The incidence and determinants of decubitus ulcers in hospital care: an analysis of routine quality management data at a university hospital.

BACKGROUND: The incidence of decubitus ulcers is an established quality indicator for external quality assurance in the inpatient setting. Epidemiologic analyses of the frequency of, and risk factors for, decubitus ulcers in routine care are lacking. METHOD: We analyzed routine decubitus-ulcer documentation data relating to all inpatients of the University Hospital of Dresden, Germany, from 2007 to 2011 (n = 246 162 patients). The prevalence and incidence of decubitus ulcers and demographic and illness-related risk factors for them were determined with the use of descriptive techniques and logistic regression models. The effort-to-benefit ratio of documenting decubitus ulcers in various care scenarios was calculated in terms of the number of additional patients to be documented for each patient with incident decubitus ulcer. RESULTS: The prevalence of decubitus ulcers was 1.21%, and their incidence during inpatient treatment was 0.78%, with significant differences across clinical care units (range of ward-specific incidences: 0.0% to 12.7%). Predictors for the development of a new decubitus ulcer during a hospital stay included higher age (odds ratio [OR] 1.03 per year, 95% confidence interval [CI] 1.02-1.03), longer hospital stay (OR 1.03 per day, 95% CI 1.031-1.033), treatment in an intensive care unit (OR 2.88, 95% CI 2.58-3.22), and transfer to the hospital from a residential nursing-care facility (OR 6.05, 95% CI 5.13-7.11). The patient's sex and the severity of disease were not correlated with the incidence of decubitus ulcers. The effort-to-benefit ratio could be improved if wards with a low incidence of decubitus ulcers (<0.5%) either entirely discontinued the current hospital-wide procedure for documenting decubitus ulcers (with one new ulcer for every 645 patients) or continued it only for patients aged 65 or older (with one new ulcer for every 902 patients). CONCLUSION: There are major differences between clinical care units in the risk of decubitus ulcers. Epidemiological analysis of routine quality management data is useful to assess the benefit of measures taken in medical care. Continuing evaluation is essential.

[Improvement of medical processes with Six Sigma - practicable zero-defect quality in preparation for surgery]. / Medizinische Prozessoptimierung durch Six Sigma - Praktikable Null-Fehler-Qualität in der OP Vorbereitung.

Six Sigma is an innovative management- approach to reach practicable zero- defect quality in medical service processes. The Six Sigma principle utilizes strategies, which are based on quantitative measurements and which seek to optimize processes, limit deviations or dispersion from the target process. Hence, Six Sigma aims to eliminate errors or quality problems of all kinds. A pilot project to optimize the preparation for neurosurgery could now show that the Six Sigma method enhanced patient safety in medical care, while at the same time disturbances in the hospital processes and failure costs could be avoided. All six defined safety relevant quality indicators were significantly improved by changes in the workflow by using a standardized process- and patient- oriented approach. Certain defined quality standards such as a 100% complete surgical preparation at start of surgery and the required initial contact of the surgeon with the patient/ surgical record on the eve of surgery could be fulfilled within the range of practical zero- defect quality. Likewise, the degree of completion of the surgical record by 4 p.m. on the eve of surgery and their quality could be improved by a factor of 170 and 16, respectively, at sigma values of 4.43 and 4.38. The other two safety quality indicators "non-communicated changes in the OR- schedule" and the "completeness of the OR- schedule by 12:30 a.m. on the day before surgery" also show an impressive improvement by a factor of 2.8 and 7.7, respectively, corresponding with sigma values of 3.34 and 3.51. The results of this pilot project demonstrate that the Six Sigma method is eminently suitable for improving quality of medical processes. In our experience this methodology is suitable, even for complex clinical processes with a variety of stakeholders. In particular, in processes in which patient safety plays a key role, the objective of achieving a zero- defect quality is reasonable and should definitely be aspirated.

Preoperative cardiopulmonary risk assessment as predictor of early noncancer and overall mortality after radical prostatectomy.

OBJECTIVES: To evaluate the capability of the preoperative cardiopulmonary risk assessment to predict early noncancer and overall mortality after radical prostatectomy for clinically localized prostate cancer. METHODS: In 444 consecutive radical prostatectomy patients, the American Society of Anesthesiologists Physical Status classification and the presence of cardiac insufficiency (New York Heart Association classification), angina pectoris (Canadian Cardiovascular Society classification), diabetes, hypertension, history of thromboembolism, and chronic obstructive or restrictive pulmonary disease were assessed. Kaplan-Meier time-event curves and Mantel-Haenszel hazard ratios were estimated for noncancer (other deaths were censored) and overall mortality. Cox proportional hazard models were used to analyze possible combined effects of risk factors. RESULTS: During an average follow-up of 4.7 years, 36 patients died: 15 of noncancer causes, 14 of prostate cancer, 6 of other cancers, and 1 in a car accident. The comorbidity scores for American Society of Anesthesiologists Physical Status classification, New York Heart Association classification, and Canadian Cardiovascular Society classification and combinations between the latter two scores were significantly associated with early noncancer mortality in a dose-response pattern. Furthermore, patients with chronic obstructive pulmonary disease were at increased risk. The association with overall mortality was less strong. CONCLUSIONS: The preoperative cardiopulmonary risk assessment may be used as a predictor of early noncancer and overall mortality after radical prostatectomy and should be evaluated further as a source of prognostic information in surgical oncology.

Renal responses to desflurane and isoflurane in patients with renal insufficiency.

BACKGROUND: The most consistent risk factor for postoperative renal failure is poor preoperative renal function. Desflurane is not contraindicated in patients with renal disease, but the data regarding its effects on renal function in these patients are sparse. METHODS: Only patients with preexisting renal disease were recruited into the study. In 51 adults undergoing elective surgery, general anesthesia was maintained using randomly desflurane or isoflurane according to a standardized protocol. Creatinine, creatinine clearance, and blood urea nitrogen were measured pre- and postoperatively. RESULTS: The administered amounts of the inhaled anesthetic agents were 1.8 +/- 2.1 minimum alveolar concentration hours (mean +/- SD) of isoflurane (24 patients) and 2.2 +/- 1.8 minimum alveolar concentration hours of desflurane (27 patients), respectively. No deterioration in renal parameters was noted when comparing the pre- and postoperative values between the groups and within the groups over time. CONCLUSION: General anesthesia with desflurane or isoflurane did not aggravate renal impairment in patients with preexisting renal insufficiency.