in medical practice, to improve quality, and to make appropriated control of the financial resources possible. Internationally, ever more organisations, associations, and institutions are concerned with the development of guidelines in many different areas of care. Making implicit knowledge explicit is one of the associated advantages of guidelines: they have a potential utility in training, in process evaluation, and in the reevaluation of outcome studies. In liability issues, their existence has a double effect: they can be used to justify medical behaviour, and they constitute a generally accepted reference point. A derivative problem is the legal liability of the compilers of the guidelines. The principle of the guideline approach can be challenged academically: science cannot give a definition of optimal care with absolute certainty. What is called objectivity often rests on methodologically disputable analyses; also the opinion of opinion leaders is not always a guarantee for scientific soundness. Moreover, patients are not all identical: biological variability, situational factors, patient expectations, and other elements play a role in this differentiation. Clinicians are often hesitant with respect to clinical guidelines: they are afraid of cookbook medicine and curtailment of their professional autonomy. Patients fear reduction of individualization of care and the use of guidelines as a rationing instrument. The effects of the introduction of clinical practice guidelines on medical practice, on the results and on the cost of care vary but are generally considered to be favourable. The choice of appropriate strategies in development, dissemination, and implementation turns out to be of critical importance. The article ends with concrete suggestions for the various steps in the development of guidelines and their actual compilation.

A model for calculating the hospital costs for pediatric endoscopy.

BACKGROUND: Hospitals increasingly need, besides effectiveness data, accurate and reliable cost data to allocate their resources as efficiently as possible. In this article, a framework to calculate the hospital costs of setting up a new activity is presented and applied to pediatric endoscopy. METHODS: The cost calculations were based on a detailed registration of labor time, materials, space, and equipment needed to perform endoscopy in pediatric patients in a tertiary care hospital, the University Hospital in Leuven, Belgium. RESULTS: The initial investment expenses amount to 70,000 ECU ($91,000 in U.S. money), assuming that the facilities of the adult endoscopy unit can be shared. The additional variable cost for each procedure, including labor time and materials, varies between 100 and about 170 ECU ($130 and $221 U.S.), depending on the type of endoscopy (upper or lower, diagnostic or therapeutic). These basic data can be used to calculate the total costs for pediatric endoscopy under alternative scenarios (e.g., varying total number of procedures). CONCLUSIONS: The costing exercise has given the hospital better insights into the working procedures (and hence costs) of pediatric endoscopy. Other organizations will be able to apply this framework in their setting, since all included cost components, as well as volumes and unit prices, are reported separately.

Cost-efficient management in surgery. The view of the hospital administrator.

The views of hospital administrators, doctors and payers on cost-efficiency in surgery do not necessarily coincide. The difference between charges and cost and the particularities of the financing mechanisms may induce situations in which savings for the society as a whole result in financial loss for the hospital. Examples are in the use of stapling devices, in ambulatory surgery, in endoscopic surgery: they all result in better quality of care and decreasing health care cost for society; they often induce, however, a not compensated increase in hospital costs. Surgeons and administrators can find each other in a common concern for optimizing efficiency. This asks for an agreement regarding the techniques and equipment to be used, and regarding the necessary minimum case load. This paper presents the case of the endoscopic cholecystectomy as an example. The second part of the paper deals with various aspects of quality and cost of the hospital product. It warns against purely technology-inspired investments which entail a risk for overconsumption and inappropriate use. It also asks for attention for the educational cost and for the continuing running cost which may result from capital investment decisions. Finally it underscores the role that surgeons can play in reducing the running cost, by paying attention to a smoother organisation of the OR activities and to the choice of materials, consumables and pharmaceuticals.

[The price of quality: health care expenditures and quality of life]. / De prijs van kwaliteit: de uitgaven voor gezondheidszorg en de kwaliteit van leven.

In an era where the substitution of health policy by budgetary arguments is imminent, this paper aims to offer some elements in the discussion on the relationship between health care expenditures and their effect on quality of life for individuals and society. Historical developments, present differences in medical consumption and in outcome, the growing interest in alternative medicine, the use of new medical technologies and observations on the expenditures for pharmaceuticals show that this relationship is not self-evident and that generalizations must be avoided. The observations lead to an argument of more efficiency in the use of health care resources.

Anesthesiology in the Belgian health care environment.

This article focuses on anesthesiology practice in the context of Belgian health care. The first part describes the organization of Belgian health care, the role of private and public initiatives, the division of responsibilities between the different health authorities, the financing mechanisms, and the central role of the compulsory social health care insurance. Quantitative information on the evolution of expenditures, services, providers, and facilities is presented. The second part of the article deals more specifically with anesthesiology and contains information on current practice. The emphasis, however, concerns recent developments in training and accreditation.

The Flemish Centre for the Study of Perinatal Epidemiology and its registry.

The Flemish Centre for the Study of Perinatal Epidemiology was formally established in 1986. Its objectives are the promotion of perinatal epidemiology and the study of maternal and perinatal mortality and morbidity. One of the means to accomplish these objectives was the creation of a databank of perinatal medicine. The registry at present covers almost 80% of all deliveries in Flanders. The registry indicates a maternal death rate of 5.8/100,000 living births whereas the Belgian official national statistics indicate a maternal death rate of 2.8/100,000. This means that either the matter is under reported at the national level or there is a real problem in the Flemish part of the country. The perinatal death rate varies among the participating services form 3.9 to 22.4%.

The changing pattern of medical activity in a major Belgian university hospital.

To evaluate the changes in the pattern of clinical activity in a 1900-bed Belgian teaching hospital in the period 1979-1987, we extracted data from the historical files of the hospital's central invoicing system. The total charge for a day of hospitalization, care and treatment increased by 83%. In this total per diem charge the share of hospital charges in the strict sense declined from 60 to 53%; the shares of charges for services and for pharmaceuticals rose, respectively, from 29 to 32, and from 10 to 15%. Within charges for services the share for diagnostic services declined by 22%; the share for surgery rose by 16%, and that for miscellaneous other services by 89%. For diagnostic services the decline was particularly clear for laboratory medicine (-32%) and for conventional imaging services (-22%), while cardiac and endoscopic investigations show a prominent expansion (+78 and +83%, respectively). In surgery the growth is quite homogeneous with the charges for urology, ophthalmology and orthopedics as the most important growers. In a group of miscellaneous, not diagnostic nor surgical services, which grows faster than all other groups, there is a marked shift from rather simple to technologically more advanced services. The increase in the pharmacy's bill results from increases in charge for both drugs (+49%) and materials (+95%). We conclude that the observed changes in charges reflect an intensification of care and an impact of technological innovation on clinical practice, including a phenomenon of substitution of old technologies for newer ones.

Use of diagnosis related groups for hospital management.

This paper gives an overview on the use of Diagnosis Related Groups (DRGs) for internal hospital management. Some figures derived from a comparative study between 3 university hospitals in Belgium are used to illustrate specific points. Attention is given to cost accounting and cost control on the one hand, and utilization review and quality assurance testing on the other. Costs have been approximated by billed charges. It is concluded that DRGs can effectively be used for hospital management, in addition to hospital financing for which some pressure also exists in Europe.

Ionic currents during hypoxia in voltage-clamped cat ventricular muscle.

To explore the mechanisms underlying the shortening of the cardiac action potential in hypoxia, we studied the effect of hypoxia on the ionic currents in cat papillary and trabecular muscles using the single sucrose gap-voltage clamp technique. For potentials positive to -70 mV, hypoxia induces an increase in time-independent outward current. The changes in the tail current suggest that time-dependent outward current is not increased but, rather, reduced. Because the time course of ik remains unchanged, we concluded that the shortening of the action potential is not a result of a change in the time-dependent outward current. In the potential range of the plateau, the amplitude of the slow inward current is not affected by hpoxia. Its time constant of inactivation appears slightly decreased. The prolongation of the action potential by epinephrine during hypoxia is accompanied by an increase in the slow inward current. As a result of these studies, we conclude that the shortening of the cardiac action potential in the early stage of hypoxia results from an increase in K+ outward background current.

Differential effects of hypoxia with age on the chick embryonic heart. Changes in membrane potential, intracellular K and Na, K efflux and glycogen.

The effects of hypoxia on different parameters of cell membrane function were studied in 7 and 19 day chick embryonic hearts. The following changes were observed: 1. Transmembrane potential: A depolarization of the cell membrane and a decrease in the duration and in the overshoot of the action potential. 2. Intracellular ion concentrations: A decrease in (K)i and an increase in (Na)i. Cellular Ca-content remained constant. 3. K efflux: An increase in the rate coefficient, which was larger in stimulated preparations. These changes were more pronounced in 19 day than in 7 day hearts. The effects of hypoxia were increased by simultaneous substrate depletion and counteracted by an excess external glucose. We conclude that: 1. The 19 day hearts are more sensitive to oxygen lack than the 7 day hearts. The difference can be correlated with the observation that the younger hearts are able to consume more glycogen during hypoxia. 2. The changes of the resting membrane potential and the overshoot of the action potential correlate with changes in respectively (K)i and (Na)i. 3. An increase in the background K current may be an important factor in explaining the shortening of the action potential during hypoxia.

Hypoxia increases potassium efflux from mammalian myocardium.

Hypoxia with or without simultaneous depletion of extracellular glucose increases 42K-efflux in cat and guinea-pig papillary muscles and bovine Purkinje fibres. The change observed in K efflux may be the result of an increase in K conductance at rest.