Evaluating an integrated approach to clinical quality improvement: clinical guidelines, quality measurement, and supportive system design.

BACKGROUND: Implementing clinical practice guidelines to change patient outcomes presents a challenge. Studies of single interventions focused on changing provider behavior demonstrate modest effects, suggesting that effective guideline implementation requires a multifaceted approach. Traditional biomedical research designs are not well suited to evaluating systems interventions. OBJECTIVES: RAND and the Army Medical Department collaborated to develop and evaluate a system for implementing guidelines and documenting their effects on patient care. RESEARCH DESIGN: The evaluation design blended quality improvement, case study, and epidemiologic methods. A formative evaluation of implementation process and an outcome evaluation of patient impact were combined. SUBJECTS: Guidelines were implemented in 3 successive demonstrations targeting low back pain, asthma, and diabetes. This paper reports on the first wave of 4 facilities implementing a low back pain guideline. METHODS: Organizational climate and culture, motivation, leadership commitment, and resources were assessed. Selected indicators of processes and outcomes of care were compared before, during, and after guideline implementation at the demonstration facilities and at comparison facilities. Logistic regression analysis was used to test for guideline effects on patient care. RESULTS: Process evaluation documented varied approaches to quality improvement across sites. Outcome evaluation revealed a significant downward trend in the percentage of acute low back pain patients referred to physical therapy or chiropractic care (10.7% to 7.2%) at demonstration sites and no such trend at control sites. CONCLUSIONS: Preliminary results suggest the power of this design to stimulate improvements in guideline implementation while retaining the power to evaluate rigorously effects on patient care.

A comparison of three strategies for risk-adjustment of outcomes for AIDS patients hospitalized for Pneumocystis carinii pneumonia.

BACKGROUND: The need for risk-adjustment of patient outcomes has been driven by the competitive health care market and the subsequent increase in comparative outcome reporting among health care institutions, among managed care plans, and among individual providers for some procedures (e.g. coronary artery bypass graft surgery). However, if the outcomes reported do not take into account patient characteristics that can be considered dimensions of risk for poor clinical outcomes or increased utilization of services, there is the possibility that inaccurate conclusions will be drawn about the quality of care provided. OBJECTIVE: The specific purpose of this study was to examine the ability of four measures, APACHE III - acute physiology scale, Quality Audit Marker - ambulation score, Quality Audit Marker - self-care ability score, and Nursing Severity Index, to predict mortality and hospital length of stay in a convenience sample of 140 males with Pneumocystis carinii pneumonia. METHODS: The study utilized a descriptive, longitudinal design. RESULTS: APACHE III - acute physiology scale (P = 0.006, odds ratio = 1.40), and Quality Audit Marker - ambulation (P = 0.037, odds ratio = 0.50), were significant predictors of hospital mortality and the APACHE III - acute physiology scale was also a predictor of mortality within 3 (P = 0.004, odds ratio = 1.13) and 6 months (P = 0.009, odds ratio = 1.10) following hospitalization. Only Quality Audit Marker - ambulation (P = 0.0001) was a significant predictor of length of stay. CONCLUSIONS: The findings of this study confirm the findings of other investigators that measures of acute clinical stability and functional status have utility as risk-adjustment approaches for the outcomes of mortality and length of stay. Further research is needed that compares the utility of generic vs. disease-specific measures for prediction of outcomes in HIV/AIDS.

Critical care information systems: essential infrastructure for critical care nursing practice.

In the three decades since the installation of the first bedside computer in the "shock ward" at the University of California and Los Angeles County Hospital, both computer technology and critical care practice have evolved rapidly. The premise of this article is that critical care information systems are an essential infrastructure for critical care nursing practice. This premise is described in terms of the critical care environment, clinical decision making in critical care, increasing demands for information about quality and costs, and national initiatives for the sharing of health care information.

Monitoring to ensure reliability of hemodynamic pressure readings.

Work is currently being done to make sure that other factors affecting reliable and valid pulmonary artery readings do not exist. Nurses have a tremendous responsibility to their patients who have pulmonary artery catheters. They must not only be knowledgeable but also must have good surveillance skills. Because there is such a discrepancy between the amount of knowledge deemed necessary in the literature and that which is actually demanded in practice, this study should be expanded and replicated. Intensive care nurses must do all they can to maintain a critically ill patient's health, and one way in which to attempt this is through adequate knowledge and treatment using pulmonary artery catheters.

Increasing reliability and validity of pulmonary artery measurements.

Pulmonary artery (PA) catheter pressure measurements are a primary means of assessing the cardiac output status of critically ill patients. Critical care nurses are responsible for obtaining these measurements accurately; yet preliminary studies demonstrate that critical care nurses have difficulty making reliable and valid PA catheter measurements. Nurses in critical care need to insure the accuracy of the PA measurements they obtain through the use of a systematic measurement process.