Factors influencing fall prevention for patients with spinal cord injury from the perspectives of administrators in Canadian rehabilitation hospitals.

BACKGROUND: Fall prevention is a priority in Canadian tertiary rehabilitation hospitals. We aimed to understand the perspectives of hospital administrators on the challenges experienced when implementing fall prevention policies/procedures for patients with spinal cord injury (SCI) in tertiary rehabilitation hospitals. METHODS: Semi-structured interviews were conducted with 10 administrators employed in six Canadian tertiary rehabilitation hospitals. Guided by an interpretive description framework, interviews were analyzed using a constant comparison approach. RESULTS: Challenges with fall prevention experienced by administrators fell into the three categories: 1) fall prevention policy and procedural challenges (e.g. fall prevention policy not SCI-specific, expectation of zero falls, determining contributing factors, learning from falls, and overall effectiveness of the fall prevention policy), 2) clinician-related challenges (e.g. variable staff adherence with the organizations' fall prevention procedures, inconsistent delivery of fall prevention education, and integrating individualized fall risks to guide clinical practice), and 3) patient-related challenges (e.g. balancing risk vs independence and rehabilitation progress, responsibility for fall prevention, and non-preventable falls). CONCLUSIONS: Fall prevention policies/procedures required by the hospitals were insufficient for clinical practice in SCI rehabilitation.

Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia.

PURPOSE: We developed a pneumonia guideline at Intermountain Health Care that included admission decision support and recommendations for antibiotic timing and selection, based on the 1993 American Thoracic Society guideline. We hypothesized that guideline implementation would decrease mortality. SUBJECTS AND METHODS: We included all immunocompetent patients > 65 years with community-acquired pneumonia from 1993 through 1997 in Utah; nursing home patients were excluded. We compared 30-day mortality rates among patients before and after the guideline was implemented, as well as among patients treated by physicians who did not participate in the guideline program. RESULTS: We observed 28,661 cases of pneumonia, including 7,719 (27%) that resulted in hospital admission. Thirty-day mortality was 13.4% (1,037 of 7,719) among admitted patients and 6.3% (1,801 of 28,661) overall. Mortality rates (both overall and among admitted patients) were similar among patients of physicians affiliated and not affiliated with Intermountain Health Care before the guideline was implemented. For episodes that resulted in hospital admission after guideline implementation, 30-day mortality was 11.0% among patients treated by Intermountain Health Care-affiliated physicians compared with 14.2% for other Utah physicians. Analysis that adjusted by logistic regression for age, sex, rural versus urban residences, and year confirmed that 30-day mortality was lower among admitted patients who were treated by Intermountain Health Care-affiliated physicians (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.49 to 0.97; P = 0.04) and was somewhat lower among all pneumonia patients (OR: 0.81; 95% CI: 0.63 to 1.03; P = 0.08). CONCLUSION: Implementation of a pneumonia practice guideline in the Intermountain Health Care system was associated with a reduction in 30-day mortality among elderly patients with pneumonia.

Medication error reporting: a survey of nursing staff.

The objective of this article is to describe findings from a medication error (ME) survey, to estimate the extent of ME underreporting by comparison of survey results with written incident reports (IRs), and to determine factors associated with IR reporting of MEs. Participants were registered nurses from the 38-bed infant unit of a pediatric hospital. Most recent ME in each of four stages of the medication process was classified as to: timing, nature, whether the error was prevented from the patient, patient injury, and completed IR. Surveys were administered to nurses during mandatory skills session and were compared with IRs for MEs for the previous 6 months. The survey response rate was 93.5 percent; 72 nurses described 177 errors, 40.3 percent observed an ME in the previous week, 62.1 percent were prevented from reaching the patient and the likelihood of prevention was reduced in the later stages of the medication process. About 30 percent of MEs resulted in IRs. Administration errors were more likely to result in IRs compared with ordering errors, especially when the error was not prevented from the patient. There were 51 IRs for MEs. A multivariate logistic regression with completed IRs as the dependent variable showed a decreased likelihood of IRs for ordering than administration errors. IRs were more likely for wrong medication or dose errors and IRs were less likely for errors prevented from reaching the patient. The study found that by augmenting IR reporting of MEs and classifying errors by stage, anonymous ME surveys can be used for monitoring and guiding improvements to hospital medication systems.

Reducing medication errors in hospitals: a peer review organization collaboration.

BACKGROUND: Motivated by published reports of the incidence, costs, causes, and nature of adverse drug events (ADEs) in hospitalized patients, in 1997 the Medicare peer review organization for Nevada and Utah initiated a voluntary project of medication error reduction for Utah hospitals. METHODS: Through project activities, hospital teams were encouraged to make changes to their medication processes based on direct evaluation of medication systems characteristics, informed by ergonomic principles and published studies of medication errors. Assessment of project effects included an evaluation of the changes implemented and results from an anonymous medication errors survey of clinical staff from participating organizations. RESULTS: Thirteen of the 39 acute care hospitals in Utah participated in 1997-1998 in the collaborative project. Participants reported substantive medication system changes that were expected to result in improved patient safety. Baseline and follow-up survey data were available for 8 of the participating hospitals. Analysis of 560 responses showed a 26.9% decrease in overall error frequency, a 12.5% increase in error detection and prevention, and a 24.1% increase in formal written reporting of errors that reached the patient. CONCLUSIONS: This project demonstrated community interest in a proactive and collaborative approach to improving patient safety. The improvement efforts were substantive and sustainable. Survey results suggest that the changes implemented in participating organizations may have reduced medication errors and improved capacity for error detection and prevention.

Frequency of subspecialty physician care for elderly patients with community-acquired pneumonia.

STUDY OBJECTIVES: Specialty societies have developed practice guidelines for the treatment of community-acquired pneumonia (CAP). To aid in adapting specialty recommendations for a pneumonia practice guideline at Intermountain Health Care, we investigated which physicians care for pneumonia patients in Utah. We wanted to understand who provides pneumonia care so as to appropriately target the guideline and design tools for implementation. DESIGN: Retrospective observational study. SETTING: Inpatient and outpatient multicenter. PATIENTS: The study population comprised 13,919 (16,420 episodes of pneumonia) Utah resident Medicare beneficiaries > or = 65 years of age who had CAP. Nursing home residents were excluded. MEASUREMENTS: We used Health Care Financing Administration billing records from 1993 through 1995 to identify the physicians involved in the care of pneumonia patients by self-designated specialty. We linked patterns of physician involvement to age, sex, residential zip code, 30-day mortality rate, and whether or not the patient was hospitalized. RESULTS: The involvement of a pneumonia specialist was limited to 11.7% of episodes, with involvement of a pulmonary specialist in 10.6%, an infectious disease (ID) specialist in 0.9%, and the involvement of both specialties in 0.2% of episodes. Greater specialty involvement was observed in episodes resulting in pneumonia hospitalization (20.0% vs 8.6%, respectively; p < 0.0001), death (20.5% vs 11.2%, respectively; p < 0.0001), and episodes among patients with urban county residential zip codes (13.7% vs 7.5%, respectively; p < 0.0001). CONCLUSION: Most episodes of pneumonia, including those with serious consequences, are treated by primary care physicians with little or no involvement from pulmonary or ID specialists. It is not known whether greater or lesser specialty physician involvement would change pneumonia costs or clinical outcomes.

Psychopathology and emotional distress among older high-utilizing health maintenance organization patients.

BACKGROUND: Rates of psychopathology are often underestimated in primary care populations, especially older patient groups. High medical utilization is often a reflection of psychopathology and/or emotional distress. Increased awareness of primary care patients' emotional distress can help to improve well-being and reduce unnecessary high utilization of medical services. This study aimed to assess the degree of psychopathology present in a sample of older health maintenance organization (HMO) patients who utilized higher-than-average amounts of medical services. METHODS: Patients in a large HMO aged 55 years old and older who exceeded the mean number of inpatient and outpatient visits in the past year were recruited. Sixty-nine patients, mostly female (69%) and white (93%), volunteered. Patients were assessed with the Medical Outcomes Study SF-36 health survey and the Symptom Checklist-90-Revised (SCL-90-R). RESULTS: Respondents made a mean of 41 visits in the previous year to medical providers, versus 24 visits per year for the average patient of this age in the HMO. Significant elevations on SCL-90-R global psychopathology, obsessive-compulsive, somatization, and depression scales were found. All patients met SCL-90-R criteria for psychiatric caseness. SF-36 health ratings were comparable with those of patients with chronic medical conditions assessed in other SF-36 samples. CONCLUSIONS: Older high-utilizing HMO patients show significantly more psychopathology and view their health status as poorer than that of other medical subpopulations; results suggest that care for these problems is rarely received.

Ambulatory care sensitive hospitalization rates in the aged Medicare population in Utah, 1990 to 1994: a rural-urban comparison.

The objective of this study is to compare the likelihood of hospitalization for conditions that are related to the adequacy and use of ambulatory health care services for Medicare beneficiaries residing in rural and urban regions in Utah. The Health Care Financing Administration's (HCFA) hospital discharge database (Utah hospitals: 1990 to 1994) was used to estimate hospitalization rates (with adjustment for out-of-state admissions) for ambulatory care sensitive conditions. Population estimates were obtained from HCFA beneficiary files. Regional hospitalization rates were obtained through ZIP code matching of the hospital discharge and beneficiary files. Medicare beneficiaries aged 65 and older residing in Utah during 1990 to 1994 are the subjects for the study. The main outcome measures include age and sex-adjusted hospitalization rates by region for the entire state and rate ratio estimates for nonurban regions. The results of the study show that Medicare beneficiaries residing in two rural-frontier regions were more likely than urban beneficiaries to be hospitalized for ambulatory care sensitive conditions. Rate ratio estimates were greater than 1.4 for both regions during the study period. These findings suggest a pattern of an increased burden of avoidable secondary complications and disease progression among Utah Medicare beneficiaries residing in some rural regions. This increased burden may be the result of limitations in the ambulatory care system, medical care provider supply, and/or beneficiary propensity to seek care. Variation in disease prevalence or hospital use patterns for these conditions also may be responsible for all or part of the observed variation in ambulatory care sensitive admission rates.

Maternal cell contamination in uncultured amniotic fluid.

The presence of maternal cells in uncultured amniotic fluid may result in error in the interpretation of prenatal tests such as direct DNA analysis and rapid aneuploidy detection by fluorescence in situ hybridization (FISH). Using simultaneous dual colour X and Y FISH, we assessed maternal cell contamination in uncultured amniotic fluids from 500 women carrying male fetuses. The presence of maternal cells was correlated with the amount of blood present in the amniotic fluid as defined by visual examination of the cell pellet after centrifugation. The overall rate of maternal cell contamination in uncultured amniotic fluid as identified using X and Y-specific probes was 21.4 per cent, compared with 0.2 per cent in cultured fluid. Sixteen per cent of slightly bloody and 55 per cent of moderately bloody uncultured fluids had at least 20 per cent maternal cells and were classified as uninformative according to our protocol for rapid aneuploidy detection. Maternal and fetal cells could not be distinguished based on morphological characteristics alone.