Douglas S. Wakefield

Respiratory rate predicts cardiopulmonary arrest for internal medicine inpatients

Objective: To assess whether vital sign measurements could identify internal medicine patients at risk for cardiopulmonary arrest.Design: Retrospective case-control study comparing 72 hours of pre-arrest vital sign measurements with 72 hours of vital sign measurements for patients from the same units who did not experience cardiopulmonary arrest.Setting: Twelve non — intensive care internal medicine units at a large midwestern academic medical center.Patients: Cases included all 59 inpatients who had experienced cardiopulmonary arrest between May 1989 and December 1990; patients who were designated do-not-resuscitate (DNR) or had less than 72 hours of vital sign recordings were excluded. Controls included 91 inpatients without cardiopulmonary arrest who were matched for units and who had 72 hours of vital sign recordings.Results: The occurrence of one or more respiratory rates >27 breaths per minute over a 72-hour period had a sensitivity of 0.5 4 and a specificity of 0.83 (odds ratio=5.56, 95% CL=2.67–11.49) in predicting cardiopulmonary arrest. Other respiratory rate thresholds were also predictive of arrest. The ability of respiratory rate to predict arrest was stronger in units with high incidences of arrest relative to units with low incidences, for example, in units for the management of gastrointestinal disease (sensitivity=1.00, specificity=0.86) and renal disease (sensitivity=0.69, specificity=0.87). Respiratory rate remained a significant predictor (p<0.001) after controlling for patient age and gender. Pulse rate and blood pressure were not predictive of cardiopulmonary arrest.Conclusions: Using elevated respiratory rates as a signal for focused diagnostic studies and therapeutic interventions in internal medicine patients may be useful in reducing the incidence of subsequent cardiopulmonary arrest, and lowering associated morbidity and mortality.

Work-arounds in health care settings: Literature review and research agenda.

Background: As health care professionals seek to balance technological and regulatory demands with the need to provide patient-centered care, all in an efficient and cost-effective manner, they may see a greater need to improvise or work around intended work practices. Health care professionals acknowledge widespread use of work-arounds, and the literature documents their prevalence and influence on performance. Despite their importance, few studies have focused exclusively on work-arounds. This suggests a key area of need in the research, particularly because work-arounds are frequently cited in the context of serious patient safety consequences. Purpose: The purpose of this article is to review the existing literature concerning work-arounds to elucidate the definition and nature of work-arounds, how work-arounds can be differentiated from similar constructs (e.g., errors, mistakes, and deviance), and the potential causes of work-arounds and to explore potential consequences of work-arounds in health care settings. Approach: We conducted a systematic review of the literature concerning work-arounds to develop themes concerning the nature of work-arounds and ideas for future research on the topic. Implications for Practice: In this article, we develop links between work-arounds and potential outcomes, particularly safety outcomes. Moreover, we discuss the manner in which open discussion can allow work-arounds to facilitate work process improvement and the role that climate and culture play in reducing work-arounds.

Nurse burnout and patient safety outcomes: nurse safety perception versus reporting behavior.

This article examines the relationship between nurse burnout and patient safety indicators, including both safety perceptions and reporting behavior. Based on the Conservation of Resources model of stress and burnout, it is predicted that burnout will negatively affect both patient safety perceptions and perceived likelihood of reporting events. Nurses from a Veterans Administration hospital completed the Maslach Burnout Inventory and safety outcomes subset of measures from the Agency for Healthcare Research and Quality Patient Safety Culture measure. After controlling for work-related demographics, multiple regression analysis supported the prediction that burnout was associated with the perception of lower patient safety. Burnout was not associated with event-reporting behavior but was negatively associated with reporting of mistakes that did not lead to adverse events. The findings extend previous research on the relationship between burnout and patient outcomes and offer avenues for future research on how nurse motivation resources are invested in light of their stressful work environment.

Cost of nosocomial infection: Relative contributions of laboratory, antibiotic, and per diem costs in serious Staphylococcus aureus infections

This study reports an analysis of the relative importance of laboratory antibiotic, and per diem costs of caring for 58 patients with serious Staphylococcus aureus nosocomial infections. Laboratory costs accounted for 2%, antibiotics for 21%, and per diem costs for 77% of total infection-related costs. Only 45% of patients were hospitalized for additional days specifically because of infection, but these patients stayed an average of 18 extra days. Nosocomial infections with S. aureus resistant to penicillinase-resistant penicillins (PRP) were more frequently associated with additional infection-related days of hospitalization than were PRP-susceptible infections. The cost of PRP-resistant infections was also significantly greater than PRP-susceptible infections, primarily because of the costs of additional days of hospitalization. Rational strategies to control costs of nosocomial infection should focus on two approaches: (1) prevention and (2) reduction of acute hospital days attributable to infections.

Understanding why medication administration errors may not be reported.

Because the identification and reporting of medication administration errors (MAE) is a nonautomated and voluntary process, it is important to understand potential barriers to MAE reporting. This paper describes and analyzes a survey instrument designed to assist in evaluating the relative importance of 15 different potential MAE-reporting barriers. Based on the responses of over 1300 nurses and a confirmatory LISREL analysis, the 15 potential barriers are combined into 4 subscales: Disagreement Over Error, Reporting Effort, Fear, and Administrative Response. The psychometric properties of this instrument and descriptive profiles are presented. Specific suggestions for enhancing MAE reporting are discussed.

Tele-Education in a Telemedicine Environment: Implications for Rural Health Care and Academic Medical Centers

Over 50 million people in the United States (about 20% of the population) live in rural areas, but only 9% of the nations physicians practice in rural communities. It is difficult to recruit and retain rural health care practitioners, partly because of issues relating to professional isolation. New and enhanced telecommunications links between community and academic hospitals show promise for reducing this isolation and enhancing lifelong learning opportunities for rural health care providers. This paper will explore some of the issues involved in using interactive video (telemedicine) networks to transmit continuing medical education programming from an academic center to multiple rural hospitals. Data from a recent University of Iowa survey of the states health educators will be presented as one approach to assessing the health care marketplace for the deployment of tele-education services.

A Diabetes Dashboard and Physician Efficiency and Accuracy in Accessing Data Needed for High-Quality Diabetes Care

PURPOSE We compared use of a new diabetes dashboard screen with use of a conventional approach of viewing multiple electronic health record (EHR) screens to find data needed for ambulatory diabetes care. METHODS We performed a usability study, including a quantitative time study and qualitative analysis of information-seeking behaviors. While being recorded with Morae Recorder software and “think-aloud” interview methods, 10 primary care physicians first searched their EHR for 10 diabetes data elements using a conventional approach for a simulated patient, and then using a new diabetes dashboard for another. We measured time, number of mouse clicks, and accuracy. Two coders analyzed think-aloud and interview data using grounded theory methodology. RESULTS The mean time needed to find all data elements was 5.5 minutes using the conventional approach vs 1.3 minutes using the diabetes dashboard (P <.001). Physicians correctly identified 94% of the data requested using the conventional method, vs 100% with the dashboard (P <.01). The mean number of mouse clicks was 60 for conventional searching vs 3 clicks with the diabetes dashboard (P <.001). A common theme was that in everyday practice, if physicians had to spend too much time searching for data, they would either continue without it or order a test again. CONCLUSIONS Using a patient-specific diabetes dashboard improves both the efficiency and accuracy of acquiring data needed for high-quality diabetes care. Usability analysis tools can provide important insights into the value of optimizing physician use of health information technologies.

Heart failure self‐management education: a systematic review of the evidence

OBJECTIVE The objective of this systematic review is to identify educational content and techniques that lead to successful patient self-management and improved outcomes in congestive heart failure education programs. METHODS MEDLINE, CINAHL and the Cochrane Central Register of Controlled Trials, as well as reference lists of included studies and relevant reviews, were searched. Eligible studies were randomised controlled trials evaluating congestive heart failure self-management education programs with outcome measures. Two of the investigators independently abstracted descriptive information, education content topics and outcomes data. RESULTS A total of 7413 patients participated in the 35 eligible congestive heart failure self-management education studies. The congestive heart failure self-management programs incorporated 20 education topics in four categories: (i) knowledge and self-management (diagnosis and prognosis, pathophysiology of how congestive heart failure affects the body, aims of treatment, management and symptoms, medication review and discussion of side-effects, knowing when to access/call the general practitioner, communication with the physician, follow up for assessment or reinforcement); (ii) social interaction and support (social interaction and support, stress, depression); (iii) fluids management (sodium restriction, fluid balance, daily measurement of weight, ankle circumference, self-monitoring and compliance relative to fluids); and (iv) diet and activity (dietary assessment and instructions, physical activity and exercise, alcohol intake, smoking cessation). A total of 113 unique outcomes in nine categories (satisfaction, learning, behaviour, medications, clinical status, social functioning, mortality, medical resource utilisation and cost) were measured in the studies. Sixty (53%) of the outcomes showed significant improvement in at least one study. CONCLUSION Educational interventions should be based on scientifically sound research evidence. The education topic list developed in this review can be used by patients and clinicians to prioritise and personalise education.

Development of a measure of clinical information systems expectations and experiences.

Background/Objectives: The purpose of this study is to describe the development and initial psychometric properties of a measure of expectations and experiences regarding the impact of clinical information systems on work process and outcomes. Research Design: Basic item analysis, confirmatory factor analysis, cross-validation factor analyses, and reliability analysis were used to assess the psychometric properties of the scale. Subjects: The initial validation sample included registered nurses from a large Midwestern rural referral hospital that implemented electronic medical records and computerized provider order entry systems. Nurses from 3 other hospitals were used to cross-validate the factor structure of the scale. Measures: The scale assesses respondents’ perceptions related to communication changes, changes in selected work behaviors, perceptions of the implementation strategy, and the impact on quality of patient care. The instrument can be used to assess perceptions before and after implementation. Results: Confirmatory factor analysis generally supported the a priori factor structure for both expectations and experiences regarding the clinical information system. The consistency of the fit to the factor models was also high across the cross-validation samples. The scales demonstrated acceptable internal consistency in all the samples. Conclusions: Our findings suggest that the measure of clinical information systems expectations and experiences offers a valid and reliable tool for assessing the perceived impact of new clinical technology on work process and outcomes. This instrument can be useful before and after technology implementation by assisting in the identification of staff perceptions and concerns, thus allowing for targeted interventions to address these issues.

Use of the appropriateness evaluation protocol for estimating the incremental costs associated with nosocomial infections.

Existing methods for estimating additional days of hospital stay due to nosocomial infections (NI) have a number of documented limitations. An alternative method described in this paper uses the Appropriateness Evaluation Protocol (AEP) to determine whether each day of acute inpatient care is appropriate based on the need for care of the NI, original cause of hospitalization (GC), or combined NI-OC requirements. Using this method to identify specific days of hospitalization due to Staphylococcus aureus nosocomial infection, we find: 1) length of stay is increased for only a minority of patients (38%); 2) an average of 20 additional days of stay occurred for patients with 1 or more days attributed to NI; and 3) an average of 52% of length of stay of patients with 1 or more days attributed to NI can be attributed to the NI. Application of the AEP-based method is a useful alternative for identifying additional days of stay due to NI.