From quality assurance to quality improvement. The Joint Commission on Accreditation of Healthcare Organizations and Emergency Care.

The transition from quality assurance to quality improvement is at an early stage, but it clearly has begun. The progressive anticipated changes in the tone and content of JCAHO standards will place the JCAHO in a different posture in relation to accredited hospitals. Standards are of course a set of requirements that must be met as a condition of accreditation. But the JCAHO's bottom line expectation will be a meaningful and demonstrated improvement in hospital performance. How hospitals reach this objective is their business. This shifts the onus of responsibility to where it belongs and suggests a more facilitative role for the JCAHO. Although the JCAHO is introducing standards requirements that are minimally essential to the achievement of improved performance, full-fledged adoption of CQI concepts will not be mandated. Management structures and styles in health care organizations vary considerably, and CQI is but one means to the desired end of improved performance. We believe, however, that it is the best means and that most organizations will discover this for themselves. Notwithstanding the magnitude of needed internal behavioral change, excellence in performance is what most health care organizations want for themselves and their patients. CQI offers them the opportunity to reach this lofty goal.

Subclavian artery false aneurysm associated with brachial plexus palsy: a complication of parenteral drug addiction.

A 35-year-old female drug addict developed a painful left supraclavicular swelling and profound left arm weakness associated with left hand paresthesia and swelling after cocaine injection into the left base of her neck. Arteriogram confirmed a 3.7-cm false aneurysm of the left subclavian artery and a filling defect of the proximal left axillary artery. Emergent intraoperative treatment consisted of false aneurysm resection, embolectomy, and placement of a prosthetic graft. Distal circulation was restored, but the neurological deficit persisted in the left arm and a fever developed in the patient, necessitating rehospitalization 3 weeks after discharge. False aneurysm, a vascular complication of parenteral drug abuse, may lead precipitously to death by exsanguination if not efficiently and effectively diagnosed and treated.

Application of clinical indicators in the emergency department.

Clinical indicators were developed and used to assess the quality of patient care resulting from the system of shared responsibility between emergency department (ED) and radiology department faculty physicians for interpretation of ED roentgenograms. The first indicator--all discrepancies in roentgenogram interpretation between ED and radiology department faculty--measured an overall discrepancy rate of 3.3% (776 films). Three hundred fifty-two apparent discrepancies were not related to the accuracy with which ED faculty interpreted films, resulting in a revised overall discrepancy rate of 1.8%. The second indicator--undesirable patient care outcomes as a result of delayed accurate radiological diagnosis--measured an occurrence rate of 0 after clinical reevaluation of more than 99% of patients within 24 hours of initial ED evaluation. Aspects of the development and use of clinical indicators are discussed in relationship to the broader monitoring and evaluating process necessary for the continuous improvement of patient care.

Physician assessments of practice patterns in emergency department radiograph interpretation.

Emergency and radiology department directors at 517 acute-care US teaching hospitals were sent identical questionnaires surveying practice patterns of ED plain film radiograph interpretation. Fifty-seven percent of ED directors and 51% of radiology department (RD) directors responded. Both groups reported that the most common practice pattern (60%) was alternating responsibility for immediate interpretation between emergency physicians and radiologists during a 168-hour week. Remaining hospitals were nearly equally divided between systems in which radiologists always provided immediate interpretation and those in which the emergency physicians always provided the initial interpretation. In all systems in which emergency physicians provided some immediate radiograph interpretation, radiologists provided subsequent review. Institutions varied as to the level of training of the physician in both the ED and RD who provided immediate radiograph interpretation; at least 30% of the institutions responding were reported to have either emergency physicians or radiologists of resident level providing immediate interpretation at least part of the 24-hour day. Interpretation discrepancy rates between emergency physicians and radiologists were estimated to be 4% to 6%. The large amount of variation among hospitals in ED radiograph interpretation systems suggests that these systems were not designed with quality of care concerns as their primary criterion. As a consequence, objective patient outcome and process measures need to be developed and measured to ensure that a particular internal system for ED radiograph interpretation is providing an acceptably high standard of patient care.

Diagnostic and therapeutic approach to axillary-subclavian vein thrombosis.

We report the cases of four patients who complained of post-exertional shoulder and/or arm discomfort, and who were diagnosed with acute or possible impending axillary-subclavian vein thrombosis. One regained full patency of a stenotic and obstructed vein after local streptokinase infusion, first rib surgical resection, and transvenous angioplasty. A second with a patent but narrowed and tented vein was treated with heat and elevation, and was referred for possible surgical correction of thoracic outlet syndrome. The third patient, who presented two weeks after the thrombotic event, experienced a poor clinical outcome characterized by recurrent thrombosis despite aggressive therapy. The fourth, whose thrombosis was the presenting sign of mediastinal lymphoma, was treated with heat and elevation with resolution of pain and swelling.

Penicillin anaphylaxis.

A case of oral penicillin anaphylaxis is described, and the terminology, occurrence, clinical manifestations, pathogenesis, prevention, and treatment of anaphylaxis are reviewed. Emergency physicians should be aware of oral penicillin anaphylaxis in order to prevent its occurrence by prescribing the antibiotic judiciously and knowledgeably and to offer optimal medical therapy once this life-threatening reaction has begun.

Exploration of the relationship between frequency of illness, attrition from alcohol treatment, neuropsychological status and field dependence.

One hundred thirty-nine male veterans receiving treatment for alcoholism were administered the Cornell Medical Index (CMI), neuropsychological tests comprising the Brain Age Quotient (BAQ) and the Group Embedded Figures Test (GEFT). Patients endorsing items on scale J (frequency of illness) of the CMI comprised a frequently ill group (27%) with the remaining patients comprising an infrequently ill group (73%). The frequently ill group patients were more likely to drop out of treatment, obtain lower BAQ scores and appear more field-dependent on the GEFT. Treatment attrition of frequently ill patients might be less if their individualized treatment plan involved greater structure consistent with their field dependent orientation and impaired neuropsychological status.

Differential drinking patterns, personality characteristics, and field articulation of court-referred and non-court-referred male alcoholics in treatment.

Male alcoholics in an inpatient rehabilitation program were selected to investigate differential characteristics of court-referred patients on measures of personality, drinking style, demograhics, and cognitive style. Seventy-eight males were separated into two groups based upon the demographic dimension of whether or not the patient was in treatment primarily as a result of legal pressures imposed due to alcohol-related motor vehicle violation (N = 23) or in treatment for a variety of personal/nonlegal reasons (N = 57). All subjects were administered the Clinical Analysis Questionnaire (CAQ), the Alcohol Use Inventory (AUI), and the Group Embedded Figures Test (GEFT). There were no differences found on any of the personality or demographic measures. There were significant differences between the legal and nonlegal groups on 11 of the 20 AUI scales. The legal group tended to be more field dependent than the nonlegal group as measured by the GEFT. The legal group does not appear to suffer as severely from the effects of alcohol as does the nonlegal group and may be in an earlier stage of problem drinking.

Cognitive style, personality traits, and treatment attrition among alcoholics.

The relationships among cognitive style, personality characteristics, and treatment attrition were examined. The Group Embedded Figures Test (GEFT), Clinical Analysis Questionnaire (CAQ(, and Minnesota Multiphasic Personality Inventory (MMPI) were administered to 78 inpatient alcoholic male veterans. Multiple linear regression analyses indicated that the GEFT and CAQ shared 24% common variance; second-order CAQ factors of Depression, Independence, and Extraversion contributed significantly. The GEFT and MMPI shared 16% common variance. Field-independent alcoholics demonstrate less psychopathology, more independence, and tend to be more introverted than field-dependent alcoholics. Cognitive style did not differ among four treatment attrition groups. Implications for treatment are discussed.

The Group Embedded Figures Test: a measure of cognitive style or cognitive impairment.

The Group Embedded Figures Test (GEFT) purports to be a measure of field articulation. The extent to which the GEFT measures apsects of personality and cognitive impairment was explored. Eighty-one male alcoholics, mean age of 42.9, receiving treatment for alcoholism at the Seattle VA Medical Center were administered the GEFT, Shipley Hartford Institute of Living Scale, the Trail Making Test (TMT), and the Clinical Analysis Questionnaire (CAQ). Multiple regression analysis indicates that Part B of the TMT and the residual abstraction score from the Shipley share 32% of the common variance with GEFT. The CAQ second-order factors of depression and independence also contributed significantly to the regression equation accounting for an additional 10% of the common variance. The results suggest the GEFT may be more a measure of cognitive impairment than personality. Alternative explanations are explored.

Cognitive deficit in middle-aged alcoholics.

Two groups of male alcoholics with mean ages of 44 and 55 and two groups of matched control subjects were tested twice, one year apart. Comparisons on verbal and adaptive ability factors derived from the Wechsler Intelligence Scale and selected Halstead--Reitan neuropsychological tests found no differences on verbal abilities. Significant improvement for the younger alcoholics on retesting indicates that previous comparisons of the neuropsychological effect of aging and alcoholism may not have sufficiently taken into account the reversibility of an alcoholic deficit. For the age range studied here, it may be only older alcoholics who appear different from control subjects.

Relationship of alcoholic personality subtypes to treatment follow-up measures.

The present study investigated the relationship of a multivariate classification of alcoholic patients based upon Minnesota Multiphasic Personality Inventory profiles taken at admission to psychopathology and drinking behavior at a 6- to 12-month follow-up interval. It was found that a subtype of patients characterized as psychoneurotic, with reactive anxiety and/or depression, evidenced significantly higher levels of psychopathology at follow-up than the remaining three subtypes. Furthermore, this subtype demonstrated higher levels of physical, social, and psychological impairment from post-treatment drinking episodes. No differences were found among the four subtypes with respect to outpatient therapists' ratings of personality change and adjustment. The findings suggest that such a multivariate classification of Minnesota Multiphasic Personality Inventory profiles has predictive utility. The results also suggest that the present subtypes would be useful in investigating the potential utility of differential therapeutic intervention strategies for different patients.

Reversibility of cognitive deficit in alcoholics.

Testing of alcoholics and matched controls on a series of psychological measures and retesting approximately 14 months later showed improvement in alcoholics' problem-solving abilities, but not to the level of controls. Improvement was not related to posttreatment drinking behavior.