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1
Tseng, Joshua, Harry C. Sax, and Rodrigo F. Alban. "Variability in Critical Care–Related Charge Markups in Medicare Patients." American Surgeon 84, no. 10 (October 2018): 1622–25. http://dx.doi.org/10.1177/000313481808401017.
Повний текст джерелаАнотація:
Charge markups for health care are variable and inflated several times beyond cost. Using the 2015 Medicare Provider Fee-For-Service Utilization and Payment Data file, we identified providers who billed for critical care hours and related procedures, including CPR, EKG interpretation, central line placement, arterial line placement, chest tube/thoracentesis, and emergent endotracheal intubation. Markup ratios (MRs), defined as the amount charged divided by the amount allowable, were calculated and compared; 42.1 per cent of physicians billing for critical care–related services were specialized in emergency medicine (EM). EM had the highest overall MR (median 4.99, IQR 3.60–6.88) and provided most of the services. MRs differed between genders in select cases (critical care hours: anesthesiology, EM, internal medicine, pulmonary and critical care medicine; CPR, pulmonary and critical care medicine; chest tube placement/thoracentesis, internal medicine). These differences in MR did not correspond to higher rates of Medicare allowable amounts ( P = NS). In conclusion, charge markups significantly varied by physician specialty. EM physicians had the highest MRs for most critical care–related services, including critical care hours, EKG interpretation, CPR, central venous line placement, and emergent endotracheal intubation. EM physicians also provided most of these services. Charge markups are associated with adverse consequences and represent potential targets for cost containment and consumer protection.
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Fok, Patrick T., David Teubner, Jeremy Purdell-Lewis, and Andrew Pearce. "Predictors of Prehospital On-Scene Time in an Australian Emergency Retrieval Service." Prehospital and Disaster Medicine 34, no. 03 (June 2019): 317–21. http://dx.doi.org/10.1017/s1049023x19004394.
Повний текст джерелаАнотація:
AbstractIntroduction:Prehospital physicians balance the need to stabilize patients prior to transport, minimizing the delay to transport patients to the appropriate level of care. Literature has focused on which interventions should be performed in the prehospital environment, with airway management, specifically prehospital intubation (PHI), being a commonly discussed topic. However, few studies have sought additional factors which influence scene time or quantify the impact of mission characteristics or therapeutic interventions on scene time.Hypothesis/Problem:The goal of this study was to identify specific interventions, patient demographics, or mission characteristics that increase scene time and quantify their impact on scene time.Methods:A retrospective, database model-building study was performed using the prehospital mission database of South Australian Ambulance Service (SAAS; Adelaide, South Australia) MedSTAR retrieval service from January 1, 2015 through August 31, 2016. Mission variables, including patient age, weight, gender, retrieval platform, physician type, PHI, arterial line placement, central line placement, and finger thoracostomy, were assessed for predictors of scene time.Results:A total of 506 missions were included in this study. Average prehospital scene time was 34 (SD = 21) minutes. Four mission variables significantly increased scene time: patient age, rotary wing transport, PHI, and arterial line placement increased scene time by 0.09 (SD = 0.08) minutes, 13.6 (SD = 3.2) minutes, 11.6 (SD = 3.8) minutes, and 34.4 (SD = 8.4) minutes, respectively.Conclusion:This study identifies two mission characteristics, patient age and rotary wing transport, and two interventions, PHI and arterial line placement, which significantly increase scene time. Elderly patients are medically complex and more severely injured than younger patients, thus, may require more time to stabilize on-scene. Inherent in rotary wing operations is the time to prepare for the flight, which is shorter during ground transport. The time required to safely execute a PHI is similar to that in the literature and has remained constant over the past two years; arterial line placement took longer than envisioned. The SAAS MedSTAR has changed its clinical practice guidelines for prehospital interventions based on this study’s results. Retrieval services should similarly assess the necessity and efficiency of interventions to optimize scene time, knowing that the time required to safely execute an intervention may reach a minimum duration. Defining the scene time enables mission planning, team training, and audit review with the aim of improved patient care.
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Jari, Irina, Alexandru G. Naum, Liliana Gheorghe, Dragos Negru, Paloma Horjinec, Bogdan M. Ciuntu, Daniel Timofte, and Manuela Ursaru. "Granuloma of Silicone Breast Implants A case report and literature review." Revista de Chimie 70, no. 3 (April 15, 2019): 940–42. http://dx.doi.org/10.37358/rc.19.3.7035.
Повний текст джерелаАнотація:
Silicone, a synthetic polymer containing the element silicon, has been used for breast implants. Complications resulting from the placement of silicone breast implants are becoming more frequent in clinical practice. Breast implant rupture is common and poses challenges for radiologists and physicians. Radiologists must be familiar with the normal and abnormal findings of common implants. Clinically apparent silicone granulomas are a relatively rare complication of breast implant placement and surgical resection is indicated when they are symptomatic or of diagnostic concern. The objective of this study is to examine the latest generations of silicone breast implants and the clinical literature related to silicone granulomas together with a case of silicon granuloma diagnosed in our service. The findings are based on diagnostic breast Ultrasound and MRI scans performed at our service.
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Sunshine, Jonathan H., Rebecca S. Lewis, Barbara Schepps, and Howard P. Forman. "Data from a Professional Society Placement Service as a Measure of the Employment Market for Physicians." Radiology 224, no. 1 (July 2002): 193–98. http://dx.doi.org/10.1148/radiol.2241011150.
Повний текст джерела
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Struck, Manuel Florian, Franziska Rost, Thomas Schwarz, Peter Zimmermann, Manuela Siekmeyer, Daniel Gräfe, Sebastian Ebel, et al. "Epidemiological Analysis of the Emergency Vascular Access in Pediatric Trauma Patients: Single-Center Experience of Intravenous, Intraosseous, Central Venous, and Arterial Line Placements." Children 10, no. 3 (March 5, 2023): 515. http://dx.doi.org/10.3390/children10030515.
Повний текст джерелаАнотація:
Vascular access in severely injured pediatric trauma patients is associated with time-critical circumstances and low incidences, whereas only scarce literature on procedure performance is available. The purpose of this study was to analyze the performance of different vascular access procedures from the first contact at the scene until three hours after admission. Intubated pediatric trauma patients admitted from the scene to a single Level I trauma center between 2008 and 2019 were analyzed regarding intravenous (IV) and intraosseous (IO) accesses, central venous catheterization (CVC) and arterial line placement. Sixty-five children with a median age of 14 years and median injury severity score of 29 points were included, of which 62 (96.6%) underwent successful prehospital IV or IO access by emergency medical service (EMS) physicians, while it failed in two children (3.1%). On emergency department (ED) admission, IV cannulas of prehospital EMS had malfunctions or were dislodged in seven of 55 children (12.7%). IO access was performed in 17 children without complications, and was associated with younger age, higher injury severity and higher mortality. Fifty-two CVC placements (58 attempts) and 55 arterial line placements (59 attempts) were performed in 45 and 52 children, respectively. All CVC and arterial line placements were performed in the ED, operating room (OR) and intensive care unit (ICU). Ten mechanical complications related to CVC placement (17.8%) and seven related to arterial line placement (10.2%) were observed, none of which had outcome-relevant consequences. This case series suggests that mechanical issues of vascular access may frequently occur, underlining the need for special preparedness in prehospital, ED, ICU and OR environments.
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Ng, Philip K., Mark J. Ault, and Lawrence S. Maldonado. "Peripherally Inserted Central Catheters in the Intensive Care Unit." Journal of Intensive Care Medicine 11, no. 1 (January 1996): 49–54. http://dx.doi.org/10.1177/088506669601100107.
Повний текст джерелаАнотація:
We report the success rate and complications of peripherally inserted central catheters (PICCs) in patients hospitalized in an intensive care unit (ICU). We performed a cohort study in the ICU of a large tertiary care, university-affiliated community hospital. All ICU patients for whom their attending physicians requested a PICC service consultation were included. Main outcome measurements included (1) the success rate for initial PICC placement, (2) the placement complication rate, and (3) the overall success and complication rate. Of the 91 consecutive attempts at PICC placement, 89 (97.8%) were successful: of the 89 successful placements, 25 (28%) required cutdown procedures. There were 20 complications of initial placement and 8 delayed complications, which occurred in 19 PICCs. Complications included recatheterization after first attempt was unsuccessful (10), catheter malposition (7), palpitations or catheter clotting (3 each), heavy bleeding or mechanical phlebitis (2 each), and arterial puncture (1). The overall success rate for completion of therapy using the PICC was 74.7%. The most frequent reasons for failure to complete therapy were catheter dislodgment in 8 patients and “infection” in 9 patients. Of these 9 patients with “infections,” 8 catheters were discontinued due to potential infection, and only 1 was removed due to confirmed infection. The confirmed infection rate was 6/10,000 patient days. The PICC appears to be a reasonable alternative to other approaches to peripheral and central venous access. The initial and overall success rates from this preliminary study justify' further evaluation of the PICC in critically ill patients.
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Baadh, Amanjit S., Stephen Rivoli, Jack Ansell, and Robert E. Graham. "Indications for Inferior Vena Cava (IVC) Filter Placement - Assessing Compliance with Accepted Standards Set by Two Professional Societies." Blood 116, no. 21 (November 19, 2010): 2553. http://dx.doi.org/10.1182/blood.v116.21.2553.2553.
Повний текст джерелаАнотація:
Abstract Abstract 2553 Background: Inferior Vena Cava (IVC) filter placement has increased significantly over the past few decades, due to expanding indications for filter placement. Indications for filter placement vary widely depending on which professional society recommendations are followed. Our objectives were to record the number of IVC filters placed in our medium sized metropolitan teaching hospital, assess the effect of medical specialty on placement and evaluate compliance with accepted standards as set by the American College of Chest Physicians (ACCP) and the Society of Interventional Radiology (SIR). Methods: Single-center, retrospective medical record review of all patients who received an IVC filter over 26 months (01/30/2008 - 4/5/2010). Inclusion criteria included patients from both sexes, all ages, filter placement within the aforementioned dates and inpatient procedures performed by interventional radiology. A total of 443 IVC filters were placed in our institution over the time period studied. 48.1% (213) of these filters were placed by interventional radiology. Of these, 187 were reviewed with 26 excluded do to incomplete patient records available at the time of review (July 2010). Medical records were reviewed for patient demographics, clinical course, and compliance with accepted guidelines set by the ACCP and SIR. Results: The average age was 75.3 years and 43.9% of the patients were males. 76.2% of patients were on the medical service (internal medicine and its subspecialties) whereas 22.8% were on non medical services. 87.2 % of filters were recommended by medicine and its subspecialties and 12.8% by non medical specialties. 43.3% of filters placed met guidelines established by the ACCP (Table 1). 79.1% of filters placed met SIR guidelines (Table 2). No documentation was available to assess compliance for 20.9% of filters. 46% of filters placed by internal medicine and its subspecialties met ACCP criteria whereas only 25% of filters recommended by non medicine specialties were compliant with criteria (p value=0.039, 95% CI). Physicians within internal medicine and its subspecialties were compliant with SIR guidelines for 84% of the filters placed, whereas only 46% of non medicine physicians met these indications (p=0.001, 95% CI). 35.8% of filters placed met SIR criteria but did not meet ACCP guidelines. Conclusions: Indications for IVC filter placement varied significantly in this study, less than half of filters placed met ACCP guidelines, yet over three-fourths met criteria set by the SIR, especially when comparing medicine and non medicine specialties. In analyzing the filters which meet indications set by SIR but not ACCP it becomes apparent that most of these are placed for patients classified as “fall risks”, failures of anticoagulation, limited cardiopulmonary reserve and medication noncompliance. Further research needs to be guided towards evaluating if these indications truly merit the placement of an IVC filter. This study strongly suggests a need for harmonization of current guidelines espoused by professional societies. A limitation of our study was that 230 filters placed by vascular surgery and interventional cardiology were not reviewed. Disclosures: No relevant conflicts of interest to declare.
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Teitelbaum, Louise, Dorothy Cotton, M. Lynne Ginsburg, and Yousery H. Nashed. "Psychogeriatric Consultation Services: Effect and Effectiveness." Canadian Journal of Psychiatry 41, no. 10 (December 1996): 638–44. http://dx.doi.org/10.1177/070674379604101006.
Повний текст джерелаАнотація:
Objectives: To determine the nature of referrals to a psychogeriatric consultation/outreach service, the types of interventions provided, and the effects and effectiveness of the service. Method: The study used a prospective approach in which 67 consecutive patients referred for psychogeriatric assessment were followed up 6 to 8 weeks after the initial assessment and then again 6 months after initial contact. Patients were rated at the time of referral and at follow-up on presence of psychiatric diagnosis, need for institutional care, and placement outcome. Results: Of the 67 patients initially seen, 51 (76%) experienced memory problems and 46 (69%) had depressed mood. Consistent with this finding, 36 (54%) were diagnosed by consultants as having a dementia, and 15 (22%) received a diagnosis of depression. The most frequent recommendations included medication changes in 34 cases (50%) and further assessments in 37 cases (55%). Although information at 6-week follow-up was available for only 58% (n = 38) of the sample, 18 (46%) patients were generally improved. Interestingly, only 12 (31%) of referring physicians indicated that they had followed the advice of the consultants. Cognitive impairment and depressive symptoms were major concerns among referring physicians. The most common recommendation made involved pharmacotherapy. While compliance of family doctors to recommendations made was poor, patients improved over time. Patients requiring inpatient assessment were very old, living alone, experiencing behavioural problems, and not depressed. Conclusions: Psychogeriatric consultations appear most useful in cases where patients are more severely affected and/or are suffering from a greater range of symptoms.
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McLean, Karen, Harriet Hiscock, Dorothy Scott, and Sharon Goldfeld. "What is the timeliness and extent of health service use of Victorian (Australia) children in the year after entry to out-of-home care? Protocol for a retrospective cohort study using linked administrative data." BMJ Paediatrics Open 3, no. 1 (January 2019): e000400. http://dx.doi.org/10.1136/bmjpo-2018-000400.
Повний текст джерелаАнотація:
IntroductionChildren entering out-of-home care have high rates of health needs across all domains of health. To identify these needs early and optimise long-term outcomes, routine health assessment on entry to care is recommended by child health experts and included in policy in many jurisdictions. If effective, this ought to lead to high rates of health service use as needs are addressed. Victoria (Australia) has no state-wide approach to deliver routine health assessments and no data to describe the timing and use of health service visits for children in out-of-home care. This retrospective cohort data linkage study aims to describe the extent and timeliness of health service use by Victorian children (aged 0–12 years) who entered out-of-home care for the first time between 1 April 2010 and 31 December 2015, in the first 12 months of care.Methods and analysisThe sample will be identified in the Victorian Child Protection database. Child and placement variables will be extracted. Linked health databases will provide additional data: six state databases that collate data about hospital admissions, emergency department presentations and attendances at dental, mental and community health services and public hospital outpatients. The federal Medicare Benefits Schedule claims dataset will provide information on visits to general practitioners, specialist physicians (including paediatricians), optometrists, audiologists and dentists. The number, type and timing of visits to different health services will be determined and benchmarked to national standards. Multivariable logistic regression will examine the effects of child and system variables on the odds of timely health visits, and proportional-hazards regression will explore the effects on time to first health visits.Ethics and disseminationEthical and data custodian approval has been obtained for this study. Dissemination will include presentation of findings to policy and service stakeholders in addition to scientific papers.
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Chow, Courtney, and Richard Rosenquist. "Trends in spinal cord stimulation utilization: change, growth and implications for the future." Regional Anesthesia & Pain Medicine 48, no. 6 (April 20, 2023): 296–301. http://dx.doi.org/10.1136/rapm-2023-104346.
Повний текст джерелаАнотація:
Chronic pain impacts more than 100 million Americans and has a significant impact on the economy and quality of life. Spinal cord stimulation (SCS) has demonstrated efficacy in managing a growing number of chronic pain conditions. This in combination with an increasing number of physicians trained in SCS placement has produced significant changes in utilization, expense and sites of service related to SCS. In particular, there has been a large increase in SCS placement by non-surgeons, use of percutaneous leads and performance in ambulatory surgery centers instead of inpatient settings. There are also notable differences in SCS use related to age, race, insurance coverage and geography. There is a large potential market and use of these therapies is predicted to grow from $2.41 billion in 2020 to $4.12 billion US dollars globally by 2027. At the same time, there is increasing scrutiny around utilization of this therapy related to cost, complications, long-term efficacy and explant rates that has the potential to impact access to this therapy in the future. We must examine our indications, technique and management to optimize outcomes and utilization of SCS going forward.
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Rajasekhar, Anita, Hany Elmariah, Darwin Ang, Lawrence Lottenberg, Rebecca Beyth, and Richard Lottenberg. "Inferior Vena Cava Filters in Trauma Patients: A National Practice Pattern Survey of U.S. Trauma Centers." Blood 120, no. 21 (November 16, 2012): 4249. http://dx.doi.org/10.1182/blood.v120.21.4249.4249.
Повний текст джерелаАнотація:
Abstract Abstract 4249 Background: Despite the paucity of randomized controlled trials and strong observational studies supporting the efficacy of inferior vena cava filters (IVCFs) in venous thromboembolism (VTE) prevention, indications for placement of IVCFs have increased. Further, evidence-based guidelines for removal of retrievable filters do not exist. The purpose of this study was to characterize contemporary IVCF practices in the prevention and management of VTE, and clarify the stakeholders in IVCF placement and retrieval among trauma centers across the United States. Methods: In September 2011 a web-based survey was distributed to 1206 members of the Eastern Association for the Surgery of Trauma (EAST) in 3 waves over 3 weeks. This 31-question multiple choice and open-ended survey addressed: 1) provider and practice characteristics, 2) trauma patient population, 3) clinical practice of IVCF placement and retrieval, and 4) pharmacologic prophylaxis (PP). Results: Of the 1059 eligible providers that care for trauma patients on a routine basis, 281 completed the survey (27% response rate); 27% were identified as trauma directors. Seventy-two percent of all responents practiced in an academic setting and 74.7% in a level-1 trauma center. Sixty percent of trauma directors reported more than 1,000 trauma admissions per year. Familiarity with the 2002 EAST and 2008 American College of Chest Physicians guidelines for IVCF placement was noted by 84.3% and 63.0% of respondents, respectively. The majority of trauma centers placed IVCFs (98.9%), of which 3.6% placed only permanent IVCFs, 27.3% only retrievable IVCFs, and 67.3% both. Only 28.4% of centers had an institutional clinical protocol for IVCF placement and 25.5% for removal of IVCFs. The most common indication for IVCF placement was acute VTE and contraindication to therapeutic anticoagulation (32.4%). Prophylactic IVCFs (pIVCFs) in high-risk patients without known VTE were utilized by 97.6% of respondents. Indications for pIVCFs included inability to receive PP (26.5%), incomplete spinal cord injury (19.8%), and complex pelvic fracture with long bone fracture (19.6%). Filter insertion was performed by interventional radiologists (48.1%), vascular surgeons (35.6%), and/or trauma surgeons (15.5%) at each institution. Ultrasound guidance was used in 23.3% of IVCFs placed and 14.0% of insertions occured at the bedside. Acute and long-term complications encountered by providers included filter migration (21.0%), recurrent VTE (15.5%), hematoma (15.5%), and inferior vena cava thrombosis (13.8%). Surveillance for lower extremity deep vein thromboses in trauma patients was performed by 52% of centers. A registry to track patients with IVCFs was maintained by 38% of centers. Decisions to refer patients for IVCF removal were made by the proceduralist service (37.7%), ordering service (38.7%), and/or service following patients after discharge (12.7%). Only 2.5% of respondents removed IVCFs prior to hospital discharge. Screening for VTE prior to IVCF removal was performed with ultrasound (28%), venogram (14.4%), or computed tomography (2.5%), however 43.3% were uncertain of the screening method. In addition to IVCFs, adjunctive VTE prophylaxis indicated by respondents were sequential compression devices (26.7%), low molecular weight heparin (39.0%), unfractionated heparin (25.2%), fondaparinux (5.4%), or aspirin (2.0%). Only 1% of respondents indicated not using PP in trauma patients with IVCFs. Formal institutional PP guidelines existed in 92.9% of institutions. The most common reasons for contraindication to PP included pelvic or retroperitoneal hematoma requiring transfusion of blood products (20.0%), traumatic brain injury (18.3%), ocular injury with hemorrhage (16.3%), coagulopathy (13.6%), and solid intra-abdominal organ injury (11.4%). Sixty-one providers (7.1%) did not indicate any absolute contraindications for PP outside of acute phase of the above injuries. Conclusion: This study confirms the widespread use of IVCFs for both acute VTE and prophylactic indications. However, considerable variation in practice patterns with regards to institutional protocols for IVCF placement and retireval as well as utilization of adjunctive pharmacologic prophylaxis exists. These differences highlight the need for well-designed randomized controlled trials to address the efficacy and safety of IVCFs in trauma patients. Disclosures: No relevant conflicts of interest to declare.
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Wood, Teresa, Valerie Sabol, Jill Engel, Deborah H. Allen, Julie A. Thompson, and Tracey L. Yap. "Using an Electromagnetic Guidance System for Placement of Small-Bowel Feeding Tubes to Reduce Feeding Start Times." Critical Care Nurse 43, no. 1 (February 1, 2023): 52–58. http://dx.doi.org/10.4037/ccn2023847.
Повний текст джерелаАнотація:
Background Cardiothoracic surgery patients have an increased risk for aspiration and may require enteral access for nutrition. Local Problem In a cardiothoracic intensive care unit, feeding start times were delayed because of scheduling conflicts with support services. An electromagnetic device (Cortrak 2 Enteral Access System, Avanos Medical) was introduced to allow advanced practice providers (nurse practitioners and physician assistants) to independently establish postpyloric access and reduce dependence on ancillary services. Methods A quality improvement study was performed. Pre- and postimplementation data included order time, service arrival, tube placement time, tube positioning, and feeding start times for 207 placements. Pre- and postimplementation surveys were conducted to evaluate advanced practice provider satisfaction with enteral tube placement practices. Results Feeding start time for initial placement decreased by 35.5% (15.6 hours to 10 hours); for subsequent placement, by 55.2% (15.5 hours to 7.0 hours). Assistance by support services decreased by 80.4% (before implementation, 100 of 100 placements [100%]; after implementation, 21 of 107 placements [19.6%]; P < .001; ϕ = 0.815). Overall, advanced practice provider satisfaction increased. Most participants said that using the electromagnetic device was faster, nutrition was delivered sooner, and implementation was a valuable practice change. Conclusions Using an electromagnetic device decreased feeding start times, reduced the need for support services, and increased advanced practice provider satisfaction with small-bowel feeding tube placement practices.
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Noor Sameh, Darwich, Ugur Umran, Anstadt Mark P, and Pedoto Michael J. "Cerebral arterial air embolism with anterior spinal cord syndrome after CT-guided hook-wire localization of Lung mass and pulmonary nodule." Journal of Neuroscience and Neurological Disorders 5, no. 1 (March 19, 2021): 006–15. http://dx.doi.org/10.29328/journal.jnnd.1001044.
Повний текст джерелаАнотація:
Systemic arterial air embolism (SAAE) is a rare but serious complication of CT-guided hook wire localization of pulmonary nodule usually with catastrophic and poor outcome. Hook wire needle localization is done pre-operatively by placing wire around or into the pulmonary nodule to provide the thoracic surgeon accurate location guidance of the target nodule for Video-Assisted Thoracoscopic Surgery (VATS) wedge resection with safety margins. Physicians should be aware of this possible complication during the procedure in order to rescue the patient promptly as it requires rapid diagnosis and management. We describe a 55-year-old male who underwent a CT-guided hook wire needle localization of left upper lobe lung cancer and left lower lobe pulmonary nodule prior to planned VATS wedge resection who developed altered mental status and bilateral lower extremities paralysis after wire placement was completed. His CT head demonstrated small air embolism in the left occipital area, confirming the diagnosis of cerebral air embolism and follow up CT and MRI of the head revealed multiple areas of brain infarction. In addition, he was diagnosed with anterior spinal cord syndrome (ACS), most likely due to anterior spinal artery ischemia from micro air embolism on the basis of clinical findings but with negative ischemic changes on MRI of the spinal cord. His mental status recovered but he remained paraplegic and transferred to inpatient rehabilitation service.
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Atallah, Joseph. "Use of Eptifibatide as a Bridge Antiplatelet Agent for Intrathecal Drug Delivery System Placement." Pain Physician 6;15, no. 6;12 (December 14, 2012): 479–83. http://dx.doi.org/10.36076/ppj.2012/15/479.
Повний текст джерелаАнотація:
Use of antiplatelet agents is becoming increasingly common, and their management may require new strategies if neuroaxial techniques are to be employed in patients who will not tolerate discontinuation of antiplatelet therapy. The patient was a 46-year-old man with a past medical history significant for coronary artery disease and who had undergone 14 stents. He developed stent thrombosis (ST) while on clopidogrel. Following the ST, he was subsequently placed on prasugrel. While on prasugrel, the patient presented for an intrathecal drug delivery system (IDDS) trial and placement due to severe peripheral neuropathy unresponsive to several conservative medical treatments. He had previously undergone an unsuccessful spinal cord stimulator trial and received no pain relief. In consultation with his outside cardiologist, the patient received permission to hold his prasugrel for 7 days prior to his intrathecal pump trial. During the trial period’s inpatient hospitalization, the patient developed chest pain. In consultation with the cardiology service in our institution, it was decided antiplatelet therapy should be re-instituted. The patient was bridged to his IDDS placement after the trial with intravenous eptifibatide. The eptifibatide drip was administered 6 hours prior to the IDDS implant. Functional platelet count was checked one hour before the IDDS was placed and the pump was placed without incident. The eptifibatide drip was reinstituted one hour after the IDDS implantation. The patient was observed for 24 hours on the eptifibatide drip, transitioned to his home dose of prasugrel, and discharged home. At outpatient follow-up one week later, the patient demonstrated no neurologic or hemorrhagic complications and was satisfied with the pain control provided by the IDDS. Prasugrel is an irreversible platelet inhibitor, which prevents ADP-induced platelet aggregation by binding the P2Y12 receptor. Patients taking prasugrel will have deficient platelet activity until new platelets have been produced, a span of approximately 7 days. Eptifibatide is an intravenous glycoprotein IIb/IIIa inhibitor with a short half-life of 2½ hours. Inhibition of glycoprotein IIb/IIIa prevents platelet activation and aggregation. The drug effect ceases once it is discontinued and restoration of platelet function is not dependent upon new platelet production. Patients requiring antiplatelet therapy in need of neuroaxial pain management procedures present challenging problems to pain management physicians. Current guidelines from the American Society of Regional Anesthesia have not identified any bridging agent suitable for patients who may not tolerate prolonged withdrawal from their antiplatelet therapy. In this case, eptifibatide was successfully utilized to bridge a patient whose comorbid conditions necessitated continuous antiplatelet therapy without the prolonged washout common to irreversible antiplatelet agents. Key words: Intrathecal drug delivery system, anticoagulation, pain, eptifibatide, antiplatelet agents.
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Douglas-Ntagha, Pamela Bernice. "Redesigning the transfer center process to adapt to increasing demands for services." Journal of Clinical Oncology 30, no. 34_suppl (December 1, 2012): 156. http://dx.doi.org/10.1200/jco.2012.30.34_suppl.156.
Повний текст джерелаАнотація:
156 Background: Hospitals are faced with limited resources and a need to provide care to patients with the greatest needs. Methods: Develop a systematic approach for accepting external transfers to the appropriate setting of care based on clinical criteria Initiate communication between external physicians and accepting MDA (MD Anderson) physicians and ICU physicians as appropriate Identify a process for documenting clinical information to ensure appropriate and timely transfers to MDA Ensure policies and procedures align with EMTALA regulation. Results: MDA ICU physicians involved in the initial decision, as appropriate External transfer acceptance based on bed availability MDA physician must be physically present to manage transfer, conduct evaluation and develop treatment plan Incorporate into procedure telephone communication with external physician, TC Medical Director, MDA accepting physician (ICU and Pedi physician as appropriate) Operational definitions for routine and urgent have been established Non-emergent transfers occur weekdays between the hours of 8AM and 5PM Transfer Acceptance Form to capture clinical information was developed. Conclusions: Problem 1: Suboptimal Communication Developed a TC form. During first eight months of operation we achieved 85% compliance with regards to documentation of transfer. Compliance continues to trend upward. Problem 2: Placement of Patients in Appropriate Care Settings Decreased utilization of MDA Emergency Center beds noted as external transfer to inpatient beds increased. Problem 3: Sporadic Arrival of Non-emergent Transfers The majority of after-hours (between 5PM and 8AM) transfers were routine and urgent prior to project. After the intervention, the number of routine and urgent after-hours transfer trended downwards. After-hour emergent transfers increased indicating appropriate utilization of beds for patients with the greatest needs. Problem 4: Lack of Systematic Screening and Documentation Retrospective medical record audits of 100% of emergent transfers were conducted by the TCMedical Directors in collaboration with the Director of Patient Resources. 97% of emergent transfers were confirmed as emergent on retrospective review.
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Do, Thao Thi, Tri Minh Trinh, Thao Thi Phuong Tran, Van Thi Tuong Nguyen, and Lam Nguyen Le. "Clinical performance of computer-aided design/computer-aided manufacture lithium disilicate ceramic endocrown restorations: A 2-year study." Journal of Conservative Dentistry and Endodontics 27, no. 1 (January 2024): 51–56. http://dx.doi.org/10.4103/jcde.jcde_99_23.
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Abstract Context: Optimal restoration methods for endodontically treated teeth (ETTs) have always remained an ongoing discussion among physicians in this day and age. ETTs have a tendency to fracture when chewing, compared to initial teeth. From the perspective of biology, preserving and restoring tooth structure is critical to maintaining biomechanical, functional, and esthetic harmony. Dental bonding techniques have lessened the necessity for post-and-core restorations in ETTs with severe substance loss. A minimally invasive endodontic restoration technique called “endocrown” was initially introduced by Bindl and Mörmann in 1999. Aims: The aim of the study was to clinically evaluate all-ceramic mandibular molar endocrowns made using computer-aided design/computer-aided manufacturing (CAD/CAM) following 2 years of follow-up. Subjects and Methods: This unblinded study contains 56 patients with 56 mandibular molars, which had severe substance loss. After teeth preparation, lithium disilicate ceramic endocrowns were manufactured with the CEREC CAD/CAM system, and cementation was performed using a composite luting agent. The endocrowns were assessed using the modified United States Public Health Service criteria at baseline, 6 months, 1 year, and 2 years following placement. Patient satisfaction was evaluated using a questionnaire. Statistical Analysis Used: This study used descriptive statistics, including mean, standard deviation, and 95% confidence intervals. Data were processed using STATA version 14.0 (StataCorp LLC, USA). Results: Two endocrowns (3.6%) failed throughout the period of observation. The high clinical rating criteria (96.4%, count of 54) and the increased satisfaction percentage (94.6%, count of 53) remained practically stable during the follow-up assessments at 6 months and after 1–2 years. Conclusions: Endocrown offers a less invasive treatment option that may be a better method for endodontically treated mandibular molars. With contemporary CAD/CAM technology and new materials, time in the chair and esthetics optimally improved, bringing satisfaction to the patient.
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Kane, Kathleen E., Robert J. Tomsho, Karen Pheasant, Thomas Stauffer, Brent Schoenfeldt, Scott Hamilton, Travis Kain, and Bryan G. Kane. "The “ICE” Study: Feasibility of Inexpensive Commercial Coolers on Mobile EMS Units." Prehospital and Disaster Medicine 29, no. 3 (June 2014): 254–61. http://dx.doi.org/10.1017/s1049023x14000545.
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AbstractIntroductionPrehospital postresuscitation induced hypothermia (IH) has been shown to reduce neurological complications in comatose cardiac-arrest survivors. Retrofitting ambulances to include equipment appropriate to initiate hypothermia, such as refrigeration units for cooled saline, is expensive. The objective of this nonhuman subject research study was to determine if inexpensive, commercially available coolers could, in conjunction with five reusable ice packs, keep two 1 L bags of precooled 0.9% normal saline solution (NSS) at or below 4°C for an average shift of eight to 12 hours in a real-world environment, on board in-service Emergency Medical Service (EMS) units, over varying weather conditions in all seasons.MethodsThe coolers were chosen based on availability and affordability from two nationally available brands: The Igloo MaxxCold (Igloo Products Corp., Katy, Texas USA) and Coleman (The Coleman Company, Wichita, Kansas USA). Both are 8.5 liter (nine-quart) coolers that were chosen because they adequately held two 1 L bags of saline solution, along with the reusable ice packs designated in the study design, and were small enough for ease of placement on ambulances. Initial testing of the coolers was conducted in a controlled environment. Thereafter, each EMS unit was responsible to cool the saline to less than 4°C prior to shift. Data were collected by emergency medical technicians, paramedics, and resident physicians working in seven different ambulance squads. Data analysis was performed using repeated measurements recorded over a 12-hour period from 19 individual coolers and were summarized by individual time points using descriptive statistics.ResultsInitial testing determined that the coolers maintained temperatures of 4°C for 12 hours in a controlled environment. On the ambulances, results based on the repeated measurements over time revealed that the saline solution samples as defined in the protocol, remained consistently below 4°C for 12 hours. Utilizing the lower bound of the 2-sided 95% exact binomial confidence intervals, there was less than a five percent chance that saline samples could not be maintained below 4°C for 12 hours, even during the summer months.ConclusionsSimple, commercially available coolers can maintain two 1 L bags of 0.9% NSS at 4°C for 12 hours in ambulances in varying environmental conditions. This suggests that EMS agencies could inexpensively initiate prehospital IH in appropriate cases.KaneKE, TomshoRJ, PheasantK, StaufferT, SchoenfeldtB, HamiltonS, KainT, KaneBG. The “ICE” study: feasibility of inexpensive commercial coolers on mobile EMS units. Prehosp Disaster Med. 2014;29(3):1-8.
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Nordyke, Robert J., Heidi Reichert, Lauren C. Bylsma, Jenny J. Jackson, Shawn M. Gage, Jon Fryzek, Prabir Roy-Chaudhury, and Theodore Lithgow. "Costs Attributable to Arteriovenous Fistula and Arteriovenous Graft Placements in Hemodialysis Patients with Medicare coverage." American Journal of Nephrology 50, no. 4 (2019): 320–28. http://dx.doi.org/10.1159/000502507.
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Introduction: Hemodialysis (HD) in end-stage renal disease (ESRD) patients requires vascular access (VA) through an arteriovenous fistula (AVF), a prosthetic arteriovenous graft (AVG), or a central venous catheter. While AVF or AVG is commonly used for HD, the economic implications of AVF versus AVG use have not been fully established. We describe the healthcare resource utilization and costs of AVF and AVG use for incident ESRD patients in the United States. Methods: This observational cohort study of AVF and AVG placements used data from the United States Renal Data System to identify and follow access placements. AVF and AVG placements after ESRD onset for incident patients from 2012 to 2014 with continuous Medicare primary coverage were included. All-cause and access-related Medicare costs were averaged over the placement lifetime and expressed as per dialysis-month costs. Results: The analysis included 38,035 AVF placements and 12,789 AVG placements. Total all-cause monthly costs for AVF averaged USD 8,508; mean monthly costs were USD 3,027 for inpatient (IP), USD 3,139 for outpatient (OP), USD 1,572 for physician services, and USD 770 for other care settings. Access-related monthly costs averaged USD 1,699 and represented 20% of all-cause charges for AVFs. Mean all-cause monthly costs for AVG were USD 9,605; by setting monthly costs were USD 3,811 for IP, USD 3,034 for OP, USD 1,881 for physician services and USD 879 for other care settings. Access-related monthly costs averaged USD 2,656 and represented 28% of all-cause charges for AVGs. Discussion/Conclusions: This study indicates that costs due to VA are a significant burden on Medicare budgets and on patients. The factors driving access-related utilization and costs merit attention in future research. Both optimizing process of care and discovery innovation may significantly accelerate better stewardship of available healthcare resources.
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Le, Aline, Le Kang, Andrew Noda, Emily Godbout, John Daniel Markley, Kimberly Lee, Amy Pakyz, et al. "Effect of Meropenem Restriction on Time Between Order and Administration in a Medical Intensive Care Unit." Infection Control & Hospital Epidemiology 41, S1 (October 2020): s470. http://dx.doi.org/10.1017/ice.2020.1145.
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Background: In this study, we assessed whether meropenem restriction led to delays in administration for patients in a medical intensive care unit (MICU) at a large tertiary-care urban teaching hospital. Methods: The antimicrobial stewardship program (ASP) at Virginia Commonwealth University Health System (VCUHS) requires approval for restricted antimicrobial orders placed between 8 a.m. and 9 p.m. Between 8 a.m. and 5 p.m. (daytime), authorized approvers include ASP and infectious diseases (ID) physicians. From 5 p.m. to 9 p.m. (evening) orders are approved by ID fellows. Orders were entered as Stat, Now, and Routine. Between 9 p.m. and 8 a.m. (night), patients receive doses without approval. Meropenem restriction began in mid-January 2018. Pre- and postmeropenem restriction periods were defined as February–December 2017 and February–December 2018. Meropenem use data were compared for adult patients in the MICU. A multivariable Cox regression model was implemented to compare (1) time from order entry to approval; (2) time from order approval to patient administration; (3) total time from order entry to patient administration, adjusting for order priority, approver (ASP, ID consult, ID fellow, pharmacy); and (4) time of day of order placement (day, eve, night). The analyses were performed using SAS version 9.4 software (SAS Institute, Cary, NC). Result: Time from order approval to patient administration was significantly decreased in the postrestriction period (HR, 1.840; P < .001) (Table 1). Stat orders were faster compared to routine orders for order entry to approval (HR, 1.735; P < .001), approval to administration (HR, 2.610; P < .001), and total time from order entry to administration (HR, 2.812; P < .001). No significant differences were found in time to approval by approving service. Time from order entry to approval was faster for nighttime orders than for daytime orders (HR, 1.399; P = .037). Conclusions: Our data indicate that the time from order entry to administration decreased following meropenem restriction in our MICU. More research is needed to identify the reason for this finding, but we postulate that this is due to an effect on drug administration prioritization within nursing workflow. These data will inform our local meropenem restriction efforts.Funding: NoneDisclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.
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Mahadev, Srihari, Olga C. Aroniadis, Luis H. Barraza, Emil Agarunov, Michael S. Smith, Adam J. Goodman, Petros C. Benias, et al. "Gastrointestinal endoscopy during the coronavirus pandemic in the New York area: results from a multi-institutional survey." Endoscopy International Open 08, no. 12 (November 27, 2020): E1865—E1871. http://dx.doi.org/10.1055/a-1264-7599.
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Abstract Background and study aims The coronavirus disease 2019 (COVID-19), and measures taken to mitigate its impact, have profoundly affected the clinical care of gastroenterology patients and the work of endoscopy units. We aimed to describe the clinical care delivered by gastroenterologists and the type of procedures performed during the early to peak period of the pandemic. Methods Endoscopy leaders in the New York region were invited to participate in an electronic survey describing operations and clinical service. Surveys were distributed on April 7, 2020 and responses were collected over the following week. A follow-up survey was distributed on April 20, 2020. Participants were asked to report procedure volumes and patient characteristics, as well protocols for staffing and testing for COVID-19. Results Eleven large academic endoscopy units in the New York City region responded to the survey, representing every major hospital system. COVID patients occupied an average of 54.5 % (18 – 84 %) of hospital beds at the time of survey completion, with 14.5 % (2 %-23 %) of COVID patients requiring intensive care. Endoscopy procedure volume and the number of physicians performing procedures declined by 90 % (66 %-98 %) and 84.5 % (50 %-97 %) respectively following introduction of restricted practice. During this period the most common procedures were EGDs (7.9/unit/week; 88 % for bleeding; the remainder for foreign body and feeding tube placement); ERCPs (5/unit/week; for cholangitis in 67 % and obstructive jaundice in 20 %); Colonoscopies (4/unit/week for bleeding in 77 % or colitis in 23 %) and least common were EUS (3/unit/week for tumor biopsies). Of the sites, 44 % performed pre-procedure COVID testing and the proportion of COVID-positive patients undergoing procedures was 4.6 % in the first 2 weeks and up to 19.6 % in the subsequent 2 weeks. The majority of COVID-positive patients undergoing procedures underwent EGD (30.6 % COVID +) and ERCP (10.2 % COVID +). Conclusions COVID-19 has profoundly impacted the operation of endoscopy units in the New York region. Our data show the impact of a restricted emergency practice on endoscopy volumes and the proportion of expected COVID positive cases during the peak time of the pandemic.
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Plymire, Christopher J., Elissa G. Miller, and Meg Frizzola. "Retrospective Review of Limitations of Care for Inpatients at a Free-Standing, Tertiary Care Children’s Hospital." Children 5, no. 12 (December 10, 2018): 164. http://dx.doi.org/10.3390/children5120164.
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Limited studies exist regarding the timing, location, or physicians involved in do-not-resuscitate (DNR) order placement in pediatrics. Prior pediatric studies have noted great variations in practice during end-of-life (EOL) care. This study aims to analyze the timing, location, physician specialties, and demographic factors influencing EOL care in pediatrics. We examined the time preceding and following the implementation of a pediatric palliative care team (PCT) via a 5-year, retrospective chart review of all deceased patients previously admitted to inpatient services. Thirty-five percent (167/471) of the patients in our study died with a DNR order in place. Sixty-two percent of patients died in an ICU following DNR order placement. A difference was noted in DNR order timing between patients on general inpatient units and those discharged to home compared with those in the ICUs (p = 0.02). The overall DNR order rate increased following the initiation of the PCT from 30.8% to 39.2% (p = 0.05), but no change was noted in the rate of death in the ICUs. Our study demonstrates a variation in the timing of death following DNR order placement when comparing ICUs and general pediatric floors. Following the initiation of the PCT, we saw increased DNR frequency but no change in the interval between a DNR order and death.
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Khramtsova, Natalia Anatolyevna. "CARDIOLOGICAL SERVICE OF THE IRKUTSK REGION - RESULTS OF 2022 AND DIRECTIONS OF DEVELOPMENT." Baikal Medical Journal 2, no. 3 (September 10, 2023): 13–15. http://dx.doi.org/10.57256/2949-0715-2023-3-13-15.
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At the end of 2022, there were several positive trends in the performance of the cardiology service. Thus, mortality from circulatory system diseases (CVD) in the Irkutsk region, according to Rosstat, decreased by 4.3% compared to 2021 and amounted to 676.3 per 100,000 population. The mortality rate from MI also decreased and reached 52.9 per 100,000 population. According to the results of the year, a decrease in the total number of deaths from myocardial infarction by 145 people was noted. The proportion of hospitalizations in specialized departments of PSO and RSC increased by 6.2%, which led to a significant decrease in the number of patients who died from myocardial infarction (MI) outside the specialized departments (-54.3%). The total number of patients with acute coronary syndrome (ACS) hospitalized in specialized departments (RCC and PSO) out of all patients with ACS increased by 13.9%. The number of patients with ST-elevation ACS who underwent reperfusion therapy, both primary PCI up to 52.6%, and after thrombolytic therapy (TLT) increased. The number of X-ray endovascular interventions on the coronary arteries for medical purposes increased by 35%, on an accrual basis by the end of the year, the figure was 3952 manipulations. At the end of the year, there was a decrease in mortality from MI by 12.7%, and the figure was 10.3%, which is one of the lowest values in the Siberian Federal District. A decrease in hospital mortality from MI was recorded both in the medical organizations of the region by 2.4%, and in PSO and RSC - by 3.3%. The coverage of dispensary observation and preferential drug provision for patients after MI, coronary artery bypass grafting, radiofrequency ablation, coronary artery stenting and stroke was 92.2%. A remote ECG system for planned patients has been introduced in the region (more than 20,000 consultations have been carried out). The format of round-the-clock reception and interpretation of ECG in patients with ACS is preserved to determine the tactics of management and routing of patients. These possibilities are necessary for making decisions on timely thrombolytic therapy at the stages of evacuation of a patient with ACS and ST segment elevation. Of the problematic aspects, there is a continuing increase in mortality from coronary heart disease by 8.1% and an increase in the number of deaths from coronary artery disease outside medical organizations. The problem of increasing mortality from chronic cardiovascular diseases is due to defects in medical examination and dispensary observation at the outpatient stage. Shortcomings in the work of primary care resulted in high mortality from coronary artery disease, myocardial infarction, CHF at home, insufficient coverage of patients with CVD by dispensary observation and poor quality of dispensary appointments. Of the main priority areas in the work of the cardiological service for the next year, the following should be highlighted: control over the implementation of clinical guidelines (recurring training and testing of doctors, paramedical personnel according to clinical recommendations, multi-level examination of the quality of medical care, the introduction of medical decision support services into practice); optimizing the routing of patients with ACS and other cardiovascular diseases to the specialized departments of the region (organization of interaction between the emergency medical service, the center for disaster medicine and medical organizations in the region, eliminating time losses during the evacuation of patients with ACS, daily monitoring of hospitalizations of the region's ACS); increase in the number of pre-hospital thrombolysis in patients with ACS with ST-segment elevation (training of paramedics and doctors of mobile ambulance teams in ECG interpretation skills and first aid skills in ACS (simulation-training cycles), the widespread introduction of a “second opinion” on ECG, the presence of thrombolytics in packing SMP, daily monitoring of prehospital thrombolysis by heads of medical organizations); development of remote telemedicine technologies; control over preferential drug provision (organization of succession between the hospital and the clinic, ensuring timely (within 72 hours) placement for dispensary observation of patients of the category of Order No. 639n, control of adherence to the prescribed therapy, exclusion of unreasonable de-escalation of doses, cancellation / replacement of drugs. at the outpatient stage, maintaining a register of DLO); dispensary observation (DN) of patients with CVD (registration in MIS of certain groups of patients with CVD for the possibility of automatic generation of lists for DN, proactive invitation to DN of patients with CVD according to a pre-formed list for examination as soon as possible). Thus, the main areas of work for primary care physicians are focused on quantitative and qualitative indicators of medical examination and dispensary observation, with the creation in each polyclinic of a system for monitoring subsidized drug provision and a system for registering high-risk patients. For the ambulance stage, strict adherence to the routing and rapid delivery of patients with ACS is required, with pre-hospital thrombolysis, training of doctors / paramedics in emergency cardiology and the introduction of a remote ECG system. At the inpatient stage of medical care, continue work to improve the profile of treatment of CVD patients by minimizing hospitalizations in therapeutic departments, for this purpose, the creation of interdistrict cardiology departments, the introduction of clinical recommendations on cardiology into wide practice and control over the continuity of care with the outpatient link.
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Drennan, Vari M., Melania Calestani, Francesca Taylor, Mary Halter, and Ros Levenson. "Perceived impact on efficiency and safety of experienced American physician assistants/associates in acute hospital care in England: findings from a multi-site case organisational study." JRSM Open 11, no. 10 (October 2020): 205427042096957. http://dx.doi.org/10.1177/2054270420969572.
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Summary Objectives To investigate the contribution, efficiency and safety of experienced physician associates included in the staffing of medical/surgical teams in acute hospitals in England, including facilitating and hindering factors. Design Mixed methods longitudinal, multi-site evaluation of a two-year programme employing 27 American physician associates: interviews and documentary analysis. Setting Eight acute hospitals, England. Participants 36 medical directors, consultants, junior doctors, nurses and manager, 198 documents. Results Over time, the experienced physician associates became viewed as a positive asset to medical and surgical teams, even in services where high levels of scepticism were initially expressed. Their positive contribution was described as bringing continuity to the medical/surgical team which benefited patients, consultants, doctors-in-training, nurses and the overall efficiency of the service. This is the first report of the positive impact that, including physician associates in medical/surgical teams, had on achieving safe working hours for doctors in training. Many reported the lack of physician associates regulation with attendant legislated authority to prescribe medicines and order ionising radiation was a hindrance in their deployment and employment. However, by the end of the programme, seven hospitals had published plans to increase the numbers of physician associates employed and host clinical placements for student physician associates. Conclusions The programme demonstrated the types of contributions the experienced physician associates made to patient experience, junior doctor experience and acute care services with medical workforce shortages. The General Medical Council will regulate the profession in the future. Robust quantitative research is now required.
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Borre, Ethan D., Suephy C. Chen, Matilda W. Nicholas, Edward W. Cooner, Donna Phinney, Amanda Morrison, Natalie Combs, and Meenal Kheterpal. "Early Implementation and Evaluation of a Teledermatology Virtual Clinic Within an Academic Medical Center." Iproceedings 6, no. 1 (December 20, 2021): e35432. http://dx.doi.org/10.2196/35432.
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Background Teledermatology can increase patient access; however, its optimal implementation remains unknown. Objective This study aimed to describe and evaluate the implementation of a pilot virtual clinic teledermatology service at Duke University. Methods Leaders at Duke Dermatology and Duke Primary Care identified a teledermatology virtual clinic to meet patients’ access needs. Implementation was planned over the exploration, preparation, implementation, and sustainment phases. We evaluated the implementation success of teledermatology using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework and prioritized outcome collection through a stakeholder survey. We used the electronic health record and patient surveys to capture implementation outcomes. Results Our process consisted of primary care providers (PCPs) who sent clinical and dermatoscopic images of patient lesions or rashes via e-communication to a teledermatology virtual clinic, with a subsequent virtual clinic scheduling of a video visit with the virtual clinic providers (residents or advanced practice providers, supervised by Duke Dermatology attending physicians) within 2-5 days. The teledermatology team reviews the patient images on the day of the video visit and gives their diagnosis and management plan with either no follow-up, teledermatology nurse follow-up, or in-person follow-up evaluation. Implementation at 4 pilot clinics, involving 19 referring PCPs and 5 attending dermatologists, began on September 9, 2021. As of October 31, 2021, a total of 68 e-communications were placed (50 lesions and 18 rashes) and 64 virtual clinic video visits were completed. There were 3 patient refusals and 1 conversion to a telephonic visit. Participating primary care clinics differed in the number of patients referred with completed visits (range 2-32) and the percentage of providers using e-communications (range 13%-53%). Patients were seen soon after e-communication placement; compared to in-person wait times of >3 months, the teledermatology virtual clinic video visits occurred on average 2.75 days after e-communication. In total, 20% of virtual clinic video visits were seen as in-person visit follow-up, which suggests that the majority of patients were deemed treatable at the virtual clinic. All patients who returned the patient survey (N=10, 100%) agreed that their clinical goals were met during the virtual clinic video visits. Conclusions Our virtual clinic model for teledermatology implementation resulted in timely access for patients, while minimizing loss to follow-up, and has promising patient satisfaction outcomes. However, participating primary care clinics differ in their volume of referrals to the virtual clinic. As the teledermatology virtual clinics scale to other clinic sites, a systematic assessment of barriers and facilitators to its implementation may explain these interclinic differences. Acknowledgments We are grateful to the Private Diagnostic Clinic and Duke Institute for Health Innovation for their support. Conflicts of Interest None declared.
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deCastro, Maria Victoria A., Laura J. Eades, Sylvia A. Rineair, and Pamela J. Schoettker. "Proactive Planning for Vascular Access Therapy: One Hospital's Plan for Success." Journal of the Association for Vascular Access 19, no. 4 (December 1, 2014): 238–43. http://dx.doi.org/10.1016/j.java.2014.07.005.
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Abstract Background: Vascular access is a critical component of care for patients in neonatal intensive care units (NICUs). Our NICU had only a small number of nurses cross-trained to perform peripherally inserted central catheter (PICC) insertions and was not able to provide coverage 24 hours a day, 7 days a week. We combined the vascular access team (VAT) and NICU PICC team to improve the timeliness of NICU PICC insertions, standardize care, and use ultrasound for all PICC placements. Methods: A paper guide tool was developed to prioritize PICC placements as emergent, same-day, or nonemergent. NICU nurses were trained to insert PICCs using ultrasound. Catheter insertion and care processes were standardized for the new centralized PICC team. NICU and VAT staff worked together to improve daily communication, hand-offs, and referrals. Criteria were developed to determine the appropriate hospital location for PICC insertions. Charge nurses began capturing information about patients with PICCs on daily planning sheets. Results: Following implementation of the new combined VAT, the average wait time for emergent and same-day insertions decreased 10%. No adverse events were reported due to a delay in PICC placement or the PICC referral process. Conclusions: Combining the NICU PICC insertion nurses and the VAT into a new centralized PICC team provided an opportunity for growth in both areas. NICU PICCs are now placed efficiently based on patient acuity and referral prioritization throughout the hospital. NICU and VAT physicians and nurses have developed a strong partnership for the provision of PICC services for NICU patients.
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Campbell, John Charles, Majid Taghavi, and Peter T. VanBerkel. "Day and Night: Locating the General Practitioner’s Panel after Hours." Applied Sciences 13, no. 10 (May 20, 2023): 6273. http://dx.doi.org/10.3390/app13106273.
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Location science is used to determine the optimal geographical placement of primary care resources with operations research models. In determining the optimal placement, we account for the objectives of both patients and physicians. These objectives and the methods used to address them differ between daytime and after-hours settings. These time settings are treated separately since primary care services are typically limited during after-hours operations. Three solution approaches are considered to address both time settings: independent, sequential, and simultaneous. The independent approach is based on the p-Median problem, and the other two approaches use modified forms of the p-Median. Three case studies are examined by applying these models to census data from Nova Scotia. Solving the daytime and after-hours problem simultaneously consistently yields the best results while considering facility-sharing constraints.
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Patel, Milesh M., Lee Eisenberg, David Witsell, and Kristine A. Schulz. "Assessment of acute otitis externa and otitis media with effusion performance measures in otolaryngology practices." Otolaryngology–Head and Neck Surgery 139, no. 4 (October 2008): 490–94. http://dx.doi.org/10.1016/j.otohns.2008.07.030.
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Objective To evaluate the acute otitis externa and otitis media with effusion performance measure sets in a clinical setting and provide preliminary data on measure compliance. Study Design and Setting Quality improvement study. Subjects and Methods Convenience sampling (N = 84) was performed at five sites of ENT and Allergy Associates, LLC. Results Physicians reported prescribing topical antibiotic preparations and assessing for auricular or periauricular pain in 98% of acute otitis externa cases (N = 55). In addition, 87% did not prescribe systemic antimicrobials. Pneumatic otoscopy was used by 76% of physicians as a method for otitis media with effusion diagnosis and 10% administered a hearing test within 6 months before tympanostomy tube placement (N = 29). Furthermore, as recommended, 86% did not prescribe decongestants or antihistamines whereas 93% and 90% did not prescribe antimicrobials or systemic steroids, respectively. Conclusion Although compliance in this study was generally high across both measure sets, actual use of the face sheet forms for appropriate patients was lower than the 80% reporting mandate by the Centers for Medicare and Medicaid Services that allows physicians to receive the monetary bonus. Incentive-based reporting should be continuously investigated to assess challenges for evaluating current measures.
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Obasi, Jennifer U., and Adrian P. Umpierrez De Reguero. "Safety Profile of Bone Marrow Aspiration and Biopsies Performed By the Hospitalist Procedure Service at an Academic Center: An Observational Study." Blood 134, Supplement_1 (November 13, 2019): 5848. http://dx.doi.org/10.1182/blood-2019-121444.
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Background: Bone marrow sampling is an invasive procedure that can be obtained by aspiration and biopsy(also called trephine biopsy) and as such, requires good technical skills to avoid complications and increase diagnostic yield. Aspirate and biopsy samples are complementary and when obtained together, are an invaluable tool toward obtaining an accurate and comprehensive profile for cellular, cytogenetic, immunophenotypic and cytological assessments. Bone marrow aspiration and trephine biopsy are generally regarded as relatively low risk procedures, however, factors that should be taken into consideration include disseminated intravascular coagulopathy, factor deficiencies, skin infections, and severe thrombocytopenia. In adults, the posterior iliac crest is often the preferred site but other accessed sites include the sternum (aspiration only) and anterior superior iliac crest in obese patients.For procedures performed at the posterior iliac spine, possible complications include pain, bleeding and infection. The hospitalist procedure service is a relatively newer advent that make up a subset of hospital medicine practice, mostly in larger academic centers. They are made up of internal medicine faculty with additional procedural training and expertise in bedside procedural care. Depending on the institution, the service performs a variety of procedures with lumbar punctures, thoracentesis and paracentesis, comprising a bulk of them. Other services include bone marrow sampling, arthrocentesis and chest tube placement. The long term impact of procedure services on inpatient hospital teams continues to be an ongoing area of research, but so far, studies have shown that these services have been associated with an increase in best practice safety process measures, increased patient satisfaction, and faster access to procedures without increasing complication rates. At our institution, this procedure is performed by hematology/oncology staff and fellows and advanced practice providers (APP) in collaboration and with direct supervision by an attending physician. Direct supervision is usually unnecessary once competency is determined. Other services qualified to provide this service at our institution include the inpatient hospitalist bedside procedure service (HBPS) and interventional radiology (particularly if needed under computed tomography (CT) guidance). Other than those performed by hematology/oncology providers, the HBPS at our institution is responsible for the majority of bone marrow aspiration and biopsies performed at the bedside. Methods: We reviewed procedure records kept by the inpatient HBPS from February 2017 through May 2019. Most bone marrow sampling were performed on patients on the adult inpatient hematology/oncology service. Other inpatient services represented included Internal Medicine, Physical Medicine and Rehabilitation (PM&R), Cardiology and Transplant (Surgical and Medical). Informed consent was obtained from all patients and/or patient surrogates. All procedures were performed at either the right or left posterior iliac crest using a powered bone marrow biopsy device (Teleflex Arrow On-Control) with an 11 gauge bone access needle, either 4 or 6 inches in length. The site was obtained via landmarks with the patient in either the prone or lateral decubitus position. Specific orders for the procedure were placed by the inpatient clinician/practitioner requesting the procedure. A technician was present at bedside to prepare slides. Results: Of the 233 patients on which bone marrow aspirates and/or biopsies were attempted, 217 (93%) were performed successfully. 16 (7%) were unsuccessful with those patients subsequently referred to interventional radiology for placement under CT guidance. Of the procedures which were successful, 181 (83.4%) were successful with the first attempt, while 36 (16.6%) required more than one attempt. 1 (0.4%) patient experienced a procedural complication secondary to a hematoma. Conclusions: We propose that bone marrow sampling performed by a hospitalist procedure services is a safe and efficacious option and alternative for busy inpatient hematology/oncology services as it can provide faster access to care for patients who need the procedure. It also helps liberate hematology/oncology providers from performing these procedures to allow them the opportunity to focus on patient care and rounds. Disclosures No relevant conflicts of interest to declare.
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Antonio, CT, JP Guevarra, PN Medina, MD Avelino, AG Agbon, DC Sepe, DD Bardelosa, MM Cengca, ML Ting, and AB Lara. "Components of compulsory service program for health professionals in low- and middle-income countries: a scoping review." Perspectives in Public Health 140, no. 1 (May 21, 2019): 54–61. http://dx.doi.org/10.1177/1757913919839432.
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Aims:The global health landscape has been characterized by shortfalls and imbalances in human resources for health (HRH), with more health workers concentrated in urban than rural areas. To address this maldistribution, some countries resorted to the implementation of a compulsory service policy for HRH. However, there is no comprehensive documentation describing the different components of such policies. This scoping review aims to determine the components for compulsory service for selected health professionals in low- and middle-income countries (LMICs).Methods:A search was conducted in MEDLINE, PLoS, Scopus, and ProQuest Central, using keywords for ‘compulsory service’, ‘return service’, ‘mandatory service’, ‘physician’, ‘dentist’, ‘nurse’, ‘midwife’, ‘physical therapist’, ‘occupational therapist’, and identified LMICs. A total of 6757 records were retrieved and assessed, from which 41 relevant records were included in the study.Results and conclusions:Common elements of a compulsory service program are the following: a comprehensive master plan, clearly articulated program goals, appropriate education and training, transparent recruitment and placement, strong institutional and system support, competitive benefits and incentives, and active management of exit from the program. Results presented in this article can serve to inform LMICs on policy, guide program development and management, and direct future research in the area of HRH to address challenges in maldistribution.
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Dittmar, Esther. "Reforming the paramedic profession? Two weeks with paramedics in Germany." International Paramedic Practice 11, no. 1 (March 2, 2021): 19–26. http://dx.doi.org/10.12968/ippr.2021.11.1.19.
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While paramedics in Anglo-American emergency medical services enjoy relative autonomy, paramedic practice in the Franco-German model deployed in Germany depends heavily on emergency physician input. Increasing demand, especially from low-acuity incidents, causes challenges in these countries. To address this, German politicians plan to implement extensive emergency care reforms and consider an update of regulations around paramedic practice. A 2-week placement allowed for practice observation, discussions with stakeholders and a review of various resources to identify current issues in Germany. These include legal discrepancies, significant local differences in scope of practice, limited career opportunities and influence on clinical guidelines. Although the update and reforms are intended to resolve some of these problems, a groundbreaking evolution of the profession from its current restrictions is not expected. Possible development of the emergency physician role and associated specialities as a response to emergency care challenges is less debated.
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Lim, Ming Yeong, Caroline Dupre Vaughn, Lauren T. Shane, and Charles S. Greenberg. "Strategies to Improve Safety and Outcomes Utilizing Systems-Based Hematologists in IVC Filter Placement and Management in an Academic Medical Center." Blood 128, no. 22 (December 2, 2016): 4739. http://dx.doi.org/10.1182/blood.v128.22.4739.4739.
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Abstract In large academic institutions, there are multiple disciplines and clinical scenarios that may require placement of inferior vena cava filters (IVCF). Both the Society of Interventional Radiology (SIR) and the American College of Chest Physicians (ACCP) have released guidelines for IVCF use, with the ACCP guidelines being more stringent due to the lack of survival benefit supported by level I data. Several publications have reported high rates of retrievable IVCF complications. In response to these risks and low retrieval rates, the U.S. FDA issued an updated safety alert in 2014 recommending that implanting physicians and clinicians responsible for the ongoing care of patients with retrievable IVCF consider removing the filter as soon as protection from pulmonary embolism is no longer needed. A systems-based hematologist (SBH) plays a vital role in navigating the health care system in the use of therapeutic and device agents that crosses multiple disciplines by implementing evidence-based strategies to improve safety and outcomes. Previously, we used our institution's electronic health record (EHR) system to assist in improving the quality of care and reducing the cost of heparin-induced thrombocytopenia management, blood product utilization in cardiac surgery and pre-procedure management of coagulopathy in chronic liver disease (Greenberg et al. Blood. Vol. 126, No. 23; Abstract 4467). As a first step, the purpose of this study was to report our healthcare system use of IVCF to: a) define the scope of practice and b) to identify areas for improvement. We propose a practical plan that will assist in improving clinician performance, patient education, and acute and chronic management of IVCF in a large healthcare network based on our recent success utilizing EHR to manage complex medical care. A retrospective review of all IVCF placement performed between July 2014 and December 2015 was conducted. A total of 181 IVCF were placed; 26 (14.4%) permanent IVCF, 143 (79.0%) retrievable IVCF, 12 (6.6%) unknown. Mean age at IVCF placement was 59.34 years (range: 19 - 85); 46.4% were male. Ninety-six (53.0%) patients had active cancer. Surgical Services and Medical Services requested IVCF placements in 112 (61.9%) patients and 69 (38.1%) patients, respectively. Only 13 (7.2%) patients had a SBH consultation prior to IVCF placement. Per SIR guidelines, 60.2% (n=109) of IVCF were placed for absolute indications, 15.5% (n=28) for relative indications, 14.4% (n=26) prophylactically and 9.9% (n=18) with no clear indications. Of the 143 retrievable IVCF, 21 patients died during their hospitalization or were discharged to hospice. Of the remaining 122 cases, documentation of the presence of an IVCF was present in 107 (87.7%) discharge summaries, and outlined instructions for filter retrieval were seen in 19 (15.6%) cases. Only 29 (23.8%) IVCF were retrieved at a mean interval of 159 days (range: 4-511 days). Of the 21 patients that had IVCF placed prophylactically, only 7 (33.3%) IVCF were retrieved. While many of the retrievable filters were placed because of an absolute contraindication (n=64) or relative indication for high-risk of complication to anticoagulation (n=13), 37 (48.1%) patients were discharged on a regimen of anticoagulant therapy. We performed a root cause analysis and identified that a lack of awareness of IVCF evidence-based indications could have played a role in filter use patterns and the lack of a structured system for IVCF tracking in some clinical services resulted in poor IVCF retrieval rates. We propose a practical plan requiring clinicians requesting for IVCF to check an evidence-based indication via EHR. When an IVCF is placed, the Anticoagulation and Bleeding Management Specialty Nurse maintains a log of these patients and provides them with an Information Sheet that lists the date, indication and type of IVCF, specific instructions on IVCF retrieval, and a follow-up appointment in the Benign Hematology clinic for anticoagulant management. The Information Sheet is uploaded onto EHR for documentation. In conclusion, we identified the scope of practice and areas that could be improved by the adoption of a centralized and coordinated approach to monitor patients with IVCF. This study demonstrates the potential impact that a SBH has on health care delivery in both the inpatient and outpatient settings. Disclosures No relevant conflicts of interest to declare.
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Jefford, Michael, Judy Evans, Linda Nolte, Amanda Piper, Liz Simkiss, and Kathryn Whitfield. "A clinical placement program for primary care professionals at a comprehensive cancer centre." Journal of Clinical Oncology 34, no. 3_suppl (January 20, 2016): 44. http://dx.doi.org/10.1200/jco.2016.34.3_suppl.44.
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44 Background: Primary care physicians (PCPs) and primary care nurses (PCNs) are likely to have a critical role in providing care for cancer survivors, especially following the end of cancer treatments. Generalists (PCPs and PCNs) express a need for information and training in post-treatment care. Based on models in other contexts a clinical placement program was developed at a comprehensive cancer centre to determine (1) its feasibility and acceptability, and (2) whether learning needs were met. Methods: Five clinical services (breast, lower gastro-intestinal, urology, skin and melanoma, late effects) participated. The program was advertised to generalists, intending to recruit 5 PCPs and 10 PCNs. Generalists received professional development points and partial reimbursement for lost income through a stipend. Pre-placement educational materials were provided. Participants were interviewed one-on-one pre and post-placement. The relevant human research ethics committee approved all aspects of the project. Results: The program exceeded recruitment goals: 16 PCPs, 12 PCNs and 9 oncologists participated. Generalists rated the placement highly: program learning outcomes entirely (63%) or partially (37%) met; personal learning needs entirely (70%) or partially met (30%); relevance to practice entirely (89%), partially (11%). Consistent themes from interviews: generalists would recommend the program to colleagues and could identify knowledge and skills transfer, however learning was largely by observation, rather than participation. Learning opportunities were skewed toward generalists, rather than oncologists. All participants showed enthusiasm to address the challenges of providing shared care for survivors. Conclusions: A clinical placement program for generalists is feasible and highly regarded. Participants described challenges to providing quality post-treatment shared care, but a willingness to address these. Future programs should consider the learning needs of cancer centre professionals.
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Moureau, Nancy L., and Ann Zonderman. "Complications of Vascular Access Device Terminal Tip Placement: A Case Study and Review of Subsequent Legal Action." Journal of the Association for Vascular Access 12, no. 1 (March 1, 2007): 33–37. http://dx.doi.org/10.2309/java.12-1-9.
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Abstract A patient experienced complications following insertion and use of 2 similar vascular access devices with tip termination apparently in the subclavian veins. The thrombotic complications that developed were identified and reported in the first incident (a) as an occluded catheter, and then (b) as bleeding complications with delayed reporting for 8 days with the second catheter. The result was symptomatic deep vein thrombosis, thoracic outlet syndrome, and permanent nerve damage in both right and left extremities used for the venous catheter. The patient brought charges of malpractice against the hospital, the home care company, one nurse, and the manufacturer, alleging permanent nerve damage, venous occlusion, and chronic pain syndromes associated with both upper extremities. During the subsequent trial, evidence of permanent loss of function to the patient's left arm and chronic pain to both arms was presented through documentation of loss of fitness and inability to perform actions necessary to his chosen career as a pilot. The pain and loss of function were directly related to terminal tip placement of the catheter and care provided in conjunction with the venous catheter. The jury trial awarded the patient a final judgment of $7.15 million, with the hospital 55% liable and 45% liability among the other defendants. The jury also added some hospital physicians to the liability of the treatment and resulting patient harm. Nurses caring for patients have a duty to assess and evaluate the patient for complications on an ongoing basis, administer the prescribed therapy, and consistently provide communication with the primary physician specific to the assessment findings. A specialized nurse or certified intravenous nurse (CRNI) is held to a higher level of knowledge, understanding, and function. In this case, a CRNI was providing care for the patient both through hospital and outpatient home care services. Medical professionals and hospitals can reduce the likelihood of liability related to adverse events with venous catheters by acquisition of current education on the devices they insert and maintain; by updating and adhering to policies and procedures based on Standards of Practice and manufacturer instructions for use; by thorough documentation of care; and by conscientious reporting of patient clinical signs and symptoms. The goal of achieving safe patient care with vascular access devices is only possible through consistent education processes with all associated clinical staff.
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Endres, Kaitlin. "Early exposure to community service learning in the medical curriculum: A model for orientation week introduction." McMaster University Medical Journal 16, no. 1 (June 12, 2019): 19–25. http://dx.doi.org/10.15173/mumj.v16i1.2017.
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Community service learning programs in pre-clerkship medical education are increasingly recognized as important in creating physicians who recognize the effects of one’s environment on their health and further strive to advocate for these patients to receive access to social programs that can improve their outcomes. The University of Ottawa Aesculapian Society recognized that an excellent method for providing early exposure to service opportunities in one’s new community is through Orientation Weeks. Prior to this year, no Orientation Week across Ontario had a philanthropy focus. Philanthropy in most students’ eyes refers to monetary donation. Understandably, Orientation Week directors continuously make the decision that asking medical students to donate money during the first week of one of many financially demanding yeas is unrealistic. Ottawa decided to incorporate philanthropy into our Orientation Week in the more inclusive form of community service, allowing students to donate their time, rather than donating their money. In addition to ensuring that philanthropy still has the opportunity to be a fundamental component of bonding during Medical School Orientation Weeks, as it does at the Undergraduate degree level, our initiative also served to facilitate early exposure to the various organizations students could complete their community service learning placements with later in their first year. Here we present our model, uO-Serves (“uOttawa-Serves”) of an Orientation Week philanthropy initiative of time-based community service in hopes that other Medical Schools will consider implementing a similar initiative within their Orientation Weeks
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Murray-Davis, Beth, Elizabeth Shaw, Brian Kerley, and Sandy Knight. "A Pilot Project of Collaborative Maternity Education: Understanding Perspectives from Family Medicine and Midwifery." Canadian Journal of Midwifery Research and Practice 12, no. 3 (May 14, 2024): 22–29. http://dx.doi.org/10.22374/cjmrp.v12i3.102.
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Background: In Canada, the decreasing numbers of family physicians and the small number of midwives providing obstetric care have been associated with a decline in access to maternity services. Several studies and policy documents support the development of models to enhance collaboration between midwives and physicians and to expose trainees to these models. A pilot project was undertaken to implement and evaluate an interprofessional learning opportunity involving midwifery students (MWSs) and family medicine residents (FMRs). Methods: The aim was to describe how FMRs and MWSs develop skills to collaborate, and to identify the feasibility of this type of education. A convenience sample of 12 FMRs and 6 MWSs in a southern Ontario suburban community and their preceptors participated in a series of educational seminars and a clinical placement within the midwifery practice. Qualitative focus groups and interviews were conducted, and data were analyzed using thematic analysis. Results: Qualitative analysis highlighted themes relating to the engaging of learners, logistical challenges, and the perceived value of interprofessional education (IPE).Conclusions: This pilot project highlights barriers to and enablers of IPE. The findings will inform the modification of the project for future use and suggest that this project could be a useful model of IPE for primary maternity care.
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Paul, Charles J., Bradley A. Erickson, Kenneth G. Nepple, and Chad R. Tracy. "Does Rounding Order Bias Discharge Efficiency? Predictors of Discharge Timing on an Academic Urology Service." Journal for Healthcare Quality 46, no. 1 (January 2024): 12–21. http://dx.doi.org/10.1097/jhq.0000000000000415.
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ABSTRACT No previous works have analyzed whether the order in which surgical teams see patients on morning rounds affects discharge efficiency at teaching hospitals. We obtained perioperative urologic surgery timing data at our academic institution from 2014 to 2019. We limited the analysis to routine postoperative day 1 discharges. Univariate and multivariate analyses were performed to determine whether various hospital and patient factors were associated with discharge timing. We analyzed 1,494 patients. Average discharge order time was 11:22 a.m. and hospital discharge 1:24 p.m. Univariate regression revealed earlier discharge order time for patients seen later in rounds by 4 minutes per sequential room cluster (p = .013) and by 12 minutes per cluster when excluding short-stay patients. Multivariate analysis revealed discharge order placement did not vary significantly by rounding order. However, time of hospital discharge did (p < .001), likely due to speed of discharge in the designated short-stay units. Attending physician was the most consistent predictor in variations of discharge timing, with statistical significance across all measured outcomes. Patients seen later in rounding progression received earlier discharge orders, but this relationship does not remain in multivariate modeling or translate to earlier discharge. These findings have helped guide quality improvement efforts focused on discharge efficiency.
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Musuuza, Jackson S., Ann Schoofs Hundt, Pascale Carayon, Karly Christensen, Caitlyn Ngam, Nicholas Haun, and Nasia Safdar. "Implementation of a Clostridioides difficile prevention bundle: Understanding common, unique, and conflicting work system barriers and facilitators for subprocess design." Infection Control & Hospital Epidemiology 40, no. 8 (June 13, 2019): 880–88. http://dx.doi.org/10.1017/ice.2019.150.
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AbstractObjective:Clostridioides difficile (C. difficile) poses a major challenge to the healthcare system. We assessed factors that should be considered when designing subprocesses of a C. difficile infection (CDI) prevention bundle.Design:Phenomenological qualitative study.Methods:We conducted 3 focus groups of environmental services (EVS) staff, physicians, and nurses to assess their perspectives on a CDI prevention bundle. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to examine 5 subprocesses of the CDI bundle: diagnostic testing, empiric isolation, contact isolation, hand hygiene, and environmental disinfection. We coded transcripts to the 5 SEIPS elements and ensured scientific rigor. We sought to determine common, unique, and conflicting factors across stakeholder groups and subprocesses of the CDI bundle.Results:Each focus group lasted 1.5 hours on average. Common work-system barriers included inconsistencies in knowledge and practice of CDI management procedures; increased workload; poor setup of aspects of the physical environment (eg, inconvenient location of sinks); and inconsistencies in CDI documentation. Unique barriers and facilitators were related to specific activities performed by the stakeholder group. For instance, algorithmic approaches used by physicians facilitated timely diagnosis of CDI. Conflicting barriers or facilitators were related to opposing objectives; for example, clinicians needed rapid placement of a patient in a room while EVS staff needed time to disinfect the room.Conclusions:A systems engineering approach can help to holistically identify factors that influence successful implementation of subprocesses of infection prevention bundles.
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Taher, A. Khaled, J. Lockwood, C. Spearen, J. Kachur, G. Pino, N. Kedzierski, and W. Tavares. "LO11: Improving patient access, care and transportation by paramedics (IMPACT): a novel curriculum toward redefining paramedic services in Ontario." CJEM 20, S1 (May 2018): S10. http://dx.doi.org/10.1017/cem.2018.73.
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Introduction: A proportion of Emergency Department (ED) visits may be treated in out-of-hospital settings. The objective of this curriculum was to expand paramedic competencies to safely risk stratify patients and divert low risk, low acuity patients from EDs with and without physician oversight. Methods: We followed Kerns 6-step Curriculum Development Framework . (a) We identified a problem, and (b) completed a needs assessment by retrospectively reviewing the clinical pathways of 3000 patients were cared for and transported by paramedics and received care at an EDs. We used this data to identify competencies (e.g., diagnostics, interventions, reasoning needs) and targeted patient types that would result in the most significant advancements to paramedic services. These were translated to (c) goals and objectives. Results: Our (d) educational strategies involved a 14-week intensive patient-type and case-based curriculum. (e) Implementation involved 3 days/wk of clinical rotations supplemented with 2 days/wk of a mixed curriculum (i.e., fixed instruction using blended didactic small and large group sessions; flexible/individualized curriculum based on identified needs; formative assessments; self and peer-directed learning; simulations). (f) Assessment involved knowledge and application tests, clinical placement and simulation assessments; case development, assignments, and OSCE. Evaluation outcomes included student performance scores across 7-dimensions, clinical placement and student feedback. Thirteen Advanced Care Paramedics from York Region Paramedic Services completed the program. Challenges included provincial stakeholder consensus, and formally addressing clinical suspicion in a protocol based field within a limited time frame. Conclusion: A curriculum for expanded paramedic practice to risk stratify and divert targeted low risk patients from EDs resulted in new paramedic competencies and scope of practice. It received high evaluations from clinical staff and students. Successful candidates will undergo a 1-year study for validation and safety.
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Dettenmeier, Patricia A. "Planning for Successful Home Mechanical Ventilation." AACN Advanced Critical Care 1, no. 2 (August 1, 1990): 267–79. http://dx.doi.org/10.4037/15597768-1990-2005.
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Home mechanical ventilation has evolved to permit discharge of patients on portable negative or positive pressure mechanical ventilators. Assessment of the patient for home discharge is initiated by a multidisciplinary team. The nurse, physician, social worker, respiratory therapist, speech therapist, occupational therapist, home health nursing agency, durable medical equipment supplier, and caregivers constitute the team. The crucial links to a successful patient discharge are an involved family and a well-developed plan of care, although patient finances also are important. The nurse develops, coordinates, and implements the teaching plan over a period of 2 or more weeks. The home caregivers provide total care for the patient several days before discharge. The home health agency and the durable medical equipment supplier provide services which ease the transition of care from hospital to home. One alternative to home discharge is placement in an extended care facility
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Kisor, David F., David R. Bright, Megan Conaway, Bruce A. Bouts, and Gregory P. Gerschutz. "Pharmacogenetics in the Community Pharmacy." Journal of Pharmacy Practice 27, no. 4 (February 13, 2014): 416–19. http://dx.doi.org/10.1177/0897190014522496.
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Introduction: Although antiplatelet therapy is a mainstay of post–percutaneous coronary intervention therapy, pharmacogenetic (PGt) considerations of therapy are often ignored despite related Food and Drug Administration warnings. Pharmacists are well situated to provide PGt guidance, and the community pharmacy is one setting where PGt testing, interpretation, and recommendations can take place to ensure optimal therapeutic outcomes. Case Report: A 65-year-old man who had a myocardial infarction that was treated with PCI and stent placement was determined by a community pharmacist to be a candidate for PGt testing to ensure optimal antiplatelet therapy. The patient was seen in the pharmacy as a part of a medication therapy management encounter and underwent genetic testing. Results of the genetic testing indicated the need for modification of therapy. The community pharmacist interpreted the results and made the appropriate recommendation to the cardiologist who in turn modified antiplatelet therapy appropriately. Conclusion: This case describes the potential for collaboration between pharmacists and physicians to optimize antiplatelet therapy through PGt testing. Points of consideration for others looking to implement related PGt services are also discussed.
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Schaller, Richard J., J. Stephen Huff, and Allan Zahn. "Comparison of a Colorimetric End-Tidal CO2 Detector and an Esophageal Aspiration Device for Verifying Endotracheal Tube Placement in the Prehospital Setting: A Six-Month Experience." Prehospital and Disaster Medicine 12, no. 1 (March 1997): 57–63. http://dx.doi.org/10.1017/s1049023x00037237.
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AbstractIntroduction:Hand held, colorimetric, end-tidal CO2 detector devices are being used to verify correct endotracheal tube (ETT) placement. The accuracy of these devices has been questioned in situations of cardiac arrest. The use of the esophageal detector device (EDD) is an easy alternative for detection of ETT placement, and may be more accurate in situations of cardiac arrest.Hypothesis:The use of the esophageal aspiration device in comparison with a colorimetric end-tidal CO2 detector is more accurate in detecting proper ETT placement and easier to use in the prehospital setting than is the colorimetric end-tidal CO2 detection device.Methods:This was a prospective alternating weeks, 6-month study in a prehospital setting. Participants included all patients older than 18 years who were intubated by the Portsmouth, Virginia Emergency Medical Services (EMS) personnel from 01 July 1993 through 31 December 1993. The aspiration device used, also known as an esophageal detector device (EDD), was a 60 ml, luer-lock syringe attached to a 15 mm ETT adapter. Its efficacy was compared with an already accepted method of ETT position detection, the colorimetric endtidal CO2 detector. Each device was used on alternating weeks, and correct ETT placement was determined by the receiving emergency department physician using standard techniques. Chi-square analysis and Fisher's Exact test were used to compare parameters, time of device use, and ease of use. Sensitivity and specificity were calculated, and provider preference was assessed using a survey instrument administered following completion of the study.Results:There were 49 patients who met the inclusion criteria, but six were excluded because of situational circumstances rendering use of the device a possible compromise of patient care. Twenty-five patients were in the EDD group, and 18 were in the endtidal CO2 detector group. There was no statistically significant difference detected between groups for the gender ratio, underlying condition, CPR in progress, perceived difficulty of intubation, or percentage of nasotracheal intubation. The EDD was significantly easier to use (p<0.005). There was no statistically significant difference in time required for use of end-tidal CO2 detector device versus the EDD. The sensitivity and specificity for correct tracheal placement using the EDD was 100%, and the sensitivity for correct tracheal placement using the end-tidal CO2 detector device was 78%. Use of the EDD was preferred over use of the end-tidal CO2 detector device by 75% of participating EMS providers. One case of nasotracheal intubation with an ETT placement above the cords raised the question of accuracy of this device in situations where direct visualization is not utilized.Conclusion:The EDD was accurate in all cases of orotracheal intubation, and was easier to use than was end-tidal CO2 detector device. It was preferred by 75% of participating EMS providers. In cases in which the ETT may be above the vocal cords, caution must be used with interpreting the results obtained by use of the EDD.
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Heintz, Brett H., Jenana Halilovic, and Cinda L. Christensen. "Impact of a Multidisciplinary Team Review of Potential Outpatient Parenteral Antimicrobial Therapy Prior to Discharge from an Academic Medical Center." Annals of Pharmacotherapy 45, no. 11 (October 11, 2011): 1329–37. http://dx.doi.org/10.1345/aph.1q240.
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Background:: Outpatient parenteral antimicrobial therapy (OPAT) is frequently prescribed at hospital discharge, often without infectious diseases (ID) clinician oversight. We developed a multidisciplinary team, including an ID pharmacist, to review OPAT care plans at hospital discharge to improve safety, clinical efficacy, practicality, and appropriateness of the proposed antimicrobial regimen. Objective: To evaluate the impact of the OPAT team on regimen safety, efficacy, and complexity; calculate the economic benefits of the service by avoiding hospital discharge delay, central venous catheter placement, or need for OPAT; and evaluate the discharge environment among OPAT referrals. Methods: In an observational design, we analyzed the impact of an OPAT team from July 2009 through June 2010 at a large academic tertiary care hospital. All patients with plans for continued parenteral therapy after discharge referred to the OPAT team were included in the analysis. Patients were excluded if OPAT was cancelled prior to processing of the referral. Results: During the 1-year study period. 569 of 644 consecutive referrals to the OPAT team met inclusion criteria, resulting in 494 OPAT courses. Interventions by an ID pharmacist were made for safety (56%), regimen complexity (41%), and efficacy (29%). Lack of formal ID physician consultation resulted in more interventions for safety (64% vs 48%, p < 0.001) and efficacy (36% vs 21%, p < 0.001). Discharge delays were avoided for 35 referrals, resulting in 228 hospital days avoided and approximately $366,000 in hospital bed cost savings. Use of OPAT was avoided in 75 referrals (13.2%), preventing central venous catheter placement in 48 patients (8.4%), resulting in an additional $58,080 in cost savings. Conclusions: The OPAT team optimized safety, efficacy, and convenience of OPAT while providing substantial cost savings. Further studies are needed to confirm the program's cost-effectiveness.
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Mahajan, Pranav, Helen Crimlisk, and Chris Kenworthy. "The Royal College of Psychiatrists Physician Associate Inceptorship Programme: Developing Educational Programmes to Support the Integration of This New Role in Psychiatric Services." BJPsych Open 8, S1 (June 2022): S27—S28. http://dx.doi.org/10.1192/bjo.2022.136.
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AimsPhysician associates (PAs) are becoming more commonplace in psychiatric services in the UK to help address long term workforce difficulties. In 2019, the NHS Long Term Plan detailed a commitment to transforming mental health care in England recognising that services were not meeting current or future increase in demand. Health Education England's (HEE) report, Stepping Forward to 2020/21: The Mental Health Workforce Plan for England, described a longer-term strategy to expand the mental health workforce, including recruiting 5,000 people into ‘new roles’ including physician associates. The NHS Mental Health Implementation Plan 2019/20–2023/24 stated an aim of recruiting 140 PAs to the workforce over five years in addition to the requirements specified in the HEE report. HEE and the Royal College of Psychiatrists (RCPsych) have sought to support the integration of PAs into psychiatric teams through the development of the Inceptorship programme. The aim was to develop a bespoke training programme for PAs to bridge the gap between university and working in mental health to be rolled out nationally.MethodsSince 2018, Sheffield Health and Social Care Trust (SHSC) have been providing an Inceptorship Programme for PAs at the trust. Unlike with trainee doctors, there was no curriculum that could be followed. The programme covers the aetiology, diagnosis and management of common psychiatric problems, communication skills and reflective practice. This programme has provided the basis for the RCPsych Inceptorship Programme supported by HEE.ResultsThe SHSC programme has been well received by the 11PAs that have been through the programme, with all PAs recommending other mental health organisations take a similar approach. There have been many additional benefits of the sessions. They allow PAs to gain peer support and it has been a forum to raise issues which often arise when integrating new roles into pre-existing MDTs.ConclusionThe RCPsych Inceptorship Programme is a PA specific educational programme. It is an important tool in addressing the gap between variable mental health experience as a student (which is limited to a 3-week placement and is variable in content) and working in a psychiatric setting. RCPsych and HEE recommend that all mental health organisations employing PAs implement an inceptorship programme based on the work carried out at SHSC. These should comprise of regular, protected sessions that provide PAs with bespoke mental health training to support their integration into psychiatric multidisciplinary teams. HEE have agreed to provide funding to help organisations facilitate it.
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Chakraborty, Samyadip, and Santanu Mandal. "Enablers of clinician involvement inclination, care delivery agility and clinical productivity." Benchmarking: An International Journal 26, no. 3 (April 1, 2019): 753–72. http://dx.doi.org/10.1108/bij-06-2017-0144.
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PurposeHealthcare services have enormous potential for growth in the country. However, the drivers of clinical productivity are yet to be explored. The purpose of this paper is to examine the effect of clinician buy-in, clinician ease of use, clinician work stream flexibility and device placement comfort on clinician’ s involvement. The study further examines the effect of converged devices implementation and wireless portable devices adoption on care delivery agility. Lastly, the authors examine the influence of clinician’s involvement and care delivery agility on clinical productivity.Design/methodology/approachMeasures for the constructs were developed from extant literature and expert feedback complemented with pre-testing. Further, perceptual responses were collected from 221 doctors through internet surveys and were analyzed using partial least squares.FindingsThe study identified clinician’s ease of use and workflow streamlining flexibility as key enablers of clinician’s involvement. Findings further reveal that converged devices implementation and wireless portable adoption as prominent enablers of care delivery agility. Further, the authors found clinician’s involvement and care delivery agility to have a positive contribution in enhancing clinical productivity.Research limitations/implicationsThe study has collected perceptual responses from doctors practicing both in hospitals and private clinics and their perceptions have been based on their experiences at those specific institutions or sites, which may limit generalizability of the current study findings. This study incorporated only doctors and ignored other assistant staffs’ perceptions who assisted and aided doctors in executing treatment procedures either in private clinics or hospitals.Practical implicationsThe study has practical implications for enhancing clinical productivity.Social implicationsThe study findings highlight the role of process focus and infrastructure focus on the human elements of involvement and agility which often play pivotal role for motivation for individual physicians and their productivity.Originality/valueThe study is the foremost to develop perceptual measures for several constructs in the healthcare services.
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Stewart, Ronald D. "Analgesia in the Field." Prehospital and Disaster Medicine 4, no. 1 (September 1989): 31–34. http://dx.doi.org/10.1017/s1049023x00038504.
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Emergency Medical Services and the care of patients in the field have taken giant steps forward over the past decade. Born of the desire of physicians to influence the mortality rates of sudden cardiac death in the community, systems of advanced life support have taken root in the urban centers in the United Kingdom, Australia, the United States, and other countries (1-3). Although originally largely designed around the concept of “mobile coronary care,” these systems soon were deluged with calls for help from all sectors of the community, and faced a variety of medical problems. As trauma gradually became recognized for the killer and maimer of young lives that it is, regional programs of trauma care were developed in the United States and led gradually to the expansion of prehospital and interhospital transport systems in which critically injured patients were being moved about, often over long distances. The growth of emergency medicine as a specialty in its own right has encouraged the study and improvement of systems of disaster and mass casualty management.Although the focus of these efforts has been largely the overall reduction of death and disability in critically ill or injured patients, controversy continues around not only the extent of field intervention but also the influence of our efforts on the outcome of these patients (4, 5). The importance of particular interventions such as intravenous line placement, administration of certain medications, the use of the pneumatic anti-shock garment, and other sacred cows of prehospital care, all have been questioned of late (6, 7).
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Craig, Elise, Erica Brotzman, Benjamin Farthing, Rachel Giesey, and Jenifer Lloyd. "Poor match rates of osteopathic applicants into ACGME dermatology and other competitive specialties." Journal of Osteopathic Medicine 121, no. 3 (February 12, 2021): 281–86. http://dx.doi.org/10.1515/jom-2020-0202.
Повний текст джерелаАнотація:
Abstract Context There has been a steady increase in the number of osteopathic (DO) medical students in the United States without a corresponding increase in DO representation in competitive specialties. Objectives To investigate the trends and impact of the Accreditation Council for Graduate Medical Education (ACGME) single accreditation system on DO match rates into dermatology and other competitive specialty programs. Methods Information was collected through public databases (Electronic Residency Application Service [ERAS]; National Resident Matching Program [NRMP]; Association of American Medical Colleges [AAMC]; National Match Service, Inc. [NMS]; and the ACGME) to evaluate the match statistics of competitive specialties, including dermatology, otolaryngology, orthopedic surgery, neurosurgery, and plastic surgery. Residency program and medical school websites and residency communications were used to confirm whether the match placements were to programs that had traditionally been ACGME-accredited or former American Osteopathic Association (AOA) programs. Results From 2012 to 2016 (pre-unification), osteopathic graduates comprised only 0.5% of the matches the specific specialties studied here and only 0.9% of ACGME dermatology positions. Post-unification (2017–2019), DOs comprised 2.0% of the matches into these specialties and 4.4% of the total ACGME dermatology positions. This apparent increase is misleading, as it is solely due to the transition of formerly AOA programs to ACGME status. The true post-unification DO match rate to traditionally ACGME programs is actually 0.6% for all competitive specialties and 0.4% for dermatology. Post-unification, 27.6% of formerly AOA positions in these competitive specialties were filled by allopathic (MD) applicants. Conclusions DO match rates into dermatology and other competitive specialties were poor prior to GME unification and continue to remain low. This situation, when coupled with the closing of many AOA programs and MDs matching into former AOA positions, threatens the future of osteopathic physicians in competitive specialties. Osteopathic recognition is one way to potentially help preserve osteopathic representation and philosophy in the single accreditation system era. Programs should not be hesitant to consider osteopathic applicants for competitive specialties.
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Tolia, Vaishal, Eddie Castillo, and David Guss. "EDTITRATE (Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency)." Journal of Telemedicine and Telecare 23, no. 4 (June 8, 2016): 484–88. http://dx.doi.org/10.1177/1357633x16648535.
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Objective Emergency Department (ED) patient volumes are unpredictable, which can result in service delays and patients leaving without care. We initiated a programme of emergency physician (EP) telepresence in the ED with the objectives of assessing feasibility, safety, patient and provider acceptance, and throughput time. Methods This was a prospective convenience study. Patients presenting to the ED during operation of the study who were planned for placement in the waiting room were considered for enrolment. A faculty EP conducted patient evaluations via telepresence with confirmatory evaluation by the onsite faculty EP prior to disposition. Patient care was either taken to completion by the telemedicine EP or initiated and handed off to the onsite team. Measures included patient demographics, triage class (ESI 1–5), throughput time and a single question satisfaction survey (rating 1–5, 5 most favourable) completed by patients, registered nurses and EPs. Patients were called within 3 days and the electronic health record reviewed at 7 days looking for unscheduled visits and adverse events. Results In total, 130 patients were enrolled. Mean triage class was 3.9 with a median throughput of 150 minutes (IQR = 116.5, 206). Non-telemedicine patients during the same time period with similar triage classes had a median throughput of 287 minutes (IQR = 199, 408). Mean satisfaction scores were: patient 4.91, nurse 4.75, onsite EP 4.47 and telemedicine EP 4.79. There was one potential misdiagnosis and no adverse events. Conclusion Patient evaluation by EP via telepresence is feasible, safe, readily accepted by patients and providers and associated with reduced throughput time.
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Landoll, Ryan R., Ronald M. Cervero, Jeffrey D. Quinlan, and Lauren A. Maggio. "Primary Care Behavioral Health Training in Family Medicine Residencies:." Family Medicine 52, no. 3 (March 6, 2020): 174–81. http://dx.doi.org/10.22454/fammed.2020.681872.
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Background and Objectives: Primary care behavioral health (PCBH) is a service delivery model of integrated care linked to a wide variety of positive patient and system outcomes. However, considerable challenges with provider training and attrition exist. While training for nonphysician behavioral scientists is well established, little is known about how to train physicians to work efficiently within integrated teams. Methods: We conducted a case study analysis of family medicine residencies in the military health system using a series of 30 to 45-minute semistructured interviews. We conducted qualitative template analysis of these cases to chart programs’ current educational processes related to PCBH. Thirteen individuals consisting of program directors, behavioral and nonbehavioral faculty, and residents across five programs participated in the study. Results: Current educational processes included a variety of content on PCBH (eg, treatment for depression, clinical referral pathways, patient-centered communication), primarily using a mix of didactic and practice-based placements. Resource allocation was seen as a critical contributor to quality. There was variability in the degree to which integrated behavioral health providers were incorporated as residency faculty, such that programs where these specialists were more incorporated reported more intentional curriculum development and health care systems-level content. Conclusions: While behavioral health content was well represented in family medicine residency curriculum, the depth and integration of content was inconsistent. More intentional and integrated curriculum accompanied faculty development and integration of behavioral health faculty. Future research should evaluate if faculty development programs and faculty status of behavioral scientists results in different educational or health care outcomes.
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Badurdeen, Dilhana, Abdellah Hedjoudje, Mohamad Itani, Lea Fayad, Jad Farha, Margo Dunlap, Lawrence Cheskin, et al. "Building an endobariatric program: lessons learned." Endoscopy International Open 08, no. 09 (August 31, 2020): E1185—E1193. http://dx.doi.org/10.1055/a-1198-4598.
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AbstractThe emphasis on treating obesity has never been more critical, yet the complexity of delivering care has become more intricate due to new procedures, variable insurance coverage, and inconsistent reimbursement. This is our experience building an endobariatric program and treating overweight and obese patients with endobariatric therapies (EBTs) over 3 years. The primary intention of this manuscript was to educate the reader on how to build an endobariatric program, identify barriers, and provide succinct solutions to establish a successful program. The secondary aim was weight loss outcomes of procedures offered at our institution. We compiled a list of lessons learned, based on the difficulties we experienced to make it easy for others embarking on this journey. Herein, we present a business development strategy to overcome impediments, whilst offering high quality service. The high cost and lack of insurance coverage are significant barriers. Marketing can be costly and is often a factor that is ignored particularly early on, when finances are limited. However, it is an integral component of growing the program. The percentage total body weight loss (%TBWL) at 6 and 12 months post ESG was 17.8 ± 6.48 and 20.6 ± 8.3 (P < 0.001), respectively. The %TBWL at 6 months post IGB was 14.9 ± 9.8 for the Orbera IGB and 12.6 ± 7.4 for the Reshape IGB. There was a trend of preference for ESG compared to IGB placement over the 3 years. The key to building a successful endobariatric program is a motivated physician leader, collaborative bariatric surgeons, institutional support, and marketing. Insurance coverage will likely occur in the near future and programs must be prepared to manage the massive influx of patients that will likely request these procedures.
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Schutzer, Matthew E., Douglas W. Arthur, and Mitchell S. Anscher. "Time-Driven Activity-Based Costing: A Comparative Cost Analysis of Whole-Breast Radiotherapy Versus Balloon-Based Brachytherapy in the Management of Early-Stage Breast Cancer." Journal of Oncology Practice 12, no. 5 (May 2016): e584-e593. http://dx.doi.org/10.1200/jop.2015.008441.
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Purpose: Value in health care is defined as outcomes achieved per dollar spent, and understanding cost is critical to delivering high-value care. Traditional costing methods reflect charges rather than fundamental costs to provide a service. The more rigorous method of time-driven activity-based costing was used to compare cost between whole-breast radiotherapy (WBRT) and accelerated partial-breast irradiation (APBI) using balloon-based brachytherapy. Materials and Methods: For WBRT (25 fractions with five-fraction boost) and APBI (10 fractions twice daily), process maps were created outlining each activity from consultation to post-treatment follow up. Through staff interviews, time estimates were obtained for each activity. The capacity cost rates (CCR), defined as cost per minute, were calculated for personnel, equipment, and physical space. Total cost was calculated by multiplying the time required of each resource by its CCR. This was then summed and combined with cost of consumable materials. Results: The total cost for WBRT was $5,333 and comprised 56% personnel costs and 44% space/equipment costs. For APBI, the total cost was $6,941 (30% higher than WBRT) and comprised 51% personnel costs, 6% space/equipment costs, and 43% consumable materials costs. The attending physician had the highest CCR of all personnel ($4.28/min), and APBI required 24% more attending time than WBRT. The most expensive activity for APBI was balloon placement and for WBRT was computed tomography simulation. Conclusion: APBI cost more than WBRT when using the dose/fractionation schemes analyzed. Future research should use time-driven activity-based costing to better understand cost with the aim of reducing expenditure and defining bundled payments.