Improving the simple, complicated and complex realities of community-acquired pneumonia.

This paper first describes efforts to improve the care for patients hospitalised with community-acquired pneumonia and the associated changes in quality measures at a rural academic medical centre. The results of the improvement interventions and the associated clinical realities, expected outcomes, measures, improvement interventions and improvement aims are then re-examined using the Glouberman and Zimmerman typology of healthcare problems--simple, complicated and complex. The typology is then used to explore the future design and assessment of improvement interventions, which may allow better matching with the types of problem healthcare providers and organisations are confronted with. Matching improvement interventions with problem category has the possibility of improving the success of improvement efforts and the reliability of care while at the same time preserving needed provider autonomy and judgement to adapt care for more complex problems.

Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques.

BACKGROUND: The modern imaging techniques of transesophageal echocardiography, CT, and MRI are reported to have up to 100% sensitivity in detecting the classic class of aortic dissection; however, anecdotal reports of patient deaths from a missed diagnosis of subtle classes of variants are increasingly being noted. METHODS AND RESULTS: In a series of 181 consecutive patients who had ascending or aortic arch repairs, 9 patients (5%) had subtle aortic dissection not diagnosed preoperatively. All preoperative studies in patients with missed aortic dissection were reviewed in detail. All 9 patients (2 with Marfan syndrome, 1 with Takayasu's disease) with undiagnosed aortic dissection had undergone >/=3 imaging techniques, with the finding of ascending aortic dilatation (4.7 to 9 cm) in all 9 and significant aortic valve regurgitation in 7. In 6 patients, an eccentric ascending aortic bulge was present but not diagnostic of aortic dissection on aortography. At operation, aortic dissection tears were limited in extent and involved the intima without extensive undermining of the intima or an intimal "flap." Eight had composite valve grafts inserted, and all survived. Of the larger series of 181 patients, 98% (179 of 181) were 30-day survivors. CONCLUSIONS: In patients with suspected aortic dissection not proven by modern noninvasive imaging techniques, further study should be performed, including multiple views of the ascending aorta by aortography. If patients have an ascending aneurysm, particularly if eccentric on aortography and associated with aortic valve regurgitation, an urgent surgical repair should be considered, with excellent results expected.

The utility of severity of illness information in assessing the quality of hospital care. The role of the clinical trajectory.

This research explored whether differentiating patients whose severity of illness worsened, improved, or remained the same over the hospital stay is a good screen for quality of care. The hypothesis was that substandard care is more likely to occur among patients who have worsened. Severity was measured using the Computerized Severity Index (CSI) and MedisGroups in 233 patients who had experienced acute myocardial infarction and 279 who had undergone coronary artery bypass graft who were admitted to four New England hospitals in 1987. Deaths and patients with discharge diagnoses indicating iatrogenic events and complications were oversampled. Potential quality problems were identified through explicit screening criteria applied by nurse researchers and implicit physician reviews. Acute myocardial infarction patients who worsened had higher rates of potential quality problems than other patients (CSI, P = 0.06; MedisGroups, P = 0.01). For the CSI, the 49.4% of patients who worsened captured 70.6% of the potentially substandard care; for MedisGroups, the 35.6% of patients who worsened also encompassed 70.6% of the problematic cases. For coronary artery bypass graft, results varied depending on how severity and quality were defined. The CSI performed better using implicit physician review to identify problematic care (P = 0.00), capturing 76.5% of substandard cases among the 41.6% of patients who worsened. In contrast, MedisGroups did better using explicit quality screens (P = 0.04), grouping 60.5% of the problematic cases among the 47.0% of patients who worsened. After removing in-hospital deaths from consideration, a worsening trajectory was generally associated with a higher fraction of potential quality problems among live discharges. This preliminary study suggests that examining changes in illness severity may be a useful screen for substandard hospital care, but its utility could vary by condition and by how quality problems are defined.

Total obstruction of the left main coronary artery.

A rare and often fatal condition, total obstruction of the left main coronary artery has been treated with increasing success in both acute and chronic clinical settings. Seventeen patients with acute occlusion have been reported in the literature. All were discovered at the time of acute periinfarction catheterization and were treated aggressively with intracoronary thrombolysis, percutaneous transluminal angioplasty, emergency bypass surgery, or a combination of techniques. Chronic total occlusion of the left main coronary artery has been reported in 59 patients, including 3 at our institution. These patients present with chronic but increasingly severe angina. A right dominant coronary anatomy is always found, usually with well-developed right-to-left collaterals. The results of surgical revascularization in our 3 patients and in 45 others described in the literature support the safety and efficacy of this approach.

Echocardiographic manifestations of tense pericardial effusion.

Echocardiography has emerged as a sensitive study in the evaluation of pericardial effusion. The specificity of echocardiographic signs in cardiac tamponade remains undefined, however. Two such signs, early diastolic collapse of the right ventricular free wall and late diastolic collapse of the right atrial wall, were observed in two patients without clinical evidence of cardiac tamponade. Increased intrapericardial pressure was documented in each patient. Accumulation of pericardial fluid under high pressure results in a reversal of the instantaneous transmural pressure gradients in early and late diastole, causing collapse of the right ventricular and the right atrial wall, respectively; however, such a tense pericardial effusion may not cause hemodynamic embarrassment severe enough to yield clinical signs of cardiac tamponade.