Are patient volume and care level in teaching hospitals variables affecting clinical outcomes in adult intensive care units?

Teixeira et al. showed that patients admitted to the intensive care unit of a teaching hospital in a non-metropolitan region needed more support, had worse prognostic indices, and had a higher nursing workload in the first 24 hours of admission. In addition, worse outcomes, including mortality, need for dialysis, pressure injury, infection, prolonged mechanical ventilation, and prolonged hospital stay, were observed in the teaching hospital. Worse outcomes were more prevalent in the teaching hospital. Understanding the importance of teaching hospitals to implement well-established care protocols is critical. OBJECTIVE: To compare the clinical outcomes of patients admitted to the intensive care unit of teaching (HI) and nonteaching (without an academic affiliation; H2) hospitals. METHODS: In this prospective cohort study, adult patients hospitalized between August 2018 and July 2019, with a minimum length of stay of 24 hours in the intensive care unit, were included. Patients with no essential information in their medical records to evaluate the study outcomes were excluded. Resuslts: Overall, 219 patients participated in this study. The clinical and demographic characteristics of patients in H1 and H2 were similar. The most prevalent clinical outcomes were death, need for dialysis, pressure injury, length of hospital stay, mechanical ventilation >48 hours, and infection, all of which were more prevalent in the teaching hospital. CONCLUSION: Worse outcomes were more prevalent in the teaching hospital. There was no difference between the institutions concerning the survival rate of patients as a function of length of hospital stay; however, a difference was observed in intensive care unit admissions.

[National certification for gynecological cancer surgery]. / Certification nationale pour la chirurgie des cancers gynécologiques.

OBJECTIVE: In France, we are lacking an identified pathway for training in gynaecological cancer surgery. The four competent French learned societies: the SFOG, the CNGOF, the SFCO and the SCGP supported by the CNU of Obstetrics & Gynaecology, and UNICANCER agreed to materialize this course and attest it by a certification awarded by a national jury. MATERIAL AND METHODS: The national committee of certification in gynaecological oncology made up of ten members, representing the 6 concerned organizations, set itself five objectives: the definition of the eligibility criteria for training centres; the determination of a check-list to be filled by the candidate; the determination of a targeted curriculum for the training in gynecological oncological surgery; the determination of the assets necessary for the certification of a candidate already in practice; and the practical organization of the certification. RESULTS: Criteria for approval of centres for training included 150 gynaecological cancer cases per year, among which 100 excisional surgeries, including twenty advanced-stage ovarian cancers. For certification of candidate who followed the curriculum established by the committee or by validation of prior experience for an actual practitioner, a candidate must validate a logbook and fill out a checklist including four parts: theoretical and practical training; research and publications; teaching and subscription to a continuing education program. The accomplished elements of the logbook and the checklist will be evaluated by a score. The first certification session is planned for the end of 2021.

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care. CONTEXT: The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy. METHODS: Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers. FINDINGS: Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures. CONCLUSIONS: Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.

Nationwide multicenter questionnaire surveys on countermeasures against antimicrobial resistance and infections in hospitals.

BACKGROUND: The goals of the National Action Plan on Antimicrobial Resistance (AMR) of Japan include "implementing appropriate infection prevention and control" and "appropriate use of antimicrobials," which are relevant to healthcare facilities. Specifically, linking efforts between existing infection control teams and antimicrobial stewardship programs was suggested to be important. Previous studies reported that human resources, such as full-time equivalents of infection control practitioners, were related to improvements in antimicrobial stewardship. METHODS: We posted questionnaires to all teaching hospitals (n = 1017) regarding hospital countermeasures against AMR and infections. To evaluate changes over time, surveys were conducted twice (1st survey: Nov 2016, 2nd survey: Feb 2018). A latent transition analysis (LTA) was performed to identify latent statuses, which refer to underlying subgroups of hospitals, and effects of the number of members in infection control teams per bed on being in the better statuses. RESULTS: The number of valid responses was 678 (response rate, 66.7%) for the 1st survey and 559 (55.0%) for the 2nd survey. More than 99% of participating hospitals had infection control teams, with differences in activity among hospitals. Roughly 70% had their own intervention criteria for antibiotics therapies, whereas only about 60 and 50% had criteria established for the use of anti-methicillin-resistant Staphylococcus aureus antibiotics and broad-spectrum antibiotics, respectively. Only 50 and 40% of hospitals conducted surveillance of catheter-associated urinary tract infections and ventilator-associated pneumonia, respectively. Less than 50% of hospitals used maximal barrier precautions for central line catheter insertion. The LTA identified five latent statuses. The membership probability of the most favorable status in the 2nd study period was slightly increased from the 1st study period (23.6 to 25.3%). However, the increase in the least favorable status was higher (26.3 to 31.8%). Results of the LTA did not support a relationship between increasing the number of infection control practitioners per bed, which is reportedly related to improvements in antimicrobial stewardship, and being in more favorable latent statuses. CONCLUSIONS: Our results suggest the need for more comprehensive antimicrobial stewardship programs and increased surveillance activities for healthcare-associated infections to improve antimicrobial stewardship and infection control in hospitals.

Predictors of nursing interns' standard precautions compliance during internship training in four teaching hospitals in Saudi Arabia.

AIM: The aim of this study was to assess compliance with standard precautions by Saudi nursing interns who were undergoing their internship training in four governmental tertiary teaching hospitals in Riyadh, Kingdom of Saudi Arabia, and to determine factors predictive of this. BACKGROUND: Cross-transmission and infection prevention when delivering care must be strictly followed by nursing interns by complying with standard precautions during internship training. DESIGN: The study employed a descriptive-correlational and cross-sectional design. METHODS: A total of 224 nursing interns participated in the study by completing the Compliance with Standard Precautions Scale Arabic version between March 2017 and June 2017. RESULTS/FINDINGS: A high overall compliance rate (84.8%) was observed. Nursing interns reported the highest compliance score in changing gloves between each patient contact and the lowest score in disposing of sharps boxes only when full. Nursing interns in hospital D showed the highest compliance rate over those in other hospitals. Age, sex, marital status, months in internship training and attendance of nursing interns in infection control seminars/trainings influenced their standard precautions compliance. CONCLUSION: The study revealed good compliance by nursing interns with standard precautions. However, regular educational and clinical interventions are still needed to improve some areas and to ensure the continuity of high levels of compliance in other areas of standard precautions among nursing interns.

Comparison of Percentage Prolonged Times to Tracheal Extubation Between a Japanese Teaching Hospital and One in the United States, Without and With a Phase I Postanesthesia Care Unit.

BACKGROUND: Prolonged times to tracheal extubation are those from end of surgery (dressing on the patient) to extubation 15 minutes or longer. They are so long that others in the operating room (OR) generally have exhausted whatever activities can be done. They cause delays in the starts of surgeons' to-follow cases and are associated with longer duration workdays. Anesthesiologists rate them as being inferior quality. We compare prolonged times to extubation between a teaching hospital in the United States with a phase I postanesthesia care unit (PACU) and a teaching hospital in Japan without a PACU. Our report is especially important during the coronavirus disease 2019 (COVID-19) pandemic. Anesthesiologists with some patients undergoing general anesthetics and having initial PACU recovery in the ORs where they had surgery can learn from the Japanese anesthesiologists with all patients recovering in ORs. METHODS: The historical cohort study included all patients undergoing gynecological surgery at a US hospital (N = 785) or Japanese hospital (N = 699), with the time from OR entrance to end of surgery of at least 4 hours. RESULTS: The mean times from end of surgery to OR exit were slightly longer at the US hospital than at the Japanese hospital (mean difference 1.9 minutes, P < .0001). The mean from end of surgery to discharge to surgical ward at the US hospital also was longer (P < .0001), mean difference 2.2 hours. The sample standard deviations of times from end of surgery until tracheal extubation was 40 minutes for the US hospital versus 4 minutes at the Japanese hospital (P < .0001). Prolonged times to tracheal extubation were 39% of cases at the US hospital versus 6% at the Japanese hospital; relative risk 6.40, 99% confidence interval (CI), 4.28-9.56. Neither patient demographics, case characteristics, surgeon, anesthesiologist, nor anesthesia provider significantly revised the risk ratio. There were 39% of times to extubation that were prolonged among the patients receiving neither remifentanil nor desflurane (all such patients at the US hospital) versus 6% among the patients receiving both remifentanil and desflurane (all at the Japanese hospital). The relative risk 7.12 (99% CI, 4.59-11.05) was similar to that for the hospital groups. CONCLUSIONS: Differences in anesthetic practice can facilitate major differences in patient recovery soon after anesthesia, useful when the patient will recover initially in the OR or if the phase I PACU is expected to be unable to admit the patient.

Nurses' job stressors and social support behaviors: Comparing public, teaching, and private hospitals.

BACKGROUND: Different work environments may create different nurses' job stressors, and in turn, may need different social support behaviors to help nurses overcome these stressors. AIMS: This study aimed at comparing nurses' job stressors and social support behaviors in three different work environments (i.e., public, teaching, and private hospitals) in Jordan and examining the predictors of these stressors and social support behaviors. MATERIALS & METHODS: This was a descriptive comparative study in which data were collected using the Nursing Stress Scale and the Inventory of Social Supportive Behaviors from 139, 190, and 135 nurses from the public, teaching, and private hospitals, respectively. Descriptive and inferential statistics including comparative and multiple linear regression statistics were used. RESULTS: The results indicated that there were no significant differences in the total scores of job stressors and social support behaviors among nurses at the three types of hospitals. However, significant differences were reported in the subscales of job stressors in teaching and public hospitals and in individual items of both scales across the three kinds of hospitals. Controlling for nurses' characteristics, the scores of both scales were not predicted by the type of hospitals. CONCLUSION: Similar to public hospitals, teaching, and private hospitals, administrators should initiate various social support behaviors in their clinical settings, and should consider the predictors of job stressors to help nurses overcome their job stressors.

Patient profiles contribute to differences in quality metrics of stroke centers.

OBJECTIVE: To examine this association by comparing patient profiles in 2 closely affiliated hospitals and by examining their association with quality metrics. METHODS: We performed a retrospective cohort study comparing a university level comprehensive stroke centers (CSC) with its teaching hospital and local stroke unit (LSU) using routinely collected quality assurance data over a 2 year period. Both hospitals were closely affiliated, shared important resources and medical staff rotated amongst both hospitals. We compared patient profiles as well as internationally recognized quality metrics and examined the association of profiles with quality metrics. RESULTS: A total of 2,462 patients were treated in the CSC and 726 in the LSU. The LSU had a longer door-to-image and door-to-needle times. Rate of systemic thrombolysis was lower in the LSU. Patient profiles differed significantly and were associated with door-to-image and door-to-needle times as well as intravenous thrombolysis rates, even when adjusted for stroke service level. The diagnostic procedures for stroke work-up were similar. Discharge management differed strongly. CONCLUSION: Although LSUs and CSCs are the primary care providers in their respective regions, differences in patient profiles may contribute to differences in performance parameters. Adjusting for patient profiles may improve the comparability of the quality of stroke care provided by hospitals belonging to different stroke service levels.

Application of a Hybrid Method for Performance Evaluation of Teaching Hospitals in Tehran.

BACKGROUND AND OBJECTIVES: Teaching hospitals often face budget limitations and lack of investment. Therefore, the optimal allocation of budget and resources plays an important role in improving the performance and service quality of these hospitals. This research aims to evaluate the performance and determine the efficiency of medical science university hospitals in Tehran. METHODS: This study identified and categorized 47 effective factors in the performance assessment of hospital units using the Preference Ranking Organization METHod for Enrichment of Evaluation II (PROMETHEE II) method. Moreover, the performance of 40 medical science university hospitals in Tehran was evaluated using an outcome-based model of data envelopment analysis (DEA) with 4 input and 8 output factors and the assumption of scale-dependent efficiency. The hospitals were also ranked according to the Andersen-Petersen (AP) method. RESULTS: PROMETHEE II results identified 12 factors as the most important in hospital performance evaluation. DEA indicated that 16 hospitals had performance scores below 1 and are thus inefficient. The AP method identified Hospital 28, which had an efficiency value of 4.533, as the best hospital. CONCLUSION: Given the results of this approach and the identification of a considerable number of teaching hospitals as inefficient hospitals, top managers of medical centers must adopt the necessary planning to improve system performance and realize the optimal application of resources.

Association between Accreditation and In-Hospital Mortality in Patients with Major Cardiovascular Diseases in South Korean Hospitals: Pre-Post Accreditation Comparison.

The direct impact of hospital accreditation on patients' clinical outcomes is unclear. The purpose of this study was to evaluate whether mortality within 30 days of hospitalization for acute myocardial infarction (AMI), ischemic stroke (IS), and hemorrhagic stroke (HS) differed before and after hospital accreditation. This study targeted patients who had been hospitalized for the three diseases at the general hospitals newly accredited by the government in 2014. Thirty-day mortality rates of three years before and after accreditation were compared. Mortality within 30 days of hospitalization for the three diseases was lower after accreditation than before (7.34% vs. 6.15% for AMI; 4.64% vs. 3.80% for IS; and 18.52% vs. 15.81% for HS). In addition, hospitals that meet the criteria of the patient care process domain have a statistically lower mortality rate than hospitals that do not. In the newly accredited Korean general hospital, it was confirmed that in-hospital mortality rates of major cardiovascular diseases were lower than before the accreditation.

Preparing a young palliative care unit for the COVID-19 pandemic in a teaching hospital in Ghana.

The emergence of the Coronavirus Disease 2019 (COVID-19) pandemic has necessitated an interim restructuring of the healthcare system in accordance with public health preventive measures to mitigate spread of the virus while providing essential healthcare services to the public. This article discusses how the Palliative Care Team of the Komfo Anokye Teaching Hospital in Ghana has modified its services in accordance with public health guidelines. It also suggests a strategy to deal with palliative care needs of critically ill patients with COVID-19 and their families.

Barriers to Quality Care in Medical Imaging at a Teaching Hospital in Ghana: Staff Perspective.

BACKGROUND: The goal of quality care is to ensure that the health care services provided to individuals and patient populations improve desired health outcomes. However, as medical imaging services increase in Ghana, empirical evidence show a low level of care. Despite this, there exists no study in the public domain on the barriers to quality care. This study, therefore, sought to identify barriers to quality care in medical imaging at a teaching hospital to provide evidence that will enable optimization of care and in improving the overall medical imaging care delivery system. METHODS: This research was a descriptive, cross-sectional study using a mixed method approach based on the dimensions of quality of care of medical imaging services from medical imaging professionals' perspective: capacity and sustainability, timeliness, safety, equity, patient-centeredness, effective communication, and appropriateness of examination. QUANTITATIVE METHOD: A 5-point Likert scale questionnaire was used. The study population included all medical imaging professionals (n = 47) at the imaging department of the hospital. However, a total of 36 agreed to participate in the study. Data were analyzed using Stata Version 13. Descriptive analyses were carried out. QUALITATIVE METHODS: Purposive sampling strategy was applied to recruit 12 management team members and key staff with vast experience in medical imaging for the study. Data collection was done using a reflective in-depth interview guide. Data were analyzed using thematic analysis. QUANTITATIVE RESULTS: The quantitative findings show more than half of the respondents (n = 23, 63.9%) currently play supervisory roles, 10 (27.8%) work more than 40 hours a week, a minority group (n = 7, 19.4%) examine more than 100 patients per week, and 21 (58.5%) reported quality improvement programs are not carried out. Overall, half (50.0%) of the respondents are unaware of the availability of standard operating procedures, 28 (77.7%) reported imaging machines are not always functional, 34 (94.5%) reported lack of adherence to equipment servicing practices, and 27 (75%) agreed that broken-down equipment are left for more than 3 months before being fixed. In addition, 26 respondents (80.5%) reported staff number is inadequate compared with the workload, whereas only 11 (30.6%) stated supervision by management is adequate. Furthermore, 12 respondents (33.4%) reported management seem interested in quality of care only after adverse event, only 5 (38.5%) of the radiologists stated they are able to meet image reporting deadlines for clients, and only 8 (22.2%) of the respondents reported the availability of means of communicating results to referring clinicians aside the normal report. QUALITATIVE RESULTS: The qualitative findings show a lack of commitment to equipment servicing, frequent nonfunctionality of imaging machines, and an undue delay in repairs of broken-down machines. In addition, there exists inadequate human resource, inadequate supervision, a lack of quality improvement programs, and educational advancement opportunities for staff. The findings further show inadequacy of hospital gowns for patients, a lack of equity, and a poor organizational culture. In addition, the study identified a lack of means of communicating urgent imaging findings and a lack of promptness and timeliness to care from the consultant radiologists. CONCLUSION: The low level of care of medical imaging services observed in Ghana is reflected in the large number of barriers to quality care identified in this study. Most barriers identified are in the capacity and sustainability, timeliness, and effective communication dimensions of quality of care. The findings have important implications for policy makers. Improvement in these areas will enable optimization of care and in improving the overall medical imaging care delivery system.

Surviving the surge: Evaluation of early impact of COVID-19 on inpatient pharmacy services at a community teaching hospital.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has presented novel challenges to healthcare systems; however, an analysis of the impact of the pandemic on inpatient pharmacy services has not yet been conducted. METHODS: Results of an observational assessment of operational and clinical pharmacy services at a community teaching hospital during the first weeks of the COVID-19 pandemic are presented. Service outcomes of the inpatient pharmacy were evaluated from February 1 to April 8, 2020. Outcomes during the weeks preceding the first COVID-19 admission (February 1 to March 11, 2020) and during the pandemic period (March 12 to April 8, 2020) were compared. Evaluated outcomes included daily order verifications, clinical interventions, and usage of relevant medications. An exploratory statistical analysis was conducted using Student's t test. RESULTS: During the pandemic period, the number of new order verifications decreased from approximately 5,000 orders per day to 3,300 orders per day (P < 0.01), a reduction of 30% during the first 4 weeks of the pandemic compared to the weeks prior. Average daily pharmacokinetic dosing consults were reduced in the pandemic period (from 82 to 67; P < 0.01) compared to the prepandemic period; however, total daily pharmacist interventions did not differ significantly (473 vs 456; P = 0.68). Dispensing of hydroxychloroquine, azithromycin, enoxaparin, and sedative medications increased substantially during the pandemic period (P < 0.01 for all comparisons). CONCLUSION: The operational and clinical requirements of an inpatient pharmacy department shifted considerably during the first weeks of the COVID-19 pandemic. Pharmacy departments must be adaptable in order to continue to provide effective pharmaceutical care during the pandemic.

National Quality Improvement Participation Among US Radiation Oncology Facilities: Compliance with Guideline-Concordant Palliative Radiation Therapy for Bone Metastases.

PURPOSE: To characterize the participation of radiation oncology (RO) in reporting quality metrics through the Centers for Medicare and Medicaid Services' (CMS) Hospital Compare database and to describe the association of hospital characteristics with RO-specific quality metrics. METHODS AND MATERIALS: Data from the CMS Hospital Compare, International Atomic Energy Agency's Directory of Radiotherapy Centre, 2010 US Census, and CMS Inpatient Prospective Payment System were linked to create an integrated data set of geographic information, facility characteristics, and quality measures, focusing on the use of external beam radiation therapy (EBRT) for bony metastases. RESULTS: Of 4829 hospitals in the Hospital Compare database, 2030 had access to radiation therapy. Among these, 814 (40%) reported on the rate of guideline-concordant EBRT for bony metastases, a RO-specific quality measure. A total of 33,614 eligible cases of bony metastases treated with EBRT were sampled. Participation in quality reporting varied significantly by geography, population type, teaching status, hospital ownership, hospital type, and hospital size. The median rate of guideline-concordant palliative EBRT utilization was 89%. Nine percent of 814 centers had a compliance rate of less than 50%. On multivariable analysis, increasing number of cases sampled (odds ratio 0.93, P = .028), increasing hospital star-rating, and above-average patient experience rating (odds ratio 0.58, P = .024) remained significantly associated with decreased odds of falling into the lowest quartile of guideline-concordant EBRT utilization. CONCLUSIONS: RO participation in a large, national quality improvement effort is nascent and reveals potential quality gaps between hospitals offering palliative EBRT for bone metastases. More robust RO-specific quality measures are needed.

Colorectal stenting in England: a cross-sectional study of practice.

INTRODUCTION: UK and European guidelines recommend consideration of a self-expandable metallic stent (SEMS) as an alternative to emergency surgery in left-sided colonic obstruction. However, there is no clear consensus on stenting owing to concern for complications and long-term outcomes. Our study is the first to explore SEMS provision across England. METHODS: All colorectal surgery department leads in England were contacted in 2018 and invited to complete an objective multiple choice questionnaire pertaining to service provision of colorectal stenting (including referrals, time, location and specialty). RESULTS: Of 182 hospitals contacted, 79 responded (24 teaching hospitals, 55 district general hospitals). All hospitals considered stenting, with 92% performing stenting and the remainder referring. The majority (93%) performed fewer than four stenting procedures per month. Most (96%) stented during normal weekday hours, with only 25% stenting out of hours and 23% at weekends. Compared with district general hospitals, a higher proportion of teaching hospitals stented out of hours and at weekends. Stenting was performed in the radiology department (64%), the endoscopy department (44%) and operating theatres (15%), by surgeons (63%), radiologists (60%) and gastroenterologists (48%). A radiologist was present in 66% of cases. Of 14 hospitals that received referrals, 3 had a protocol, 3 returned patients the same day and 4 returned patients for management in the event of failure. CONCLUSIONS: All responding hospitals in England consider the use of SEMS in colonic obstruction. Nevertheless, there is great variation in stenting practices, and challenges in terms of access and expertise. Centralisation and regional referral networks may help maximise availability and expertise but more work is needed to support this.

Frequency and classification of errors in laboratory medicine at a veterinary teaching hospital in the United States.

BACKGROUND: The accuracy of laboratory data is of utmost importance. Data regarding laboratory error in human laboratories are often extrapolated into veterinary settings. One study investigated the rate and type of errors in a European commercial veterinary laboratory, but that data might not directly apply to an educational setting. OBJECTIVES: This study determined the frequency and type of errors in laboratory medicine at a veterinary teaching hospital. METHODS: Errors associated with clinical pathology samples were recorded over two 60-day periods. The first period included a time when new students and house officers started at the veterinary school. The second time period was 6 months later. The errors were assigned to categories, and the frequency of each was calculated. Sample hemolysis, icterus, and lipemia were evaluated separately using an automated index, as these conditions could be pathologic or the result of error. Frequencies of error and hemolysis, icterus, and lipemia were assessed between the groups. RESULTS: Total error rates were 4.7% and 3.5% for the first and second periods, respectively. The frequency of each error subclassification was similar to those observed in the veterinary and human literature, with preanalytic error predominating. Statistically significant differences in the overall error rate and percentage of preanalytic errors that occurred outside of and within the laboratory were observed comparing differences between the two periods. CONCLUSIONS: The overall error rate in this veterinary teaching hospital was slightly higher than that previously reported in other settings, although a proportion of errors was as expected. Areas needing improvement were identified, and strategies to reduce error could be developed.

The impact of a computerised decision support system on antibiotic usage in an English hospital.

Background Antimicrobial resistance is correlated with the inappropriate use of antibiotics. Computerised decision support systems may help practitioners to make evidence-based decisions when prescribing antibiotics. Objective This study aimed to evaluate the impact of computerized decision support systems on the volume of antibiotics used. Setting A very large 1200-bed teaching hospital in Birmingham, England. Main outcome measure The primary outcome measure was the defined daily doses/1000 occupied bed-days. Method A retrospective longitudinal study was conducted to examine the impact of computerised decision support systems on the volume of antibiotic use. The study compared two periods: one with computerised decision support systems, which lasted for 2 years versus one without which lasted for 2 years after the withdrawal of computerised decision support systems. Antibiotic use data from June 2012 to June 2016 were analysed (comprising 2 years with computerised decision support systems immediately followed by 2 years where computerised decision support systems had been withdrawn). Regression analysis was applied to assess the change in antibiotic consumption through the period of the study. Result From June 2012 to June 2016, total antibiotic usage increased by 13.1% from 1436 to 1625 defined daily doses/1000 bed-days: this trend of increased antibiotic prescribing was more pronounced following the withdrawal of structured prescribing (computerised decision support systems). There was a difference of means of - 110.14 defined daily doses/1000 bed days of the total usage of antibiotics in the period with and without structured prescribing, and this was statistically significant (p = 0.026). From June 2012 to June 2016, the dominant antibiotic class used was penicillins. The trends for the total consumption of all antibiotics demonstrated an increase of use for all antibiotic classes except for tetracyclines, quinolones, and anti-mycobacterial drugs, whereas aminoglycoside usage remained stable. Conclusion The implementation of computerised decision support systems appears to influence the use of antibiotics by reducing their consumption. Further research is required to determine the specific features of computerised decision support systems, which influence increased higher adoption and uptake of this technology.