What Ambulatory Care Managers Need to Know About Examination Room Utilization Measurement and Analysis.

Demand for ambulatory care visits is projected to increase 22% between 2008 and 2025. Given this growth, ambulatory care managers need to proactively plan for efficient use of scarce resources (ie, space, equipment, and staff). One important component of ambulatory care space (the number of examination rooms) is dependent on multiple factors, including variation in demand, hours of operation, scheduling, and staff. The authors (1) outline common data collection methods, (2) highlight analysis and reporting considerations for examination room utilization, and (3) provide a strategic framework for short- and long-term decision making for facility design or renovation.

Decline in ACEI/ARB Prescribing as Heart Failure Core Metrics Improve During Computer-Based Clinical Decision Support.

Computer-based clinical decision-support systems are effective interventions to improve compliance with guidelines and quality measures. However, understanding of their long-term impact, including unintended consequences, is limited. The authors assessed the clinical impact of the sequential implementation of 2 such systems to improve the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) in inpatients with heart failure. Compliance with the core measure improved from 91.0% at baseline to 93.6% with the Pharmacy Care (P-Care) Rule and to 96.4% with the Centricity-Blaze (CE-Blaze) Rule. At the same time, prescriptions for ACEIs/ARBs documented in the hospital discharge summary decreased from 83.2% at baseline to 75.8% with the P-Care rule and to 64.1% with the CE-Blaze Rule. The inpatient mortality rate and the 30-day readmission rate did not change significantly. Better documentation of contraindications in the electronic medical record seems to account for the core measure improvement, even as ACEI/ARB therapy has unexpectedly declined.

ACEi/ARB for systolic heart failure: closing the quality gap with a sustainable intervention at an academic medical center.

BACKGROUND: National guidelines recommend angiotensin converting enzyme inhibitor (ACEi) or angiotensinogen receptor blocker (ARB) therapy for patients with left ventricular systolic dysfunction (LVSD), including those with symptomatic heart failure (HF). However, guideline adherence has not been optimal. The goal of this quality improvement project is to devise and implement a sustainable care-delivery model in a 920-bed academic hospital center that would improve ACEi/ARB adherence before hospital discharge. METHODS: The Model of intervention is: (1) a computer-based daily screening program; (2) inpatient pharmacist e-flag message; and (3) alerts for inpatient care teams. Its operating algorithm: If eligible adult HF/LVSD inpatients are not on ACEi or ARB nor documentation of contraindications, a flag alert is generated; deficiency is confirmed by a pharmacist and conveyed to the patient-care teams; if alert is acted on and care brought into adherence, the screening program would not re-flag the same patients the succeeding day; if not, the patients would be re-flagged daily until reaching adherence. We compared ACEi/ARB adherence before, during, and after the intervention. RESULTS: Baseline performance (percentage of eligible HF/LVSD patients receiving ACEi/ARB) was 87.5%. After implementation of the Model the ACEi/ARB adherence rate at the time of hospital discharge rose to 96.7% (P < 0.002) and was sustained for 21 months without needing additional personnel. CONCLUSIONS: A carefully designed, computer-based care-delivery model is highly efficient and sustainable for enhancing ACEi/ARB adherence.