Charles D. Callahan

Decreased Mortality Associated With Prompt Gram Staining of Blood Cultures

Gram stains of positive blood cultures are the most important factor influencing appropriate therapy. The sooner appropriate therapy is initiated, the better. Therefore, it is reasonable to expect that the sooner Gram stains are performed, the better. To determine the value of timely Gram stains and whether improvement in Gram stain turnaround time (TAT) is feasible, we compared data for matched pairs of patients with cultures processed promptly (<1 hour TAT) with data for patients with cultures not processed promptly (> or =1 hour TAT) and then monitored TAT by control charting.In 99 matched pairs, average difference in time to detection of positive blood cultures within a pair of patients was less than 0.1 hour. For the less than 1 hour TAT group, the average TAT and crude mortality were 0.1 hour and 10.1%, respectively; for the 1 hour or longer TAT group, they were 3.3 hours and 19.2%, respectively (P < .0001 and P = .0389, respectively). After multifaceted efforts, we achieved significant improvement in the TAT for Gram stains.

The clinical utility of the Rey Auditory-Verbal Learning Test in medical rehabilitation

Recent research has reported the Rey Auditory-Verbal Learning Test Trial V (RAVLT-V) score to be a sensitive indicator of global cognitive functioning, not merely verbal learning skills. The concurrent validity of the RAVLT-V relative to other neuropsychological measures frequently utilized in medical rehabilitation was investigated in a sample of 64 outpatients diagnosed with traumatic brain injury (TBI). The sample was predominantly male (77%), white (97%), youthful (31.4±11.5 years), high school educated, and an average of 53 months postinjury. Using stepwise multiple regression analysis, a three-variable model consisting of gender, Wechsler Memory Scale-Revised Delayed Memory Index, and Trailmaking Part B (time) accounted for 61% of the variance in RAVLT-V scores. These findings suggest that in TBI patients, the RAVLT taps not only specific verbal learning and memory, but also global cognitive functions. Sensitivity to diffuse neuropsychological changes and ease/speed of administration make the RAVLT a valuable tool in medical rehabilitation settings.

Application of statistical process control to physician-specific emergency department patient satisfaction scores: a novel use of the funnel plot.

OBJECTIVESnEmergency department (ED) patient satisfaction remains a high priority for many hospitals. Patient surveys are a common tool for measuring patient satisfaction, and process improvement efforts are aimed at improving patient satisfaction scores. In some institutions, patient satisfaction scores can be calculated for each emergency physician (EP). ED leaders are faced with the task of interpreting individual as well as group physician scores to identify opportunities for improvement. Analysis of these data can be challenging because of the relatively small numbers of returned surveys assignable to a single physician, variable numbers of surveys returned for each physician and high standard deviations (SDs) for individual physician scores. The objective was to apply statistical process control methodology to analyze individual as well as group physician patient satisfaction scores. The novel use of funnel plots to interpret individual physician patient satisfaction scores, track individual physician scores over two successive 8-month periods, and monitor physician group performance is demonstrated.nnnMETHODSnPatient satisfaction with physicians was measured using Press Ganey surveys for a 65,000-volume ED over two successive 8-month periods. Using funnel plots, individual physician patient satisfaction scores were plotted against the number of surveys completed for each physician for each 8-month period. Ninety-fifth and 99th percentile control limits were displayed on the funnel plots to illustrate individual physician patient satisfaction scores that are within, versus those that are outside of, expected random variation. Control limits were calculated using mean patient satisfaction scores and SDs for the entire group of physicians. Additional funnel plots were constructed to demonstrate changes in individual physicians patient satisfaction scores as a function of increasing numbers of returned surveys and to illustrate changes in the groups patient satisfaction scores between the first and second 8-month intervals after the institution of process improvement efforts aimed at improving patient satisfaction.nnnRESULTSnFor the first 8-month period, 34,632 patients were evaluated in and discharged from the ED, with 581 surveys returned for 21 physicians. The mean (±SD) overall group physician patient satisfaction score was 81.8 (±24.7). Returned surveys per physician ranged from 2 to 58. For the second period, 34,858 patients were evaluated and discharged from the ED, with 670 patient satisfaction surveys returned for 20 physicians. The mean (±SD) overall physician score for all surveys returned during the second period was 85.0 (±22.2). Returned surveys per physician ranged from 8 to 65.nnnCONCLUSIONSnThe application of statistical control methodology using funnel plots as a means of analyzing ED group and physician patient satisfaction scores was possible. The authors believe that using funnel plots to analyze scores graphically can rapidly help determine the significance of individual physician patient satisfaction scores. In addition, serial funnel plots may prove to be useful as a means of measuring changes in patient satisfaction, particularly in response to quality improvement interventions.

Utility of a seven-subtest version of the WAIS-R among an Alzheimer's disease sample.

Recent health care sector changes have created a need for shorter, more focused neuropsychological assessments. The WAIS-R provides useful information on patients general cognitive abilities, but poses problems in that it is time-consuming and may contribute to fatigue, especially among geriatric patients with dementia. This study evaluated Wards (1990) 7-subtest version of the WAIS-R among 32 patients with presumptive Alzheimers disease. Among all patients, the abbreviated test underestimated full WAIS-R scores by an average of 2.0, 0.2, and 1.8 points for the Verbal Intelligence Quotient (VIQ), Performance Intelligent Quotient (PIQ), and Full-Scale Intelligence Quotient (FSIQ). This general finding held true regardless of whether scores were generated using the standard WAIS-R method (for patients age 75 and younger) or using age corrections (i.e., Mayo Older Americans Normative Studies [MOANS]) for older patients. Most patients scored within the mean standard errors of measurement defined in the WAIS-R manual for VIQ, PIQ, and FSIQ. In general, the 7-subtest and full versions of the WAIS-R yielded similar findings among this closely screened sample, but further testing among a more typical sample of patients with multiple risk factors for dementing conditions is needed.

The neuropsychology of Kuf's Disease: a case of atypical early onset dementia.

Adult Neuronal Ceroid Lipofuscinosis (Adult NCL), also known as Kufs Disease, is a rare progressive encephalopathic disease that results in dementia. This report describes the presentation, diagnosis, neuroanatomy, and management of Adult NCL. A neuropsychological case study of Adult NCL is presented, emphasizing early onset of psychiatric symptoms, motor involvement, and severe diffuse cognitive impairment. The patients neuropsychological course is documented over a 2-year period, with findings interpreted within the context of current models of cortical and subcortical dementia. The biopsychosocial impact of misdiagnosis and pharmaceutical management are discussed.

Comparing neuropsychological and psychiatric evaluation of competency in rehabilitation: a case example

This report describes the case of a 20-year-old man who sustained a gunshot wound to the forehead, resulting in traumatic brain injury and C2 ventilator-dependent quadriplegia. Issues of personal control and autonomy typified his psychological adjustment. The question of competency to refuse medical treatment arose when he disallowed intervention for a suspected ear infection not confirmed by culture. Subsequently, the patient was alternately described as incompetent by a psychiatrist and competent by a medical ethics review panel. These decisions are interpreted within the context of existing medical-legal literature and historical precedent of competency in civil law. Central to competency evaluation is the patients ability to recognize that a decision-making process is required, to review the pros and cons of various options, and to communicate a decision. Importantly, this decision need not be in accordance with the opinion of family or the health care team. Neuropsychological screening indicated the patients cognitive abilities were within functional limits, and he subsequently agreed to treatment after experiencing pain and fever, and learning of a positive culture. It is concluded that a two-pronged neuropsychological evaluation of competency based on the patients information processing capabilities is most appropriate in medical rehabilitation settings.