American journal of medical quality : the official journal of the American College of Medical Quality
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The authors' goal was to determine if a national intensive care unit (ICU) collaborative to reduce central line-associated bloodstream infections (CLABSIs) would succeed in Hawaii. The intervention period (July 2009 to December 2010) included a comprehensive unit-based safety program; a multifaceted approach to CLABSI prevention; and monitoring of infections. The primary outcome was CLABSI rate. ⋯ The overall mean CLABSI rate decreased from 1.5 infections per 1000 catheter days at baseline (January to June 2009) to 0.6 at 16 to 18 months postintervention (October to December 2010). The median rate was zero CLABSIs per 1000 catheter days at baseline and remained zero throughout the study period. Hawaii demonstrated that the national program can be successfully spread, providing further evidence that most CLABSIs are preventable.
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Hospital-wide mortality rates are used as a measure of overall hospital quality. However, their parsimony and apparent simplicity belie significant conceptual and methodological concerns. For many diagnoses included in hospital-wide mortality, the association between short-term mortality and quality of care is not well established. ⋯ Many of these result from substantial interprovider heterogeneity in diagnosis frequency, sample sizes, and patient severity. Hospital-wide mortality is problematic as a quality metric for public reporting, although hospitals may elect to use such measures for other purposes. Potential alternative approaches include multidimensional composite metrics or mortality measurement limited to selected conditions and procedures for which the link between hospital mortality and quality is clear, legitimate exclusions are uncommon, and sample sizes, end points, and risk adjustment are adequate.
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It is widely believed that timely follow-up decreases hospital readmissions; however, the literature evaluating time to follow-up is limited. The authors conducted a retrospective analysis of patients discharged from a tertiary care academic medical center and evaluated the relationship between outpatient follow-up appointments made and 30-day unplanned readmissions. ⋯ The timing of postdischarge follow-up did not affect readmissions. Further research is needed to determine such factors and to prospectively study time to outpatient follow-up after discharge and the decrease in readmission rates.
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The authors question whether the d-dimer assay and pulmonary computed tomography angiography (CTA) are being used appropriately to evaluate suspected acute pulmonary embolism (PE) at their hospital. To answer this question, a retrospective review was performed on all emergency department (ED) patients who underwent d-dimer assay and/or CTA from August 15, 2008, to August 14, 2009. ⋯ This result suggests that d-dimer assay and CTA are used inappropriately to evaluate patients with suspected acute PE in our ED. The low threshold for initiating an evaluation for PE decreases the prevalence of PE in this population.
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Comparative Study
Apples and oranges: comparison of ACS-NSQIP observed outcomes with premier's quality manager-predicted outcomes.
The National Surgical Quality Improvement Program (NSQIP) is used by the American College of Surgeons to measure and report surgical quality and outcomes. Premier's Quality Manager (QM) generates expected outcomes from patient charts. The authors compared observed NSQIP morbidity and mortality outcomes with those predicted by QM. ⋯ NSQIP identified 478 postoperative occurrences, whereas QM predicted 714 patients with at least 1 complication; 223 of these were subclassified as patients with at least 1 morbid complication (C statistic, 0.83). QM did not perform as well in predicting the observed NSQIP morbidities. Surgical leaders and hospital administrators must critically evaluate products before adopting programs designed to improve patient outcomes or making decisions regarding physician practice.