Medium-sized Community Hospital Research Articles

The Need for Assessment and Reassessment of the Hospital Cancer Conference

For many years, a traditional event at hospitals throughout the United States has been the convening of intermittent conferences that serve as formats for discussing patient cancer management. These conferences have been generally associated with appropriate gustatory delights to further the attraction of these meetings. Generally a moderator has been responsible for developing the case list utilizing recent patients diagnosed or treated at the hospital. Because the desire to include the multidisciplinary concept (surgery, radiation oncology, and medical oncology) of cancer management has driven the case selection, a potpourri of case presentations has been the goal to create cross-cultural dialogue and encourage participation. It has been my pleasure to attend many of these cancer conferences as a surveyor for the Accreditation (formally “Approvals”) Program of the Commission on Cancer of the American College of Surgeons. These conferences held at small and medium-sized community hospitals, medical school-associated teaching hospitals, and National Cancer Institute-designated institutions are as diverse as the institutions involved. Some include crisp PowerPoint presentations of only three or four patients. Other formats include 10, 15, or more patients in an attempt to blend education along with clinical management. My issue with most of these conferences is that they are based on a “show and tell” mentality rather than serving as treatment-planning conferences utilizing the expertise of the participating multidisciplinary experts. It has been a pleasure to see that more recently “organ-based” (breast, hepatopancreaticobiliary, gastrointestinal) and “diseased-based”(sarcoma, melanoma) conferences have been created to serve as true treatment-planning conferences that facilitate decision making, especially in this era of neoadjuvant therapy. This is truly the format that should be supported—not the anachronistic approaches of the traditional hospital “tumor board.” In this issue of Annals, Wright et al. describe the prevalence of multidisciplinary cancer conferences (MCCs) in the province of Ontario, Canada, and analyze the barriers to the adoption of meaningful planning conferences.1 General surgeons throughout Ontario were queried about their perceptions regarding MCC implementation. In reply to a survey, a reasonable (44%) response was obtained, which represented surgeons working in both community and academic institutions. Only 52% of hospitals had MCCs, which were held over a variety of frequencies ranging from weekly to monthly. The majority of those surgeons responding had positive responses favoring the educational and collegial nature of these conferences. The obvious lacuna in the study is the absence of any data that indicates that patients who are discussed have benefited from these multidisciplinary enclaves. Although published examples exist of cancer conference follow-up that assess adherence to management recommendations, these examples are few and the methodology to capture these data are problematic.2–4 Recent strategies by the American College of Surgeons Commission on Cancer have urged inclusion of published guidelines to serve as benchmarks of multidisciplinary care at COC accredited hospitals. Aside from guideline overview, the ideal multidisciplinary cancer conference should include a meaningful discussion of treatment options supported by evidenced-base reports. Clinical staging should result from presentations of all relevant physical examination, imaging, laboratory, and pathological assessments. From these data, the clinical stage should be derived, which permits a logical discussion of all treatment options. Appropriate clinical trials should be reviewed to enhance patient care and trial accrual. Ideally these conferences should be organ- or disease-based and should incorporate all practitioners who have a stake in that particular patient’s care. No treatment should be initiated before discussion in a multidisciplinary enclave. Our Canadian brethren plan to use their study results to push for inclusion of MCCs in the appropriate hospitals in Ontario. The really challenging project is to craft a template that would ensure a meaningful treatment outcome for the patients presented. Although collegiality and education are laudable goals, the traditional MCC, absent of meaningful treatment planning, can no longer be our paradigm. The authors correctly invoke the importance of teleconferencing, especially from academic centers, and I personally believe this is a laudable goal. Because one of the barriers to effective MCC in the Canadian study is lack of administrative support, we would do well to share this study with our administrative management teams. Quality management of our patients with cancer begins with the full support of our administrators, physicians, and all cancer care providers to maintain the quest for ideal cancer treatment.

Internet point of care learning at a community hospital

Internet point of care (PoC) learning is a relatively new method for obtaining continuing medical education credits. Few data are available to describe physician utilization of this CME activity. We describe the Internet point of care system we developed at a medium-sized community hospital and report on its first year of utilization. We reviewed all completed Internet PoC report forms for 1 year to determine what percentage of our medical staff participated. Using a Likert-type scale, physicians were asked to rate the effectiveness of this method as a means for obtaining CME credit and for improving patient care. From a medical staff of 355, 7 physicians (2%) completed an Internet PoC form in the first year of use. The number of completed forms ranged from 1 to 18 for each individual who used the system. On a 5-point Likert scale, physicians rated this method as follows: good answer found to question = 4.4, knowledge base was improved = 4.0, patient benefited from the information = 4.0, and good way to learn new information = 4.2. A small number of physicians utilized this method for obtaining CME credit, but some individuals really embraced it. Those who used it liked it as a way to obtain CME and many felt strongly that it improved patient care. Other hospitals are encouraged to develop an Internet PoC reporting system for their medical staff.

Is Case Volume the Only Surrogate for Oncologic Surgical Quality?

Is Case Volume the Only Surrogate for Oncologic Surgical Quality?

Reduction of Injuries Associated with Patient Handling

Nurses experience more back injuries than the general population due to their physically demanding work. Research indicates that the implementation of a comprehensive patient-handling program will reduce the number of patient-handling injuries and associated sequelae. A significant barrier to the effectiveness of safe patient-handling programs includes lack of appropriate and easily accessible equipment for caregivers. Caregivers were questioned to identify changes in the use of and perceptions about patient-handling equipment following the implementation of a patient-handling program at a medium-sized nonprofit community hospital. The study found an increased use of patient-handling equipment by caregivers following the implementation of a patient-handling program, with a significant improvement in the perception of patient-handling equipment. Effective planning to adequately address each of the elements of a comprehensive patient-handling program is essential to program success.

Utilization Patterns of Hospital Emergency Services and the Implications for Traditional Infection Control Surveillance Models. A Study of Community Acquired MRSA Skin and Soft Tissue Infections in ED Patients of a Medium-Sized Community Hospital in 2005

Utilization Patterns of Hospital Emergency Services and the Implications for Traditional Infection Control Surveillance Models. A Study of Community Acquired MRSA Skin and Soft Tissue Infections in ED Patients of a Medium-Sized Community Hospital in 2005

Physician Factors as an Indicator of Technological Device Adoption

This paper analyzes a sample interventional cardiologist's demographic, academic, and professional characteristics to provide an understanding of their technological device adoption styles. The study sample consisted of 15 physicians from two large Midwestern hospitals, one an academic medical center and the other a medium-sized community hospital. Interventional cardiologists were identified through their online physician profile and respective departments. A questionnaire was developed to assess each physician's self-perceived adoption style, their awareness of the new technology, their participation in clinical trials, organizational support, and how various factors influence their adoption of new technology. Lastly, a database of bare metal and drug eluting stents was examined to document the number of stents used by each physician. Pragmatic and observational findings are presented from the questionnaire, physician profile, to database on stent use. The paper concludes with a discussion of the managerial and forecasting implications and methods to promote technology adoption.

In-Hospital Care Pathways for, Stroke

Section Editor: Graeme J. Hankey MD, FRCP Care pathways are structured care plans that are used by the different members of the multidisciplinary team and are usually implemented to manage more than one aspect of patient care (eg, diagnosis, investigation, acute stroke treatment). When used within a case management framework, care pathways can assist health care professionals with clinical decision-making, and they aim to promote organized and efficient patient care that is based on the best-available research evidence and clinical guidelines.1,2 A care pathway can take the form of a printed or electronic document, and it often replaces the patient’s case record for the duration of the hospital stay. Many hospitals have adopted this tool, often as one of the components of a continuous quality improvement scheme, with an aim to improve the quality of stroke care, reduce variation of standards, minimize resource utilization, and educate health care staff.3,4 But is there sufficient evidence to support the use of care pathways for the management of stroke patients? The first Cochrane review of in-hospital care pathways for stroke found some evidence that care pathways may increase the use of certain investigations and reduce the likelihood of urinary tract infections and readmission to hospital.5 However, this benefit …

The association between emergency department crowding and time to antibiotic administration

Study objectives: There is concern that crowding in our nation's emergency departments (EDs) leads to lower quality of care, but there is little evidence that this is the case. Time to antibiotic administration (TTAA) for patients with community acquired pneumonia (CAP) is a national hospital quality measure used by the Centers for Medicare and Medicaid and the Joint Commission on Accreditation of Healthcare Organizations where performance is critical. Our objective was to determine the relationship between crowding and TTAA for CAP patients. Methods: We conducted a retrospective observational cohort study using the encounter database from a medium-sized community hospital in Connecticut to identify patients admitted with CAP from December 2001 through December 2002. Crowding was defined in 2 ways: (1) when the CAP patient arrived exceeded bed capacity; and (2) length of stay for patients in the when the CAP patient arrived exceeded national (4 hours). Our outcome measure was based on national performance measures of TTAA for CAP (240 minutes). We reviewed medical records to determine TTAA for CAP patients. CAP cases were included in TTAA determination if age was older than 18 years, admitting diagnosis was CAP, hospital discharge diagnosis was CAP, and admission was from home or a nursing home. CAP cases were excluded from TTAA determination if antibiotic therapy was given before presentation, the patient was in the hospital during the previous 10 days, or if immunodeficiency, Pneumocystis carinii pneumonia, or tuberculosis was suspected. We sought a sample size (N=310) to detect a 1-way difference of 12 minutes in TTAA with α=0.05 and β=0.80. Bivariate analyses were completed using simple linear regression and t test. Secondary analyses were also completed stratifying for pneumonia severity index (PSI) and the shift the CAP patient registered. Results: We identified 438 CAP patients, of whom 302 met criteria for inclusion in the national quality measure. Patients' age was 71.8±16.8 years; 133 (44%) were women; 88 (29%) had a PSI of 90 or less (stable for outpatient treatment); and 264 (87%) were treated between 7 am and 11 pm. The correlation coefficient for versus TTAA was R =0.05 ( P =.37) and for length of stay versus TTAA was R =0.02 ( P =.69). Using census greater than or equal to capacity definition of crowded, the difference between TTAA during crowded and uncrowded periods was 2.4 minutes ( P =.91). Using ED length of stay greater than or equal to national mean definition of crowded, this difference was 8.8 minutes ( P =.75). Data stratified by PSI of 90 or less versus greater than 90 and by arrival between 7 am and 11 pm versus 11 pm to 7 am revealed no statistically significant associations. Post hoc analyses, although statistically not significant, show that TTAA was shorter at lower ( Conclusion: crowding, by or length of stay criteria, does not have a statistically significant association with TTAA for patients admitted with CAP. These results demonstrate that crowding is a complex problem, and more research is needed to understand its effect on patient care.

A retrospective study of the effect of postoperative indomethacin rectal suppositories on the need for narcotic analgesia in patients who had a cesarean delivery while they were under regional anesthesia

Objective: This study was undertaken to assess the efficacy of rectal indomethacin as an analgesic after cesarean delivery, comparing narcotic usage in patients receiving indomethacin with patients who received only standard narcotic analgesics. Study Design: A retrospective study of patient records consisting of 297 women who underwent cesarean delivery while they were under regional anesthesia in a medium-sized community hospital from February 1996 through December 1999. Narcotic usage was determined as morphine equivalents whereby 10 mg morphine sulfate equals 30 mg oxycodone equals 50 mg hydrocodone equals 75 mg meperidine. Indomethacin was administered as 50-mg rectal suppositories. Statistical analysis was done by Pearson correlation and independent Student t test analysis. Results: Narcotic usage was reduced by an average of 16 morphine equivalents (28%) in the indomethacin group. Pearson correlation revealed correlation at the .01 level; independent Student t test analysis revealed a P value of .001. Thus the mean amount of narcotic analgesic administered was significantly less in patients treated with indomethacin rectal suppositories. Conclusion: In this uncontrolled trial the use of indomethacin rectal suppositories resulted in a significant reduction in narcotic use in the postcesarean hospital recovery period as measured in morphine equivalents. (Am J Obstet Gynecol 2001;184:1544-8.)

Transparent Research

Transparent research is a strategy in which the subjects of ethnographic research are fully involved in designing the research project, collecting the data, and analyzing results. Transparent research is a variety of action research in that inquiry is designed to serve the needs of the people studied. However, it is also scholarly research intended to serve disciplinary goals. An advantage of this approach is that theoretical and practical knowledge gained by practitioners that would not otherwise be known by academic scholars is incorporated into research results. This article develops the idea of transparent research by presenting two case studies. One concerns the emergency medicine department of a medium-sized community hospital. The other concerns a congregational development project, developed in partnership with an Episcopal diocese, and focused on a single congregation.

Evaluation and implementation of the gel test for indirect antiglobulin testing in a community hospital laboratory.

The gel test, developed by Lapierre in 1984, was designed to standardize antiglobulin testing while improving sensitivity and specificity of the method. Anti-human serum immunoglobulin G (IgG) mixed with Sephadex G100 (gel phase) in a microtube traps red cell-IgG agglutination complexes during migration through the gel in a centrifugation step. Agglutination complexes are visibly detectable at various levels in the microtube as an inverse function of antibody coated on red cells. Unsensitized red cells form a cell pellet at the base of the microtube. To determine if indirect anti-human globulin testing could be standardized and simplified by replacing the tube test with the gel test without compromising quality or increasing costs. A medium-sized community hospital. In a blinded retrospective study, we used patient sera (n = 40), which included 10 positive specimens containing 18 known antibodies. Sixteen antibodies were detected and identified with the tube method (1 anti-D and 1 anti-C not detected). By the gel test, 18 antibodies were detected and identified. All negative samples showed 100% concordance. Favorable results were obtained in a nonblinded prospective correlation study (n = 121). Our technologists found the gel test easier to read and more reproducible and reliable than the tube method; they also found increased sensitivity for detecting weakly reacting antibodies. We successfully introduced the gel test into our laboratory as the standard method for indirect antiglobulin testing. Following implementation, improved personnel management was achieved. The gel test is a reliable and advantageous method and is appropriate for routine use for detection and identification of alloantibodies in a community hospital transfusion service laboratory.

Response of Consultants to the Emergency Department: A Preliminary Report

Study objective: To determine the timeliness of response of consultants called to evaluate patients in the emergency department of a community hospital. Methods: Consultation requests from an ED located in a medium-sized community hospital were studied for a 1-month period. Data collected included name and specialty of the consultant, urgency of patients’ conditions, times of pages, and times of consultants’ responses and arrival in the ED. Results: Two hundred forty-one consultations were requested and 199 data forms relating to 21 staff physicians were analyzed. Mean number of pages required to reach a consultant was 1.5±.4. Mean time from the first page to telephone response was 8±6 minutes and from first page to ED arrival was 42±23 minutes. Mean time from the first page to the consultant’s arrival in the ED was significantly shorter for emergency (17±10 minutes) than for urgent or nonurgent patients (50±41 and 41±23 minutes, respectively). There were wide variations in individual patterns of response; the 7 fastest consultants had a mean first page to arrival time of 25±10 minutes, and for the slowest 5 consultants the time was 56±24 minutes. Conclusion: Response times of consultants to the ED vary depending on the urgency of the patient’s condition and individual behavior patterns. [Vosk A: Response of consultants to the emergency department: A preliminary report. Ann Emerg Med November 1998;32:574-577.]

Establishing a Pain Management Program in a Community Hospital

Despite growing consensus in the pain management community that pain can be treated more effectively, and ought to be, commitment to pain management is too frequently lacking. Herein we describe an ongoing effort to develop a pain management program in a medium-sized community hospital, the kind of inpatient setting in which most patients with pain are treated. We intend that our experience will be useful to others undertaking similar projects. Evaluation of these efforts has included staff and patient assessments of current pain management practices using chart audits, staff surveys, and patient interviews. The results were used to design education programs for the nursing and medical staff. Follow-up audits and surveys to determine effectiveness and to shape future work are described in detail.

The open Gamma Knife Center concept.

A freestanding Gamma Knife radiosurgery center has been open for just over 1 year in La Jolla, Calif., USA, located in the grounds of a medium-sized community hospital. The center employs a full-time medical physicist and neurosurgical nurse together with clerical personnel. The neurosurgeons and radiation oncologists are drawn from the entire community and bill their fees separately. Written protocols for each indication to be treated govern patient eligibility and suggested treatment algorithms. Additionally, each patient to be treated is presented in conference, and a treatment strategy (i.e., radiosurgery, craniotomy, conventional radiation therapy) is decided. Twenty new physicians and physicists have begun training to use the Gamma Knife in the first year. Certification must be achieved before a clinician can be physician of record.

Nosocomial enterococcal infections: Association with use of third-generation cephalosporin antibiotics

Enterococcal infections consistently account for approximately 10% of all nosocomial infections reported to the Centers for Disease Control. There is concern that an increase in nosocomial enterococcal infection is due to the increased severity of inpatient illnesses and to the widespread use of broad-spectrum beta-lactam antibiotics. Nosocomial enterococcal infections were analyzed at our medium-sized community hospital over a time period spanning 9 years. A significant increase in the infection rate was detected during the latter half of 1986. This increase was due primarily to a disproportionate rise in the incidence of the urinary tract as a site of infection. There were no associated clusters of infection, no predilection for certain patient care areas, and no preceding change in the hospital infection control policies and procedures. Total hospital use of cephalosporins remained stable during the period of increased enterococcal infections, but use of third-generation cephalosporins almost doubled in 1986 compared with the 4 preceding years. Selective pressure of third-generation cephalosporin use appeared to be a factor in the increased incidence of nosocomial enterococcal urinary tract infection.

Personnel Time and Preparation Costs for Compounded Versus Premixed Intravenous Admixtures in Three Community Hospitals

Personnel time requirements and costs associated with the ordering, preparation, and administration of manually compounded versus premixed i.v. admixtures were determined at three for-profit community hospitals. The three hospitals, all owned by one corporation, ranged in size from 160 to 239 beds. At each hospital, pharmacists or technicians manually compounded admixtures in glass bottles or plastic bags. Work flow descriptions of the activities involved in the preparation and administration of admixtures were created, and time-motion and work-sampling techniques were used to observe three to five pharmacists or technicians in each hospital over a seven-day period. Drug waste also was monitored. At the conclusion of the baseline study, each hospital switched to the premixed products that they had chosen to evaluate; admixtures of cefazolin sodium, cefoxitin sodium, gentamicin sulfate, and potassium chloride were available. After a two-week acclimation period, the seven-day study was repeated. Average total labor time ranged from 5.6 to 9.1 minutes per compounded admixture to 4.1 to 7.7 minutes per premixed admixture. The percentage of total labor time devoted to compounding, delivering, stocking, and other physical handling of materials decreased by 64% for admixtures of gentamicin or potassium chloride and by 67% for admixtures of cefazolin or cefoxitin. The average reduction in annual costs for accessories, labor time, wasted drugs, and inventory at each hospital was +15,000. Additional savings were realized from overall lower acquisition costs for the premixed products at the study hospitals. The use of premixed i.v. admixtures reduced preparation time and labor and material costs in three small- and medium-sized community hospitals.

Efficacy of the follow-up system in the community hospital emergency department

Emergency department patients are believed to have high rates of noncompliance with instructions to obtain follow-up care. A study of emergency department patients at a medium-sized community hospital without clinics showed that compliance is better than rates previously published for hospital follow-up clinics. There was significantly less compliance by patients referred to an unknown on-call physician (59.4%) compared with patients referred to their own private physicians (83.7%) or back to the emergency department (73.2%). Compliance improved (79.2%), however, when the emergency physician discussed the case with the on-call physician and the patient was so informed. This phone call significantly increased the likelihood of compliance by one third. The phone call served as an introduction and a liaison between the patient and the on-call physician. The major reason for noncompliance with advised follow-up was that the patients "felt better" or didn't "feel it was necessary" (36%), rather than "expense" or "inability to get appointment in time" (8%).

Sequential CK and LD Isoenzyme Interpretation by Microcomputer

A microcomputer program for rapidly interpreting and reporting sequential creatine kinase and lactate dehydrogenase isoenzymes written in BASIC is described. The program uses a combination of algorithmic logic and matrix-searching functions, correlates abnormalities from up to three patient samples, and arrives at a pattern diagnosis. Program execution is simple and has proved reliable in 1,000 samples from a large university hospital and a medium-sized community hospital.

Development of a Research Program in a Community Teaching Hospital

Affiliation between community hospitals and university centers has become a prominent trend. St Mary's Hospital, a 298-bed community hospital, affiliated with the University of Rochester, School of Medicine and Dentistry, and in five years developed an academic program. The strategies we utilized included the following: (1) definition of the number of specialists needed for the hospital's patient population; (2) development of specific subspecialty units with more than one member with the primary intent of fostering an investigative program; (3) analysis of total projected faculty salary and laboratory renovation and equipment costs to allow staged development of the program; (4) design of a flexible research areas; and (5) joint use of equipment and space with the Clinical Laboratory Service. The program was financed through third-party reimbursement, faculty-generated Department of Medicine funds, gifts by private patrons, and extramural grants. At a time of diminishing investigative support, a medium-sized community hospital can develop a research program.

The DuPont Automatic Clinical Analyzer in the Medium-Sized Community Hospital

The DuPont Automatic Clinical Analyzer in the Medium-Sized Community Hospital Get access R. W. Alexander R. W. Alexander Search for other works by this author on: Oxford Academic PubMed Google Scholar Laboratory Medicine, Volume 5, Issue 5, 1 May 1974, Pages 31–33, https://doi.org/10.1093/labmed/5.5.31 Published: 01 May 1974