Lately the use of noninvasive ventilation (NIV) has gained popularity as an alternative to traditional invasive ventilation for the management of patients presenting with acute respiratory failure.This is largely due to the fact that NIV reduces the risks associated with invasive ventilation.The lack of published guidelines for the effective use of NIV has prompted the researchers' interest in the development of a clinical pathway for the use of NIV in adult patients in the critical care unit (CCU).The aim of the research was to identify the compulsory components to be included in the clinical pathway and to develop a clinical pathway for NIV.The research design utilised for this study was qualitative, contextual, explorative and descriptive in nature.The study consisted of three phases: Phase 1: Explorative phase -Identify the compulsory components of the clinical pathway; Phase 2: Literature control -to confirm the components for inclusion in the clinical pathway; and Phase 3: Development of a clinical pathway for NIV.A draft clinical pathway was developed based on the findings of Phase 1 and 2. The members of the multidisciplinary team were given an opportunity to comment on the draft clinical pathway.These inputs were included in the development of the final clinical pathway for NIV.The aims and objectives of the study were realised and culminated in the development of a clinical pathway for NIV which can be implemented in the critical care unit.
Objectives: To measure the reliability of data mining for indicators related to patient treatment at hospital discharge. Methods: Design: Retrospective cohort study. Population: Patients discharged alive after an admission for heart failure in a general internal medicine department from 2009 to 2010. Data: Key treatments at patient's discharge extracted from the clinical information system compared with data extracted manually from the medical records. Endpoint: Accuracy of data mining for treatment prescription. Analysis: Sensitivity, specificity, positive and negative predictive values (PPVs and NPVs) of data mining for angiotensin-converting enzyme (ACE) inhibitors and betablockers prescription discharge. The gold standard was manual data extraction. We then investigated causes of discrepancies between the two methods. Results: A total of 724 patients were included. At discharge, 85.2% received an ACE inhibitor and 72.4% a beta-blocker. For ACE inhibitors, data mining yielded a sensitivity of 90%, a specificity of 100%, a PPV of 100% and an NPV of 64%. Corresponding values for beta-blockers were 95%, 100%, 100% and 88%, respectively. Main causes for discrepancy were: omission of some molecules in the electronic query used; non-standard writing of a prescription in the clinical information system; formats incorrectly interpreted by the query. Conclusion: Immediate reliance on data mining for drug prescription is currently unwarranted because this complex process is still prone to errors. Results should be manually checked before they can be used as quality indicators.
Ventilator-associated pneumonia (VAP) is the leading cause of death among hospital-acquired infections and prolongs time spent on the ventilator, length of intensive care unit (ICU) stay and length of hospital stay after discharge from the ICU. The ventilator bundle of the Institute of Healthcare Improvement includes five evidence-based guidelines which are proven to be effective in the prevention of VAP. The main purpose of this study is to determine the incidence of VAP at two intensive care units at the Jessa Hospital. In addition, compliance rates with the different elements of the VAP bundle are determined. From 1 January 2011 to 31 March 2011 an explorative study was conducted on a 18-bed surgical intensive care unit (SICU) and a six-bed medical intensive care unit (MICU). VAP was diagnosed using Johanson et al. criteria. Bedside observations and analysis of the electronic patient record were performed in order to determine compliance relative to the VAP bundle. At the SICU 10 VAPs were diagnosed resulting in an incidence of 38.46% and a VAP rate of 22.56. Three VAPs were diagnosed at the MICU. The incidence of VAP at the MICU was 18.75% resulting in a VAP rate of 18.75%. Compliance to all elements of the VAP bundle was observed in 0.52% (SICU) and 19.64% (MICU) of the observations. Compliance at the level of individual elements of the bundle varies between 1.03% and 99.48% (SICU) and 32.14% and 100% (MICU).
The Dutch national health-care policy has two opposing objectives: firstly care has to be cost-effective and secondly the quality of care has to improve. To meet these objectives in the clinical care for congestive heart failure (CHF), the Haga Hospital Heart Centre decided to investigate whether care according to a care pathway would be the solution. The objective of this study was to gain the support of the medical doctors (MDs) for implementation of a CHF care pathway. This was accomplished by providing insight through a process analysis of care as registered in the medical records. The survey was a retrospective process description of the design of the data collection protocol and research process evaluating the current care with international guidelines. The results of the research and the process of data collection facilitated a thorough evaluation of the delivered care. This resulted in an invaluable insight by the MDs into the results and registration of the medical care to CHF patients. In order to reveal the internal urgency of the design and implementation of a care pathway quantification of the care parameters is essential to gain insight into the care processes. With this insight the MDs are more likely to support a care pathway.
STUDY DESIGN:A randomized controlled trial.OBJECTIVE:To assess the effectiveness of Delitto's classification-based treatment approach compared with usual physical therapy care in patients with subacute or chronic low back pain.SUMMARY OF BACKGROUND DATA:No trial has evaluated this approach in patients with subacute and chronic low back pain.METHODS:Before randomization, all patients were classified by research physical therapists according to a modified version of Delitto's classification-based system. Randomization was computer-generated, with centralized allocation concealment. The statistician and the physical therapists were unblinded. Patients and assistants who collected follow-up questionnaires were blinded. Follow-up assessments were completed at 8, 26, and 52 weeks. The primary analysis was performed according to the intention-to-treat principle, using multilevel analysis. The main outcomes were global perceived effect, disability (Oswestry Disability Index, 0-100), and pain intensity (Numerical Rating Scale, 0-10). Secondary outcomes were quality of life, fear-avoidance beliefs, and psychosocial status. RESULTS.: A total of 156 patients were included (classification-based group, n = 74; usual physical therapy group, n = 82). There were no statistically significant differences between the treatment groups for any of the outcomes at any of the follow-up time points. After 8 weeks, patients in the classification-based group had greater global perceived effect scores; adjusted odds ratio of 1.01 (95% confidence interval [CI], 0.31 to 3.28), and higher adjusted Oswestry Disability Index and Numerical Rating Scale scores; mean adjusted differences of 0.48 points (95% CI, -4.59 to 3.63) and 0.49 points (95% CI, -1.34 to 0.37) respectively, but all differences were statistically nonsignificant.CONCLUSION:The classification-based system used in this study was not effective for improving physical therapy care outcomes in a population of patients with subacute and chronic low back pain.
Clinical pathways attempt to increase efficiency by organizing the care delivery process into individual analysable steps. We evaluate a digital clinical pathway for electrocardioversion in atrial fibrillation with a nurse coordinator in the ongoing consecutive experience in clinical practice. This paper describes the implementation and effects of introducing a clinical pathway. The pathway was launched in January 2008. Up to January 2009, 450 all-comer elective patients have been treated using this integrated digital clinical pathway without exception. Treatment and outpatient check-up appointments are made immediately for all patients. The pathway reduced walk-through times significantly. A clinical pathway for cardioversion patients is safely and efficaciously introduced in a teaching hospital.
The objective of this study was to conduct a literature review to assess the importance of teacher training on the economic assessment for professionals working in the Cuban National Health Service (NHS). The assessment will be used as a working tool to guide the process of decision-making in the health sector and to increase the efficiency of different actions to be undertaken in the country. We conducted a literature review to search comprehensive information about this topic at the national and international levels with the intention of incorporating this discipline as a component of crucial importance for the pursuit of efficiency in the Cuban health-care system. Teacher training in economic evaluation applied to the field of health is considered an aspect that improves the rational use of different health technologies, which implies an efficient use of resources for the NHS in Cuba. Although the costs of these therapies are becoming more substantial, their assessment in terms of efficiency allows us to identify effective and less costly interventions for the health sector in Cuba by defining the best strategies to support the process of decision-making. We can confirm that the teacher training in economic evaluation of health professionals for the NHS has been a pressing need. The goal is to develop an economic culture that enables the personnel to show an increased efficiency in performing their normal duties and tasks when developing health interventions that are organized and developed in the country.
