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Biomedical subjects

I P Gunn

Publications and source records attributed to I P Gunn.

At least 19 recordsLinked to original sources
PubMed2000

Patient safety and human error: the big picture.

For most of the past century, health care literature including many books written about health care and its quality have documented the problems of errors in health care delivery. That outcomes of care have differed significantly among hospitals has also inferred that perhaps the "best practices" or the appropriate resources may not have been used, although most of these study results have be adjusted for case mix. The Institute of Medicine's recent publication, "To Err is Human," represents their review of studies quantifying medical errors in health care and their recommendations for eliminating such errors to the extent possible. One should note that, while using the term "medical," it does not infer that all errors are made by physicians. It recommends shifting the focus of study from blaming the health providers to studying the "system" in which health care is provided, believing that most of the errors committed are not reckless but rather result from system variables. The Institute of Medicine's recommendations are broad and cover a variety of quality assurance mechanisms. It recommends mandatory reporting of these errors to a central agency via a state mechanism, with better and broader legislation to make peer review, for purposes of studying errors with a view toward making change in the system, privileged information, and not subject to subpoena. The American Medical Association and American Nurses Association, in their testimony before the US Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education and Related Agencies, on December 13, 1999, support the recommendations in general with a few reservations.

Humans↗
PubMed2000

Rural health care and the nurse anesthetist.

As they work in all types of practice arrangements and settings with and without anesthesiologists, certified registered nurse anesthetists have been and continue to be the principle anesthesia providers in rural hospitals in the United States. As such, they are responsible for providing anesthesia services to about 1 quarter of the US population that resides in rural and frontier areas of this country. Rural health care is characterized by its necessity to provide a broad array of services with lesser resources than are typically available in metropolitan or urban areas. The rural population is characterized as having a higher proportion of elderly people and children under the age of 18, a higher incidence of chronic diseases, a lower mortality rate (albeit a slightly higher infant mortality rate), and a 40% higher mortality rate resulting from accidents. Rural residents are poorer and less likely to have job-related health insurance benefits or Medicare supplemental insurance. Despite the significant rise in the number of anesthesiologists in the past 10 to 15 years, there is no evidence that they are attracted to practice in these areas. As sole anesthesia providers in many of these rural hospitals, rural CRNAs have both common and unique problems and issues that confront them. However, from available reports, their communities are satisfied with their services, providing evidence of the capability of CRNAs to function satisfactorily without the anesthesiologist.

Hospitals, Rural↗
PubMed2000

Thoughts on the "new nursing shortage".

The nursing shortage is a frequently recurring phenomena in the United States and in many developed countries worldwide. It is time that serious consideration be given to the necessary changes that are essential for supplying an adequate nursing force worldwide. This article compares the late 1980s nursing shortage in the United States with the current one and finds that many of the same causes are prevalent. These causes stem from the gender-based history of modern nursing and the cultural- and professional-based problems that nursing has had great difficulty changing and are discussed in this article. The decentralization of health care has also created greater demand for nurses. The nursing component of a hospital's budget representing its largest component has also been targeted by hospital administrations and ownership as a source for supporting other departments or functions at the expense of nursing personnel. Finally, the vast opportunities that have opened up to women since the Civil Rights Act in the 1960s and today's booming economy and high-technology environments make nursing much less attractive and competitive in today's market. Also, the managed care movement has significantly contributed to problems of nursing. Nursing educators have also found that the 3 levels of nursing education has confused today's high school graduates, leading to their rejection of nursing as a career. Thus, efforts are underway in nursing education to correct this problem--one that is beginning to be corrected through role differentiation that is now seen in many hospitals, but most prevalent in so-called "magnet" hospitals. Investigators have done much research--first in distinguishing the difference between magnet and nonmagnet hospitals, and now, regarding patient outcomes from those hospitals. These can lead to the efforts of nursing to come to grips with multiple entry points for a single licensure. However, the problems associated with the barriers to practice, prompted by long outdated mores and cultural influences discussed in this article that must change if nursing is to remain a viable and attractive profession in the 21st century. Investigators have found higher mortality rates between magnet and nonmagnet hospitals, favoring the magnet hospitals that have a better nurse-to-patient ratio, higher baccalaureate registered nurse staffs, and greater nursing autonomy. It is time that decision makers take heed and make changes. Nothing less than the lives of patients are at stake.

Career Choice↗
PubMed2000

Death of a journal: lost opportunities, new challenges, or both?

The announced cessation of publication of CRNA: The Clinical Forum for Nurse Anesthetists brings into focus the problems that confront smaller subscription-based professional journals in a print or paper mode. We are in an age in which there is a high level of competition for peoples' time and attention, in an environment where there is a danger of information overload. Electronic media are competing with print media, and there are advantages and disadvantages to both. This is not only within the realm of news, sports, and entertainment, but professional information as well. Debates will abound as to how best, and in what medium, research should be made available to professions and the public. Unfortunately, the revelations in the past few years of the poor state of published research in our print journals, despite peer review, makes it more difficult to advocate them in a climate where the shift may well be toward electronic journals. Although many print journals have also gone online, they usually limit the viewership to abstracts or a few articles. Some of thejournals that have been created as online journals and have their articles peer reviewed have not been in existence long enough to examine the extent to which the peer-review system is any better than for print journals. It is exceedingly important that research and its conclusions that make its way into either print or online journals are reliable and valid before we apply them to our practice. Relying on individual readers to make that determination is problematic, because most readers are not that astute in sophisticated research methods and statistics. With the loss of this journal, CRNA opportunities for research and commentary publication are lost. It will produce new challenges to interested CRNAs who choose to balance this loss with new opportunities.

Humans↗
PubMed1999

Commentary: issues and perspectives affecting CRNA practice. Regulation of health professionals, Part 1: Telepractice.

Although the requirement to protect the public welfare and safety is a right guaranteed to the states by the US Constitution's 10th amendment, which grants states the "police powers" of government, it is not an absolute power. The Commerce clause of the Constitution limits the power of states in creating barriers to intrastate commerce. Changes in the health care delivery system of the US, such as the use of corporate models such as managed care entities and health maintenance organizations, as well as health insurers' development of utilization reviews before approval of reimbursable procedures in individual cases, has prompted concerns with regard to the care of patients occurring outside the state in which the patient resides, by health care professionals not licensed in that state. Many states have considered such decision making an "unauthorized practice of medicine, or other practice" creating the necessity for some providers to obtain an many as 20 licenses to cover their practice. The practice of telemedicine (or telenursing or telehealth) falls into this quagmire, and thus efforts are ongoing to try to find ways to permit such practices while maintaining quality control, with or without additional state licenses.

Humans↗
PubMed1999

Regulation of health care professionals, Part 2: Validation of continued competence.

Today's demand for professional accountability regarding patient outcomes of care stems from two principle concerns: (1) the risks associated with health care services and their delivery, and (2) health care cost-containment and wanting to get the best care with the best patient outcomes at the best cost. Whereas patient outcomes are a function of multiple factors, health care professionals and their practice are considered key to those outcomes. Today's society and particularly the payers for health care services, have grown skeptical of professions and their willingness to do a good job of self-policing their own members, incompetent performers. In the 1970s, this early skepticism and the concurrent malpractice crisis led professionals and state regulators over time to move beyond the one-time testing for a lifelong credential so long as you didn't get into major problems, to considering alternatives for assuring continued competency in practice. The first efforts focused on voluntary or mandatory requirements for continuing education as a basis of attesting to continuing or recredentialing (licensure or certification). Unfortunately, this continuing education process has never been validated, demonstrating its efficacy in assuring continued professional competence and currency of knowledge as it plays out in practice and patient outcomes. Reasonable assumptions are no longer publicly acceptable; evidence is being demanded. Also, a problem that has plagued private credentialers has been the legal concept of a license or certification as a lifelong property right based on the such conditions when it was awarded. Credentialing bodies have been at legal risk in removing a license or certification for failure to comply with new criteria, particularly if the criteria has not been validated as making a difference. Rather than looking solely at currency of knowledge and competence in its utilization (including the associated technology), it is now being recommended that a multifaceted methodology be used in assessing those professional attributes deemed essential for achieving quality patient outcomes.

Certification↗
PubMed1999

Health care delivery and change: thoughts on Lema's "... of dinosaurs, dodos and anesthesia personnel".

Problems in health care delivery relative to access, costs, and quality have been debated for more than a quarter of a century. Health care costs have significantly increased since the implementation of the Medicare/Medicaid legislation. Cost containment has been high on the agendas of government officials, legislators, health policy decision makers, business leaders, and economists since the 1980s. There has been a shift toward market medicine and managed care as a means for cost containment. Although some costs were contained for a short period, they are once again rising significantly, and there is growing dissatisfaction with this shift. The United States is not alone in this dilemma. Mark Lema, MD, PHD, editor of the ASA Newsletter, wrote a thought-provoking editorial in the July 1999 issue, raising concerns about change, relationships, reimbursement, and demise relative to anesthesia personnel. In response, this article primarily raises the issue of health manpower mix as a major factor in the cost of health care delivery regarding these systems. Whereas change is inevitable, it is difficult for state and federal governments in the United States to force change because of the number of special interests involved in campaign financing involving elected government officials. It is nevertheless important for health professionals to be involved in the changes that come about, or change will be made for them. It is essential to renew society, institutions, and individuals in order to prevent decay and obsolescence. If we don't make the future, the future will make us.

Anesthesiology↗
PubMed1998

A critique of Michael L. Millenson's book, Demanding medical excellence: doctors and accountability in the information age, and its relevance to CRNAs and nursing.

Michael L. Millenson's well-documented book, Demanding Medical Excellence: Doctors and Accountability in the Information Age, is a wake up call to both medicine and nursing for somewhat different reasons. Millenson decries the lack of scientific-based medical practice and medicine's failure to wake up due to its own historical studies. He cites data that 85% of current practice has not been scientifically validated despite medicine's claims of the physician-scientist. He outlines a historical chronology of advocacy for better practice based on concerns and studies that demonstrates significant differences in patient outcomes, adjusted for case mix, across hospitals studied. Millenson advocates the development of a broader base of benchmarking and best practices, reflected in clinical practice guidelines, recognizing the resistance of physicians to their use. He further advocates incorporating more fully information-age computers in the delivery of quality care by programming them to the tasks they are best suited for in informing and alerting us to flawed memories, orders, and abnormal laboratory and radiologic data. The relevance of Millenson's book to CRNAs and nursing in general is twofold: (1) He discusses the National Halothane Study and the subsequent Stanford Institutional Differences Study. The latter study confirmed what was found in the National Halothane Study concerning significant differences in patient outcomes across studied hospitals but did not address the role of the hospital's primary anesthesia provider, anesthesiologists, or CRNAs in these differences, as did the latter. He addresses the lack of publication and dissemination of the institutional outcome differences of these studies performed in the 1960s and 1970s, but he does not address the anesthesia provider portion of the Stanford Study. (2) While Millenson does mention nursing briefly and advocates its involvement in clinical practice guideline development, he does not discuss the profession's own concerns about the lack of scientific validation of our nursing practice. Research serves as a principal cornerstone for scientifically based clinical practice guidelines or best practices. Millenson and others address some of the problems associated with current research and the problems associated with the peer review system in the publication of methodologically flawed and politically motivated published studies. The Abenstein and Warner study in Anesthesia and Analgesia in 1996 is a prime example of the latter. A recent British Medical Journal editorial characterized medical literature as disorganized and biased (BMJ.1998;317[7152]:160). It further cites a study that found that over 95% of articles in medical journals did not meet minimum standards for quality or clinical relevance. While that figure may be high, we know that flawed and biased research is within the MEDLINE database, even though some studies have been retracted based on overt fraud. However, retraction has not stopped other researchers or practitioners from publishing retracted research in their own publications. Consumers of MEDLINE should be aware of this problem and be prepared to question the validity of research prior to adopting their conclusions. In the development of "best practices," flawed research may be as bad as personal biases and flawed memories. The potential adverse implications of flawed research for scientifically (evidenced) based practice and for health policy decisions by government and health payers with regard to the delivery of health services and its reimbursement requires that all involved do a better job of assuring that only valid, methodologically sound, and unbiased research is published, is included in the MEDLINE database, and is used in the care afforded to people in need.

Bias↗
PubMed1998

Setting the record straight on nurse anesthesia and medical anesthesiology education.

The history, qualifications, capabilities, and legal status of nurse anesthetists in the United States have been perceived by organized anesthesiology as both a professional and economic threat to the medical specialty. Such threats often lead to turf battles in which groups try to seek public affirmation of their point of view through ongoing public and/or government relation debate and activism. Medicine, including anesthesiology, has used educational preparation of physician and nurse specialists as a favorite topic for such activism. In this nation's competitive environment, facts are often prone to distortion knowingly or unconsciously. This article is aimed at setting right the facts in the current debate used by the American Society of Anesthesiologists in regards to the comparative analysis of CRNA and anesthesiologist education. Because medicine most often uses length of education as a quality measure of that education, regardless of the validity of such arguments, this comparison is set within that framework. Unfortunately, it will not be the last work on this subject.

Anesthesiology↗
PubMed1998

Evidence-based practice, research, peer review, and publication.

For about a quarter of a century, concerns have been expressed about published biomedical research. It became more acute after some published research and broad dissemination was found fraudulent. With the emphasis now being placed on scientifically validated or evidence-based practice, it has become more imperative that clinical guidelines be based on credible information in our textbooks and research literature. Since the early 1990s, it has been found that much of the research in our electronic databases does not meet quality standards and often is irrelevant, calling into questions problems with peer review, including the selection and publication process of our journals. This column is devoted to calling attention to these problems not only to CRNAs and other researchers, but also to the consumers of research who often use it to make changes in their practice. It also calls attention to the CRNA community about the movement toward calls for greater accountability in practice, both as to quality and cost, from which the movement toward evidence-based practice, the identification and benchmarking of best practices, and the development and implementation of clinical practice guideline has evolved. To feel ownership in anesthesia-related clinical practice guidelines, CRNAs must become involved in their development and implementation.

Clinical Nursing Research↗
PubMed1996

The national distribution of Certified Registered Nurse Anesthetists across metropolitan and nonmetropolitan settings.

The purpose of this study is to describe the metropolitan and nonmetropolitan distribution of Certified Registered Nurse Anesthetists actively practicing across the United States. More than 3,000 counties of the United States were categorized according to degree of urbanization by utilizing the rural-urban continuum codes for metropolitan and nonmetropolitan counties developed within the U.S. Department of Agriculture. Zip code information was used to locate all actively practicing CRNAs by county of residence. Applying the rural-urban continuum codes to this database revealed a descriptive national distribution of CRNAs across geographical areas. Data show that 81.3% (18,086) of CRNAs reside in metropolitan counties and that 18.7% (4,182) reside in nonmetropolitan areas. The greatest number of CRNAs (8,519) are found in central counties of metropolitan areas of one million population or more. The lowest number of CRNAs (90) are found in completely rural counties of fewer than 2,500 urban population adjacent to a metropolitan area, and 160 CRNAs reside in counties of fewer than 2,500 population not adjacent to a metropolitan area. Differences in age, gender distribution, educational credentials, and population ratios are also noted between metropolitan and nonmetropolitan CRNAs.

Adult↗