Seetharaman Hariharan

A new tool for measurement of process‐based performance of multispecialty tertiary care hospitals

There is an increasing need of a model for the process-based performance measurement of multispecialty tertiary care hospitals for quality improvement. Analytic hierarchy process (AHP) is utilized in this study to evolve such a model. Each step in the model was derived by group-discussions and brainstorming sessions among experienced clinicians and managers. This tool was applied to two tertiary care teaching hospitals in Barbados and India. The model enabled identification of specific areas where neither hospital performed very well, and helped to suggest recommendations to improve those areas. AHP is recommended as a valuable tool to measure the process-based performance of multispecialty tertiary care hospitals.

The Effect of Preemptive Analgesia in Postoperative Pain Relief—A Prospective Double-Blind Randomized Study

OBJECTIVE To analyze the effect of infiltration of local anesthetics on postoperative pain relief. DESIGN Prospective randomized double-blind trial. Setting. University Teaching Hospital in Barbados, West Indies. PATIENTS Patients undergoing total abdominal hysterectomy. Interventions. Patients were randomly allocated into one of four groups according to the wound infiltration: 1) preoperative and postoperative 0.9% saline; 2) preoperative saline and postoperative local anesthetic mixture (10 mL 2% lidocaine added to 10 mL 0.5% bupivacaine); 3) preoperative local anesthetic mixture and postoperative saline; and 4) preoperative and postoperative local anesthetic mixture. Both patients and investigators were blinded to the group allocation. All patients received pre-incision tenoxicam and morphine, standardized anesthesia, and postoperative morphine by patient-controlled analgesia. Outcome measures. The amount of morphine used and the intensity of pain as measured by visual analog pain scale were recorded at 1, 2, 3, 4, 8, 12, 24, and 48 hours postoperatively. RESULTS Eighty patients were studied with 20 in each group. Total dose of morphine used by patients who received preoperative and postoperative local anesthetic infiltration was lesser compared to other groups, although there was no statistically significant difference. Similarly, there was no difference in the intensity of pain between any groups. CONCLUSIONS Local anesthetic infiltration before and/or after abdominal hysterectomy does not reduce the intensity of postoperative pain and analgesic requirements.

Managing healthcare quality using logical framework analysis

Purpose - The purpose of this paper is to develop an integrated quality management model that identifies problems, suggests solutions, develops a framework for implementation and helps to evaluate dynamically healthcare service performance. Design/methodology/approach - This study used the logical framework analysis (LFA) to improve the performance of healthcare service processes. LFA has three major steps - problems identification, solution derivation, and formation of a planning matrix for implementation. LFA has been applied in a case-study environment to three acute healthcare services (Operating Room utilisation, Accident and Emergency, and Intensive Care) in order to demonstrate its effectiveness. Findings - The paper finds that LFA is an effective method of quality management of hospital-based healthcare services. Research limitations/implications - This study shows LFA application in three service processes in one hospital. This very limited population sample needs to be extended. Practical implications - The proposed model can be implemented in hospital-based healthcare services in order to improve performance. It may also be applied to other services. Originality/value - Quality improvement in healthcare services is a complex and multi-dimensional task. Although various quality management tools are routinely deployed for identifying quality issues in healthcare delivery, they are not without flaws. There is an absence of an integrated approach, which can identify and analyse issues, provide solutions to resolve those issues, develop a project management framework to implement those solutions. This study introduces an integrated and uniform quality management tool for healthcare services.

Managing healthcare performance in analytical framework

Purpose – The purpose of the paper is to develop an integrated framework for performance management of healthcare services. Design/methodology/approach – This study develops a performance management framework for healthcare services using a combined analytic hierarchy process (AHP) and logical framework (LOGFRAME). The framework is then applied to the intensive care units of three different hospitals in developing nations. Numerous focus group discussions were undertaken, involving experts from the specific area under investigation. Findings – The study reveals that a combination of outcome, structure and process-based critical success factors and a combined AHP and LOGFRAME-based performance management framework helps manage performance of healthcare services. Practical implications – The proposed framework could be practiced in hospital-based healthcare services. Originality/value – The conventional approaches to healthcare performance management are either outcome-based or process-based, which cannot reveal improvement measures appropriately in order to assure superior performance. Additionally, they lack planning, implementing and evaluating improvement projects that are identified from performance measurement. This study presents an integrated approach to performance measurement and implementing framework of improvement projects.

Futility-of-care decisions in the treatment of moribund intensive care patients in a developing country

PurposeTo analyze the characteristics of moribund patients in a surgical intensive care unit (ICU) and highlight the dilemmas inherent in treating such patients.MethodsData on all patients admitted to the surgical ICU during the period of three years from July 1999 to June 2002 were collected prospectively. Data were collected on very ill patients who died, in whom it appeared obvious that treatment could not have improved their condition and whose death could have been anticipated. The case notes were subjected to further analysis to determine the difficulties encountered in managing patients whose therapy was considered to be futile.ResultsOf 662 admissions, 100 (15.1%) died and 30 (4.5%) patients were treated aggressively, even after a prognosis which reflected futile treatment. The overall mean length of stay for survivors was 7.5 ± 9.0 [standard deviation (SD)] days and that for the non-survivors was 12.8 ± 18.1 (SD;P < 0.001). The cost incurred for the treatment of non-survivors was significantly higher than that for the surviving patients. The factors relating to the decisions to continue futile therapy were age of the patient, legal considerations, family wishes and differing opinions between treating physicians.ConclusionConsideration of futility during end-of-life care did not receive adequate attention in this unit which incurred additional human and material resources.RésuméObjectifAnalyser les caractéristiques des patients moribonds d’une unité de soins intensifs chirurgicaux (USI) et souligner les dilemmes inhérents au traitement de ces patients.MéthodeNous avons rassemblé prospectivement les données concernant tous les patients admis à l’USI chirurgicaux de juillet 1999 à juin 2002. Nous avons gardé les données sur des patients gravement malades qui sont décédés, pour qui il est apparu évident que le traitement n’avait pas amélioré la condition et dont la mort pouvait être prévue Les informations ont été ensuite soumises à une analyse supplémentaire afin de préciser les difficultés de prise en charge de ces patients dont le traitement était considéré inutile.RésultatsDes 662 patients admis, 100 (15,1 %) sont décédés et 30 (4,5 %) ont reçu un traitement énergique, même après un pronostic qui révélait l’inutilité du traitement. La moyenne globale de la longueur du séjour hospitalier des survivants a été de 7,5 ± 9,0 jours [écart type] et celle des non survivants a été de 12,8 ± 18,1 jours (écart type; P < 0,001). Le coût du traitement des non survivants a été significativement plus élevé que celui des survivants. Les facteurs qui ont amené à poursuivre un traitement inutile étaient l’âge du patient, des préoccupations légales, des demandes de la famille et des divergences d’opinions entre les médecins traitants.ConclusionOn ne se préoccupe pas suffisamment de l’inutilité des soins aux personnes en fin de vie à l’USI chirurgicaux, ce qui entraîne l’utilisation de ressources humaines et matérielles supplémentaires.

Performance measurement of intensive care services in hospitals:The case of Barbados

The Intensive Care Unit (ICU) being one of those vital areas of a hospital providing clinical care, the quality of service rendered must be monitored and measured quantitatively. It is, therefore, essential to know the performance of an ICU, in order to identify any deficits and enable the service providers to improve the quality of service. Although there have been many attempts to do this with the help of illness severity scoring systems, the relative lack of success using these methods has led to the search for a form of measurement, which would encompass all the different aspects of an ICU in a holistic manner. The Analytic Hierarchy Process (AHP), a multiple-attribute, decision-making technique is utilised in this study to evolve a system to measure the performance of ICU services reliably. This tool has been applied to a surgical ICU in Barbados; we recommend AHP as a valuable tool to quantify the performance of an ICU. Copyright

Trends in breast cancer mortality in Trinidad and Tobago—A 35-year study

BACKGROUND Breast cancer is the most frequently diagnosed cancer among women worldwide. This study examines the breast cancer mortality patterns and trends in the Caribbean island state, Trinidad and Tobago for the 35-year period, 1970-2004. METHODS A retrospective analysis of the trends in breast cancer mortality from 1970 to 2004 was conducted. Crude mortality per 100,000 women, age-standardized mortality using World Standard population and age-stratified mortality were calculated and comparison was made between age groups above and below 50 years. RESULTS A general pattern of increase was observed in both crude and age-standardized mortality. The overall average crude mortality was 15.6 per 100,000 women (95% confidence interval (CI) 13.9-17.1) and the average age-standardized mortality was 18.0 per 100,000 women (95% CI 16.7-19.2). There was a pattern of increase in mortality with increasing age. The mortality rate was considerably higher for the age groups above 50 years than those less than 50 years of age both showing an upward trend over the 35-year period. CONCLUSIONS Breast cancer mortality continued to increase over the 35-year period in Trinidad and Tobago. This study did not identify the exact reasons for this increasing trend. However, it is known that Trinidad and Tobago is becoming much more industrialized. It may be speculated that decrease in fertility rates, increase in the incidence of obesity and hormone utilization could have influenced this trend.

The economic impact of hospitalization for diabetic foot infections in a Caribbean nation.

CONTEXT Foot infection is the most common complication of diabetes mellitus in the Caribbean. Diabetic foot infections place a heavy burden on health care resources in the Caribbean. OBJECTIVE To evaluate the treatment-related costs for diabetic foot infections in a Caribbean nation. METHODS We identified all patients with diabetic foot infections in a 730-bed hospital serving a catchment population of approximately 400,000 persons from June 1, 2011 through July 31, 2012. The following data were collected: details of infection, antibiotic usage, investigations performed, number of physician consultations, details of operative treatment, and duration of hospitalization. Total charges were tallied to determine the final cost for inhospital treatment of diabetic foot infections. RESULTS There were 446 patients hospitalized with diabetic foot infections, yielding approximately 0.75% annual risk for patients with diabetes to develop foot infections. The mean duration of hospitalization was 22.5 days. Sixteen patients (3.6%) were treated conservatively without an operative procedure and 430 (96.4%) required some form of operative intervention. There were 885 debridements, 193 minor amputations and 60 major amputations, 7102 wound dressings, 2763 wound cultures, and 27,015 glucometer measurements. When the hospital charges were tallied, a total of US

Laparoscopic Management of a Massive Splenic Cyst

13,922,178 (mean, US

Perforated left-sided diverticulitis with faecal peritonitis: is the Hinchey classification the best guide for surgical decision making?

31,216) were spent to treat diabetic foot infections in these 446 patients during 1 year at this hospital. CONCLUSIONS Each year, the government of Trinidad and Tobago spends US