Reliability of hospital data for population-based studies of air pollution

The use of hospital databases for research into the respiratory effects of air pollution has been questioned. In an attempt to address that issue, reabstracts of 1,279 discharge records from 14 Montreal hospitals were compared with the universal health insurance database of Quebec. Agreement levels on discharge diagnoses were 94.9% for asthma; 75.5% for all other respiratory diagnoses combined, including upper airway infections, pneumonia, and coronary obstructive pulmonary disease (COPD) (90% after ignoring disagreements between closely related respiratory diagnoses); and 93.1% for a nonrespiratory comparison group. Factors associated with misclassification included use of nonurgent admissions; delays in hospital admission from emergency rooms; and differences in levels of diagnostic agreement between hospitals, age groups, and outcome groups. These should be taken into account in air pollution epidemiologic research in which databases of the kind commonly maintained in North American health care systems are used.     

Infection control activities in six hospitals: a comparison

Using a case study design, the aim of this research was to assess and evaluate the activities of the infection control departments in six hospitals. An additional aim was to examine the knowledge base of nursing staff in the clinical setting with regard to hospital policy and systems of infection control audit. The results from the study indicate that five hospitals used an infection control audit tool based on the same content. Nursing staff in the clinical areas that were surveyed had limited knowledge with regards to infection control policies, budgets and risk assessment. The value of education to improve standards of infection control within these hospitals was clearly demonstrated.     

Hospital reorganization after merger

Major organizational changes among hospitals, like system affiliation, merger, and closure, would seem to offer substantial opportunities for hospitals and health systems to be strategic in the local reconfiguration of health services. This report presents the results of a unique survey on what happened to hospitals after mergers occurring between 1983 and 1988, inclusive. Building on an ongoing verification process of the American Hospital Association, surviving institutions from all 74 mergers that occurred during the study frame were surveyed in the fall of 1991. Responses were received from 60 of the 74 mergers (81%), regarding the primary, postmerger use of the hospitals involved. Topics surveyed included the premerger competition between the hospitals and in their environment, and what happened to the hospitals after their mergers. Mergers frequently served to convert acute, inpatient capacity to other functions, with less than half of acquired hospitals continuing acute services after merger. In the context of health care reform, mergers may offer an expeditious way locally to restructure health services. Evidence on the postmerger uses of hospitals and about the reasons given for merger suggests that mergers may reflect two general strategies: elimination of direct acute competitors or expansion of acute care networks.     

The preparation for elective interventions--the spectrum and dissemination of somatic and psychological measures in Germany

INTRODUCTION: The positive effects of preoperative preparation on postoperative recovery in patients undergoing elective surgery have been demonstrated. On that account, we surveyed the practice procedures of preoperative preparation for elective surgery patients at German hospitals. METHODS: During November 1994, we sent 1500 questionnaires to the directors of anaesthesiology departments in Germany. A total of 590 questionnaires (39.3%) were completed and returned. The participating hospitals range in size from 20 to 2600 beds (mean = 364; s = 334,97), totalling together more than 1.7 million surgical operations per year. RESULTS: The surveyed hospitals used one or more of the following procedures for pre-operative preparation: 573 (98.6%) of the replying hospitals used medical anxiolysis, 415 (71.3%) applied preoperative respiratory therapy. Furthermore, 222 (38.5%) of the studied hospitals trained their patients in postoperative relevant behaviour (respiratory therapy n = 167; physiotherapy n = 63 and patient-controlled analgesia n = 41). 74 (13%) offered psychological counselling, 29 (5%) made use of other psychological techniques (muscle relaxation; autogenic training, biofeedback) and 26 (4%) used other preparatory methods like video tapes (n = 13), music (n = 5), acupuncture (n = 4). DISCUSSION: Nearly all hospitals prepared their patients for surgery with a pre-op visit and anxiolytic medications. Further preparatory methods in most surveyed hospitals are only used on a case-by-case basis. At present psychological methods of preoperative preparation are not routinely used in clinical practice in Germany. CONCLUSIONS: Existing possibilities for optimising preoperative preparation in patients undergoing elective surgery are not used regularly. Preoperative preparation needs to be improved, especially in patients undergoing major surgery. Standardisation of management procedures and integration of several professional groups and regular application of known procedures for preoperative preparation may lead to cost-saving optimisation of the duration of hospital stay.     

A national survey of practicing psychologists' attitudes toward psychotherapy treatment manuals.

There has been considerable debate and little empirical data on the role of psychotherapy treatment manuals in clinical practice. Attitudes toward treatment manuals are a potentially important determinant of how likely practitioners are to use manual-based treatments in clinical practice. A total of 891 practicing psychologists nationwide were surveyed about their attitudes toward treatment manuals and their ideas about the content of manuals. Practitioners held widely varying attitudes toward treatment manuals, and ideas about what constitutes a manual were associated with attitudes in a predictable way. Recommendations are made for how to gather more useful information about practitioners' attitudes toward the many changes affecting current models of clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preliminary report of data collection in hospital quality assurance programs--a project of the Association of Hospitals of the Czech Republic

OBJECTIVES: This was the first attempt of the association representing all acute care hospitals in the Czech Republic to collect mutual data which might be used for quality assurance (QA) purposes and which might lead to the development of national standards of care which could be used for hospital accreditation. Data collected included information which was available universally and which could be measured; in addition, information was intended to be similar in each hospital. In most cases, the data collection systems were based on financial information and data had to be identified which might be used for QA purposes, rather than being able to design a system specific for QA purposes. DESIGN: Since the hospital payment system was established in 1992, hospitals have had to develop data collection systems to measure clinical activity; this current study was based on this data collection, adapted to QA purposes. SETTING: The Executive Committee of the Hospital Association agreed to a pilot study of hospitals in 1993; data were collected from approximately 40 hospitals, beginning in 1994. STUDY PARTICIPANTS: Hospitals were chosen based on their ability to collect data and participate in the program, and it was determined that there should be variability in the hospitals, in size, location and activities, but that the data collected should be generic. INTERVENTIONS: Raw data included 33 different items, most of which were irrelevant to QA. Using a computer program, various combinations of data were reviewed and evaluated to ascertain the most appropriate for QA purposes. MAIN OUTCOME MEASURES: Data were chosen for study which included (a) data from the largest departments in the individual hospitals; (b) length of stay for patients hospitalized in these departments; (c) number of occupied beds/physician in the department and (d) mortality/1000 admissions to the department. RESULTS: The combination of (1) a long length of stay; (2) a high occupied bed/doctor ratio; and (3) a high mortality rate/1000 admissions might be indicators of poor quality. Additional factors to consider include: the type of department-emergency, cancer, geriatric, etc.; the nature of the medical activity-acute, referral, primary care, etc.; whether or not "social" beds are included and, generally, comparability among departments. However, as a pilot study, certain indicators can be determined which then can be used for future study to determine quality of care. The ability to cooperate and collect seemingly comparable data indicates reason for optimism in the future; more detailed and accurate studies can be carried out which will enable assessment of the quality of care given in comparable situations in hospitals throughout the Czech Republic.     

Effects of market position and competition on rural hospital closures

OBJECTIVE: To examine the dynamic effects of competition and hospital market position on rural hospital closures. DATA SOURCE/STUDY SETTING: Analysis of all rural community hospitals operating between 1984 and 1991, with the exception of sole-provider hospitals. Data for the study are obtained from four sources: the AHA Annual Surveys of Hospitals, the HCFA Cost Reports, the Area Resource File, and a hospital address file constructed by Geographic Inc. DATA COLLECTION AND ANALYSIS: Variables are merged to construct pooled, time-series observations for study hospitals. Hospital closure is specified as a function of hospital market position, market level competition, and control variables. Discrete-time logistic regressions are used to test hypotheses. PRINCIPAL FINDINGS: Rural hospitals operating in markets with higher density had higher risk of closure. Rural hospitals that differentiated from others in the market on the basis of geographic distance, basic services, and high-tech services had lower risks of closure. Effects of market density on closure disappeared when market position was included in the model, indicating that differentiation in markets should be taken into account when evaluating the effects of competition on rural hospital closure. CONCLUSIONS: Our findings suggest that rural hospitals can reduce competitive pressures through differentiation and that accurate measures of competition in geographically defined market areas are critical for understanding competitive dynamics among rural hospitals.     

User's requests (from a practitioner's perspective)

As a practitioner, I have to rely on outside clinical laboratories and affiliated hospitals to perform laboratory tests. In this abstract, I describe specific problems I have encountered with third-party laboratories, and propose solutions for these problems to optimize use of laboratory tests. BLOOD TESTS: The most frequent problem in ordering blood tests is the lack of detailed information regarding sampling conditions. I often have to call laboratories to check whether the sample should be serum or plasma, what volume is needed, whether the sample should be cooled, etc. I propose that clinical laboratories should provide practitioners' manuals that describe specific sampling information. ULTRASONOGRAPHY: Most laboratories do not keep the data from ultrasonographic tests. The lack of these is most problematic when test results are interpreted differently by laboratories and by practitioners. Retaining the data would also help private laboratories improve the quality of the test by enabling them to compare their interpretations with others'. ANNUAL MEDICAL SCREENING: Even if an abnormal finding is detected at medical screening clinics, the final diagnosis is usually not sent back to the screening facilities. This is highly recommended to establish an official system that mediates the feedback to screening centers. MRI: Due to miscommunication between practitioners and radiologists, the test is sometimes performed inappropriately. A thorough consultation should occur before the test to clarify specific goals for each patient. PATHOLOGICAL TESTS: Interpretation of results is often inconsistent among laboratories. Independent clinical laboratories tend to report results without indicating sample problems, while pathology departments at affiliated hospitals tend to emphasize sample problems instead of diagnosis or suggesting ways to improve sample quality. Mutual communication among laboratories would help standardize the quality of pathological tests.     

Psychologists' membership on the medical staff of university teaching hospitals.

Senior psychologists on the faculties of the 115 US schools of medicine were surveyed to ascertain whether or not they were full voting members of the medical staff of their university hospital. Results indicate that despite the fact that some of these teaching hospitals had dropped psychologists from full membership on the medical staff following the recent rounds of hospital reaccreditation site visits by the Joint Commission on Accreditation of Hospitals (JCAH), 6 of these hospitals had recently amended their bylaws to include qualified psychologists as full voting members. A review of the JCAH accreditation policies reveals that the medical staff of a hospital had more discretion in this area than previously may have been apparent. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Minimally invasive surgery. Implications for hospitals, health workers, and patients

Minimally invasive surgery is one of the great innovations of health care in the 20th century. It promises to revolutionise surgery by allowing many more operations to be performed with minimal hospitalisation. Pressure from patients has caused many techniques to spread rapidly before they have been adequately assessed. This must be resisted, and policy makers must pay more attention to minimally invasive surgery to ensure that good assessments are made. The widespread use of minimally invasive techniques has important implications for hospitals and health workers. As more patients are treated on an outpatient basis, fewer hospital beds will be needed, and traditional operating rooms will have to adapt to a greater turnover of patients. Surgeons will have to acquire new operating skills, possibly requiring formal training and accreditation, and, as different specialties fight for control of new technologies, surgery may eventually be merged with internal medicine so that specialists will deal with organ systems. Postoperative care will have to be carried out in the community rather than in hospitals, and policy makers will need to reorganise their health systems to cope with these developments.     

Effect of mobile phone on life-saving and life-sustaining systems]

Since the beginning of the nineties there have been warnings not to use mobile phones in the vicinity of medical devices. Functional failures of dialysis machines, respirators and defibrillators prompted the banning of their use in many hospitals in Scandinavia, and then in other countries. Since we believe that a general ban in hospitals is problematic, we decided to investigate the influence of mobile telephone on life-saving and/or life-support systems, with the aim of establishing rules for its use in hospitals. We investigated available phones of varying power of the C-, D- and E-net, as also of a cordless phone meeting the DECT standard. The aim was to identify the devices susceptible to interference and determine the minimum distances at which interference occurred. A total of 224 devices classified into 23 types of devices were examined. Nine different sets of transmission conditions were applied, giving a total of 2016 tests. Our results permit the conclusion that the ban on mobile phones in hospitals is based not on actual events, but on theoretical considerations in the absence of any practical information on the actual susceptibility of devices and their reaction to the electromagnetic fields involved. The fact that hazardous situations are very rare is due firstly to the need for the simultaneous occurrence of four coincidences, and the fail-save feature of medical devices. We would therefore recommend that all life-saving and life-support systems that can also be used outside the hospital should be made mobile phone-proof. When apnoea monitors and respirators are protected from such interference, hazardous situations could be avoided by establishing the rule: "No portables, and mobile phones only at a distance of at least 1 metre from medical devices". With regard to emergency telephones, the minimum distance to medical devices should be at least 1.5 metres.     

A national survey on seclusion and restraint in state psychiatric hospitals

OBJECTIVES: State psychiatric hospitals across the U.S. were surveyed to develop national normative data on the incidence of seclusion and restrain and of injuries to patients and staff resulting from aggression by patients. METHODS: A survey instrument was sent to 225 state hospitals requesting information for a one-year period on the number of patients placed in seclusion or restraint, the number of discrete incidents of seclusion and restraint, the number of hours patients spent in seclusion or restraint, and the number of injuries to patients and staff attributable to aggression by patients. Rates of seclusion, restraint, and injuries were calculated to control for variation in hospital censuses. Percentile ranks for the various rates were calculated to allow hospitals to compare their rates. RESULTS AND CONCLUSIONS: A total of 101 state hospitals in 44 states and the District of Columbia returned the survey. In general, smaller hospitals had higher rates of seclusion and restraint. However, large standard deviations in the mean rates suggested considerable variability between hospitals in the sample. Small positive correlations between rates of seclusion and rates of restraint suggested that the hospitals did not use of the two interventions exclusively.     

Effect of monochloramine disinfection of municipal drinking water on risk of nosocomial Legionnaires' disease

BACKGROUND: Many Legionella infections are acquired through inhalation or aspiration of drinking water. Although about 25% of municipalities in the USA use monochloramine for disinfection of drinking water, the effect of monochloramine on the occurrence of Legionnaires' disease has never been studied. METHODS: We used a case-control study to compare disinfection methods for drinking water supplied to 32 hospitals that had had outbreaks of Legionnaires' disease with the disinfection method for water supplied to 48 control-hospitals, with control for selected hospital characteristics and water treatment factors. FINDINGS: Hospitals supplied with drinking water containing free chlorine as a residual disinfectant were more likely to have a reported outbreak of Legionnaires' disease than those that used water with monochloramine as a residual disinfectant (odds ratio 10.2 [95% CI 1.4-460]). This result suggests that 90% of outbreaks associated with drinking water might not have occurred if monochloramine had been used instead of free chlorine for residual disinfection (attributable proportion 0.90 [0.29-1.00]). INTERPRETATION: The protective effect of monochloramine against legionella should be confirmed by other studies. Chloramination of drinking water may be a cost-effective method for control of Legionnaires' disease at the municipal level or in individual hospitals, and widespread implementation could prevent thousands of cases.     

Expression of tie receptor tyrosine kinase in human leukemia cell lines

BACKGROUND AND STUDY AIMS: Endoscopic screening of all dyspeptic patients is not cost-effective, nor is it feasible in many health-care delivery systems. To select the most appropriate candidates, various preendoscopic screening strategies have been proposed, some of which include Helicobacter pylori serology and patient age. We assessed the value of these two criteria in preendoscopic screening of a large series of dyspeptic patients, and compared the results obtained in a referral hospital (university center with an extensive H. pylori research program) with those in nonreferral hospital (participating centers that did not have such a program). PATIENTS AND METHODS: Blood samples for determination of anti-H. pylori IgG antibody were collected from patients with uninvestigated dyspepsia undergoing endoscopy at one referral hospital and in 93 nonreferral hospitals throughout Italy. For IgG antibody assay, an in-house enzyme-linked immunosorbent assay (ELISA) technique was used in the referral hospital, while a commercial kit was used in the nonreferral hospitals. RESULTS: A total of 1638 patients were evaluated at the referral hospital (845 men and 793 women, mean age 46.1 years, range 18-89), and 3281 at the nonreferral hospitals (1718 men and 1563 women, mean age 48.8, range 18-96), respectively. If endoscopy had not been performed in patients who were seronegative for H. pylori and younger than 45 years, 19% versus 17.5% of the tests would have been avoided in the referral and nonreferral hospitals, respectively, while six of 304 ulcers (2%) and no cancers would have been missed versus 35 of 557 ulcers (6.3%) and two of 557 cancers (0.3%). CONCLUSIONS: A screening strategy based on age and H. pylori serology is a valid means of selecting dyspeptic patients for endoscopy; however, the policy needs further refinement for use in nonreferral hospitals.     

Thrombolysis plus aortic counterpulsation: improved survival in patients who present to community hospitals with cardiogenic shock

OBJECTIVES: We sought to explore the potential benefit of combining intraaortic balloon counterpulsation (IABP) with thrombolysis for acute myocardial infarction (MI) complicated by cardiogenic shock. BACKGROUND: In community hospitals, this condition is usually managed with thrombolysis alone. METHODS: We reviewed the charts of 335 patients from two community hospitals who presented with acute MI and had cardiogenic shock between 1985 and 1995. RESULTS: Of 46 patients who underwent thrombolysis within 12 h of acute infarction with confirmed cardiogenic shock, 27 underwent IABP and 19 did not. Age, systolic blood pressure with shock, pulmonary artery catheter use, pulmonary capillary wedge pressure and the incidence of diabetes mellitus and anterior MI did not differ between groups. Patients treated with IABP were somewhat more likely to have prior MI and had a significantly greater cardiac index (2.0 vs. 1.5 liters/min per m2, p = 0.04). Although no deaths occurred within 2 h of presentation, patients not treated with IABP tended to die earlier (6.8 +/- 5 vs. 23.8 +/- 19 h, p = 0.13). Patients treated with IABP had a significantly higher rate of community hospital survival (93% vs. 37%, p = 0.0002), and more of them were transferred for revascularization (85% vs. 37%). Of 30 patients transferred for revascularization, 27 underwent angioplasty or bypass surgery; hospital survival was 74%. Patients treated with IABP also had a significantly higher overall hospital and 1-year survival rate (67% vs. 32%, p = 0.019). CONCLUSIONS: Survival may be enhanced and transfer for revascularization facilitated when community hospitals use both thrombolysis and IABP to treat patients with acute MI complicated by cardiogenic shock.     

Medical waste treatment and disposal methods used by hospitals in Oregon, Washington, and Idaho

This study investigated medical waste practices used by hospitals in Oregon, Washington, and Idaho, which includes the majority of hospitals in the U.S. Environmental Protection Agency's (EPA) Region 10. During the fall of 1993, 225 hospitals were surveyed with a response rate of 72.5%. The results reported here focus on infectious waste segregation practices, medical waste treatment and disposal practices, and the operating status of hospital incinerators in these three states. Hospitals were provided a definition of medical waste in the survey, but were queried about how they define infectious waste. The results implied that there was no consensus about which agency or organization's definition of infectious waste should be used in their waste management programs. Confusion around the definition of infectious waste may also have contributed to the finding that almost half of the hospitals are not segregating infectious waste from other medical waste. The most frequently used practice of treating and disposing of medical waste was the use of private haulers that transport medical waste to treatment facilities (61.5%). The next most frequently reported techniques were pouring into municipal sewage (46.6%), depositing in landfills (41.6%), and autoclaving (32.3%). Other methods adopted by hospitals included Electro-Thermal-Deactivation (ETD), hydropulping, microwaving, and grinding before pouring into the municipal sewer. Hospitals were asked to identify all methods they used in the treatment and disposal of medical waste. Percentages, therefore, add up to greater than 100% because the majority chose more than one method. Hospitals in Oregon and Washington used microwaving and ETD methods to treat medical waste, while those in Idaho did not. No hospitals in any of the states reported using irradiation as a treatment technique. Most hospitals in Oregon and Washington no longer operate their incinerators due to more stringent regulations regarding air pollution emissions. Hospitals in Idaho, however, were still operating incinerators in the absence of state regulations specific to these types of facilities.     

Structure and activities of hospital drug committees in Germany

OBJECTIVES: Hospital drug committees have been established to ensure rational drug use. However, with regard to their structure and duties remarkable differences between European countries may exist, reflecting the differences in drug legislation and market. Our aim was to obtain information about the structure, present activities and decision-making processes of hospital drug committees in Germany and especially the role of clinical pharmacologists in these committees. METHODS: In 1995, a questionnaire with 36 items was designed and sent to all 450 hospitals in Germany with more than 400 beds. One hundred forty three returned questionnaires were evaluated. RESULTS: According to hospital size, the median value for the annual drug budget (including the cost of blood and blood-derived products) in 1993 ranged between DM 2.4 million for hospitals with less than 500 beds and DM 30.0 million for university hospitals with more than 1,000 beds. In 53.2% of drug committees, a pharmacist holds the position of chairman, followed by medical specialists (32%); (clinical) pharmacologists hold this position in only 7.7% of the general hospitals, but in almost 50% of the university hospitals. In most cases, all clinical specialities are represented in the drug committee the number of members ranging between 5 and 40 (median 12). The number of drugs included in the internal drug list, ranging between 400 in hospitals with < 500 beds and about 700 in university hospitals, strongly correlated with the number of beds and, interestingly, with the number of drug committee members. Treatment guidelines were implemented mainly for antiinfectives (87%), infusion solutions (30%), anti-emetic drugs (5-HT3-receptor antagonists, 27%) and blood and blood-derived products such as intravenous immunoglobulins (23%). However, effective control of these guidelines was only performed in about 50% of the hospitals. A drug information service was provided in most hospitals, where 95% of queries were answered by pharmacists. CONCLUSION: The results of our survey showed that German hospital drug committees vary considerably with regard to their function and control mechanisms of drug use. Most of the responders would appreciate a more intensive exchange of current problems and treatment guidelines. Although the process of pharmacotherapeutic decision making should be supported by clinical pharmacologists, experts in this field are often not involved in German hospital drug committees.     

Hygienic practices and acute respiratory illness in family and group day care homes

BACKGROUND: The Dutch guideline on hospital policy for the prevention of nosocomial spread of methicillin-resistant Staphylococcus aureus (MRSA) states that patients transferred from hospitals abroad must be placed in strict isolation immediately on admission to a hospital in the Netherlands. Three patients colonized with both MRSA and a multiresistant Acinetobacter were transferred from hospitals in Mediterranean countries to 3 different hospitals in the Netherlands. Despite isolation precautions, Acinetobacter spread in 2 of the 3 hospitals, whereas nosocomial spread of MRSA did not occur. METHODS: For outbreak analysis, the Acinetobacter isolates, identified as Acinetobacter baumannii by the use of amplified ribosomal DNA restriction analysis, were comparatively typed by 4 methods. Comparison of isolation measures in the hospitals was performed retrospectively. RESULTS: In the 2 hospitals in which nosocomial spread of Acinetobacter occurred, most of the epidemiologically related isolates were indistinguishable from the index strains. In these 2 hospitals, isolation measures were in concordance with those recommended for the prevention of contact transmission. The precautions of the hospital in which no outbreak occurred included the prevention of airborne transmission. CONCLUSIONS: Precautions recommended for multiresistant gram-negative organisms are insufficient for the prevention of nosocomial spread of multiresistant Acinetobacter. The airborne mode of spread of acinetobacters should be taken into account, and guidelines should be revised accordingly.