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PubMed2004

[Implementation of an internal transfer pricing system for anaesthesia services].

Internal transfer pricing system (ITPS) of anaesthesia services is established to guarantee a close connection of delivered service and the budget of the department of anaesthesia. In most cases a time-based system is used with the pricing unit being calculated as the quotient from the enumerator "costs" divided by the denominator "anaesthesia time in minutes". The implementation of a transfer pricing system requires the identification of all relevant costs caused by the department of anaesthesia and a cost centre structure is needed which allocates all costs correctly according to their cause. The regulations regarding cost calculations as defined by the German DRG System should be considered. To generate valid data not only the necessary technical infrastructure is needed, but also detailed training of the staff and plausibility checks are needed to ensure correct and complete data. Subsequent agreements with the hospital administration are necessary in order to adjust the system if extrinsic cost increases occur. This paper gives a step-by-step guidance for the successful implementation of an internal transfer pricing system based on anaesthesia time.

Anesthesia Department, Hospital↗

PubMed2006

[New licensing regulations for physicians. Main areas of reform and first results of the implementation process].

Since October 2003 medical education in Germany has been given a new more up-to-date basis, the "New Licensing Regulations for Physicians". They represent a reform of both the structure and the content of medical education making great demands on medical faculties and medical students; e.g. elective courses during the first and second cycles of the curriculum, interdisciplinary courses (so-called 'cross-sectional courses'), practical clinical courses of several weeks in five specialties, and family medicine as an option for choice during the last year are central issues of the reform. The number of state-controlled medical examinations has been reduced from four to two. It is now the responsibility of medical faculties to assess the knowledge, clinical skills and professional attitudes of students with respect to the numerous specialties which are part of medical education. This paper presents the essential innovations and describes the current state of the implementation process. It also points out problems that deserve reconsideration. Although the full implementation of the new licensing regulations is still in progress, it might be said that they have already initiated important changes in medical education in Germany.

Curriculum↗

PubMed2006

[Has anything changed in the quality of continuing education in orthopaedic/trauma surgery? Evaluation 1 year after implementation of a new code of practice for resident training in orthopaedic/trauma surgery in Bavaria].

OBJECTIVE: It was the aim of this study to evaluate any changes in the quality of orthopaedic/trauma training 1 year after implementation of the new code of practice for resident training in Bavarian clinics. METHODS: A questionnaire was prepared by the Educational Committee and the Junges Forum of the German Trauma Society and sent to all 120 instructors (and their medical staff) for resident training in Bavaria for general surgery, trauma surgery as well as orthopaedic/trauma surgery on July 26 2005. RESULTS: While 56% of the chairmen claimed to perform a structured, curricular training, only 18% of the residents could verify this. In a similar manner, the majority of chairmen were satisfied with the new code of practice for resident training, while the majority of residents and attendings were not. CONCLUSION: One year after implementation of a new code of practice for resident training in Bavaria, surgical training structures are not well established. There is a large discrepancy in the evaluation of training quality between chairmen and residents. It is therefore imperative to develop recommendations for structuring orthopaedic/trauma training.

Education, Medical, Graduate↗

PubMed2006

[Implementation of a competency-based graduate medical education program in a neurology department].

BACKGROUND: Competency-based programs have long been the basis of graduate medical education in British and North America. Such formally defined program structures are lacking in German graduate medical education. METHODS: The methods and assessment tools used in a curriculum-based program of graduate education in medical specialties are presented. The feasibility of the program was tested in day-to-day use in a pilot study conducted within a neurology department. Experience of it during a 1-year period after implementation has also been collected. RESULTS: It was found that implementation of the program is feasible providing that both the trainers and the students are well motivated, that adequate resources are provided, and that a formal training system is provided for the trainers. This is confirmed by the 1-year experience of the program in routine clinical practice. CONCLUSIONS: The competency-based program presented, which is compatible with many quality management systems, offers management and assessment tools that will make for more satisfactory postgraduate medical education.

Clinical Competence↗

PubMed2006

[Clinical pathways. Implementation in a urological department].

BACKGROUND: Clinical pathways are directions for standardised treatment processes for different diseases or procedures in a hospital. These pathways are developed within a team of several professions and are used as order and procedure sheets. Experiences with this element of quality management are limited in Germany. METHODS: The development and the implementation process of 15 pathways in a urological department are described. A clinical pathway for female incontinence surgery (suburethral tape) is presented as an example. The effects of the pathways are evaluated on a routine basis. RESULTS: Seventy-two percent of the patients were treated according to a clinical pathway. The advantages of clinical pathways are a better structuring and transparency of medical processes, a reduction of documentation, improvements in medical education and savings in time, hospital stay of the patients and costs. Expenses for pharmaceuticals were significantly reduced in connection with development of the pathways. CONCLUSIONS: The implementation of clinical pathways is a complex but rewarding project. It can be expected that clinical pathways will be rapidly distributed in the near future and that they will contribute to improvements of health care quality.

Critical Pathways↗

PubMed2005

Glycaemic control and severe hypoglycaemia following training in flexible, intensive insulin therapy to enable dietary freedom in people with type 1 diabetes: a prospective implementation study.

AIMS/HYPOTHESIS: The aim of this study was to evaluate the implementation of a course teaching flexible, intensive insulin therapy on glycaemic control and severe hypoglycaemia in routine care. METHODS: This is a continuous quality-assurance project involving hospital diabetes centres. Every third year each centre re-examines 50 consecutive patients (evaluation sample) 1 year after participation in the course. Ninety-six diabetes centres in Germany participated and 9,583 patients with type 1 diabetes (190 evaluation samples) were re-examined between 1992 and 2004. The intervention was a 5-day inpatient course for groups of up to ten patients with a fixed curriculum of education and training for dietary flexibility and insulin adjustment. The main outcome measures were HbA1c and severe hypoglycaemia. RESULTS: Mean baseline HbA1c was 8.1%, and had decreased to 7.3% at follow-up; incidence of severe hypoglycaemia was 0.37 events per patient per year prior to intervention and 0.14 after intervention. In mixed-effects models adjusted for effects of centres, age and diabetes duration, the mean difference was -0.7% (95% CI -0.9 to -0.6%, p<0.0001) for HbA1c and -0.21 events per patient per year (95% CI -0.32 to -0.11, p=0.0001) for severe hypoglycaemia, with similar results for evaluation samples, with a maximum of 10% of patients lost to follow-up. Before intervention, the incidence of severe hypoglycaemia was three-fold higher in the lowest quartile than in the highest quartile of HbA1c, whereas the risk was comparable across the range of HbA1c values after intervention. CONCLUSIONS/INTERPRETATION: Implemented as part of a continuous quality-assurance programme the self-management programme is effective and safe in routine care. Improvement of glycaemic control can be achieved without increasing the risk of severe hypoglycaemia.

Adult↗

PubMed2003

Patient assessment using standardized bone mineral density values and a national reference database: implementing uniform thresholds for the reimbursement of osteoporosis treatments in Belgium.

Dual-energy X-ray absorptiometry (DXA) devices from the three main manufacturers provide different bone mineral density (BMD) values, due in part to technical differences in the algorithms for bone mineral content (BMC) and area measurements and in part to the use of different manufacturer-derived reference databases. As a result, significant differences exist between Hologic, Lunar and Norland systems in the reported young normal standard deviation scores or T-scores. In a number of European countries, including Belgium, a T-score below -2.5 is one of the key criteria for reimbursement of osteoporosis treatments. This paper addresses the first attempt to implement a nationwide, uniform expression of BMD in patients, in order to harmonize drug reimbursement. To this end, measures were taken to implement a uniform expression of BMD in Belgian patients, by converting each manufacturer's absolute BMD to standardized BMD (sBMD) values and by establishing a single national reference range.

Absorptiometry, Photon↗

PubMed1999

Computerized surveillance of adverse drug reactions in hospital: implementation.

OBJECTIVE: To implement and measure the effects of automatic computerized laboratory signals (ALS) as a detection support tool of adverse drug reactions (ADRs) in hospital. METHODS: This was a prospective observational study of a total of 192 patients (199 sequential medical admissions) during a 2-month period in a 34-bed medical ward at the Hadassah University Hospital, Jerusalem, Israel. The study involved the routine (daily) distribution to staff physicians of lists of automatic signals generated from computerized laboratory data as potential indicators of ADRs. Patient charts were reviewed by the clinical pharmacology team for ADRs and to see whether these were recognized by the staff physicians. RESULTS: Seventy-one ADRs were detected in 64 of the 199 (32%) admissions. Twenty-seven per cent of the ADRs were serious, 9% of the admissions were due to ADRs. Two hundred and ninety-five ALS were generated involving 69% of the admissions. Sixty-one per cent of the ADRs were identified by ALS. ALS were present in 58% of the ADR negative admissions. Eighty-five per cent of the ADRs were recognized as such and 19% of the ALS-positive ADRs were not recognized by the staff physicians. CONCLUSIONS: The routine implementation of ALS doubled the number of ADRs recognized by the physicians while patients were hospitalized in the medical ward. The use of the system appeared valid, simple and potentially cost-effective.

Adverse Drug Reaction Reporting Systems↗

PubMed2001

Implementation and evaluation of a 3D one-step late reconstruction algorithm for 3D positron emission tomography brain studies using median root prior.

A fully three-dimensional (3D) one-step late (OSL), maximum a posteriori (MAP) reconstruction algorithm based on the median root prior (MRP) was implemented and evaluated for the reconstruction of 3D positron emission tomography (PET) studies. The algorithm uses the ordered subsets (OS) scheme for convergence acceleration and data update during iterations. The algorithm was implemented using the software package developed within the EU project PARAPET (www.brunel.ac.uk/~masrppet). The MRP algorithm was evaluated using experimental phantom and real 3D PET brain studies. Various experimental set-ups in terms of activity distribution and counting statistics were considered. The performance of the algorithm was assessed by calculating figures of merit such as: contrast, coefficient of variation, activity ratio between two regions and full width at half of maximum for resolution measurements. The performance of MRP was compared with that of 3D ordered subsets-expectation maximisation (OSEM) and 3D re-projection (3DRP) algorithms. In all the experimental situations considered, MRP showed: (1) convergence to a stable solution, (2) effectiveness in noise reduction, particularly for low statistics data, (3) good preservation of spatial details. Compared with the OSEM and 3DRP algorithms, MRP provides comparable or better results depending on the parameters used for the reconstruction of the images.

Algorithms↗

PubMed2002

Preparation and implementation of seven ecological compensation plans for Dutch highways.

First-generation compensation plans (CPs) for Dutch highway projects have been evaluated with respect to implementation of the compensation principle (1993), which aims to counterbalance the adverse ecological impacts of large-scale development projects. Decision-making on the seven projects took place between 1993 and 1995. Specifically, we considered: (a) the processes employed to prepare and implement the compensation plans; (b) the methods used to identify, plan, and execute the compensation measures; and (c) the results yielded by these methods. We conclude that the CPs were prepared fairly uniformly, particularly in terms of the processes and methodologies used to derive compensation measures. Five of the seven CPs had become operational by 2001 and initial experience is now being gained on land acquisition and transfer of compensation sites to nature conservation trusts. Further progress of CPs is likely to be seriously hampered by growing demand for land for development in general and associated increases in real estate prices. Several problems are addressed and recommendations made with respect to: (a) developing a legal basis for the compensation principle; (b) the relationship with re-allotment projects; (c) estimation of compensation costs; (d) an annual bias of CP budgets to account for rising costs; (e) contingency measures; and (f) criteria for CP (ex-post) evaluation.

Conservation of Natural Resources↗

PubMed2001

Effective planning and implementation of ecological rehabilitation projects: a case study of the regional municipality of Waterloo (Ontario, Canada).

The literature guides environmental planning and, specifically, how to use ecological rehabilitation projects to achieve long-term planning goals and landscape-scale environmental sustainability. There is, however, a perceived gap between principles in the literature and the use of them by practitioners involved in smaller-scale ecological rehabilitation projects. Using interviews with practitioners involved in 11 projects within the Regional Municipality of Waterloo, Ontario, Canada, we tested whether practitioners used five principles for effective planning and implementation of ecological rehabilitation that we derived from the literature. These five principles were: establishing political and ecological context, using ecologically appropriate objectives and practices, using comparative multidisciplinary and cross-scale approaches, using adaptive planning and implementation, and establishing good communication within and external to projects. Few projects followed all five principles, and practitioners indicated that they used three more project-specific principles: obtaining political/social support, promoting projects and changing attitudes about projects, and securing sufficient and persistent funding to maintain a project's life. While the literature emphasizes that ecological rehabilitation is only effective if projects are coordinated on a watershed basis, most practitioners focused solely on the goals of their specific project. The gap between literature and practice may arise because most practitioners are new to the field of ecological rehabilitation and still are focused on the methods involved. Time pressures force practitioners to obviate the literature and get projects started quickly, lest support evaporate. Complicating these difficulties is decreased support from federal and provincial governments for large-scale environmental planning. It is unclear whether ecological rehabilitation projects in Waterloo Region (at least) will ever become effective at promoting landscape-scale ecological goals or remain smaller-scale stop-gaps.

Animals↗

PubMed1998

Practical implementation of a modified continual reassessment method for dose-finding trials.

PURPOSE: We describe a practical, reliable, efficient dose-finding design for cytotoxic drugs applied in a multi-institutional setting. METHODS: The continual reassessment method (CRM) was modified for use in phase I trials conducted through the New Approaches to Brain Tumor Therapy (NABTT) Consortium. Our implementation of the CRM uses (1) a simple dose-toxicity model to guide data interpolation, (2) groups of three patients to minimize calculations and stabilize estimates, (3) investigators' clinical knowledge or opinion in the form of data to make the process easier to understand, and (4) a flexible computer program and interface to facilitate calculations. RESULTS: The modified CRM was used in two dose-finding trials of 9-aminocamptothecin in patients with newly diagnosed and recurrent glioblastoma who were taking anticonvulsant medication. The CRM located the maximum tolerated dose (MTD) efficiently in both trials. Compared to conventional designs, the CRM required slightly more than half the number of patients expected, did not greatly overshoot the MTD (i.e. no patients were treated at dangerously high doses), and did not underestimate the MTD. CONCLUSIONS: Our experience demonstrates the feasibility of implementing this design in multi-institutional trials and the possibility of performing dose-finding studies that require fewer patients than conventional methods.

Antineoplastic Agents↗

PubMed2006

[Conceiving and implementing an ISO 9001:2000 quality management system: quality improvement and efficiency increase over 3 years at the Dept. of Ophthalmology, Sultan Qaboos University in Oman].

BACKGROUND: Oman is a developing country of the Middle East with a University Hospital in a national health system. Problems related to documentation, structure, and procedure prevailing in a multicultural environment result in a lack of productivity. The aim of this study was to test the feasibility of introducing a quality management system according to ISO 9001:2000 into a university department of ophthalmology with special reference to quality and efficiency data over 3 years. MATERIALS AND METHODS: Standardized types of documentation (35 documents, 183 forms and formats, and 453 registers) under a formal roof (booklets for work instructions, quality management, procedures) were conceived in 2001 and implemented, and were evaluated by descriptive statistics over the years 2002-2005 with respect to quality and efficiency. In 2005, the departmental QMS was merged into the QMS of the whole hospital. RESULTS: Establishment of "responsibility clusters" with structured surveillance tasks, procedural improvements, and continuous audits resulted in a significant quality improvement already during the implementation until ISO 9001:2000 certification in 2002, and over the following 3 years. The data were assessed by non-conformities documented monthly (total inpatients: -50%, outpatients: -20%, operating theater: -100%, teaching: -10%; p <0.05) and increased efficiency assessed by the most important performance indicators (before QMS vs a median of 3 years with QMS): major surgery: +459%, inpatient stay: -49.7%, occupancy rate: +63.9%, technical diagnostics: +292.9%, postgraduate teaching total: +740%, research output total: +330% (p <0.05). CONCLUSIONS: It is feasible to introduce the quality management system according to ISO 9001:2000 into a developing country in the Middle East. It has an immediate effect on the increase of efficiency (measured by performance indicators) and quality in all systems providing the possibility for regional benchmarking.

Academic Medical Centers↗

PubMed2026

Precision ID mtDNA Whole Genome Panel and sequencing of telogen hairs - perspectives for validation and implementation in casework.

Shed hair is a commonly encountered type of forensic evidence. Shed telogen hairs generally contain insufficient or highly degraded nuclear DNA for STR profiling; however, mtDNA analysis of telogen hair and hair shafts remains possible. We validated whole mitochondrial genome (mtGenome) sequencing using the Precision ID mtDNA Whole Genome Panel (Thermo Fisher Scientific) and subsequently implemented the panel for the analysis of telogen hair, buccal, and casework samples. We analysed 90 diluted DNA samples containing 3-3,600 mtDNA copies, shed telogen hairs and their corresponding mtDNA from buccal swabs from 91 individuals, and 11 archived DNA extracts from hair samples in criminal cases. Complete mtGenome sequences were consistently recovered in 99% of samples across DNA dilution series at DNA input levels as low as 47 mtDNA copies, demonstrating the assay's robustness under low-template conditions. We obtained complete and reproducible mtGenome sequences with ≥ 327 mtDNA copies/µL from telogen hair samples. After applying ISFG recommendations and excluding low-confidence discrepancies associated with high-strand bias, heteroplasmic variants and sequencing artifacts, mtGenome sequence concordance increased from 93.4% to 100%. None of the 16 negative controls produced complete mtDNA sequences. Six negative controls showed low-level mtDNA signal (2-8 variants), consisting predominantly of common polymorphisms. These samples did not yield complete mtGenome sequences and showed no correspondence to any of the analysed samples. Finally, archived telogen hair samples from criminal cases presented complete mtGenome sequences with an average read depth of 1,037x.Our findings highlight the reliability of mtDNA analysis of telogen hairs using the Precision ID mtDNA Whole Genome Panel for implementation in forensic casework.

Forensic casework↗

PubMed2002

Schema design and implementation of the grasp-related mirror neuron system.

Mirror neurons within a monkey's premotor area F5 fire not only when the monkey performs a certain class of actions but also when the monkey observes another monkey (or the experimenter) perform a similar action. It has thus been argued that these neurons are crucial for understanding of actions by others. We offer the hand-state hypothesis as a new explanation of the evolution of this capability: the basic functionality of the F5 mirror system is to elaborate the appropriate feedback - what we call the hand state - for opposition-space based control of manual grasping of an object. Given this functionality, the social role of the F5 mirror system in understanding the actions of others may be seen as an exaptation gained by generalizing from one's own hand to an other's hand. In other words, mirror neurons first evolved to augment the "canonical" F5 neurons (active during self-movement based on observation of an object) by providing visual feedback on "hand state," relating the shape of the hand to the shape of the object. We then introduce the MNS1 (mirror neuron system 1) model of F5 and related brain regions. The existing Fagg-Arbib-Rizzolatti-Sakata model represents circuitry for visually guided grasping of objects, linking the anterior intraparietal area (AIP) with F5 canonical neurons. The MNS1 model extends the AIP visual pathway by also modeling pathways, directed toward F5 mirror neurons, which match arm-hand trajectories to the affordances and location of a potential target object. We present the basic schemas for the MNS1 model, then aggregate them into three "grand schemas" - visual analysis of hand state, reach and grasp, and the core mirror circuit - for each of which we present a useful implementation (a non-neural visual processing system, a multijoint 3-D kinematics simulator, and a learning neural network, respectively). With this implementation we show how the mirror system may learn to recognize actions already in the repertoire of the F5 canonical neurons. We show that the connectivity pattern of mirror neuron circuitry can be established through training, and that the resultant network can exhibit a range of novel, physiologically interesting behaviors during the process of action recognition. We train the system on the basis of final grasp but then observe the whole time course of mirror neuron activity, yielding predictions for neurophysiological experiments under conditions of spatial perturbation, altered kinematics, and ambiguous grasp execution which highlight the importance of the timing of mirror neuron activity.

Animals↗

PubMed2006

Assessment of implementation of a standardized parenteral formulation for early nutritional support of very preterm infants.

INTRODUCTION: Parenteral nutrition (PN) plays an important role in the nutritional support of very preterm newborns. It has been suggested that a high proportion of PN orders could be standardized. In 2002, we implemented in our unit the preparation of three standardized formulations for PN adapted to the nutritional requirements of premature infants<32 weeks. Following this change of practice, a retrospective observational study was conducted to evaluate the relevance of the implemented standardized PN regime. Twenty premature inborn infants<32 weeks gestation who had received standardized (STD) PN in 2003 were matched for 20 infants who had received individualized (IND) PN in 2001. Adequacy of nutrition was assessed by comparing daily intravenous nutrient intake and biochemical parameters during the first week. Amino-acid intakes on day 3 were higher in the STD group (1.5+/-0.2 g/kg/d vs. 0.9+/-0.5, p<0.001), and the calcium phosphate intakes were better balanced. The cumulated intake of amino acids for the first week was greater in the STD group (+20% ; p=0.0003). Biochemical parameters were similar in both groups. Insulin infusions were less frequent in the STD group (p<0.06). CONCLUSION: Standardized parenteral formulations provided higher early intakes of amino acid and glucose, a better calcium phosphate ratio, and a greater amount of amino-acid intakes during the first week while maintaining the same biochemical parameters. This strategy forms part of an approach concerning quality control and the respect of good professional practice for the preparation of parenteral nutrition solutions.

Amino Acids↗

PubMed2006

Implementation of the laparoscopic simulator in a gynecological residency curriculum.

BACKGROUND: In view of the current emphasis on increasing patient safety and quality control in laparoscopic surgery, there is a growing need to improve laparoscopic training. This study was conducted to investigate if and when residents reached performance standards for basic laparoscopic skills on a boxtrainer and to analyze the current state of implementation of laparoscopic simulators in a gynecological residency curriculum. METHODS: Residents across all 6 years of residency (postgraduate year [PGY] 1-6) were tested once on our boxtrainer by performing five inanimate tasks (pipe cleaner, rubber band, beads, cutting circle, intracorporeal knot tying). A sumscore for the five tasks was calculated for each participant (sum of all scores). Scores were calculated by adding completion time and penalty points, thus rewarding both speed and precision. These data were compared with scores of laparoscopic experts, which were set as performance standards. RESULTS: Of the participants, 111 were residents (7 PGY1, 27 PGY2, 29 PGY3, 28 PGY4, 14 PGY5, 6 PGY6) and 8 were experts. At the end of residency, PGY6 residents reached the performance standard for all tasks except intracorporeal knot tying. It was not until PGY5 that residents reached the performance standard for the pipe cleaner task; PGY1, for rubber band; PGY5, for beads; PGY4, for circle cutting; and PGY6, for sumscore. Throughout residency PGY6 had a mean total of only 3.6 h of simulator training experience. No correlation was found between this previous voluntary simulator training experience and performance on our boxtrainer during this study (sumscore), and between previous voluntary simulator training and total laparoscopic procedures performed. In a combined multivariate analysis, sumscore performance remained significantly associated with the number of laparoscopic procedures performed by residents when they were working as as a primary surgeon (p = 0.002), and not with the cumulative hours of simulator training during residency prior to participating in this study (p = 0.15). CONCLUSIONS: In a current Dutch gynecological residency curriculum, residents do not reach all performance standards for basic laparoscopic skills on the boxtrainer. We conclude that the voluntary simulator training program has a substantial risk to fail and that the implementation of the laparoscopic skills simulator in the current residency curriculum is in its infancy.

Female↗

PubMed2005

Infection control in a hernia clinic: 24 year results of aseptic and antiseptic measure implementation in 4,620 "clean cases".

Post Mesh Herniorrhaphy Infection [PMHI] occurs between 3 to 4% of inguinal and 8 to 14% of ventral herniorrhaphies producing an unacceptably high morbidity. Before opening a Hernia Clinic, our infection rate was around 5% for "clean" inguinals and 8% for "clean" ventral herniorrhaphies. Starting in 1982 we implemented a stricter operative aseptic protocol plus the per-operative administration of 1 g of intravenous Cefazolin. In addition, wounds were irrigated with a solution containing 80 mgs of Gentamycin Sulphate dissolved in 250 ml of Normal Saline Solution. During a period of 25 years these measures were used in 4300 consecutive "clean "Inguinal and 320 "clean" Ventral herniorrhaphies. Since the implementation of the above-mentioned aseptic and antiseptic steps no further wound infections were encountered. In our hands, the combination of rigorous aseptic operating room routine plus intravenous and topical antibiotics have, up to now, effectively eliminated wound infections in "clean" herniorrhaphy cases.

Anti-Bacterial Agents↗