RESUMEN
OBJECTIVE: Uncontrolled hyperglycemia and iatrogenic hypoglycemia represent common and frequently preventable quality and safety issues. We sought to demonstrate the effectiveness of a hypoglycemia reduction bundle, proactive surveillance of glycemic outliers, and an interdisciplinary data-driven approach to glycemic management. POPULATION: all hospitalized adult non-intensive care unit (non-ICU) patients with hyperglycemia and/or a diagnosis of diabetes admitted to our 550-bed academic center across 5 calendar years (CYs). INTERVENTIONS: hypoglycemia reduction bundle targeting most common remediable contributors to iatrogenic hypoglycemia; clinical decision support in standardized order sets and glucose management pages; measure-vention (daily measurement of glycemic outliers with concurrent intervention by the inpatient diabetes team); educational programs. MEASURES AND ANALYSIS: Pearson chi-square value with relative risks (RRs) and 95% confidence intervals (CIs) were calculated to compare glycemic control, hypoglycemia, and hypoglycemia management parameters across the baseline time period (TP1, CY 2009-2010), transitional (TP2, CY 2011-2012), and mature postintervention phase (TP3, CY 2013). Hypoglycemia defined as blood glucose <70 mg/dL, severe hypoglycemia as <40 mg/dL, and severe hyperglycemia >299 mg/dL. RESULTS: A total of 22,990 non-ICU patients, representing 94,900 patient-days of observation were included over the 5-year study. The RR TP3:TP1 for glycemic excursions was reduced significantly: hypoglycemic stay, 0.71 (95% CI, 0.65 to 0.79); severe hypoglycemic stay, 0.44 (95% CI, 0.34 to 0.58); recurrent hypoglycemic day during stay, 0.78 (95% CI, 0.64 to 0.94); severe hypoglycemic day, 0.48 (95% CI, 0.37 to 0.62); severe hyperglycemic day (>299 mg/dL), 0.76 (95% CI, 0.73 to 0.80). CONCLUSION: Hyperglycemia and hypoglycemia event rates were both improved, with the most marked effect on severe hypoglycemic events. Most of these interventions should be portable to other hospitals.
Asunto(s)
Hiperglucemia/terapia , Hipoglucemia/prevención & control , Adulto , Anciano , Glucemia/análisis , Femenino , Humanos , Hiperglucemia/sangre , Pacientes Internos , Masculino , Persona de Mediana EdadRESUMEN
In a fairly short period of time, data envelopment analysis (DEA) has grown into a powerful quantitative, analytical tool for measuring the relative performance of similar organizations. DEA has been successfully applied to traditional service industries such as universities and hospitals as well as to trades as diverse as banking and manufacturing. To the best of our knowledge, however, DEA has not been applied in the academic medicine healthcare setting. This paper discusses fundamental DEA models and some of their extensions, the arena into which we introduced DEA, and an example from our own institution exploring how DEA can advance the value proposition within an academic healthcare organization.
Asunto(s)
Centros Médicos Académicos/organización & administración , Benchmarking/estadística & datos numéricos , Eficiencia Organizacional/estadística & datos numéricos , California , Interpretación Estadística de Datos , Toma de Decisiones en la Organización , Técnicas de Apoyo para la Decisión , Economía Hospitalaria , Humanos , Modelos Organizacionales , Escalas de Valor RelativoRESUMEN
In this paper, we describe: 1) the environmental forces driving performance measurement and management in the University of California San Diego Department of Medicine; 2) the systematic process used by the department to implement a Balanced Scorecard; 3) the initial direct and indirect outcomes of this effort; 4) the opportunities and challenges to the Balanced Scorecard as a management directive; and 5) future directions.
Asunto(s)
Centros Médicos Académicos/organización & administración , Benchmarking/organización & administración , Sector de Atención de Salud/organización & administración , Objetivos Organizacionales , Facultades de Medicina/organización & administración , California , Atención a la Salud/organización & administración , Humanos , Garantía de la Calidad de Atención de Salud/organización & administraciónRESUMEN
BACKGROUND: Hospital-acquired (HA) venous thromboembolism (VTE) is a common source of morbidity/mortality. Prophylactic measures are underutilized. Available risk assessment models/protocols are not prospectively validated. OBJECTIVES: Improve VTE prophylaxis, reduce HA VTE, and prospectively validate a VTE risk-assessment model. DESIGN: Observational design. SETTING: Academic medical center. PATIENTS: Adult inpatients on medical/surgical services. INTERVENTIONS: A simple VTE risk assessment linked to a menu of preferred VTE prophylaxis methods, embedded in order sets. Education, audit/feedback, and concurrent identification of nonadherence. MEASUREMENTS: Randomly sampled inpatient audits determined the percent of patients with "adequate" VTE prevention. HA VTE cases were identified concurrently via digital imaging system. Interobserver agreement for VTE risk level and judgment of adequate prophylaxis were calculated from 150 random audits. RESULTS: Interobserver agreement with 5 observers was high (kappa score for VTE risk level = 0.81, and for judgment of "adequate" prophylaxis = 0.90). The percent of patients on adequate prophylaxis improved each of the 3 years (58%, 78%, and 93%; P < 0.001) and reached 98% in the last 6 months of 2007; 361 cases of HA VTE occurred over 3 years. Significant reductions for the risk of HA VTE (risk ratio [RR] = 0.69; 95% confidence interval [CI] = 0.47-0.79) and preventable HA VTE (RR = 0.14; 95% CI = 0.06-0.31) occurred. We detected no increase in heparin-induced thrombocytopenia (HIT) or prophylaxis-related bleeding using administrative data/chart review. CONCLUSIONS: We prospectively validated a VTE risk-assessment/prevention protocol by demonstrating ease of use, good interobserver agreement, and effectiveness. Improved VTE prophylaxis resulted in a substantial reduction in HA VTE.
Asunto(s)
Pacientes Internos , Tromboembolia Venosa/prevención & control , Centros Médicos Académicos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Sistemas de Entrada de Órdenes Médicas , Persona de Mediana Edad , Modelos Teóricos , Observación , Estudios Prospectivos , Medición de Riesgo/métodos , Adulto JovenRESUMEN
BACKGROUND: Structured subcutaneous insulin order sets and insulin protocols are widely advocated. The intervention effects are not well reported. OBJECTIVE: Assess the impact of these interventions on insulin use patterns, hypoglycemia, and glycemic control. DESIGN: Prospective observational. SETTING: 400-bed academic center. PATIENTS: Adult non-critical care inpatients with diabetes or hyperglycemia and point-of-care (POC) glucose testing. INTERVENTIONS: Structured insulin orders, insulin management algorithm. MEASUREMENTS: Percent of insulin orders with basal insulin. Percent uncontrolled patient-stays (day-weighted mean glucose >or=180 mg/dL) and uncontrolled patient-days (patient-day mean glucose >or=180 mg/dL). Percent of monitored patient-days and patient-stays with hypoglycemia (glucose Asunto(s)
Algoritmos
, Índice Glucémico/efectos de los fármacos
, Hospitalización
, Hipoglucemia/tratamiento farmacológico
, Insulina/análogos & derivados
, Glucemia/metabolismo
, Manejo de la Enfermedad
, Esquema de Medicación
, Índice Glucémico/fisiología
, Humanos
, Hipoglucemia/sangre
, Inyecciones Subcutáneas
, Insulina/administración & dosificación
, Insulina de Acción Prolongada
, Estudios Prospectivos