CT Pulmonary Angiography: Using Decision Rules in the Emergency Department.

PURPOSE: The aim of this study was to assess the appropriateness of utilization and diagnostic yields of CT pulmonary angiography (CTPA), comparing two commonly applied decision rules, the pulmonary embolism (PE) rule-out criteria (PERC) and the modified Wells criteria (mWells), in the emergency department (ED) setting. METHODS: Institutional review board approval was obtained for this HIPAA-compliant, prospective-cohort, academic single-center study. Six hundred two consecutive adult ED patients undergoing CTPA for suspected PE formed the study population. The outcome was positive or negative for PE by CTPA and at 6-month follow-up. PERC and mWells scores were calculated. A positive PERC score was defined as meeting one or more criteria and a positive mWells score as >4. The percentage of CT pulmonary angiographic examinations that could have been avoided and the diagnostic yield of CTPA using PERC, mWells, and PERC applied to a negative mWells score were calculated. RESULTS: The diagnostic yield of CTPA was 10% (61 of 602). By applying PERC, mWells, and PERC to negative mWells score, 17.6% (106 of 602), 45% (273 of 602), and 17.1% (103 of 602) of CT pulmonary angiographic examinations, respectively, could have been avoided. The diagnostic yield in PERC-positive patients was higher than in mWells-positive patients (10% [59 of 602] vs 8% [49 of 602], P < .0001). Among PERC-negative and mWells-negative patients, the diagnostic yields for PE were 1.9% (2 of 106) and 4% (12 of 273), respectively (P = .004). The diagnostic yield of a negative PERC score applied to a negative mWells score was 1.9% (2 of 103). CONCLUSIONS: The use of PERC in the ED has the potential to significantly reduce the utilization of CTPA and misses fewer cases of PE compared with mWells, and it is therefore a more efficient decision tool.

Improving the care of elderly adults undergoing surgery in Michigan.

OBJECTIVES: To determine whether failure to rescue, as a driver of mortality, can be used to identify which hospitals attenuate the specific risks inherent to elderly adults undergoing surgery. DESIGN: Retrospective cohort study. SETTING: State-wide surgical collaborative in Michigan. PARTICIPANTS: Older adults undergoing major general or vascular surgery between 2006 and 2011 (N = 24,216). MEASUREMENTS: Thirty-four hospitals were ranked according to risk-adjusted 30-day mortality and grouped into tertiles. Within each tertile, rates of major complications and failure to rescue were calculated, stratifying outcomes according to age (<75 vs ≥ 75). Next, differences in failure-to-rescue rates between age groups within each hospital were calculated. RESULTS: Failure-to-rescue rates were more than two times as high in elderly adults as in younger individuals in each tertile of hospital mortality (26.0% vs 10.3% at high-mortality hospitals, P < .001). Within hospitals, the average difference in failure-to-rescue rates was 12.5%. Nine centers performed better than expected, and three performed worse than expected, with the largest differences exceeding 25%. CONCLUSION: Although elderly adults experience higher failure-to-rescue rates, this does not account for hospitals' overall capacity to rescue individuals from complications. Comparing rates of younger and elderly adults within hospitals may identify centers where efforts toward complication rescue favor, or are customized for, elderly adults. These centers should be studied as part of the collaborative's effort to address the disparate outcomes that elderly adults in Michigan experience.

Doing it by yourself.

The DoH (1999) describes how it 'needs leaders who are motivated, self aware, socially skilled and able to work together with others across professional and organisational boundaries'. Self-medication incorporates all professional groups and divisions within Calderdale and Huddersfield NHS Trust; we work in partnership with the pharmacy departments. The main purpose of any organisation in the health and social sector is to ensure that a high quality service is delivered to service users (Martin 2001), so self-medication is now being given the attention it deserves. Assessment will be integral to every service user's stay and will continue throughout their stay, including transfer from secondary to primary care. It is expected that following its introduction, quality will improve; patients will receive their medication on time and it is anticipated that discharge delays will reduce. We acknowledge however that this will be difficult to demonstrate, as often medical conditions are cited as reasons for admission, not non-compliance with medication regimes. We see ourselves as being competent in the roles of change agents and our styles have changed throughout the process. We have worked together as equals and focused on one outcome. It will call on all our professional and educational skills to mould staff so that they are ready to embrace the change. Perhaps the lesson that has been learned so far is that, despite meticulous planning, the actions of others for whom we are not responsible can seriously disrupt the plan. The opportunity to manage change through experiential learning, reflection and the transfer of knowledge has been challenging while enhancing our personal growth and self-awareness. The project has been extended until March 2004 because of the merger and the associated increased workload. Becoming a project manager, leader and change agent has proved to be an exciting, interesting and challenging experience, although at times we felt isolated. The project has now entered a phase that involves intense staff training and phase one of introduction.