Emergency Drugs for the Oral and Maxillofacial Surgeon Office.

This article illustrates the indications and mechanism of action of core emergency medications as well as emergency medications for intravenous sedation in the oral and maxillofacial surgeon office. The recognition of medical emergencies and comprehensive knowledge of pharmaceutical medical intervention can prevent deterioration in medical emergencies. In addition, this article also reviews common dosages as well as administration techniques that should be regularly reviewed and be fundamental knowledge to the oral surgeon and staff.

The State Following Approximation Method.

A function approximation method is developed which aims to approximate a function in a small neighborhood of a state that travels within a compact set. The method provides a novel approximation strategy for the efficient approximation of nonlinear functions for real-time simulations and experiments. The development is based on the theory of universal reproducing kernel Hilbert spaces over the n -dimensional Euclidean space. Several theorems are introduced which support the development of this state following (StaF) method. In particular, it is shown that there is a bound on the number of kernel functions required for the maintenance of an accurate function approximation as a state moves through a compact set. In addition, a weight update law, based on gradient descent, is introduced where arbitrarily close accuracy can be achieved provided the weight update law is iterated at a sufficient frequency, as detailed in Theorem 4. An experience-based approximation method is presented which utilizes the samples of the estimations of the ideal weights to generate a global approximation of a function. The experience-based approximation interpolates the samples of the weight estimates using radial basis functions. To illustrate the StaF method, the method is utilized for derivative estimation, function approximation, and is applied to an adaptive dynamic programming problem where it is demonstrated that the stability is maintained with a reduced number of basis functions.

Approximate Dynamic Programming: Combining Regional and Local State Following Approximations.

An infinite-horizon optimal regulation problem for a control-affine deterministic system is solved online using a local state following (StaF) kernel and a regional model-based reinforcement learning (R-MBRL) method to approximate the value function. Unlike traditional methods such as R-MBRL that aim to approximate the value function over a large compact set, the StaF kernel approach aims to approximate the value function in a local neighborhood of the state that travels within a compact set. In this paper, the value function is approximated using a state-dependent convex combination of the StaF-based and the R-MBRL-based approximations. As the state enters a neighborhood containing the origin, the value function transitions from being approximated by the StaF approach to the R-MBRL approach. Semiglobal uniformly ultimately bounded (SGUUB) convergence of the system states to the origin is established using a Lyapunov-based analysis. Simulation results are provided for two, three, six, and ten-state dynamical systems to demonstrate the scalability and performance of the developed method.

Residents' engagement in quality improvement: a systematic review of the literature.

PURPOSE: Residents are being asked to participate in quality improvement (QI) initiatives in hospitals and clinics with increasing frequency; however, the effectiveness of improving patient care through residents' participation in QI initiatives is unknown. METHOD: A thorough, systematic review of the English-language medical literature published between 1987 and October 2008 was performed to identify clinical QI initiatives in which there was active engagement of residents. Multiple search strategies were employed using PubMed, EMBASE, CINAHL, and ERIC. Articles were excluded in which residents played a passive or peripheral role in the QI initiative. RESULTS: Twenty-eight articles were identified that documented residents' active leadership, development, or participation in a clinical QI initiative, such as curriculum change, clinical guideline implementation, or involvement with a clinical QI team. The role and participation of residents varied widely. Measures of patient health are described as outcomes in the QI initiatives of 5 of the 28 articles. Twenty-three articles described process improvements in patient care or residents' education as the outcome measure. CONCLUSION: There are few articles that describe the clinical or educational effectiveness of residents' participation in QI efforts; the authors describe barriers that may be partly responsible. They conclude that there is a great need for additional research on the effectiveness of residents' participation in QI initiatives, particularly as they affect patient health outcomes.

"Renters" or "owners"? Residents' perceptions and behaviors regarding error reduction in teaching hospitals: a literature review.

PURPOSE: Residents' attitudes, practices, and behaviors vary in response to medical error within the context of the culture of their institutions. The purpose of this study was to conduct a systematic review of the literature focused on residents' attitudes and behaviors regarding medical errors in teaching hospitals, including a qualitative review of barriers and proposed countermeasures related to residents' engagement in patient safety. METHOD: The electronic literature databases of MEDLINE, CINAHL, and ERIC were searched for articles published between January 1988 and June 2008. The search strategy yielded 124 articles. A scoring system was developed to assess the quality of the overall literature. RESULTS: Nineteen studies met eligibility criteria, with 17 published since 2005. There were 12 cross-sectional, 5 qualitative, 1 cohort and 1 pre-post intervention study. Quality assessment scores ranged from 5.5 to 12.5 (possible range 1.0-16.0). Three studies obtained a score of < or = 8.0, 5 obtained scores of 8.5 to 10.5, and 11 studies had scores of 11.0 to 12.5. Personal, environmental, and system barriers, and environmental and system countermeasures, were identified. CONCLUSIONS: Although the published literature on this topic is limited, those articles that exist identify barriers that make residents reluctant to engage in institutional error identification and/or reduction. Key factors identified included a fear of retribution and the perception of residents as transient care providers. Whereas several countermeasures have been promulgated, the literature reveals scant evidence of their effectiveness. Institutions should recognize and capitalize on the unique experiences of residents and their potential to become owners in patient safety initiatives.

Residents' and attending physicians' handoffs: a systematic review of the literature.

PURPOSE: Effective communication is central to patient safety. There is abundant evidence of negative consequences of poor communication and inadequate handoffs. The purpose of the current study was to conduct a systematic review of articles focused on physicians' handoffs, conduct a qualitative review of barriers and strategies, and identify features of structured handoffs that have been effective. METHOD: The authors conducted a thorough, systematic review of English-language articles, indexed in PubMed, published between 1987 and June 2008, and focused on physicians' handoffs in the United States. The search strategy yielded 2,590 articles. After title review, 401 were obtained for further review by trained abstractors. RESULTS: Forty-six articles met inclusion criteria, 33 (71.7%) of which were published between 2005 and 2008. Content analysis yielded 91 handoffs barriers in eight major categories and 140 handoffs strategies in seven major categories. Eighteen articles involved research on handoffs. Quality assessment scores for research studies ranged from 1 to 13 (possible range 1-16). One third of the reviewed research studies obtained quality scores at or below 8, and only one achieved a score of 13. Only six studies included any measure of handoff effectiveness. CONCLUSIONS: Despite the negative consequences of inadequate physicians' handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Using the Morbidity and Mortality conference to teach and assess the ACGME General Competencies.

PURPOSE: The weekly Morbidity and Mortality (M&M) conference, a Residency Review Committee on Surgery required conference, is a hallmark of general surgery residency training. This conference has been used traditionally to teach and assess the ACGME General Competencies of patient care and medical knowledge. The author's department has changed the format of their weekly M&M conference so that it enables them to teach and assess residents also in terms of the ACGME General Competencies of practice-based learning and improvement, professionalism, interpersonal and communication skills, and systems-based practice. METHODS: Each Monday the chief resident on each teaching service compiles a list of patient discharges and deaths for the previous week. Although all deaths are presented, only significant patient complications are selected for the following week's M&M conference. This 2-week preparation period enables the resident, who was primarily involved in the care of the patient, to thoroughly review the case and prepare his/her presentation. At the conference, the resident presents the patient's history and discusses the complication or death, not only in terms of the patient care provided (traditional M&M model), but also it analyzes the case in terms of health-care systems problems that may have contributed to the patient's morbidity and/or mortality; patient safety issues; communication problems with the patient, family, or other health-care workers; and ethnic or ethical issues related to the care provided. The case is then reviewed by faculty surgeons. Again, not only is the patient care critiqued, but also systems problems, communication problems, and ethical dilemmas. Each resident who presents a case at the M&M conference also completes a practice-based improvement log. This form analyzes the patient's outcome including factors leading to the complication and/or mortality, opportunities for systems improvement, patient safety or communication problems, ethnic or ethical issues, what the resident would do different in his/her practice, and references consulted for this case. These forms are reviewed with the resident by the Residency Director and become part of the resident's portfolio. CONCLUSION: The restructuring of the M&M conference so that a case is analyzed with all ACGME General Competencies has made the M&M conference more interesting and has improved the educational aspects of the conference. Analyzing a case according to the various ACGME General Competencies has provided another method to teach these competencies to their residents and a tool to determine whether the residents are meeting the competencies.

Institutioning a clinical practice guideline to decrease the rate of normal appendectomies.

With the advent of laparoscopic appendectomy, the rate of normal appendectomies increased at our institution. To decrease our rate of normal appendectomies, we instituted a clinical practice guideline in January 1999 for the preoperative evaluation and treatment of patients with possible acute appendicitis. The medical records of 464 consecutive patients who underwent either open or laparoscopic appendectomy with a preoperative diagnosis of acute appendicitis between January 1, 1997, and December 31, 2000, were reviewed. The decision of open versus laparoscopic appendectomy was made at the time of surgery by the attending surgeon. Two hundred twelve patients (116 females, 96 males) underwent an appendectomy for acute appendicitis (142 open, 70 laparoscopic) from January 1, 1997 through December 31, 1998, prior to the institution of the guideline. Two hundred fifty-two patients (117 females, 135 males) underwent an appendectomy for acute appendicitis (193 open, 59 laparoscopic) from January 1, 1999, through December 31, 2000 (after the guideline was instituted). Prior to the guideline, the normal appendectomy rate was 21.7 per cent (18.3% open, 28.6% laparoscopic). After the guideline was instituted, the normal appendectomy rate was 16.7 per cent (14.5% open, 23.7% laparoscopic). In females, the normal appendectomy rate prior to the guideline was 31.0 per cent (26.6% open, 36.5% laparoscopic) while the normal appendectomy rate after the guideline was 23.1 per cent (19.0% open, 31.6% laparoscopic), P = 0.172. In males, the normal appendectomy rate prior to the guideline was 10.4 per cent (11.5% open, 5.6% laparoscopic) while the normal appendectomy rate after the guideline was 11.1 per cent (11.4% open, 9.5% laparoscopic), P = 0.861. By instituting a guideline for the diagnosis and treatment of possible acute appendicitis, we were able to decrease our rate of normal appendectomies. Although statistical significance was not reached, there is a trend toward decreasing the rate of normal appendectomies in females after the guideline was instituted.