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1.
Pediatr Emerg Care ; 28(1): 12-6, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-22193693

RESUMO

BACKGROUND: Unsuccessful or traumatic lumbar punctures (LPs) occur commonly and contribute to patient discomfort and to challenges in medical decision making in the pediatric emergency department (ED). OBJECTIVE: We produced an instructional video demonstrating the best practices in pediatric LP technique. We hypothesized that the performance of LPs would change and the rate of successful LPs would increase after watching the video. METHODS: This was a prospective study of LPs performed in an urban, academic pediatric ED before and after an educational intervention. Lumbar punctures performed during year 1 constituted the control arm. During year 2, all medical practitioners working in the ED watched the instructional video, and this constituted the interventional arm. The practitioner performing the LP completed a standardized data collection form after each LP procedure, and medical records were reviewed. RESULTS: Data forms were collected on 668 LPs during the study period, 391 during year 1 and 277 during year 2. There was neither a significant change in overall LP success rate between the 2 years (56.8% year 1 vs 53.4% year 2) nor a significant difference in median number of LP attempts required per patient (P = 0.78). Seventy-eight percent of participants who viewed the LP video during year 2 stated that the video helped increase their comfort level with performing LPs. The odds of using the techniques endorsed in the educational video were significantly higher during year 2 compared to year 1 for use of local anesthetic, early stylet removal, and vertical patient position. CONCLUSIONS: The video increased practitioners' comfort level with the performance of pediatric LPs and adherence to evidence-based best practices. It was not associated with an increased rate of successful LPs.


Assuntos
Educação Continuada/métodos , Educação Médica/métodos , Medicina de Emergência/educação , Pediatria/educação , Punção Espinal/métodos , Gravação de Videoteipe , Adolescente , Criança , Pré-Escolar , Competência Clínica , Educação Médica Continuada/métodos , Avaliação Educacional , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Curva de Aprendizado , Masculino , Dor/prevenção & controle , Assistentes Médicos/educação , Assistentes Médicos/estatística & dados numéricos , Médicos/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Manejo de Espécimes/instrumentação , Manejo de Espécimes/métodos , Traumatismos da Medula Espinal/prevenção & controle , Punção Espinal/efeitos adversos , Punção Espinal/instrumentação , Estudantes de Medicina/estatística & dados numéricos , Adulto Jovem
2.
J Gen Intern Med ; 23(6): 755-61, 2008 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-18369679

RESUMO

BACKGROUND: Challenges in implementing electronic health records (EHRs) have received some attention, but less is known about the process of transitioning from legacy EHRs to newer systems. OBJECTIVE: To determine how ambulatory leaders differentiate implementation approaches between practices that are currently paper-based and those with a legacy EHR system (EHR-based). DESIGN: Qualitative study. PARTICIPANTS: Eleven practice managers and 12 medical directors all part of an academic ambulatory care network of a large teaching hospital in New York City in January to May of 2006. APPROACH: Qualitative approach comparing and contrasting perceived benefits and challenges in implementing an ambulatory EHR between practice leaders from paper- and EHR-based practices. Content analysis was performed using grounded theory and ATLAS.ti 5.0. RESULTS: We found that paper-based leaders prioritized the following: sufficient workstations and printers, a physician information technology (IT) champion at the practice, workflow education to ensure a successful transition to a paperless medical practice, and a high existing comfort level of practitioners and support staff with IT. In contrast, EHR-based leaders prioritized: improved technical training and ongoing technical support, sufficient protection of patient privacy, and open recognition of physician resistance, especially for those who were loyal to a legacy EHR. Unlike paper-based practices, EHR-based leadership believed that comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome. CONCLUSIONS: Leadership at paper- and EHR-based practices in 1 academic network has different priorities for implementing a new EHR. Ambulatory practices upgrading their legacy EHR have unique challenges.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Sistemas Computadorizados de Registros Médicos/organização & administração , Administração da Prática Médica/organização & administração , Atitude Frente aos Computadores , Hospitais de Ensino , Humanos , Entrevistas como Assunto , Cidade de Nova Iorque , Inovação Organizacional , Diretores Médicos
3.
Inform Prim Care ; 16(4): 277-84, 2008.
Artigo em Inglês | MEDLINE | ID: mdl-19192329

RESUMO

OBJECTIVES: To determine pre-implementation perspectives of institutional, practice and vendor leadership regarding best practice for implementation of two ambulatory electronic health records (EHRs) at an academic institution. DESIGN: Semi-structured interviews with ambulatory care network and information systems leadership, medical directors, practice managers and vendors before EHR implementation. Results were analysed using grounded theory with ATLAS.ti version 5.0. MEASUREMENTS: Qualitative data on perceived benefits of EHRs as well as facilitators and barriers to successful implementation. RESULTS: Interviewees perceived data accessibility, quality and safety measurement, improvement and reporting as benefits of EHR use. Six themes emerged for EHR implementation best practice: effective communication; successful system migration; sufficient hardware, technical equipment, support and training; safeguards for patient privacy; improved efficiency; and a sustainable business plan. CONCLUSIONS: Achieving the benefits of EHRs identified by our interviewees depends on successful implementation and use. Further identification of best implementation practices for EHRs is required, given the financial and clinical consequences of poor implementation.


Assuntos
Instituições de Assistência Ambulatorial , Difusão de Inovações , Sistemas Computadorizados de Registros Médicos/organização & administração , Atitude Frente aos Computadores , Comunicação , Confidencialidade , Administradores de Instituições de Saúde/psicologia , Entrevistas como Assunto , Cidade de Nova Iorque , Estudos de Casos Organizacionais , Desenvolvimento de Programas/métodos
4.
Acad Emerg Med ; 11(7): 736-43, 2004 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-15231460

RESUMO

OBJECTIVE: The authors sought to derive maximally sensitive prediction rules for identifying children with significant fractures after acute twisting injuries to the ankle. METHODS: The authors prospectively enrolled a convenience sample of patients younger than 18 years of age who presented to the pediatric emergency department of an urban, tertiary care center after sustaining acute twisting injuries of the ankle. The ankle was defined in two regions: the malleolar zone and the midfoot zone. Clinical findings were documented on standardized data collection sheets by faculty physicians before completion of ankle and/or foot radiograph series. Significant fracture was defined a priori as any fracture other than an avulsion < or =3 mm. The authors conducted binary recursive partitioning with cross-validation to develop models to predict fracture. RESULTS: Data from 717 enrolled patients with a median age of 12.9 years were analyzed. Significant malleolar zone and midfoot zone fractures were diagnosed in 81 of 682 (11.9%) and 10 of 173 (5.8%) patients for whom ankle and foot radiographs were obtained. Recursive partitioning identified patients at low risk for malleolar zone fracture if 1) they had no bone tenderness at either malleolus or the region just proximal to the fibula malleolus or 2) they had bone tenderness at either malleolus but were able to walk four steps in the emergency department and had no swelling at either malleolus. The two-part malleolar zone rule had a sensitivity of 100% and specificity of 19.1% on the learning data and 95.1% (95% confidence interval [95% CI] = 87.8% to 98.6%) and 20.0% (95% CI = 16.8% to 23.4%) on the test data. Tenderness either at the proximal fifth metatarsal or cuboid identified midfoot zone fractures with a sensitivity of 100% and specificity of 31.9% on the learning data and 90.0% (95% CI = 55.4% to 99.7%) and 35.0% (95% CI = 27.7% to 42.8%) on the test sample. CONCLUSIONS: A set of sensitive prediction rules was developed to identify children with significant fractures after twisting injuries to the ankle. External validation and refinement of the rules will be needed before recommendation of widespread use.


Assuntos
Traumatismos do Tornozelo/complicações , Traumatismos do Tornozelo/diagnóstico , Protocolos Clínicos , Medicina de Emergência/métodos , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/etiologia , Adolescente , Criança , Feminino , Fíbula/lesões , Fraturas Ósseas/classificação , Humanos , Masculino , Ossos do Metatarso/lesões , Valor Preditivo dos Testes , Estudos Prospectivos , Ossos do Tarso/lesões , Tíbia/lesões
5.
Pediatr Emerg Care ; 20(2): 85-88, 2004 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-14758304

RESUMO

OBJECTIVES: Although often managed differently than older children, no study has specifically described the clinical course of urinary tract infections (UTIs) in young infants. Our objective was to determine the risk of progression of illness and the pattern of fever resolution in infants younger than 60 days of age with Gram-negative rod UTIs. METHODS: We completed a retrospective medical chart review. Patients younger than 60 days of age presenting to an urban, tertiary care pediatric hospital were included if they had single organism growth of Gram-negative rods in any amount from suprapubic aspiration samples or more than 10,000 cfu/mL from catheterized specimens. Significant progression of illness was defined as the need for transfer to an intensive care setting. Fever was defined as a rectal temperature of 38.0 degrees C or higher or an axillary temperature 37.0 degrees C or higher. Temperatures were assigned to blocks of 4 hours. RESULTS: Of 128 patients with available records, none were transferred from the general pediatric ward to the intensive care unit and 2 were transferred to a step-down unit for events potentially unrelated to the UTI. No patient had a positive repeat urine culture. For patients with fever, median time to fever resolution was within the 4 to 8 hour time block. Eighty-five percent of the febrile patients became afebrile within 24 hours and only 3.6% were febrile after 48 hours. CONCLUSIONS: Progression of illness in infants with Gram-negative rod UTIs is unlikely. Fever resolution is rapid. If subsequent studies concur with our findings, outpatient therapy or short-stay unit admission may become a viable management strategy.


Assuntos
Infecções por Bactérias Gram-Negativas , Infecções Urinárias , Antibacterianos/uso terapêutico , Bacteriemia/complicações , Bacteriemia/microbiologia , Contagem de Colônia Microbiana , Progressão da Doença , Feminino , Febre/etiologia , Bactérias Gram-Negativas/isolamento & purificação , Infecções por Bactérias Gram-Negativas/complicações , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Sistemas de Informação Hospitalar , Humanos , Lactente , Recém-Nascido , Masculino , Meningites Bacterianas/complicações , Estudos Prospectivos , Estudos Retrospectivos , Infecções Urinárias/complicações , Infecções Urinárias/tratamento farmacológico , Urina/microbiologia
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