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Biomedical subjects

Peter J Pronovost

Publications and source records attributed to Peter J Pronovost.

At least 19 recordsLinked to original sources
PubMed2007

Human immunodeficiency virus and hepatitis testing and prevalence among surgical patients in an urban university hospital.

BACKGROUND: Human immunodeficiency virus (HIV), hepatitis B, and hepatitis C represent significant public health problems in an urban community. Early diagnosis and treatment of these infections can improve survival and allow for preventive strategies to reduce further transmission within a community. The aim of this study was to evaluate the surgical setting as a potential opportunity for early diagnosis of HIV, hepatitis B, and hepatitis C among trauma and non-trauma patients. METHODS: We performed a retrospective review of patients presenting for surgery over a 10-year period (July 1994 to July 2004) in an urban, university-based general surgical practice that includes all trauma services, as well as emergency department, inpatient, and outpatient surgical consultations. Data collected included diagnosis, operation, age, race, history of intravenous drug abuse, and HIV, hepatitis B, and hepatitis C test results. RESULTS: Among 2876 patients presenting for surgery, testing for blood-borne pathogens was less likely among trauma patients (21%, 79/380) compared to non-trauma patients (47%, 1183/2496) (P < .001). Among patients tested, the incidence of blood-borne pathogens was similar in the two groups: HIV (26% trauma vs 24% non-trauma, not significant [NS]), hepatitis B (4% trauma vs 3% non-trauma, NS), hepatitis C (33% trauma vs 41% non-trauma, NS), and co-infection with HIV and hepatitis C (18% trauma vs 12% non-trauma, NS). In both groups, blood-borne pathogens were associated with intravenous drug abuse (P < .01). CONCLUSION: HIV, hepatitis B, and hepatitis C are common in an urban community among both trauma and non-trauma surgical patients, although testing is less common among trauma patients. Testing of patients during a surgical admission may represent an excellent opportunity for early disease-specific services and preventive interventions.

AIDS Serodiagnosis↗
PubMed2006

The national trend in quality of emergency department pain management for long bone fractures.

BACKGROUND: Despite national attention, there is little evidence that the quality of emergency department (ED) pain management is improving. OBJECTIVES: To compare the quality of ED pain management before and after implementation of the Joint Commission on the Accreditation of Healthcare Organizations' standards in 2001. METHODS: The authors performed a retrospective cohort study by using the National Hospital Ambulatory Medical Care Survey from 1998-2003. Patients who presented to the ED with a long bone fracture (femur, humerus, tibia, fibula, radius, or ulna) were compared. The authors extracted data on patient, visit, and hospital characteristics. The primary outcomes were the proportion of patients who received assessment of pain severity and who received analgesic treatment. RESULTS: There were 2,064 patients with a qualifying fracture in the study period, 834 from 1998-2000 and 1,230 from 2001-2003. Compared with the early period, a higher proportion of patients in the late period had their pain assessed (74% vs. 57%), received opiates (56% vs. 50%), and received any analgesic (76% vs. 56%). Patients in the late period had higher odds of receiving any analgesia (adjusted odds ratio [OR], 1.43) and opioid analgesia (adjusted OR, 1.27) compared with the early period. Patients in the middle age group (adjusted OR, 2.28) or those seen by physician assistants (adjusted OR, 2.05) were more likely, whereas those with Medicaid (adjusted OR, 0.58) and those in the Northeast were less likely, to receive opiates. CONCLUSIONS: Although the quality of ED pain management for acute fractures appears to be improving, there is still room for further improvement.

Adult↗
PubMed2006

Quality of life after acute respiratory distress syndrome: a meta-analysis.

OBJECTIVE: To summarize long-term quality of life (QOL) and the degree of variation in QOL estimates across studies of acute respiratory distress (ARDS) survivors. DESIGN: A systematic review of studies evaluating QOL in ARDS survivors was conducted. Medline, EMBASE, CINAHL, pre-CINAHL, and the Cochrane Library were searched, and reference lists from relevant articles were evaluated. Two authors independently selected studies reporting QOL in adult survivors of ARDS or acute lung injury at least 30 days after intensive care unit discharge and extracted data on study design, patient characteristics, methods, and results. MEASUREMENTS AND RESULTS: Thirteen independent observational studies (557 patients) met inclusion criteria. Eight of these studies used eight different QOL instruments, allowing only qualitative synthesis of results. The five remaining studies (330 patients) measured QOL using the Medical Outcomes Study 36-Item Short Form survey (SF-36). Mean QOL scores were similar across these studies, falling within a range of 20 points for all domains. Pooled domain-specific QOL scores in ARDS survivors 6 months or later after discharge ranged from 45 (role physical) to 66 (social functioning), or 15-26 points lower than population norms, in all domains except mental health (11 points) and role physical (39 points). Corresponding confidence intervals were no wider than +/-9 points. Six studies all found stable or improved QOL over time, but only one found significant improvement beyond 6 months after discharge. CONCLUSIONS: ARDS survivors in different clinical settings experience similar decrements in QOL. The precise magnitude of these decrements helps clarify the long-term prognosis for ARDS survivors.

Humans↗
PubMed2006

Adverse events during medical and surgical hospitalizations for persons with schizophrenia.

CONTEXT: Persons with schizophrenia have a high risk of premature mortality. It is not clear if greater risk for adverse events during hospitalization is a contributing factor. OBJECTIVES: To estimate the prevalence of adverse events in medical and surgical hospitalizations for persons with schizophrenia compared with those for persons without schizophrenia and to examine the relation between adverse events and intensive care unit admission, in-hospital death, length of stay, and total charges for hospitalizations for persons with schizophrenia. DESIGN: Cross-sectional study. SETTING: We studied discharges from all Maryland acute care hospitals' medical and surgical services in 2001 and 2002. Patients There were 1746 medical and surgical hospitalizations for adults with a secondary diagnosis of schizophrenia and 732 158 for adults without schizophrenia. MAIN OUTCOME MEASURES: For primary outcomes, we applied the Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs), which were developed to detect adverse events in administrative data. We compared PSIs for hospitalizations for patients with a secondary diagnosis of schizophrenia with those for patients without and determined the association between schizophrenia and each PSI adjusting for patient and hospital characteristics. For hospitalizations for patients with schizophrenia, for secondary outcomes we examined the association between each PSI and intensive care unit admission, in-hospital death, length of stay, and total charges. RESULTS: Hospitalizations for patients with schizophrenia had the following higher adjusted relative odds of having PSIs compared with those for patients without schizophrenia: infections due to medical care (odds ratio [OR], 2.49 [95% confidence interval (CI), 1.28 to 4.88]); postoperative respiratory failure (OR, 2.08 [95% CI, 1.41 to 3.06]); postoperative deep venous thrombosis (OR, 1.96 [95% CI, 1.18 to 3.26]); and postoperative sepsis (OR, 2.29 [95% CI, 1.49 to 3.51]). For hospitalizations for patients with schizophrenia, having respiratory failure or sepsis resulted in at least twice the adjusted odds for intensive care unit admission and death. The median adjusted increase in length of stay was at least 10 days, and median hospital charges were elevated by at least $20 000 for infections due to medical care, respiratory failure, deep venous thrombosis, and sepsis. CONCLUSIONS: Medical and surgical hospitalizations for persons with schizophrenia had at least twice the odds of several types of adverse events than those for persons without schizophrenia. These adverse events were associated with poor clinical and economic outcomes during the hospital admission. Efforts to reduce these adverse events should become a research priority.

Cross-Sectional Studies↗
PubMed2006

Sharpless surgery: a prospective study of the feasibility of performing operations using non-sharp techniques in an urban, university-based surgical practice.

CONTEXT: Percutaneous injuries occur frequently during surgical procedures and represent a significant occupational hazard to operating room personnel. OBJECTIVES: To evaluate the feasibility of performing select general surgical procedures using a combination of non-sharp devices and techniques to replace the conventional use of scalpels and needles. DESIGN, SETTING, AND PARTICIPANTS: Candidate procedures for which sharpless techniques could replace conventional scalpels and suture needles were identified preoperatively in an urban, university-based general surgical practice over a 1-year period (June 2003-June 2004). Non-sharp techniques included monomeric 2-octyl cyanoacrylate adhesive, electrocautery, tissue stapler, and minimally invasive instrumentation. Conventional scalpels and suture needles were readily available and used whenever necessary. MAIN OUTCOME MEASURES: We rated the feasibility of performing specific procedures without sharps. We also documented the rate of overall reversion to sharps during operations on patients that had been identified preoperatively as candidates for sharpless surgery. RESULTS: Of 358 procedures performed in the general surgery university practice, 91 were identified preoperatively as appropriate for sharpless surgery. Of these, 86.8% (79/91) were completed without the use of sharps, including 13/22 (59.1%) open laparotomy procedures, 20/22 (90.9%) laparoscopic procedures, and 46/47 (97.8%) soft tissue procedures. Intraoperative reversion to sharps occurred in 12 cases when deemed necessary by the surgeon. CONCLUSIONS: Select common procedures can be performed entirely with sharpless techniques, eliminating the risk to surgical personnel associated with intraoperative percutaneous injuries.

Academic Medical Centers↗
PubMed2006

Targeting errors in the ICU: use of a national database.

The authors believe that as we move from viewing adverse event reporting system as punitive, and as the safety culture improves, reporting will likely increase. Voluntary incident reporting systems can be used to improve patient safety in the ICU by identifying broken or inadequate systems that lead to adverse events [26]. Voluntary external reporting systems such as the ICUSRS can be used to target errors and produce evidence-based best practice measures to improve patient safety in the ICU.

Adverse Drug Reaction Reporting Systems↗
PubMed2006

Ethical and practical aspects of disclosing adverse events in the emergency department.

Physicians and hospitals should be aware of the ethical duty to disclose a medical error that causes harm to a patient. Disclosure should be made to the affected patient or, when appropriate, to a family member of the patient. The manner in which the disclosure process is performed is also important. In emergency medicine, disclosure discussions are problematic because of the limited nature of the patient-physician relationship. The initial disclosure can be conducted in a way that maintains or even improves the relationship with the patient, or in a manner that damages trust. This article discusses the importance of disclosure in emergency medicine; the ethical basis for, and barriers to, disclosure; and the key elements of the disclosure process.

Emergency Medicine↗
PubMed2006

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

BACKGROUND: Teamwork is an important component of patient safety. In fact, communication errors are the most common cause of sentinel events and wrong-site operations in the US. Although efforts to improve patient safety through improving teamwork are growing, there is no validated tool to scientifically measure teamwork in the surgical setting. STUDY DESIGN: Operating room personnel in 60 hospitals were surveyed using the Safety Attitudes Questionnaire. Surgeons, anesthesiologists, certified registered nurse anesthetists, and operating room nurses rated their own peers and each other using a 5-point Likert scale (1 = very low, 5 = very high). RESULTS: Overall response rate was 77.1% (2,135 of 2,769). Ratings of teamwork differed substantially by operating room caregiver type, with the greatest differences in ratings shown by physicians: surgeons (F[4, 2058] = 41.73, p < 0.001), and anesthesiologists (F[4, 1990] = 53.15, p < 0.001). The percent of operating room caregivers rating the quality of collaboration and communication as "high" or "very high" was different by caregiver role and whether they were rating a peer or another type of caregiver: surgeons rated other surgeons "high" or "very high" 85% of the time, and nurses rated their collaboration with surgeons "high" or "very high" only 48% of the time. CONCLUSIONS: Considerable discrepancies in perceptions of teamwork exist in the operating room, with physicians rating the teamwork of others as good, but at the same time, nurses perceive teamwork as mediocre. Given the importance of communication and collaboration in patient safety, health care organizations should measure teamwork using a scientifically valid method. The Safety Attitudes Questionnaire can be used to measure teamwork, identify disconnects between or within disciplines, and evaluate interventions aimed at improving patient safety.

Analysis of Variance↗
PubMed2006

The checklist--a tool for error management and performance improvement.

Levels of cognitive function are often compromised with increasing levels of stress and fatigue, as is often the norm in certain complex, high-intensity fields of work. Aviation, aeronautics, and product manufacturing have come to rely heavily on checklists to aid in reducing human error. The checklist is an important tool in error management across all these fields, contributing significantly to reductions in the risk of costly mistakes and improving overall outcomes. Such benefits also translate to improving the delivery of patient care. Despite demonstrated benefits of checklists in medicine and critical care, the integration of checklists into practice has not been as rapid and widespread as with other fields. This narrative is a guide to the evolution of medical and critical care checklists, and a discussion of the barriers and risks to the implementation of checklists.

Aviation↗
PubMed2006

Toward learning from patient safety reporting systems.

PURPOSE: To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety. MATERIALS AND METHODS: Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm. RESULTS: Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm. CONCLUSIONS: The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.

Adult↗
PubMed2006

A web-based tool for the Comprehensive Unit-based Safety Program (CUSP).

BACKGROUND: An organization's ability to change is driven by its culture, which in turn has a significant impact on safety. The six-step Comprehensive Unit-Based Safety Program (CUSP) is intended to improve local culture and safety. A Web-based project management tool for CUSP was developed and then pilot tested at two hospitals. HOW ECUSP WORKS: Once a patient safety concern is identified (step 3), a unit-level interdisciplinary safety committee determines issue criticality and starts up the projects (step 4), which are managed using project management tools within eCUSP (step 5). On a project's completion, the results are disseminated through a shared story (step 6). CASE STUDIES: OSF St. Joseph's Medical Center-The Medical Birthing Center (Bloomington, Illinois), identified 11 safety issues, implemented 11 projects, and created 9 shared stories--including one for its Armband Project. The Johns Hopkins Hospital (Baltimore) Medical Progressive Care (MPC4) Unit identified 5 safety issues and implemented 4 ongoing projects, including the intravenous (IV) Tubing Compliance Project. DISCUSSION: The eCUSP tool's success depends on an organizational commitment to creating a culture of safety.

Health Facilities↗
PubMed2006

Operating room briefings: working on the same page.

This tool, which takes one or two minutes to use, provides a structured approach to promote effective interdisciplinary communication and teamwork in the operating room--or any other area, such as an intensive care unit, inpatient unit, or outpatient clinic.

Humans↗
PubMed2006

Operating room debriefings.

This tool helps assess factors that positively and negatively contributed to an adverse event, near miss, or inefficiency during an operation-or any procedure.

Efficiency, Organizational↗