Perioperative management of proximal hip fractures in the elderly: the surgeon and the anesthesiologist.

The comprehensive management of proximal hip fractures in elderly patients requires dedicated and responsive teamwork. Elderly patients often present with several comorbidities and the immediate treatment of a fracture has to optimize both medical therapy and analgesic control in order to reduce surgical and anesthetic complications and to preserve as much cognitive functioning as possible. The elderly are uniquely exposed to complications related to bed rest, delirium and postoperative cognitive dysfunction (POCD), which appear to be independent factors of morbidity. Anesthetic management that includes good perioperative pain management can influence the patient's inflammatory response and possibly decrease the incidence of POCD. The best choice of surgical treatment depends on the type of fracture as well as the patient's age and medical condition. However, the type of anesthesia management, which includes neuraxial blocks, peripheral nerve blocks and/or general anesthesia, has to be tailored towards generated the best outcome. We present a review from a surgical and anesthetic perspective on the most common perioperative issues in proximal fracture repair.

Measuring the benefits of clinical decision support: return on investment.

In an effort to provide high quality care in a more cost-effective manner, health care providers have found it necessary to implement a series of decision support strategies designed to improve outcomes of care. While each of these strategies has measurable benefits, they each come along with additional costs. This article will describe a methodology for measuring the costs and direct and indirect benefits from decision support activities.

Tetanic stimulation leads to increased accumulation of Ca(2+)/calmodulin-dependent protein kinase II via dendritic protein synthesis in hippocampal neurons.

mRNA for the alpha-subunit of CaMKII is abundant in dendrites of neurons in the forebrain (Steward, 1997). Here we show that tetanic stimulation of the Schaffer collateral pathway causes an increase in the concentration of alpha-CaMKII in the dendrites of postsynaptic neurons. The increase is blocked by anisomycin and is detected by both quantitative immunoblot and semiquantitative immunocytochemistry. The increase in dendritic alpha-CaMKII can be measured 100-200 micrometer away from the neuronal cell bodies as early as 5 min after a tetanus. Transport mechanisms for macromolecules from neuronal cell bodies are not fast enough to account for this rapid increase in distal portions of the dendrites. Therefore, we conclude that dendritic protein synthesis must produce a portion of the newly accumulated CaMKII. The increase in concentration of dendritic CaMKII after tetanus, together with the previously demonstrated increase in autophosphorylated CaMKII (Ouyang et al., 1997), will produce a prolonged increase in steady-state kinase activity in the dendrites, potentially influencing mechanisms of synaptic plasticity that are controlled through phosphorylation by CaMKII.

Measuring the benefits of clinical decision support: return on investment.

In an effort to provide high quality care in a more cost-effective manner, health care providers have found it necessary to implement a series of decision support strategies designed to improve outcomes of care. While each of these strategies has measurable benefits, they each come along with additional costs. This article will describe a methodology for measuring the costs and direct and indirect benefits from decision support activities.

Inpatient clinical decision-support systems: determining the ROI.

Healthcare providers faced with increasing pressure to provide high-quality, cost-effective care have implemented clinical decision-support programs to drive the appropriate process improvement activities needed to achieve successful care outcomes. Each of these activities requires the commitment of the necessary technology and human resources. To measure the return on investment (ROI) of decision-support activities, providers need to establish a methodology for capturing the costs and benefits of implementing decision-support-directed process-improvement activities.

Measuring the benefit of performance improvement and decision support.

In an effort to provide high quality care in a more cost-effective manner, health care providers have found it necessary to implement a series of decision support strategies designed to improve outcomes of care. While each of these strategies has measurable benefits, each comes along with additional costs. As more and more technology becomes available and more labor resources are devoted to these efforts, it becomes crucial to be able to assess the costs and benefits of these programs. A return-on-investment methodology is used to assess the financial impact of service-related operating expenses compared to revenue gains from service delivery. However, unlike traditional return-on-investment models, in health care, benefits are frequently gained from cost avoidance rather than from revenue enhancement activities. This article will describe a methodology for measuring the direct and indirect costs and qualitative and quantitative benefits of decision support activities.

A practical approach to managing care under managed care. Case examples in pulmonary medicine.

As managed care medicine penetrates the health care marketplace, all those involved in the health care delivery process will have to redesign and restructure the way they provide health care services. With the current emphasis on controlling health care costs, providers will be compelled to come up with the successful strategies and methodologies that lead to the delivery of cost-effective high-quality care with positive, successful patient outcomes. Having the capability to analyze the information necessary to identify, measure, and monitor processes and outcomes is one of the key critical factors for success. Using information to identify opportunities for improvement, developing and implementing the appropriate process improvement activities, and being able to document and demonstrate the results of one's efforts are crucial for survival in a competitive managed care market.

Healthcare resource management: integrating apples and oranges.

Over the past several years this journal has published numerous articles on the merits and benefits of effective resource management. Independently, these articles have supported the value of effective supply and materials management, management engineering and system restructuring, and clinical resource management in being able to save healthcare dollars by designing and injecting efficiencies into the healthcare delivery system. While most of these resource management activities have utilized very similar strategies (see Table 1 "Tools For Improvement"), much of the process revision and progress has remained within the walls of their own individual disciplines. Any widescale attempts to try to fully integrate all of these activities have been hampered by the intricacies of trying to mix apples and oranges. Despite these individual departmental gains, the challenge to conserve healthcare costs continues to permeate throughout all levels of the organization, and institutions are finally beginning to recognize the added value of merging these activities into a more centralized coordinated approach to resource management. Presented is a discussion on the potential value of developing a well-focused, integrated resource management program.

Benchmarking outcomes for diagnosis and AMI: a multidisciplinary hospital performance improvement project.

A multihospital process improvement study was designed to evaluate outcomes related to the treatment of Acute Myocardial Infarction (AMI). Time to diagnosis, time to intervention and outcomes of treatment were assessed through a risk adjusted database allowing individual hospital comparisons to benchmark results.

Bacterial endocarditis following endoscopic variceal sclerotherapy.

We report the case of a patient in whom bacterial endocarditis developed on a native valve after variceal sclerotherapy. We are concerned about the discrepant recommendations for antibiotic prophylaxis in the literature and consider that our report, which we take to be the first, suggests reasons for prophylactic antibiotic treatment in selected patients undergoing sclerotherapy.

Case management.

Providing cost-effective high quality healthcare services ranks as the number one concern for anyone involved with the healthcare delivery system. While quality of care should always be the number one priority, controlling healthcare costs receives most of the attention. With limited healthcare dollars and providers assuming more of the financial risk for services rendered, a whole assortment of cost-containment strategies are being introduced in an effort to maintain some semblance of financial viability. Healthcare providers can approach cost control from two different angles. On the fixed-cost operational overhead side, traditional cost-containment techniques have focused on downsizing, maximizing productivity, staffing redesign, improved purchasing contracts, standardization, inventory control, and other more individualized restructured service models. On the variable-cost clinical side, cost control has been approached by introducing a variety of cost-containment strategies designed to improve efficiency and effectiveness of provider performance. While many of these strategies, previously discussed in the Journal of Healthcare Resource Management have stressed the importance of education, guidelines, pathways, and other clinical "tools for improvement," the success of many of these tools resides in the ability to provide real-time intervention. Real-time intervention rather than the more passive retrospective variance analysis has the greatest potential for producing cost savings by actually making a recommendation that prevents the unwanted event from occurring. In many institutions, the case manager bears the responsibility for monitoring and managing these programs. This article describes various case management models currently used by different institutions.

Using information management to implement a clinical resource management program.

BACKGROUND: This article provides a consultant's account of a 250-bed community hospital's experience in implementing the Clinical Resource Management (CRM) program, a four-stage process of using information to identify opportunities for improvement, developing an effective resource management team, implementing process improvement activities, and measuring the impact on outcomes of care. CASE STUDY EXAMPLE--CONGESTIVE HEART FAILURE: The chair of the departments of internal medicine and family practice selected congestive heart failure for in-depth study. A task force focused on treatment and patient disposition in the emergency room (ER), where most of the nonelective admissions originated. A set of standardized ER orders was developed that emphasized rapid and effective diuresis through the initiation of a progressive diuretic dosing schedule directly linked to patient response. LESSONS AND REFLECTIONS: Factors critical to the success of the CRM program included allocating adequate time to promote and sell the value and importance of the program, as well as securing the support of both information systems and physicians. The main barriers to success involved limitations in the information system infrastructure and delays attributable to committee review. Short-term results from the CRM program were encouraging, with average lengths of stay reduced by 0.5 days and average costs of care reduced by 12% for the ten diagnoses studied with no adverse results. Nonstudy diagnoses showed no notable improvement. CONCLUSIONS: Recognizing the growing importance of information management not only for clinical decision support but for accommodating all the necessary internal and external reporting requirements will require a significant commitment and investment in technology and personnel resources.

Identification of a phosphorylation site for calcium/calmodulindependent protein kinase II in the NR2B subunit of the N-methyl-D-aspartate receptor.

The N-methyl-D-aspartate (NMDA) subtype of excitatory glutamate receptors plays critical roles in embryonic and adult synaptic plasticity in the central nervous system. The receptor is a heteromultimer of core subunits, NR1, and one or more regulatory subunits, NR2A-D. Protein phosphorylation can regulate NMDA receptor function (Lieberman, D. N., and Mody, I. (1994) Nature 369, 235-239; Wang, Y. T., and Salter, M. W. (1994) Nature 369, 233-235; Wang, L. -Y., Orser, B. A., Brautigan, D. L., and MacDonald, J. F. (1994) Nature 369, 230-232). Here we identify a major phosphorylation site on subunit NR2B that is phosphorylated by Ca2+/calmodulin-dependent protein kinase II (CaM kinase II), an abundant protein kinase located at postsynaptic sites in glutamatergic synapses. For the initial identification of the site, we constructed a recombinant fusion protein containing 334 amino acids of the C terminus of the NR2B subunit and phosphorylated it with CaM kinase II in vitro. By peptide mapping, automated sequencing, and mass spectrometry, we identified the major site of phosphorylation on the fusion protein as Ser-383, corresponding to Ser-1303 of full-length NR2B. The Km for phosphorylation of this site in the fusion protein was approximately 50 nM, much lower than that of other known substrates for CaM kinase II, suggesting that the receptor is a high affinity substrate. We show that serine 1303 in the full-length NR2B and/or the cognate site in NR2A is a major site of phosphorylation of the receptor both in the postsynaptic density fraction and in living hippocampal neurons.