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Ventilator-associated pneumonia (VAP) is a complication of ventilator care that produces excess, avoidable resource use and treatment costs. Control of VAP is an important aspect of quality of care improvement for long-term care hospitals (LTCHs) since they provide post-acute ventilator care for many Medicare beneficiaries. Data for Medicare patients discharged from LTCHs during CY 2004 who received continuous mechanical ventilation are examined (N=13,759). Nearly 25% of Medicare LTCH ventilator patients acquired VAR Despite having lower mortality and less co-morbidity than non-VAP patients, length of stay (LOS) and total charges were both higher for VAP patients. Some of this excess is avoidable., INTRODUCTION Ventilator-associated pneumonia (VAP) refers to nosocomial pneumonia occurring in patients receiving mechanical ventilation 48 hours or more after airway intubation. It is a common complication of care that affects [...]

Objectives. To document and assess the experiences of 104 Agency for Healthcare Research and Quality (AHRQ)-funded health information technology (health IT) grantees in planning and implementing health IT systems. Data Source. Grant proposals and interviews with the AHRQ health IT grantees. Data Collection Method. Extracted descriptive data from the health IT grant proposals; conducted telephone interviews with principal investigators. Principal Findings. AHRQ funding of the health IT projects provided important support for health IT development work in various health care settings. Successful implementation required commitment from top management, dedicated staff and financial resources, an open process to encourage buy-in and enthusiasm by end users, and sheer persistence. Technologies required tailoring to the specific organization's needs. Grantees felt their projects could be replicated by others, if organizations had ample IT expertise and resources. Evaluating the value of health IT was hampered by the absence of validated instruments and measures, organizational demands that competed with data collection, and lack of evaluation expertise among health IT implementers. Conclusions. Experiences of the health IT grantees provide rich information for use by health care providers, AHRQ, and other policy makers to help strengthen future health IT development efforts, including the need to improve evaluation design and standards to assess impact. Key Words. Health IT, information technology, patient safety, evaluation, In its report, To Err Is Human: Building a Safer Health System (2000), the Institute of Medicine (IOM) called upon the health care community and policy makers to build a [...]

Objective. Evaluate short-term effects of the Patient Safety Improvement Corps (PSIC), an Agency for Healthcare Research and Quality--sponsored program to train state teams in patient safety skills/tools, to assess its contribution to building a national infrastructure supporting effective patient safety practices. Data Source. Self-reported information gathered from (1) group interviews at the end of each year; (2) individual telephone interviews 1 year later; (3) faxed information forms 2 years later. Study Design. Program evaluation of immediate and short-term process and impact (use of skills/tools, information sharing, changes in practice). Data Collection. Semistructured interviews; faxed forms. Principal Findings. One year after training, approximately half of Year 1 and 2 state agency representatives reported they had initiated or modified legislation to strengthen safe practices, and modified adverse event oversight procedures. Approximately three-quarters of hospital representatives said training contributed to modifications to adverse event oversight procedures and promotion of patient safety culture. Two years posttraining, approximately three-quarters of Year 1 trainees said they continued to use many skills/tools. Conclusions. The PSIC contributed to building a national infrastructure supporting effective patient safety practices. Expanded training is needed to reach a larger fraction of the population for which this training is important. Key Words. Patient safety, infrastructure, training program, program evaluation, The Patient Safety Improvement Corps (PSIC) is a nationwide training program that is a key component of the patient safety initiative operated by the Agency for Healthcare Research and Quality [...]

Objective. To estimate the effect of medical errors on medical expenditures, death, readmissions, and outpatient care within 90 days after surgery. Data Sources. 2001-2002 MarketScan insurance claims for 5.6 million enrollees. Study Design. The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) were used to identify 14 PSIs among 161,004 surgeries. We used propensity score matching and multivariate regression analyses to predict expenditures and outcomes attributable to the 14 PSIs. Principal Findings. Excess 90-day expenditures likely attributable to PSIs ranged from $646 for technical problems (accidental laceration, pneumothorax, etc.) to $28,218 for acute respiratory failure, with up to 20 percent of these costs incurred postdischarge. With a third of all 90-day deaths occurring postdischarge, the excess death rate associated with PSIs ranged from 0 to 7 percent. The excess 90-day readmission rate associated with PSIs ranged from 0 to 8 percent. Overall, 11 percent of all deaths, 2 percent of readmissions, and 2 percent of expenditures were likely due to these 14 PSIs. Conclusions. The effects of medical errors continue long after the patient leaves the hospital. Medical error studies that focus only on the inpatient stay can underestimate the impact of patient safety events by up to 20-30 percent. Key Words. Medical errors, patient safety, expenditures, The Committee on the Quality of Health Care in America was established in 1998 by the Institute of Medicine (IOM), and its first report estimated that between 44,000 and 98,000 [...]

Objective. To evaluate the impact of rigorous WalkRounds on frontline caregiver assessments of safety climate, and to clarify the steps and implementation of rigorous WalkRounds. Data Sources/Study Setting. Primary outcome variables were baseline and post WalkRounds safety climate scores from the Safety Attitudes Questionnaire (SAQ). Secondary outcomes were safety issues elicited through WalkRounds. Study period was August 2002 to April 2005; seven hospitals in Massachusetts agreed to participate; and the project was implemented in all patient care areas. Study Design. Prospective study of the impact of rigorously applied WalkRounds on frontline caregivers assessments of safety climate in their patient care area. WalkRounds were conducted weekly and according to the seven-step WalkRounds Guide. The SAQ was administered at baseline and approximately 18 months post-WalkRounds implementation to all caregivers in patient care areas. Results. Two of seven hospitals complied with the rigorous WalkRounds approach; hospital A was an academic teaching center and hospital B a community teaching hospital. Of 21 patient care areas, SAQ surveys were received from 62 percent of respondents at baseline and 60 percent post WalkRounds. At baseline, 10 of 21 care areas (48 percent) had safety climate scores below 60 percent, whereas post-WalkRounds three care areas (14 percent) had safety climate scores below 60 percent without improving by 10 points or more. Safety climate scale scores in hospital A were 62 percent at baseline and 77 percent post-WalkRounds (t = 2.67, p = .03), and in hospital B were 46 percent at baseline and 56 percent post WalkRounds (t = 2.06, p = .06). Main safety issues by category were equipment/facility (A [26 percent] and B [33 percent]) and communication (A [24 percent] and B [18 percent]). Conclusions. WalkRounds implementation requires significant organizational will; sustainability requires outstanding project management and leadership engagement. In the patient care areas that rigorously implemented WalkRounds, frontline caregiver assessments of patient safety increased. SAQ results such as safety climate scores facilitate the triage of quality improvement efforts, and provide consensus assessments of frontline caregivers that identify themes for improvement. Key Words. WalkRounds, patient safety, safety culture, safety climate, quality improvement, senior leader partnerships, WalkRounds were introduced in 1999 as a program for hospital leadership to sustain good relations with frontline caregivers, promote conversations to identify hazards, and gather information to enhance decision making [...]

Objective: To evaluate whether ethics rounds stimulated ethical reflection. Methods: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to stimulate ethical reflection and promote mutual understanding between professions but not to offer solutions. Questionnaires directly before and after rounds were answered by 194 respondents. The analyses were primarily content analysis with Boyd's framework but were also statistical in nature. Findings: Seventy-six per cent of the respondents reported a moderate to high rating regarding new insights on ethical problem identification, but the ethics rounds did not seem to stimulate the ethical reflection that the respondents had expected (p Conclusion: The findings show the need for interprofessional reflective ethical practice but a balance between ethical reflection and problem solving is suggested if known patients are discussed. Further research is needed to explore the most effective leadership for reflective ethical practice.

Objective. To use changes in Medicaid health maintenance organization (HMO) penetration across markets over time to test for effects on the extent of Medicaid participation among physicians and to test for differences in the effects of increased use of commercial versus Medicaid-dominant plans within the market. Data Sources/Study Setting. The nationally representative Community Tracking Study's Physician Survey for three periods (1996-1997, 1998-1999, and 2000-2001) on 29,866 physicians combined with Centers for Medicare and Medicaid Services (CMS) and InterStudy data. Study Design. Market-level estimates of Medicaid HMO penetration are used to test for (1) any participation in Medicaid and (2) the degree to which physicians have an "open" (i.e., nonlimited) practice accepting new Medicaid patients. Models account for physician, firm, and local characteristics, Medicaid relative payment levels adjusted for geographic variation in practice costs, and market-level fixed effects. Principal Findings. There is a positive effect of increases in commercial Medicaid HMO penetration on the odds of accepting new Medicaid patients among all physicians, and in particular, among office-based physicians. In contrast, there is no effect, positive or negative, from expanding the penetration of Medicaid-dominant HMO plans within the market. Increases in cost-adjusted Medicaid fees, relative to Medicare levels, were associated with increases in the odds of participation and of physicians having an "open" Medicaid practice. Provider characteristics that consistently lower participation among all physicians include being older, board certified, a U.S. graduate and a solo practitioner. Conclusions. The effects of Medicaid HMO penetration on physician participation vary by the type of plan. If states are able to attract and retain commercial plans, participation by office-based physicians is likely to increase in a way that opens existing practices to more new Medicaid patients. Other policy variables that affect participation include the presence of a federally qualified health center (FQHC) in the county and cost-adjusted Medicaid fees relative to Medicare. Key Words. Medicaid, physician participation, HMOs, States have recently increased their use of Medicaid managed care in order to assure predictable cost increases by shifting financial risk onto plans and to potentially improve patient access and [...]

Evaluation of pain and sedation in the PICU patient population is challenging. This article provides an overview of sedation and analgesia assessment tools developed for the critical pediatric patient who is mechanically ventilated and pharmacologically paralyzed. Studies reviewed include adult critical care, pediatric, and neonatal patients. No single tool has emerged that can adequately address pain management in the mechanically ventilated pharmacologically paralyzed pediatric patient. Nurses, as an integral part of the health care of critical pediatric patients, should endeavor to develop evidence-based methods for the evaluation of simple yet accurate scales to monitor sedation and pain in the pharmacologically paralyzed pediatric patient., In the Pediatric Intensive Care Unit (PICU), sedation and analgesia are administered to provide comfort and pain relief, decrease anxiety, and prevent accidental removal of lifesaving devices. Many patients are [...]