Deryk Chen

Performance of a pediatric ambulatory anesthesia program – a developing country experience

Background:  The aim of this study was to evaluate the performance of a pediatric ambulatory anesthesia program in a tertiary care teaching hospital in a developing country.

Innovation management using logical framework in hospital-based healthcare units

Innovation is part and parcel of any service in todays environment, so as to remain competitive. Quality improvement in healthcare services is a complex, multi-dimensional task. This study proposes innovation management in healthcare services using a logical framework. A problem tree and an objective tree are developed to identify and mitigate issues and concerns. A logical framework is formulated to develop a plan for implementation and monitoring strategies, potentially creating an environment for continuous quality improvement in a specific unit. We recommend logical framework as a valuable model for innovation management in healthcare services.

The utilities of the therapeutic intervention scoring system (TISS-28)

Background and Aims: The study evaluates the utility of therapeutic intervention scoring system (TISS-28) in quantifying the resource utilization, costs and predicting outcome of critically ill patients. Materials and Methods: TISS-28 was prospectively applied to patients consecutively admitted to the intensive care units (ICU) of three public teaching hospitals and two private hospitals in Trinidad on a daily basis for a period of eight weeks. Demographic data, diagnoses on admission, nurse-patient ratio, ICU length of stay and hospital outcomes were recorded. Simplified acute physiology score (SAPS)-II was applied for all adult patients. Costs were calculated from data collected from the public hospitals in relation to TISS-28 score. Results : TISS-28 scores of five hundred and ninety-five patient-days were analyzed. The median daily TISS-28 per patient was 27 [24.5, 30.6 quartiles (IQR)]; the median day-1 TISS-28 score was 29 (25, 33 IQR) and the median last day TISS-28 score was 25 (21, 30 IQR). The overall average TISS per nurse was 26.2 per day. The mean cost per patient per day was 414 US dollars. The discriminatory function of day-1 TISS-28 as a prognostic scoring system was less compared to SAPS II as shown by the area under the receiver operating characteristic curve (0.65 compared to 0.71). Conclusions: TISS-28 is useful for evaluating the resource utilization and costs and may not be useful as a prognostic scoring system

Managing healthcare quality in project management framework

Healthcare professionals routinely deploy various quality management tools and techniques in order to improve performance of healthcare delivery. However, they are characterised by fragmented approach i.e., they are not linked with the strategic intent of the organisation. This study introduces a holistic quality improvement method, which integrates all quality improvement projects with the strategic intent of the healthcare organisations. It first identifies a healthcare system and its environment. The Strengths, Weaknesses, Opportunities and Threats (SWOT) of the system are then derived with the involvement of the concerned stakeholders. This leads to developing the strategies in order to satisfy customers in line with the organisations competitive position. These strategies help identify a few projects, the implementation of which ensures achievement of desired quality. The projects are then prioritised with the involvement of the concerned stakeholders and implemented in order to improve the system performance. The effectiveness of the method has been demonstrated using a case study of an intensive care unit at the Eric Williams Medical Sciences Complex Hospital in Trinidad. Copyright

Cost evaluation in the intensive care units of Trinidad applying the cost-blocks method - an international comparison.

This study evaluated the costs of intensive care in Trinidad applying the cost‐blocks method. Data regarding demographics, severity of illness, therapeutic interventions and length of stay were prospectively recorded for 111 patients admitted to four intensive care units during a 3‐month period. Annual costs, cost per admission, cost per patient‐day and cost per therapeutic intervention score point were derived. The cost‐block for staff, especially medical staff, was the largest proportion of the expenditure. Process of care and outcome were comparable, whereas costs were lower than the developed countries. The median cost per intensive care unit bed per year and cost per patient per day in Trinidad were £133 117 and £366, respectively, in comparison with £265 163 and £904 in the UK. The cost‐blocks method is a useful framework for evaluating the costs of intensive care and for comparing costs between countries.

Perioperative outcome of colorectal cancer and validation of CR-POSSUM in a Caribbean country

OBJECTIVE To evaluate the risk-adjusted perioperative outcome of colorectal cancer surgery, applying the Colorectal Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (CR-POSSUM). METHODS A retrospective chart review of patients who underwent colorectal cancer surgery from 2004 to 2007 was done. Data including demographics and physiological data for CR-POSSUM were recorded. Predicted mortality was calculated; validation of CR-POSSUM was done using Hosmer-Lemeshow goodness-of-fit and Receiver Operating Characteristic (ROC) Curve analyses. RESULTS 232 patients were studied. The overall mean CR-POSSUM score was 18.3+/-3.8 (SD). Predicted mortality was 7.7%, observed mortality was 6.9% and the standardized mortality ratio was 0.9. 34.4% of patients presented with Dukes Stage C or D and had a higher risk of mortality (Odds Ratio (OR) 3.1, 95% Confidence Intervals (CI) 1.1, 9.1). Emergency surgery was associated with a higher risk of mortality (OR 4.7, 95% CI 1.5, 14.1). CR-POSSUM calibrated well (Hosmer-Lemeshow Chi-square value 4.3; df: 8; p=0.82) and fairly discriminated outcome as shown by the area under the ROC Curve 0.69, (Standard Error: 0.07). CONCLUSIONS Perioperative outcome of colorectal surgery in Trinidad and Tobago is comparable to the developed countries as evaluated by the CR-POSSUM. Patients presenting for emergency surgery and those with advanced stages of cancer had higher perioperative mortality.

Does preoperative psychological status of patients affect postoperative pain? A prospective study from the Caribbean

Objectives: Patients with high anxiety states in the preoperative period often have more intense postoperative pain, despite adequate pain control during the intraoperative period. This study aimed to determine the relationship between the preoperative psychological status and the pain experienced postoperatively in a sample of Caribbean patients. Design and methods: A prospective study was conducted in elective surgical adult patients at a teaching hospital in the Caribbean. Patients’ preoperative psychological status was assessed using Hospital Anxiety and Depression Scale (HADS), and a preoperative ‘expected’ pain score was recorded. Postoperatively, ‘observed’ pain scores at 4 and 24 hours and the maximum pain score during 24 hours were recorded. Demographic data and clinical details including data regarding postoperative analgesia were collected. Expected and observed pain scores were compared between patients with and without anxiety and depression. Results: A total of 304 patients were enrolled. The overall prevalence of anxiety and depression was 43% and 27%, respectively, based on the HADS scores. There were significant associations between the postoperative pain scores and factors such as preoperative anxiety and depression (HADS) scores, preoperative expected pain scores, patient educational level, presence of preoperative pain and surgical duration. Age, gender, ethnicity and type of anaesthesia did not impact postoperative pain scores. Conclusion: The presence of preoperative anxiety and depression as indicated by HADS score may significantly influence postoperative pain. Other factors such as educational level, presence of preoperative pain and surgical duration may also impact postoperative pain. Some of these factors may be modifiable and must be addressed in the preoperative period.

Patient Perception of the Utility of the Preanesthetic Clinics in a Caribbean Developing Country

JUSTIFICATIVA Y OBJETIVOS: La percepcion de los pacientes respecto de la utilidad del Ambulatorio de Evaluacion Preanestesica como tambien el flujo de pacientes, no fueron extensamente estudiados en el mundo en desarrollo. El objetivo de este estudio fue analizar ese aspecto. METODOS: Se realizo una investigacion aplicando un cuestionario entre los pacientes atendidos en el Ambulatorio de Evaluacion Preanestesica de un hospital subcontratado de ensenanza en Trinidad. Como comparacion, ese cuestionario tambien se distribuyo a los pacientes atendidos en el Ambulatorio de Cirugia General. Los parametros demograficos, incluyendo edad, sexo, nivel escolar y estado fisico ASA se registraron. Otros datos registrados incluian el flujo de pacientes y los detalles respecto del equipo medico. RESULTADOS: De los 220 pacientes atendidos en el Ambulatorio de Evaluacion Pre-anestesica, un 92,7% participaron del estudio. La validez del cuestionario fue apoyada por el coeficiente alfa de Cronbach (0,67). El tiempo promedio para la derivacion al ambulatorio de cirugia para la Clinica Preanestesica fue de 50 dias; el tiempo promedio de espera en la clinica fue de 2,7 horas y el de espera por la cirugia despues de la aceptacion por parte del ambulatorio fue de 12 dias. Las opiniones de los pacientes respecto de los beneficios de la clinica y tiempo de espera no tuvieron ningun influjo por la edad ni por el nivel cultural. Segun los pacientes, la atencion en el Ambulatorio de Evaluacion Preanestesica fue benefica, pero los tiempos de espera fueron considerados extensos. CONCLUSIONES: Segun los pacientes, la consulta en el Ambulatorio de Evaluacion Preanestesica antes del procedimiento quirurgico fue util y la atencion fue considerada satisfactoria.

Knowledge and attitudes of medical and nursing practitioners regarding non-beneficial futile care in the intensive care units of Trinidad and Tobago

Objective To determine the knowledge and attitudes of healthcare personnel regarding the provision of non-beneficial futile care in the intensive care units at the major public hospitals in Trinidad and Tobago. Method Prospective data collection was done using a questionnaire administered to the medical and nursing staff of the intensive care units. The questionnaire was designed to capture the opinions regarding the futile care offered to terminally ill patients at the intensive care units. The responses were based on a five-point Likert scale. The influence of factors such as age, gender, duration of work experience, religious belief, ethnicity, occupational category and educational status on the responses were analysed. Results A total of 274 completed responses (86% response rate) were obtained from doctors and nurses. The frequency with which the respondents encountered ethical or legal problems in the intensive care unit varied widely from ‘daily’ to ‘yearly’. The majority felt that knowledge of ethics is important, and only 32% knew the legal issues pertaining to their work. Eighty percent of doctors and nurses had no knowledge of an existing Hospital Ethics Committee and its role in ethical dilemmas. Although 62% said their decisions regarding futile care will be influenced by their scientific knowledge, only 32% agreed to withdraw care. Eighty percent said that the government should pass appropriate laws regarding withdrawal of futile care. Conclusions Most healthcare providers in intensive care unit are not knowledgeable in the ethical and legal issues of non-beneficial futile care. There is a need to devise means to bring awareness and educate intensive care unit healthcare providers in this subject.

Efficacy of a separate informed consent for anesthesia services: A prospective study from the Caribbean

Background and Aims: This study aimed to determine whether a separate written consent form improved the efficacy of the informed consent process for anesthesia in adult patients undergoing elective surgery at a tertiary care teaching hospital. Material and Methods: We randomized patients into two groups prospectively. The first group (Group A) signed the hospitals standard Consent for Operation form only while the second group (Group B) signed a separate Consent for Anesthesia form additionally. Patients were interviewed postoperatively with an eight-item questionnaire with responses in a 5-point Likert scale. A composite adequacy of consent index was generated from the responses and analyzed. Results: Two hundred patients (100 in each group) were studied. All patients indicated that the anesthesiologist(s) had their permission to proceed with their anesthesia care. The mean adequacy of consent index score in Group B was higher than that of Group A (30.6 ± 4.6 [standard deviation (SD)] vs. 27.9 ± 5.2 [SD]) (P < 0.001). The separate written consent had a positive impact on the patients’ understanding of the nature and purpose of the intended anesthesia procedures (P = 0.04), satisfaction with the adequacy of information provided about common side effects (P < 0.001) and rare but serious complications (P = 0.008). Conclusions: A separate written consent for anesthesia improved the efficacy of the informed consent process with respect to better information about the nature and purpose of anesthesia, common side effects, and rare but serious complications.