The Effect of Adding Comorbidities to Current Centers for Disease Control and Prevention Central-Line-Associated Bloodstream Infection Risk-Adjustment Methodology.

BACKGROUND Risk adjustment is needed to fairly compare central-line-associated bloodstream infection (CLABSI) rates between hospitals. Until 2017, the Centers for Disease Control and Prevention (CDC) methodology adjusted CLABSI rates only by type of intensive care unit (ICU). The 2017 CDC models also adjust for hospital size and medical school affiliation. We hypothesized that risk adjustment would be improved by including patient demographics and comorbidities from electronically available hospital discharge codes. METHODS Using a cohort design across 22 hospitals, we analyzed data from ICU patients admitted between January 2012 and December 2013. Demographics and International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) discharge codes were obtained for each patient, and CLABSIs were identified by trained infection preventionists. Models adjusting only for ICU type and for ICU type plus patient case mix were built and compared using discrimination and standardized infection ratio (SIR). Hospitals were ranked by SIR for each model to examine and compare the changes in rank. RESULTS Overall, 85,849 ICU patients were analyzed and 162 (0.2%) developed CLABSI. The significant variables added to the ICU model were coagulopathy, paralysis, renal failure, malnutrition, and age. The C statistics were 0.55 (95% CI, 0.51-0.59) for the ICU-type model and 0.64 (95% CI, 0.60-0.69) for the ICU-type plus patient case-mix model. When the hospitals were ranked by adjusted SIRs, 10 hospitals (45%) changed rank when comorbidity was added to the ICU-type model. CONCLUSIONS Our risk-adjustment model for CLABSI using electronically available comorbidities demonstrated better discrimination than did the CDC model. The CDC should strongly consider comorbidity-based risk adjustment to more accurately compare CLABSI rates across hospitals. Infect Control Hosp Epidemiol 2017;38:1019-1024.

Electronically Available Comorbidities Should Be Used in Surgical Site Infection Risk Adjustment.

BACKGROUND: Healthcare-associated infections such as surgical site infections (SSIs) are used by the Centers for Medicare and Medicaid Services (CMS) as pay-for-performance metrics. Risk adjustment allows a fairer comparison of SSI rates across hospitals. Until 2016, Centers for Disease Control and Prevention (CDC) risk adjustment models for pay-for-performance SSI did not adjust for patient comorbidities. New 2016 CDC models only adjust for body mass index and diabetes. METHODS: We performed a multicenter retrospective cohort study of patients undergoing surgical procedures at 28 US hospitals. Demographic data and International Classification of Diseases, Ninth Revision codes were obtained on patients undergoing colectomy, hysterectomy, and knee and hip replacement procedures. Complex SSIs were identified by infection preventionists at each hospital using CDC criteria. Model performance was evaluated using measures of discrimination and calibration. Hospitals were ranked by SSI proportion and risk-adjusted standardized infection ratios (SIR) to assess the impact of comorbidity adjustment on public reporting. RESULTS: Of 45394 patients at 28 hospitals, 573 (1.3%) developed a complex SSI. A model containing procedure type, age, race, smoking, diabetes, liver disease, obesity, renal failure, and malnutrition showed good discrimination (C-statistic, 0.73) and calibration. When comparing hospital rankings by crude proportion to risk-adjusted ranks, 24 of 28 (86%) hospitals changed ranks, 16 (57%) changed by ≥2 ranks, and 4 (14%) changed by >10 ranks. CONCLUSIONS: We developed a well-performing risk adjustment model for SSI using electronically available comorbidities. Comorbidity-based risk adjustment should be strongly considered by the CDC and CMS to adequately compare SSI rates across hospitals.

QUEST®: A Data-Driven Collaboration to Improve Quality, Efficiency, Safety, and Transparency in Acute Care.

BACKGROUND: In 2008 Premier (Premier, Inc., Charlotte, North Carolina) began its Quality, Efficiency, and Safety with Transparency (QUEST®) collaborative, which is an acute health care organization program focused on improving quality and reducing patient harm. METHODS: Retrospective performance data for QUEST hospitals were used to establish trends from the third quarter (Q3; July­September) of 2006 through Q3 2015. The study population included past and present members of the QUEST collaborative (N = 356), with each participating hospital considered a member. The QUEST program engages with member hospitals through a routine-coaching structure, sprints, minicollaboratives, and face-to-face meetings. RESULTS: Cost and efficiency data showed reductions in adjusted cost per discharge for hospitals between Q3 2013 (mean, $8,296; median, $8,459) and Q3 2015 (mean, $8,217; median, $7,895). Evidence-based care (EBC) measures showed improvement from baseline (Q3 2006; mean, 77%; median, 79%) to Q3 2015 (mean, 95%; median, 96%). Observed-to-expected (O/E) mortality improved from 1% to 22% better-than-expected outcomes on average. The QUEST safety harm composite score showed moderate reduction from Q1 2009 to Q3 2015, as did the O/E readmission rates--from Q1 2010 to Q3 2015--with improvement from a 5% to an 8% better-than-expected score. CONCLUSION: Quantitative and qualitative evaluation of QUEST collaborative hospitals indicated that for the 2006-2015 period, QUEST facilities reduced cost per discharge, improved adherence with evidence-based practice, reduced safety harm composite score, improved patient experience, and reduced unplanned readmissions.

Hospital variability in use of anticoagulant strategies during acute myocardial infarction treated with an early invasive strategy.

BACKGROUND: During a myocardial infarction, no single best approach of systemic anticoagulation is recommended, likely due to a lack of comparative effectiveness studies and trade-offs between treatments. METHODS AND RESULTS: We investigated the patterns of use and site-level variability in anticoagulant strategies (unfractionated heparin [UFH] only, low-molecular-weight heparin [LMWH] only, UFH+LMWH, any bivalirudin) of 63 796 patients with a principal diagnosis of myocardial infarction treated with an early invasive strategy with percutaneous coronary intervention at 257 hospitals. About half (47%) of patients received UFH only, 6% UFH+LMWH, 7% LMWH only, and 40% bivalirudin. Compared with UFH, the median odds ratio was 2.90 for LMWH+UFH, 4.70 for LMWH only, and 3.09 for bivalirudin, indicating that 2 "identical" patients would have a 3- to 4-fold greater likelihood of being treated with anticoagulants other than UFH at one hospital compared with another. We then categorized hospitals as low- or high-users of LMWH and bivalirudin. Using hierarchical, multivariate regression models, we found that low bivalirudin-using hospitals had higher unadjusted bleeding rates, but the risk-adjusted and anticoagulant-adjusted bleeding rates did not differ across the hospital anticoagulation phenotypes. Risk-standardized mortality and risk-standardized length of stay also did not differ across hospital phenotypes. CONCLUSIONS: We found substantial site-level variability in the choice of anticoagulants for invasively managed acute myocardial infarction patients, even after accounting for patient factors. No single hospital-use pattern was found to be clinically superior. More studies are needed to determine which patients would derive the greatest benefit from various anticoagulants and to support consistent treatment of patients with the optimal anticoagulant strategy.

Economic impact of redundant antimicrobial therapy in US hospitals.

BACKGROUND: Overutilization of antimicrobial therapy places patients at risk for harm and contributes to antimicrobial resistance and escalating healthcare costs. Focusing on redundant or duplicate antimicrobial therapy is 1 recommended strategy to reduce overutilization and its attendant effects on patient safety and hospital costs. OBJECTIVE: This study explored the incidence and economic impact of potentially redundant antimicrobial therapy. METHODS: We conducted a retrospective analysis of inpatient administrative data drawn from 505 nonfederal US hospitals. All hospitalized patients discharged between January 1, 2008, and December 31, 2011, were eligible for study inclusion. Potentially redundant antimicrobial therapy was identified from pharmacy records and was defined as patients receiving treatment with overlapping antibiotic spectra for 2 or more consecutive days. RESULTS: We found evidence of potentially inappropriate, redundant antimicrobial coverage for 23 different antimicrobial combinations in 394 of the 505 (78%) hospitals, representing a total of 32,507 cases. High-frequency redundancies were observed in 3 antianaerobic regimens, accounting for 22,701 (70%) of the cases. Of these, metronidazole and piperacillin-tazobactam accounted for 53% (n = 17,326) of all potentially redundant cases. Days of redundant therapy totaled 148,589, representing greater than $12 million in potentially avoidable healthcare costs. CONCLUSIONS: Our study suggests that there may be pervasive use of redundant antimicrobial therapy within US hospitals. Appropriate use of antimicrobials may reduce the risk of harm to patients and lower healthcare costs.

Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes.

IMPORTANCE Current guidelines allow substantial discretion in use of noninvasive cardiac imaging for patients without acute myocardial infarction (AMI) who are being evaluated for ischemia. Imaging use may affect downstream testing and outcomes. OBJECTIVE To characterize hospital variation in use of noninvasive cardiac imaging and the association of imaging use with downstream testing, interventions, and outcomes. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of hospitals using 2010 administrative data from Premier, Inc, including patients with suspected ischemia on initial evaluation who were seen in the emergency department, observation unit, or inpatient ward; received at least 1 cardiac biomarker test on day 0 or 1; and had a principal discharge diagnosis for a common cause of chest discomfort, a sign or symptom of cardiac ischemia, and/or a comorbidity associated with coronary disease. We excluded patients with AMI. MAIN OUTCOMES AND MEASURES At each hospital, the proportion of patients who received noninvasive imaging to identify cardiac ischemia and the subsequent rates of admission, coronary angiography, and revascularization procedures. RESULTS We identified 549,078 patients at 224 hospitals. The median (interquartile range) hospital noninvasive imaging rate was 19.8% (10.9%-27.7%); range, 0.2% to 55.7%. Median hospital imaging rates by quartile were Q1, 6.0%; Q2, 15.9%; Q3, 23.5%; Q4, 34.8%. Compared with Q1, Q4 hospitals had higher rates of admission (Q1, 32.1% vs Q4, 40.0%), downstream coronary angiogram (Q1, 1.2% vs Q4, 4.9%), and revascularization procedures (Q1, 0.5% vs Q4, 1.9%). Hospitals in Q4 had a lower yield of revascularization for noninvasive imaging (Q1, 7.6% vs Q4, 5.4%) and for angiograms (Q1, 41.2% vs Q4, 38.8%). P <.001 for all comparisons. Readmission rates to the same hospital for AMI within 2 months were not different by quartiles (P = .51). Approximately 23% of variation in imaging use was attributable to the behavior of individual hospitals. CONCLUSIONS AND RELEVANCE Hospitals vary in their use of noninvasive cardiac imaging in patients with suspected ischemia who do not have AMI. Hospitals with higher imaging rates did not have substantially different rates of therapeutic interventions or lower readmission rates for AMI but were more likely to admit patients and perform angiography.

Measuring cardiac waste: the premier cardiac waste measures.

The authors developed 8 measures of waste associated with cardiac procedures to assist hospitals in comparing their performance with peer facilities. Measure selection was based on review of the research literature, clinical guidelines, and consultation with key stakeholders. Development and validation used the data from 261 hospitals in a split-sample design. Measures were risk adjusted using Premier's CareScience methodologies or mean peer value based on Medicare Severity Diagnosis-Related Group assignment. High variability was found in resource utilization across facilities. Validation of the measures using item-to-total correlations (range = 0.27-0.78), Cronbach α (.88), and Spearman rank correlation (0.92) showed high reliability and discriminatory power. Because of the level of variability observed among hospitals, this study suggests that there is opportunity for facilities to design successful waste reduction programs targeting cardiac-device procedures.

Development of a method to measure and compare hospital waste: the Premier hospital waste index.

The authors developed 15 measures and a comparative index to assist acute care facilities in identifying and monitoring clinical and administrative functions for health care waste reduction. Primary clinical and administrative data were collected from 261 acute care facilities contained within a database maintained by Premier Inc, spanning October 1, 2010, to September 30, 2011. The measures and 4 index models were tested using the Cronbach α coefficient and item-to-total and Spearman rank correlations. The final index model was validated using 52 facilities that had complete data. Analysis of the waste measures showed good internal reliability (α = .85) with some overlap. Index modeling found that data transformation using the standard deviation and adjusting for the proportional contribution of each measure normalized the distribution and produced a Spearman rank correlation of 0.95. The waste measures and index methodology provide a simple and reliable means to identify and reduce waste and compare and monitor facility performance.

Acute mortality in critically ill patients undergoing echocardiography with or without an ultrasound contrast agent.

OBJECTIVES: The objective of this observational study was to compare 48-h all-cause mortality (as well as hospital stay mortality) among critically ill patients who underwent echocardiography either with or without an ultrasound contrast agent (UCA). BACKGROUND: The safety of perflutren-based UCAs has been questioned by the U.S. Food and Drug Administration (particularly when administered to critically ill patients) following rare reports of deaths or life-threatening adverse reactions that occurred in close temporal relationship to UCA administration. METHODS: This was a retrospective observational outcome study conducted in critically ill patients to compare all-cause 48-h and hospital stay mortality subsequent to echocardiography procedures performed either with or without a UCA. The study utilized discharge data from a database maintained by Premier, Inc. (Charlotte, North Carolina). Premier's database is the largest U.S. hospital-based, service-level comparative database for quality and outcomes research, and provides detailed resource utilization data along with patients' primary and secondary diagnoses and procedure billing codes. A propensity score-matching algorithm between UCA-enhanced echocardiography patients and non-contrast-enhanced echocardiography patients was utilized to reduce the potential for imbalance in covariates of selected patients in the comparison of mortality between groups. RESULTS: Patients undergoing echocardiography with a UCA had lower mortality at 48 h compared with patients undergoing non-contrast-enhanced echocardiography (1.70% vs. 2.50%), with an odds ratio = 0.66 (95% confidence interval [CI]: 0.54 to 0.80). Patients undergoing echocardiography with a UCA had lower hospital stay mortality compared with patients undergoing noncontrast echocardiography (14.85% vs. 15.66%), with an odds ratio = 0.89 (95% CI: 0.84 to 0.96). CONCLUSIONS: In critically ill, propensity-matched hospitalized patients undergoing echocardiography, use of a UCA is associated with a 28% lower mortality at 48 h in comparison with patients undergoing non-contrast-enhanced echocardiography. These results are reassuring, given previous reports suggesting an association between UCAs and increased mortality in critically ill patients.

Health care utilization, costs, and readmission rates associated with hyponatremia.

PURPOSE: Hyponatremia is associated with higher morbidity and mortality rates among hospitalized patients. Our study evaluated health care utilization and associated costs of patients hospitalized with a primary diagnosis of hyponatremia. METHODS: Hospitalized patients with a primary discharge diagnosis of hyponatremia (aged ≥ 18 years) were identified from the Premier Perspective™ database (January 1, 2007-March 31, 2010) and matched to non-hyponatremic (non-HN) patients using a combination of exact patient characteristic matching and propensity score matching. Univariate and multivariate statistics were used to compare hospital resource usage, costs, and 30-day readmission rates between cohorts. RESULTS: Hospital length of stay (LOS) (± standard deviation) (3.78 ± 3.19 vs 3.54 ± 3.26 days; P < 0.001) and cost ($5396 ± $6500 vs $4979 ± $6152; P < 0.001 for the hyponatremic [HN] and non-HN patient cohorts, respectively) were greater for the HN cohort, but intensive care unit (ICU) costs ($3554 ± $6463 vs $3484 ± $8510; P = 0.828) and ICU LOS (2.37 ± 3.47 vs 2.52 ± 3.87; P = 0.345) did not differ between cohorts. The ICU admission rate (7.9% vs 4.4%; P < 0.001), as well as the 30-day readmission rate (12.1% vs 2.9%; P < 0.001) were greater for the HN cohort. After adjustment for key patient characteristics, hyponatremia was associated with a 7.6% increase in hospital LOS, an 8.9% increase in hospital costs, and a 9% increase in ICU costs. Hyponatremia was associated with an increased risk of ICU admission (odds ratio, 1.89, confidence limits, 1.72, 2.07; P < 0.001) and 30-day hospital readmission for hyponatremia (odds ratio, 4.76; confidence limits, 4.31, 5.26; P < 0.001). CONCLUSION: Compared with non-HN patients, patients with a primary diagnosis of hyponatremia use a greater amount of hospital resources and represent a challenge to hospital profitability due to the increased likelihood of 30-day readmission.

Hyponatremia-associated healthcare burden among US patients hospitalized for cirrhosis.

INTRODUCTION: Hyponatremia is a frequent comorbid condition of patients hospitalized for cirrhosis and a predictor of disease severity and mortality. This study evaluated the healthcare burden of hyponatremia among patients hospitalized for cirrhosis in the real world. METHODS: Hyponatremic (HN) patients (>-18 years of age) with cirrhosis were identified using the Premier Hospital Database (January 1, 2007 to March 31, 2010) and matched to non-HN patients with cirrhosis using a combination of exact patient characteristics and propensity score matching. Univariate and multivariate statistics were utilized to compare hospital resource utilization, cost, and 30-day hospital re-admission among patient cohorts. RESULTS: The study population included 21,864 subjects (HN 10,932; non-HN 10,932). The hospital length of stay (LOS) (7.63 ± 7.4 vs. 5.89 ± 6.2 days; P < 0.001), hospital cost ($13,842 ± $20,702 vs. $11,140 ± $20,562; P < 0.001), intensive care unit (ICU) LOS (4.58 ± 4.7 vs. 3.59 ± 4.4 days; P < 0.001), and ICU cost ($7,038 ± $7,781 vs. $5,360 ± $7,557; P < 0.001) were greater for the HN cohort, as was the 30-day re-admission rate (all cause: 31.1% vs. 24.8%; P < 0.001; hyponatremia related: 25.1% vs. 11.0%; P < 0.001). Multivariate analysis showed that hyponatremia was associated with a 29.5% increase in hospital LOS, a 26.6% increase in overall hospital cost, a 23.2% increase in S. ICU LOS, and a 28.6% increase in ICU cost. Additionally, hyponatremia was associated with an increased risk of 30-day hospital re-admission (all cause: odds ratio [OR] 1.37; confidence interval [CI] 1.28-1.46; P < 0.001; hyponatremia related: OR 2.68; CI 2.48-2.90; P < 0.001). CONCLUSION: Hyponatremia in patients with cirrhosis is a predictor of increased hospital resource use and 30-day hospital re-admission, and represents a potential target for intervention to reduce healthcare expenditures for patients hospitalized for cirrhosis.

Healthcare resource burden associated with hyponatremia among patients hospitalized for heart failure in the US.

OBJECTIVE: To evaluate the burden of hyponatremia in terms of hospital resource utilization, costs, and 30-day hospital readmission among patients hospitalized for heart failure (HF) in routine clinical practice. METHODS: Hyponatremic (HN) patients (≥18 years of age) with HF discharged between January 2, 2007 and March 31, 2010 were selected from the Premier Hospital Database and matched to non-HN HF patients using exact and propensity score matching. Univariate and multivariate statistics were utilized to compare hospital resource utilization (total and intensive care unit (ICU)) and associated costs and 30-day hospital readmission among cohorts. RESULTS: The study population included 51,710 subjects (HN = 25,855, non-HN = 25,855). In comparison to the non-HN cohort, length of stay (LOS) (7.7 ± 8.3 vs 6.3 ± 7.6 days, p < 0.001), hospitalization cost ($13,339 ± $19,273 vs $10,475 ± 15,157, p < 0.001), ICU LOS (4.9 ± 5.4 vs 4.2 ± 5.4 days, p < 0.001) and ICU cost ($7195 ± $9522 vs $5618 ± 10,919, p < 0.001) as well as rate of 30-day readmission (all cause: 25.3% vs 22.2%, p < 0.001; hyponatremia-related: 21.4% vs 5.0%, p < 0.001) were greater for the HN cohort. After adjustment, hyponatremia was associated with a 21.5% increase in hospital LOS, a 25.6% increase in hospital cost, a 13.7% increase in ICU LOS and a 24.6% increase in ICU cost. Additionally, hyponatremia was associated with increased risk of ICU admission (Odds Ratio (OR) = 1.58, [CI = 1.37, 1.84], p < 0.001) and 30-day hospital readmission (all cause: OR = 1.19, [CI = 1.14, 1.24], p < 0.001; hyponatremia-related: 5.10 [CI = 4.77, 5.46], p < 0.001). LIMITATIONS: Laboratory data for serum sodium level are not available in the Premier database and the severity of hyponatremia could not be established, although several patient variables were controlled for in this study by exact and propensity score matching techniques. CONCLUSIONS: Hyponatremia in HF patients is a predictor of increased hospital resource use and represents a potential target for intervention to reduce healthcare expenditures.

Evaluation of incremental healthcare resource burden and readmission rates associated with hospitalized hyponatremic patients in the US.

BACKGROUND: Hyponatremia is a prevalent electrolyte disorder in hospitalized patients indicative of greater morbidity and mortality. A large-scale retrospective analysis was conducted to evaluate the incremental burden of hospitalized hyponatremic (HN) versus non-HN patients in terms of hospital resource utilization, costs, and hospital readmissions in the real-world setting. METHODS: HN patients (≥18 years) were selected from the Premier Hospital Database between January 1, 2007 and March 31, 2010 and matched to a non-HN control cohort using propensity score matching. Bivariate and multivariate statistics were employed to evaluate the differences in healthcare resource utilization, costs, and hospital readmissions between patient cohorts. RESULTS: Among the matched patient cohorts, length of stay (LOS) (8.8 ± 10.3 vs 7.7 ± 8.5 days, P < 0.001), hospital admission costs ($15,281 ± $24,054 vs $13,439 ± $22,198, P < 0.001), intensive care unit (ICU) LOS (5.5 ± 7.9 vs 4.9 ± 7.1 days, P < 0.001), and ICU costs ($8525 ± $13,342 vs $7597 ± $12,695, P < 0.001) were greater for the HN versus non-HN cohort, as were hospital readmission rates 30 days postdischarge. Multivariate regressions further demonstrated that hyponatremia was associated with an increase of 10.9% for LOS, 8.2% for total hospitalization costs, 10.2% for ICU LOS, and 8.9% for ICU costs. Additionally, after multivariate adjustment, hyponatremia was associated with a 15.0% increased chance for hospital readmission 30 days postdischarge (P < 0.0001). CONCLUSIONS: Hyponatremia is an independent predictor of increased hospitalization LOS and cost, ICU admission and cost, and 30-day hospital readmission, and therefore represents a potential target for intervention to reduce healthcare expenditures for a large population of hospitalized hyponatremic patients.

Examining nurses' attitudes regarding the value, role, interest, and experience in research in an acute care hospital.

This study examined nurses' attitudes regarding the value of and their role, interest, and experience in research in an acute care hospital. A correlational design explored the relationship between attitudes about nursing research, involvement, educational background, and experience. The results indicated an increasing level of value and interest in research for those nurses with greater educational attainment, certified specialty, previously taken research course, research experience, and a nursing position in education. The findings suggest that additional education and guided projects are needed for those nurses with little or no previous research experience.

Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma: a prospective randomized study.

BACKGROUND: Heterotopic ossification around the elbow can result in pain, loss of motion, and impaired function. We hypothesized that a single dose of radiation therapy could be administered safely and acutely after elbow trauma, could decrease the number of elbows that would require surgical excision of heterotopic ossification, and might improve clinical results. METHODS: A prospective randomized study was conducted at three medical centers. Patients with an intra-articular distal humeral fracture or a fracture-dislocation of the elbow with proximal radial and/or ulnar fractures were enrolled. Patients were randomized to receive either single-fraction radiation therapy of 700 cGy immediately postoperatively (within seventy-two hours) or nothing (the control group). Clinical and radiographic assessment was performed at six weeks, three months, and six months postoperatively. All adverse events and complications were documented prospectively. RESULTS: This study was terminated prior to completion because of an unacceptably high number of adverse events reported in the treatment group. Data were available on forty-five of the forty-eight patients enrolled in this study. When the rate of complications was investigated, a significant difference was detected in the frequency of nonunion between the groups. Of the nine patients who had a nonunion, eight were in the treatment group. The nonunion rate was 38% (eight) of twenty-one patients in the treatment group, which was significantly different from the rate of 4% (one) of twenty-four patients in the control group (p = 0.007). There were no significant differences between the groups with regard to the prevalence of heterotopic ossification, postoperative range of motion, or Mayo Elbow Performance Score noted at the time of study termination. CONCLUSIONS: This study demonstrated that postoperative single-fraction radiation therapy, when used acutely after elbow trauma for prophylaxis against heterotopic ossification, may play a role in increasing the rate of nonunion at the site of the fracture or an olecranon osteotomy. The clinical efficacy of radiation therapy could not be determined on the basis of the sample size. Further research is needed to determine the role of limited-field radiation for prophylaxis against heterotopic ossification after elbow trauma.

Early goal-directed therapy: improving mortality and morbidity of sepsis in the emergency department.

BACKGROUND: The growing number of patients with severe sepsis or septic shock and the resulting mortality rate (30%) require changes in the current protocols used to treat these conditions. Through adaptation of early goal-directed therapy (EGDT), Carolinas Medical Center developed a process improvement strategy for decreasing mortality associated with severe sepsis and septic shock. Before implementing the EDGT protocol, the ED did not follow a written management protocol for septic patients. METHODS: Following establishment of an interdisciplinary team, several process improvement activities were conducted, including the development of a standardized algorithm and treatment protocol, a physician order sheet, a nursing flow sheet, and a code sepsis response team. RESULTS: A total of 381 patients were enrolled: 79 in the pre-intervention phase and 302 in the postintervention phase. Mortality rates decreased from 27% pre-intervention to 19% postintervention (-8% absolute mortality; 95% confidence interval [C.I.], 7-9; p = .2138). There were significant differences between the pre- and postintervention groups for endotracheal intubation (17%, p = .0012), crystalloid infusion (1.4 L, p < .0001), vasopressor administration (33%, p < .0001), and packed red blood cells (34%, p < .0001). Both groups were generally similar in their demographics, comorbidities, and vital signs. DISCUSSION: As a result of this process improvement initiative, patients who might have received delayed and/or inadequate treatment for severe sepsis or septic shock are now receiving effective, life-saving treatment. Because of the emphasis on training, consistency in applying the protocol, relatively few changes in current ED practice, and low direct expenditures for equipment, the protocol can be easily integrated into existing ED environments to allow hospitals to quickly implement this successful, best-practice program.

The relationship between organizational factors and resident satisfaction with nursing home care and life.

We examined the relationships between nursing home (NH) resident satisfaction and NH organizational characteristics, while controlling for the effect of resident characteristics within facilities. We used a stratified, random sample of NHs (N = 72) from two states and a prescreened and randomized sample of 1496 residents. Data sources included resident interviews, an administrator survey, the Minimum Data Set (MDS), and the Online Survey, Certification and Reporting System (OSCAR). Using Hierarchical Linear Modeling (HLM) techniques, we found that non-chain affiliation, certified nursing assistant staffing, and provision of a family council had significant positive effects on total resident satisfaction. The presence of a special care unit was associated with lower levels of satisfaction.

Report cards and nursing homes.

PURPOSE: We first describe which states have produced nursing home report cards; second, we compare what information is provided in these report cards; third, we identify data sources used to produce the report cards; and, finally, we examine seven factors previously shown to be associated with the usefulness of report-card information and provide several examples from current reporting efforts to illustrate how nursing home report cards could be improved. DESIGN AND METHODS: We searched the Web sites for each state agency responsible for elder affairs-nursing homes. For those states identified as having a nursing home report card, we further examined the information presented. RESULTS: We identified 19 states as having nursing home report cards (AZ, CO, FL, IL, IN, IO, MD, MA, MS, NV, NJ, NY, OH, PA, RI, TX, UT, VT, and WI). The information presented in these report cards differs quite substantially across states, although the data sources for report cards do not differ substantially. How the information is presented and our evaluation of the usefulness of the information is also highly varied. IMPLICATIONS: Providing nursing home report-card information may be important in helping elders and their families choose a nursing facility. With 19 states identified in our research as providing nursing home report-card information on the World Wide Web, we were surprised and encouraged at this number of initiatives. We give some insight into the kinds of information that can be found on these report cards and what steps could be taken to improve how the information is presented.

Consumer satisfaction in long-term care: state initiatives in nursing homes and assisted living facilities.

PURPOSE: We report the results of a survey of state initiatives that measure resident satisfaction in nursing homes and assisted living facilities, and we describe several model programs for legislators and public administrators contemplating the initiation of their own state programs. DESIGN AND METHODS: Data on state initiatives and programs were collected during March and April 2000 through a mailed questionnaire and follow-up telephone interviews and were current as of September 2002. RESULTS: Of the 50 states surveyed, 50 responses were received (response rate = 100%); 12 states (24%) reported the use of consumer satisfaction measures, and 7 (Florida, Iowa, Ohio, Oregon, Texas, Vermont, and Wisconsin) reported using resident satisfaction data within their consumer information systems for nursing homes or assisted living facilities. Additionally, 2 states (Iowa and Wisconsin) use resident satisfaction data for facility licensing and recertification. The design of the instruments and collection methods vary in these states, as do the reported response rates, per-resident cost, and the purpose for satisfaction data collection. IMPLICATIONS: State satisfaction efforts are in an early stage of development. Well-produced, easily understandable reports on nursing home and assisted living quality could provide information and guidance for patients and families contemplating the utilization of long-term care services. Dissemination of quality information may also facilitate sustained quality and efficiency improvements in long-term care facilities and thus enhance the quality of care for and quality of life of long-term care residents.