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1.
Gen Dent ; 68(1): 50-55, 2020.
Article in English | MEDLINE | ID: mdl-31859663

ABSTRACT

The edentulous population is increasing globally regardless of the advancement in dental materials and technology. Computer-engineered complete dentures can significantly reduce clinical time, provide better patient satisfaction, and enable digital record archiving. A patient's existing denture provides useful information for the fabrication of new dentures. An examination checklist can be used to ensure a methodical evaluation of the patient's oral conditions and existing dentures and guide the clinician in deciding whether to continue treatment or refer the patient to a specialist. Once the decision is made to continue treatment, the clinician can duplicate the patient's existing dentures and make necessary corrections. The corrected duplicates can then be used as custom trays and record bases and sent to a laboratory for digital design and fabrication of new dentures. This case report describes the replacement of 30-year-old, ill-fitting dentures with digitally designed and milled prostheses that restored the vertical dimension of occlusion, masticatory function, and esthetics. In addition, an examination checklist to aid in treatment planning is offered.


Subject(s)
Computer-Aided Design , Denture Design , Mouth, Edentulous , Adult , Denture Design/methods , Denture, Complete , Esthetics, Dental , Humans , Mouth, Edentulous/rehabilitation , Patient Satisfaction
2.
Am J Infect Control ; 45(9): 1011-1013, 2017 Sep 01.
Article in English | MEDLINE | ID: mdl-28431851

ABSTRACT

BACKGROUND: Anesthesia workstations (AWs) are a reservoir for pathogenic organisms potentially associated with surgical site infections. This study examined the effectiveness of the Tru-D SmartUVC device (Tru-D LLC, Nashville, TN) on bioburden reduction (BR) on AWs. METHODS: Strips of tissue inoculated with a known concentration of either Staphylococcus aureus, Enterococcus faecalis, or Acinetobacter sp were placed on 22 high-touch surfaces of an AW. Half of the AW surfaces received direct ultraviolet (UV) light exposure and half received indirect exposure. Two inoculated strips, in sterile tubes outside of the room, represented the control. Trials were conducted on AWs in an operating room and a small room. Strips were placed in a saline solution, vortexed, and plated on blood agar to assess BR by the number of colony forming units. RESULTS: All experimental trials, compared with controls, exhibited a BR >99%. There was a significantly greater reduction of E faecalis colony forming units in the operating room AW under direct exposure (P = .019) compared with indirect exposure. There was no significant difference in reduction when comparing AWs between rooms. CONCLUSION: Regardless of room size and exposure type, automated UV-C treatment greatly influences BR on AW high-touch surfaces. Hospitals instituting an automated UV-C system as an infection prevention adjunct should consider utilizing it in operating rooms for BR as part of a horizontal infection prevention surgical site infection-reduction strategy.


Subject(s)
Acinetobacter/radiation effects , Disinfection/methods , Enterococcus faecalis/radiation effects , Staphylococcus aureus/radiation effects , Ultraviolet Rays , Acinetobacter/growth & development , Anesthesia/methods , Colony Count, Microbial , Durable Medical Equipment/microbiology , Enterococcus faecalis/growth & development , Humans , Microbial Viability/radiation effects , Patients' Rooms , Staphylococcus aureus/growth & development
3.
Am J Infect Control ; 45(6): 695-697, 2017 Jun 01.
Article in English | MEDLINE | ID: mdl-28189412

ABSTRACT

We examined the perceptions and barriers to nonsurgical scrubbed hand hygiene in the operating room and endoscopy procedure room using 2 anonymous Likert-scale surveys. Results indicated poor role modeling, inconvenience, and the need to monitor hand hygiene and feedback data to providers because of poor self-awareness of hand hygiene practices.


Subject(s)
Attitude of Health Personnel , Guideline Adherence , Hand Hygiene/standards , Health Knowledge, Attitudes, Practice , Health Personnel/psychology , Adult , Cross Infection/prevention & control , Cross Infection/psychology , Endoscopy/standards , Female , Humans , Male , Middle Aged , Operating Rooms/standards , Perception , Surveys and Questionnaires
4.
J Clin Anesth ; 32: 214-23, 2016 Aug.
Article in English | MEDLINE | ID: mdl-27290979

ABSTRACT

OBJECTIVE: To understand the decisional practices of anesthesia providers in managing intraoperative glucose levels. DESIGN: This is a retrospective cohort study. SETTING: Operating rooms in an academic medical center. PATIENTS: Adult patients undergoing surgery. INTERVENTION: Intraoperative blood glucose management based on an institutional protocol. MEASUREMENTS: Glucose management data was extracted from electronic medical records to determine compliance to institutional glucose management protocol that prescribes hourly glucose measurements and insulin doses to maintain glucose levels between 100 to 140mg/dL. Effect of patient and surgery specific factors on compliance to glucose management protocol was explored. MAIN RESULTS: In 1903 adult patients compliances to hourly glucose measurements was 72.5% and correct insulin adjustments was 12.4%. Insulin was under-dosed compared to the prescribed value by a mean of 0.85U/h (95% CI 0.76-0.95). Multivariate analysis showed that compliance to hourly glucose measurements decreased with increasing length of the procedure (OR=0.92 per hour, 95% CI 0.89-0.95) but increased with ASA status codes (OR=1.25 per ASA unit, 95% CI=1.06-1.49). Greater compliance to correct insulin adjustment was found in diabetic patients compared with non-diabetic patients (OR=1.31, 95% CI 1.09-1.55). On average, providers administered progressively more insulin with an additional 0.11U/h (95% CI=0.00-0.21] for every additional 10kg/m(2) of BMI and 0.20U/h (95% CI=0.01-0.39) less in diabetic patients than in non-diabetic patients. With the above practice pattern, the mean±SD of glucose level was 158±36mg/dL. Hypoglycemic (<60mg/dL) incident rate was 0.1% (9/8301 measurements) while hyperglycemic (>180mg/dL) incident rate was 28%. Glucose levels were within the target range (100-140mg/dL) only 28% of the time. CONCLUSIONS: Low compliance and considerable variability in initiating and following institutional glucose management protocol were observed.


Subject(s)
Academic Medical Centers , Blood Glucose/analysis , Clinical Decision-Making/methods , Hyperglycemia/prevention & control , Hypoglycemia/prevention & control , Intraoperative Care/methods , Aged , Blood Glucose/drug effects , Cohort Studies , Female , Humans , Hyperglycemia/blood , Hypoglycemia/blood , Insulin/blood , Insulin/therapeutic use , Male , Middle Aged , Practice Guidelines as Topic , Retrospective Studies
5.
Am J Surg ; 211(2): 390-7, 2016 Feb.
Article in English | MEDLINE | ID: mdl-26687964

ABSTRACT

BACKGROUND: House staff quality improvement projects are often not aligned with training institution priorities. House staff are the primary users of inpatient problem lists in academic medical centers, and list maintenance has significant patient safety and financial implications. Improvement of the problem list is an important objective for hospitals with electronic health records under the Meaningful Use program. METHODS: House staff surveys were used to create an electronic problem list manager (PLM) tool enabling efficient problem list updating. Number of new problems added and house staff perceptions of the problem list were compared before and after PLM intervention. RESULTS: The PLM was used by 654 house staff after release. Surveys demonstrated increased problem list updating (P = .002; response rate 47%). Mean new problems added per day increased from 64 pre-PLM to 125 post-PLM (P < .001). CONCLUSIONS: This innovative project serves as a model for successful engagement of house staff in institutional quality and safety initiatives with tangible institutional benefits.


Subject(s)
Academic Medical Centers , Electronic Health Records , Internship and Residency , Meaningful Use , Safety , Attitude of Health Personnel , Female , Humans , Male , Organizational Objectives
6.
Anesth Analg ; 122(3): 893-902, 2016 Mar.
Article in English | MEDLINE | ID: mdl-26599793

ABSTRACT

BACKGROUND: Postoperative hyperglycemia has been associated with poor surgical outcome. The effect of intraoperative glucose management on postoperative glucose levels and the optimal glycemic threshold for initiating insulin are currently unknown. METHODS: We performed a retrospective cohort study of surgery patients who required intraoperative glucose management with data extracted from electronic medical records. In patients who required glucose management, intraoperative glucose levels and insulin therapy were compared against postoperative glucose levels during 3 periods: first postoperative level within 1 hour, within the first 12 hours, and 24 hours of the postoperative period. Logistic regression models that adjusted for patient and surgical factors were used to determine the association between intraoperative glucose management and postoperative glucose levels. RESULTS: In 2440 patients who required intraoperative glucose management, an increase in mean intraoperative glucose level by 10 mg/dL was associated with an increase in postoperative glucose levels by 4.7 mg/dL (confidence interval [CI], 4.1-5.3; P < 0.001) for the first postoperative glucose measurement, 2.6 mg/dL (CI, 2.1-3.1; P < 0.001) for the mean first 12-hour postoperative glucose, and 2.4 mg/dL (CI, 2.0-2.9; P < 0.001) for the mean first 24-hour postoperative glucose levels (univariate analysis). Multivariate analysis showed that these effects depended on (interacted with) body mass index and diabetes status of the patient. Both diabetes status (regression coefficient = 12.2; P < 0.001) and intraoperative steroid use (regression coefficient = 10.2; P < 0.001) had a positive effect on elevated postoperative glucose levels. Intraoperative hyperglycemia (>180 mg/dL) was associated with postoperative hyperglycemia during the first 12 hours and the first 24 hours. However, interaction with procedure duration meant that this association was stronger for shorter surgeries. When compared with starting insulin for an intraoperative glucose threshold of 140 mg/dL thus avoiding hyperglycemia, initiation of insulin for a hyperglycemia threshold of 180 mg/dL was associated with an increase in postoperative glucose level (7 mg/dL; P < 0.001) and postoperative hyperglycemia incidence (odds ratio = 1.53; P = 0.01). CONCLUSIONS: A higher intraoperative glucose level is associated with a higher postoperative glucose level. Intraoperative hyperglycemia increases the odds for postoperative hyperglycemia. Adequate intraoperative glucose management by initiating insulin infusion when glucose level exceeds 140 mg/dL to prevent hyperglycemia is associated with lower postoperative glucose levels and fewer incidences of postoperative hyperglycemia. However, patient- and procedure-specific variable interactions make the relationship between intraoperative and postoperative glucose levels complicated.


Subject(s)
Blood Glucose/metabolism , Hyperglycemia/drug therapy , Hyperglycemia/etiology , Intraoperative Care/methods , Postoperative Care/methods , Surgical Procedures, Operative , Adult , Aged , Aged, 80 and over , Cohort Studies , Diabetes Mellitus/blood , Diabetes Mellitus/drug therapy , Female , Humans , Hyperglycemia/blood , Hypoglycemic Agents/therapeutic use , Insulin/therapeutic use , Male , Middle Aged , Postoperative Complications/blood , Postoperative Complications/drug therapy , Retrospective Studies , Steroids/therapeutic use , Treatment Outcome , Young Adult
7.
J Clin Monit Comput ; 30(3): 301-12, 2016 Jun.
Article in English | MEDLINE | ID: mdl-26067402

ABSTRACT

Poor perioperative glycemic management can lead to negative surgical outcome. Improved compliance to glucose control protocol could lead to better glucose management. An Anesthesia Information Management System based decision support system-Smart Anesthesia Manager™ (SAM) was used to generate real-time reminders to the anesthesia providers to closely adhere to our institutional glucose management protocol. Compliance to hourly glucose measurements and correct insulin dose adjustments was compared for the baseline period (12 months) without SAM and the intervention period (12 months) with SAM decision support. Additionally, glucose management parameters were compared for the baseline and intervention periods. A total of 1587 cases during baseline and 1997 cases during intervention met the criteria for glucose management (diabetic patients or non-diabetic patients with glucose level >140 mg/dL). Among the intervention cases anesthesia providers chose to use SAM reminders 48.7 % of the time primarily for patients who had diabetes, higher HbA1C or body mass index, while disabling the system for the remaining cases. Compliance to hourly glucose measurement and correct insulin doses increased significantly during the intervention period when compared with the baseline (from 52.6 to 71.2 % and from 13.5 to 24.4 %, respectively). In spite of improved compliance to institutional protocol, the mean glucose levels and other glycemic management parameters did not show significant improvement with SAM reminders. Real-time electronic reminders improved intraoperative compliance to institutional glucose management protocol though glycemic parameters did not improve even when there was greater compliance to the protocol.


Subject(s)
Blood Glucose/metabolism , Decision Support Systems, Clinical , Monitoring, Intraoperative/methods , Adult , Aged , Computer Systems , Diabetes Mellitus/blood , Diabetes Mellitus/drug therapy , Female , Humans , Hyperglycemia/blood , Hyperglycemia/drug therapy , Infusions, Intravenous , Insulin/administration & dosage , Intraoperative Complications/blood , Intraoperative Complications/drug therapy , Male , Middle Aged , Monitoring, Intraoperative/statistics & numerical data , Point-of-Care Systems , Prospective Studies
8.
Anesth Analg ; 118(1): 206-14, 2014 Jan.
Article in English | MEDLINE | ID: mdl-24247227

ABSTRACT

BACKGROUND: Intraoperative hypotension and hypertension are associated with adverse clinical outcomes and morbidity. Clinical decision support mediated through an anesthesia information management system (AIMS) has been shown to improve quality of care. We hypothesized that an AIMS-based clinical decision support system could be used to improve management of intraoperative hypotension and hypertension. METHODS: A near real-time AIMS-based decision support module, Smart Anesthesia Manager (SAM), was used to detect selected scenarios contributing to hypotension and hypertension. Specifically, hypotension (systolic blood pressure <80 mm Hg) with a concurrent high concentration (>1.25 minimum alveolar concentration [MAC]) of inhaled drug and hypertension (systolic blood pressure >160 mm Hg) with concurrent phenylephrine infusion were detected, and anesthesia providers were notified via "pop-up" computer screen messages. AIMS data were retrospectively analyzed to evaluate the effect of SAM notification messages on hypotensive and hypertensive episodes. RESULTS: For anesthetic cases 12 months before (N = 16913) and after (N = 17132) institution of SAM messages, the median duration of hypotensive episodes with concurrent high MAC decreased with notifications (Mann Whitney rank sum test, P = 0.031). However, the reduction in the median duration of hypertensive episodes with concurrent phenylephrine infusion was not significant (P = 0.47). The frequency of prolonged episodes that lasted >6 minutes (sampling period of SAM), represented in terms of the number of cases with episodes per 100 surgical cases (or percentage occurrence), declined with notifications for both hypotension with >1.25 MAC inhaled drug episodes (δ = -0.26% [confidence interval, -0.38% to -0.11%], P < 0.001) and hypertension with phenylephrine infusion episodes (δ = -0.92% [confidence interval, -1.79% to -0.04%], P = 0.035). For hypotensive events, the anesthesia providers reduced the inhaled drug concentrations to <1.25 MAC 81% of the time with notifications compared with 59% without notifications (P = 0.003). For hypertensive episodes, although the anesthesia providers' reduction or discontinuation of the phenylephrine infusion increased from 22% to 37% (P = 0.030) with notification messages, the overall response was less consistent than the response to hypotensive episodes. CONCLUSIONS: With automatic acquisition of arterial blood pressure and inhaled drug concentration variables in an AIMS, near real-time notification was effective in reducing the duration and frequency of hypotension with concurrent >1.25 MAC inhaled drug episodes. However, since phenylephrine infusion is manually documented in an AIMS, the impact of notification messages was less pronounced in reducing episodes of hypertension with concurrent phenylephrine infusion. Automated data capture and a higher frequency of data acquisition in an AIMS can improve the effectiveness of an intraoperative clinical decision support system.


Subject(s)
Anesthesia/methods , Computer Systems , Decision Support Systems, Clinical , Hypertension/diagnosis , Hypotension/diagnosis , Intraoperative Complications/diagnosis , Adult , Aged , Databases, Factual , Disease Management , Female , Humans , Hypertension/epidemiology , Hypertension/therapy , Hypotension/epidemiology , Hypotension/therapy , Information Management , Intraoperative Complications/epidemiology , Intraoperative Complications/therapy , Male , Middle Aged , Retrospective Studies
10.
Anesthesiology ; 118(4): 874-84, 2013 Apr.
Article in English | MEDLINE | ID: mdl-23442753

ABSTRACT

BACKGROUND: Reduced consumption of inhalation anesthetics can be safely achieved by reducing excess fresh gas flow (FGF). In this study the authors describe the use of a real-time decision support tool to reduce excess FGF to lower, less wasteful levels. METHOD: The authors applied a decision support tool called the Smart Anesthesia Manager™ (University of Washington, Seattle, WA) that analyzes real-time data from an Anesthesia Information Management System to notify the anesthesia team if FGF exceeds 1 l/min. If sevoflurane consumption reached 2 minimum alveolar concentration-hour under low flow anesthesia (FGF < 2 l/min), a second message was generated to increase FGF to 2 l/min, to comply with Food and Drug Administration guidelines. To evaluate the tool, mean FGF between surgical incision and the end of procedure was compared in four phases: (1) a baseline period before instituting decision rules, (2) Intervention-1 when decision support to reduce FGF was applied, (3) Intervention-2 when the decision rule to reduce flow was deliberately inactivated, and (4) Intervention-3 when decision rules were reactivated. RESULTS: The mean ± SD FGF reduced from 2.10 ± 1.12 l/min (n = 1,714) during baseline to 1.60 ± 1.01 l/min (n = 2,232) when decision rules were instituted (P < 0.001). When the decision rule to reduce flow was inactivated, mean FGF increased to 1.87 ± 1.15 l/min (n = 1,732) (P < 0.001), with an increasing trend in FGF of 0.1 l/min/month (P = 0.02). On reactivating the decision rules, the mean FGF came down to 1.59 ± 1.02 l/min (n = 1,845). Through the Smart Anesthesia Messenger™ system, the authors saved 9.5 l of sevoflurane, 6.0 l of desflurane, and 0.8 l isoflurane per month, translating to an annual savings of $104,916. CONCLUSIONS: Real-time notification is an effective way to reduce inhalation agent usage through decreased excess FGFs.


Subject(s)
Anesthesia, Inhalation/instrumentation , Anesthetics, Inhalation/administration & dosage , Decision Support Techniques , Monitoring, Intraoperative/instrumentation , Administration, Inhalation , Anesthesia, Inhalation/methods , Desflurane , Humans , Isoflurane/administration & dosage , Isoflurane/analogs & derivatives , Methyl Ethers/administration & dosage , Monitoring, Intraoperative/methods , Sevoflurane
11.
IEEE Trans Biomed Eng ; 60(1): 207-10, 2013 Jan.
Article in English | MEDLINE | ID: mdl-22736635

ABSTRACT

Anesthesia information management systems (AIMS) are being increasingly used in the operating room to document anesthesia care. We developed a system, Smart Anesthesia Manager™ (SAM) that works in conjunction with an AIMS to provide clinical and billing decision support. SAM interrogates AIMS database in near real time, detects issues related to clinical care, billing and compliance, and material waste. Issues and the steps for their resolution are brought to the attention of the anesthesia provider in real time through "pop-up" messages overlaid on top of AIMS screens or text pages. SAM improved compliance to antibiotic initial dose and redose to 99.3 ± 0.7% and 83.9 ± 3.4% from 88.5 ± 1.4% and 62.5 ± 1.6%, respectively. Beta-blocker protocol compliance increased to 94.6 ± 3.5% from 60.5 ± 8.6%. Inadvertent gaps (>15 min) in blood pressure monitoring were reduced to 34 ± 30 min/1000 cases from 192 ± 58 min/1000 cases. Additional billing charge capture of invasive lines procedures worth $144,732 per year and 1,200 compliant records were achieved with SAM. SAM was also able to reduce wastage of inhalation anesthetic agents worth $120,168 per year.


Subject(s)
Anesthesia/methods , Decision Support Systems, Clinical , Monitoring, Intraoperative/methods , Anesthesia/economics , Computer Communication Networks , Humans , Monitoring, Intraoperative/economics , Monitoring, Intraoperative/instrumentation , User-Computer Interface
12.
J Healthc Qual ; 34(5): 39-47; quiz 48-9, 2012.
Article in English | MEDLINE | ID: mdl-22860887

ABSTRACT

To achieve sustainable reductions in healthcare-associated infections (HAIs), the University of Washington Medical Center (UWMC) deployed a collaborative, systems-level initiative. With the sponsorship of senior leadership, multidisciplinary teams were established to address healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA), central-line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and respiratory virus infections. The goal of the initiative was to eliminate these four HAIs among medical center inpatients by 2012. In the first 24 months of the project, the number of healthcare-associated MRSA cases decreased 58%; CLABSI cases decreased 54%. Staff and provider compliance with infection prevention measures improved and remained strong, for example, 96% compliance with hand hygiene, 98% compliance with the recommended influenza vaccination program, and 100% compliance with the VAP bundle. Achieving these results required an array of coordinated, systems-level interventions. Critical project success factors were believed to include creating organizational alignment by declaring eliminating HAIs as an organizational breakthrough goal, having the organization's executive leadership highly engaged in the project, coordination by an experienced and effective project leader and manager, collaboration by multidisciplinary project teams, and promoting transparency of results across the organization.


Subject(s)
Bacteremia/prevention & control , Catheter-Related Infections/prevention & control , Cooperative Behavior , Cross Infection/prevention & control , Infection Control/methods , Methicillin-Resistant Staphylococcus aureus , Pneumonia, Ventilator-Associated/prevention & control , Respiratory Tract Infections/prevention & control , Respiratory Tract Infections/virology , Staphylococcal Infections/prevention & control , Humans , Models, Organizational , Organizational Objectives , Washington/epidemiology
13.
Jt Comm J Qual Patient Saf ; 38(6): 283-8, 2012 Jun.
Article in English | MEDLINE | ID: mdl-22737780

ABSTRACT

BACKGROUND: Continuation of perioperative beta-blockers for surgical patients who are receiving beta-blockers prior to arrival for surgery is an important quality measure (SCIP-Card-2). For this measure to be considered successful, name, date, and time of the perioperative beta-blocker must be documented. Alternately, if the beta-blocker is not given, the medical reason for not administering must be documented. METHODS: Before the study was conducted, the institution lacked a highly reliable process to document the date and time of self-administration of beta-blockers prior to hospital admission. Because of this, compliance with the beta-blocker quality measure was poor (-65%). To improve this measure, the anesthesia care team was made responsible for documenting perioperative beta-blockade. Clear documentation guidelines were outlined, and an electronic Anesthesia Information Management System (AIMS) was configured to facilitate complete documentation of the beta-blocker quality measure. In addition, real-time electronic alerts were generated using Smart Anesthesia Messenger (SAM), an internally developed decision-support system, to notify users concerning incomplete beta-blocker documentation. RESULTS: Weekly compliance for perioperative beta-blocker documentation before the study was 65.8 +/- 16.6%, which served as the baseline value. When the anesthesia care team started documenting perioperative beta-blocker in AIMS, compliance was 60.5 +/- 8.6% (p = .677 as compared with baseline). Electronic alerts with SAM improved documentation compliance to 94.6 +/- 3.5% (p < .001 as compared with baseline). CONCLUSIONS: To achieve high compliance for the beta-blocker measure, it is essential to (1) clearly assign a medical team to perform beta-blocker documentation and (2) enhance features in the electronic medical systems to alert the user concerning incomplete documentation.


Subject(s)
Adrenergic beta-Antagonists/administration & dosage , Anesthesia , Documentation/statistics & numerical data , Information Systems/organization & administration , Quality Indicators, Health Care/organization & administration , Academic Medical Centers/organization & administration , Guideline Adherence/organization & administration , Hospital Bed Capacity, 300 to 499 , Humans , Information Management/methods , Medical Errors/prevention & control , Medical Order Entry Systems , Practice Guidelines as Topic , Quality Improvement/organization & administration , Washington
15.
Surg Infect (Larchmt) ; 12(1): 57-63, 2011 Feb.
Article in English | MEDLINE | ID: mdl-21166624

ABSTRACT

BACKGROUND: Timely re-dosing of antibiotic for prolonged surgical cases is an important measure in reducing the risk of surgical site infections. For the anesthesia team, which generally administers the antibiotic re-doses, it is difficult to keep track of and remember the exact timing requirements. We explored the efficacy of two types of electronic reminders to aid the anesthesia team in performing timely antibiotic re-doses. METHODS: The first electronic reminder was a timer-triggered "blinking button" feature in the Anesthesia Information Management System (AIMS). The second was generated with a real-time decision support system, the Smart Anesthesia Messenger (SAM). The AIMS reminder was applied for the first five months of the study, whereas the SAM reminder was applied for the second five months. A retrospective analysis was performed to evaluate the efficacy of the reminder messages in improving the antibiotic re-dose success rate. RESULTS: In a total of 940 cases, the anesthesia team was reminded of the need for antibiotic re-dosing with AIMS, whereas in 922 cases, the SAM system gave the reminder. The AIMS reminders achieved a timely re-dose success rate of 62.5% ± 1.6%, whereas the SAM reminders achieved a significantly higher success rate: 83.9% ± 3.4% (p < 0.001). CONCLUSIONS: Compared with the simple reminders generated with AIMS, the relevant, informative messages generated with SAM were more effective in improving compliance with timely antibiotic re-doses.


Subject(s)
Anti-Bacterial Agents/administration & dosage , Antibiotic Prophylaxis/methods , Electronics, Medical/instrumentation , Reminder Systems/instrumentation , Surgical Wound Infection/prevention & control , Guideline Adherence/statistics & numerical data , Humans , Middle Aged , Retrospective Studies
16.
Anesth Analg ; 111(5): 1293-300, 2010 Nov.
Article in English | MEDLINE | ID: mdl-20841414

ABSTRACT

BACKGROUND: Administration of prophylactic antibiotics during surgery is generally performed by the anesthesia providers. Timely antibiotic administration within the optimal time window before incision is critical for prevention of surgical site infections. However, this often becomes a difficult task for the anesthesia team during the busy part of a case when the patient is being anesthetized. METHODS: Starting with the implementation of an anesthesia information management system (AIMS), we designed and implemented several feedback mechanisms to improve compliance of proper antibiotic delivery and documentation. This included generating e-mail feedback of missed documentation, distributing monthly summary reports, and generating real-time electronic alerts with a decision support system. RESULTS: In 20,974 surgical cases for the period, June 2008 to January 2010, the interventions of AIMS install, e-mail feedback, summary reports, and real-time alerts changed antibiotic compliance by -1.5%, 2.3%, 4.9%, and 9.3%, respectively, when compared with the baseline value of 90.0% ± 2.9% when paper anesthesia records were used. Highest antibiotic compliance was achieved when using real-time alerts. With real-time alerts, monthly compliance was >99% for every month between June 2009 and January 2010. CONCLUSIONS: Installation of AIMS itself did not improve antibiotic compliance over that achieved with paper anesthesia records. However, real-time guidance and reminders through electronic messages generated by a computerized decision support system (Smart Anesthesia Messenger, or SAM) significantly improved compliance. With such a system a consistent compliance of >99% was achieved.


Subject(s)
Anesthesiology/instrumentation , Anti-Bacterial Agents/administration & dosage , Antibiotic Prophylaxis , Decision Support Systems, Clinical , Feedback, Psychological , Online Systems , Reminder Systems , Surgical Wound Infection/prevention & control , Documentation , Drug Administration Schedule , Electronic Mail , Guideline Adherence , Humans , Medical Records Systems, Computerized , Practice Guidelines as Topic , Program Development , Program Evaluation , Surgical Procedures, Operative , Time Factors , Washington
17.
Endocr Pract ; 14(5): 556-63, 2008.
Article in English | MEDLINE | ID: mdl-18753097

ABSTRACT

OBJECTIVE: To demonstrate the benefit of an institutionally implemented glucose control intervention based on serum and plasma glucose values in the acute inpatient setting. METHODS: In a retrospective analysis, all serum and plasma glucose values from the laboratory information system database from 1999 through 2005 were used to assess implementation of 2 new hospital-wide intravenous and subcutaneous protocols aimed at lowering blood glucose values without increasing the number of hypoglycemic events. In our analysis, we used both a per-patient hyperglycemic index (HGI), an area-under-the-curve analysis, and hospital-wide geometric mean blood glucose to assess glucose control. Bedside capillary blood glucose measurements were not included. RESULTS: More than 630,000 serum and plasma glucose results were available for analysis. The percentage of results above the protocol target of 180 mg/dL decreased from 16.4% before the intervention to 10.0% after the intervention (P<.00001), and we found no change in the proportion of "critical" hypoglycemic results (<50 mg/dL). The hospital-wide geometric mean decreased significantly and coincided with a significant decrease in the fraction of patients with poor glucose control (based on the HGI) from 27.6% to 18.7% (P<.00001). The geometric mean blood glucose was found to be an excellent marker for the HGI (r2 = 0.99). CONCLUSION: We are the first to report improvements in glucose control over an extended period with use of both hospital-wide intravenous and subcutaneous insulin protocols in an academic hospital setting. Furthermore, hospital-wide mean blood glucose levels are excellent surrogates for the more comprehensive calculation of per-patient HGI.


Subject(s)
Blood Glucose/analysis , Hyperglycemia/drug therapy , Plasma/chemistry , Serum/chemistry , Hospitals , Humans , Hyperglycemia/blood , Hypoglycemic Agents/administration & dosage , Hypoglycemic Agents/therapeutic use , Insulin/administration & dosage , Insulin/therapeutic use , Retrospective Studies , Treatment Outcome
19.
Anesthesiology ; 103(1): 33-9, 2005 Jul.
Article in English | MEDLINE | ID: mdl-15983454

ABSTRACT

BACKGROUND: The purpose of this study was to identify the patterns of liability associated with malpractice claims arising from management of the difficult airway. METHODS: Using the American Society of Anesthesiologists Closed Claims database, the authors examined 179 claims for difficult airway management between 1985 and 1999 where a supplemental data collection tool was used and focused on airway management, outcomes, and the role of the 1993 Difficult Airway Guidelines in litigation. Chi-square tests and multiple logistic regression analysis compared risk factors for death or brain damage (death/BD) from two time periods: 1985-1992 and 1993-1999. RESULTS: Difficult airway claims arose throughout the perioperative period: 67% upon induction, 15% during surgery, 12% at extubation, and 5% during recovery. Death/BD with induction of anesthesia decreased in 1993-1999 (35%) compared with 1985-1992 (62%; P < 0.05; odds ratio, 0.26; 95% confidence interval, 0.11-0.63; P = 0.003). In contrast, death/BD associated with other phases of anesthesia did not significantly change over the time periods. The odds of death/BD were increased by the development of an airway emergency (odds ratio, 14.98; 95% confidence interval, 6.37-35.27; P < 0.001). During airway emergencies, persistent intubation attempts were associated with death/BD (P < 0.05). Since 1993, the Airway Guidelines were used to defend care (8%) and criticize care (3%). CONCLUSIONS: Death/BD in claims from difficult airway management associated with induction of anesthesia but not other phases of anesthesia decreased in 1993-1999 compared with 1985-1992. Development of additional management strategies for difficult airways encountered during maintenance, emergence, or recovery from anesthesia may improve patient safety.


Subject(s)
Insurance Claim Review/statistics & numerical data , Intubation, Intratracheal/adverse effects , Intubation, Intratracheal/statistics & numerical data , Perioperative Care/statistics & numerical data , Adult , Aged , Female , Humans , Hypoxia, Brain/epidemiology , Hypoxia, Brain/mortality , Intubation, Intratracheal/mortality , Male , Middle Aged , Monte Carlo Method , Perioperative Care/adverse effects , Perioperative Care/mortality
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