Janice Fitzgerald

Improving the care of patients with regard to chemotherapy-induced nausea and emesis: the effect of feedback to clinicians on adherence to antiemetic prescribing guidelines.

PURPOSE To evaluate the effect of performance and outcomes feedback on adherence to clinical practice guidelines regarding chemotherapy-induced nausea and emesis (CINE). METHODS Institutional CINE clinical practice guidelines were developed based on American Society of Clinical Oncology guidelines. Consecutive administrations of moderately/highly emetogenic chemotherapy were assessed for errors. Baseline statistical process control (SPC) charts were created and mean errors per administration were calculated. Prospective SPC charts were used to measure the effect of guideline development and distribution, a visiting lecturer, and ongoing feedback regarding compliance with guidelines employing SPC charts. Patients were surveyed regarding the extent and severity of CINE for 5 days postadministration. These outcomes were then shared with physicians. RESULTS Baseline compliance was poor (mean, 0.87 omissions per chemotherapy administration), largely because of inadequate adherence to recommendations for delayed CINE management. Most patients experienced delayed nausea, particularly on day 3 postchemotherapy. Physician prescribing performance did not undergo sustained improvement despite guideline development or distribution, a lecture by a visiting expert, or sharing of adherence data with clinicians. Once patient outcomes were shared, physicians accepted the need for compliance and instituted nurse practitioner antiemetic prescribing, with almost complete compliance and concurrent measurable reduction in day 3 nausea. SPC charts documented improvements in both outcomes. CONCLUSIONS SPC charts effectively monitor ongoing compliance and patient symptoms and represent appropriate outcome measurement and change facilitation tools. However, physician participation in guideline development and evidence of poor compliance alone did not improve prescribing performance. Only evidence of patient CINE experience coupled with noncompliance improved results.

Use of antihypertensive agents in the management of patients with acute ischemic stroke

Background: To protect the ischemic penumbra, guidelines have recommended against treating all but the severest elevations in blood pressure during acute ischemic stroke. Objective: To determine how often antihypertensive agents were used in routine clinical practice and whether this use was consistent with guideline recommendations. Methods: The records of patients discharged with ischemic stroke in 2000 at Baystate Medical Center in Springfield, MA, were reviewed. Adherence was evaluated by examining the use of antihypertensive agents in the context of daily blood pressure recordings during the first 4 days of hospitalization. Therapy was considered appropriate in the setting of severe hypertension (systolic blood pressure of >220 mm Hg or mean arterial blood pressure of >130 mm Hg) and potentially harmful in the setting of relative (systolic blood pressure of <120 mm Hg or mean arterial blood pressure of <85 mm Hg) or absolute (systolic blood pressure of <90 mm Hg or mean arterial blood pressure of <60 mm Hg) hypotension. Results: One hundred (65%) of the 154 ischemic stroke patients were treated with antihypertensive agents. Forty-two percent of those who had received therapy prior to admission had their regimen intensified, and 36% of previously untreated patients had therapy initiated. Sixteen (11%) patients had hypertension severe enough to warrant treatment upon arrival, and 34 (22%) had at least one episode of severe hypertension during the first 4 hospital days. Sixty-five (65%) patients developed relative hypotension on a day when antihypertensive agents were administered, and five (5%) developed absolute hypotension. Conclusions: Most patients with acute ischemic stroke are treated with antihypertensive agents despite the absence of severe hypertension. Although low blood pressure is common among treated patients, frank hypotension is unusual.

Four years' experience with a hospitalist‐led medical emergency team: An interrupted time series

BACKGROUND The effect of Medical Emergency Teams (METs) on cardiopulmonary arrests (codes) and fatal codes remains unclear and widely debated. OBJECTIVE To describe the implementation of a hospitalist-led MET and compare the number of code calls and code deaths before and after implementation. DESIGN Interrupted time series. SETTING Tertiary care academic medical center. PATIENTS All hospitalized patients. INTERVENTION Implementation of an MET, consisting of a critical care nurse, respiratory therapist, intravenous therapist, and the patients physician. MEASUREMENTS Number of MET calls, code calls, cardiac arrests and other medical crises, and code deaths per 1000 admissions, stratified by location (inside vs outside critical care). RESULTS From implementation in March 2006 through December 2009, the MET logged 2717 calls, most commonly for respiratory distress (33%), cardiovascular instability (25%), and neurological abnormality (20%). Overall code calls declined significantly between pre-implementation and post-implementation of the MET from 7.30 (95% confidence interval [CI] 5.81, 9.16) to 4.21 (95% CI 3.42, 5.18) code calls per 1000 admissions. Outside of critical care, code calls declined from 4.70 (95% CI 3.92, 5.63) before the MET was implemented to 3.11 (95% CI 2.44, 3.97) afterwards, primarily due to a decrease in medical crises, which averaged 3.29 events per 1000 admissions (95% CI 2.70, 4.02) before implementation and decreased to 1.72 (95% CI 1.28, 2.31) afterwards. Code calls within critical care also declined. The rate of fatal codes was not affected. CONCLUSIONS A hospitalist-led MET decreased code call rates but did not affect mortality rates.

The role of the institutional review board in quality improvement: a survey of quality officers, institutional review board chairs, and journal editors

PURPOSE There has been growing concern about whether and when quality improvement activities require Institutional Review Board (IRB) review and informed consent. We sought to determine whether quality officers, IRB chairs, and journal editors share similar views about the role of IRB review and informed consent in quality improvement. METHODS A survey consisting of six quality improvement scenarios detailing the development, implementation, and evaluation of a clinical practice guideline for the management of patients with acute myocardial infarction was mailed to all medical directors of quality and IRB chairpersons at hospitals with at least 400 beds that are members of the Council of Teaching Hospitals of the Association of American Medical Colleges. The same survey was mailed to the editors of all U.S. medical journals that appear in Abridged Index Medicus. RESULTS Quality officers were less likely than IRB chairs to believe that IRB review was required for all but one of the scenarios. When a clinical practice guideline developed by a national specialty society was implemented locally and its effects evaluated by chart review and telephone calls to patients, 47% (44/94) of IRB chairs, 66% (25/38) of journal editors, but only 20% (20/100) of quality officers believed the activity should be subjected to IRB review. Among those who thought that IRB review was required, there were similar but less striking differences in the perceived need for informed consent. Agreement between quality officers and IRB chairs within the same institution was poor, ranging from 44% to 52% for three of the six scenarios. CONCLUSION In light of the pressing need to improve quality while protecting the rights of patients, efforts should be supported to clarify the role of the IRB in quality improvement activities.

Mortality rates as a measure of quality and safety, "caveat emptor".

The objective of this study was to demonstrate the impact of a single ICD-9 (International Statistical Classification of Diseases and Related Health Problems, Version 9) code on the observed-to-expected mortality ratios for acute care hospitals, calculated using administrative data. The study was a retrospective analysis of mortality data and prospective measurement of the impact of a change in coding on expected mortality rates. Measurement included overall mortality observed-to-expected mortality index for 2 hospitals and rate of use of the palliative care ICD-9 code. The main result was that both retrospective and prospective applications of this single ICD-9 code significantly reduced observed-to-expected mortality ratios. Both regulators and hospitals need to be aware of the impact of the quality of coding on publicly reported quality and patient safety data.

Predictors of Medical Management in Patients Undergoing Elective Cardiac Catheterization for Chronic Ischemic Heart Disease

Compared with medical therapy, percutaneous coronary intervention (PCI) does not reduce mortality or myocardial infarction in patients with stable angina. Therefore, PCI should be guided by refractory anginal symptoms and not just lesion characteristics.

Case Study: Preventing Surgical Complications at Baystate Medical Center

An academic medical centers experience in a collaborative surgical infection prevention project may be instructive for other organizations.

Radiologists' Recommendations for Additional Imaging on Inpatient CT Studies: Do Referring Physicians Follow Them?

Objectives Studies have found that recommendations for additional imaging (RAI) accompany up to 31% of index computed tomography (CT) scans. In this study we assessed the frequency with which recommendations are accepted by the referring physician and the impact of AI on case management. Methods We performed a cross-sectional study of all index CT scans of the chest, abdomen, and pelvis performed on adult inpatients during a 1-month period at a tertiary medical center. Each radiology report was examined for mention of RAI. We used a standardized abstraction tool to review medical records for the indication for the RAI (related to original diagnosis vs incidental finding), the clinician’s rationale for pursuing or discarding the RAI, and the impact of the AI on the inpatient treatment plan. Results Among the 430 scans reviewed, most (57.7%) were of the abdomen/pelvis. RAI was recommended in 67 cases (odds ratio [OR] 15.6%; 95% confidence interval [CI] 12.4–19.3) and AI was completed in 24 of 67 cases (35.8%). Factors associated with a recommendation for AI were the presence of an incidental finding (OR 3.5, 95% CI 1.7–6.8) and verbal communication of the result to the ordering provider (OR 2.09, 95% CI 1.23–3.5). When performed, AI altered the treatment plan 75% (18/24) of the time. Among the 43 cases in which AI was not performed, 34.1% were deferred to outpatient, 13.6% underwent alternative clinical intervention, and 13.6% were judged unnecessary by the primary team. No rationale was documented in the chart for the remaining 38.6%. Conclusions Despite concerns about autoreferral by radiologists for AI studies, we found a lower rate than in many prior studies, which may reflect a change in clinical practice. One-third of these recommendations were implemented and verbal communication was strongly associated with the likelihood of second image ordering. In the majority of the cases, the AI affected patient management. Based on these findings, radiologists should consider calling the ordering provider to increase the likelihood that the primary team will follow their recommendations.