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From JAMA Surgery: “Revisiting nursing’s effect on surgical quality and cost” and “Comparison of the value of nursing work environments in hospitals across different levels of patient risk”

by jmiller on June 22, 2016

When nursing is the focus of a major medical journal, it deserves considerable attention, particularly coming from this month’s JAMA Surgery.  The article concludes: “Hospitals with better nursing environments and above-average staffing levels were associated with better value (lower mortality with similar costs) compared with hospitals without nursing environment recognition and with below-average staffing, especially for higher-risk patients.  These results do not suggest that improving any specific hospital’s nursing environment will necessarily improve its value, but they do show that patients undergoing general surgery at hospitals with better nursing environments generally receive care of higher value.”  “Improvements in surgical safety remain an important focus of hospitals and clinicians.  With nearly 100,000 patients dying per year in the United States after undergoing elective surgery and mortality rates varying from 2-fold to 10-fold across hospitals, excess surgical mortality qualifies as a significant public health problem.  Unfortunately, the precise means to improve surgical safety remain elusive.  The authors evaluate differences in patient outcomes and cost between hospitals with better nursing work environments, determined by Magnet status and higher nurse-to-bed ratios, and matched controls.  Two key findings: first, hospitals with better nursing environments have a nearly 20% lower failure-to-rescue rate than control hospitals, and second, the overall value of care delivered was superior to that of control hospitals. To read full-text, click here.

Adaptation of Airline Crew Resource Management Principles to Dentistry

by jmiller on June 2, 2016

AAMC recently hosted its first-ever “Virtual Grand Rounds” at the James and Sylvia Earl Simulation to Advance Innovation and Learning (SAIL) Center. Guest speaker Mark Pinsky, a dentist, international airline captain and aviation expert, discussed how surgeons can apply aviation methodologies to surgical processes. He presented a concept of adapting the use of aviation checklists as an organizational tool to empower each member of the surgical team to organize thoughts, identify errors and increase situational awareness.  Combining such systematic solutions with simulation practice could have a positive impact on improving quality and outcomes.  (JADA, 2010)  Click here to read full text.

Medical Error: The Third Leading Cause of Death in the U.S.

by jmiller on May 5, 2016

In the news, (BMJ, May 3) .  The article explains that the 1999 Institute of Medicine (IOM report is limited and outdated.  The results were contested by Leape in 1993, a chief  investigator of the 1984 Harvard study which published an article arguing that the study’s estimate was too low, contending that 78% rather than 51% of the 180,000 iatrogenic deaths were preventable. Similarly,  the Inspector General of the USDHHS Office examining the health records of hospital inpatients in 2008, reported that 180,000 deaths due to medical error a year among Medicare beneficiaries alone, a rate of 1.13%.  If this rate is applied to all registered US hospital admissions in 2013, it translates to over 400,000 deaths a year, more than four times the IOM estimate.  The ICD-10 coding system has limited ability to capture most types of medical error.  At best, there are only a few codes where the role of error can be inferred, such as the code for anticoagulation causing adverse effects and the code for overdose.  When a medical error results in death, both the physiologic cause of the death and the related problem with deliver of care should be captured.  Data should be shared nationally and internationally to improve safety, much in the way scientists share data about disease.  Click here to read full-text.

Which oral anticoagulant for atrial fibrillation?

by jmiller on April 21, 2016

Direct-to-consumer advertisements continue to urge patients who take warfarin for atrial fibrillation to ask their doctors about the benefits of one or another of the newer anticoagulants.  This review  (Medical Letter, April 11) addresses the efficacy, bleeding and reversibility of direct oral anticoagulants.  The article concludes that “the direct oral anticoagulants dabigatran (Pradaxa), apixaban (Eliquis), eoxaban (Savaysa, and rivaroxaban (Zarelto) have been at least as effective as warfarin (Coumadin, and others) in preventing stroke or systemic embolism in patients with nonvalvular atrial fibrillation, and they may appear to be safer.  Patients well-controlled on warfarin (INR stable in the therapeutic range) could stay on it.  For all others, one of the direct oral anticoagulants might be a better choice.  Head-to-head comparisons of the new drugs are lacking.”  Click here to read full text.

Zika Virus and Pregnancy – Online First – NEJM

by jmiller on April 14, 2016

In a series of “online first” articles, and also reported in this weeks news, the NEJM has made the following articles available:  Zika virus infection in pregnant women in Rio de Janeiro – preliminary report; Zika virus and birth defects – Reviewing the evidence for causality; Zika virus infection with prolonged maternal viremia and fetal brain abnormalities; Zika virus and microcephaly; Evidence of sexual transmission of Zika virus ; Zika virus associated with microcephaly.  Click here to read this compendium of articles.

Zika Virus

by jmiller on April 14, 2016

In an “online first” series from the NEJM this week, this segment includes general information:  Zika Virus; The Zika Challenge; Zika Virus in the Americas: Yet another arbovirus threat.  Click here to read full text.

Zika virus as a cause of neurologic disorders

by jmiller on April 14, 2016

In a series of “online first: articles published in the NEJM this week, the focus is on Zika virus in the United States.  The articles in this set include:  Zika virus as a cause of neurologic disorders and Zika virus associated with meningoencephalitis.  Click here to read full text.

Mediterranean diet and fracture risk in postmenopausal women

by jmiller on March 29, 2016

This early online article and editorial (JAMA Intern Med) concludes, “Higher adherence to a Mediterranean diet is associated with a lower risk for hip fractures.  These results support that a healthy dietary pattern may play a role in maintaining bone health in postmenopausal women.”  Click here to read article and editorial.

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