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Assessing clinical virulence differences between vancomycin-resistant Enterococcus faecium (VREF) strains resistant to linezolid (LRVRE) and linezolid-susceptible VRE (LSVRE) strains is difficult due to confounding patient variables. Galleria mellonella is a validated host interaction model allowing straightforward organism virulence assessment. The objective of this study was to assess the virulence of VREF in G. mellonella according to linezolid resistance and clinical outbreak status. A genetically related pair of VREF strains with and without genotypically confirmed linezolid resistance was selected for analysis. Additionally, six strains of LSVRE and two strains of LRVRE were selected according to epidemiologic outbreak status. Mortality of G. mellonella was assessed daily over a 5-day period and analyzed using Kaplan-Meier survival curves and log rank tests. Linezolid resistance did not have a significant effect on G. mellonella mortality in the genetically related pair (P = 0.93). There was no significant difference in mortality over time between strains (non-outbreak [i.e., no patient transmissions were recorded] [n = 2] versus outbreak [i.e., transmission occurred between 3 or more patients in a period of 30 days] [n = 6], P = 0.84; extensive transmission [i.e., the isolate was transmitted between at least 80 patients] [n = 2] versus limited transmission [i.e., the isolate was transmitted between fewer than 10 patients] [n = 4], P = 0.78). These results suggest that patients infected with LRVRE or outbreak strains of VREF are at no greater risk of poor outcomes mediated by organism virulence than those infected with LSVRE or non-outbreak strains.

Objective: Previous studies have shown that most medical inpatients receive treatment supported by strong evidence (evidence-based treatment), but they have not assessed whether and how physicians actually use evidence when making their treatment decisions. We investigated whether physicians would change inpatient treatment if presented with the results of a literature search., Design: Before-after study., Setting: Large public teaching hospital., Participants: Random sample of 146 inpatients cared for by 33 internal medicine attending physicians., Interventions: After physicians committed to a specific diagnosis and treatment plan, investigators performed standardized literature searches and provided the search results to the attending physicians., Measurements and Main Results: The primary study outcome was the number of patients whose attending physicians would change treatment due to the literature searches. These changes were evaluated by blinded peer review. A secondary outcome was the proportion of patients who received evidence-based treatment before and after the literature searches. Attending physicians changed treatment for 23 (18%) of 130 eligible patients (95% confidence interval, 12% to 24%) as a result of the literature searches. Overall, 86% of patients (112 of 130) received evidence-based treatments before the searches and 87% (113 of 130) after the searches. Changes were not related to whether patients were receiving evidence-based treatment before the search (P =.6). Panels of peer reviewers judged the quality of patient care as improved or maintained for 18 (78%) of the 23 patients with treatment changes., Conclusions: Searching the literature could improve the treatment of many medical inpatients, including those already receiving evidence-based treatment.

Objective: The incidence of colonization and infection with vancomycin-resistant enterococci (VRE) has increased dramatically in the last 5 yrs, especially in intensive care units (ICUs). We studied VRE-colonization in patients on admission to a medical ICU (MICU) where VRE colonization is endemic., Design: Prospective, descriptive analysis., Setting: An MICU of a public hospital., Patients: Three hundred and one consecutively admitted patients., Measurements and Main Results: Rectal swabs were obtained on admission from all patients. VRE isolates from all colonized patients were genetically fingerprinted by pulsed-field gel-electrophoresis (PFGE). Forty-three (14%) of 301 patients were colonized with VRE on MICU admission. Three (7%) of these 43 patients were admitted directly from the community without prior hospital contact. Risk of colonization on admission was related to the length of stay in the hospital before MICU-admission (odds ratio 4.65 for patients with a stay of at least 3 days) and previous in-hospital use of antibiotics. Of 22 VRE PFGE strain types recognized in the MICU during the study period, four (18%) were introduced by patients admitted directly from the community and ten (45%) were introduced by patients admitted from other hospital wards., Conclusions: These results show that although ICUs are considered epicenters for antibiotic resistance, sources extraneous to our MICU (e.g., other wards) contributed the majority of VRE strain types in the unit.

An internal chart review of warfarin patients revealed a 44 percent complication rate resulting in higher treatment costs, and identified patient noncompliance, access to monitoring, and insufficient patient education as contributing factors. A warfarin usage guideline was created to assist physicians with warfarin management and subsequently the Anticoagulation Center (ACC) was established. To date over 950 patients have been managed through the ACC with therapeutic international normalized ratios an average of 82 percent of the time. Fewer bleeds and treatment failures have occurred in the ACC group, and a patient satisfaction survey revealed that ACC patients were very satisfied with their care more often than non-ACC patients.

Study Objective: To evaluate the applicability of a short-stay protocol for exclusion of acute ischemic heart disease without hospital admission and to analyze these results in the context of a conceptual model., Methods: An observational study of patients who presented with chest pain to the emergency department of an 886-bed inner-city municipal hospital and who needed hospital admission to rule out acute myocardial infarction (AMI). Patients were assessed by ED attending physicians to determine eligibility for an alternative, 12-hour protocol in an ED chest pain observation unit (CPOU) followed by immediate exercise testing. Outcome measures were proportion of patients eligible for the short-stay protocol, risk factor profile, and reasons for exclusion., Results: Of 500 patients screened, 446 had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% confidence interval [CI], 48.7% to 57.9%) were found to have low probability for AMI. After study exclusion criteria were applied to the patient cohort, 63 patients (14.1%; 95% CI, 10.9% to 17.3%) were eligible for the protocol. The most common reasons for exclusion were history of coronary artery disease (46%) and inability to perform an interpretable exercise tolerance test (42%)., Conclusion: Although most admitted patients with chest pain (53%) were at low probability for AMI, only a minority (14%) were eligible for a short-stay protocol that required patients to be free of known coronary artery disease and able to perform an exercise tolerance test. Factors affecting the operations and efficiency of a CPOU include clinical characteristics of the target patient population, protocol tests used, and hospital occupancy and reimbursement patterns.

An urban medical center uses outcomes data so that physicians can comp are their performance with that of their peers. Physician demand for this data is present, and the benefits of constructive use appear to justify the effort.

The Veterans Administration Lakeside Medical Center (VALMC) is a 500-bed hospital located in downtown Chicago providing a broad scope of inpatient and outpatient medical services for more than 12,000 veterans. The VALMC Pharmacy and Therapeutics Committee requested a study to evaluate doxazosin mesylate (Cardura) to determine if this agent would be an acceptable alternative to other formulary agents. It appears that doxazosin provides several therapeutic advantages, including once-daily dosing, when compared with other more costly antihypertensive agents.

Measuring clinical and financial outcomes in health care is a science in the early stages of development and implementation. Many tools and techniques are derived from industry models of continuous quality improvement and epidemiology. Epidemiologic (enumerative) and statistical process control (analytic) methods are effective alternatives to traditional quality assurance methods of evaluating patient care that encompass clinical and financial outcomes. Their use has resulted in significant improvement of clinical outcomes and financial performance, and has increased physician involvement in the process. Although cost will be the driving force of health care reform for the next few years, demonstration of high-quality care by providers through outcomes measurement will differentiate long-term from short-term winners in an environment of managed competition. This fact will make the science of outcomes management increasingly more important.

At EHS Christ Hospital and Medical Center, an eight-step process improvement model was developed that incorporates continuous quality improvement concepts for monitoring, evaluating and improving patient care. Nursing home residents admitted with pneumonia were identified as the group having the most influence on mortality and costs associated with treatment of pneumonia at our hospital. A multidisciplinary team evaluated clinical resource use and patient care processes, and identified root causes of various influencing treatment. Clinical guidelines were created and outcomes were defined, resulting in significant improvement in the clinical management of these patients. Average length of stay decreased from 8.6 days in 1992 to 7.6 days in 1993, with a charge reduction of $1830 per patient. The methodologic framework of a process improvement program combines epidemiologic, clinical, and quality improvement sciences. This mix is essential in improving patient care and quantifying outcomes.

Diversity has been a reality for American's health care field for years. Yet, a 1993 study conducted by the American College of Healthcare Executives and the National Association of Health Services Executives found that management opportunities for minorities are often limited; ethnic and racial minorities represent nearly 20 percent of all hospital employees, yet hold only 1 percent of top hospital management positions; and graduate school enrollments and graduation of minorities have declined. The article will set forth the major business implications of diversity management in health care in an increasingly competitive labor market. It will challenge assumptions and provide a blueprint for health care institutions to position themselves as future industry leaders.

An active nursing committee structure supports a healthcare organization's ability to provide high-quality care. Traditionally, the success of a committee structure has been measured quantitatively in terms of staff nurse participation or the number of policies processed. The authors describe the process by which one nursing division evaluated their committee structure in terms of achieving the goals of their strategic plan, communication effectiveness, and the benefits and costs of participation.

This article will describe our hospital's transition to a patient-centered care environment as a response to rising costs within the hospitals and a desire to improve the quality of patient care through systems improvement. The involvement of pharmacy managers in the new organizational structure will be detailed, as well as their new roles and responsibilities as care center leaders. The traditional pharmacy management structure has been replaced by a team approach to decision making and problem solving. Challenges exist to the pharmacy managers as they reorganize to accommodate new responsibilities within the care centers. Opportunities exist within this setting to support pharmaceutical care.

A concurrent audit was made of 92 patients with plasma or serum digoxin levels of 3.0 ng/ml or more. Evidence of digoxin toxicity was present in 44 of these patients, and premature blood sampling accounted for the high levels in 30 nontoxic patients. Another 14 patients tolerated high digoxin levels without apparent adverse effects. Impaired renal function appeared to increase the risk of digoxin toxicity, even though digoxin levels were similar in patients with and without toxicity. Pharmacokinetic predictions based on patient weight and creatinine clearance often deviated considerably from measured digoxin levels even when these were drawn appropriately.

The development and implementation of an active adverse drug reaction reporting program in a university teaching hospital is described. The progression from a solely voluntary system to a multidisciplinary program consisting of both voluntary and involuntary components is discussed. A total of 1,011 adverse reactions were reported between July 1, 1988 and July 22, 1992. The most common reaction reported was rash. Antibiotics were most commonly implicated in the reactions reported. As a single agent, digoxin was involved most frequently. Voluntary reporting by physicians, nurses, and pharmacists accounted for approximately 24% of the adverse reactions reported. Occurrence screening by the Quality Assurance department produced approximately 76% of the reports.

Need proof that health care construction is booming? Just look at the model (below) of Northwestern Memorial Hospital's $580 million replacement facility, to be built in the heart of Chicago.

Study Objective: To demonstrate that a complete and rapid clinical history can be obtained using a self-administered, bilingual questionnaire., Design: A post-test experimental design was used to evaluate time spent obtaining the history and information completeness for the two groups., Setting: Urban county emergency department., Participants: All patients were non-English-speaking Hispanic women who presented with gynecologic complaints., Methods: Fifty-five patients completed a history questionnaire in Spanish on a form that displayed their responses in English on the carbon copy. In the control group, a history was obtained using a bilingual interpreter., Results: Average completion time was significantly less (t = 14.38; P < .0001) for the experimental group (chi 2 = 5.67 minutes; SD, 1.89) than for controls (chi 2 = 14.58 minutes; SD, 4.19). There was no statistical difference in review criteria for documentation between groups., Conclusion: Using a bilingual questionnaire to obtain a clinical history results in more rapid patient evaluation without affecting the quality of information obtained.

In spite of a small increase in nursing school enrollments for the first time in five years, the demand for nursing services will continue to outstrip the supply during this decade. The solutions to this dilemma are obvious: More efficient use of the current supply of nurses and increased numbers of people entering the nursing profession. This article addresses the second solution, exploring the influence of physicians on career choices in nursing and describing a model doctor/nurse relationship that brings nurses pride and job satisfaction.

Uses actual hospital-based experiences to draw attention to and illustrate how modern chaplaincy may fall into forms of paternalism and iatrogenesis. Notes particularly how high tech iatrogenesis and high touch chaplaincy may interact in counterproductive ways. Opines that the church once again needs a revisioning of health which is based on theological notions of the church as sustaining community and as a school for empowerment.

"If it ain't broke, don't fix it" is a classic quote that is still heard. Although health professionals strive for continuous improvement in the understanding, prevention, and treatment of pathology, they commonly ignore the system for health care delivery. DUE provides an effective mechanism for continuous examination of the system and improvement of patient outcome as it relates to drug therapy. The movement toward integration of DUE and clinical profiles will bring the Medical Center closer to realizing the ultimate goal of total quality care.

Regionalized perinatal care is intended to guarantee pregnant women and neonates access to appropriate care regardless of ability to pay. Its effectiveness depends on the willingness of hospitals to transfer high-risk patients according to established protocols and affiliations. This study examines maternal transfers (n = 896) to Cook County Hospital (CCH), a public facility and a designated perinatal center in Chicago. In 1987 and 1988, the majority (68%) of maternal transfers to CCH came from out-of-network hospitals, and 52% of these came directly from another perinatal center. The data indicate that 62% of the out-of-network transfers who delivered were medically high-risk. The study also documents the transfer of women in active labor, a violation of federal law. The term "perinatal dumping" is introduced to mean the transfer of high-risk pregnant women between hospitals for economic rather than medical reasons. Strategies for safeguarding the integrity of regionalized perinatal care are discussed.

Nurse administrators were faced with how to staff for a rapid expansion in number of beds in the face of a 15% nurse vacancy rate. The authors discuss how they addressed this issue through their multifaceted strategic plan.

Humana CEO David Jones is convinced that the for-profit corporation can turn around troubled Michael Reese Hospital and Medical Center in Chicago. Not in years, Jones says, but in a matter of months. Despite Reese's problems, stemming from an unfavorable patient mix, high overhead and aging physical plant, Jones is convinced he can turn the hospital around by late 1992. "I know Chicago, and I've wanted to get into Chicago in a big way for a long time," Jones says. "I believe it's going to be a great challenge to us. But I feel it's a fantastic opportunity for Humana."

Convincing evidence exists that psychosocial factors have a major impact on both outcome and costs in the medical/surgical services in general hospitals. This paper describes the Human Services Department's impact on social work and consultation-liaison psychiatry, using a data-based management system across five specialties: 1) social work; 2) consultation-liaison psychiatry; 3) supportive care (hospice); 4) home care (home health discharge planning); and 5) pastoral care, which offers opportunities for research and quality assurance monitoring. Time spent in service delivery was used to estimate the cost per hour: 1) pastoral care $96; 2) social work $36; 3) consultation-liaison psychiatry $59; 4) home care $49. Referral to social work was preferred for a range of family and discharge planning services. Consultation-liaison services were preferred for depression, paranoid behavior, and management problems. Referral overlap was noted for "coping with diagnosis" for social work and consultation-liaison psychiatry. Using a computerized data base format for documenting the referral process, work accomplished, and time spent among those services providing mental health care in the general hospital permits the observation of redundancy of services delivered and their costs.

The implementation of a pharmacy-enforced policy for documenting drug allergies is described. After two incidents at a 600-bed teaching hospital in which patients experienced severe allergic reactions to drugs, an audit was conducted to evaluate the existing drug allergy documentation policy. Physicians documented allergies in medical charts and treatment orders for 68% and 78% of patients, respectively; no initial drug orders contained this information. Nurses documented allergies in admission assessments, medication records, and charts for 71%, 61%, and 15% of patients, respectively. Only 2% of pharmacy computerized drug profiles contained allergy information. A new policy for drug allergy documentation was instituted. Physicians provide allergy information on the first written drug order. Nurses independently solicit allergy information and check it against that provided by the physician. Pharmacists enter the information into the patient's drug profile. If the information has not been obtained, the drug is not dispensed. Repeat audits two months and one year after the policy was put in place showed significant improvements in the completeness and accuracy of drug allergy documentation by pharmacists and physicians. In general, documentation by nurses did not improve to the degree found for pharmacists and physicians. A policy that gave pharmacists the primary responsibility for ensuring that drug allergy information was obtained before drugs were dispensed was effective in improving allergy documentation by physicians and pharmacists.