Repeating Human Performance Themes in Five Health Care Adverse Events

Public dread following well-publicized accidents energized the desire to learn from adverse events in health care. This paper summarizes an attempt to partner medical and human factors expertise to identify repeating human performance themes across adverse events. An interdisciplinary team interviewed 30 health care personnel from multiple facilities about five complex medical incidents. Ninety human performance themes were examined for each incident. Of these, ten human performance themes were identified to be salient in at least three of the incidents. Although none of these themes directly point to solutions, they increase our understanding of recurring themes across medical cases and can point to similar themes, and how they have been addressed, in other high-consequence, complex, socio-technical domains, such as aviation.

Collaborative Cross-Checking to Enhance Resilience

There has been a longstanding consensus that supporting error detection and recovery processes is critical for very high safety levels because it increases system resilience. System resilience is defined in Resilience Engineering as successful adaptation to variations, changes, and surprises by organizations, groups, or individuals. Cross-checking is a critical component of resilience because it can enable detection of erroneous assessments or actions while negative consequences can be mitigated or eliminated. Prior studies suggest that cross-checking where an additional human with a fresh perspective breaks fixations may be an effective strategy. Nevertheless, collaborative cross-checking remains a somewhat murky concept. In this paper, we describe in detail three healthcare incidents where collaborative cross-checking played a key role. Emerging patterns that provide opportunities for follow-on research are discussed.

New Arctic Air Crash Aftermath Role-Play Simulation™: Orchestrating a Fundamental Surprise

We describe an aviation scenario-based role-play simulation used to teach healthcare practitioners about barriers to learning from accidents. Participants searched for the causes of the crash in a scenario that encouraged a “garden path” explanation that the root cause was a risky decision to take off despite visible ice on the wings. During a debriefing session, the actual structure of how the system failed is revealed, including over 100 active and latent contributors to the failure with a multitude of potential lessons to improve safety. The dissonance between lessons learned during the role-play and the potential lessons creates a “fundamental surprise” situation that allows oversimplified assumptions of how complex systems fail to be challenged.

Handoffs During Nursing Shift Changes in Acute Care

Handoffs during the nursing shift change were directly observed on two acute care wards each of a private and public hospital, for a total of 236 patient updates by 49 nurses during 14 shift changes. Data from the three wards which conducted audio-taped updates were transcribed. The transcriptions and field notes were analyzed for the existence and frequency of 21 strategies used in high reliability organizations. In addition, we iteratively categorized the interruptions, questions, and statements made during the updates. Finally, we iteratively categorized stances towards decisions communicated during the updates. Implications of the findings are discussed.

Barriers to Implementing Wrong Site Surgery Guidelines: A Cognitive Work Analysis

In this paper, we explore the barriers wrong-site surgery guidelines face when applied in current work practice. Over 40 hours of direct observation of the entire care process (from initial consultation through post-operative care) were conducted. A breakdown in communication between surgical team members and the patient, operating room policy and procedures, incomplete patient assessment, staffing issues, distraction, and availability of pertinent information were identified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1998. In response to the high visibility of wrong-sited surgeries, the American Academy of Orthopedic Surgeons (AAOS) among others, developed guidelines intended to reduce the risk but failed to account for the dynamic complex environment. Several process elements emerged from our analysis of observation and interview data as they affected the outpatient surgical process of identification. This paper suggests strategies to enhance resiliency already present in the system.

Variations in efficiency and the relationship to quality of care in the veterans health system

There is widespread belief that the US health care system could realize significant improvements in efficiency, savings, and patient outcomes if care were provided in a more integrated and accountable way. We examined efficiency and its relationship to quality of care for medical centers run by the Veterans Health Administration of the Department of Veterans Affairs (VA), a national, vertically integrated health care system that is accountable for a large patient population. After devising a statistical model to indicate efficiency, we found that VA medical centers were highly efficient. We also found only modest variation in the level of efficiency and cost across VA medical centers, and a positive correlation overall between greater efficiency and higher inpatient quality. These findings for VA medical centers suggest that efforts to drive integration and accountability in other parts of the US health care system might have important payoffs in reducing variations in cost without sacrificing quality. Policy makers should focus on what aspects of certain VA medical centers allow them to provide better care at lower costs and consider policies that incentivize other providers, both within and outside the VA, to adopt these practices.

Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections

BACKGROUND

Health care-associated infections with methicillin-resistant Staphylococcus aureus (MRSA) have been an increasing concern in Veterans Affairs (VA) hospitals.

METHODS

A "MRSA bundle" was implemented in 2007 in acute care VA hospitals nationwide in an effort to decrease health care-associated infections with MRSA. The bundle consisted of universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene, and a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients. Each month, personnel at each facility entered into a central database aggregate data on adherence to surveillance practice, the prevalence of MRSA colonization or infection, and health care-associated transmissions of and infections with MRSA. We assessed the effect of the MRSA bundle on health care-associated MRSA infections.

RESULTS

From October 2007, when the bundle was fully implemented, through June 2010, there were 1,934,598 admissions to or transfers or discharges from intensive care units (ICUs) and non-ICUs (ICUs, 365,139; non-ICUs, 1,569,459) and 8,318,675 patient-days (ICUs, 1,312,840; and non-ICUs, 7,005,835). During this period, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage who were screened at transfer or discharge increased from 72% to 93%. The mean (±SD) prevalence of MRSA colonization or infection at the time of hospital admission was 13.6±3.7%. The rates of health care-associated MRSA infections in ICUs had not changed in the 2 years before October 2007 (P=0.50 for trend) but declined with implementation of the bundle, from 1.64 infections per 1000 patient-days in October 2007 to 0.62 per 1000 patient-days in June 2010, a decrease of 62% (P<0.001 for trend). During this same period, the rates of health care-associated MRSA infections in non-ICUs fell from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days, a decrease of 45% (P<0.001 for trend).

CONCLUSIONS

A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care-associated transmissions of and infections with MRSA in a large health care system.

Infrastructure for quality transformation: measurement and reporting in veterans administration intensive care units

BACKGROUND Veterans Health Administration (VA) intensive care units (ICUs) develop an infrastructure for quality improvement using information technology and recruiting leadership. METHODS Setting Participation by the 183 ICUs in the quality improvement program is required. Infrastructure includes measurement (electronic data extraction, analysis), quarterly web-based reporting and implementation support of evidence-based practices. Leaders prioritise measures based on quality improvement objectives. The electronic extraction is validated manually against the medical record, selecting hospitals whose data elements and measures fall at the extremes (10th, 90th percentile). results are depicted in graphic, narrative and tabular reports benchmarked by type and complexity of ICU. RESULTS The VA admits 103 689±1156 ICU patients/year. Variation in electronic business practices, data location and normal range of some laboratory tests affects data quality. A data management website captures data elements important to ICU performance and not available electronically. A dashboard manages the data overload (quarterly reports ranged 106-299 pages). More than 85% of ICU directors and nurse managers review their reports. Leadership interest is sustained by including ICU targets in executive performance contracts, identification of local improvement opportunities with analytic software, and focused reviews. CONCLUSION Lessons relevant to non-VA institutions include the: (1) need for ongoing data validation, (2) essential involvement of leadership at multiple levels, (3) supplementation of electronic data when key elements are absent, (4) utility of a good but not perfect electronic indicator to move practice while improving data elements and (5) value of a dashboard.

Liberation and animation: strategies to minimize brain dysfunction in critically ill patients

Acute brain dysfunction, usually manifested as delirium, occurs in up to 80% of critically ill patients. Delirium increases costs of hospitalizations and affects short-term outcomes such as duration of mechanical ventilation, intensive care unit (ICU) length of stay, and the hospital length of stay. Long-term consequences-cognitive impairment and increased risk of death-can be devastating. For adequate recognition and management it is imperative to implement a successful delirium monitoring and assessment strategy. A liberation and animation strategy can reduce both the incidence and the duration of delirium. Liberation aims to reduce the harmful effects of sedative exposure through use of target-based sedation protocols, spontaneous awakening trials, and proper choice of sedative as well as liberation from the ventilator and the ICU. Animation refers to early mobilization, which reduces delirium and improves neurocognitive outcomes. Delirium is a serious problem with important consequences and can be prevented or improved using the information that we have learned in the last decade.

Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis

OBJECTIVES

Hyperglycemia during critical illness is common and is associated with increased mortality. Intensive insulin therapy has improved outcomes in some, but not all, intervention trials. It is unclear whether the benefits of treatment differ among specific patient populations. The purpose of the study was to determine the association between hyperglycemia and risk- adjusted mortality in critically ill patients and in separate groups stratified by admission diagnosis. A secondary purpose was to determine whether mortality risk from hyperglycemia varies with intensive care unit type, length of stay, or diagnosed diabetes.

DESIGN

Retrospective cohort study.

SETTING

One hundred seventy-three U.S. medical, surgical, and cardiac intensive care units.

PATIENTS

Two hundred fifty-nine thousand and forty admissions from October 2002 to September 2005; unadjusted mortality rate, 11.2%.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A two-level logistic regression model determined the relationship between glycemia and mortality. Age, diagnosis, comorbidities, and laboratory variables were used to calculate a predicted mortality rate, which was then analyzed with mean glucose to determine the association of hyperglycemia with hospital mortality. Hyperglycemia was associated with increased mortality independent of illness severity. Compared with normoglycemic individuals (70-110 mg/dL), adjusted odds of mortality (odds ratio, [95% confidence interval]) for mean glucose 111-145, 146-199, 200-300, and >300 mg/dL was 1.31 (1.26-1.36), 1.82 (1.74-1.90), 2.13 (2.03-2.25), and 2.85 (2.58-3.14), respectively. Furthermore, the adjusted odds of mortality related to hyperglycemia varied with admission diagnosis, demonstrating a clear association in some patients (acute myocardial infarction, arrhythmia, unstable angina, pulmonary embolism) and little or no association in others. Hyperglycemia was associated with increased mortality independent of intensive care unit type, length of stay, and diabetes.

CONCLUSIONS

The association between hyperglycemia and mortality implicates hyperglycemia as a potentially harmful and correctable abnormality in critically ill patients. The finding that hyperglycemia-related risk varied with admission diagnosis suggests differences in the interaction between specific medical conditions and injury from hyperglycemia. The design and interpretation of future trials should consider the primary disease states of patients and the balance of medical conditions in the intensive care unit studied.

Using human factors methods to design a new interface for an electronic medical record

The Veterans Health Administration (VHA) is a leader in development and use of electronic patient records and clinical decision support. The VHA is currently reengineering a somewhat dated platform for its Computerized Patient Record System (CPRS). This process affords a unique opportunity to implement major changes to the current design and function of the system. We report on two human factors studies designed to provide input and guidance during this reengineering process. One study involved a card sort to better understand how providers tend to cognitively organize clinical data, and how that understanding can help guide interface design. The other involved a simulation to assess the impact of redesign modifications on computerized clinical reminders, a form of clinical decision support in the CPRS, on the learnability of the system for first-time users.

Evidence-Based Practice to Reduce Central Line Infections

BACKGROUND

In 2003, through the Greater Cincinnati Health Council nine health care systems agreed to participate and fund 50% of a two-year project to reduce hospital-acquired infections among patients in intensive care units (ICU) and following surgery (SIP).

METHODS

Hospitals were randomized to either the CR-BSI or SIP project in the first year, adding the alternative project in year 2. Project leaders, often the infection control professionals, implemented evidence-based practices to reduce catheter-related blood stream infections (CR-BSIs; maximal sterile barriers, chlorhexidine) at their hospitals using a collaborative approach. Team leaders entered process information in a secure deidentifled Web-based database.

RESULTS

Of the four initial sites randomized to CR-BSI reduction, all reduced central line infections by 50% (CR-BSI, 1.7 to 0.4/1000 line days, p < .05). At the project midpoint (3 quarters of 2004), adherence to evidence-based practices increased from 30% to nearly 95%.

DISCUSSION

The direct role of hospital leadership and development of a local community of practice, facilitated cooperation of physicians, problem solving, and success. Use of forcing functions (removal of betadine in kits, creation of an accessory pack and a checklist for line insertion) improved reliability. The appropriate floor for central line infections in ICUs is < 1 infection /1,000 line days.

Compliance with intended use of Bar Code Medication Administration in acute and long-term care: an observational study

OBJECTIVE

To identify the types and extent of workaround strategies with the use of Bar Code Medication Administration (BCMA) in acute care and long-term care settings.

BACKGROUND

Medication errors are the most commonly documented cause of adverse events in hospital settings. Scanning of bar codes to verify patient and medication information may reduce medication errors.

METHOD

A prospective ethnographic study was conducted using targeted observation. Fifteen acute care and 13 long-term care nurses were directly observed during medication administration at small, medium, and large Veterans Administration hospitals to detect workaround strategies.

RESULTS

Noncompliance with recommended practices was observed in all settings and facilities. A larger proportion of acute care nurses than long-term care nurses scanned bar-coded wristbands to identify patients (53% vs. 8%, p = .016). A larger proportion of acute care nurses than long-term care nurses administered bar-coded medications immediately after scanning (93% vs. 23%, p < .001).

CONCLUSION

Workaround strategies were employed with BCMA that increased efficiency but created new potential paths to adverse events. There was a significant difference in the rate of use of workaround strategies between acute and long-term care.

APPLICATION

The extent of workaround strategies varied by care setting and facility. BCMA should be tailored to the long-term care setting, including increasing the efficiency of use. Hospitals implementing bar coding should facilitate the intended use through equipment procurement, implementation, and quality improvement strategies.

Variation in outcomes in Veterans Affairs intensive care units with a computerized severity measure*

OBJECTIVE

To quantify the variability in risk-adjusted mortality and length of stay of Veterans Affairs intensive care units using a computer-based severity of illness measure.

DESIGN

Retrospective cohort study.

SETTING

A stratified random sample of 34 intensive care units in 17 Veterans Affairs hospitals.

PARTICIPANTS

A consecutive sample of 29,377 first intensive care unit admissions from February 1996 through July 1997.

INTERVENTIONS

Standardized mortality ratio (observed/expected deaths) and observed minus expected length of stay (OMELOS) with 95% confidence intervals were estimated for each unit using a hierarchical logistic (standardized mortality ratio) or linear (OMELOS) regression model with Markov Chain Monte Carlo simulation. We adjusted for patient characteristics including age, admission diagnosis, comorbid disease, physiology at admission (from laboratory data), and transfer status.

MEASUREMENTS AND MAIN RESULTS

Mortality across the intensive care units for the 12,088 surgical and 17,289 medical cases averaged 11% (range, 2-30%). Length of stay in the intensive care units averaged 4.0 days (range, mean unit length of stay 3.0-5.9). Standardized mortality ratio of the intensive care units varied from 0.62 to 1.27; the standardized mortality ratio and 95% confidence interval were <1 for four intensive care units and >1.0 for seven intensive care units. OMELOS of the intensive care units ranged from -0.89 to 1.34 days. In a random slope hierarchical model, variation in standardized mortality ratio among intensive care units was similar across the range of severity, whereas variation in length of stay increased with severity. Standardized mortality ratio was not associated with OMELOS (Pearson's r = .13).

CONCLUSIONS

We identified intensive care units whose indicators for mortality and length of stay differ substantially using a conservative statistical approach with a severity adjustment model based on data available in computerized clinical databases. Computerized risk adjustment employing routinely available data may facilitate research on the utility of intensive care unit profiling and analysis of natural experiments to understand process and outcome links and quality efforts.

Exploring barriers and facilitators to the use of computerized clinical reminders

OBJECTIVE

Evidence-based practices in preventive care and chronic disease management are inconsistently implemented. Computerized clinical reminders (CRs) can improve compliance with these practices in outpatient settings. However, since clinician adherence to CR recommendations is quite variable and declines over time, we conducted observations to determine barriers and facilitators to the effective use of CRs.

DESIGN

We conducted an observational study of nurses and providers interacting with CRs in outpatient primary care clinics for two days in each of four geographically distributed Veterans Administration (VA) medical centers.

MEASUREMENTS

Three observers recorded interactions of 35 nurses and 55 physicians and mid-level practitioners with the CRs, which function as part of an electronic medical record. Field notes were typed, coded in a spreadsheet, and then sorted into logical categories. We then integrated findings across observations into meaningful patterns and abstracted the data into themes, such as recurrent strategies. Several of these themes translated directly to barriers and facilitators to effective CR use.

RESULTS

Optimally using the CR system for its intended purpose was impeded by (1) lack of coordination between nurses and providers; (2) using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions; (3) workload; (4) lack of CR flexibility; and (5) poor interface usability. Facilitators included (1) limiting the number of reminders at a site; (2) strategic location of the computer workstations; (3) integration of reminders into workflow; and (4) the ability to document system problems and receive prompt administrator feedback.

CONCLUSION

We identified barriers that might explain some of the variability in the use of CRs. Although these barriers may be difficult to overcome, some strategies may increase user acceptance and therefore the effectiveness of the CRs. These include explicitly assigning responsibility for each CR to nurses or providers, improving visibility of positive results from CRs in the electronic medical record, creating a feedback mechanism about CR use, and limiting the overall number of CRs.

Value for taxpayers' dollars: what VA care would cost at medicare prices

Critics charge that Veterans Health Administration (VA) medical centers are inefficient and the cost of veteran health care would be reduced if VA purchased care for its patients directly from private-sector providers. This analysis compares VA medical care expenditures with estimates of total payments under a hypothetical Medicare fee-for-service payment system reimbursing providers for the same counts of each service VA medical centers provided in fiscal 1999. At six study sites, hypothetical payments were more than 20 percent greater than actual budgets. Nationally, this represented more than 3 billion US dollars in 1999 and more than 5 billion US dollars in 2003. Data limitations suggest the estimate is conservative. Less than half of the difference is due to VA's low pharmacy costs. The study demonstrates the potential savings to patients and taxpayers of the VA health care system.

An irreplaceable safety culture

Intensive care unit (ICU) clinicians are sources of errors and of resilience. When they learn how to juggle many competing goals, remain vigilant, and tell safety stories--all in the context of changing technologies and demand--they can create safe settings of care. Other strategies (eg, using computerized tools and implementing safety procedures) are important, but alone they are not sufficient. An ICU needs a safety culture that is rooted in a committed leadership, the acknowledgment that error is inevitable, a reporting system, and continuous learning. The all too common norm, "no harm no foul," is an obstacle. ICU leaders can use a campaign strategy to spread the safety practices that sustain a safety culture. They should attend to the political, marketing, and military aspects of such campaigns and recognize that people's time and attention are limited and built projects from existing ongoing pilots. Pilots can compete for people's attention; it has pull when it exemplifies a moral idea, simplifies work, and gives the health care professional more control and feedback. Under these conditions, the campaign will release individuals' passions and add energy and insight to the campaign itself.

Fifteen best practice recommendations for bar-code medication administration in the Veterans Health Administration

BACKGROUND

Since 2000, the Veterans Health Administration (VHA) has pioneered the development and deployment of a bar-code medication administration (BCMA) system. Based on VHA experience, 15 "best practices" for BCMA implementation, integration, and maintenance are recommended.

METHODS

Data were collected on potential barriers to the effectiveness of BCMA to improve patient safety by direct observation of medication administration, simulated BCMA use in a laboratory setting, a survey of nursing informatics specialists regarding policies and procedures, and 30 unstructured interviews with diverse stakeholders.

RECOMMENDATIONS

Fifteen practices were proposed, categorized by implementation and continuous improvement, training, troubleshooting, contingency planning, equipment maintenance, medication administration, and maintenance of paper patient wristbands. For example, Recommendation 15 ("Periodic replacement of wristbands") advises weekly bar-coded wristband replacement in long term care settings to improve the scanning reliability.

DISCUSSION

Lessons learned about best practices to address challenges may offer insight to others considering implementation of bar-code technology.

Understanding the Complexity of Registered Nurse Work in Acute Care Settings

Nursing shortages and patient safety mandates require nursing managers and administrators to consider new ways of understanding the complexity of healthcare provider work in actual situations. The authors report findings from a study guided by an innovative research approach to explore factors affecting registered nurse performance during real work on acute care medical-surgical units. Our findings suggest beginning targets for interventions to improve patient safety, as well as recruitment and retention, through support for registered nurse work.

Estimating private sector professional fees for VA providers

OBJECTIVES

To describe new methods used to estimate inpatient and outpatient Medicare-based professional fees for Veterans Health Administration (VA) services.

METHODS

National VA utilization files provided estimates of inpatient physician services, whereas local provider and utilization files gave counts of outpatient services by physicians, nurse practitioners, physician assistant, clinical psychologists, and clinical social workers. Services from ambulatory surgery, emergency room, and clinics (eg, dermatology and gastroenterology) were coded by study health information management staff (coders). VA-based billing information was edited against Medicare guidelines. Estimates for VA services without comparable Medicare fees were obtained from other commercial sources.

RESULTS

Hypothetical professional fees for VA services were 17% more ($109 million vs. $93 million) than the VA budget for physicians over 1 fiscal year at six sites. Total payments of nearly $21 million were generated for VA inpatient care. In fiscal year 1999, there were 30,209 admissions (of which 4549 were psychiatric) to the study sites; 30,518 discharges; 229,783 inpatient days, including 27,235 in critical care units; and 38,348 surgical days of care.

DISCUSSION

Differences between the VA and the private sector maybe overstated because VA salaries of nonphysicians were not included in the VA budgets. Conversely, the extent to which VA professional services were undercounted in VA information systems used in this study may understate the difference. Future research may consider additional data collection approaches or information systems enhancements to enumerate more accurately all provider services that are reimbursable in the private sector.

Methods for estimating and comparing VA outpatient drug benefits with the private sector

OBJECTIVES

To estimate and compare Veterans Health Administration (VA) expenditures for outpatient pharmaceuticals for veterans at six VA facilities with hypothetical private sector costs.

METHODS

Using the VA Pharmacy Benefits Management Strategic Health Care Group (PBM) database, we extracted data for all dispensed outpatient prescriptions from the six study sites over federal fiscal year 1999. After extensive data validation, we converted prescriptions to the same units and merged relevant VA pricing information by National Drug Code to Redbook listed average wholesale price and the Medicaid maximal allowable charge, where available. We added total VA drug expenditures to personnel cost from the pharmacy portion of that medical center's cost distribution report.

RESULTS

Hypothetical private sector payments were $200.8 million compared with an aggregate VA budget of $118.8 million. Using National Drug Code numbers, 97% of all items dispensed from the six facilities were matched to private sector price data. Nonmatched pharmaceuticals were largely generic over-the-counter pain relievers and commodities like alcohol swabs. The most commonly prescribed medications reflect the diseases and complaints of an older male population: pain, cardiovascular problems, diabetes, and depression or other psychiatric disorders.

CONCLUSIONS

Use of the VA PBM database permits researchers to merge expenditure and prescription data to patient diagnoses and sentinel events. A critical element in its use is creating similar units among the systems. Such data sets permit a deeper view of the variability in drug expenditures, an important sector of health care whose inflation has been disproportionate to that of the economy and even health care.

Methods for estimating private sector payments for VA acute inpatient stays

OBJECTIVES

To describe methods for estimating hypothetical private sector payments for Veterans Health Administration (VA) acute inpatient stays.

METHODS

We assumed all VA hospitalizations would have occurred under a hypothetical VA system that paid private sector providers but had the current benefit package for VA patients. We compared aggregate budgets for VA inpatient care (less physician salaries) at six VA hospitals over federal fiscal year 1999 to aggregated hypothetical private sector payments developed using VA diagnosis-related groups matched to metropolitan-based average Medicare payments. Counts of care came from the VA's statistical analysis system (SAS) inpatient files. Inpatient stays with both medical or surgical and psychiatric or rehabilitation care were counted as two stays. An external auditor conducted three reviews of VA coding practices during the study year, and the appropriateness of admissions was examined using a commercial utilization review tool.

RESULTS

For 30,518 inpatient discharges, hypothetical payments were $188 million, compared with the VA budget of $171 million. Fifteen of the 25 most frequent diagnosis-related groups in the VA were also in the top 25 for Medicare in 1998 and 1999. Audits established that the overall financial impact of VA coding problems was similar to that in the private sector.

DISCUSSION

Differences in organization, practice, and incentives limit estimates of the financial impact of shifting VA acute inpatient care to the private sector.

Methods to estimate and compare VA expenditures for assistive devices to Medicare payments

OBJECTIVE

To describe the methods used to estimate and compare Veterans Health Administration (VA) annual expenditures for assistive devices and their repair at six VA hospitals with payments for those same devices in the private sector.

METHODS

Information about dispensed assistive devices and their costs was extracted from (1) the VA's National Prosthetic Patient Database, (2) each site's listing of the VA's Denver Distribution Center cost center in the Cost Distribution Jurisdictional Report, and (3) review of invoices for implanted prosthetics at each study site. We estimated private sector payments by applying Medicare geographically adjusted rates for purchases or rentals, where rates existed, or by inflating VA costs by 30%.

RESULTS

The VA spent a total of $30.6 million for prosthetics at the six sites in fiscal year 1999, of which $14.2 million was for items captured in the National Prosthetic Patient Database, $3.4 million for the Denver Distribution Center, and more than $8.1 million for implants. Indirect VA costs were estimated at $4.8 million. Hypothetical private sector payments were estimated at $49.8 million.

CONCLUSIONS

Unlike Medicare, VA both contracts to provide assistive devices (through a competitive bidding process) and dispenses devices it has purchased. This approach results in significantly lower expenditures, consistent with other reports. Generalizing these cost savings to other private or federal programs covering assistive devices requires further study.

Automated intensive care unit risk adjustment: results from a National Veterans Affairs study

CONTEXT

Comparison of outcome among intensive care units (ICUs) requires risk adjustment for differences in severity of illness and risk of death at admission to the ICU, historically obtained by costly chart review and manual data entry.

OBJECTIVE

To accurately estimate patient risk of death in the ICU using data easily available in hospital electronic databases to permit automation.

DESIGN AND SETTING

Cohort study to develop and validate a model to predict mortality at hospital discharge using multivariate logistic regression with a split derivation (17,731) and validation (11,646) sample formed from 29,377 consecutive first ICU admissions to medical, cardiac, and surgical ICUs in 17 Veterans' Health Administration hospitals between February 1996 and July 1997.

MAIN OUTCOME MEASURES

Mortality at hospital discharge adjusted for age, laboratory data, diagnosis, source of ICU admission, and comorbid illness.

RESULTS

The overall hospital death rate was 11.3%. In the validation sample, the model separated well between survivors and nonsurvivors (area under the receiver operating characteristic curve = 0.885). Examination of the observed vs. the predicted mortality across the range of mortality showed the model was well calibrated.

CONCLUSIONS

Automation could broaden access to risk adjustment of ICU outcomes with only a small trade-off in discrimination. Broader use might promote valid evaluation of ICU outcomes, encouraging effective practices and improving ICU quality.

Methods to determine private sector payment for VA outpatient services: institutional payments to providers

OBJECTIVES

To describe methods used to estimate hospital institutional (facility) payments for providing Veterans Health Administration (VA) outpatient services.

METHODS

A series of audits compared the accuracy of outpatient coding at six VA medical centers in federal fiscal year 1999 with private sector standards. Outpatient records were processed through industry standard software to determine validity and remove inappropriate services. Private sector payments were estimated by applying average payment data from Medicare cost reports and Medicare outpatient prospective payment schedules to counts of VA services.

RESULTS

Coding audits found little difference in accuracy between VA and the community. Physician visits generated the most estimated payments and deviated most from Medicare payment experience. Radiology and laboratory services were the next highest expenditure categories for both the VA and Medicare. The proportion of radiology payments in VA data was notably lower and ambulatory surgery notably higher than Medicare's experience. Within major categories, the relative rankings of VA and Medicare services were consistent.

DISCUSSION

Differences in payment criteria make exact cost comparisons of hospital-based and office-based settings difficult, particularly physician visits. Two VA clinical software applications, radiology and laboratory, provide information not readily convertible to a claims format; these applications need significant changes to be used for these purposes. They understate radiology services and overstate laboratory services compared with private sector standards. In addition, the laboratory application contains inappropriate or unspecified codes that cannot be accurately valued for many reasons.

Impact of different measures of comorbid disease on predicted mortality of intensive care unit patients

BACKGROUND

Valid comparison of patient survival across ICUs requires adjustment for burden of chronic illness. The optimal measure of comorbidity in this setting remains uncertain.

OBJECTIVES

To examine the impact of different measures of comorbid disease on predicted mortality for ICU patients.

DESIGN

Retrospective cohort study.

SUBJECTS

Seventeen thousand eight hundred ninety-three veterans from 17 geographically diverse VA Medical Centers and 43 ICUs were studied, admitted between February 1, 1996 and July 31, 1997.

MEASURES

ICD-9-CM codes reflecting comorbid disease from hospital stays before and including the index hospitalization from local VA computer databases were extracted, and three measures of comorbid disease were then compared: (1) an APACHE-weighted comorbidity score using comorbid diseases used in APACHE, (2) a count of conditions described by Elixhauser, and (3) Elixhauser comorbid diseases weighted independently. Univariate analyses and multivariate logistic regression models were used to determine the contribution of each measure to in-hospital mortality predictions.

RESULTS

Models using independently weighted Elixhauser comorbidities discriminated better than models using an APACHE-weighted score or a count of Elixhauser comorbidities. Twenty-three and 14 of the Elixhauser conditions were significant univariate and multivariable predictors of in-hospital mortality, respectively. In a multivariable model including all available predictors, comorbidity accounted for less (8.4%) of the model's uniquely attributable chi statistic than laboratory values (67.7%) and diagnosis (17.7%), but more than age (4.0%) and admission source (2.1%). Excluding codes from prior hospitalizations did not adversely affect model performance.

CONCLUSIONS

Independently weighted comorbid conditions identified through computerized discharge abstracts can contribute significantly to ICU risk adjustment models.

The "New Look" approach to patient safety: a guide for clinical nurse specialist leadership

This article describes a complex system model based on human performance factors that is borrowed from other industries but can be used by clinical nurse specialists for making progress in patient safety. Traditional approaches to investigation and follow-up of errors in healthcare organizations have not resulted in improvement in patient safety. The New Look approach described in this article emphasizes the complexity in which healthcare workers make decisions about patient c are every day and how increased learning about the resiliency of healthcare workers in the face of multiple system gaps and discontinuities will lead to long-lasting improvements in safety. The article describes how the clinical nurse specialist can lead efforts using the New Look human performance-based approach in 4 areas: changing to a nonpunitive culture, learning about system complexity, learning about healthcare worker resiliency, and preparing for the complexity of introducing change.

Improving patient safety by identifying side effects from introducing bar coding in medication administration

OBJECTIVE

In addition to providing new capabilities, the introduction of technology in complex, sociotechnical systems, such as health care and aviation, can have unanticipated side effects on technical, social, and organizational dimensions. To identify potential accidents in the making, the authors looked for side effects from a natural experiment, the implementation of bar code medication administration (BCMA), a technology designed to reduce adverse drug events (ADEs).

DESIGN

Cross-sectional observational study of medication passes before (21 hours of observation of 7 nurses at 1 hospital) and after (60 hours of observation of 26 nurses at 3 hospitals) BCMA implementation.

MEASUREMENTS

Detailed, handwritten field notes of targeted ethnographic observations of in situ nurse-BCMA interactions were iteratively analyzed using process tracing and five conceptual frameworks.

RESULTS

Ethnographic observations distilled into 67 nurse-BCMA interactions were classified into 12 categories. We identified five negative side effects after BCMA implementation: (1) nurses confused by automated removal of medications by BCMA, (2) degraded coordination between nurses and physicians, (3) nurses dropping activities to reduce workload during busy periods, (4) increased prioritization of monitored activities during goal conflicts, and (5) decreased ability to deviate from routine sequences.

CONCLUSION

These side effects might create new paths to ADEs. We recommend design revisions, modification of organizational policies, and "best practices" training that could potentially minimize or eliminate these side effects before they contribute to adverse outcomes.

Automated computerized intensive care unit severity of illness measure in the Department of Veterans Affairs: preliminary results. SISVistA Investigators. Scrutiny of ICU Severity Veterans Health Sysyems Technology Architecture

OBJECTIVE

To evaluate the feasibility of an automated intensive care unit (ICU) risk adjustment tool (acronym: SISVistA) developed by selecting a subset of predictor variables from the Acute Physiology and Chronic Health Evaluation (APACHE) III available in the existing computerized database of the Department of Veterans Affairs (VA) healthcare system and modifying the APACHE diagnostic and comorbidity approach.

DESIGN

Retrospective cohort study.

SETTING

Six ICUs in three Ohio Veterans Affairs hospitals.

PATIENT SELECTION

The first ICU admission of all patients from February 1996 through July 1997.

OUTCOME MEASURE

Mortality at hospital discharge.

METHODS

The predictor variables, including age, comorbidity, diagnosis, admission source (direct or transfer), and laboratory results (from the +/- 24-hr period surrounding admission), were extracted from computerized VA databases, and APACHE III weights were applied using customized software. The weights of all laboratory variables were added and treated as a single variable in the model. A logistic regression model was fitted to predict the outcome and the model was validated using a boot-strapping technique (1,000 repetitions).

MAIN RESULTS

The analysis included all 4,651 eligible cases (442 deaths). The cohort was predominantly male (97.5%) and elderly (63.6 +/- 12.0 yrs). In multivariate analysis, significant predictors of hospital mortality included age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.04-1.09), comorbidity (OR, 1.11; 95% CI, 1.08-1.15), total laboratory score (OR, 1.07; 95% CI, 1.06-1.08), direct ICU admission (OR, 0.39; 95% CI, 0.31-0.49), and several broad ICU diagnostic categories. The SISVistA model had excellent discrimination and calibration (C statistic = 0.86, goodness-of-fit statistics; p > .20). The area under the receiver operating characteristic curve of the validated model was 0.86.

CONCLUSIONS

Using common data elements often found in hospital computer systems, SISVistA predicts hospital mortality among patients in Ohio VA ICUs. This preliminary study supports the development of an automated ICU risk prediction system on a more diverse population.

Patients with stable chronic obstructive pulmonary disease can safely undergo intravenous dipyridamole thallium-201 imaging

BACKGROUND

Patients with chronic obstructive pulmonary disease are usually excluded from intravenous dipyridamole thallium-201 testing. We developed a nurse-administered protocol to screen and pretreat patients so they could be safely tested.

METHODS AND RESULTS

We prospectively screened patients referred for intravenous dipyridamole thallium testing and retrospectively reviewed a comparison group of patients who had undergone intravenous dipyridamole testing before our bronchospasm protocol. We studied 492 consecutive patients referred for intravenous dipyridamole thallium testing, separating those with complete data (n = 451) into two groups: group A (n = 72), patients assessed to be at risk for intravenous dipyridamole-induced bronchospasm who received our bronchospasm treatment protocol; and group B (n = 379), patients assessed to be free of risk, who did not receive our bronchospasm protocol. Group C (n = 89) was a retrospective comparison group of patients who had undergone intravenous dipyridamole testing before initiation of the protocol. Patients were considered at risk for an adverse event if any of the following were present: peak flow < or =400 ml at the time of the test (spirometry by nurse) that increased to >400 ml after bronchodilator treatment, wheezing audible with stethoscope, history of chronic obstructive pulmonary disease or asthma or dyspnea on exertion at less than four blocks, or resting respiratory rate >18 breaths/min. The test was considered contraindicated if resting oxygen saturation was <85%, respiratory rate < or =36 breaths/min, or peak flow measured by peak flowmeter <400 ml after bronchodilator inhalant (albuterol or metaproterenol sulfate by spacer) at a dose of up to six puffs. One minute after injections of thallium-201, patients at risk were given 50 mg aminophylline by slow intravenous injection. We looked for major and minor adverse effects and divided them into three categories: (1) minor events (transient headache, abdominal discomfort, or nausea), wheezing (audible by stethoscope but without marked respiratory distress), (2) marked events (severe bronchospasm or severe ischemia defined as wheezing audible with or without stethoscope, respiratory rate >20 breaths/min or increased by 10 from pretest evaluation, oxygen desaturation to <90%, hypoventilation [reduced respiratory rate with decreased mental status], respiratory arrest, chest pain, horizontal ST-segment depression > or =1 mm on the electrocardiogram in any lead, symptomatic hypotension), or (3) other intravenous dipyridamole-induced side effects (persistent headache, dizziness, flushing, nausea, dyspnea, and ischemic chest pain) or anginal equivalent. The protocol properly identified patients with impaired pulmonary function. There was no difference in the frequency of adverse marked events among groups A, B, or C (1 % vs 4% vs 2%, p = 0.25). Patients in group A had more minor side effects than those in group B (53% vs 35%, p = 0.004). Specifically, patients in group A were more likely to wheeze (39% vs 1 %, p = <0.001), but wheezing in group A was self-limited or responded to treatment as described in the protocol. The prevalence of positive thallium-201 scans in group A (44%) compared with group C (49%) was not different (p = 0.15).

CONCLUSIONS

A nurse-administered risk assessment and pretreatment protocol (1) properly identified patients with impaired pulmonary function, (2) permitted completion of intravenous dipyridamole testing in patients at risk for bronchospasm without an increased incidence of marked adverse events, and (3) did not appear to influence the interpretation of the thallium test.

Left ventricular dysfunction in deteriorating patients with chronic obstructive pulmonary disease

OBJECTIVE

To evaluate the effectiveness of simple clinical variables and radionuclide ventriculogram in separating those patients with isolated chronic obstructive pulmonary disease (COPD) from those with COPD and coexisting left ventricular dysfunction (LVD).

DESIGN

Retrospective record review of 77 patients with increasing dyspnea, defined as recent deterioration in exercise tolerance, new use of corticosteroids, or recent hospital admission for COPD; referred to the outpatient Pulmonary Rehabilitation Program at the Cincinnati Veterans Affairs Medical Center from July 1987 to October 1992.

SETTING

Outpatient medical clinic.

PATIENTS

Veterans who were referred to the Pulmonary Rehabilitation Program.

MEASUREMENTS

History and physical findings, pulmonary function tests, arterial blood gases, distance achieved in a 12-min walk, dyspnea score, electrocardiogram, chest radiograph, and radionuclide multigated ventriculography.

RESULTS

Twenty-five of 77 patients evaluated in the Pulmonary Rehabilitation Program for increasing dyspnea were functionally more limited (12-min walk 10.4 vs 13.9 laps; MRC score 2.68 vs 2.06; p < 0.05) and had left ventricular dysfunction (LVD) (left ventricular ejection fraction < 40%) associated with wall motion abnormalities on radionuclide ventriculogram. Careful standard clinical evaluation did not separate those patients with COPD from those with both COPD and LVD.

CONCLUSIONS

LVD was found in 32% of patients with COPD presenting with symptomatic deterioration. Since the therapeutic approach to these two disorders differs, the identification of patients with LVD is important. Prospective studies are needed to identify the most cost-effective approach to this problem of coexisting disease and to evaluate the benefit from therapy.

Anthropometric and pulmonary function test profiles of outpatients with stable chronic obstructive pulmonary disease

PURPOSE

To determine the prevalence of abnormalities in the nutritional status, and their correlation with pulmonary function test results, in a population of outpatients with stable chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

During 1 year of study, body weight, height, triceps skinfold, arm muscle circumference, and pulmonary function parameters were assessed in 126 patients. On the basis of body mass index (BMI = weight/height2) of less than 20, 20 to 27, and greater than 27, the patients were divided into underweight (n = 29, 23%), normal weight (n = 67, 53.2%), and overweight (n = 30, 23.8%), respectively.

RESULTS

Diffusing capacity for carbon monoxide (DLCO), both as absolute and percent predicted, differed significantly among the three groups, being lowest in the underweight and highest in the overweight patients. A significant and positive correlation was present between BMI as the independent variable and DLCO, forced expiratory volume in 1 second, and its ratio to forced vital capacity. A significant and negative correlation existed between BMI and residual volume and its ratio to total lung capacity.

CONCLUSION

A substantial number of stable COPD patients (46.8%) have nutritional abnormalities. BMI is a simple and accurate indicator of nutritional status in these patients. BMI correlates significantly with some tests of pulmonary function.

Studies on the mechanism of decreased neutrophil adherence to postconfluent cultured endothelial cells

The adherence of neutrophils (PMN) to endothelium is a crucial early step in neutrophil-mediated vascular injury. However, vascular injury is not a necessary event in inflammatory states, which suggests that endogenous mechanisms may protect endothelial cells from neutrophil-mediated injury. Previous studies suggested that leukocytes adhered in greater numbers to vascular endothelium in vivo and in vitro, where the contiguity of the cells was disrupted and where endothelial cells were actively migrating and proliferating. We studied the effect of development of a confluent monolayer on adherence of human PMN to cultured bovine calf aortic endothelial cells and investigated several mechanisms by which this effect might occur. We found that adherence of quiescent and activated PMN decreased with development of a confluent endothelial cell monolayer. A similar effect was found using human umbilical-vein endothelial cells. In contrast, adherence of nylon wool-nonadherent, thymus-derived lymphocytes increased. Variation in neutrophil adherence was not due to adherence of PMN to exposed tissue culture plastic or to exposed matrix components in preconfluent cultures, nor due to products released into culture supernatants. Diminished PMN adherence to postconfluent monolayers may have been related to changes in endothelial cell glycoproteins because neuraminidase or cycloheximide pretreatment augmented PMN adherence to postconfluent cultures more than to preconfluent cultures. However, the extent of total cell surface sialation, as assessed by neuraminidase-releasable [3H]glucosamine from metabolically labeled monolayers, did not differ between pre- and postconfluent cultures, suggesting that some specific sialated cell surface constituent is responsible for decreased PMN adherence to postconfluent monolayers.(ABSTRACT TRUNCATED AT 250 WORDS)