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5 comments published for 4 articles.

Articles			Comments
	Patient Safety: Patient Safety At Ten: Unmistakable Progress, Troubling Gaps Wachter ( January/February 2010 ) [Abstract] [Full text] [PDF]		Evidence-Based Design As A Patient Safety Tool Eileen B. Malone   ( 7 January 2010 ) Read every Comment to this article
	Palliative Care & End-of-Life: A New Medicare End-Of-Life Benefit For Nursing Home Residents Huskamp et al. ( January/February 2010 ) [Abstract] [Full text] [PDF]		Hospice A Good Match For Nursing Homes Sheila C. Roedler   ( 7 January 2010 ) Read every Comment to this article
	Caregivers & the Workforce: Bridging Troubled Waters: Family Caregivers, Transitions, And Long-Term Care Levine et al. ( January/February 2010 ) [Abstract] [Full text] [PDF]		Need For Incentives For Family Caregiver Training Sherry White   ( 7 January 2010 ) Read every Comment to this article
	Web Exclusives: The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian District Hospitals McCord et al. ( September/October 2009 ) [Abstract] [Full text] [PDF]		The Limiting Factor: Staff, Facilities, Or Both? Mwidimi Ndosi, et al.   ( 7 January 2010 ) Tanzanian Hospital Study: Authors Respond Colin W. McCord, et al.   ( 11 January 2010 ) Read every Comment to this article

Patient Safety: Patient Safety At Ten: Unmistakable Progress, Troubling Gaps Wachter ( January/February 2010 ) [Abstract] [Full text] [PDF] Patient Safety At Ten: Unmistakable Progress, Troubling Gaps Evidence-Based Design As A Patient Safety Tool 7 January 2010 Eileen B. Malone, Senior Partner Mercury Healthcare Consulting LLC Send comment to journal: Re: Evidence-Based Design As A Patient Safety Tool ebmalone{at}msn.com Eileen B. Malone Thank you for Robert Watcher’s helpful report card about patient safety progress and opportunities. This excellent article provides important lessons and points the way for additional improvements. However, it misses one potential safety domain: the impact of evidence-based design on patient safety and high-quality health care. Evidence-based design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.[1] Roger Ulrich and colleagues' 2008 article, “A Review of the Research Literature on Evidence-Based Healthcare Design”[2], builds on an extensive literature review conducted in 2004.[3] It finds that there is a growing body of rigorous studies to guide health care design, especially in the reduction of health care-associated infections and other patient and staff outcomes. Other high-risk industries like aviation have long understood the role that the physical environment plays in supporting preferred human responses. We can create health care environments that engender the same kind of safe and reliable responses, by including proven evidence-based designed features to improve patient safety outcomes. Health care construction investments have more than doubled over the past decade. Investments of $45 billion are projected in 2009 and 2010. They are expected to rise to $55 billion by 2013 to accommodate growing and aging populations, inadequate and aging facilities, and increased health care consumerism.[4] We have a singular opportunity to study and design a next generation of health care facilities that support the best patient and staff outcomes. There is a growing field of health care practitioners, administrators, researchers, and architects dedicated to understanding the impacts of the physical environment on patient safety. This effort is being led by the not-for-profit organization, The Center for Health Design, through its Pebble Project Partners program research initiative, involves diverse health care organizations that have committed to applying evidence-based design process to create healing environments and measure the impacts on safety and health, the quality of care, and operational efficiency. I hope that when Watcher updates the patient safety progress report in five years, he will include the impact of evidence-based designed environments in the battle to improve patient safety and quality of health care. NOTES 1. The Center for Health Design (2009). Evidence-based Design Accreditation and Certification Study Guide One. Concord, California: The Center for Health Design, p 2. 2. Ulrich, R.S., Zimring, C., Zhu, X., DuBose, J., Seo, H., Choi, Y., Quan, X., Josephy, A. (2008). A review of the scientific literature on evidence-based healthcare design. Healthcare Environments Research and Design Journal, 1(3), 61-125. 3. Ulrich, R.S., Zimring, C., Joseph, A., Quan, X., Choudhury, B. (2004). The role of the physical environment in the hospital of the 21st century: A once-in-a-lifetime opportunity. Concord, CA: The Center for Health HERD. 4. FMI Corporation (2009). FMI 3rd Quarter 2009 Report, p. 8. http://www.fminet.com/assets/FMI2009Q3Outlook.pdf (Accessed 4 December 2009).

Palliative Care & End-of-Life: A New Medicare End-Of-Life Benefit For Nursing Home Residents Huskamp et al. ( January/February 2010 ) [Abstract] [Full text] [PDF] A New Medicare End-Of-Life Benefit For Nursing Home Residents Hospice A Good Match For Nursing Homes 7 January 2010 Sheila C. Roedler, Administrator Hospice Sunset Send comment to journal: Re: Hospice A Good Match For Nursing Homes sroedler{at}embarqmail.com Sheila C. Roedler I agree that having an end-of-life care benefit for long-term care facilities would be positive, especially for those patients/families who cannot be certified for hospice due to ineligibility (six months or less prognosis). However, I must disagree in the authors' statement ( which I may have misinterpreted) that hospice is not a good fit. Hospice is and can be a great fit for Long Term Care Facilities. When a hospice team and a nursing facility work side by side in developing care plans for patients, the results are amazing. I believe that a better choice would be to review the Medicare hospice guidelines for when a patient is eligible for hospice services and the possibility of providing palliative care while a patient continues treatment. I also believe that the documentation and regulations on hospice patients residing in a long-term care facility should mirror each other as much as possible. An example would be combined care plan meetings (hospice requires 14 days, long-term care facilities required quarterly). This is an example of working smarter and not working harder!

Caregivers & the Workforce: Bridging Troubled Waters: Family Caregivers, Transitions, And Long-Term Care Levine et al. ( January/February 2010 ) [Abstract] [Full text] [PDF] Bridging Troubled Waters: Family Caregivers, Transitions, And Long-Term Care Need For Incentives For Family Caregiver Training 7 January 2010 Sherry White, Project Director Schmieding Home Caregiver Training Project University of Arkansas for Medical Sciences Send comment to journal: Re: Need For Incentives For Family Caregiver Training slwhite2{at}uams.edu Sherry White Over the course of the last 15 years I have worked as a geriatric nurse in both institutional and home care settings. I also cared for my own parents so I have seen firsthand from two different perspectives the problems with our existing system. I commend you for speaking out and bringing more attention to the problems faced by family caregivers and the need for more education and support programs. The university I work for offers classes on family caregiving, but rarely do we have 6, 8, or even 10 attendees. Once in a blue moon we will have an older enlightened couple attend purely for the purpose of preparing to care for each other. It seems that by the time family members are providing care, they are too busy to attend classes, or they arrive in the class frustrated and looking for some magical way to make what they do easy. I would like to see more effort made to enroll people in caregiver classes early on, before they actually need the skills, and I would like to see the private insurance industry work together to support caregiver education program by incentivizing enrollment, similar to what the car insurance industry does for driver safety programs.

Web Exclusives: The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian District Hospitals McCord et al. ( September/October 2009 ) [Abstract] [Full text] [PDF] The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian... The Limiting Factor: Staff, Facilities, Or Both? 7 January 2010 Mwidimi Ndosi, PhD Student University of Leeds, Fredirick Mashili (MD) Send comment to journal: Re: The Limiting Factor: Staff, Facilities, Or Both? ndosie{at}gmail.com Mwidimi Ndosi, et al. The contribution of nonphysician clinicians to providing clinical services is not new. Indeed, health care demand in the Western world has seen deployment of nurses and other allied health professionals in undertaking extended roles that were traditionally in the remit of doctors.[1] This allows a flexible approach to the delivery of care, where the patient's needs and outcomes are more important than the traditional professional boundaries. In resource-limited countries where the health demands are enormous and resources are scarce, it is even more important to investigate the effectiveness and efficiency of care provided by the available workforce. For this reason I would commend the authors for researching in this area. This study sought to assess the “the quality of emergency obstetrical surgery by Assistant Medical Officers (AMOs) in Tanzania district hospitals.” We are surprised at why the authors chose not to undertake a pragmatic randomized controlled trial (RCT) of effectiveness with at least a non-inferiority design[2], which would have provided more reliable evidence than the review of records only. Knowing the weaknesses of records review (i.e. missing, incomplete, or inaccurate records) and the problems of record keeping in rural Tanzania, it would be interesting to know how the authors managed to obtain and determine the validity of the 39,500 plus 1,134 records they reviewed. Probably the authors could describe the limitations of their methods in detail, indicating the proportion of data that were missing or of questionable validity in both their retrospective and prospective reviews. The authors conclude that “the shortage of staff capable of doing emergency obstetrical surgery is not a limiting factor in Tanzania.” We think that the level of evidence provided by their data is not robust enough to make such a claim.[3] Indeed, in resource-poor facilities, there may well be no difference between the outcomes of AMOs and those of Medical Officers (MOs) in managing emergencies. Although MOs are more skilled and knowledgeable, their clinical decisions may be limited by the lack of more advanced equipment such as emergency ultrasound and basic supplies such as blood, IV fluids, and drugs. We agree with the authors that improvement of existing hospitals and transport and referral systems is vital in improving maternity mortality. However, there are likely to be some “interactions effects” between the type of facility (mission or government hospital) and the type of staff (i.e. MOs and AMOs). It would have been more useful to know the effect sizes of this interaction in all indicators and outcomes. We think that the evidence provided by this study is not robust enough to draw policy implications for Tanzania, let alone other African countries. However, we welcome the results and hope that they will provide a baseline for a future better-conducted study. NOTES 1. O'Brien JM. How nurse practitioners obtained provider status: lessons for pharmacists. American Journal of Health-System Pharmacy 2003;60(22):2301. 2. Blackwelder WC. Current Issues in Clinical Equivalence Trials. Journal of Dental Research 2004;83(suppl 1):C113-115. 3. Evans D. Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of clinical nursing 2003;12(1):77-84. The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian... Tanzanian Hospital Study: Authors Respond 11 January 2010 Colin W. McCord, Associate Professor of Surgery, retired Columbia University, NY, Godfrey Mbaruku, Caetano Pereira, Calist Nzabuhakwa, Staffan Bergstrom Send comment to journal: Re: Tanzanian Hospital Study: Authors Respond cwm1{at}columbia.edu Colin W. McCord, et al. There seems to be persistent confusion about the design of our review of obstetrical outcomes in 14 Tanzanian hospitals. To recapitulate our discussion in the Methods section: This was not a sample study or a retrospective review of clinical records. In order to make a valid comparison of the surgical results produced by Assistant Medical Officers (AMOs) and Medical Officers (MOs) working in all the hospitals in the two regions, we trained selected staff in each hospital to create a separate clinical record within 24 hours of admission for every patient with any of several defined obstetrical complications seen in a four-month period. The record was detailed enough to include such things as the time interval between admission and operation as well as whether and when blood transfusion was provided. It was continued until death or discharge. One university hospital was excluded, because it did not have AMOs doing surgery. Supervisors and principal investigators visited each hospital three times during the four months to check maternity and operating room records, looking for complicated cases for which there was no record. None were found. Because more than 85% of complicated obstetrical patients were managed by AMOs in these hospitals, the number of operations by MOs was much smaller than the number done by AMOs, but the numbers were large enough to permit statistical analysis. Significant differences between mission and government hospitals were found for several measures of quality and outcome. For the same measures, there were no differences between AMOs and MOs. A randomized controlled trial would have been impossible in these small hospitals in which operations are done by whoever is on call at a given time. Of course an RCT would not be appropriate here, because this was not a sample study, but a prospective review of all operations done in all hospitals serving a population of 4 million. There were no differences in acute or chronic risk factors for patients managed by AMOs and MOs. This review was not the basis for the Tanzanian government's decision to deploy 1300 AMOs, trained and authorized to perform major surgery. That decision was made forty years ago by a government determined to create a hospital system in a situation where no physicians were available. The operative mortality rate of less than 2% achieved in these complicated obstetrical patients would seem to validate this decision. Other countries will need to look at their own availability of trained personnel and make their own decisions on how to meet the need. It can be noted that, while 30% "Met Need" is certainly far too low, it is two to five times greater than the reported Met Need in rural Uganda and Kenya - two countries with a much larger supply of doctors, but without AMOs authorized to do surgery.