Developing a patient complaint tracking system to improve performance.

BACKGROUND: Assessing patient satisfaction exclusively through close-ended scaled survey questions may not provide a complete picture of patients' concerns. Only recently has the role of complaint data as a management tool received attention. FORMATION OF THE TEAM AND THE DATABASE: The Complaint Management Team was created in January 1997 at Hartford Hospital (Conn) to develop a coding and reporting mechanism for complaints (negative comments) gathered from patient surveys. Developing the codebook was an evolutionary process. A database was designed to collect three separate complaints and the verbatim text associated with the code. REPORTING: Department-specific, location-specific, and organization wide reports are generated. Quarterly department-specific reports are used to trend the incidence of complaint themes, identify specific locations with problems, and initiate improvement efforts. OVERALL FINDINGS: Since March 1997, most complaints have fallen into five major categories--accommodations (environment), quality of care (care and treatment), respect and caring (humaneness or attitudes and behaviors), timeliness, and communication. The hospital's real estate department has completed a project focused on increasing patient satisfaction with parking. Two projects are still in progress; one is focused on increasing patient satisfaction with respect and staff caring attitude/behaviors, and one on improving satisfaction with the level of noise on the units. DISCUSSION: Approximately 4,000 survey complaints are coded every year. One limitation of the database is that all sources of complaints received throughout the organization are not yet captured. Another limitation is that the outcomes measurement section has exclusive access to the database. CONCLUSIONS: The patient complaint tracking system enables staff, managers, teams, and departments to develop improvement efforts based on quantitative and qualitative data.

99mTc technegas ventilation and perfusion lung scintigraphy for the diagnosis of pulmonary embolus.

UNLABELLED: Lung scintigraphy is used widely for diagnosis of pulmonary embolus (PE). Technegas ventilation imaging has many advantages over other methods, but little outcome data exists on this technique. The aims of this study were to better define the role of lung scintigraphy in the management of patients with suspected PE and to evaluate technegas ventilation imaging by following patient outcomes. METHODS: A group of 717 out of 834 consecutive patients, referred to a university teaching hospital for lung scintigraphy to confirm or refute the diagnosis of PE, was followed for 18-30 mo to determine clinical outcome. The follow-up endpoints were death as a result of PE, death as a result of hemorrhage after treatment for PE, uncomplicated survival, survival with subsequent PE, nonfatal hemorrhage after treatment for PE and recurrence of PE in treated patients. Ventilation imaging was performed using technegas, and perfusion imaging was performed using intravenous 99mTc macroaggregated albumin. The modified PIOPED (Prospective Investigation of Pulmonary Embolism Diagnosis) diagnostic criterion was used for interpretation of lung scintigraphy. RESULTS: Diagnostic results included 3.5% normal studies, 67.4% assessed as low probability for PE, 10% as moderate probability for PE and 19.1% as high probability for PE. A total of 231 patents received therapy with heparin, followed by warfarin, including those receiving anticoagulation therapy for other conditions. Ninety-six percent of patients with normal and low probability studies (n = 508) had good outcomes, 6 patients died as a result of PE and 12 subsequently developed PE. The odds ratio for death by PE in this group was 0.2. Of the 72 moderate probability studies, 39 patients were untreated. In this group there was 1 death due to PE, and PE subsequently developed in 2 patients. None of the remaining 33 treated patients died, but 4 patients experienced bleeding complications. The odds ratio for death by PE in the moderate probability group was 0.7. In those patients with high-probability studies, there were 8 deaths by PE, 6 deaths by hemorrhage, 11 nonfatal hemorrhages and 7 patients who experienced recurrences of PE. The odds ratios in this group were 6 and 10 for death by PE, or death by PE and the treatment of PE, respectively. CONCLUSION: The use of the modified PIOPED diagnostic classification is valid for technegas lung scintigraphy. Using technegas, normal/low-probability and high-probability results are highly predictive of respective outcomes. Technegas lung scintigraphy reduces the number of indeterminate studies.

Pain control following elective gastrointestinal surgery: is epidural anesthesia warranted?

Fifty-nine patients undergoing elective major gastrointestinal surgery were entered into a prospective, randomized trial between January 1993 and July 1994 comparing the effectiveness, side effects, and hospital costs of postoperative epidural anesthesia (Group 1, n = 29) and intramuscular narcotic injections (Group 2, n = 30). Epidural catheters were inserted by a team that supervised catheter care and infusion rates in the postoperative period. The nonepidural group received intramuscular injections on a regular basis. Patients filled out visual analog scales to measure levels of pain ( 1 = minimal, 10 = maximal) every eight hours. Patient activity, bowel, and urinary function were recorded by the nursing staff. Control of pain (as measured by the daily average visual analog score) was more effective in Group 1 (P < .001) on postoperative days 1-3 (1.3 vs 3.6 on day 1, 0.7 vs 2.6 on day 2, 0.9 vs 3 on day 3). There was no significant difference in mean values between groups 1 and 2 with respect to first ambulation on the hospital ward, onset of liquid diet, intake of solid food, first spontaneous voiding, first bowel movement, length of hospitalization, or charge of hospitalization ($13,439 +/- 7,452 vs $11,821 +/- 6,630). We conclude that epidural anesthesia significantly lessens incisional pain following major elective lower gastrointestinal surgery when compared to analgesic injections alone. However, while not statistically significant, the overall charge was increased by 14% in the epidural group. This finding should be examined in light of the relatively low pain level in patients receiving narcotic injections alone.

Resection for cure of adenocarcinoma of the head of the pancreas: the greater Hartford experience.

BACKGROUND: Nationally, the results of pancreaticoduodenectomy for adenocarcinoma of the pancreas have improved. Therefore, we examined our experience with this operation. METHODS: A retrospective review of tumor registry data from four greater Hartford, Connecticut, hospitals identified 51 patients who underwent pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas between 1982 and 1992. RESULTS: The 30-day operative mortality rate for the group was 4%. Life table survival analysis revealed a five-year survival rate of 15% and a median survival of 15 months. Twelve patients had postoperative radiation therapy and chemotherapy. The median survival in this group was 36 months, significantly longer than that of the nonadjuvant therapy group (13 months, P < .02). No difference in operative mortality or ultimate survival was seen between the hospital with the largest experience and the three other hospitals. CONCLUSIONS: Pancreaticoduodenectomy can be performed safely at hospitals with relatively low pancreaticoduodenectomy volume. Survival rates are longer than in past reviews.

Outpatient management of patients with large multinodular goitres treated with fractionated radioiodine.

The efficacy of fractionated out-patient radioiodine therapy in 38 patients with compressive symptoms due to long-standing large multinodular goitres was assessed. The diagnosis was established by clinical assessment in addition to technetium-99m pertechnetate thyroid scan or computed tomography scan of the thyroid and mediastinum. Oral iodine-131 therapy was administered as a 2.22 GBq (60 mCi) cumulative dose over 4 months (555 MBq per month). All patients were monitored with serum thyroid-stimulating hormone and free thyroxine (+/- free tri-iodothyronine) assays before the treatment and after each dose fraction. Clinical and biochemical follow-up was performed on all patients and ranged from 6 to 45 months after therapy. The patients consisted of 35 female and three male patients with a median age of 59 years (range 37-87 years). Prior to treatment 20 patients were biochemically hyperthyroid and 18 were euthyroid. Overall, 71% of patients reported a subjective improvement in compressive symptoms and 29% reported no change. Clinically assessed reduction in goitre size occurred in 92% of patients while there was no change in 8%. At 3 months of follow-up, 31% of patients had become hypothyroid and at 18 months 66% were hypothyroid. Seven hyperthyroid patients (35%) became euthyroid and 13 hyperthyroid patients (65%) became hypothyroid. Three patients who became hypothyroid experienced neck soreness (transient in one patient, persistent in two patients). There were no differences in outcome between patients who were hyperthyroid and those who were euthyroid prior to treatment. Fractionated out-patient radioiodine therapy showed excellent short- and medium-term safety, was very well tolerated and offered a satisfactory alternative treatment to surgery.

99Tcm-pyrophosphate myocardial scintigraphy: the role of volume-rendered three-dimensional imaging in the diagnosis of acute myocardial infarction.

The aim of this study was to evaluate the role of volume-rendered three-dimensional imaging in the diagnosis of acute myocardial infarction (AMI) using 99Tcm-pyrophosphate (99Tcm-PYP) scintigraphy in a diagnostically difficult group of patients. In total, 117 patients were studied using planar, single photon emission tomography (SPET) and 3-D volume-rendered imaging performed 3 h after receiving 555 MBq (15 mCi) of 99Tcm-PYP intravenously. 555MBq (15 mCi) of 99Tcm-PYP intravenously. Two teams of physicians reported in a blinded and random fashion on each planar, SPET and 3-D rotating image study. Individual reports were compared with reports that used all three imaging modalities in combination. Observer reproducibility was between 85 and 90% and inter-observer team agreement was between 87 and 91%. A score based on clinical history, electrocardiography, serum cardiac enzyme levels and cardiac risk factors was validated and used as a de facto 'gold standard' for AMI for 75 of the subjects for whom all these details were available. The sensitivity, specificity and overall accuracy of combined planar, SPET and 3-D rotating image modalities were all 84%. Analysis of each modality in isolation showed SPET imaging to have the highest sensitivity (74%) and specificity (89%). In combination with SPET and planar imaging, 3-D rotation image presentation increases diagnostic sensitivity without appreciably altering overall diagnostic accuracy. 99Tcm-PYP myocardial SPET imaging shows good utility in the diagnosis of AMI in diagnostically difficult patients.

Surgical residents in the 1990s. Issues and concerns for men and women.

OBJECTIVE: To survey the concerns of surgical residents in New England and to determine whether similarities or differences exist based on gender. DESIGN/SETTING: A survey was distributed to all 21 surgical residency programs. The survey consisted of six demographic questions and 23 items, which the residents coded on a Likert-type scale. PARTICIPANTS: Surgical residents enrolled in a general surgical residency or specialty residents completing general surgery requirements. INTERVENTION: Distribution and completion of the survey. MAIN OUTCOME MEASURE: Prominent concerns among residents during training years and gender differences based on these concerns. RESULTS: All programs responded. A completed survey was returned by 501 residents (73%), 378 (75%) of whom were male and 123 (25%) of whom were female. On a scale of 1 to 5 (from no concern to major concern), the five most important issues were work hours (mean, 3.4), personal finances (mean, 3.1), quantity and quality of formal education (mean, 3.0 each), and postponement of family plans (mean, 2.9). Six items surveyed were of more concern to women than men; availability of role models, mentors, or both; comfort in expressing emotions at work; initiating and maintaining personal relationships; having children during residency; and postponing family plans. CONCLUSIONS: Three of the highest-reported concerns for the entire group are issues that could conceivably be controlled by surgical chairpersons and program directors. In contrast, only one of the six concerns that differed for men and women is directly program related. The remaining five issues require changes in societal values for these differences to dissolve.

Personality types of flight crew members in a hospital-based helicopter program.

PURPOSE: To determine the personality preferences of flight crew members in a hospital-based helicopter emergency medical service (HEMS) using the Myers-Briggs Type Indicator (MBTI), and to differentiate and compare these preferences between crew specialties and a historical control population. METHODS: A prospective cohort study was conducted of all active crew members (nurses, respiratory therapists and pilots) in a hospital-based flight program. Data collected included the results of the MBTI, gender, age and years of flight experience. RESULTS: Crew members were represented by 14 of 16 possible MBTI personality types, with three types predominating. For each crew specialty, extroversion preferences predominated over introversion, and perceiving characteristics predominated over judging characteristics. Differences existed by crew specialty for the sensing-intuition and thinking-feeling dimensions. CONCLUSIONS: A personality typology has been established for individual and group preferences within one hospital-based HEMS program. This data begins to develop a data base and an investigative protocol for understanding some of the human factors regarding flight programs. Future research should focus on expanding the data base and exploring specific crew interactions based on additional diagnostic and evaluative methodologies.

Purification of mitogenic proteins derived from Phaseolus vulgaris: isolation of potent and weak phytohemagglutinins possessing mitogenic activity.

Commercially obtained phytohemagglutinin (PHAP) derived from Phaseolus vulgaris contains 17 different protein bands when analyzed by acrylamide gel electrophoresis. When it is subjected to CM-Sephadex chromatography followed by molecular sieving on Sephadex G150, several species of potent mitogenic proteins, which differ greatly in their hemagglutinating capacity, are obtained. A low hemagglutinating mitogen (L-PHAP), homogeneous by several different criteria, is the most potent mitogen isolated, and also possesses potent leukoagglutinating activity. It is a glycoprotein with a molecular weight of 115,000, containing glucosamine, mannose, xylose, and fucose or arabinose. Also isolated is a mixture of at least two closely related proteins possessing high hemagglutinating capacity, with hemagglutination titers 250 times more potent than L-PHAP. This material is a slightly less potent mitogen than L-PHAP and also possesses leukoagglutinating capacity, although of a lower order of magnitude. Its amino acid and carbohydrate composition are similar to L-PHAP, but it contains approximately twice as much carbohydrate and is slightly larger as determined by molecular sieving.