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1.
Crit Pathw Cardiol ; 19(2): 49-54, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32356955

RESUMEN

Novel coronavirus-19 disease (COVID-19) is an escalating, highly infectious global pandemic that is quickly overwhelming healthcare systems. This has implications on standard cardiac care for ST-elevation myocardial infarctions (STEMIs). In the setting of anticipated resource scarcity in the future, we are forced to reconsider fibrinolytic therapy in our management algorithms. We encourage clinicians to maintain a high level of suspicion for STEMI mimics, such as myopericarditis which is a known, not infrequent, complication of COVID-19 disease. Herein, we present a pathway developed by a multidisciplinary panel of stakeholders at NewYork-Presbyterian/Columbia University Irving Medical Center for the management of STEMI in suspected or confirmed COVID-19 patients.


Asunto(s)
Infecciones por Coronavirus/diagnóstico , Vías Clínicas/normas , Control de Infecciones/normas , Neumonía Viral/diagnóstico , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/terapia , Costo de Enfermedad , Prestación de Atención de Salud/normas , Humanos , Pandemias , Aceptación de la Atención de Salud
2.
Lima; Perú. Ministerio de Salud; 20200500. 32 p. tab, graf.
Monografía en Español | LILACS, LIPECS | ID: biblio-1096368

RESUMEN

El documento contiene los procedimiento para el manejo de las personas afectadas por COVID-19 en áreas de atención critica.


Asunto(s)
Pacientes , Infecciones por Coronavirus , Vías Clínicas , Cuidados Críticos
3.
Lima; Perú. Ministerio de Salud; 20200400. 22 p. tab.
Monografía en Español | LILACS, LIPECS | ID: biblio-1095757

RESUMEN

El documento lista los procedimientos médicos y sanitarios contenidos en el plan esencial de aseguramiento en salud.PEAS vigente y su costo estándar.


Asunto(s)
Preparaciones Farmacéuticas , Vías Clínicas , Lista de Precios , Formulario Farmacéutico
4.
Med Care ; 58(5): e31-e38, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32187105

RESUMEN

BACKGROUND: The Department of Veterans Affairs (VA) cares for more patients with hepatitis C virus (HCV) than any other US health care system. We tracked the implementation strategies that VA sites used to implement highly effective new treatments for HCV with the aim of uncovering how combinations of implementation strategies influenced the uptake of the HCV treatment innovation. We applied Configurational Comparative Methods (CCMs) to uncover causal dependencies and identify difference-making strategy configurations, and to distinguish higher from lower HCV treating sites. METHODS: We surveyed providers to assess VA sites' use of 73 implementation strategies to promote HCV treatment in the fiscal year 2015. CCMs were used to identify strategy configurations that uniquely distinguished higher HCV from lower HCV treating sites. RESULTS: From the 73 possible implementation strategies, CCMs identified 5 distinct strategy configurations, or "solution paths." These were comprised of 10 individual strategies that collectively explained 80% of the sites with higher HCV treatment starts with 100% consistency. Using any one of the following 5 solution paths was sufficient to produce higher treatment starts: (1) technical assistance; (2) engaging in a learning collaborative AND designating leaders; (3) site visits AND outreach to patients to promote uptake and adherence; (4) developing resource sharing agreements AND an implementation blueprint; OR (5) creating new clinical teams AND sharing quality improvement knowledge with other sites AND engaging patients. There was equifinality in that the presence of any one of the 5 solution paths was sufficient for higher treatment starts. CONCLUSIONS: Five strategy configurations distinguished higher HCV from lower HCV treating sites with 100% consistency. CCMs represent a methodological advancement that can help inform high-yield implementation strategy selection and increase the efficiency and effectiveness of future implementation efforts.


Asunto(s)
Antivirales/uso terapéutico , Vías Clínicas , Hepatitis C/tratamiento farmacológico , Cumplimiento de la Medicación , Humanos , Evaluación de Programas y Proyectos de Salud , Estados Unidos , United States Department of Veterans Affairs , Servicios de Salud para Veteranos
5.
BMJ ; 368: m540, 2020 Mar 11.
Artículo en Inglés | MEDLINE | ID: mdl-32161042

RESUMEN

OBJECTIVE: To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery. DESIGN: Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES: Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017. ELIGIBILITY CRITERIA: Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded. DATA EXTRACTION AND SYNTHESIS: Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared. RESULTS: 117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions. CONCLUSIONS: Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions. STUDY REGISTRATION: Prospero CRD42016035662.


Asunto(s)
Vías Clínicas , Complicaciones Posoperatorias/prevención & control , Enfermedades Respiratorias/prevención & control , Analgesia Epidural , Expectorantes/uso terapéutico , Fluidoterapia , Hemodinámica , Humanos , Cuidados Intraoperatorios , Modalidades de Fisioterapia , Terapia Respiratoria , Vasoconstrictores/uso terapéutico
6.
Ann R Coll Surg Engl ; 102(4): 308-311, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-32081023

RESUMEN

INTRODUCTION: Survival for colorectal cancer is improved by earlier detection. Rapid assessment and diagnostic demand have created a surge in two-week rule referrals and have subsequently placed a greater burden on endoscopy services. Between 2009 and 2014, a mean of 709 patients annually were referred to Royal Surrey County Hospital with a detection rate of 53 cancers per year giving a positive predictive value for these patients of 7.5%. We aimed to assess what impact the 2015 changes in National Institute for Health and Care Excellence referral criteria had on local cancer detection rate and endoscopy services. METHODS: A prospectively maintained database of patients referred under the two-week rule pathway for April 2017-2018 was sub-analysed and the data cross-referenced with all diagnostic reports. FINDINGS: There were 1,414 referrals, which is double the number of previous years; 80.6% underwent endoscopy as primary investigation and 62 cancers were identified, 51 being of colorectal and anal origin (positive predictive value 3.6%). A total of 88 patients were diagnosed, with other significant colorectal disease defined as high-risk adenomas, colitis and benign ulcers. Overall, a total of 10.6% of our two-week rule patients had a significant finding.Since the 2015 referral criteria, despite a dramatic rise in two-week rule referrals, there has been no increase in cancer detection. It has placed significant pressure on diagnostic services. This highlights the need for a less invasive, cheaper yet sensitive test to rule out cancer such as faecal immunochemical testing that can enable clinicians to triage and reduce referral to endoscopy in symptomatic patients.


Asunto(s)
Neoplasias Colorrectales/diagnóstico , Vías Clínicas/normas , Detección Precoz del Cáncer/normas , Sangre Oculta , Triaje/normas , Colonoscopía/estadística & datos numéricos , Neoplasias Colorrectales/epidemiología , Vías Clínicas/estadística & datos numéricos , Bases de Datos Factuales/estadística & datos numéricos , Detección Precoz del Cáncer/métodos , Humanos , Uso Excesivo de los Servicios de Salud/prevención & control , Uso Excesivo de los Servicios de Salud/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Valor Predictivo de las Pruebas , Prevalencia , Derivación y Consulta/normas , Derivación y Consulta/estadística & datos numéricos , Factores de Tiempo , Reino Unido/epidemiología
7.
Acta Orthop ; 91(2): 139-145, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-31928088

RESUMEN

Background and purpose - We established a care pathway for hip fracture patients, a "Hip Fracture Unit" (HFU), aiming to provide better in-hospital care and thus improve outcome. We compared the results after introduction of the HFU with a historical control group.Patients and methods - The HFU consisted of a series of measures within the orthopedic ward, such as reducing preoperative waiting time, increased use of nerve blocks, early mobilization, and osteoporosis treatment. 276 patients admitted from May 2014 to May 2015 constituted the HFU group and 167 patients admitted from September 2009 to January 2012 constituted the historical control group. Patients were followed prospectively up to 12 months post fracture.Results - Mean preoperative waiting time was 24 hours in the HFU group and 29 hours in the control group (p = 0.003). 123 patients (47%) in the HFU were started on anti-osteoporosis treatment while in hospital. "Short Physical Performance Battery" score (SPPB) was mean 5.5 in the HFU group and 3.8 in the control group at 4 months (p < 0.001), and 5.7 vs. 3.6 at 12 months (p < 0.001). The mortality rate at 4 months was 15% in both groups. No statistically significant differences were found in readmissions, complications, new nursing home admissions, in Barthel ADL index or a mental capacity test at the follow-ups.


Asunto(s)
Artroplastia de Reemplazo de Cadera/normas , Vías Clínicas/organización & administración , Fijación Interna de Fracturas/normas , Fracturas de Cadera/cirugía , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/métodos , Conservadores de la Densidad Ósea/uso terapéutico , Vías Clínicas/normas , Femenino , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodos , Fracturas de Cadera/rehabilitación , Estudio Históricamente Controlado/métodos , Unidades Hospitalarias/organización & administración , Hospitalización , Humanos , Masculino , Noruega , Fracturas Osteoporóticas/prevención & control , Complicaciones Posoperatorias , Recuperación de la Función , Resultado del Tratamiento , Listas de Espera
8.
Br J Anaesth ; 124(3): 243-250, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31902590

RESUMEN

BACKGROUND: Preoperative anaemia affects one third of patients undergoing cardiac surgery and is associated with increased mortality and morbidity. Although it is recommended that perioperative teams should identify and treat patients with preoperative anaemia before surgery, introducing new treatment protocols can be challenging in surgical pathways. The aim of this study was to assess the feasibility and effectiveness of introducing a preoperative intravenous iron service as a national initiative in cardiac surgery. METHODS: We performed a multicentre, stepped, observational study using the UK Association of Cardiothoracic Anaesthesia and Critical Care Research Network. The primary feasibility outcome was the ability to set up an anaemia and intravenous iron clinic at each site. The primary efficacy outcome was change in haemoglobin (Hb) concentration between intervention and operation. Secondary outcomes included blood transfusion and hospital stay. Patients with anaemia were compared with non-anaemic patients and with those who received intravenous iron as part of their routine treatment protocol. RESULTS: Seven out of 11 NHS hospitals successfully set up iron clinics over 2 yr, and 228 patients were recruited into this study. Patients with anaemia who received intravenous iron were at higher surgical risk, were more likely to have a known previous history of iron deficiency or anaemia, had a higher rate of chronic kidney disease, and were slightly more anaemic than the non-treated group. Intravenous iron was administered a median (inter-quartile range, IQR [range]) of 33 (15-53 [4-303]) days before surgery. Preoperative intravenous iron increased [Hb] from baseline to pre-surgery; mean (95% confidence interval) change was +8.4 (5.0-11.8) g L-1 (P<0.001). Overall, anaemic compared with non-anaemic patients were more likely to be transfused (49% [59/136] vs 27% (22/92), P=0.001) and stayed longer in hospital (median days [IQR], 9 [7-15] vs 8 [6-11]; P=0.014). The number of days alive and at home was lower in the anaemic group (median days [IQR], 20 [14-22] vs 21 [17-23]; P=0.033). CONCLUSION: The development of an intravenous iron pathway is feasible but appears limited to selected high-risk cardiac patients in routine NHS practise. Although intravenous iron increased [Hb], there is a need for an appropriately powered clinical trial to assess the clinical effect of intravenous iron on patient-centred outcomes.


Asunto(s)
Anemia Ferropénica/tratamiento farmacológico , Procedimientos Quirúrgicos Cardíacos , Hierro/administración & dosificación , Cuidados Preoperatorios/métodos , Administración Intravenosa , Anciano , Anciano de 80 o más Años , Anemia Ferropénica/sangre , Anemia Ferropénica/complicaciones , Transfusión Sanguínea/estadística & datos numéricos , Vías Clínicas/organización & administración , Estudios de Factibilidad , Femenino , Hemoglobinas/metabolismo , Humanos , Hierro/uso terapéutico , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Medicina Estatal/organización & administración
9.
J Surg Oncol ; 121(4): 662-669, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31930513

RESUMEN

BACKGROUND: We aimed to evaluate the safety and efficacy of a clinical pathway (CP) for enhanced recovery after surgery (ERAS) in gastric cancer patients, including early oral feeding and discharge on postoperative day 4. METHODS: We performed a prospective, single-center, phase II clinical trial. Based on proposed indications for an ERAS CP in our retrospective study, we enrolled 133 patients younger than 65 years who were undergoing minimally invasive subtotal gastrectomy. The primary endpoint was the ERAS CP completion rate. Secondary endpoints included complication, mortality, hospital stay, and readmission. RESULTS: Among 133 patients, six patients were dropped out from this study. The ERAS CP completion rate (77.2%, 98 of 127) was comparable to the historical control group that completed a conventional CP (85.4%, P = .085). The postoperative complication incidence (13.4%, 15 of 127) was also similar to that of the conventional CP group (9.5%, P = .174). We identified reduced hospital stays (4.7 ± 1.3 vs 7.2±2.3 days; P < .001) and lower hospital costs ($7771 vs 8539; P < .001) in the ERAS CP group compared with the conventional CP group. CONCLUSIONS: An ERAS CP can be safely and effectively adopted for patients with gastric cancer without increasing the complication rate and could shorten hospital stays. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01642953).


Asunto(s)
Vías Clínicas , Recuperación Mejorada Después de la Cirugía , Neoplasias Gástricas/cirugía , Femenino , Gastrectomía/efectos adversos , Gastrectomía/métodos , Gastrectomía/normas , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/normas , Estudios Prospectivos
10.
BMC Health Serv Res ; 20(1): 46, 2020 Jan 17.
Artículo en Inglés | MEDLINE | ID: mdl-31952534

RESUMEN

BACKGROUND: How interactions during patient-provider encounters in Swedish primary care construct access to further care is rarely explored. This is especially relevant nowadays since Standardized Cancer Patient Pathways have been implemented as an organizational tool for standardizing the diagnostic process and increase equity in access. Most patients with symptoms indicating serious illness as cancer initially start their diagnostic trajectory in primary care. Furthermore, cancer symptoms are diverse and puts high demands on general practitioners (GPs). Hence, we aim to explore how presentation of bodily sensations were constructed and legitimized in primary care encounters within the context of Standardized Cancer Patient Pathways (CPPs). METHODS: Participant observations of patient-provider encounters (n = 18, on 18 unique patients and 13 GPs) were carried out at primary healthcare centres in one county in northern Sweden. Participants were consecutively sampled and inclusion criteria were i) patients (≥18 years) seeking care for sensations/symptoms that could indicate cancer, or had worries about cancer, Swedish speaking and with no cognitive disabilities, and ii) GPs who met with these patients during the encounter. A constructivist approach of grounded theory method guided the data collection and was used as a method for analysis, and the COREQ-checklist for qualitative studies (Equator guidelines) were employed. RESULTS: One conceptual model emerged from the analysis, consisting of one core category Negotiating bodily sensations to legitimize access, and four categories i) Justifying care-seeking, ii) Transmitting credibility, iii) Seeking and giving recognition, and iv) Balancing expectations with needs. We interpret the four categories as social processes that the patient and GP constructed interactively using different strategies to negotiate. Combined, these four processes illuminate how access was legitimized by negotiating bodily sensations. CONCLUSIONS: Patients and GPs seem to be mutually dependent on each other and both patients' expertise and GPs' medical expertise need to be reconciled during the encounter. The four social processes reported in this study acknowledge the challenging task which both patients and primary healthcare face. Namely, negotiating sensations signaling possible cancer and further identifying and matching them with the best pathway for investigations corresponding as well to patients' needs as to standardized routines as CPPs.


Asunto(s)
Vías Clínicas/normas , Médicos Generales/psicología , Negociación , Neoplasias/terapia , Relaciones Médico-Paciente , Sensación , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Atención Primaria de Salud , Investigación Cualitativa , Suecia
11.
J Trauma Acute Care Surg ; 88(2): 314-319, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31804417

RESUMEN

BACKGROUND: Timely angioembolization (AE) is known to improve outcomes of patients with hemorrhage resulting from pelvic fracture. The hybrid emergency room system (HERS) is a novel trauma resuscitation room equipped with a computed tomography scanner, fluoroscopy equipment, and an operating room setup. We hypothesized that the HERS would improve the timeliness of AE for pelvic fracture. METHODS: A retrospective medical record review of patients who underwent AE for pelvic fracture at our institution from April 2015 to December 2018 was conducted. Patients' demographics, location of AE, Injury Severity Score, Revised Trauma Score, probability of survival by the trauma and injury severity score (TRISS Ps) method, presence of interventional radiologists (IRs) upon patient arrival, time from arrival to AE, and in-hospital mortality were analyzed. These data were compared between patients who underwent AE in the HERS (HERS group) and in the regular angio suite (non-HERS group). RESULTS: Ninety-six patients met the inclusion criteria. The HERS group comprised 24 patients, and the non-HERS group, 72 patients. Interventional radiologists were more frequently present upon patient arrival in the HERS than non-HERS group (IRs, 79% vs. 22%, p < 0.01). The time from arrival to AE was shorter in the HERS than non-HERS group (median [range], 46 [5-75] minutes vs. 103 [2-690] minutes, p < 0.01). There were no differences in the rate of in-hospital mortality (13% vs. 15%, p = 0.52) between the two groups. Survivors in the HERS group had a lower probability of survival by the trauma and injury severity score (median [range], 61% [1%-98%] vs. 93% [1%-99%], p < 0.01) than survivors in the non-HERS group. CONCLUSION: The HERS improved the timeliness of AE for pelvic fracture. More severely injured patients were able to survive in the HERS. The new team building involving the addition of IRs to the traditional trauma resuscitation team will enhance the benefit of the HERS. LEVEL OF EVIDENCE: Therapeutic, level IV.


Asunto(s)
Embolización Terapéutica/métodos , Servicio de Urgencia en Hospital/organización & administración , Fracturas Óseas/complicaciones , Hemorragia/terapia , Huesos Pélvicos/lesiones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Vías Clínicas/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Fracturas Óseas/diagnóstico , Fracturas Óseas/terapia , Hemorragia/etiología , Hemorragia/mortalidad , Mortalidad Hospitalaria , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente/organización & administración , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Tiempo de Tratamiento , Resultado del Tratamiento , Adulto Joven
12.
J Stroke Cerebrovasc Dis ; 29(1): 104477, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31699573

RESUMEN

BACKGROUND: A nationally recommended practice to accelerate thrombolytic therapy for acute ischemic stroke is to route emergency medical services (EMS)-transported stroke patients directly to the computed tomography (CT) scanner on arrival. We evaluated door-to-needle time with direct-to-CT routing versus emergency department (ED)-bed first routing. METHODS: This was a retrospective analysis from a large regionalized stroke system. Paramedics utilize the modified Los Angeles Prehospital Stroke Screen and transport acute stroke patients to Approved Stroke Centers. Individual stroke centers postarrival protocols vary, with some routing patients directly to CT. Stroke centers report treatment and outcomes to a registry, from which data were abstracted from May 2015 through April 2016. Adult patients transported by EMS and treated with thrombolytic therapy were included. The primary outcome was door-to-needle time. Secondary outcome was door-to-imaging time. RESULTS: EMS transported 6315 patients for suspected stroke and 789 (13%) were treated with thrombolysis at 41 stroke centers, 171 (22%) at hospitals with direct-to-CT routing and 618 (78%) at hospitals with ED-bed routing. Patient characteristics were similar between groups. Door-to-needle time was not different in the 2 groups, median 57 minutes (interquartile range [IQR] 44-76) for CT routing versus 54 minutes (IQR 40-74) for ED routing, median difference 3 (95% CI -1, 7), P == .2. Door-to-imaging time was shorter with CT routing compared to ED routing, median 13 minutes (IQR 8-21) and 16 minutes (IQR 10-24), respectively. CONCLUSIONS: In this regional stroke system, hospitals with protocols for routing EMS-transported stroke patients directly to CT did not have reduced door-to-needle compared to hospitals without such protocols.


Asunto(s)
Servicio de Urgencia en Hospital , Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Tiempo de Tratamiento , Tomógrafos Computarizados por Rayos X , Tomografía Computarizada por Rayos X/instrumentación , Transporte de Pacientes , Administración Intravenosa , Anciano , Anciano de 80 o más Años , Vías Clínicas , Femenino , Humanos , Los Angeles , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Sistema de Registros , Estudios Retrospectivos , Factores de Tiempo
15.
J Stroke Cerebrovasc Dis ; 29(2): 104552, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31839545

RESUMEN

BACKGROUND AND AIM: Performance measures have been extensively studied for acute ischemic stroke, leading to guideline-established benchmarks. Factors influencing care efficiency for intracerebral hemorrhage (ICH) are not well delineated. We sought to identify factors associated with early recognition of ICH and to assess the association between early recognition and completion of emergency care tasks. METHODS: Consecutive patients with spontaneous ICH were enrolled in an observational cohort study conducted from 2009 to 2017 at an urban comprehensive stroke center, excluding patient transferred from other hospitals. We used stroke team activation as the indicator of early recognition and measured completion times for multiple ICH-relevant performance metrics including door to computed tomography (CT) acquisition and door to hemostatic medication initiation. RESULTS: We studied 204 cases. All stroke-related performance times were faster in patients managed with stroke team activation compared to no activation, including quicker door to CT acquisition (median 24 versus 48 minutes, P < .001) and door to hemostatic medication initiation (63 versus 99 minutes, P = .005). These associations were confirmed in adjusted models. Stroke codes were activated in 43% of cases and were more likely in patients with shorter onset-to-arrival times, higher National Institutes of Health Stroke Scale scores, and higher Glasgow Coma Scale scores. CONCLUSIONS: Stroke team activation was associated with more rapid diagnostic and therapeutic interventions for patients with ICH, but activation did not occur in the majority of cases, implying absence of early recognition. A stroke team activation process improves care performance, but leveraging the advantages of existing systems will require improved triage tools to identify ICH in the acute setting.


Asunto(s)
Hemorragia Cerebral/tratamiento farmacológico , Servicio de Urgencia en Hospital/normas , Hemostáticos/administración & dosificación , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Tiempo de Tratamiento/normas , Anciano , Anciano de 80 o más Años , Hemorragia Cerebral/diagnóstico por imagen , Vías Clínicas/normas , Esquema de Medicación , Diagnóstico Precoz , Femenino , Humanos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente/normas , Estudios Prospectivos , Factores de Tiempo , Tomografía Computarizada por Rayos X/normas , Resultado del Tratamiento
16.
Int J Med Inform ; 135: 104052, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31865190

RESUMEN

BACKGROUND: Clinical pathways (CPs) increase in popularity and are known to lead to several benefits in the hospital environment. Clinical pathways can be either paper-based or software-based. It is known that paper-based CPs can result in more paperwork instead of simplifying daily routines of healthcare workers. Insufficient research has been done on the acceptance of software-based CPs by different user groups. Our aim in this study was to assess the effectiveness of the software-based CPs (CPS) from the perspective of healthcare professionals in the hospital environment as well as to investigate the differences in perceived effectiveness between user groups. METHODS: Using surveys and interviews, data were collected in four departments of an academic medical center. A distinction was made between decision makers (DM) and executive staff (ES). The surveys contained questions based on the Technology Acceptance Model and four objectives of the software defined by the hospital. Statistical tests were used to investigate the effectiveness of CPS and study the differences between DM and ES. Interviews were recorded and transcribed based on grounded theory principals. RESULTS: After implementation, monitoring protocol-based working was significantly improved (p = .026) and significantly higher efficiency on the work floor was reported (p = .046). ES perceived the software as less useful than expected (Md = 3.25 vs. Md = 2.75, p = .028) compared to DM and were less convinced of its ability to improve monitoring protocol-based working. The most important benefits of CPS as perceived by its users are the better overview of tasks it provides and facilitating documentation. Negative aspects mentioned were the lack of usability and the inflexibility of the software, and particularly ES claimed that the software did not increase their effectiveness. CONCLUSION: Our study showed that CPS is effective from healthcare professionals' perspective due to its ability to increase monitoring of protocol-based working and by enhancing the efficiency on the work floor. However, the users also acknowledge that the software lacks usability and is not flexible enough, which results in an additional workload. Policy makers should be more focused on informing and training executive staff more thoroughly when implementing a CPS. Our results strongly suggest that executive staff members need to be convinced of its usefulness and the added value a CPS provides. Preferably, they should be involved in the design phase of the software.


Asunto(s)
Programas Informáticos , Estudios Controlados Antes y Después , Vías Clínicas , Toma de Decisiones , Personal de Salud , Humanos , Países Bajos , Encuestas y Cuestionarios
17.
Int J Med Inform ; 133: 104015, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31683142

RESUMEN

OBJECTIVE: A clinical pathway is one of the tools used to support clinical decision making that provides a standardized care process in a specific context. The objective of this research was to develop a method for building data-driven clinical pathways using electronic health record data. MATERIALS AND METHODS: We proposed a matching rate-based clinical pathway mining algorithm that produces the optimal set of clinical orders for each clinical stage by employing matching rates. To validate the approach, we utilized two different datasets of deidentified inpatient records directly related to total laparoscopic hysterectomy (TLH) and rotator cuff tears (RCTs) from a hospital in South Korea. The derived data-driven clinical pathways were evaluated with knowledge-based models by health professionals using a delta analysis. RESULTS: Two different data-driven clinical pathways, i.e., TLH and RCTs, were produced by applying the matching rate-based clinical pathway mining algorithm. We identified that there were significant differences in clinical orders between the data-driven and knowledge-based models. Additionally, the data-driven clinical pathways based on our algorithm outperformed the models by clinical experts, with average matching rates of 82.02% and 79.66%, respectively. CONCLUSION: The proposed algorithm will be helpful for supporting clinical decisions and directly applicable in medical practices.


Asunto(s)
Vías Clínicas , Registros Electrónicos de Salud , Histerectomía , Lesiones del Manguito de los Rotadores , Femenino , Humanos , Pacientes Internos , Laparoscopía , República de Corea
18.
J Surg Res ; 245: 354-359, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31425875

RESUMEN

BACKGROUND: Enhanced recovery pathways (ERPs) can decrease length of stay (LOS) and improve colorectal surgery outcomes in private health care; however, their efficacy in the public realm, comprised largely of underserved and uninsured patients, remains uncertain. MATERIALS AND METHODS: An ERP without social interventions was implemented at a private hospital (PH) and a safety-net hospital (SNH) within a large academic medical center in 2014. Process and outcome metrics from 100 patients in the 18 mo before ERP implementation at each institution were retrospectively compared with a similar group after ERP implementation. Primary outcomes were LOS, 30-d readmission, and reoperation. RESULTS: Post-ERP groups were older than pre-ERP (P = 0.047, 0.034), with no difference in sex or body mass index. Rate of open versus minimally invasive was similar at the SNH (P = 0.067), whereas more post-ERP patients at PH underwent open surgery (P = 0.002). Ninety six percentage of PH patients were funded through private insurance or Medicare, verses 6% at the SNH. LOS at PH decreased from 8.1 to 5.9 d (P = 0.028) and at SNH from 7.0 to 5.1 d (P = 0.004). There was no change in 30-d all-cause readmission (PH P = 0.634; SNH P = 1) or reoperation (PH P = 0.610; SNH P = 0.066). CONCLUSIONS: ERP reduced LOS in both private and safety-net settings without addressing social determinants of health. Readmission and reoperation rates were unchanged. As health care moves toward a bundled payment model, ERP can help optimize outcomes and control costs in the public arena.


Asunto(s)
Cirugía Colorrectal , Vías Clínicas , Recuperación Mejorada Después de la Cirugía , Hospitales Privados/estadística & datos numéricos , Proveedores de Redes de Seguridad/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Estudios Retrospectivos
19.
Isr Med Assoc J ; 12(21): 796-800, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31814342

RESUMEN

BACKGROUND: The use of graphic depictions (pictorials) to represent medical conditions is an accepted method that can complement standard methodology of comprehensive geriatric assessment. OBJECTIVES: To use the clinical pathway method to develop a comprehensive geriatric genogram assessment tool (CGGAT), which could supplement the written summary letter and recommendations. METHODS: We used the critical paths method to develop a tool to facilitate implementation of the comprehensive geriatric assessment recommendations. A multidisciplinary group of clinicians used the critical pathways method to develop a CGGAT. RESULTS: We used the CGGAT to depict the physical and functional status of patients and to complement the textual historical information, family dynamics, and current patient issues. CGGAT is a simple instrument that provides a visual structure and it can facilitate the sharing of information among team members, encourage interdisciplinary dialogue, enhance understanding and adherence on the part of patients and professionals, and reduce the burden on the clinicians who conduct the initial comprehensive geriatric assessment. CONCLUSIONS: We showed the benefits and obstacles related to the adaptation of this new tool and provide recommendations for further development.


Asunto(s)
Atención Integral de Salud/métodos , Gráficos por Computador , Vías Clínicas , Evaluación Geriátrica/métodos , Anciano , Ambiente , Femenino , Disparidades en el Estado de Salud , Humanos , Masculino , Evaluación Nutricional , Grupo de Atención al Paciente/organización & administración , Pruebas Psicológicas
20.
Spine (Phila Pa 1976) ; 44 Suppl 24: S1-S12, 2019 Dec 15.
Artículo en Inglés | MEDLINE | ID: mdl-31790063

RESUMEN

STUDY DESIGN: A modified Delphi method was used to establish consensus. Subject matter experts were invited to participate as the expert panel. Best practice statements were distributed to the panel. Panel members were asked to mark "agree" or "disagree" after a series of statements during several rounds until either consensus could be obtained or the practice method was deemed unable to achieve consensus. OBJECTIVE: Lumbar total disc replacement (TDR) is acknowledged as an alternative to spinal fusion in appropriately selected patients. There is a lack of unanimity on the appropriate postoperative patient protocols and rehabilitation expectations for the procedure. The long-term viability of Lumbar TDR, further adoption in the community setting and specific patient outcomes are contingent on the existence of appropriate postoperative recovery programs. SUMMARY OF BACKGROUND DATA: Currently there are no established methods for postoperative care following lumbar TDR. Establishing a postoperative clinical pathway algorithm may improve patient outcomes with respect to lumbar TDR. METHOD: A lumbar TDR expert panel of 22 spine surgeons employed a modified Delphi method to drive consensus on postoperative care following single-level Lumbar TDR. The panel first reviewed literature and guidelines relevant to postoperative care following lumbar TDR. Panel members considered 21 survey questions intended to determine "standard-practice" postoperative care recommendations for patients who have undergone lumbar TDR for the initial recovery phase (0-4 wk) and rehabilitation (4-20 wk). Each panel member participated in a round of anonymous voting followed by a group discussion. Consensus was defined as 80% agreement or higher among the respondents. RESULTS: Consensus was achieved in 11 of the 21 survey questions. There was a high degree of consensus around the key goals for both the initial recovery and rehabilitation phases, ceased use of narcotics for pain management by 4 weeks postoperative, unrestricted walking immediately following surgery, timelines for physical therapy (within 2-4 wk) and return to work based on level of activity (as early as 1 wk postoperative). Lack of agreement included the use of back bracing and timing of postoperative visits. Generally, panel members felt that patient expectations regarding return to function were different following lumbar TDR versus fusion and warrant further study. CONCLUSION: Surgeon and patient alignment around postoperative expectations may significantly affect the long-term results of lumbar TDR. This surgeon consensus study found agreement for immediate postoperative ambulation, rapid reduction in opioids within the first month, and early return to work. When expectations are appropriately set with patients preoperatively, both provider and patient have shared goals in the return-to-function process. LEVEL OF EVIDENCE: 5.


Asunto(s)
Vértebras Lumbares/cirugía , Planificación de Atención al Paciente , Cuidados Posoperatorios , Reeemplazo Total de Disco/rehabilitación , Algoritmos , Analgésicos Opioides/uso terapéutico , Consenso , Vías Clínicas , Técnica Delfos , Humanos , Aparatos Ortopédicos , Modalidades de Fisioterapia , Reinserción al Trabajo , Caminata
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