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We performed a return-on-investment analysis comparing the investment in surgical site infection (SSI) prevention programs in a hospital setting to the savings from averted SSI cases.
A retrospective case costing study using aggregated patient data to determine the incidence and costs of SSI infection in surgical departments over time. We calculated return on investment to the hospital and conducted several sensitivity and scenario analyses.
Data were compiled for the Ottawa Hospital (TOH), a Canadian tertiary-care teaching institution.
We used aggregated records for all hospital patients who underwent surgical procedures between April 2010 and January 2015.
We estimated the potential cost savings of the hospital’s surgical quality improvement program, namely the Surgeons National Surgical Quality Improvement Program (NSQIP) and the Comprehensive Unit-based Safety Program (CUSP).
From 2010 to 2016, TOH invested C$826,882 (US$624,384) in surgical quality improvement programs targeting SSI incidence and accrued C$1,885,110 (US$1,423,460) in cumulative savings from averted SSI cases, generating a return of $2.28 (US$3.02) per dollar invested (95% confidence interval [CI], −0.67 to 7.37). The study findings are sensitive to the estimated cost to the hospital per SSI case and the rate reduction attributable to the prevention program.
The NSQIP and CUSP have produced a positive return on investment at TOH; however, the result rests on several assumptions. This positive return on investment is expected to continue if the hospital can continue to reduce SSI incidence at least 0.25% annually without new investments. Findings from this study highlight the need for continuous program evaluation of the quality improvement initiatives.
Following release by emergency department (ED) for acute heart failure (AHF), returns to ED represent important adverse health outcomes. The objective of this study was to document relapse events and factors associated with return to ED in the 14-day period following release by ED for patients with AHF.
The primary outcome was the number of return to ED for patients who were release by ED after the initial visit, for any related medical problem within 14 days of this initial ED visit.
Return visits to the EDs occurred in 166 (20%) patients. Of all patients who returned to ED within the 14-day period, 77 (47%) were secondarily admitted to the hospital. The following factors were associated with return visits to ED: past medical history of percutaneous coronary intervention or coronary artery bypass graft (aOR=1.51; 95% CIs [1.01-2.24]), current use of antiarrhythmics medications (1.96 [1.05-3.55]), heart rate above 80 /min (1.89 [1.28-2.80]), systolic blood pressure below 140 mm Hg (1.67[1.14-2.47]), oxygen saturation (SaO2) above 96% (1.58 [1.08-2.31]), troponin above the upper reference limit of normal (1.68 [1.15-2.45]), and chest X-ray with pleural effusion (1.52 [1.04-2.23]).
Many heart failure patients (i.e. 1 in 5 patients) are released from the ED and then suffer return to ED. Patients with multiple medical comorbidities, and those with abnormal initial vital signs are at increased risk for return to ED and should be identified.
To determine the outcomes of patients discharged from the emergency department (ED) with a bloodstream infection (BSI) and how these outcomes are influenced by antibiotic treatment.
We identified every BSI in adult patients discharged from our ED to the community between July 1, 2002, and March 31, 2011. The medical records of all cases were reviewed to determine antibiotic treatment in the ED and at discharge. Microorganism sensitivities were used to determine whether antibiotics were appropriate. These data were linked to population-based administrative data to determine specific patient outcomes within the subsequent 2-week period: death, urgent hospitalization, or an unplanned return to the ED.
A total of 480 adults with BSI were identified (1.49 cases per 1,000 adults discharged from the department). Compared to controls (321,048 patients), BSI patients had a significantly higher risk of urgent hospitalization (adjusted OR 2.1 [95% CI 1.6–2.8]) and unplanned return to the ED (adjusted OR 4.1 [95% CI 3.3–4.9]). Outcome risk was significantly lowered in BSI patients who received appropriate antibiotics in the ED and at discharge. In elderly patients, the risk of urgent hospitalization increased significantly as the time to appropriate antibiotics was delayed.
BSI patients discharged from the ED have a significantly increased risk of urgent hospitalization and unplanned return to the ED in the subsequent 2 weeks. These risks decrease significantly with the timely provision of appropriate antibiotics. Our results support the aggressive use of measures ensuring that such patients receive appropriate antibiotics as soon as possible.
Information gaps, defined as previously collected information that is not available to the treating physician, have implications for patient safety and system efficiency. For patients transferred to an emergency department (ED) from a nursing home or seniors residence, we determined the frequency and type of clinically important information gaps and the impact of a regional transfer form.
During a 6-month period, we studied consecutive patients who were identified through the National Ambulatory Care Reporting System database. Patients were over 60 years of age, lived in a nursing home or seniors residence, and arrived by ambulance to a tertiary care ED. We abstracted data from original transfer and ED records using a structured data collection tool. We measured the frequency of prespecified information gaps, which we defined as the failure to communicate information usually required by an emergency physician (EP). We also determined the use of the standardized patient transfer form that is used in Ontario and its impact on the rate of information gaps that occur in our community.
We studied 457 transfers for 384 patients. Baseline dementia was present in 34.1% of patients. Important information gaps occurred in 85.5% (95% confidence interval [CI] 82.0%–88.0%) of cases. Specific information gaps along with their relative frequency included the following: the reason for transfer (12.9%), the baseline cognitive function and communication ability (36.5%), vital signs (37.6%), advanced directives (46.4%), medication (20.4%), activities of daily living (53.0%) and mobility (47.7%). A standardized transfer form was used in 42.7% of transfers. When the form was used, information gaps were present in 74.9% of transfers compared with 93.5% of the transfers when the form was not used (p < 0.001). Descriptors of the patient's chief complaint were frequently absent (81.0% for head injury [any information about loss of consciousness], 42.4% for abdominal pain and 47.1% for chest pain [any information on location, severity and duration]).
Information gaps occur commonly when elderly patients are transferred from a nursing home or seniors residence to the ED. A standardized transfer form was associated with a limited reduction in the prevalence of information gaps; even when the form was used, a large percentage of the transfers were missing information. We also determined that the lack of descriptive detail regarding the presenting problem was common. We believe this represents a previously unidentified information gap in the literature about nursing home transfers. Future research should focus on the clinical impact of information gaps. System improvements should focus on educational and regulatory interventions, as well as adjustments to the transfer form.
To maintain continuity of care when a patient's care is transferred between physicians, continuity of patient information is required. This survey determined how, and how well, Ontario emergency departments (EDs) communicate patient information to physicians in the community.
We surveyed Ontario ED chiefs to determine the most common media and methods used for disseminating information. We measured the perceived quality of their system, which was regressed against the hospital teaching status and community size using generalized logits modelling. Finally, we elicited the components of an ideal communication system for the ED.
One hundred and forty-three (85.6%) Ontario ED chiefs participated. The ED record of treatment was the most commonly used medium (95%). Postal service was the most common (55%) method of disseminating information. Thirty-three chiefs (23%) perceived the quality of communicating patient information from their ED as unsatisfactory or inadequate. This perception was significantly more prevalent in larger communities (excellent v. unsatisfactory [odds ratio (OR) 44.9, 95% confidence interval (CI) 13.9-140] and satisfactory v. unsatisfactory [OR 2.9, 95% CI 1.6-5.1]) and in teaching hospitals (satisfactory v. unsatisfactory [OR 9.7, 95% CI 4.7-20.3]). Seventy-eight percent of responding chiefs felt that patient information should be disseminated using electronic means, either through email or server access.
To communicate patient information to community physicians, Ontario ED chiefs report that a copy of the ED record of treatment is sent by postal service. More than one-fifth of ED chiefs perceived communication from their department as unsatisfactory or inadequate. Studies that assess the completeness and accuracy of the record of treatment are required as a first step for measuring the quality of patient information communication in the Ontario ED system.