Patient Care Categories Research Articles

88 Most Adverse Events in the Emergency Department are Present on Arrival: Burden and Types of Events Identified

Relatively little is known about adverse events (AEs) - physical injury to a patient due to health care that requires some intervention - and the characterization of patient harm in the ED. Even less is known about the nature of AEs occurring in the ED vs. those occurring prior to arrival, ie, how often ED visits result from AEs occurring elsewhere in the health system. This is a secondary evaluation of data from a retrospective observational study testing the ED Trigger Tool at an urban, academic medical center (data from 10/1/2014 - 10/31/2015; 92,860 eligible visits). Patients aged ≥18 completing a visit were eligible for inclusion. We performed dual independent level 1 nurse review of 4,772 visits sampled from records with ≥1 of 97 candidate triggers (findings that increase the likelihood of an AE), followed by a confirmatory level 2 physician review of records with putative AEs. AE severity was characterized with the MERP index. AEs were categorized using the ED Taxonomy of Adverse Events and Near Misses, which includes categories, subcategories and modifier terms. Reviewers indicated whether AEs occurred in the ED or were present on arrival (POA). We present descriptive data, bivariate associations between patient sociodemographics, triggers and POA AEs detected and multivariable modeling identifying POA AEs. Analyses were conducted using SAS 9.4 and R. We identified 965 AEs, of which 614 were POA and 351 occurred in the ED. Patients with POA AEs were more often white (51% vs 40%) and older (median age 62 vs 55 ) compared to patients with AEs in the ED, with no difference in distribution by sex (53% female overall). Medication and Patient Care categories account for over 70% of both ED and POA AEs. POA AEs included more health care Associated Infections and Surgical/Procedural AEs, and fewer Device-related AEs than those occurring in the ED. Key differences are visible at the subcategory level. Medication-related hypotension is a common AE in the ED (23%) but is rarely POA (3%). Medication-related bleeding is a common POA AE (21%) but is rarely an ED AE (3%). Medication-related Allergic Reaction is common to both (∼10-13%). Eight EDTT triggers are associated with POA AEs. The joint presence of any two of these triggers occurs in 9.4% of all visits in the population, has a positive predictive value of 39.6% for POA AEs, and identifies POA AEs similar to those described in Table 1. The ED trigger tool is a promising new approach to quality and safety review and identifies a broad scope of event types. The majority (64%) of AEs detected in the ED are present on arrival. This underscores the role of the ED not only as a safety net for patients but also for patient harm that occurs elsewhere in the health system. This also demonstrates that it may be important for surveillance methods to distinguish between POA and ED events for internal quality improvement.Tabled 1ED (N=351 AEs)POA (N=614 AEs)CategorySubcategory% of AEsCategorySubcategory% of AEsMedication63.20%Medication58%Hypotension23.40%Bleeding21.20%Allergic Reaction10.30%Allergic Reaction13.80%Hypoxia9.40%Fall5.90%Other4.30%Other4.20%Nausea/Vomiting4.30%Hypotension3.40%Glycemic Event3.70%Delirium2.60%Bleeding3.40%Dizziness2.40%Delirium2.00%Patient Care14.30%Device13.40%Failure Monitor7.70%Infiltration/Extravasation13.10%Fall5.90%Other2.80%Patient Care17.10%Delayed Treatment2.00%Failure Monitor6.60%Delayed Treat.5.40%HCAI11.10%Other4.80%Pneumonia4.70%Fall3.10%Surgical Site Infection*2.80%Delayed Dx2.30%Glycemic Event2.00%Surgical/ Procedural11.10%Hypoxia2.00%Other3.70%Wound Complication**2.80%Surgical/ Procedural5.10%Ileus/Obstruction2.00%Bleeding2.00%Device5.00%HCAI<1%Infection2.00%Frequencies of AE categories/subcategories for POA and ED events. Rare subcategories are omitted for clarity; and an event may have more than one subcategory.HCAI - Healthcare Associated Infection*< 30 Days Post-Op; Up To 1 Year If Implanted Hardware Present**Non-infectious Open table in a new tab

Medical Education in the Caribbean

There is a projected shortage of primary care physicians in the United States, and providers other than U.S medical graduates may be needed to fill the gap. The authors conducted this study to quantify the contribution that Caribbean-educated physicians make to the U.S. primary care workforce. Using May 2011 American Medical Association Physician Masterfile and Educational Commission for Foreign Medical Graduates data, the authors identified physicians whose Masterfile records indicated that they provided direct patient care. They classified these physicians according to the type of medical school from which they graduated: graduates of Caribbean medical schools (C-IMGs), graduates of other international medical schools (non-C-IMGs), graduates of U.S. MD-granting medical schools (USMGs), and graduates of U.S. DO-granting medical schools (DOs). They then calculated the frequencies and percentages of self-designated primary care specialties for each physician classification. There were 684,469 physicians in direct patient care categories for whom data were available concerning medical school and self-designated specialty. About one-quarter of these physicians were graduates of international medical schools (C-IMGs: 3.0%, n = 20,333; non-C-IMGs: 20.4%, n = 139,415), and approximately three-quarters were U.S. medical school graduates (USMGs: 70.3%, n = 481,061; DOs: 6.4%, n = 43,660). Overall, C-IMGs had the highest proportion of physicians practicing in primary care specialties (56.7%) compared with non-C-IMGs (42.3%), USMGs (32.9%), and DOs (54.0%). More than half of Caribbean-educated physicians involved in direct patient care are practicing in primary care specialties, thereby making an important contribution to the U.S. primary care workforce.

Resident perceptions of service versus clinical education.

The Accreditation Council for Graduate Medical Education states that education needs to have priority over service. There is a potential for residents to have a negative perception of activities termed service. To understand how residents of one obstetrics and gynecology program conceptualize service and clinical education in their daily training experiences. We conducted a qualitative survey using semistructured interviews with 9 residents in obstetrics and gynecology. Verbatim transcripts underwent phenomenologic analysis for themes and statements exemplifying the essence and nuances of residents' experiences. The conceptualization of service and clinical education encompassed 6 categories, with some overlap between terms. The category education encompassed (1) tasks and situations with some educational value termed indirect patient care; (2) tasks and situations with high educational values subdivided into direct patient care and teacher-learner interactions; and (3) traditional educational activities, including reflection. Service denoted: (1) tasks and situations with little to no educational value subdivided into indirect and direct patient care categories; (2) tasks and situations with some educational value described as direct patient care; and (3) community service to patients and communities. Definitions and the relative educational value of service and clinical education experiences overlapped considerably, but they varied by systematic, environmental, and personal factors. Service was used interchangeably to connote negative experiences that interfered with educational goals and positive experiences at the core of the profession's higher calling, the raison d'être of many physicians. The community needs to agree on the definitions of these terms and clarify the meaning of an appropriate balance.

Sistema de Classificação de Pacientes Pediátricos: construção e validação de categorias de cuidados

A classificação de pacientes é essencial para o gerenciamento de uma unidade. Entretanto, a literatura não dispõe de conceituações de categorias de pacientes pediátricos. Os objetivos deste estudo foram definir e validar categorias de cuidado de pacientes pediátricos, de acordo com o grau de dependência da equipe de enfermagem. Utilizou-se revisão bibliográfica para definição das categorias de cuidado e a validação de conteúdo das categorias propostas foi realizada por um grupo de juízes envolvidos em assistência e gerência de unidades pediátricas e por juízes envolvidos em ensino e pesquisa de pediatria e construção de instrumentos de classificação de pacientes. Foram estabelecidas e validadas cinco categorias de cuidados: Mínimos, Intermediários, Alta dependência, Semi-intensivo e Intensivo. A validação das categorias de cuidado subsidiou a construção de um sistema de classificação de pacientes pediátricos que poderá contribuir para o processo de tomada de decisão do enfermeiro na prática gerencial e assistencial.

The social worker's role in the hospital: seen through the eyes of other healthcare professionals

Social workers in hospitals necessarily work alongside other healthcare professionals, and the perspectives on social work held by doctors and senior nurses are relevant both to their relationship with social workers and to the smooth running of the hospital. An exploratory investigation in the East Anglian Region has produced profiles of perceived social work practice in six different patient-care categories: surgical and orthopaedic, accident and emergency, medicine for the elderly, psychogeriatric medicine, psychiatry and paediatrics. The social worker's functions are recognized as including statutory responsibilities in child protection and mental health, and there are some secondary roles that often reflect a social worker's personal interest or sphere of expertise. The social worker's primary role, however, is deemed to be that of discharge planning - a task which has been given statutory force under the National Health Service (NHS) and Community Care Act 1990. The nurses and doctors interviewed rated the quality of social work practice predominantly by the extent to which the social worker was seen to identify unambiguously with the hospital and its ethos; but they also set great store by the presence and easy accessibility of a social worker, and they preferred regular contact with the same person. They saw the social worker as a key agent within the health care framework, and acknowledged that the social care role and the social worker's link with the community were crucial components of good hospital practice.

Development of a pediatric burn pain and anxiety management program.

To facilitate effective management of pain and anxiety, and to permit more objective assessment of changes in this management, a pain and anxiety guideline was developed and has been followed uniformly for 3 years. The guideline describes four patient care categories: (1) ventilated acute, (2) nonventilated acute, (3) chronic acute, and (4) reconstructive. A small and consistent formulary was emphasized. A specific guideline for background, procedural, and transition pain and anxiety management was developed for each patient care category. All pain and anxiety medications given to all acutely burned children admitted to the Institute for 12 consecutive months were recorded, and daily pain and anxiety discomfort scores were noted using a 5-level action-based bedside scoring system. Doses of individual pain and anxiety medications were calculated as mg per kg per patient-day in each category, and all doses were found to be within guideline specifications. The efficacy of the guideline was judged by four discomfort scores: (1) background pain, (2) procedural pain, (3) background anxiety, and (4) procedural anxiety, and were adequate in all patient categories. There were no complications related to overmedication experienced during the interval. Our objective was to develop a guideline for pain and anxiety management that: (1) was safe and effective over a broad range of ages and injury acuities seen in the unit, (2) was explicit in its recommendations, (3) had a limited formulary to optimize staff familiarity with agents used, and (4) took advantage of the presence of a bedside nurse to continuously evaluate efficacy and intervene when needed through dose-ranging. Although many drugs are appropriate, our choices were based on institutional familiarity and simplicity. This process of developing a clear and consistent guideline can be duplicated in any unit.

The impact of do-not-resuscitate and patient care category policies on CPR and ventilator support rates: Arch Intern Med 1996; 156/4: 405–408

Background: Cardiopulmonary resuscitation (CPR) is automatically provided in the event of a cardiac or pulmonary arrest, unless an order not to resuscitate is written. When successful, CPR usually leads to mechanical ventilatory support. A patient care category (PCC) policy, which replaces a do-not-resuscitate (DNR) policy, assigns a category on admission describing care to be provided. This PCC policy is perceived to avoid more unnecessary or undesired medical care that includes CPR and subsequent mechanical ventilatory support than a DNR policy. Objective: To compare total rates of CPR and days of mechanical ventilatory support before and after instituting DNR and PCC policies. Methods: A 7-year (1984 through 1990) retrospective review of rates of CPR and days of mechanical ventilatory support (DVS) in a community-teaching hospital was conducted. Two years were considered the baseline in which an institutional order not-to-resuscitate policy was nonexistent. Two years were during which an institutional DNR policy existed. Three years were during which an institutional PCC policy replaced the DNR policy. Results: Compared with baseline years, during the DNR years mortality increased (8%), and CPR (—17%) and DVS (—8%) per 1000 admissions and CPR per 100 deaths (—26%) decreased. Compared with baseline years, during the PCC years mortality was unchanged and CPR (—61%) and DVS (—46%) per 1000 admissions and CPR per 100 deaths (—60%) decreased. Compared with DNR years, during the PCC years mortality ( —8%), CPR (—53%), and DVS (—42%) per 1000 admissions and CPR per 100 deaths ( —46%) decreased. Conclusions: A DNR policy significantly decreases the rates of CPR and DVS, but only modestly. A PCC policy dramatically decreases the rates of CPR and DVS with no change in mortality. (Arch Intern Med. 1996;156:405-408)

How rational is the crossmatching of blood in a pediatric emergency department?

To determine if typed and crossmatched blood ordered in a pediatric emergency department (ED) is actually used for transfusion and if some ordering patterns are not cost-effective. Retrospective medical record review. Emergency department records and blood bank logs were reviewed daily to identify patients who had a type and crossmatch (T&C) ordered; inpatient records were then reviewed. A priori diagnostic and patient care categories were determined. Physicians and nurses providing care were unaware of the study. An inner-city, tertiary care, pediatric trauma center ED. A consecutive sample of ED patients who had a T&C ordered from October 1, 1993, through January 31, 1994. None. Outcome measures included age, general category of diagnosis, number of units of blood crossmatched and transfused within 7 days, hemoglobin concentration in the ED, surgical procedures in the operating room, and hospital charges for typed and crossmatched blood. For trauma patients, the Pediatric Trauma Score was recorded. The crossmatch-to-transfusion (C/T) ratio was calculated for each diagnostic category (the typical C/T ratio for US hospitals is 2). We calculated a new ratio, the patient-to-transfusion (P/T) ratio, to correct for the transfusion of numerous units of blood in a few patients. Two hundred eighty-two patients had 468 U of blood typed and crossmatched. Fifty-six patients received a total of 110 U of blood. The mean hemoglobin concentration was 81 g/L for patients who received a transfusion and 117 g/L for patients who did not receive a transfusion (P < .001). The C/T ratio for all patients was 4.3. The P/T ratio for all patients was 5.3. Sixty-four surgery patients had 78 U of blood typed and crossmatched; 1 U of blood was transfused to 1 patient, yielding a C/T ratio of 78 and a P/T ratio of 64. Ninety-one units of blood were typed and crossmatched for 38 major trauma patients; 20 U of blood were transfused to 2 patients, 19 U were transfused to 1 patient with a Pediatric Trauma Score of 4, and 1 U was transfused to a patient with a Pediatric Trauma Score of 7. The C/T ratio for major trauma patients was 4.6, and the P/T ratio was 19. Forty-five children with ventriculoperitoneal shunt problems had 51 U of blood typed and crossmatched, but no blood was transfused. Children with sickle-cell disease had a C/T ratio of 2.2 and a P/T ratio of 3.3; those with cancer diagnoses had a C/T ratio of 1.6 and a P/T ratio of 1.3. During the 4-month study period, the hospital charged $84,726 for these T&Cs. The charge for T&Cs never used for transfusion was $65,643 (77.5%). Most typed and crossmatched units of blood ordered in our pediatric ED were never used for transfusion. The C/T and P/T ratios were high for many diagnostic categories, suggesting inefficient blood ordering and patient management. Transfusions were uncommon in children with the following problems: ventriculoperitoneal shunt malfunction, virtually all surgical diagnoses, cancer with a hemoglobin concentration greater than 105 g/L, and trauma patients with a Pediatric Trauma Score of greater than 7.

Needs of caregivers of clinic and hospice cancer patients.

This prospective correlational study compared the self-identified needs of 55 caregivers of clinic (n = 25) and hospice (n = 30) cancer patients. Patients identified their family caregivers who filled out the Home Caregiver Need Survey (HCNS) and a demographic data form. The HCNS measures the importance and satisfaction of needs on two seven-point Likert-type scales. Descriptive statistics and t tests were used to analyze the data. Caregivers of both clinic and hospice cancer patients ranked the needs items in the Information and Spiritual categories as most important. Variation in types of information occurred between the groups. Clinic caregivers were less satisfied with how well their needs in the Information category were met. Differences between the groups in the importance scores were significant at the 0.001 level for the needs in the Patient Care and Personal Care categories. Differences in the satisfaction scores between the groups were significant at the 0.001 level for needs in the Household and Patient Care categories. The HCNS is helpful for assessing and screening caregiver needs and identifying differences in needs between groups. Health care providers in clinics and hospices must individualize teaching to meet the specific needs of caregivers, particularly those needs related to information.

The Impact of Do-Not-Resuscitate and Patient Care Category Policies on CPR and Ventilator Support Rates

Cardiopulmonary resuscitation (CPR) is automatically provided in the event of a cardiac or pulmonary arrest, unless an order not to resuscitate is written. When successful, CPR usually leads to mechanical ventilatory support. A patient care category (PCC) policy, which replaces a do-not-resuscitate (DNR) policy, assigns a category on admission describing care to be provided. This PCC policy is perceived to avoid more unnecessary or undesired medical care that includes CPR and subsequent mechanical ventilatory support than a DNR policy. To compare total rates of CPR and days of mechanical ventilatory support before and after instituting DNR and PCC policies. A 7-year (1984 through 1990) retrospective review of rates of CPR and days of mechanical ventilatory support (DVS) in a community-teaching hospital was conducted. Two years were considered the baseline in which an institutional order not-to-resuscitate policy was nonexistent. Two years were during which an institutional DNR policy existed. Three years were during which an institutional PCC policy replaced the DNR policy. Compared with baseline years, during the DNR years mortality increased (8%), and CPR (-17%) and DVS (-8%) per 1000 admissions and CPR per 100 deaths (-26%) decreased. Compared with baseline years, during the PCC years mortality was unchanged and CPR (-61%) and DVS (-46%) per 1000 admissions and CPR per 100 deaths (-60%) decreased. Compared with DNR years, during the PCC years mortality (-8%), CPR (-53%), and DVS (-42%) per 1000 admissions and CPR per 100 deaths (-46%) decreased. A DNR policy significantly decreases the rates of CPR and DVS, but only modestly. A PCC policy dramatically decreases the rates of CPR and DVS with no change in mortality.

The impact of do-not-resuscitate and patient care category policies on CPR and ventilator support rates

The impact of do-not-resuscitate and patient care category policies on CPR and ventilator support rates

Casemix classification and health care of the elderly.

The Australian national diagnosis-related groups (AN-DRGs) patient classification has highlighted the distinction between different categories of inpatient care and ambulatory care, and the need for an explicit definition of boundaries of associated categories. A nationally consistent definition of these patient care categories, and of episodes of care according to illness acuity, will facilitate the design of additional casemix classifications to supplement AN-DRGs. Specific features of the AN-DRGs classification will have a major impact on health care of the elderly through incentives created by funding arrangements based on this classification. The use of age as an AN-DRG classification criterion, as a surrogate for definitive secondary diagnoses, should be regarded as an interim measure pending improvement in medical record documentation, further analysis of the relationship of age partitions to these secondary diagnoses, and ongoing improvement of AN-DRG design. The complex process of development of casemix classifications for subacute and ambulatory care has commenced, and will also have a profound impact on health care of the elderly and on all specialities concerned with both acute and chronic illness, again because of financial incentives in the classification design. Funding for development and refinement of each of these casemix classifications will be required if the anticipated benefits are to occur.