bluuebunny/crossref_metadata_2025_split huggingface dataset:
Organizational interventions to implement improvements in patient care: a structured review of reviews
Authors: Wensing Michel , Wollersheim Hub , Grol Richard 
Published: February 2006

Abstract

Background
Changing the organization of patient care should contribute to improved patient outcomes as functioning of clinical teams and organizational structures are important enablers for improvement.

Objective
To provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care.

Design
Structured review of published reviews of rigorous evaluations.

Data sources
Published reviews of studies on organizational interventions.

Review methods
Searches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003.
Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings.

Results
A total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain.

Conclusion
There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty.
Designing theoretically-informed implementation interventions
Authors:   The Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG)
Published: February 2006

Abstract
Clinical and health services research is continually producing new findings that may contribute to effective and efficient patient care. However, the transfer of research findings into practice is unpredictable and can be a slow and haphazard process. Ideally, the choice of implementation strategies would be based upon evidence from randomised controlled trials or systematic reviews of a given implementation strategy. Unfortunately, reviews of implementation strategies consistently report effectiveness some, but not all of the time; possible causes of this variation are seldom reported or measured by the investigators in the original studies. Thus, any attempts to extrapolate from study settings to the real world are hampered by a lack of understanding of the effects of key elements of individuals, interventions, and the settings in which they were trialled. The explicit use of theory offers a way of addressing these issues and has a number of advantages, such as providing: a generalisable framework within which to represent the dimensions that implementation studies address, a process by which to inform the development and delivery of interventions, a guide when evaluating, and a way to allow for an exploration of potential causal mechanisms. However, the use of theory in designing implementation interventions is methodologically challenging for a number of reasons, including choosing between theories and faithfully translating theoretical constructs into interventions. The explicit use of theory offers potential advantages in terms of facilitating a better understanding of the generalisability and replicability of implementation interventions. However, this is a relatively unexplored methodological area.
Implementing and managing self-management skills training within primary care organisations: a national survey of the expert patients programme within its pilot phase
Authors: Lee Victoria , Kennedy Anne , Rogers Anne 
Published: February 2006

Abstract
A key element of the United Kingdom (UK) health policy reform in relation to chronic disease management is the introduction of a national programme seeking to promote self-care from within the National Health Service (NHS). The mainstay of the Expert Patients Programme (EPP) is a six-week training course that provides the opportunity for anyone with a long-term condition to develop new skills to manage their condition better on a day-to-day basis. The course forms part of the NHS self-care support programme, is administered by Primary Care Trusts (PCTs) and delivered by people who have personal experience of living with a long-term condition.
The NHS' official Expert Patients Programme website presently states that, "Pilot EPP courses began at 26 NHS PCT sites across England in May 2002, and by May 2004 approximately 300 PCTs had either actively implemented pilot courses or had committed to joining. The majority of PCTs are now coming to the end of the pilot phase, with many implementing plans to make EPP sustainable for the long-term." The NHS website heralds the pilot "a success."
A national, postal survey of PCT EPP Leads was undertaken in order to examine both the evolvement of EPP during its pilot stage and future plans for the programme. A questionnaire was sent out to the 299 PCTs known to have committed to the EPP pilot, and an excellent 100% response rate was obtained over a 3-month period (April-July 2005). One marker of success of the Expert Patients Programme implementation is the actual running of courses by the Primary Care Trusts. This paper explores the extent to which the implementation of the pilot can indeed be viewed as a "success," primarily in terms of the number of courses run, and considers the extent to which PCTs have carried out all that they were committed to do. Findings suggest that the more time an EPP Lead dedicates to the Programme, the more likely it is that EPP has run successfully in the past, and the more likely it is that it will continue to run successfully in the future. Other factors indicating future EPP success include collaborating across PCTs to share co-ordinators, tutors, and funding.
Randomized Controlled Trial of Single‐Operator vs. Two‐Operator Ultrasound Guidance for Internal Jugular Central Venous Cannulation
Authors: Milling Truman , Holden Carlos , Melniker Lawrence , Briggs William M. , Birkhahn Robert , Gaeta Theodore 
Published: February 2006

Objectives:
Use of ultrasound guidance for central line placement generally requires two operators: one to hold the transducer and the other to guide the needle. The authors propose a single‐operator technique and compare it with the two‐operator technique for placement of internal jugular central lines.
Methods:
This was a randomized clinical trial conducted from June to September 2004 in a U.S. urban teaching hospital. Enrollment packets were randomized to dynamic single operator (D1) and dynamic two operator (D2). The procedure was performed under ultrasound visualization in the transverse plane. The primary outcome measure was cannulation success. A complete Bayesian analysis using noninformative priors to estimate the probability of similarity of outcomes for D1 and D2 was performed. All variables are reported with 95% confidence intervals (CIs) where appropriate.
Results:
Forty‐four patients were enrolled from the emergency department and intensive care unit. Twenty‐three patients were randomized to D1, and 21 to D2. Cannulation success was 96% (95% CI = 85% to 100%) for D1 and 95% (95% CI = 83% to 100%) for D2. There was a 90% probability that the success rates of these two groups differed by less than 10% of each other.
Conclusions:
This one‐person technique appears to be equivalent to the standard two‐person technique for successful ultrasound‐guided internal jugular central venous catheterization with respect to overall success.
Quality of Emergency Care on the Night Shift
Authors: Silbergleit Robert , Kronick Steven L. , Philpott Shelia , Lowell Mark J. , Wagner Chris 
Published: February 2006

Objectives:
To determine whether performance decrements at night actually translate into worsened measures of quality of patient care in the emergency department (ED). Emergency physicians and healthcare workers are sleepier and less cognitively proficient at night than during the day. Despite a lack of data, medical errors have been attributed to these deficits, and pharmacologic solutions recently have been suggested.
Methods:
The authors studied 36 months of emergency care and measured quality indicators, including early mortality (deaths occurring after arrival in the ED or within 48 hours of hospital admission), frequency of return after ED discharge, time to thrombolysis in acute myocardial infarction (AMI), frequency of aspirin use in AMI, and performance of endotracheal intubation. Comparisons were by time of day in eight‐hour epochs.
Results:
There were 345,000 patient encounters in the study period. The distribution in time was determined for 25,079 sampled ED visits, 3,666 admissions, and 507 early deaths. Estimated early mortality was 0.5% (95% CI = 0.0 to 1.0%) greater at night compared with during the day. There was no effect of time of day on 1,828 returns with admission after ED discharge. In 257 patients who received thrombolytics for AMI, mean time‐to‐treatment and frequency of aspirin use were not worse at night. In 443 emergent endotracheal intubations, there was no difference at night in the duration or number of attempts required, or in protocol adherence.
Conclusions:
Quality indicators used in this study do not demonstrate marked deficits in patient care occurring at night. A very small, but measurable, increase in early mortality was identified. Improved measures to counter circadian disruption warrant study but may result in minimal improvements in patient care.
Defining Mild, Moderate, and Severe Pain by Using the Color Analogue Scale with Children Presenting to a Pediatric Emergency Department
Authors: McConahay Tom , Bryson Matt , Bulloch Blake 
Published: February 2006

Objectives:
To define in centimeters what constitutes mild, moderate, and severe acute pain in children by using the Color Analogue Scale (CAS) for pain.
Methods:
This was a prospective study, using convenience sampling, of all children presenting to a pediatric ED between the ages of 5 and 16 years with a complaint of pain. Children were excluded if they had altered sensorium, were clinically unstable or required admission to the ICU, or were developmentally delayed. Children were asked to mark their pain severity on the standardized 10‐cm CAS. To use this measure, children were asked to slide the marker to the point on the scale that best described the pain they were currently experiencing. They then were asked to describe their pain as “none,”“mild,”“moderate,” or “severe.”
Results:
A total of 169 children were enrolled with a mean age of 10.1 years (SD ± 3.2 years). Males accounted for 94 (55%); 89 (52.7%) were Hispanic, 63 (37.3%) were white, 8 (4.7%) were African American, and 9 (5.3%) were “others.” In children who considered their pain to be mild (n= 34), the median score was 3.5 cm, and the mean score was 3.47 cm (95% CI = 2.95 to 3.99). For those with moderate pain (n= 68), the median score was 6.0 cm, the mean score was 6.04 cm (95% CI = 5.67 to 6.41), and if the pain was considered severe (n= 67) the median score was 8.5 cm, and the mean score was 8.28 cm (95% CI = 7.85 to 8.71).
Conclusions:
This study quantifies what constitutes mild, moderate, and severe pain on the CAS scale. This information should be used to properly triage children with painful conditions and to identify appropriate patients for enrollment in analgesic studies.
The Validity of Using Multiple Imputation for Missing Out‐of‐hospital Data in a State Trauma Registry
Authors: Newgard Craig D. 
Published: February 2006

Objectives:
To assess 1) the agreement of multiply imputed out‐of‐hospital values previously missing in a state trauma registry compared with known ambulance values and 2) the potential impact of using multiple imputation versus a commonly used method for handling missing data (i.e., complete case analysis) in a typical multivariable injury analysis.
Methods:
This was a retrospective cohort analysis. Multiply imputed out‐of‐hospital data from 1998 to 2003 for four variables (intubation attempt, Glasgow Coma Scale score, systolic blood pressure, and respiratory rate) were compared with known values from probabilistically linked ambulance records using measures of agreement (κ, weighted κ, and Bland–Altman plots). Ambulance values were assumed to represent the “true” values for all analyses. A hypothetical multivariable regression model was used to demonstrate the impact (i.e., bias and precision of model results) of handling missing out‐of‐hospital data with multiple imputation versus complete case analysis.
Results:
A total of 6,150 matched ambulance and trauma registry records were available for comparison. Multiply imputed values for the four out‐of‐hospital variables demonstrated fair to good agreement with known ambulance values. When included in typical multivariable analyses, multiple imputation increased precision and reduced bias compared with using complete case analysis for the same data set.
Conclusions:
Multiply imputed out‐of‐hospital values for intubation attempt, Glasgow Coma Scale score, systolic blood pressure, and respiratory rate have fair to good agreement with known ambulance values. Multiple imputation also increased precision and reduced bias compared with complete case analysis in a typical multivariable injury model, and it should be considered for studies using out‐of‐hospital data from a trauma registry, particularly when substantial portions of data are missing.
Anechoic Stripe Size Influences Accuracy of FAST Examination Interpretation
Authors: Ma O. John , Gaddis Gary 
Published: February 2006

Objectives:
Accurate and precise interpretations of Focused Assessment with Sonography for Trauma (FAST) findings are important factors in managing trauma patients. The objectives were to analyze the influence of anechoic stripe (AS) size on interpretation accuracy by emergency physicians (EPs) and to assess the precision of FAST examination interpretation as a function of EP FAST experience.
Methods:
A prospective comparison study of FAST examination interpretation by 11 emergency medicine faculty (FAC), nine community attending EPs (ATT), and nine senior emergency medicine residents (RES) was conducted; these physicians were then divided into more experienced and less experienced cohorts to assess precision. Participants interpreted video recordings of the four standard views from five FAST examinations (20 total video clips); each examination contained views with various AS sizes. Accuracy of FAST examination interpretation was calculated for each group stratified by size of AS. Precision (reproducibility) of FAST examination interpretation was assessed by calculating κ values.
Results:
With large, moderate, or no AS, no significant differences in accuracy were found between groups. For small AS, significant differences in accuracy were found between the ATT and RES groups and between the combined FAC + ATT group and the RES group. κ was good to excellent when the nth and the (n + 1)th experienced physicians in the more experienced cohort were compared. κ values reflected that the more experienced cohort was more precise than the less experienced cohort.
Conclusions:
AS size visible on FAST examinations and EP experience level with FAST examination interpretation exerted a significant influence on the interpretation accuracy of videotaped FAST examinations. In addition, precision was enhanced by increased EP experience with FAST.
The Decision to Use Topical Anesthetic for Intravenous Insertion in the Pediatric Emergency Department
Authors: Fein Joel A. , Gorelick Marc H. 
Published: February 2006

Objectives:
Topical anesthetic creams to reduce the pain of intravenous (IV) placement may be more effectively used in the emergency setting if they are applied by nurses in the triage area of the emergency department or soon after the patient is placed into a room. This strategy requires accurate prediction of which patients will require IV placement. The objective of this study was to compare triage nurse judgment regarding IV placement in pediatric patients with a triage prediction rule using chief complaint, referral status, and high‐risk medical history. A secondary objective was to evaluate whether the presence of the anesthetic cream placed in triage influenced the subsequent decision to place an IV and thus invalidate the prediction strategy.
Methods:
Triage nurses were randomly assigned to a prediction score group (PRD), classifying patients as “IV likely” if the prediction score was ≥2, or an “own judgment” (RN JDGMT) group, classifying any patient that he or she considered to have a ≥50% risk of receiving an IV. The rate of actual IV placement in the emergency department treatment rooms was compared between the triage prediction strategies. To assess the influence of the presence of lidocaine 2.5% and prilocaine 2.5% (EMLA cream) on the judgment to place an IV, only 75% of the “IV likely” patients had EMLA applied in triage; the IV placement rate was compared between “IV likely” patients who did or did not have EMLA applied.
Results:
The authors enrolled 3,790 of 5,025 (75.4%) of eligible patients. The RN JDGMT group predicted 165 of 250 (66%; 95% confidence interval = 59% to 72%) of IVs placed, compared with 127 of 305 (41%; 95% CI = 36% to 47%) in the PRD group (p < 0.0001). Positive predictive values were 59% and 53% for the RN JDGMNT and PRD groups, respectively. There was no difference in IV placement rates in the “IV likely” patients who did and did not have EMLA applied.
Conclusions:
Triage nurse judgment to predict eventual IV placement had greater sensitivity and similar predictive value compared with a prediction model based on medical history and chief complaint. The triage placement of topical anesthetic in pediatric patients did not change the eventual rate of IV placement.
The Impact of a Concurrent Trauma Alert Evaluation on Time to Head Computed Tomography in Patients with Suspected Stroke
Authors: Chen Esther H. , Mills Angela M. , Lee Bruce Y. , Robey Jennifer L. , Zogby Kara E. , Shofer Frances S. , Reilly Patrick M. , Hollander Judd E. 
Published: February 2006

Background:
Emergency department (ED) overcrowding threatens quality of care by delaying the time to diagnosis and treatment of patients with time‐sensitive diseases, such as acute stroke.
Objective:
The authors hypothesized that the presence of a trauma alert evaluation would impede the time to head computed tomography (hCT) in patients with stroke‐like symptoms.
Methods:
This was a secondary analysis of prospectively collected data on patients with potential stroke who received an hCT in an urban trauma center ED from January 1, 2004, to November 30, 2004. Structured data collection included historical and examination items, National Institutes of Health (NIH) stroke scale score, laboratory and radiographic results, and final diagnosis. Admitted patients were followed in hospital. Patients who presented within one hour following a trauma evaluation were compared with patients who presented without concurrent trauma for triage time until completion of hCT. Chi‐square, t‐tests, and 95% confidence intervals (95% CIs) were used for comparisons.
Results:
The 171 patients enrolled had a mean (± standard deviation) age of 60.7 (± 7) years; 60% were female; and 58% were African American. Of these, 72 patients had a significant cerebrovascular event (38 [22%] ischemic stroke, 25 [15%] transient ischemic attack, seven [4%] intracranial hemorrhage, one [0.6%] subarachnoid hemorrhage, and one [0.6%] subdural hematoma). The remaining diagnoses included 4.6% migraine, 2.3% seizure, 2.9% syncope, 2.3% Bell's palsy, and 2.9% vertigo. There was no significant difference in time to hCT in patients who presented during a trauma activation and those who did not (99 minutes [interquartile range (IQR) = 24–156] vs. 101 minutes [IQR = 43–151.5]; p = 0.537). In subgroup analysis of patients with a significant cerebrovascular event, times to hCT were also similar (24 minutes [IQR = 12–99] vs. 61 minutes [IQR = 15–126]; p = 0.26).
Conclusions:
In the authors' institution, the presence of concurrent trauma evaluation does not delay CT imaging of patients with potential stroke.
Demographic Factors and Their Association with Outcomes in Pediatric Submersion Injury
Authors: Lee Lois K. , Mao Cheng , Thompson Kimberly M. 
Published: February 2006

Objectives:
To describe the epidemiology and outcomes of serious pediatric submersion injuries and to identify factors associated with an increased risk of death or chronic disability.
Methods:
A retrospective database review of 1994–2000 Massachusetts death and hospital discharge data characterized demographic factors; International Classification of Diseases, Ninth Revision (ICD‐9), Clinical Modification (ICD‐9‐CM), or ICD‐10 injury codes; and outcomes for state residents 0–19 years of age identified with unintentional submersion injuries. The authors performed logistic regression analysis to correlate outcomes with risk and demographic factors.
Results:
The database included 267 cases of serious submersion injury, defined as those requiring hospitalization or leading to death. Of these 267 patients, 125 (47%) drowned, 118 (44%) were discharged home, 13 (5%) were discharged home with intravenous therapy or with availability of a home health aide, and 11 (4%) were discharged to an intermediate care/chronic care facility. The authors observed a trend of improved outcome in successively younger age groups (p < 0.0001). The multivariable logistic regression analysis showed an increased likelihood of poor outcome for males compared with females (odds ratio [OR]: 2.52; 95% confidence interval [95% CI] = 1.31 to 4.84) and for African Americans compared with whites (OR: 3.47; 95% CI = 1.24 to 9.75), and a decreased likelihood of poor outcome for Hispanics compared with whites (OR: 0.056; 95% CI = 0.013 to 0.24).
Conclusions:
After serious pediatric submersion injuries, the overall outcome appears largely bimodal, with children primarily discharged home or dying. The observations that better outcomes occurred among younger age groups, females, and Hispanic children, with worse outcomes in African American children, suggest that injury prevention for submersion injuries should consider differences in age, gender, and race/ethnicity.