Qualitative analysis of healthcare provider perspectives to evaluating beta-lactam allergies.

BACKGROUND: There is a lack of understanding of the barriers reported by healthcare providers when evaluating beta-lactam allergies, but knowledge of these barriers is required for practical and effective implementation interventions. METHODS: Twenty-five healthcare providers, consisting of physicians, nurses and pharmacists practicing in the areas of intensive care, emergency medicine, infectious disease and general hospital practice, were interviewed between September 2021 and July 2023. Twenty-three of these providers were practising in the USA. A semi-structured interview guide grounded in the Theoretical Domain Framework was used for the interviews. Deductive and inductive analysis was performed on the interview transcripts, and translated into intervention recommendations using the Behaviour Change Wheel. RESULTS: Widely held beliefs included a lack of clear policy for the evaluation of allergies, confusing or missing documentation of allergy information, confidence in their own and their colleagues' ability to evaluate allergies when information is available, and pharmacists as the provider most equipped to evaluate beta-lactam allergies. CONCLUSIONS: Health systems should adopt and disseminate policies for the evaluation of beta-lactam allergies, and promote the use of pharmacists in the evaluation of drug allergies when possible. Allergy sections of electronic health records should be reworked to encourage unambiguous documentation of allergy reactions and support using previously tolerated beta-lactam antibiotics.

Arm versus forearm tourniquet for carpal tunnel decompression - Which is better? A randomized controlled trial.

UNLABELLED: Tourniquet pain is a common source of complaint for patients undergoing carpal tunnel decompression and practice varies as to the tourniquet position used. There is little evidence to suggest benefit of one position over another. Our aim was to compare patient and surgeon experience of forearm and arm tourniquets. Following a power calculation, 100 patients undergoing open carpal tunnel decompression under local anaesthetic were randomized to either an arm or a forearm tourniquet. Measurements of blood pressure, heart rate and pain were taken at 2.5 min intervals. The operating surgeon also provided a visual analogue scale rating for the extent of bloodless field achieved and for any obstruction caused by the tourniquet. There was no statistically significant inter-group difference in patient pain or physiological response, tourniquet time, bloodless field or length of procedure. The degree of obstruction caused by the tourniquet was significantly higher in the forearm group. LEVEL OF EVIDENCE: I. Prospective Randomized Controlled Trial.

A comparison of voluntarily reported medication errors in intensive care and general care units.

BACKGROUND: Few institutions currently track intensive care unit (ICU)-specific medication safety data. A comparison of medication error data for intensive care and general care units may determine if ICU-specific surveillance is needed. OBJECTIVE: To compare the type, cause, contributing factors, level of staff initiating an error, medication use process node, drug classes and patient outcomes for voluntarily reported medication errors occurring in ICUs and general care units. DESIGN: Retrospective evaluation of voluntarily reported medication errors over 4.5 years at a 647-bed academic medical centre containing greater than 120 ICU beds. Adult patients with a reported medication error in intensive care and general care units were included. Medication error data were compared for ICUs with general care units. MAIN MEASURES AND RESULTS: There were a total of 3252 medication errors reported with 541 and 2711 occurring in ICUs and general care units, respectively. Primary types of medication errors were prescribing in the ICUs and omission in the general care units. Leading causes of medication errors were procedure/protocol not followed and knowledge deficit in the ICU and general care units. More frequently there was no contributing factor identified for medication errors in the ICUs. The top three drugs associated with medication errors in the ICUs were opioid analgesics, beta-lactam antimicrobials and blood coagulation modifiers compared with anti-asthma/bronchodilators, narcotic analgesics and vaccines in the general care units. The level of care provided after the error was observation increased/initiated in ICUs and no additional care in general care units. Prolonged hospitalisation was a result of medication errors in 1% of ICU cases and 0.4% of general care unit errors (p = 0.056). Medication errors were associated with harm in 12% and 6% of cases in the ICUs and general care units, respectively (p<0.001). CONCLUSION: Type, contributing factors, drug classes and patient outcomes associated with voluntarily reported medication errors differ in intensive care and general care units so it is important to develop surveillance systems that analyse ICU-specific data allowing systematic changes for this patient population.

Administration of enoxaparin by continuous infusion in a naturalistic setting: analysis of renal function and safety.

STUDY OBJECTIVE: To describe the clinical use and safety of continuous infusion (CI) enoxaparin in a naturalistic setting and to evaluate the influence of renal function on enoxaparin elimination. DESIGN: Retrospective medical record review. SETTING: 1000-bed tertiary care teaching centre. PATIENTS: Hospitalized patients that received enoxaparin by CI during a 2-year period. INTERVENTIONS: None. MEASUREMENTS: Specific details of dosage and monitoring were collected. Adverse drug reactions (ADR) were recorded. Creatinine clearance (CrCl) was calculated using Cockroft and Gault and Brater equations. A population pharmacokinetic analysis was performed using the non-linear mixed effect model (NONMEM). For patients located in the intensive care unit (ICU) and ward, POSTHOC pharmacokinetic parameter estimates were evaluated using the Wilcoxon rank-sum. Pearson correlation coefficient was calculated to determine the association between renal function and anti-Xa clearance. MAIN RESULTS: Sixty-seven patients received enoxaparin by CI of which 61.2% were in the ward and 38.8% in the ICU. The average initial rate and duration of infusion were 5.2 mg/h and 5.6 days, respectively. The number of anti-Xa concentration measurements averaged five per patient. Nine patients experienced an ADR. The most frequent ADR was gastrointestinal bleeding (n = 4). Among the 67 patients, 48 had available anti-Xa concentrations and were included in the NONMEM model. The anti-Xa CL and volume of distribution for ICU and ward patients averaged 0.64 +/- 0.34 L/h, 10.6 +/- 1.55 L and 1.01 +/- 0.39 L/h, 9.08 +/- 1.17 L, respectively. CrCl was not a significant covariate when included in the NONMEM model, and the association between CrCl and anti-Xa clearance was not significant (R2 = 0.0005; P = 0.8916). CONCLUSIONS: This study is the first to report the use and safety of prolonged CI enoxaparin. Pharmacokinetic parameters of enoxaparin differ in ICU vs. ward patients. Overall, we found the safety of CI to be comparable to subcutaneous administration. Also, we found no effect of renal function on enoxaparin elimination.

The little things: perceptions of breastfeeding support.

OBJECTIVE: To describe how maternal-child staff nurses support breastfeeding mothers during the postpartum hospital stay and how these mothers perceive the support received from the nurses. DESIGN: Ethnographic. SETTING: Data were collected at a community hospital in southeastern Florida. PARTICIPANTS: Unstructured interviews were conducted with seven maternal-child nurses caring for breastfeeding mothers. The investigator observed 12 nurses' interactions with breastfeeding mothers and newborns. Eight breastfeeding mothers were interviewed, using a semistructured guide, in the hospital before discharge and at 2 and 6 weeks postpartum. RESULTS: Nurses supported breastfeeding mothers by providing information and interpersonal support. Breastfeeding mothers expected the nurses to support their feeding efforts by providing information, encouragement, and interpersonal support. CONCLUSION: Health care providers can help breastfeeding mothers, but the support offered must be the kind that mothers want.

Nutrition for the childbearing years.

OBJECTIVE: To review the literature on preconceptional nutrition and nutrition during pregnancy and lactation, focusing on recommendations from the Institute of Medicine. DATA SOURCES: Computerized searches on MEDLINE, CINAHL, National Institutes of Health and Institute of Medicine web sites. STUDY SELECTION: Articles from indexed journals and reports from government sources relevant to the topics of this review and published after 1990 (except for classic findings) were evaluated. DATA EXTRACTION: Data were analyzed under the headings of preconceptional nutrition, prenatal nutrition, nutrition during lactation, and nursing implications. DATA SYNTHESIS: The nutrition a woman receives before conception, during pregnancy, and during lactation affects her health and the health of her child. Information on the amount and timing of prenatal weight gain, recommended intakes of vitamins and minerals, and nutrition and activity during lactation have been revised in the last 10 years. CONCLUSIONS: The health, size, and growth of the infant are dependent on the timing and amount of weight gain during pregnancy and on maternal nutrition during lactation. Prenatal weight gain also affects a woman's future risk of obesity.

Groups and decision making.

A hallmark of clinical service management in particular, and contemporary health care in general, is the team approach. Yet, many managers do not have appropriate background and skills for group leadership. This article reviews some essential characteristics of groups and suggests strategies for facilitating group decision making.

Resolving conflicts: principles and practice.

Physicians and other medical professionals undergo extensive professional training for the privilege of obtaining their professional licenses. For most physicians, clinical training is conducted in extremely competitive circumstances. Many physicians endorse competition as an appropriate method for producing greater individual and collective competence within the profession. Competition, however, is a very limited way to resolve conflicts. And, in the current environment of greater resource restrictions and reform, the competitive model, at best, seems short-sighted. Many of the current relationships involving physicians and others are transitional, involving various partners in numerous practice and professional relationships. For example, medical practices are merging; hospitals are engaging physicians in numerous business structures, even employment. However, longer term relationships are enhanced by mutual respect and collaboration, rather than chronic competition to "win" one's rights over another. Thus, the need among physicians to enhance their conflict resolution skills is expanded in today's environment.

How to cope with difficult people. Identify and manage five behavioral patterns.

Almost every health-care organization (like all types of organizations) has one or two "difficult people." The behavior patterns of these individuals and personalities make daily work and interactions emotionally draining and unnecessarily complicated. Managers may consider terminating the recalcitrant employees as the quickest solution. The current shortage of medical technologists, however, gives laboratory managers a strong incentive to retain their staff members--even the difficult ones. This article addresses five types of difficult people as described in an emerging literature and makes recommendations for achieving and maintaining personal and professional stability in the midst of such situations.

Patterns and trends in health care governance.

Recent studies show that many hospital chief executive officers spend more than 50% of their time preparing materials for governing board meetings. In view of the impact of governing boards on the function of the hospital and its executives, this issue of DRG Monitor summarizes recent trends in health care governance, including the role and responsibilities of hospital trustees, the size, composition, and terms of office of governing boards, structures and functions of committees, and other emerging issues.

The physician executive and professional grief.

With the introduction of competitive forces and concommitant changes in health care reimbursement programs, physicians are experiencing profound disruption in their personal expectations and career plans. This article proposes that the loss of established professional traditions is no different, in terms of emotional and psychological impact, than the loss of a loved one. Thus, many physicians may need to complete grief work before they can functionally adapt to contemporary realities. The dynamics of loss, grief work, and functional adaptation are discussed, along with recommendations for supportive interventions to help individuals adjust to a competitive health care environment.

Five roadblocks to effective partnerships in a competitive health care environment.

Five major roadblocks stand between medical staffs and their partners in a competitive health care environment. Reports from more than 300 physician leaders, board members, and hospital executives show that these barriers are significant in both strategic and perceptual ways. Success in an ambiguous, competitive, and most often unforgiving economic environment means that the health care delivery team of the future will have to find its way around or through each of these barriers. Recommendations for developing successful partnership relations are made herein for each of the five roadblocks described.

Growing pains: twelve lessons from corporate restructuring.

Corporate reorganization is a realignment of resources to enhance competitive strength and can follow one of two lines, vertical or horizontal. Whichever strategy is used, the reason for it remains unchanged: to provide a structural hierarchy through which strategic market niches are acquired and resources are economically deployed throughout the system. Healthcare corporate restructuring, however, is encountering growing pains, some of which were inevitable and others avoidable. When the healthcare organizational landscape is surveyed, 12 lessons can be learned about corporate reorganization: 1. Reorganization should be based on anticipated market and environmental conditions. 2. Form follows function. 3. Interdependence among multiple corporate units must be clearly acknowledged. 4. Reorganization is much more costly and politically charged than it appears at first. Reserved rights must be clearly defined. 6. The purpose and composition of the parent governing board must be distinguished from those of subsidiary boards. 7. Clarification of roles and relationships between the parent and subsidiaries is critical. 8. Unrealistic expectations of success should be confronted through up-front planning, negotiation, and creative problem solving. 9. False assumptions about corporate staffing needs create internal system warfare. 10. Physician support is crucial for success. 11. Hospital-based management skills and understanding may be inadequate for making personnel decisions in subsidiaries other than the hospital. 12. Competitive strategies must be strategically determined and must not be taken gamesmanship.

Developing strategic direction for governing boards.

This study compares selected characteristics of community hospital governing boards with those of high technology industries acknowledged for successful transitions in a rapidly changing competitive environment. Sponsored by the Estes Park Institute, the purpose of this investigation was to identify emerging governance issues and to propose a normative model for nonprofit community health care systems. Results suggest that for health care systems to succeed in a rapidly changing competitive environment, strategic alterations in top-level governance structures will be necessary to focus on market-driven policy issues, with accompanying changes toward smaller boards composed of expert directors. Trends and implications for board terms, committee structures, and relationships between the board and chief executive officers are also discussed.