Leveraging information technology towards enhancing patient care and a culture of safety in the US.

OBJECTIVES: To heighten awareness about the critical issues currently affecting patient care and to propose solutions based on leveraging information technologies to enhance patient care and influence a culture of patient safety. METHODS: Presentation and discussion of the issues affecting health care today, such as medical and medication-related errors and analysis of their root causes; proliferation of medical knowledge and medical technologies; initiatives to improve patient safety; steps necessary to develop a culture of safety; introduction of relevant enabling technologies; and evidence of results. RESULTS AND CONCLUSION: Medical errors affect not only mortality and morbidity, but they also create secondary costs leading to dissatisfaction by both provider and patient. Health care has been slow to acknowledge the benefits of enabling technologies to affect the quality of care. Evaluation of recent applications, such as the computerized patient record, physician order entry, and computerized alerting systems show tremendous potential to enhance patient care and influence the development of a culture focused on safety. They will also bring about changes in other areas, such as workflow and the creation of new partnerships among providers, patients, and payers.

The role of preoperative epoetin alfa in men undergoing radical retropubic prostatectomy.

PURPOSE: The safety and effects on hematocrit of recombinant human erythropoietin (epoetin alfa) were evaluated in men undergoing radical retropubic prostatectomy. MATERIALS AND METHODS: Between February 1, 1997 and November 2, 1998, 305 men with clinically localized adenocarcinoma of the prostate underwent radical retropubic prostatectomy performed by a single surgeon (H. L.). Of these men 283 with a baseline hematocrit of less than 48% received 600 IU/kg. epoetin alfa 14 days (-14) and 7 days (-7) before radical retropubic prostatectomy. Hematocrit was measured at baseline on day -14, on day -7, just before anesthesia induction on day 0, immediately postoperatively and on the day of discharge home. The number of allogeneic units transfused, and all intraoperative and postoperative complications were recorded. RESULTS: Mean hematocrit at baseline on day -14 and at induction on day 0 was 42.9% and 45.8%, respectively (p = 0.0001). The frequency of hematocrit decreasing, showing no change or increasing 0.1 to 1.9, 2.0 to 3.9 or greater than 4.0 hematocrit points was 16.5%, 0.5%, 23%, 22% and 38%, respectively. Of the men 17% had no increase in hematocrit. A weak correlation existed between baseline hematocrit and the erythropoietic response to epoetin alfa (r2 = 0.06). Mean change in hematocrit after treatment with epoetin alfa in the quartile baseline hematocrit groups 34.2 to 41.4, 41.5 to 43.2, 43.3 to 44.9 and 45.0 to 48.0 hematocrit points was 3.71, 2.45, 3.86 and 1.02 hematocrit points, respectively. Of the surgical candidates 22 (9.1%) achieved an induction hematocrit of greater than 51%. Of the 283 men receiving epoetin alfa 21 (7.4%) also received an allogeneic transfusion. The transfusion rate did not correlate with induction hematocrit. The only adverse cardiovascular event was an uncomplicated postoperative pulmonary embolus. CONCLUSIONS: Our prospective study demonstrates that epoetin alfa given preoperatively in 2 doses of 600 IU/kg. is safe for significantly increasing hematocrit in men before radical retropubic prostatectomy. It is intuitive that the significant increase in hematocrit decreases the requirement for allogeneic blood transfusion.

Does site specific labeling of sextant biopsy cores predict the site of extracapsular extension in radical prostatectomy surgical specimen.

PURPOSE: We determine whether site specific labeling of sextant prostate biopsy cores predicts the site of extracapsular extension in a radical prostatectomy specimen, thereby justifying increased cost of pathological evaluation. MATERIALS AND METHODS: Between January 1994 and December 1997, 407 radical prostatectomies were performed at our institution by a single surgeon (H. L.). Surgical specimens showing extracapsular extension were examined by a single pathologist (J. M.) to identify the site of extension. Several different methods of submitting transrectal ultrasound guided biopsy cores were used since the majority of cases did not undergo biopsy at our institution. In 243 cases sextant biopsies were labeled right versus left. Of these cases 103 specimen cores were individually labeled. The ability of the positive biopsy core location to predict the location of extracapsular extension in the surgical specimen was determined. Univariate and multivariate logistic regression analyses were performed to assess the ability of biopsy core characteristics, including Gleason score, percentage of cancer in the core, core location and number of positive cores in the specimen, to predict the site of extracapsular extension. A similar analysis was performed for the 243 cases with right versus left core labeling. RESULTS: The positive predictive value was 8.9+/-2.2% for a single positive core to identify the location of extracapsular extension correctly in the individually labeled core cases. The absence of cancer in a sextant biopsy had a negative predictive value of 96.9+/-1.4%. The overall sensitivity was 59.4+/-3.8% for a positive biopsy core. In the right versus left core cases the positive predictive value was 12.9+/-3.0% with a sensitivity of 85.1+/-3.2%. In an individual core Gleason score 8 or greater and/or cancer in more than 50% of tissue enhanced the positive predictive value but not to a clinically useful level. Multivariate logistic regression identified Gleason score, number of positive ipsilateral cores and base position of the positive biopsy as the most predictive variables for the site of extracapsular extension. CONCLUSIONS: When submitting biopsy specimens by individually labeled core or right versus left core, the positive predictive value of an individual positive core for the location of extracapsular extension is not sufficient to guide the surgical decision to spare or excise a neurovascular bundle. Therefore, the clinical information provided by individually labeled or right versus left core labeling does not justify the increased associated costs.

Multimedia education in left ventricular ejection fraction assessment.

This paper reports the results of a small study that tested whether the skills of both trained and untrained observers could be quantitatively assessed and improved through multimedia computer-based instruction in the visual assessment of left ventricular ejection fraction (LVEF) through echocardiography. We found that multimedia educational applications can both speed the process of acquiring clinical skills in visual quantification of LVEF from echocardiography and also offer learners quantitative feedback on their progress toward acquiring these skills.

Computer-aided learning validation: a CAI-critical mission.

Despite a marked increase in computer-assisted instructional applications (CAI) over the past few years, little attention has been paid to revising traditional approaches toward educational testing. This paper reports a CAI project that emphasizes integrating the testing and training of visual judgmental capacities of health care professionals. It takes advantage of the computer's ability to display digital video segments and to record and compare user learning accomplishment and at the same time a normative performance scale can be developed. The program uses a method which, in addition to validating the efficacy of the project itself, collects data and stratifies users' level of proficiency by integrating pre-test and post-test modules. Routine incorporation of these principles in CAI may provide a more effective means of correctly evaluating the individual's mastery of a topic.