Value of repeat head computed tomography after traumatic brain injury: systematic review and meta-analysis.

Diagnosis and management of traumatic brain injury (TBI) is crucial to improve patient outcomes. While initial head computed tomography (CT) scan is the optimum tool for quick and accurate detection of intracranial hemorrhage, the guidelines on use of repeat CT differ among institutions. Three systematic reviews have been conducted on a similar topic; none have performed a comprehensive meta-analysis of all studies. Search of Medline, the Cochrane Library database, and Clinicaltrials.gov , and a hand search of conference abstracts and references for all completed studies reporting data on change in management following repeat CT was conducted. Two authors reviewed all studies and extracted data using a standardized form. A proportional meta-analysis was conducted using the random-effects model for outcomes related to any change in management following repeat CT. Any change in management included intracranial intervention, change in intracranial pressure monitoring, and/or administration of drug therapy. Search results yielded 6982 references. In all, 41 studies enrolling 10,501 patients were included. Change in management following repeat CT was reported in 13 prospective and 28 retrospective studies and yielded a pooled proportion of 11.4% (95% confidence interval [CI] 5.9-18.4) and 9.6% (95% CI 6.5-13.2), respectively. In a subgroup analysis of mild TBI patients (Glasgow Coma Scale score 13 to 15), five prospective and nine retrospective studies reported on change in management following repeat CT with the pooled proportion across prospective studies at 2.3% (95% CI 0.3-6.3) and across retrospective studies at 3.9% (95% CI 2.3-5.7), respectively. The evidence suggests that repeat CT in patients with TBI results in a change in management for only a minority of patients. Better designed studies are needed to address the issue of the value of repeat CT in the management of TBI.

Hospital outcomes for a home-based palliative medicine consulting service.

BACKGROUND: There is a growing need for palliative care services located outside of hospitals. OBJECTIVE: This study's objective was to evaluate a home-based, nonhospice, palliative medicine (PM) consultation practice within a fee-for-service environment. METHOD: Hospital and emergency department (ED) utilization and cost data obtained from administrative records were analyzed with longitudinal analyses to compare use 18 months before and after service enrollment in a single patient group. PARTICIPANTS: Patients (N=369) with advanced complex illness (ACI) referred for home-based palliative consultation participated in the study. INTERVENTION: Consultation conducted by nurse practitioners included a multidimensional assessment with recommendations to outpatient physicians for symptom management and guidance to patient and family for goals of treatment and advanced care planning (ACP). Nurse practitioners were supported by a collaborating PM physician. Follow-up visits varied by need for symptom management and ACP. RESULTS: Total hospitalizations, total hospital days, total and variable costs, and probability of a 30-day readmission were significantly reduced in the 18-month period following program enrollment. However, probability of an ED visit was not reduced. CONCLUSIONS: While requiring replication with rigorous methods, preliminary results suggest a home-based PM practice may reduce hospital utilization for ACI patients.

An analysis of the New York University Emergency Department Algorithm's suitability for use in gauging changes in ED usage patterns.

BACKGROUND: The Emergency Department Algorithm (EDA) developed at New York University uses administrative discharge data to distill hundreds of International Classification of Diseases-9 codes for emergency department (ED) visits into 4 categories, making it attractive to researchers and policy makers. The EDA has been used to analyze patterns of ED visits in a wide variety of locations and populations. However, there are concerns regarding the validity and use of the EDA for research and policy. OBJECTIVE: To explain the findings of previous EDA users that it appears to lack sensitivity in detecting changes in ED utilization patterns. STUDY DESIGN: Mathematical simulation was used to analyze and explain the performance of the EDA in detecting differences in utilization patterns across hypothetical ED populations. Sensitivity analysis was used to illustrate the magnitude of changes in EDA outputs relative to changes in ED populations using a national sample of actual ED patients. RESULTS: The vast majority of possible EDA outputs are clustered so tightly as to show no significant change in outputs between different hypothetical populations. Sensitivity analysis shows that changes in EDA outputs are not nearly as great as the magnitude of the input differences across real-world populations. CONCLUSIONS: The EDA categorizes a very large variety of ED visits into a relatively small group of outputs. Its operating characteristics suggest that the EDA is insufficiently sensitive to changes in ED utilization patterns to be useful in assessing interventions to change them. This finding should caution potential users to consider the EDA's limitations before using it.

Hourly rounding: challenges with implementation of an evidence-based process.

Introduction of an evidence-based practice change, such as hourly rounding, can be difficult in the hospital setting. This study used ethnographic methods to examine problems with the implementation of hourly rounding on 2 similar inpatient units at our hospital. Results indicate that careful planning, communication, implementation, and evaluation are required for successful implementation of a nursing practice change.

Association of health information technology and teleintensivist coverage with decreased mortality and ventilator use in critically ill patients.

BACKGROUND: Little evidence exists to support implementing various health information technologies, such as telemedicine, in intensive care units. METHODS: A coordinated health information technology bundle (HITB) was implemented along with remote intensivist coverage (RIC) at a 727-bed academic community hospital. Critical care specialists provided bedside coverage during the day and RIC at night to achieve intensivist coverage 24 hours per day, 7 days per week. We evaluated the effect of HITB-RIC on mortality, ventilator and vasopressor use, and the intervention length of stay. We compared our results with those achieved at baseline. RESULTS: A total of 954 control patients who received care for 16 months before the implementation of HITB-RIC and 959 study patients who received care for 10 months after the implementation were included in the analysis. Mortality for the control and intervention groups were 21.4% and 14.7%, respectively. In addition, the observed mortality for the intervention group was 75.8% (P < .001) of that predicted by the Acute Physiology and Chronic Health Evaluation IV hospital mortality equations, which was 29.5% lower relative to the control group. Regression results confirm that the hospital mortality of the intensive care unit patients was significantly lower after implementation of the intervention, controlling for predicted risk of mortality and do-not-resuscitate status. Overall, intervention patients also had significantly less (P = .001) use of mechanical ventilation, controlling for body-system diagnosis category and severity of illness. CONCLUSION: The use of HITB-RIC was associated with significantly lower mortality and less ventilator use in critically ill patients.

Understanding the role of the promotora in a Latino diabetes education program.

We explore the role of the promotora de salud (health promoter) who provided diabetes self-management education to Puerto Rican diabetics in her community. The education program was developed as a hospital and community-based organization partnership. Information from both Spanish-language focus groups with 35 class participants and an in-depth interview with the promotora indicated patients appreciated having the classes taught in Spanish by a Latina promotora from their community. Respondents reported satisfaction with the program, increased ability to self-manage diabetes, and strengthened connections with other Latino diabetics. Terms patients used for the promotora included comadre, hijita, and buena profesora. Some of these words denote almost kinship-level connections, suggesting that patients were forming strong connections with the promotora. Specific promotora roles were identified but varied among patients, promotora, and the literature. This hospital and community-based organization partnership promotora model appears to be effective for providing chronic disease self-management education in an urban community setting.