Improving Care for Critical Care Patients by Strategic Alignment of Quality Goals With a Physician Financial Incentive Model.

BACKGROUND AND OBJECTIVES: The passage of the Affordable Care Act has ignited a shift from the pay-for-performance model to value-based care with a particular relevance in critical care settings. Provider incentive programs are widely considered as a means to reward providers based on the achievement of preset quality metrics. This article aims to demonstrate the effects of a provider incentive program in the critical care delivery system in a large academic center in the Northeastern United States. METHODS: This article describes the results of a retrospective analysis of a performance-driven quality improvement initiative at a critical care facility of an academic medical center using a quasi-experimental pre-/posttest design. A set of quality measures was selected as outcome metrics. Selection criteria for the process measures are as follows: (i) the metric goals should be influenced by the physician's input to a large degree; (ii) the measure must be transparent and accessible within the hospital-wide data reporting system; (iii) the metric that required group effort and interdisciplinary collaboration to achieve; and (iv) the measure must directly affect patient outcome. The outcome metrics are central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), standardized infection ratio (SIR), Foley catheter and central line utilization standardized utilization ratio (SUR), hand hygiene compliance, and adherence to respiratory recovery pathway goals. These metrics were tracked from for 3 years with success defined as achieving set benchmarks for each metric. RESULTS: The average CLABSI SIR and CAUTI SIR across all intensive care units (ICUs) decreased by 44% (P = .05) and 87% (P = .02) over 3 years as well as the central line and Foley catheter utilization falling by 41% and 30%, respectively. Hand hygiene compliance in the ICUs improved for the same period by 27 percentage points, as did compliance with the respiratory recovery pathway program by 4 percentage points. CONCLUSION: The use of a physician-driven financial incentive model in a critical care setting measured by outcome metrics dependent on physician input is successful with rigorous implementation and careful evaluation.

Mechanisms of nanoparticle-mediated photomechanical cell damage.

Laser-assisted killing of gold nanoparticle targeted macrophages was investigated. Using pressure transient detection, flash photography and transmission electron microscopy (TEM) imaging, we studied the mechanism of single cell damage by vapor bubble formation around gold nanospheres induced by nanosecond laser pulses. The influence of the number of irradiating laser pulses and of particle size and concentration on the threshold for acute cell damage was determined. While the single pulse damage threshold is independent of the particle size, the threshold decreases with increasing particle size when using trains of pulses. The dependence of the cell damage threshold on the nanoparticle concentration during incubation reveals that particle accumulation and distribution inside the cell plays a key role in tissue imaging or cell damaging.

Reduction of background in optoacoustic image sequences obtained under tissue deformation.

For real-time optoacoustic imaging of the human body, a linear array transducer and reflection mode optical irradiation is preferably used. Experimental outcomes however revealed that such a setup results in significant image background, which prevents imaging structures at the ultimate depth limited only by the optical attenuation of the irradiating light and the signal noise level. Various sources of image background, such as bulk tissue absorption, reconstruction artifacts, and backscattered ultrasound, could be identified. To overcome these limitations, we developed a novel method that results in significantly reduced background and increased imaging depth. For this purpose, we acquire, in parallel, a series of optoacoustic and echo-ultrasound images while the tissue sample is gradually deformed by an externally applied force. Optoacoustic signals and background signals are differently affected by the deformation and can thus be distinguished by image processing. This method takes advantage of a combined optoacoustic/echo-ultrasound device and has a strong potential for improving real-time optoacoustic imaging of deep tissue structures.