Improvement of blood utilization at a governmental general hospital in the state of Kuwait

Red blood cells [RBCs] transfusions have saved lives and expedited the recovery of illnesses to millions of patients. However, RBCs transfusions carry high risk of life threatening complications and economic burden. The present study aimed at assessing the appropriateness of RBCs transfusion at one Ministry of Health hospital in Kuwait and to assess the effect of multiple interventions for improving the appropriateness of RBCs utilization. The present study used one group pre-test post-test quasi experimental design. To assess the appropriateness of RBCs transfusions, 185 records were reviewed in each of pre and post intervention phases. Improvement interventions included involvement of hospital administrators and heads of departments, development of the hospital transfusion guidelines, improvement of participant physicians' knowledge, and improvement of blood transfusion documentation. The present study revealed 22.4% reduction in the total number of RBCs transfusions in the post intervention phase as compared to pre intervention phase. However, low rate of appropriateness of RBCs transfusion in pre intervention phase [40.4%] was encountered which was minimally improved to 46.5% following implementation of multiple improvement interventions. Physicians showed very low compliance with completion of the newly introduced blood transfusion request and consent forms. The appropriateness of red blood cells transfusions at the study hospital is low before and after implementation of the improvement interventions. Documentation of blood transfusion is deficient at the study hospital. It is recommended to strengthen the blood transfusion interventions used in the present study and to implement these interventions in Ministry of Health Hospitals in Kuwait to improve the appropriateness of RBCs transfusions

Validation of TIMI and GRACE acute coronary risk scores in Alexandria governorate and their role in the comparison of quality of care between hospitals

Risk stratification in acute coronary syndrome [ACS] aims to identify those patients who might benefit prognostically from further investigation and treatment. In addition, risk stratification models have been used by health authorities and hospitals in quality management activities. The present study aimed at validating the Thrombolysis in Myocardial Infarction [TIMI] and The Global Registry of Acute Coronary Events [GRACE] risk scores for prediction of mortality in patients with ACS in Alexandria governorate. In addition, the study aimed also at using one of the validated risk scores to compare risk adjusted mortality among participating hospitals. The study was conducted at hospitals belonging to 3 different health care organizations in Alexandria. All admitted patients with the diagnosis of ACS throughout a period of 6 months were included in the study [n=606]. Discriminatory capacity and calibration of the TIMI and GRACE risk scores for detection of in-hospital mortality and mortality within six months of index admission were assessed. The study showed that both TIMI and GRACE risk scores had high c statistics of 0.70 or higher. GRACE scores showed equal or higher c statistics than TIMI scores denoting better discriminatory capacity. TIMI risk score showed good calibration while GRACE risk score showed lower calibration capacity with certain patient categories. The GRACE risk score was used to calculate the standardized in-hospital mortality ratio which was higher than 1 for all participating hospitals indicating higher than expected mortality for ACS patients in these hospitals. GRACE risk score showed good discriminatory capacity, suggesting that it is suitable for clinical use among ACS patients in Alexandria governorate. It was recommended to use GRACE risk score for risk adjustment in quality management activities

Factors associated with hospitalization for type2 diabetic patients at a teaching hospital in Saudi Arabia

Increasing prevalence of diabetes all over the world intensifies the demand for health care services, and particularly for inpatient care. The present study aims at identifying factors associated with hospitalization for patients with type 2 diabetes mellitus at a teaching hospital in Saudi Arabia. To achieve the objectives of the study, comparison was made between hospitalized and non-hospitalized type 2 diabetic patients using a retrospective case-control design. Four categories of factors namely, socio-demographic, outpatient clinic, clinical and quality indicators were investigated to elicit their relation with hospitalization among type 2 diabetes patients. Univariate analysis and stepwise multiple regression analysis were employed. Hospitalization was found to be independently associated with male gender, frequent visitors of outpatient clinics other than diabetes clinic, patients with nephropathy and patients with HbA1c >/= 7%. Limited number of cases and controls received the recommended ambulatory care for diabetes patients as evidenced by the marked low level of process of care indicators for diabetes patients. Conclusions and recommendations: Hospitalization was related to a limited number of factors many of which require better ambulatory care at outpatient clinics of the study hospital. It was recommended to continuously monitor the identified significant variables using the hospital electronic medical record system in order to target those patients at high risk for hospitalization

Missed appointments at a university hospital in eastern Saudi Arabia: Magnitude and association factors

Missed appointment is a common problem in ambulatory settings that has serious clinical and economic impacts. The present study aims at quantifying the burden of missed appointments and revealing the factors associated with it at a teaching hospital in Eastern Saudi Arabia. Two designs were used: a retrospective descriptive design to describe the magnitude of missed appointments during the year 2007, and a case-control design to identify factors associated with missed appointment. The association of socio-demographic, clinical, visit, and other factors with missed appointment was investigated through interviewing 150 cases and 150 controls. Univariate and stepwise multivariate logistic regression analyses were performed to determine the statistical significance of investigated factors. The rate of missed appointments at the study hospital in 2007 was 23.72%. Factors found to be associated with missed appointments were city of residence, duration from registration to appointment, reason of the visit and presence of pain at visit time. The main reasons given by patients for no-show were unavailability of transportation means [22.6%] and forgetting the appointment [17.3%]. The rate of missed appointment was high at the study hospital. Few factors were found to be significantly associated with missed appointments; many of them are not under the control of the hospital. Providing means of transportation and patient reminders can help reduce the problem

Identification of drug cost reduction opportunities in a university hospital in Saudi Arabia

Expenditure on medications represents significant proportion of the total hospital budget. Establishing an effective drug cost management program is a priority area for hospitals that must begin with determining the current costs and pattern of use of medications. The aim of the present study is to determine the cost and pattern of drug utilization at the study hospital in order to identify cost reduction opportunities. A descriptive retrospective design was used to examine the cost and pattern of drug utilization for all admissions during the period from: 1[st] January 2006 to 30[th] June 2006 in an university hospital in Eastern Saudi Arabis. Electronic patient data as well as manual drug cost data were obtained and merged to create the analysis database. The study revealed that the total drug cost at the study hospital was SR 11, 823, 666.9 [mean per admission=SR 2123.5 and median per admission=SR 357.3] during the study period. Antibiotics were responsible for 35.8% of the total inpatient drug costs followed by blood products which accounted for 20.6% of the total inpatient drug costs. Further investigation of both groups revealed that the combination of piperacillin and tazobactam represented 4.5% of prescribed drugs and accounted for almost half of the inpatient ntbiotic costs [SR 2, 064, 916.8] and 17.4% of the total hospital's inpatient drug costs. Human alumin and intravenous immunoglobulin were responsible for the majority of cost of blood products. Piperacillin and tazobactam, human albumin, and intravenous immunoglobulin other than Rho [D] immunoglobulin are responsible for high percentage of drug expenditure at the study hospital while being prescribed to a limited number of patients. Designing a drug cost management program to target these three drugs will increase the likelihood of achieving significant cost reduction

Effect of pelvic floor exercises and faradic current stimulation in elderly males with idiopathic detrusor overactivity

The purpose of the present study was to determine the effect of pelvic floor exercises and faradic current stimulation to sacral dermatomes on parameters of frequency/volume charts [FVC's] in patients with idiopathic detrusor overactivity. 42 male patients [mean age 69.40 +/- 2.70 years] with idiopathic detrusor overactivity participated in the study. Patients were categorized into three homogenous groups; exercise, stimulation and control, each group included 14 patients. Patients of the exercise group received a program of pelvic floor exercise while patients of the stimulation group received a program of faradic current stimulation to sacral dermatomes. The results showed a highly significant [p<0.01] reduction of mean number of episodes of emergency per 24-hour between pre- and post-intervention measures for exercise and stimulation groups, in which it was 5.52 +/- 0.54 vs. 1.6 +/- 0.353 and 5.52 +/- 0.51 vs. 2.7 +/- 0.36 respectively. While on comparing pre- and post-intervention mean voids frequency per 24-hour for exercise and stimulation groups, the results showed a highly significant [p<0.01] increase in the mean values of pre-intervention measures in which it was 9.77 +/- 0.70 vs. 5.83 +/- 0.76 and 9.66 +/- 0.57 vs. 8.09 +/- 0.69 respectively. Multiple paired comparisons of the mean parameters of FVC's using Dunnett t test among exercise, stimulation and control groups after the intervention showed a high statistical significant difference [p<0.01] of all parameters of FVC's in exercise group. While post-intervention results of electrical stimulation group showed that there were insignificant differences of means; daytime voiding frequency, nighttime voiding volume, total voids volume per 24-hour, fluid intake per 24-hour and functional bladder capacity in milliliters. The results showed the efficacy of practicing pelvic floor exercise and electrical stimulation programs in improving bladder functions. Pelvic floor exercises were more efficient in improving bladder functions than that occurred with electrical stimulation

Coping strategies and quality of life among mothers of handicapped children

The birth of a baby is usually anticipated with great excitement and expectations of a future filled with happiness and success. This exuberance may become muted with the birth of a handicapped child. It does not matter if the handicap is blindness, retardation or a physical abnormality. The family into which this child is born will change in many ways. The long term out come of handicapped condition depends on family adjustment, and coping strategies which in the long run often are equal to or of greater importance than the technical and medical procedures. Mothers of handicapped children who may experience additional stressors such as unmet service needs and financial problems would inevitably lead to pathology and mal-adaptation pattern of coping. Mothers who use mal-adaptive coping strategies have feeling of disappointment, high level of stress, depression, low level of confidence, marital dis adjustement, as well as difficult in relationship and reduced social contact. Mothers who are successfully coping with having a handicapped child, are able to effectively mobilize their internal and external resources, to deal with the special needs of their child and have a high quality of life, regardless of the disability. Nurses have a great responsibility in helping the mothers to use an effective coping strategies that enable them to take care of their handicapped child while still maintaining their own satisfactory lives. Assessment of the coping strategies helps the nurse to identify the unique way for managing the mothers stress. Assessment of facilitators and inhibitors to the coping and quality of life in mothers of handicapped children allows the descripition from a new point of view, giving valuable information for improving the families health care and for resource allocation. Hence the purpose of this research is to assess the coping strategies and the quality of life among mothers with handicapped child, and to identify the facilitators and inhibitors to the coping. The study was conducted at Jameyat Fatat, Al-Khalig, Female Special Education Center, and the out patient department of King Fahed Hospital, Kingdom of Saudi Arabia. The subjects of this study consisted of one hundred and twenty mothers that have one handicapped child between 6 and 13 years of age. Three tools were used in this study, The Personal and demographic characteristics, The Coping Inventory for Stressful Situations [CISS]. And the Quality-of-life scale [QOL]. In addition, an interview was conducted using open-ended questions to elicit the facilitators and inhibitors to effective coping. The study revealed that more than half of the mothers used emotional coping strategies [53.3%], followed by problem-focus coping [29.08%] then avoidance coping strategies [20.8%]. The mean score for quality of life among the mothers of handicapped child is relatively low [Mean=59.4 +/- 31.19]. The study also showed that mothers who used problem-focus coping strategies have higher quality of life than the mothers who utilized emotional or avoidance as a way of coping. The present study indicate that mothers reported "Faith in God" and "Husband's support and understanding" as the most important facilitator for coping, this is followed by, "physical support from, family, friend, neighbors, and relatives". "The presence of maid servant", "Financial support", " Professional support", were reported next. The most common inhibiting for coping reported by the mothers are "Lack of acceptance of the handicapped child by others", "Financial constraints", and "Problems related to professionals"

Bed utilization fluctuations at a University Hospital in Eastern Saudi Arabia and their impact on Hospital cost

As the demand for and complexity of inpatient care increases and hospital beds become more and more expensive and difficult to obtain, the appropriate use of hospital beds becomes increasingly important. The aim of the present study was to assess the actual hospital capacity and to study fluctuations in hospital occupancy rate during the year 2002 at a University Hospital in Eastern Saudi Arabia, and their impact on hospital cost. Results of the present study showed that 61 beds were not conforming to the standard definition of hospital beds; constituting 15.6% of the actual hospital capacity. Wellborn nursery cribs and delivery beds accounted for the majority of these beds [82.0%]. The present study revealed low average hospital occupancy rate in 2002 [62.0%] together with fluctuations in the average occupancy rates of all departments ranging between 30.9% and 77.0%; coefficient of variation ranges from 0.11 to 0.92. The observed low occupancy rate resulted in wasting of a large proportion of the hospital fixed costs amounting to 133, 591, 943 Saudi Riyals. Recommendations for improving the occupancy rate of the hospital and reducing its fluctuations are presented

use of continuous quality improvement methodology to improve nurses' infection control practices at a general hospital in Alexandria

The aim of the present study was to assess the effectiveness of continuous quality improvement [CQI] methodology in improving selected nurses' infection control practices at a general hospital in Alexandria. The study population consisted of important infection control practices performed by nurses. Important practices were defined as high-volume, high-risk, high-cost, and problem-prone activities. Based on these criteria, three practices were selected: [1] handwashing, [2] surgical site dressing, and [3] peripheral intravenous catheterization. The present study used pre-test post-test design to examine nurses' practices before and after implementation of CQI project. It consisted of the following three distinct phases: [1] observation of nurses' practices before intervention, [2] implementation of a quality improvement project, and [3] observation of nurses' practices following implementation of the project. After implementation of CQI interventions, the percentage of times in which indicated handwashing/alcohol hand rubbing was performed increased from 1.7% to 2.8%, and the percentage of times nurses complied with recommended handwashing practices increased for 5 of actual 7 steps. Nurses' practices of surgical site dressing technique showed statistically significant improvement in all 12 steps after implementation of CQI interventions. The proportion of occasions in which nurses complied with recommended procedure for peripheral intravenous catheterization significantly improved after implementation of CQI intervention in 9 of 12 steps

Impact of a clinical pathway for acute myocardial infarction on length of stay and quality of care in intensive care units of the critical care department of Alexandria Main University Hospital

A clinical pathway defines the optimal care process, sequencing and timing of interventions for a particular diagnosis or procedure. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this study is to determine whether clinical pathway implementation would alter process of care, hospital stay and mortality rates for acute myocardial infarction at Alexandria Main University Hospital. The study consisted of three phases: pre-intervention phase, development and dissemination of a clinical pathway for acute myocardial infarction and post- intervention evaluation phase. Process and outcome indicators were used to assess the quality of care provided to patients with acute myocardial infarction before and after implementation of the pathway. Results revealed that 4 process indicators out of 7 showed significant improvement namely, the utilization of thrombolytic therapy [from 76.9 to 88.5%], B-blockers at admission [from 28.5% to 50.0%], ACE inhibitors at discharge [from 61.2% to 75.2%] and smoking cessation counselling [from zero to 86.7%]. There was also reduction of variation in length of ICU stay as 67.7% achieved length of stay goal of 3 days after implementation of the pathway. ICU mortality was decreased from 20.8% to 6.9% after implementation of the pathway. These data suggest that the implemented acute myocardial infarction pathway lead to improved patient care and utilization of resources by providing a structured framework and educational guide to assist in the delivery of care to patients admitted with myocardial infarction