The Veterans Affairs shift change physician-to-physician handoff project.

BACKGROUND: Few studies on the safety or efficacy of current patient handoff systems exist, and few standardized electronic medical record (EMR)-based handoff tools are available. An EMR handoff tool was designed to provide a standardized approach to handoff communications and improve on previous handoff methods. METHODS: In Phase I, existing handoff methods were analyzed through abstraction of printed handoff sheets and questionnaires of internal medicine residents at Department of Veterans Affairs medical centers (VAMCs). In Phase II, the handoff tool was designed, and the software was tested and revised through user feedback and regular conference calls. Phase III involved postimplementation systematic abstraction of printed handoff sheets and questionnaires of internal medicine residents. Two VAMCs participated in abstraction of printed handoff sheets, with four VAMCs responding to the questionnaires. RESULTS: Handoffs were abstracted for 550 patients at baseline and 413 postimplementation. Improvements were found in consistency of information transfer for all handoff content, including code status, floor location, room number, two types of identifying information, typed format, medication, and allergy lists (p = .01). The 63 and 51 questionnaires completed pre- and postimplementation, respectively, showed improvement in perceptions of ease of use, efficiency, and readability (p < .05) and in perceptions of patient safety and quality (p < .01) without causing omission (p < .01) or commission of information (p = .02). DISCUSSION: This standardized EMR-based handoff software improved data accuracy and content consistency, was well-received by users, and improved perceptions of handoff-related patient safety, quality, and efficiency. A final version of the software was incorporated into the national EMR software program and made available to all VAMCs.

Racial differences in mortality among veterans hospitalized for exacerbation of chronic obstructive pulmonary disease.

This study compared mortality in African American and white patients admitted to veterans affairs (VA) hospitals for chronic obstructive pulmonary disease (COPD) exacerbation and determined the potential impact of differences in intensive care unit (ICU) admission and mechanical ventilation. Administrative data from 2003-2006 identified African American (n = 7159) and white (n = 43820) patients admitted to VA hospitals with COPD exacerbation. Hierarchical logistic regression was used to compare risk-adjusted 30-day or inhospital mortality in African American and white patients. African Americans were more likely than whites to be admitted to ICUs (19.1% vs 17.2%, respectively; p < .001) and to receive mechanical ventilation (4.8% vs 4.1%, p < .001). African Americans had lower unadjusted mortality than white patients overall (7.1% vs 9.2%, p < .001), and among patients admitted to ICUs (16.9% vs 20.3%, p < .01) and non-ICU wards (4.8% vs 6.9%, p < .001). Mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs 31.4%, p = .34). The risk-adjusted odds of death were lower for African Americans relative to white patients (OR, 0.71; p < .001) and in analyses that further adjusted for ICU admission and ventilation use (OR, 0.69; p <.001). Mortality was lower in African Americans than white veterans admitted for COPD exacerbation, even after adjusting for differences in ICU admission rates and ventilatory support. The lower risk-adjusted mortality in African Americans was not explained by more aggressive care.

Use of mechanical and noninvasive ventilation in black and white chronic obstructive pulmonary disease patients within the Veterans Administration health care system.

BACKGROUND: Black patients are more likely than white patients to prefer and receive more life-sustaining interventions in advanced stages of disease. However, little is known about potential racial differences in use of mechanical ventilation (MV), and the newer modality of noninvasive ventilation (NIV), in treatment of chronic obstructive pulmonary disease (COPD). OBJECTIVE: To determine if rates of MV and NIV use differ among black and white patients admitted to Veterans Administration (VA) hospitals for COPD exacerbation. RESEARCH DESIGN: Retrospective cohort analysis of VA database FY2003 to FY2005 including 153 hospitals nationwide. SUBJECTS: All black (n = 479) and white (n = 31,537) patients admitted with COPD exacerbation. MEASURES: Ventilation use during hospitalization as identified by ICD-9-CM codes for MV and NIV. Hierarchical logistic regression compared rates of MV or NIV use among black and white patients, adjusting for patient characteristics and accounting for hospital-level variation. RESULTS: Unadjusted rates of MV were higher in black patients than in white patients (4.1% vs. 3.0%; P < 0.001), but similar for NIV (6.0% vs. 6.1%; P = 0.65). The adjusted odds of MV for black patients relative to white patients remained higher (OR = 1.27, 95% CI: 1.01-1.54; P < 0.01) while the adjusted odds of NIV remained similar (OR = 0.94, 95% CI: 0.82-1.08; P = 0.38). CONCLUSIONS: Black patients with COPD exacerbation in VA hospitals are more likely than white patients to receive MV, and this difference is not explained by available clinical or demographic variables. By contrast, black and white patients are equally likely to receive NIV. These findings suggest that unmeasured factors, such as patient preferences or disease severity, may be affecting the use of MV in this setting and therefore warrant further investigation.

Goals of care toward the end of life: a structured literature review.

Goals of care are often mentioned as an important component of end-of-life discussions, but there are diverse assessments regarding the type and number of goals that should be considered. To address this lack of consensus, we searched MEDLINE (1967-2007) for relevant articles and identified the number, phrasing, and type of goals they addressed. An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for family/caregiver. These goals can be used to articulate goal-oriented frameworks to guide decision making toward the end of life and thereby harmonize patients' treatment choices with their values and medical conditions.

Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis.

BACKGROUND: Previous medication management research has focused on hospital and long-term care facility settings, where drug-utilization reviews are used to reduce medication errors. Patients receiving home health care (HHC) are without the benefit of systematic drug-utilization reviews. OBJECTIVE: The purpose of this study was to review medication use in elderly patients receiving HHC to identify the prevalence of potentially inappropriate medication (PIM) use, dangerous drug interactions (DDIs), and other patterns of medication use. METHODS: This retrospective chart review was conducted using data from Medicare recipients aged > or =65 years who were patients of Scott & White Memorial Hospital and Clinic, Scott, Sherwood and Brindley Foundation, Temple, Texas, in 2002. Pharmacists compiled medication profiles based on admissions data. PIM use was identified using the Beers criteria. DDIs were identified using the Multidisciplinary Medication Management Project criteria. Polyphsarmsacy was identified in patients receiving > or =9 medications. RESULTS: Data from 786 patients were included (mean [SD] age, 78 [7] years [range, 65-100 years; median, 78 years]; 36% men; 86% white; and 53% admitted to HHC after a hospital stay). The mean (SD) number of medications was 8.0 (3.7), with 39% of patients receiving polypharmacy. PIM use was identified in 31% of patients. DDIs were identified in 10% of patients, with a significantly higher prevalence in men (P < 0.01). Rates of PIM use and DDIs were 37% and 20%, respectively, in patients receiving polypharmacy. CONCLUSION: In this retrospective data analysis in this population of elderly patients receiving HHC in 2002, PIM and DDI were prevalent, and polypharmacy was associated with increased rates of PIM use and DDIs.