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PURPOSE: Dim light vision disturbances (DLD) comprise a wide range of symptoms affecting the quality of vision at low illumination including glare, halos, and starbursts. This exploratory study investigated 1.0% phentolamine mesylate ophthalmic solution (PMOS) as a treatment to improve vision and image quality for patients with DLD. METHODS: In this placebo-controlled, randomized, double-masked clinical trial, 24 adult patients with severe DLD were randomized in a 2:1 ratio to receive either one dose of PMOS or placebo. Subjects were eligible if they reported experiencing severe night vision difficulty that was not eliminated by distance spectacle correction and scored ≥0.3 log units below the normal range of contrast sensitivity assessed under mesopic conditions with glare at ≥2 spatial frequencies. Key efficacy outcomes were change from baseline in pupil diameter, contrast sensitivity, and visual acuity. Safety measures including intraocular pressure, conjunctival hyperemia, and systemic effects were also assessed. RESULTS: Eight subjects were randomized to placebo (63% female; mean age 47 years) and 16 were randomized to PMOS (75% female; mean age 42 years). Mean (SD) pupil diameter of PMOS-treated subjects decreased significantly - 1.3 mm (0 to - 2.8 mm) with p < 0.0001. Mean contrast sensitivity with glare in PMOS-treated subjects improved significantly post-treatment at spatial frequencies 3, 6, 12, and 18 cycles per degree (p ≤ 0.03). PMOS also demonstrated improvements in the numbers of letters read for mesopic and photopic, high- and low-contrast visual acuity (LCVA). Importantly, a statistically greater proportion of PMOS-treated eyes registered mesopic LCVA 5 letter (69% vs. 31%, p = 0.029) and 10 letter (34% vs. 6%, p = 0.04) improvement, with a trend at 15 letters (19% vs. 0%, p = 0.16). PMOS was well tolerated with the only reported side effect being a mild increase in conjunctival hyperemia. CONCLUSION: PMOS was well tolerated and effectively reduced pupil size with improvements in contrast sensitivity and visual acuity in adults with severe DLD. Future Phase 3 studies should be conducted to further evaluate its potential to treat DLD. TRIAL REGISTRATION: The trial registration number is NCT04004507 (02/07/2019). Retrospectively registered.
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Hiperemia , Cegueira Noturna , Adulto , Sensibilidades de Contraste , Feminino , Ofuscação , Humanos , Masculino , Pessoa de Meia-Idade , Visão Noturna , Soluções Oftálmicas , Fentolamina/uso terapêutico , Transtornos da Visão/tratamento farmacológicoRESUMO
SIGNIFICANCE: After a dilated eye examination, many patients experience symptoms of prolonged light sensitivity, blurred vision, and cycloplegia associated with pharmacological mydriasis. Phentolamine mesylate ophthalmic solution (PMOS) may expedite the reversal of mydriasis in patients, potentially facilitating return to functional vision and reducing barriers to obtaining dilated eye examinations. PURPOSE: The protracted reversal time after pharmacologically induced pupil dilation impairs vision. We tested the hypothesis that PMOS rapidly reduces pupil diameter in this acute indication. METHODS: In this double-masked placebo-controlled, randomized, two-arm crossover phase 2b trial, we evaluated the effects of one drop of 1% PMOS applied bilaterally in subjects who had their pupils dilated by one of two common mydriatic agents: 2.5% phenylephrine or 1% tropicamide. End points included change in pupil diameter, percent of subjects returning to baseline pupil diameter, and accommodative function at multiple time points. RESULTS: Thirty-one subjects completed the study (15 dilated with phenylephrine and 16 with tropicamide). Change in pupil diameter from baseline at 2 hours after maximal dilation with 1% PMOS was -1.69 mm and was significantly greater in magnitude compared with placebo for every time point beyond 30 minutes (P < .05). At 2 hours, a greater percentage of study eyes given 1% PMOS returned to baseline pupil diameter compared with placebo (29 vs. 13%, P = .03), which was this also seen at 4 hours (P < .001). More subjects treated with PMOS in the tropicamide subgroup had at least one eye returning to baseline accommodative amplitude at 2 hours (63 vs. 38%, P = .01). There were no severe adverse events, with only mild to moderate conjunctival hyperemia that resolved in most patients by 6 hours. CONCLUSIONS: Phentolamine mesylate ophthalmic solution at 1% reversed medically induced pupil dilation more rapidly than placebo treatment regardless of which mydriatic was used (adrenergic agonists and cholinergic blockers) with a tolerable safety profile.
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Antagonistas Adrenérgicos alfa/farmacologia , Midriáticos/administração & dosagem , Fentolamina/farmacologia , Pupila/efeitos dos fármacos , Acomodação Ocular/fisiologia , Administração Oftálmica , Adolescente , Adulto , Estudos Cross-Over , Método Duplo-Cego , Humanos , Masculino , Soluções Oftálmicas , Fenilefrina/administração & dosagem , Distúrbios Pupilares , Tropicamida/administração & dosagem , Adulto JovemRESUMO
PURPOSE: Phentolamine mesylate ophthalmic solution (PMOS), applied to the eye topically, was shown previously to have beneficial effects in patients with dim light vision disturbances (DLD), including decreased pupil diameter (PD), improved best-corrected distance visual acuity (BCDVA), as well as lower intraocular pressure (IOP). The ORION-1 trial evaluated the long-term safety and efficacy of PMOS in a glaucomatous, presbyopic population. PATIENTS AND METHODS: In this randomized, double-masked, multi-center, placebo-controlled, multiple-dose Phase 2b trial, 39 patients with elevated IOP were randomized to receive one evening dose of study medication or placebo for 14 days. The primary outcome measure was mean change in diurnal IOP, and the key secondary outcome measures included changes in PD, distance-corrected near visual acuity (DCNVA), and conjunctival hyperemia. RESULTS: Use of 1% PMOS did not lead to a statistically significant decrease in diurnal IOP compared to placebo (P = 0.89) but trended toward a greater decrease in patients with lower IOP baselines. PMOS produced a statistically significant mean 20% PD reduction under both photopic and mesopic conditions that was sustained for 36 hours post-dosing. A statistically significant number of patients with PMOS compared to placebo demonstrated ≥1 line of improvement in photopic DCNVA at day 8 (P = 0.0018), day 15 (P = 0.0072), and day 16 (P = 0.0163), with a trend for 2- and 3-line improvements at all time points. There was no statistical difference in conjunctival hyperemia compared to placebo. CONCLUSION: Although mean IOP was not lowered significantly, daily evening dosing of 1% PMOS was found to be well tolerated with no daytime conjunctival redness and demonstrated improvement in DCNVA with sustained PD reduction in a glaucomatous and presbyopic population. Smaller pupil size can have beneficial effects in improving symptoms of presbyopia and DLD, which will be the focus of further studies.
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STUDY OBJECTIVE: We evaluate the short- and long-term effect of a computerized provider order entry-based patient verification intervention to reduce wrong-patient orders in 5 emergency departments. METHODS: A patient verification dialog appeared at the beginning of each ordering session, requiring providers to confirm the patient's identity after a mandatory 2.5-second delay. Using the retract-and-reorder technique, we estimated the rate of wrong-patient orders before and after the implementation of the intervention to intercept these errors. We conducted a short- and long-term quasi-experimental study with both historical and parallel controls. We also measured the amount of time providers spent addressing the verification system, and reasons for discontinuing ordering sessions as a result of the intervention. RESULTS: Wrong-patient orders were reduced by 30% immediately after implementation of the intervention. This reduction persisted when inpatients were used as a parallel control. After 2 years, the rate of wrong-patient orders remained 24.8% less than before intervention. The mean viewing time of the patient verification dialog was 4.2 seconds (SD=4.0 seconds) and was longer when providers indicated they placed the order for the wrong patient (4.9 versus 4.1 seconds). Although the display of each dialog took only seconds, the large number of display episodes triggered meant that the physician time to prevent each retract-and-reorder event was 1.5 hours. CONCLUSION: A computerized provider order entry-based patient verification system led to a moderate reduction in wrong-patient orders that was sustained over time. Interception of wrong-patient orders at data entry is an important step in reducing these errors.
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Erros Médicos/prevenção & controle , Sistemas de Registro de Ordens Médicas , Adulto , Criança , Serviço Hospitalar de Emergência/organização & administração , Feminino , Humanos , Masculino , Erros Médicos/estatística & dados numéricos , Sistemas de Registro de Ordens Médicas/organização & administração , Sistemas de Registro de Ordens Médicas/estatística & dados numéricos , Segurança do PacienteRESUMO
Measurement is the basis for assessing potential improvements in healthcare quality. Measures may be classified into four categories: volume, structure, outcome, and process (VSOP). Measures of each type should be used with a full understanding of their cost and benefit. Although volume and structure measures are easily collected, impact on healthcare results is not always clear. Process measures are generally more difficult and expensive to collect, and the relationship between process and outcomes is only recently being explored. Knowledge of measure types and relationships among them, as well as emerging evidence on the role of patient satisfaction, must be used to guide improvements and ultimately for demonstrating value in healthcare.
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Atenção à Saúde/normas , Satisfação do Paciente , Qualidade da Assistência à Saúde/organização & administração , HumanosRESUMO
Since its inception in 2006, the New York City (NYC) Task Force for Patients with Burns has continued to develop a city-wide and regional response plan that addressed the triage, treatment, transportation of 50/million (400) adult and pediatric victims for 3 to 5 days after a large-scale burn disaster within NYC until such time that a burn center bed and transportation could be secured. The following presents updated recommendations on these planning efforts. Previously published literature, project deliverables, and meeting documents for the period of 2009-2010 were reviewed. A numerical simulation was designed to evaluate the triage algorithm developed for this plan. A new, secondary triage scoring algorithm, based on co-morbidities and predicted outcomes, was created to prioritize multiple patients within a given acuity and predicted survivability cohort. Recommendations for a centralized patient and resource tracking database, plan operations, activation thresholds, mass triage, communications, data flow, staffing, resource utilization, provider indemnification, and stakeholder roles and responsibilities were specified. Educational modules for prehospital providers and nonburn center nurses and physicians who would provide interim care to burn injured disaster victims were created and pilot tested. These updated best practice recommendations provide a strong foundation for further planning efforts, and as of February 2011, serve as the frame work for the NYC Burn Surge Response Plan that has been incorporated into the New York State Burn Plan.
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Benchmarking/métodos , Queimaduras/epidemiologia , Planejamento em Desastres/métodos , Algoritmos , Unidades de Queimados , Queimaduras/prevenção & controle , Humanos , Cidade de Nova Iorque/epidemiologia , Triagem/métodosRESUMO
BACKGROUND: In 2008 New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, New York City, the largest not-for-profit, nonsectarian hospital in the United States, created and implemented a novel approach--the Housestaff Quality Council (HQC)--to engaging house-staff in quality and patient safety activities. METHODS: The HQC represented an innovative collaboration between the housestaff, the Department of Anesthesiology, the Division of Quality and Patient Safety, the Office of Graduate Medical Education, and senior leadership. As key managers of patient care, the housestaff sought to become involved in the quality and patient safety decision- and policy-making processes at the hospital. Its members were determined to decrease or minimize adverse events by facilitating multimodal communication, ensuring smart work flow, and measuring outcomes to determine best practices. The HQC, which also included frontline hospital staff or managers from areas such as nursing, pharmacy, and information technology, aligned its initiatives with those of the division of quality and patient safety and embarked on two projects--medication reconciliation and use of the electronic medical record. More than three years later, the resulting improvements have been sustained and three new projects--hand hygiene, central line-associated bloodstream infections, and patient handoffs--have been initiated. CONCLUSIONS: The HQC model is highly replicable at other teaching institutions as a complementary approach to their other quality and patient safety initiatives. However, the ability to sustain positive momentum is dependent on the ability of residents to invest time and effort in the face of a demanding residency training schedule and focus on specialty-specific clinical and research activities.
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Distinções e Prêmios , Hospitais de Ensino/organização & administração , Segurança do Paciente , Qualidade da Assistência à Saúde/organização & administração , Gestão da Segurança/organização & administração , Comitês Consultivos/organização & administração , Infecções Relacionadas a Cateter/prevenção & controle , Continuidade da Assistência ao Paciente/organização & administração , Registros Eletrônicos de Saúde/organização & administração , Desinfecção das Mãos , Humanos , Joint Commission on Accreditation of Healthcare Organizations , Liderança , Inovação Organizacional , Recursos Humanos em Hospital , Estados UnidosRESUMO
In meeting the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements, teaching hospitals often find it challenging to ensure effective involvement of housestaff in the area of quality and patient safety (QPS). Because housestaff are the frontline providers of care to patients, and medical errors occasionally occur based on their actions, it is essential for health care organizations to engage them in QPS processes.In early 2008 a Housestaff Quality Council (HQC) was established at New York-Presbyterian Hospital, Weill Cornell Medical Center, to improve QPS by engaging housestaff in policy and decision-making processes and to promote greater housestaff participation in QPS initiatives. It was quickly realized that the success of the HQC was highly contingent on alignment with the institution's overall QPS agenda. To this end, the position of resident QPS officer was created to strengthen the relationship between the hospital's strategic goals and the HQC. The authors describe the success of the resident QPS officers at their institution and observe that by appointing and supporting resident QPS officers, hospitals will be better able to meet their quality and safety goals, residency programs will be able to fulfill their required ACGME core competencies, and the overall quality and safety of patient care can be improved. Simultaneously, the creation of this position will help to create a new cadre of physician leaders needed to further the goals of QPS in health care.
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Equipes de Administração Institucional/organização & administração , Internato e Residência/organização & administração , Relações Interprofissionais , Cultura Organizacional , Gestão da Segurança/organização & administração , Centros Médicos Acadêmicos , Hospitais de Ensino/organização & administração , Humanos , Corpo Clínico Hospitalar/organização & administração , Cidade de Nova Iorque , Inovação Organizacional , Gestão da Segurança/métodosRESUMO
Ten years after the 1999 Institute of Medicine report, it is clear that despite significant progress, much remains to be done to improve quality and patient safety (QPS). Recognizing the critical role of postgraduate trainees, an innovative approach was developed at New York-Presbyterian Hospital, Weill Cornell Medical Center to engage residents in QPS by creating a Housestaff Quality Council (HQC). HQC leaders and representatives from each clinical department communicate and partner regularly with hospital administration and other key departments to address interdisciplinary quality improvement (QI). In support of the mission to improve patient care and safety, QI initiatives included attaining greater than 90% compliance with medication reconciliation and reduction in the use of paper laboratory orders by more than 70%. A patient safety awareness campaign is expected to evolve into a transparent environment where house staff can openly discuss patient safety issues to improve the quality of care.
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Equipes de Administração Institucional/organização & administração , Internato e Residência , Corpo Clínico Hospitalar/normas , Melhoria de Qualidade/organização & administração , Gestão da Segurança/organização & administração , Comunicação , Humanos , Relações Interprofissionais , Corpo Clínico Hospitalar/organização & administração , New York , Cultura OrganizacionalRESUMO
At New York-Presbyterian Hospital, Weill Cornell Medical Center, an innovative approach to involving housestaff in quality and patient safety, policy and procedure creation, and culture change was led by the Department of Anesthesiology of the Weill Medical College of Cornell University. A Housestaff Quality Council was started in 2008 that has partnered with hospital leadership and clinical departments to engage the housestaff in quality and patient safety initiatives, resulting in measurable improvements in several patient care projects and enhanced working relationships among various clinical constituencies. Ultimately this attempt to change culture has found great success in fostering a relationship between the housestaff and the hospital in ways that have and will continue to improve patient care.
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Serviço Hospitalar de Anestesia/organização & administração , Cultura Organizacional , Melhoria de Qualidade/organização & administração , Gestão da Segurança , Atitude do Pessoal de Saúde , Comunicação , Registros Eletrônicos de Saúde , Humanos , Liderança , Erros Médicos/prevenção & controle , Corpo Clínico Hospitalar , Cidade de Nova Iorque , Pacientes , Médicos , Papel Profissional , Recursos HumanosRESUMO
Since 2006, the Joint Commission has required all hospitals to have a process in place for medication reconciliation (MR). Although it has been shown that MR decreases medical errors, achieving compliance has proven difficult for many health care institutions. This article describes a housestaff-championed intervention of a "hard stop" for on-admission MR orders that led to a statistically significant increase in compliance that was sustained at 6 months after intervention. Academic medical centers, which comprise large numbers of housestaff, can improve compliance with on-admission MR by engaging housestaff in the development of solutions and in communication to their peers, leading to sustained results.
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Centros Médicos Acadêmicos/normas , Erros Médicos/prevenção & controle , Corpo Clínico Hospitalar , Reconciliação de Medicamentos , Admissão do Paciente , Fidelidade a Diretrizes , Humanos , Erros Médicos/tendências , New York , Recursos HumanosRESUMO
BACKGROUND: Little is known about the actual treatment of patients with chronic obstructive pulmonary disease (COPD), either in the inpatient or outpatient settings. We hypothesized that there are substantial opportunities for improvement in adherence with current guidelines and recommendations. METHODS: We reviewed the medical records of all patients hospitalized with acute exacerbation of COPD between January 2005 and December 2006 at 5 New York City hospitals. RESULTS: There were 1285 unique patients with 1653 hospitalizations. Of these 1653, 83% were for patients with a prior history of COPD and 368 (22%) represented repeat admissions during our study period. The majority were treated during their hospitalization with a combination of systemic steroids (85%), bronchodilators (94%) and antibiotics (80%). There were 59 deaths (3.6%). Smoking cessation counseling was offered to 48% of active smokers. Influenza and pneumococcal vaccines were administered to half of eligible patients. On discharge, only 46.0% were prescribed maintenance bronchodilators and 24% were not prescribed any inhaled therapy. Even in the 226 unique patients (17.6%) readmitted at least once during course of the study, on discharge only 44.7% were prescribed maintenance bronchodilators and 23% were not prescribed any regular inhaled therapy. CONCLUSIONS: Patients hospitalized with acute exacerbation of COPD generally receive adequate hospital care, but there may be opportunities to improve care pharmacologically and with smoking cessation counseling and vaccination during and after hospitalization.
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Readmissão do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Doença Pulmonar Obstrutiva Crônica/terapia , Qualidade da Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Broncodilatadores/uso terapêutico , Estudos de Coortes , Comorbidade , Feminino , Glucocorticoides/uso terapêutico , Humanos , Vacinas contra Influenza/administração & dosagem , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Alta do Paciente/estatística & dados numéricos , Vacinas Pneumocócicas/administração & dosagem , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/mortalidade , Estudos Retrospectivos , Abandono do Hábito de FumarRESUMO
Understanding how and why errors in healthcare happen is essential to improving patient safety. Yet exposure to this learning process is usually limited to those events occurring in one's own institution. Virtual Safety Rounds expands this learning opportunity to multiple hospitals. Twice each month physicians; nurses; and quality, risk, and patient safety staff participate in a discussion about a recent safety event within the healthcare system. Within this safe collegial environment experiences, plans of correction and lessons learned are shared. Hospitals are learning from each other without having to experience the patient safety issue directly.
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Erros Médicos/prevenção & controle , Interface Usuário-Computador , Comunicação por Videoconferência , Competência Clínica , Humanos , Gestão da Segurança/métodos , Estados UnidosRESUMO
An extraordinary number of health care quality and patient safety indicators have been developed for hospitals and other health care institutions; however, few meaningful indicators exist for comprehensive assessment of hospital emergency management. Although health care institutions have invested considerable resources in emergency management preparedness, the need for universally accepted, evidence-based performance metrics to measure these efforts remains largely unfulfilled. We suggest that this can be remediated through the application of traditional health care quality paradigms, coupled with novel analytic approaches to develop meaningful performance data in hospital emergency management.
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Benchmarking , Serviço Hospitalar de Emergência/organização & administração , Indicadores de Qualidade em Assistência à Saúde/normas , Planejamento em Desastres , Serviço Hospitalar de Emergência/normasRESUMO
The objective of this study was to describe a draft response plan for the tiered triage, treatment, or transportation of 400 adult and pediatric victims (50/million population) of a burn disaster for the first 3 to 5 days after injury using regional resources. Review of meeting minutes and the 11 deliverables of the draft response plan was performed. The draft burn disaster response plan developed for NYC recommended: 1) City hospitals or regional burn centers within a 60-mile distance be designated as tiered Burn Disaster Receiving Hospitals (BDRH); 2) these hospitals be divided into a four-tier system, based on clinical resources; and 3) burn care supplies be provided to Tier 3 nonburn centers. Existing burn center referral guidelines were modified into a hierarchical BDRH matrix, which would vector certain patients to local or regional burn centers for initial care until capacity is reached; the remainder would be cared for in nonburn center facilities for up to 3 to 5 days until a city, regional, or national burn bed becomes available. Interfacility triage would be coordinated by a central team. Although recommendations for patient transportation, educational initiatives for prehospital and hospital providers, city-wide, interfacility or interagency communication strategies and coordination at the State or Federal levels were outlined, future initiatives will expound on these issues. An incident resulting in critically injured burn victims exceeding the capacity of local and regional burn center beds may be a reality within any community and warrants a planned response. To address this possibility within New York City, an initial draft of a burn disaster response has been created. A scaleable plan using local, state, regional, or federal health care and governmental institutions was developed.
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Queimaduras/prevenção & controle , Defesa Civil , Planejamento em Desastres/organização & administração , Incidentes com Feridos em Massa , Socorro em Desastres , Serviços Urbanos de Saúde , Queimaduras/epidemiologia , Humanos , Cidade de Nova Iorque/epidemiologia , Transferência de Pacientes , Triagem , Estados Unidos/epidemiologia , População UrbanaRESUMO
Hospital preparedness for nosocomial or community-wide outbreaks of communicable disease includes the capability for rapid, self-reliant administration of prophylaxis to its workforce, with the goal of minimal disruption of patient care, here called hospital "self-prophylaxis." We created a new discrete-event simulation model of a hypothetical hospital wing to compare the operational charateristics of standard single-line, "first-come, first-served" dispensing clinics with those of 2 staff management strategies that can dramatically reduce staff waiting time while centralizing dispensing around existing pharmacy-distribution points.
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Antibioticoprofilaxia/estatística & dados numéricos , Planejamento em Desastres/organização & administração , Surtos de Doenças/prevenção & controle , Controle de Infecções/métodos , Recursos Humanos em Hospital , Planejamento em Desastres/métodos , Administração Hospitalar , Humanos , Controle de Infecções/organização & administração , Modelos Organizacionais , Saúde Ocupacional , Pesquisa Operacional , Gestão da Segurança/métodos , Gestão da Segurança/organização & administração , Gerenciamento do Tempo , Listas de EsperaRESUMO
BACKGROUND: Clinicians are an essential component of the medical response to an emergency in which there are actual or suspected injuries. However, little is known about the institutional notification methods for clinicians during emergencies, particularly for off-site staff. Further, there is little knowledge regarding clinicians' level of awareness of the emergency plans at hospitals with which they are affiliated, or of their knowledge regarding the notification protocols involved in plan activation during an emergency. If physicians are unaware of how to respond to an actual or threatened emergency, the effectiveness of any hospital emergency plan is severely limited. OBJECTIVE: This study sought to examine hospital emergency plans, institutional clinician notification, and recall procedures, as well as clinicians' level of knowledge regarding the emergency notification and recall protocol(s) at the hospital(s) with which they are affiliated. METHODS: Written surveys were sent to hospital emergency coordinators, chiefs of service, and individual clinicians employed by a large, multihospital healthcare system in a major urban area. RESULTS: We found that 64 percent of respondents' hospitals had a recall protocol; of those, 53 percent required that the hospital contact clinicians, with 17 percent of those hospitals using a central operator to make the calls. Of the chiefs of services who participated, 56 percent claimed to be very familiar with their facility's emergency plan, and 53 percent knew that it had been activated at least once in the past year. CONCLUSIONS: Hospital emergency responders are not sufficiently knowledgeable of their institutions' emergency plans. In order to ensure sufficient surge capacity and timely response, a tiered activation system, intimately familiar to potential responders, should be developed, taught, and drilled by hospitals to formalize physician call-up.
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Planejamento em Desastres/organização & administração , Sistemas de Comunicação entre Serviços de Emergência/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Conhecimentos, Atitudes e Prática em Saúde , Hospitais/estatística & dados numéricos , Médicos , Humanos , Fatores de Tempo , Estados Unidos , População UrbanaRESUMO
BACKGROUND: Clinical guidelines support the use of preoperative B-blocker in select patients. Patient safety groups have sought to measure the level of adherence to these recommendations. OBJECTIVE: This study was performed to compare the utilization of preoperative B-blocker with current guidelines across multiple diverse institutions. DESIGN: Retrospective chart review was performed of inpatients undergoing noncardiac surgery across 5 hospital centers during 2003 to 2004. The primary outcome of interest was the administration of preoperative B-blocker. PARTICIPANTS: The study sample included 1,304 randomly selected patients meeting the guideline criteria for preoperative B-blockade. MEASUREMENTS AND MAIN RESULTS: Among patients meeting recommendations for preoperative B-blocker, only 44% (430/983) received B-blocker before surgery. Patients who had not previously received B-blocker were given B-blocker before surgery in only 14% (85/600) of cases. Target heart rates goals for perioperative B-blockade were achieved in 26% (113/430) of cases. Predictors for initiating preoperative B-blocker included nonelective surgery or a history of hypertension or diabetes. Individual hospitals were independently predictive of preoperative B-blocker administration in multivariable models. CONCLUSIONS: Preoperative B-blocker was significantly underutilized when compared with the current guideline recommendations. Target heart rate goals were not achieved in clinical practice, and few hospitalized patients had preoperative B-blockade initiated. The lack of adherence to preoperative B-blocker recommendations in practice may be impacted by ongoing clinical questions regarding the appropriate selection of candidates for this therapy. Further efforts toward achieving guideline recommendations for preoperative B-blocker use should be focused on the subset of patients that are uniformly agreed upon to be at high risk for cardiac events.
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Antagonistas Adrenérgicos beta/uso terapêutico , Cooperação do Paciente , Idoso , Idoso de 80 Anos ou mais , Demografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New York , Cuidados Pré-Operatórios , Estudos Retrospectivos , Software , Recusa do Paciente ao TratamentoRESUMO
BACKGROUND: We assessed the clinical impact of an interdisciplinary, cardiac nurse practitioner-facilitated chest pain (CP) initiative that stresses an early invasive approach for patients with CP with acute coronary syndromes in traditionally underserved patient populations, including females, blacks, Hispanics, and patients older than 60 years. METHODS: Two groups of patients were identified: Pre-CP initiative (December 1999-February 2000) and post-CP initiative (December 2000-February 2001). RESULTS: Analysis of 714 patients revealed significantly more cardiac diagnoses post-CP initiative (61% pre-CP initiative vs. 73% post-CP initiative, P = 0.002), including in patients with myocardial infarction (MI) who were older than 60 years, females, and Hispanics. There was a significant increase in rates of cardiac catheterizations within 1 week of admission (10.5% vs. 20.4%, P <0.001), including in Hispanics. For rates of coronary artery stenting and/or bypass grafting (CABG), there was also a significant increase post-CP initiative (2.5% vs. 10.1%, P = 0.0005), as well as for Hispanics. Length of stay was significantly reduced for patients older than 60 years (8.3 vs. 5.8 days, P = 0.002). CONCLUSION: Establishment of an interdisciplinary, cardiac nurse practitioner-facilitated CP initiative is associated with improvement in several clinical processes and outcomes: increased cardiac disease diagnosis in females, Hispanics, and patients older than 60 years; increased rates of cardiac catheterizations in Hispanic patients, increased rates of coronary artery stenting and/or CABG, particularly in Hispanic patients; and decreased length of stay in patients older than 60 years. These data support a targeted interdisciplinary CP initiative as a strategy to systematically enhance access to cardiovascular diagnosis in underserved patient populations.