Pharmacy staffing, workload, and productivity benchmarks in state psychiatric hospitals.

PURPOSE: Current benchmark statistics on staffing, workload, and productivity in hospital pharmacy departments of state psychiatric hospitals are described and assessed by hospital size. METHODS: An electronic survey of state psychiatric hospitals was conducted. Hospitals were categorized based on number of occupied beds. Descriptive statistics using Student's t tests, Pearson's chi-square tests, and Pearson's correlation coefficients were used to characterize the data and compare productivity by hospital size. RESULTS: Responses were received from 41 of 116 hospitals, yielding a response rate of 35.3%. Respondent hospitals did not differ from nonrespondents based on demographic data. Average inpatient census, patient days per year, expenditures, and workload were found to correlate positively with hospital size (r = 0.381-0.991, p < 0.05). Over 30% of hospitals reported using no indicators to monitor pharmacy productivity. Productivity ratios differed between very small-small and medium-large hospital groups: mean pharmaceutical expenditures per 100 occupied beds and per 1,000 patient days (p = 0.017 and 0.05, respectively), mean full-time equivalents (FTEs) per 1,000 doses dispensed or administered per month and per 100 occupied beds (p = 0.042 and 0.026, respectively), and mean pharmacist and technician FTEs per 100 occupied beds (p = 0.012 and 0.019, respectively). CONCLUSION: A survey of pharmacies in state psychiatric hospitals provided metrics data on staffing, workload, and productivity that may be used as benchmarks in efforts to improve workforce efficiency, pharmaceutical care services, and financial performance.

An innovative approach to improve ear, nose and throat surgical access for remote living Cape York Indigenous children.

INTRODUCTION: On a background of high rates of severe otitis media (OM) with associated hearing loss, children from the Torres Strait and Cape York region requiring ear, nose and throat (ENT) surgery, faced waiting times exceeding three years. After numerous clinical safety incidents were raised, indicating a failure of the current system to deliver appropriate care, the governing Hospital and Health service opted to deliver surgical care through an alternate process. ENT surgeries were performed on 16 consented children from two remote locations via the private health care system, funded by a health provider partnership. METHODS: We examined the collaboration processes alongside clinical findings from this ENT surgery. Collated patient data, included patient demographics, clinical and audiometry presentation features were reviewed and compared pre and post-operatively. Cost savings associated with the use of TeleHealth post-operatively were briefly examined. RESULTS: Surgeries were successfully completed in all 16 children. The reported mean waitlist time for ENT surgery was 1.2 years. Pre-surgery pure-tone average hearing thresholds were reported at left: 30.9 dB, right: 38.2 dB. The majority of presentations were for bilateral OM with Effusion (69%). Post-surgical follow up indicated successful clinical outcomes in 80% of patients and successful hearing outcomes in 88% of patients. Mean difference pure-tone average hearing thresholds, left: 8.4 dB and right: 11.2 dB. Furthermore, the majority of patients reported improved hearing and breathing. The use of TeleHealth for post-operative review enabled a minimum cost saving of AUD$21,664 for these 16 children. Overall, a high level of staffing resources was required to successfully coordinate this intense surgical activity. CONCLUSION: This innovative approach to a health system crisis enabled successful ENT surgical and hearing outcomes in 16 children, whose waitlisted time grossly exceeded state health recommendations. Using private health facilities funded by a health partnership, while unlikely to be a suitable model of care for routine service delivery; may be applied as an adjunct service model when blockages and delays lead to sub-standard service provision. This approach may be applicable to other health care facilities when facing extended elective surgery wait times in ENT or other specialty areas.

Reducing Hospital-Acquired Infections Among the Neurologically Critically Ill.

BACKGROUND: Hospital-acquired infections (HAIs) result in excess morbidity, mortality, and resource consumption. Immobilized, ventilator-dependent ICU patients are at the highest risk of HAI. METHODS: Despite broad implementation of relevant bundles, HAI incidence in our neuro ICU remained high, particularly catheter-associated urinary tract infections (CAUTIs) and ventilator-associated events (VAEs). We reviewed the administrative data and nosocomial infection markers (NIMs) for all neurology and cranial neurosurgery patients admitted to our neuro ICU between January 2011 and May 2014, identified and implemented interventions, and measured effects using National Healthcare Safety Network (NHSN)-defined CAUTIs and VAEs. Interventions included (1) reviewing Foley catheter use, including indications and alternatives, and instituting daily rounds, continuously questioning the ongoing need for a catheter; (2) re-educating neuro ICU personnel in insertion and maintenance technique, introducing a new kit that simplified and standardized sterile insertion; and (3) placing a mobile CT in the neuro ICU since our patients required repeated transports for brain imaging and since we found correlations between frequencies of these transports, and both respiratory and urinary NIMS. RESULTS: VAEs decreased 48 %, Foley use decreased 46 %, CAUTIs decreased from 11/1000 catheter days to 6.2. Overall complication rate decreased 55 %, ICU length of stay 1.5 days, and risk-adjusted mortality 11 %. CONCLUSIONS: Combining a multidisciplinary approach with rigorous analysis of objective data, we decreased total HAIs by 53 % over 18 months. Key drivers were decreased urinary catheter use and decreased patient transport from the ICU for imaging.

Nicotine replacement therapy use at home after use during a hospitalization.

INTRODUCTION: We assessed whether providing inpatient smokers with nicotine replacement therapy (NRT) to relieve withdrawal symptoms while hospitalized was associated with self-initiated NRT use soon after hospital discharge. METHODS: We conducted an observational study of 1,895 cigarette smokers admitted to a large hospital over 24 months (July 2007 through June 2009) and seen by a tobacco counselor during hospitalization. Participants were surveyed at 2 weeks after discharge to assess postdischarge NRT use. We calculated adjusted rate ratios (ARRs) for the effect of NRT use in the hospital on the rate of NRT use after discharge, adjusting for gender, age, hospital service, intention to quit, baseline smoking level, length of stay, and counseling duration. RESULTS: 62 percent (1,166/1,895) of enrolled participants received NRT during hospitalization. The survey response rate was 72%. 42 percent (544/1,293) of survey respondents reported initiating postdischarge NRT use within 2 weeks of discharge. NRT use after discharge was more likely to be reported by those who used it in hospital whether they had ever used it prior to hospitalization (ARR: 5.64, 95% CI: 3.95-8.05) or had never used it before (ARR: 4.68, 95% CI: 3.25-6.73). CONCLUSIONS: Smokers who received NRT during a hospitalization were more likely to use it after discharge compared with those who did not use NRT in hospital. By encouraging use of this effective cessation aid, supplementing counseling with NRT for hospitalized smokers may promote smoking cessation efforts after discharge.

An interactive voice response system to continue a hospital-based smoking cessation intervention after discharge.

INTRODUCTION: Hospitalized smokers benefit from tobacco counseling received in hospital only if it continues after discharge. Interactive voice response (IVR) technology may be useful in delivering this care. METHODS: We conducted a randomized controlled trial testing two intensities of follow-up contact using an IVR system; 738 cigarette smokers who received inpatient counseling at an academic medical center were enrolled. Participants were randomized to receive four IVR calls during the first month postdischarge that included the offer of a call back (CB) from a smoking counselor (IVR + CB, N = 368) or 1 IVR call at 2 weeks postdischarge that assessed smoking outcomes without offering any counseling support (IVR, N = 370). All were assessed by human telephone call at 12 weeks. Postdischarge counseling and medication utilization rates and self-reported smoking cessation were assessed at 2 and 12 weeks postdischarge. RESULTS: Of those randomized to IVR + CB, 59% received a CB offer and 34% of those receiving offers accepted. Cessation rates did not differ between IVR + CB and IVR at 2 weeks (39% vs. 39%, rate ratio: 1.02, 95% CI: 0.85-1.22) or 12 weeks (29% vs. 26%, rate ratio: 1.11, 95% CI: 0.90-1.41). Medication use did not differ by group but was higher among those accepting versus declining CB offers (69% vs. 52%, p < .05). CONCLUSIONS: An IVR system is feasible for postdischarge follow-up and support for hospitalized smokers. Participants, especially pharmacotherapy users, took advantage of postdischarge counseling offers, although offers were not associated with increased smoking cessation.

A comparison of four international surveys of tobacco dependence treatment provision: implications for monitoring the Framework Convention on Tobacco Control.

AIMS: Article 14 of the Framework Convention on Tobacco Control (FCTC) requires countries to implement systems to provide tobacco dependence treatment. We report on global efforts to monitor the implementation of Article 14, and compare the surveys used in this effort. DESIGN: Cross-sectional comparison of agreement (concordance and discordance) among the four main surveys used to monitor tobacco dependence treatment provision. SETTING: Four global surveys of tobacco treatment provision. PARTICIPANTS: The four surveys were Raw et al. (2009), the Framework Convention Alliance (FCA) Monitor, World Health Organization (WHO) MPOWER survey and the FCTC Party Reports. MEASUREMENTS: Concordance as measured by percentage providing the same answers, as well as kappa statistic of inter-rater agreement. FINDINGS: The four surveys used to monitor Article 14 implementation vary widely in countries sampled, questions asked, respondent characteristics and survey design. The four surveys generally show a moderate to high concordance (kappa > 0.60) with each other across most survey pairs and most domains, except for the MPOWER and FCTC Party governmental surveys (63% overall concordance, kappa =0.26). This concordance was lower than any other survey pair examined. Government respondents to the WHO MPOWER and FCTC Party Report surveys provided answers to the same question domains with relatively poorer concordance than those from surveys of non-governmental or mixed governmental/non-governmental sources. CONCLUSIONS: Current surveys of tobacco dependence treatment provision are in general agreement with each other except for the two official government surveys that rely on governmental respondents. We believe that this points to the continued need for independent non-governmental monitoring of FCTC protocol implementation.

Dengue in north Queensland, 2005-2008.

The dengue vector, the mosquito Aedes aegypti, is present in urban settings in north Queensland, thereby putting the region at risk of outbreaks of dengue. This review describes some features of the 9 outbreaks of dengue that occurred in north Queensland over the 4 years, 2005-2008.

An international survey of training programs for treating tobacco dependence.

AIMS: The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) requires countries to implement tobacco dependence treatment programs. To provide treatment effectively, a country needs trained individuals to deliver these services. We report on the global status of programs that train individuals to provide tobacco dependence treatment. DESIGN: Cross-sectional web-based survey of tobacco treatment training programs in a stratified convenience sample of countries chosen to vary by WHO geographic region and World Bank income level. PARTICIPANTS: Key informants in 48 countries; 70% of 69 countries who were sent surveys responded. MEASUREMENTS: Program prevalence, frequency, duration and size; background of trainees; content (adherence to pre-defined core competencies); funding sources; challenges. FINDINGS: We identified 61 current tobacco treatment training programs in 37 (77%) of 48 countries responding to the survey. Three-quarters of them began in 2000 or later, and 40% began after 2003, when the FCTC was adopted. Programs estimated training 14,194 individuals in 2007. Training was offered to a variety of professionals and paraprofessionals, but most often to physicians and nurses. Median program duration was 16 hours, but programs' duration, intensity and size varied widely. Most programs used evidence-based guidelines and reported adherence to core tobacco treatment competencies. Training programs were less frequent in low-income countries and in Africa. Securing funding was the major challenge for most programs; current funding sources were government (58%), non-government organizations (23%), pharmaceutical companies (17%) and, in one case, the tobacco industry. CONCLUSION: Training programs for tobacco treatment providers are diverse and growing. Most upper- and middle-income countries have programs, and most programs appear to be evidence-based. However, funding is a major challenge. In particular, more programs are needed for non-physicians and for low-income countries.

Multiple outbreaks of dengue serotype 2 in north Queensland, 2003/04.

OBJECTIVES: To describe the various investigations and responses to multiple outbreaks of dengue serotype 2 that occurred in north Queensland in 2003/04. METHODS: Details about each case were collated so as to target mosquito-control responses including control of mosquito breeding sites, interior spraying of selected premises, and a novel 'lure and kill' approach using lethal ovitraps. Phylogenetic analyses were undertaken to determine the genetic relatedness of viruses isolated during the outbreaks. RESULTS: Except for a two-month hiatus in mid-2003, the outbreaks continued for 16 months and included approximately 900 confirmed cases, with three severe cases and one death. The available evidence suggests that the mosquito-control measures were effective, but delays in recognising the outbreaks in Cairns and the Torres Strait coupled with intense mosquito breeding contributed to the extensive nature of the outbreaks. Phylogenetic analyses showed that there had been only two major outbreaks, one that spread from Cairns to Townsville, the other from the Torres Strait to Cairns; both were initiated by viraemic travellers from Papua New Guinea. CONCLUSIONS: Phylogenetic analyses were essential in understanding how the outbreaks were related to each other, and in demonstrating that dengue had not become endemic. Further innovative approaches to dengue surveillance and mosquito control in north Queensland are necessary. IMPLICATIONS: Dengue outbreaks have become more frequent and more severe in north Queensland in recent years, raising the possibility that dengue viruses could become endemic in the region leading to outbreaks of dengue haemorrhagic fever.

A prospective trial of a novel, silicone-based, silver-coated foley catheter for the prevention of nosocomial urinary tract infections.

OBJECTIVE: To evaluate the efficacy of silicone-based, silver ion-impregnated urinary catheters in the prevention of nosocomial urinary tract infections (NUTIs). DESIGN: Prospective, crossover study to compare the efficacy of a silicone-based, hydrogel-coated, silver-impregnated Foley catheter with that of a silicone-based, hydrogel-coated catheter in the prevention of NUTIs. SETTING: Adult medical and surgical wards of a university teaching hospital. RESULTS: A total of 3,036 patients with catheters were evaluated; 1,165 (38%) of the catheters were silver impregnated, and 1,871 (62%) were not silver impregnated. Study groups were not identical; there were more men, a shorter duration of catheterization, and fewer urine cultures per 1,000 catheter-days in the silver catheter group. The rate of NUTIs per 1,000 Foley-days was 14.29 in the silver catheter group, compared with 16.15 in the nonsilver catheter group (incidence rate ratio, 0.88; 95% confidence interval, 0.70-1.11; P = .29). The median length of catheterization prior to the onset of a urinary tract infection (ie, exposure time) was 4 days for each group. There were no differences in the recovery of gram-positive, gram-negative, or fungal organisms in NUTIs. In a multivariate survival analysis, no factors, including silver catheters, were protective against NUTI. CONCLUSIONS: Unlike previous trials of latex-based, silver ion-impregnated Foley catheters, we found that silicone-based, silver-impregnated Foley catheters were not effective in preventing NUTIs; however, this study was affected by differences in the study groups. Prospective trials remain important in assessing the efficacy and cost-effectiveness of new silver-coated products.

Handheld computer surveillance: shoe-leather epidemiology in the "palm" of your hand.

BACKGROUND: Although urinary tract infections (UTIs) are the most common nosocomial infection, active UTI surveillance is often not feasible for infection control departments. METHODS: As part of an ongoing urinary catheter evaluation, we investigated the accuracy and cost-effectiveness of using handheld personal digital assistants (PDA) and computer-based UTI surveillance in comparison with traditional surveillance of UTIs among medical intensive care unit (MICU) patients. From September 22, 2000, to October 22, 2000, an infection control practitioner (ICP) actively surveyed all MICU patients who had a urinary catheter to determine criteria for a nosocomial UTI as defined by the Centers for Disease Control and Prevention (CDC). Research assistants visited the unit each day to determine which patients had urinary catheters, and this information was uploaded to a database designed for laboratory-based UTI surveillance. Patients with a urinary catheter were included if admitted to the MICU for >48 hours and excluded if symptoms developed <48 hours after admission. RESULTS: Both data collection methods identified 8 UTIs within the 1-month period, with 3 UTIs meeting inclusion criteria. Traditional surveillance required 8 hours weekly, whereas the PDA-computer surveillance required 1-and-a-half hours weekly. Traditional surveillance correctly attributed all 3 UTIs to the MICU. The PDA-computer surveillance incorrectly attributed the location of 2 of the UTIs. In both cases, the UTI occurred less than 48 hours after the patient was transferred from the MICU. CONCLUSION: Our data demonstrate that PDA surveillance detects nosocomial UTIs efficiently and is a novel, timesaving technique that realizes a cost savings in the first year.

A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance.

BACKGROUND: Examination of knowledge, attitudes, and beliefs of house staff physicians will be important in developing interventions to improve antimicrobial use and prevent resistance. METHODS: A 75-item survey was distributed to house staff physicians on nonpediatric services in a university teaching hospital. Knowledge was assessed with a 10-question quiz. RESULTS: The survey was completed by 179 (67%) of 269 house staff physicians on 5 specialties. Outside and inside the intensive care unit, 21% and 25% of respondents, respectively, reported that they were using antibiotics optimally. Surgeons were significantly more likely than other physicians to report that they were regularly seeking input into antimicrobial selections (P<.001). Of the 170 physicians who completed the survey, 88% agreed antibiotics are overused in general and 72% also agreed this was the case at their institution (r = 0.56; P<.05); 96% agreed that hospitals in general face serious problems with antibiotic resistance and 93% agreed that their hospital faces these same problems (r = 0.57; P<.05); 97% agreed that better use of antibiotics would reduce resistance; 32% stated that they had not had formal teaching on antimicrobial agents in the last year (medicine residents reported significantly more formal teaching than others [P =.001]); and 90% wanted more education about antimicrobials and 67% wanted more feedback on antimicrobial selections. The mean antimicrobial quiz score was 28%, with medicine residents scoring significantly higher than others (P =.04). Upper-level residents did not perform better than interns. CONCLUSIONS: This survey (1) revealed that house staff are aware of the importance of antimicrobial resistance and believe better antimicrobial use will help this problem and (2) demonstrated differences between specialties with respect to antimicrobial use and knowledge. House staff at our hospital have suboptimal knowledge about antimicrobials, and this knowledge did not increase appreciably over the course of their training. Antimicrobial education is needed and is likely to be well received by house staff physicians in academic centers but may be more effective if it is tailored to specific specialties.

PHASE: a randomised, controlled trial of supervised self-help cognitive behavioural therapy in primary care.

BACKGROUND: Common mental health problems account for up to 40% of all general practitioner (GP) consultations. Patients have limited access to evidence-based psychological therapies. Cognitive behavioural therapy self-help strategies offer one potential solution. AIM: To determine differences in clinical outcome, patient satisfaction and costs, between a cognitive behavioural-based self-help package facilitated by practice nurses compared to ordinary care by GPs for mild to moderate anxiety and depression. DESIGN OF STUDY: Randomised controlled trial. SETTING: Seventeen primary healthcare teams. METHOD: Patients presenting to their GP with mild to moderate anxiety and/or depression were recruited to the study and randomised to receive either a self-help intervention facilitated by practice nurses or ordinary care. The self-help intervention consisted of up to three appointments: two 1 week apart and a third 3 months later. There were no restrictions on ordinary care. RESULTS: Intention-to-treat analysis showed that patients treated with practice nurse-supported cognitive behavioural therapy self-help attained similar clinical outcomes for similar costs and were more satisfied than patients treated by GPs with ordinary care. On-treatment analysis showed patients receiving the facilitated cognitive behavioural therapy self-help were more likely to be below clinical threshold at 1 month compared to the ordinary care group (odds ratio [OR] = 3.65, 95% confidence interval [CI] = 1.87 to 4.37). This difference was less well marked at 3 months (OR = 1.36, 95% CI = 0.52 to 3.56). CONCLUSION: Facilitated cognitive behavioural self-help may provide a short-term cost-effective clinical benefit for patients with mild to moderate anxiety and depression. This has the potential to help primary care provide a choice of effective psychological as well as pharmacological treatments for mental health problems.

Dengue in north Queensland, 2002.

In 2002 three separate outbreaks of dengue were detected in north Queensland, including the first documented outbreak of dengue 4 in Australia. Molecular analyses identified Thailand and Indonesia as the likely origin of two of the outbreaks. Investigations during 2002 also included a suspected dengue outbreak in the Torres Strait which proved to be a false alarm, and a number of imported cases of dengue in north Queensland.