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PubMed2005

Statistical process control for radiotherapy quality assurance.

Every quality assurance process uncovers random and systematic errors. These errors typically consist of many small random errors and a very few number of large errors that dominate the result. Quality assurance practices in radiotherapy do not adequately differentiate between these two sources of error. The ability to separate these types of errors would allow the dominant source(s) of error to be efficiently detected and addressed. In this work, statistical process control is applied to quality assurance in radiotherapy for the purpose of setting action thresholds that differentiate between random and systematic errors. The theoretical development and implementation of process behavior charts are described. We report on a pilot project is which these techniques are applied to daily output and flatness/symmetry quality assurance for a 10 MV photon beam in our department. This clinical case was followed over 52 days. As part of our investigation, we found that action thresholds set using process behavior charts were able to identify systematic changes in our daily quality assurance process. This is in contrast to action thresholds set using the standard deviation, which did not identify the same systematic changes in the process. The process behavior thresholds calculated from a subset of the data detected a 2% change in the process whereas with a standard deviation calculation, no change was detected. Medical physicists must make decisions on quality assurance data as it is acquired. Process behavior charts help decide when to take action and when to acquire more data before making a change in the process.

Humans↗

PubMedDate not supplied

Cost-effectiveness of midwifery services vs. medical services in Quebec. LEquipe dEvaluation des Projets-Pilotes Sages-Femmes.

This study compared the cost-effectiveness of midwife services provided in birth centres operating as pilot projects with current hospital-based medical services in the province of Quebec. One thousand midwives' clients were matched with 1,000 physicians' clients on the basis of socio-demographic characteristics and obstetrical risk. Direct costs for the prenatal, intrapartum and postpartum periods were estimated. Effectiveness was assessed on the basis of three clinical indicators and four indices related to the individualization of care as assessed by women. Results show that the costs of midwife services were barely lower than or equal to those of physician services, but cost-effectiveness ratios were to the advantage of the midwife group, except for one clinical indicator (neonatal ventilation). Overall, this study provides rational support for the process of legalizing midwifery in the province.

Birthing Centers↗

PubMed2005

Social work at the heart of the medical team.

This paper proposes one model of hospital social work delivery services that places social work in a facilitative role within the medical team, and describes a pilot project designed to evaluate these services. Social work's role in this teaching hospital setting was tailored to provide patients and medical staff access to social work services upon admission, rather than at the time of discharge. This change places social work at the pivotal juncture to improve medical care and addresses the social, cultural and environmental concerns as they surface during patient stay. Unique to this demonstration model is the added advantage of placing the social worker at the hub of the physician-led medical team. Medical students, residents, and attending physicians all learn, observe, and experience the advantages social workers bring to the process. Educating medical students on teams with social workers bodes well for the profession. The authors summarize the program design, results and implications for social work practice in a teaching hospital setting.

Hospitals, Teaching↗

PubMed2001

The Collection of Indirect and Nonmedical Direct Costs (COIN) form: a new tool for collecting the invisible costs of androgen independent prostate carcinoma.

BACKGROUND: There are limited data available regarding the cost of care in patients with androgen independent prostate carcinoma (AIPC), and there are no data on the impact of direct nonmedical and indirect costs (DNM/IC). This lack of data, along with the feasibility of collecting DNM/IC, was examined in patients with AIPC who took part in a randomized trial using a newly developed questionnaire, the Collection of Indirect and Nonmedical Direct Costs (COIN) form. METHODS: Patients with AIPC were randomized to one of three treatment arms: 1) strontium only (strontium 4 Mci in Week 1 and Week 12) (STRONT); 2) vinblastine 4 mg/m(2) per week for 3 weeks then 1 week off and estramustine, 10 mg/kg per day (CHEMO); or 3) a combination of treatments outlined in the arms for CHEMO and STRONT (CHEMO/STRONT). Direct medical costs were collected through the hospital billing system. DNM/IC data were obtained prospectively using the COIN form. Cost data were analyzed for a period of 6 months. RESULTS: Twenty-nine patients were randomized, after which the protocol was closed because of poor accrual. The median survival of the patients was 22.3 months. The mean and median total costs for the 20 of 29 patients with complete cost information were $12,647 and $11,257 over 6 months, respectively. DNM/IC represented 11% of the total cost (range, from < 1% to 42%); in 20% of participating individuals, these costs accounted for 35-42% of total costs. Failure to collect complete cost information was due to early death, administrative difficulties, and loss to follow-up. CONCLUSIONS: In this pilot project, the collection of these cost data using the COIN form was feasible and practical and was limited primarily by logistic, not form specific, issues. DNM/IC were found to be a significant proportion of total costs (up to 42%) in selected patients, and this information proved to be a useful addition to the cost analysis. Approximately 98 patients would be required to detect a 20% difference in total costs between arms in a properly powered, randomized trial. Considering the potentially significant impact on total costs, DNM/IC data should be included in future cost-analysis studies of patients with AIPC and other diseases.

Adenocarcinoma↗

PubMed1994

[Organization and significance of quality control in recent surgical methods exemplified by 85 consecutive thoracoscopic interventions].

The rapid evolution or rather revolution of minimally invasive surgical techniques is stimulating new technical and clinical innovations. Quality control is of great importance in new areas of technical development where standards do not yet exist. By recording detailed documentation of patient data, indications, operative procedures and initial follow-up we can compare this new technology with the gold standard therapy. This documentation system for thoracoscopic interventions was developed together with the Swiss Group of Laparoscopic and Thoracoscopic Surgeons. This pilot project of 85 consecutive thoracoscopic interventions will demonstrate the acceptability, clinical application and ease with which data can be analyzed. Operative techniques are described in detail: 20 diagnostic interventions with biopsy, 19 apical parietal pleurectomies (+/- resections of bullous lung tissue), 10 therapeutic lung tissue resections, 19 palliative pleurodesis, 5 treatments of pleural empyema, 1 mediastinal tumor resection, 1 esophagectomy, 4 thoracic sympathectomies plus 6 other procedures. Data entry is efficient with mean total time of 10 min for each record. All of the data are entered into a computer database. The possibilities for interpreting and combining this data are presented. The operative techniques can easily be related with history, indications, anesthesia, complications and results. First evaluation of thoracoscopic efficiency is possible. In addition, a detailed analysis of intra- and postoperative complications and of the hospital course can be performed.

Documentation↗

PubMed1975

Stenting in experimental laryngeal injuries.

This experimental pilot project studies acute laryngeal injuries in 20 dogs and compares the use of three types of stenting materials with using no stent at all following the production of a "controlled airway deforming injury." Each injury was repaired meticulously using stainless steel wire to immobilize the cartilage separations, and fine catgut to close the mucosal lacerations. Animals were killed after observation for periods of two to six weeks postoperatively. Marked infection, ulceration, and granulation tissue formation were observed in most of the stented animals, with the nonstented animals showing the most complete and uncomplicated healing. In this experimental model, acute laryngeal "fractures" were adequately stabilized by suturing and a stable cartilaginous framework supported the healing intralaryngeal soft tissues. Avoidance of stenting in this animal series appears to decrease infection, ulceration, and granulation tissue formation resulting in improved healing.

Acute Disease↗

PubMed2000

Optimization of TEOAE recording protocols: a linear protocol derived from parameters of a time-frequency analysis: a pilot study on neonatal subjects.

Linear and non-linear TEOAE protocols were compared in terms of nine parameters in order to define the protocol producing recordings with the highest signal quality (lowest noise and highest signal-to-noise ratio). The pilot project acquired data using ILO-92 apparatus from 220 neonates (397 ears) at the second/third day after birth in three European laboratories. A Gabor spectrogram time-frequency representation of the recordings showed considerable frequency dispersion in TEOAE latencies >4.0 ms. The data, analysed with a Wilcoxon test, indicated that a linear TEOAE protocol: (i) generates recordings of a lower noise and a higher signal-to-noise (S/N) ratio in the 2.0, 3.0, 4.0 kHz TEOAE bands; (ii) the increase in the S/N ratio can result in a decrement of the required number of TEOAE sweeps; (iii) the higher values of S/N can be used in the estimation of more robust pass-fail criteria, minimizing the percentage of false positives and negatives.

Acoustic Stimulation↗

PubMed1989

Evaluation of care in psychogeriatric units: family support in quality of care.

As institutionalised psychogeriatric patients are very vulnerable, a pilot project was undertaken to develop an instrument to evaluate the quality of their care. The proposed instrument is based on qualitative findings from observations, interviews, records and literature review. It focuses on individual patients, groups of patients, families and the unit, and includes nine items which are measured in terms of administrative, affective and instrumental aspects of care. This paper only describes the data gathered on one of these foci--the involvement of families as both providers of care and as clients requiring support. From the data it appears that the family role as a provider of care is enhanced by support received from the staff and, therefore, family support was selected as an item by which to evaluate quality of care. Material from the data was used as examples for assigning quantitative values to aspects of family involvement.

Aged↗

PubMed1999

Understanding what is important for women who live with multiple sclerosis.

In this pilot-project eight women with multiple sclerosis (MS), four Continence Nurse Advisers (CNAs) and one researcher formed a participatory action research (PAR) group. Ten group sessions were held in 1997. The CNAs found that 80 of their referrals for continence management were women with MS and they wanted to explore the way in which women manage their incontinence. Although the group was brought together to discuss incontinence, other emergent themes were raised by the women. These themes were: women's ad hoc experience with community services, their problems concerning access to toilets for the disabled, concern with health professionals' lack of knowledge about MS, their formidable experiences of hospitalisation and respite care admissions, their individual efforts in maintaining wellness in the context of chronic illness and the effect of MS on sexual relationships.

Adaptation, Psychological↗

PubMedDate not supplied

Complications of vascular access: results of a European multi centre study of the EDTNA/ERCA Research Board.

The pilot project of the Research Board of EDTNA/ERCA handled the management of vascular accesses (VA) in European dialysis centres. In the first part of the study, centre policies related to VA management were investigated. In the second part of the study, individual patients were followed prospectively during one year. This paper reports on several topics of the second part of the project, investigating complications of the VA related to centre, patient characteristics and dialysis techniques used. Complications most frequently observed were thrombosis, stenosis, infection, bleeding and flow problems. Gradually more infections and flow problems were observed if the centre size and the patients/nurse ratio went up. Complication rate was not significantly influenced by age, gender, renal diagnosis, time on dialysis or medication used by the patient. In contrast, the number of vascular accesses in the past and interventions in the VA before first use resulted in an increased number of complications. Nurses have a key role in the prevention, manipulation and outcome of vascular access related complications.

Adolescent↗

PubMed2000

Evaluation of medical students' performance using the anaesthesia simulator.

OBJECTIVES: A pilot project assessing clinical performance was undertaken using the Anaesthesia Simulation Centre at the University of Toronto. The purpose of this study was to determine the reliability of assessments of medical students' performance using the simulator as an evaluation tool, to compare these assessments to written and clinical evaluations and to elicit student opinion. Simulator assessments were performed at the completion of the anaesthesia rotation. DESIGN: Twenty-four of 177 University of Toronto medical students participated in a videotaped simulator session with an attending faculty. These 24 students were based at Sunnybrook Health Science Centre. During the session, each student worked through one of six predetermined cases involving discrete patient problems based on the list of core objectives. Five evaluators independently assessed each student's videotaped performance using standardized performance evaluation criteria and data were examined for inter-rater reliability. Clinical and written examination marks were compared to simulator assessments. A student questionnaire was administered and descriptive data obtained. SETTING: The University of Toronto. SUBJECTS: Medical students. RESULTS: The intraclass correlation coefficient (ICC) of inter-rater reliability was 0.87. There was poor correlation between the simulator and written examination marks (r=0.19, P=0.38) and between the simulator and clinical marks (r=0.04, P=0.87). The simulator experience was highly rated by students: learning experience 4.6 +/- 0.51, appropriate content 4.4 +/- 0.74, use as evaluation tool, 4.1 +/- 0.92 (1=poor, 5=excellent). CONCLUSIONS: Our pilot data suggest that the simulator is a reliable assessment method for medical students' performance. Further work may justify the inclusion of the simulator as an evaluation and education tool and expanded to incorporate learning objectives of other medical disciplines.

Anesthesiology↗

PubMed2006

Acute coronary syndrome nurses: perceptions of other members of the health care team.

Acute coronary syndromes (ACS) are a major health care problem and result in a large number of hospital admissions each year. Nurses across the NHS are being empowered to undertake a growing range of responsibilities but little research evidence exists related to the impact on patient care nor working practice with other health professionals. This paper reports part of the evaluation of a British Heart Foundation pilot project to place an 'ACS nurse' in participating hospitals. In each of 5 hospitals, 100 staff across accident and emergency, general medicine and cardiac specialities were sent a questionnaire. The response rate was 33%. Respondents felt that the ACS nurse role was beneficial to patient care and had little overlap with existing roles within the hospital. Support for nurse initiated thrombolysis was high, but comments reflected the on-going debate around accountability and training. Communication and problem solving were identified as key elements of the ACS nurse role. Findings in this study show support for the integration of an ACS nurse role as a way to provide improved care to ACS patients.

Acute Disease↗

PubMed2000

Simple pain rating scales hide complex idiosyncratic meanings.

Assumptions of reliability and consistency of self-report of pain by patients using visual analogue scales (VAS) and numerical rating scales (NRS) are based on narrow considerations of possible sources of error. This study examined patients' use of VASs and NRSs, by their own description, with particular attention to rating of multiple pains, of different dimensions of pain, and of interpretation and use of lower and upper endpoints and increments on the scales. These have implications for the approximation of the scales to psychometric requirements. An interview developed from a small pilot project was given to 78 volunteer chronic pain patients embarking on a pain management course, and consisted of both forced choice questions and free response. Data are described with reference to lack of concordance between patients and of consistency within patients; responses suggested that ratings incorporate multiple partially differentiated dimensions of pain, with particular importance placed on function or mobility. Labels assigned to scale endpoints by researchers, whether lexical or numerical, appeared to affect their use; however, covert relabelling of scale points was revealed in free response. The action of arriving at a rating is better conceptualised as an attempt to construct meaning, influenced by and with reference to a range of internal and external factors and private meanings, rather than as a task of matching a distance or number to a discrete internal stimulus.

Adult↗

PubMed1995

The assessment of clinical competency: an overview and preliminary report of Canadian physiotherapy programs.

This pilot project was designed to collect information on the student assessment formats used by Canadian Physiotherapy programs. A mail questionnaire was used to gather the information. Practical exams generally consist of one to two cases with one examiner present. Little examiner training takes place. The Objective Structured Clinical Examination is being used at five universities. Stations are generally five to ten minutes long, with five to fifteen stations per exam. Patient and examiner training is sporadic. Multiple Choice Question Exams are used regularly with 40-150 questions being included. The respondents were generally satisfied with their clinical placement assessments. None of the respondents showed an understanding of standard setting. Various responses and methods of using the assessment procedures are not in accordance with research findings on the use of these methods. This may indicate a need for faculty development in the area of measurement and evaluation.

Canada↗

PubMed1998

When the morning after is Sunday: pharmacist prescribing of emergency contraceptive pills.

Pharmacists are well positioned to play a major role in increasing access to emergency contraceptive pills (ECPs). A pilot project in Washington State is testing direct pharmacist prescribing. Through a collaborative drug therapy agreement, a licensed prescriber, such as a physician, delegates to a pharmacist the authority to prescribe ECPs directly to women who meet the assessment criteria. Currently pharmacists at 111 Washington State pharmacies have collaborative agreements in place, and the number of participating pharmacies continues to increase. The response to this initiative has been extremely positive. Women who have received ECPs directly from pharmacists rate their interactions with the pharmacists positively and overwhelmingly cite convenience as the primary reason for going directly to the pharmacy. Physicians and other providers with independent prescribing authority can play a pivotal role by working with pharmacists to replicate the Washington State initiative in the states that allow it.

Contraceptives, Postcoital↗

PubMed2004

[Midwife-led labour in a Swiss hospital].

A midwife-led labour care model was introduced in a Swiss University Hospital. This new model enabled expectant mothers who had a low risk medical history to give birth with the support of only a midwife. The model has been evaluated as part of a pilot project in a comparative study. A quantitative-explorative design was chosen. Labour with only a midwife in comparison with the traditional presence of a doctor and a midwife resulted in fewer invasive procedures, while the outcome parameters were similar in both groups. The post partum hospital stay of the women in the midwife-only group was significantly shorter than in the midwife-and-doctor group. The midwife-only model appealed to a certain group of women and their partners who generally had a higher level of education. Women in both groups were highly satisfied with the midwifery care; the possibility of giving birth in hospital with the presence of a midwife alone was very much appreciated. Under an economic aspect the results of the study provide preliminary indications that delivery by a midwife alone involves lower costs and therefore increased income for the hospital in question.

Female↗

PubMed1962

The appearance of pyrimethamine resistance in Plasmodium falciparum following self-medication by a rural community in Ghana.

During the preparatory phase of the Malaria Eradication Pilot Project in Ghana, a weekly pyrimethamine regimen was instituted at two hyperendemic villages, primarily to assess the reliability of self-administration techniques under local conditions.After initial supervised individual administrations, weekly distribution of family drug requirements was made to a responsible member of each household by volunteer community leaders.Although parasite rates fell from 71% to 6.5% after four weeks, recurrence of Plasmodium falciparum parasitaemia was observed by the 37th week. Resistance in that species was confirmed, associated with successful sporogony in Anopheles gambiae, after supervised pyrimethamine treatment equivalent to twice the routine dosage.Emergence of this high-grade drug resistance was attributable to irregular self-administration by the local population of the tablets collected for each household. It was therefore concluded that under the conditions obtaining, self-medication was not a reliable method for mass distribution of pyrimethamine.

Antimalarials↗

PubMed2005

Fostering youth leadership to address workplace and community environmental health issues: a university-school-community partnership.

Many communities of color are disproportionately exposed to workplace and community environmental hazards. This article presents the results of a pilot project designed by a university-school-community partnership to develop youth leadership to confront these exposures. Using a popular empowerment education approach, students applied peer education, research, and organizing skills learned in the classroom to community-based internships in a service-learning model. Evaluation results from pretests and posttests, focus groups, and in-depth interviews demonstrated that students shared what they learned about young workers' rights and environmental justice with family and friends. They developed a critical analysis of environmental inequities, created a citywide youth coalition that advocates around legal, educational, and environmental issues affecting youth, and implemented campaigns to enforce child labor laws and to prevent school construction on contaminated land. This multifaceted model can serve as an important foundation to develop youth leaders to influence environmental policies in a variety of communities.

Adolescent↗