A tool to assess nontechnical skills of perfusionists in the cardiac operating room

OBJECTIVES

This study aimed to develop the Perfusionists' Intraoperative Non-Technical Skills tool, specifically to the perfusionists' context, and test its inter-rater reliability.

METHODS

An expert panel was convened to review existing surgical nontechnical skills taxonomies and develop the Perfusionists' Intraoperative Non-Technical Skills tool. During a workshop held at a national meeting, perfusionists completed the Perfusionists' Intraoperative Non-Technical Skills ratings after watching 4 videos displaying simulated cardiac operations. Two videos showed "good performance," and 2 videos showed "poor performance." Inter-rater reliability analysis was performed and intraclass correlation coefficient was reported.

RESULTS

The final version of the Perfusionists' Intraoperative Non-Technical Skills taxonomy contains 4 behavioral categories (decision making, situation awareness, task management and leadership, teamwork and communication) with 4 behavioral elements each. Categories and elements are rated using an 8-point Likert scale ranging from 0.5 to 4.0. A total of 60 perfusionist raters were included and the comparison between rating distribution on "poor performance" and "good performance" videos yielded a statistically significant difference between groups, with a P value less than .001. A similar difference was found in all behavioral categories and elements. Reliability analysis showed moderate inter-rater reliability across overall ratings (intraclass correlation coefficient, 0.735; 95% confidence interval, 0.674-0.796; P < .001). Similar inter-rater reliability was found when raters were stratified by experience level.

CONCLUSIONS

The Perfusionists' Intraoperative Non-Technical Skills tool presented moderate inter-rater reliability among perfusionists with varied levels of experience. This tool can be used to train and assess perfusionists in relevant nontechnical skills, with the potential to enhance safety and improve surgical outcomes.

Patient Attribution-A Call for a System Redesign

This Viewpoint discusses several shortcomings in patient attribution systems from the perspective of physicians and patients and proposes strategies to improve patient attribution accuracy to better advance the goals of alternative payment models.

Identifying dominant environmental predictors of freshwater wetland methane fluxes across diurnal to seasonal time scales

While wetlands are the largest natural source of methane (CH₄ ) to the atmosphere, they represent a large source of uncertainty in the global CH₄ budget due to the complex biogeochemical controls on CH₄ dynamics. Here we present, to our knowledge, the first multi-site synthesis of how predictors of CH₄ fluxes (FCH4) in freshwater wetlands vary across wetland types at diel, multiday (synoptic), and seasonal time scales. We used several statistical approaches (correlation analysis, generalized additive modeling, mutual information, and random forests) in a wavelet-based multi-resolution framework to assess the importance of environmental predictors, nonlinearities and lags on FCH4 across 23 eddy covariance sites. Seasonally, soil and air temperature were dominant predictors of FCH4 at sites with smaller seasonal variation in water table depth (WTD). In contrast, WTD was the dominant predictor for wetlands with smaller variations in temperature (e.g., seasonal tropical/subtropical wetlands). Changes in seasonal FCH4 lagged fluctuations in WTD by ~17 ± 11 days, and lagged air and soil temperature by median values of 8 ± 16 and 5 ± 15 days, respectively. Temperature and WTD were also dominant predictors at the multiday scale. Atmospheric pressure (PA) was another important multiday scale predictor for peat-dominated sites, with drops in PA coinciding with synchronous releases of CH₄ . At the diel scale, synchronous relationships with latent heat flux and vapor pressure deficit suggest that physical processes controlling evaporation and boundary layer mixing exert similar controls on CH₄ volatilization, and suggest the influence of pressurized ventilation in aerenchymatous vegetation. In addition, 1- to 4-h lagged relationships with ecosystem photosynthesis indicate recent carbon substrates, such as root exudates, may also control FCH4. By addressing issues of scale, asynchrony, and nonlinearity, this work improves understanding of the predictors and timing of wetland FCH4 that can inform future studies and models, and help constrain wetland CH₄ emissions.

Accessing novel fluorinated heterocycles with the hypervalent fluoroiodane reagent by solution and mechanochemical synthesis

A new and efficient strategy for the rapid formation of novel fluorinated tetrahydropyridazines and dihydrooxazines has been developed by fluorocyclisation of β,γ-unsaturated hydrazones and oximes with the fluoroiodane reagent. Mechanochemical synthesis delivered fluorinated tetrahydropyridazines in similar excellent yields to conventional solution synthesis, whereas fluorinated dihydrooxazines were prepared in much better yields by ball-milling.

Recovery support specialists inside the jail: a program description of treatment engagement for opioid use disorder

Purpose

People living with opioid use disorder (OUD) disproportionately encounter the criminal justice system. Although incarcerated individuals with OUD face higher risk for withdrawals, relapses and overdoses, most jails fail to offer comprehensive medications for OUD (MOUD), including recovery support services and transition of care to a community provider. The purpose of this paper is to describe the development and implementation of a comprehensive MOUD program at a large county jail system in Maricopa County, Arizona.

Design/methodology/approach

The authors used the Sequential Intercept Model (SIM) to develop a community-based, multi-organizational program for incarcerated individuals with OUD. The SIM is a mapping process of the criminal justice system and was applied in Maricopa County, Arizona to identify gaps in services and strengthen resources at each key intercept. The program applies an integrated care framework that is person-centered and incorporates medical, behavioral and social services to improve population health.

Findings

Stakeholders worked collaboratively to develop a multi-point program for incarcerated individuals with OUD that includes an integrated care service with brief screening, MOUD and treatment; a residential treatment program; peer support; community provider referrals; and a court diversion program. Recovery support specialists provide education, support and care coordination between correctional and community health services.

Originality/value

OUD is a common problem in many correctional health centers. However, many jails do not provide a comprehensive approach to connect incarcerated individuals with OUD treatment. The Maricopa County, Arizona jail system opioid treatment program is unique because of the ongoing support from recovery support specialists during and after incarceration.

Public Policy Impact of the COVID-19 Pandemic on Blood Supply in the United States

The COVID-19 pandemic has precipitated an acute blood shortage for medical transfusions, exacerbating an already tenuous blood supply system in the United States, contributing to the public health crisis, and raising deeper questions regarding emergency preparedness planning for ensuring blood availability. However, these issues around blood availability during the pandemic are related primarily to the decline in supply caused by reduced donations during the pandemic rather than increased demand for transfusion of patients with COVID-19.The challenges to ensure a safe blood supply during the pandemic will continue until a vaccine is developed, effective treatments are available, or the virus goes away. If this virus or a similar virus were capable of transmission through blood, it would have a catastrophic impact on the health care system, causing a future public health emergency that would jeopardize the national blood supply.In this article, we identify the impact of the COVID-19 pandemic on blood supply adequacy, discuss the public health implications, propose recovery strategies, and present recommendations for preparing for the next disruption in blood supply driven by a public health emergency.

Ultrathin and Robust Hydrogel Coatings on Cardiovascular Medical Devices to Mitigate Thromboembolic and Infectious Complications

Thromboembolic and infectious complications stemming from the use of cardiovascular medical devices are still common and result in significant morbidity and mortality. There is no strategy to date that effectively addresses both challenges at the same time. Various surface modification strategies (e.g., silver, heparin, and liquid-impregnated surfaces) are proposed yet each has several limitations and shortcomings. Here, it is shown that the incorporation of an ultrathin and mechanically robust hydrogel layer reduces bacterial adhesion to medical-grade tubing by 95%. It is additionally demonstrated, through a combination of in vitro and in vivo tests, that the hydrogel layer significantly reduces the formation and adhesion of blood clots to the tubing without affecting the blood's intrinsic clotting ability. The adhesion of clots to the tubing walls is reduced by over 90% (in vitro model), which results in an ≈60% increase in the device occlusion time (time before closure due to clot formation) in an in vivo porcine model. The advantageous properties of this passive coating make it a promising surface material candidate for medical devices interfacing with blood.

Factors associated with errors in the heparin dose response test: recommendations to improve individualized heparin management in cardiopulmonary bypass

BACKGROUND

A critical aspect of cardiopulmonary bypass (CPB) is to achieve full anticoagulation to prevent thrombosis and consumptive coagulation without using excessive amount of heparin. This can be achieved with heparin dose response (HDR) test in vitro to calculate an individualized heparin bolus to reach a target activated clotting time (ACT) and heparin concentration. However, we often observe that the measured ACT (mACT) with the calculated heparin bolus gives significant errors, both positive (mACT is higher than expected) and negative (mACT is lower), from expected ACT (eACT).

METHODS

We performed a retrospective study of 250 patients who underwent cardiac surgery to attain an error distribution of the mACT from eACT with calculated heparin bolus. In addition, it is aimed to identify possible patterns of baseline ACT (bACT), calculated heparin concentration (CHC) and HDR slope that are associated with the significant positive and negative errors.

RESULTS

We found that individualized heparin bolus by HDR test is consistently underestimated while it gave a significant number of positive and negative errors. Further analysis indicates that significant negative errors correlate with high bACT and slope and low CHC while significant positive errors with low bACT and slope and high CHC.

CONCLUSION

The mACT can be substantially different from eACT. The accuracy of the HDR test appears to be dependent upon bACT, slope, and CHC. Based on our analysis, we provide several recommendations and a flow chart to improve the quality of individualized heparin management on CPB.

A framework for oral health care value-based payment approaches

BACKGROUND

Dental practice has remained relatively insulated from payment upheavals in the broader health care system. The prevailing value-based payment (VBP) models in health care are largely absent in oral health care. The authors present an oral health care value-based payment framework for dentistry.

METHODS

The authors developed a VBP framework for oral health care, which describes 9 distinct methods to create VBP approaches in dentistry. The framework is based on the Centers for Medicare & Medicaid Services Learning Action Network framework for health care payment reform.

RESULTS

The oral health care value-based payment framework includes 4 payment categories and 9 separate payment mechanisms. These 9 payment mechanisms range on a value continuum, each with different financial risks and rewards as well as distinct value implications.

CONCLUSIONS

Although dental practice has made extraordinary advances in restorative dentistry, payers and policy makers are advocating for greater value outcomes. VBP models seek to deliver better care more efficiently by means of providing oral health providers the resources needed to increase the value proposition. With relatively minor modifications in practice patterns, VBP models can be developed and implemented for oral health care.

PRACTICAL IMPLICATIONS

This article can be used as a road map to take steps toward oral health care VBP approaches. The framework highlights how dentistry can learn from payment reforms under way in the health care system and present a model for oral health care payment and care delivery reform, and provides recommendations to advance oral health care VBP.

Efficacy and cost-effectiveness of behavioral interventions in nonclinical settings for improving health outcomes

This paper examines three distinct examples of interventions in nonclinical settings selected to highlight the challenges and opportunities for evaluating cost-effectiveness in the field of health psychology and behavioral medicine. Nonclinical settings are defined as those involving systems outside of traditional medical/clinical settings, and include interventions tested in clinical settings that can also be implemented in nonclinical settings. The examples in this paper reflect the use of a varying degree of existing cost-effectiveness data and previous health economic analyses. First, the Chronic Disease Self-Management Program model reflects an intervention protocol designed to increase patients' confidence and mastery in their ability to manage their conditions that has been shown to be cost effective for a variety of chronic disease conditions. Second, the cost and cost-effectiveness of tobacco quitlines (e.g., National Tobacco Quit Line) has been the subject of several preliminary cost-effectiveness examinations and has proven to have significant reach and impact on tobacco-related behaviors. Finally, environmental interventions for promoting walking and physical activity in community-based contexts (e.g., PATH trial) are presented and have been shown to be highly relevant for demonstrating cost-effectiveness. Overall, the disciplines of health psychology and behavioral medicine are in a unique position to develop, implement, and evaluate a broader range of interventions in more diverse environments than cost-effectiveness applications in more traditional, clinical settings. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Activation of the hypervalent fluoroiodane reagent by hydrogen bonding to hexafluoroisopropanol

Hexafluoroisopropan-2-ol is an excellent solvent for promoting fluorinations with the stable hypervalent fluoroiodane reagent without any transition metals or TREAT-HF activators.

A 2015-2016 Survey of American Board of Cardiovascular Perfusion Certified Clinical Perfusionists: Perfusion Profile and Clinical Trends

To document the current perfusion workforce status and to anticipate the future demands of an ever-changing perfusion workplace environment, a valid survey is needed to help guide the future of the perfusion workforce. The American Board of Cardiovascular Perfusion (ABCP) sponsored a survey of Certified Clinical Perfusionist (CCP) demographic and clinical trends that was linked electronically to the 2015-2016 ABCP online recertification process. Of 3,875 eligible CCP's, 3,056 (78.9%) responded to the survey. The 12 survey questions covered the topics of gender, age, education levels, years of clinical experience, annual clinical activity exposure, high fidelity simulation experience, recertification requirement satisfaction and professional activity requirement contentment. The results of the ABCP annual survey are being published in accordance with the ABCP's commitment to establish and maintain interactive communication with the community of CCPs. The goal of this survey is to present the perfusion and health-care community with important statistics related to the current field of perfusion and establish trends to guide the future of perfusion.

Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback

OBJECTIVE

To improve safety practices and reduce adverse events in perinatal units of acute care hospitals.

DATA SOURCES

Primary data collected from perinatal units of 14 hospitals participating in the intervention between 2008 and 2012. Baseline secondary data collected from the same hospitals between 2006 and 2007.

STUDY DESIGN

A prospective study involving 342,754 deliveries was conducted using a quality improvement collaborative that supported three primary interventions. Primary measures include adoption of three standardized care processes and four measures of outcomes.

DATA COLLECTION METHODS

Chart audits were conducted to measure the implementation of standardized care processes. Outcome measures were collected and validated by the National Perinatal Information Center.

PRINCIPAL FINDINGS

The hospital perinatal units increased use of all three care processes, raising consolidated overall use from 38 to 81 percent between 2008 and 2012. The harms measured by the Adverse Outcome Index decreased 14 percent, and a run chart analysis revealed two special causes associated with the interventions.

CONCLUSIONS

This study demonstrates the ability of hospital perinatal staff to implement efforts to reduce perinatal harm using a quality improvement collaborative. Findings help inform the relationship between the use of standardized care processes, teamwork training, and improved perinatal outcomes, and suggest that a multiplicity of integrated strategies, rather than a single intervention, may be essential to achieve high reliability.

Decreasing Malpractice Claims by Reducing Preventable Perinatal Harm

OBJECTIVE

To evaluate the association of improved patient safety practices with medical malpractice claims and costs in the perinatal units of acute care hospitals.

DATA SOURCES

Malpractice and harm data from participating hospitals; litigation records and medical malpractice claims data from American Excess Insurance Exchange, RRG, whose data are managed by Premier Insurance Management Services, Inc. (owned by Premier Inc., a health care improvement company).

STUDY DESIGN

A quasi-experimental prospective design to compare baseline and postintervention data. Statistical significance tests for differences were performed using chi-square, Wilcoxon signed-rank test, and t-test.

DATA COLLECTION

Claims data were collected and evaluated by experienced senior claims managers through on-site claim audits to evaluate claim frequency, severity, and financial information. Data were provided to the analyzing institution through confidentiality contracts.

PRINCIPAL FINDINGS

There is a significant reduction in the number of perinatal malpractice claims paid, losses paid, and indemnity payments (43.9 percent, 77.6 percent, and 84.6 percent, respectively) following interventions to improve perinatal patient safety and reduce perinatal harm. This compares with no significant reductions in the nonperinatal claims in the same hospitals during the same time period.

CONCLUSIONS

The number of perinatal malpractice claims and dollar amount of claims payments decreased significantly in the participating hospitals, while there was no significant decrease in nonperinatal malpractice claims activity in the same hospitals.

Single, percutaneous, femoral venous cannulation for cardiopulmonary bypass

Percutaneous femoral venous cannulation for cardiopulmonary bypass has emerged as an indispensable technique in the management of cardiac surgical procedures requiring cardiopulmonary bypass. A review of cases at Brigham and Women's Hospital (Boston, MA, USA) relying solely on percutaneous femoral venous cannulation for venous return to the heart-lung machine demonstrated achievable blood flow and complexity of case-load. Operations performed in this manner include, but are not limited to, coronary artery bypass grafting (CABG), valve, CABG/valve, and aortic procedures. Minimally invasive procedures and re-operations comprise a portion of each group. Complications of cardiopulmonary bypass and site-related complications were considered. Percutaneous femoral venous cannulation is a safe method to provide most patients with adequate venous return to perform any cardiac surgery. Patients demanding greater flow than this method will provide, may require a second venous cannula at some time during cardiopulmonary bypass. Perfusion (2007) 22, 211—215.

Clinical validity of PROMIS Depression, Anxiety, and Anger across diverse clinical samples

OBJECTIVES

The purpose of this study was to evaluate the responsiveness to change of the PROMIS negative affect measures (depression, anxiety, and anger) using longitudinal data collected in six chronic health conditions.

STUDY DESIGN AND SETTING

Individuals with major depressive disorder (MDD), back pain, chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and cancer completed PROMIS negative affect instruments as computerized adaptive test or as fixed-length short form at baseline and a clinically relevant follow-up interval. Participants also completed global ratings of health. Linear mixed effects models and standardized response means (SRM) were estimated at baseline and follow-up.

RESULTS

A total of 903 individuals participated (back pain, n = 218; cancer, n = 304; CHF, n = 60; COPD, n = 125; MDD, n = 196). All three negative affect instruments improved significantly for treatments of depression and pain. Depression improved for CHF patients (anxiety and anger not administered), whereas anxiety improved significantly in COPD groups (stable and exacerbation). Response to treatment was not assessed in cancer. Subgroups of patients reporting better or worse health showed a corresponding positive or negative average SRM for negative affect across samples.

CONCLUSION

This study provides evidence that the PROMIS negative affect scores are sensitive to change in intervention studies in which negative affect is expected to change. These results inform the estimation of meaningful change and enable comparative effectiveness research.

Integrating Quality Improvement and Continuing Professional Development at an Academic Medical Center: A Partnership Between Practice Plan, Hospital, and Medical School

INTRODUCTION

While quality improvement (QI) initiatives can be a highly effective means for improving health care delivery in academic medical centers (AMCs), many health care professionals are not formally trained in basic QI methodology, engaging clinicians in QI activities can be challenging, and there is often a lack of integration and coordination among QI functions (eg, Departments of Quality and Safety, Continuing Professional Development). In our AMC, we undertook a collaborative approach to achieve better vertical and horizontal integration of our QI education efforts. This article provides a case example describing our organizational context, what was done, and with what effect and makes our example and lessons learned available to others.

METHODS

We developed a new educational QI program that was jointly planned and implemented by a group comprising major QI stakeholders. This project was intended to create horizontal organizational linkages between continuing professional development, clinicians, the hospital, and QI department and produce QI activities that aligned with the strategic objectives of senior management.

RESULTS

The group developed and implemented a curriculum based on Lean methodology and concepts from the Institute for Health Care Improvement Model for Improvement. Two cohorts (27 teams) completed the training and planned and implemented QI projects. All projects were aligned with organizational quality, safety, and patient experience goals. The majority of projects met their aim statements.

DISCUSSION

This case description provides an example of successful horizontal integration of an AMCs' QI functions to disseminate knowledge and implement meaningful QI aligned with strategic objectives (vertical integration).

Abstract IA53: Challenges of implementing interventions in “small populations.”

The ability to harness the benefits of big data has had a revolutionary impact on science, with its focus on the volume and variety of data sources and application of both traditional and innovative analytic methods appropriate for large, aggregated datasets. We are concerned, however, about the opposite: small data for which the size, dispersion, or accessibility of the population of interest makes it difficult to obtain adequate sample sizes to test specific research questions. Data from these groups, however, are critical if we want to include health-related issues across all populations in cancer research.

An example of the potential negative ramifications of not including underrepresented groups in research or inappropriately aggregating them across groups-- comes from the study of racial and ethnic health disparities and issues of equity in the US. Intervention research often does not include a wide range of racial/ethnic subgroups; so it is not feasible to test whether an intervention created specifically for the majority group is also efficacious for the subgroups. Likewise, the ability to test whether an intervention can be altered for a particular subgroup is also often not possible. Epidemiologic and surveillance research usually involves the inclusion of “minority or underserved populations” in addition to white/non-Hispanic white (NHW) groups. While this has allowed for a better understanding of these smaller populations and provides some progress toward addressing health inequities, there remain pockets of communities that are severely underrepresented within the broader minority and underserved populations.

Citation Format: Shobha Srinivasan, Richard P. Moser, Gordon Willis, William Riley, Mark Alexander. Challenges of implementing interventions in “small populations.” [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA53.

Leveraging intensive longitudinal data to better understand health behaviors

Behavioral scientists have historically relied on static modeling methodologies. The rise in mobile and wearable sensors has made intensive longitudinal data (ILD) -- behavioral data measured frequently over time -- increasingly available. Consequently, analytical frameworks are emerging that seek to reliably quantify dynamics reflected in these data. Employing an input-output perspective, dynamical systems models from engineering can characterize time-varying behaviors as processes of change. Specifically, ILD and parameter estimation routines from system identification can be leveraged together to offer parsimonious and quantitative descriptions of dynamic behavioral constructs. The utility of this approach for facilitating a better understanding of health behaviors is illustrated with two examples. In the first example, dynamical systems models are developed for Social Cognitive Theory (SCT), a prominent concept in behavioral science that considers interrelationships between personal factors, the environment, and behaviors. Estimated models are then obtained that explore the role of SCT in a physical activity intervention. The second example uses ILD to model day-to-day changes in smoking levels as a craving-mediated process of behavior change.

The promise of intensive longitudinal data capture for behavioral health research

Advances in technology and the associated cultural norms, especially the advent of the smartphone, offer an unprecedented opportunity to collect data on relevant health behaviors and experiences unobtrusively at a greater frequency and in greater volumes than ever before. This special issue will acquaint the readership of Nicotine and Tobacco Research with the potential for intensive longitudinal data and will illustrate some innovative analytic techniques for addressing research questions associated with this type of complex data. This introductory article will provide a brief history of the analytic techniques for intensive longitudinal data and will point to some resources that support and enable the use of these techniques.

Local health department factors associated with performance in the successful implementation of community-based strategies: a mixed-methods approach

OBJECTIVES

We examined which local health department (LHD)-level factors contributed to successful implementation of policy, systems, and environmental change strategies in Minnesota.

METHODS

We used a retrospective mixed-methods design to evaluate the relationship between the Statewide Health Improvement Plan (SHIP) grant initiative and key predictor variables (2009-2011). We obtained quantitative capacity data for 91 cities and counties in Minnesota; in addition, we conducted 15 key informant interviews to examine factors that facilitated and acted as barriers to LHD performance.

RESULTS

Grantee performance was distributed as follows: exceeds expectations (29.7%), meets expectations (55.0%), and is approaching expectations (15.3%). Organizational quality improvement (QI) maturity was strongly positively associated with grantee performance on SHIP. Organizations with high QI maturity, effective leadership, efficient decision-making, and successful regional or cross-jurisdictional partnerships were more likely to be rated as exceeding expectations.

CONCLUSIONS

This study successfully translated practice-based research findings into tangible outcomes, including new system-level performance measures for local public health and recommendations for shaping the statewide initiative examined in this study. The approach taken in this study to systematically monitor communications, dissemination, and translation may be a model for others.

Blood product recalls in the United States

BACKGROUND

The blood recall process is intended to remove from use products that may be harmful, but characteristics of recalls nationally have not been reported.

STUDY DESIGN AND METHODS

We analyzed recalls of all blood products for 2010 and categorized the reason for the recall, the organizations producing the recalled products, and the Food and Drug Administration (FDA) district in which the blood was collected.

RESULTS

During 2010, there were 2468 recalls involving 8278 blood products. None of the recalls was considered to have a reasonable probability of causing serious adverse health consequences or death (FDA Class I). The most common reasons for recalls were donation and donor qualification (73%) and finished product quality control (14%). The FDA class of recalls varied by recall reason, month of the year, FDA district, number of units of blood collected per FDA district, and number of units of blood collected by the blood center. The number of recalls per 100,000 units of blood and the reason for recall varied by FDA district and blood centers collecting smaller numbers of units had more recalls.

CONCLUSION

The absence of Class I recalls suggests a high level of quality and safety in the US blood supply. Organizations that collected larger numbers of units of blood had fewer recalls and there may be some FDA influences since the number and reason for the recalls varied by FDA district.

Federal efforts to define and advance telehealth--a work in progress

BACKGROUND

The integration of telecommunications and information systems in healthcare is not new or novel; indeed, it is the current practice of medicine and has been an integral part of medicine in remote locations for several decades. The U.S. Government has made a significant investment, measured in hundreds of millions of dollars, and therefore has a strong presence in the integration of telehealth/telemedicine in healthcare. However, the terminologies and definitions in the lexicon vary across agencies and departments of the U.S. Government. The objective of our survey was to identify and evaluate the definitions of telehealth/telemedicine across the U.S. Government to provide a better understanding of what each agency or department means when it uses these terms.

METHODOLOGY

The U.S. Government, under the leadership of the Health Resources and Services Administration in the U.S. Department of Health and Human Services, established the Federal Telemedicine (FedTel) Working Group, through which all members responded to a survey on each agency or department's definition and use of terms associated with telehealth.

RESULTS AND CONCLUSIONS

Twenty-six agencies represented by more than 100 individuals participating in the FedTel Working Group identified seven unique definitions of telehealth in current use across the U.S. Government. Although many definitions are similar, there are nuanced differences that reflect each organization's legislative intent and the population they serve. These definitions affect how telemedicine has been or is being applied across the healthcare landscape, reflecting the U.S. Government's widespread and influential role in healthcare access and service delivery. The evidence base suggests that a common nomenclature for defining telemedicine may benefit efforts to advance the use of this technology to address the changing nature of healthcare and new demands for services expected as a result of health reform.

Creating quality improvement culture in public health agencies

OBJECTIVES

We conducted case studies of 10 agencies that participated in early quality improvement efforts.

METHODS

The agencies participated in a project conducted by the National Association of County and City Health Officials (2007-2008). Case study participants included health directors and quality improvement team leaders and members. We implemented multiple qualitative analysis processes, including cross-case analysis and logic modeling. We categorized agencies according to the extent to which they had developed a quality improvement culture.

RESULTS

Agencies were conducting informal quality improvement projects (n = 4), conducting formal quality improvement projects (n = 3), or creating a quality improvement culture (n = 4). Agencies conducting formal quality improvement and creating a quality improvement culture had leadership support for quality improvement, participated in national quality improvement initiatives, had a greater number of staff trained in quality improvement and quality improvement teams that met regularly with decision-making authority. Agencies conducting informal quality improvement were likely to report that accreditation is the major driver for quality improvement work. Agencies creating a quality improvement culture were more likely to have a history of evidence-based decision-making and use quality improvement to address emerging issues.

CONCLUSIONS

Our findings support previous research and add the roles of national public health accreditation and emerging issues as factors in agencies' ability to create and sustain a quality improvement culture.

Evaluating the impact a proposed family planning model would have on maternal and infant mortality in Afghanistan

OBJECTIVE

This study aimed to assess the potential impact a proposed family planning model would have on reducing maternal and infant mortality in Afghanistan.

BACKGROUND

Afghanistan has a high total fertility rate, high infant mortality rate, and high maternal mortality rate. Afghanistan also has tremendous socio-cultural barriers to and misconceptions about family planning services.

METHODS

We applied predictive statistical models to a proposed family planning model for Afghanistan to better understand the impact increased family planning can have on Afghanistan's maternal mortality rate and infant mortality rate. We further developed a sensitivity analysis that illustrates the number of maternal and infant deaths that can be averted over 5 years according to different increases in contraceptive prevalence rates.

RESULTS

Incrementally increasing contraceptive prevalence rates in Afghanistan from 10% to 60% over the course of 5 years could prevent 11,653 maternal deaths and 317,084 infant deaths, a total of 328,737 maternal and infant deaths averted.

CONCLUSION

Achieving goals in reducing maternal and infant mortality rates in Afghanistan requires a culturally relevant approach to family planning that will be supported by the population. The family planning model for Afghanistan presents such a solution and holds the potential to prevent hundreds of thousands of deaths.

The effect of consumer incentives on Medicaid beneficiaries' compliance with well-child visit guidelines

The Affordable Care Act of 2010 recommends that consumer incentives be employed to increase the use of preventive care by Medicaid beneficiaries, but few evaluative studies exist. This study evaluates a Target gift card incentive employed by a Minnesota health plan serving Medicaid beneficiaries over the period 2002-2003. Lacking a contemporaneous control group, the proximity between the child's residence and the nearest Target store was used as the intervention variable. Using alternative specifications for the intervention variable, results of the difference-in-differences equations suggest that the incentive program significantly increased the likelihood that a Medicaid beneficiary would have a well-child visit.

Using lean techniques to define the platelet (PLT) transfusion process and cost-effectiveness to evaluate PLT dose transfusion strategies

BACKGROUND

Platelet (PLT) doses of 1.1 × 10(11), 2.2 × 10(11), and 4.4 × 10(11) /m(2) body surface area are equally effective in preventing bleeding. These different dose strategies involve different numbers of transfusions. We conducted a cost analysis of three separate PLT dose therapies.

STUDY DESIGN AND METHODS

A process map of preparation and administration of a PLT transfusion identified 46 steps (23 steps in the blood bank and 23 steps on the care unit). Time studies were conducted for these 46 steps. Supply costs and personnel costs were estimated based on time studies. We conducted a cost analysis of three separate treatment regimes involving 16 transfusions per patient for the low-dose, 12 transfusions for medium-dose, and eight transfusions for high-dose regimes.

RESULTS

The time and the cost of the transfusion process for the blood bank were 32.41 minutes and $21.93 per unit, and for the patient care unit, 58.36 minutes and $57.71 per unit. The total cost for a course of PLT therapy per patient ranged from $4503.77 to $7014.59 for three different PLT doses. For a simulated bone marrow transplantation unit with 259 patients annually, there would be approximately a $700,000 difference among the clinically equivalent low-, medium-, and high-dose treatment options.

CONCLUSIONS

The overall cost of transfusion therapy is more influenced by the cost of the product than the cost of providing the transfusion. Depending on the cost adjustment by the supplier for different doses of PLTs, a low-dose transfusion strategy can be less costly.

In vitro comparison of two different methods of cell washing

The storage of red blood cells (RBC) results in increased concentrations of plasma free hemoglobin, potassium, glucose, and lactate, among other undesirable substances. These concentrations continue to increase as RBC products age and can cause deleterious effects to the patient. In the setting of cardiac surgery, the autotransfusion devices are routinely used to wash blood that is shed from the surgical site. These devices could also be used to wash stored RBC units obtained from the blood bank. The objective of this study was to compare the product created by washing a unit of RBCs with the AutoLog autotransfusion device in the operating room to the washed products from a standard cell washer in the blood bank.

Eleven outdated RBC units (stored for >42 days at 4°C) were split in half. One half was washed using the Medtronic AutoLog device; the other half was washed using the blood bank’s Cobe 2991 Cell Processor. Analytes were measured on samples from the unwashed parent unit and from the washed daughter units. The parameters measured included hematocrit, free hemoglobin, lactate, lactate dehydrogenase (LDH), potassium, glucose, and pH.

When compared to the original untreated RBCs, the glucose, lactate, and potassium levels were decreased when washed in an autotranfusion device. Additionally, the free hemoglobin and LDH levels were significantly lower with the Medtronic Autolog cell saver than in the COBE 2991 Cell Processor.

Washing the RBC donor units in an autotransfusion device prior to transfusion can effectively attenuate the increases seen in glucose, potassium, free hemoglobin, and LDH associated with RBC storage lesion.

Hand sanitizer dispensers and associated hospital-acquired infections: friend or fomite?

BACKGROUND

Waterless alcohol-based hand sanitizers are an increasingly popular method of hand hygiene and help prevent hospital-acquired infection (HAI). Whether hand sanitizer dispensers (HSDs) may themselves harbor pathogens or act as fomites has not been reported.

METHODS

All HSDs in the surgical intensive care unit of an urban teaching hospital were cultured at three sites: The dispenser lever, the rear underside, and the area surrounding the dispensing nozzle.

RESULTS

All HSDs yielded one or more bacterial species, including commensal skin flora and enteric gram-negative bacilli. Colonization was greatest on the lever, where there is direct hand contact.

CONCLUSION

Hand sanitizer dispensers can become contaminated with pathogens that cause HAI and thus are potential fomites.

Knowledge, attitudes and practices surveys of blood donation in developing countries

BACKGROUND AND OBJECTIVES

  Knowledge, attitude and practice (KAP) surveys have been used in many countries to understand factors that influence blood donation and as the basis for communication and donor mobilization strategies.

MATERIALS AND METHODS

  A search was conducted of publically available databases, and studies with the following characteristics were selected: (1) the study was a knowledge, attitude and practice or KAP plus behaviour survey; (2) the subject of the survey was blood donation; (3) the survey was performed between 1995 and 2011; and (4) the survey was performed in countries classified as emerging and developing by the International Monetary Fund.

RESULTS

  Eighteen KAP studies conducted in seventeen developing countries were identified. There was considerable difference in the structure, population surveyed and conduct of the KAP studies. The common following themes emerged: misinformation about blood donation, fear of blood donation, willingness to donate for family and friends, concern about selling blood and a failure to transfer positive attitudes into actual blood donation.

CONCLUSION

  Despite considerable differences in the culture and demographics of developing countries, several common themes emerged from different KAP surveys.

Methicillin-susceptible Staphylococcus aureus nasal colonization and the risk of subsequent methicillin-resistant Staphylococcus aureus infections among hospitalized patients

Few data exist on the risk of methicillin-resistant Staphylococcus aureus (MRSA) infections among known methicillin-susceptible S. aureus (MSSA) carriers. In a cohort of 2991 hospitalized MSSA carriers, 22 (22%) of 98 S. aureus infections that occurred within a subsequent 6-month period were caused by MRSA. Recent fluoroquinolone use was an independent predictor of MRSA infections (P < .001).

Relative to the general US population, chronic diseases are associated with poorer health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS)

OBJECTIVES

The Patient-Reported Outcomes Measurement Information System (PROMIS) allows assessment of the impact of chronic conditions on health-related quality of life (HRQL) across diseases. We report on the HRQL impact of individual and comorbid conditions as well as conditions that are described as limiting activity.

STUDY DESIGN AND SETTING

Data were collected through online and clinic recruitment as part of the PROMIS item calibration sample (n=21,133). Participants reported the presence or absence of 24 chronic health conditions and whether their activity was limited by each condition.

RESULTS

Across health status domains, the presence of a chronic condition was associated with poorer scores than those without a diagnosis, particularly for those individuals who reported that their condition was disabling. The magnitude of detriment in HRQL was more pronounced for individuals with two or more chronic conditions and could not be explained by sociodemographic factors. Patterns of HRQL deficits varied across disease and comorbidity status.

CONCLUSION

The impact of chronic conditions, particularly when experienced with comorbid disease, is associated with detriments in HRQL. The negative impact on HRQL varies across symptoms and functional areas within a given condition.

Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies

BACKGROUND

In Reason's safety model, high-reliability healthcare organisations are characterised by multiple layers of defensive barriers in depth associated with increased levels of safety in the care delivery system. However, there is very little empirical evidence describing and defining defensive barriers in healthcare settings or systematic analysis documenting the nature of breaches in these barriers. This study uses in situ simulation to identify defensive barriers and classify the nature of active and latent breaches in these barriers.

METHODS

An in situ simulation methodology was used to study team performance during obstetrics emergencies. The authors conducted 46 trials of in situ simulated obstetrics emergencies in two phases at six different hospitals involving 823 physicians, nurses and support staff from January 2006 to February 2008. These six hospitals included a university teaching hospital, two suburban community hospitals and three rural hospitals. The authors created a high-fidelity simulation by developing scenarios based on actual sentinel events.

RESULTS

A total of 965 breaches were identified by participants in 46 simulation trials. Of the 965 breaches, 461 (47.8%) were classified as latent conditions, and 494 (51.2%) were classified as active failures.

CONCLUSIONS

In Reason's model, all sentinel events involve a breached protective layer. Understanding how protective layers breakdown is the first step to ensure patient safety and establish a high reliability. These findings suggest where to invest resources to help achieve a high reliability. In situ simulation helps recognise and remedy both active failures and latent conditions before they combine to cause bad outcomes.

Representativeness of the Patient-Reported Outcomes Measurement Information System Internet panel

OBJECTIVES

To evaluate the Patient-Reported Outcomes Measurement Information System (PROMIS), which collected data from an Internet polling panel, and to compare PROMIS with national norms.

STUDY DESIGN AND SETTING

We compared demographics and self-rated health of the PROMIS general Internet sample (N=11,796) and one of its subsamples (n=2,196) selected to approximate the joint distribution of demographics from the 2000 U.S. Census, with three national surveys and U.S. Census data. The comparisons were conducted using equivalence testing with weights created for PROMIS by raking.

RESULTS

The weighted PROMIS population and subsample had similar demographics compared with the 2000 U.S. Census, except that the subsample had a higher percentage of people with higher education than high school. Equivalence testing shows similarity between PROMIS general population and national norms with regard to body mass index, EQ-5D health index (EuroQol group defined descriptive system of health-related quality of life states consisting of five dimensions including mobility, self-care, usual activities, pain/discomfort, anxiety/depression), and self-rating of general health.

CONCLUSION

Self-rated health of the PROMIS general population is similar to that of existing samples from the general U.S. population. The weighted PROMIS general population is more comparable to national norms than the unweighted population with regard to subject characteristics. The findings suggest that the representativeness of the Internet data is comparable to those from probability-based general population samples.