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Chapter 59. Listing of All Practices, Categorical Ratings, and Comments (continued)

Comments Section

1. Medium strength of evidence for computerized physician order entry: although randomized control trials have been conducted, findings from sophisticated "home grown" systems only 2-3 sites may not be fully generalizable. In addition, the impact of the practice on adverse events has not been as well studied as for the non-clinical outcome, medication errors.

2. Cost of CPOE is substantially higher than for most other practices in the high cost category.

3. The impact of clinical pharmacists consultation services may be less than that of CPOE due to logistics of screening large volumes of orders to target those most prone to error or most consequential.

4. Estimate of effect size based on single study with limited target (only antibiotic treatments).

5. Cost influenced by whether existing computer systems are used in pharmacy services.

6. For nomogram protocols, study strength medium because the major concern (bleeding) is not addressed in most studies.

7. Effect size greater than 15% for surrogate markers; not bleeding or clot rate.

8. Anticoagulation clinics: Both inpatient and outpatient venues studied, so some heterogeneity among results.

9. Self-management of warfarin (coumadin): on average the cost per patient is low, but the aggregated cost is medium from the perspective of an insurer or integrated system.

10. Higher complexity of implementation because self-management practice displaces locus of control out of institution and may engender debate over insurance coverage. Other countries cover this practice, but it is currently not covered by Medicare in the United States.

11. Unit-dosing is a ubiquitous practice that has surprisingly little evidence of effectiveness; evidence is old and mixed.

12. Study strength is affected because outcomes measured are not the major outcomes of interest—i.e., ADEs.

13. The implementation ratings are related to patient safety only, but note that institutions may also implement this practice for cost-savings due to less drug loss and better inventory control.

14. Study design for handwashing compliance practices generally had short duration of follow-up; no randomized control trials.

15. Unclear effect size due to mixed results and no clear pattern in a group of heterogeneous practices.

16. Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

17. There are a number of studies of barrier precautions, but most are Level 3 study designs so the strength is not rated as "High."

18. Potential decrease in provider interaction with patients may cause psychological, as well as other, effects if care from clinicians is compromised.

19. Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

20. Impact upgraded from "medium" to "high" rating because of public health impact of more antibiotic-resistant pathogens.

21. Practice requires active, ongoing monitoring and input from infection control officers to make sure proper drugs are prescribed. Also, vigilance includes need for institution-wide monitoring of pathogens.

22. The effect size of using silver alloy catheters is unclear: a well-done meta-analysis is positive, showing decrease in bacteriuria, but more recent results of possibly better designed individual studies are mixed regarding benefit. Also, the actual strength of the link, however intuitive, between bacteriuria and clinically significant urinary tract infection is unclear.

23. Effect size of using suprapubic catheters is unclear because of some heterogeneity in studies. Results are generally positive, but no meta-analysis yet conducted. In addition, the effect on outcome of clinically significant urinary tract infections is also unclear.

24. Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

25. With antibiotic-impregnated catheters made with minocycline, there is the theoretical risk of increased antibiotic resistance.

26. Pneumonia outcome was significantly reduced, but mortality was not.

27. Meta-analysis of 6 randomized controlled trials showed significant and large relative risk reduction, but 2 other randomized controlled trials showed no impact.

28. Benefit observed in prevention of ventilator-acquired pneumonia; no established benefit for mortality.

29. High complexity for implementation since it requires retraining for a new practice.

30. Most benefit in reducing pneumonia and mortality occurs when both IV and topical decontamination are used. Topical (by itself) only reduces ventilator-associated pneumonia. However, topical carries less potential for harm (i.e., antibiotic resistance).

31. Medium vigilance for harm because of public health concerns due to possible increase in antibiotic resistance. The Center for Disease Control and Prevention (CDC) and the American Thoracic Society (ATS) both recently reviewed this topic and did not recommend this practice.

32. If sucralfate were used because of its possible effect on reducing risk of ventilator-acquired pneumonia, it would displace a practice that has more established benefit for GI bleeding (H2 blockers).

33. The study strength for localizing care to high volume centers is evaluated across a range of practices. There are large variations in evidentiary base across specific practices. Evidence is not structured to determine effect on patient safety. Although the literature includes possible benchmarks/thresholds for volume levels for specific procedures, the evidence is related more to quality enhancement than to improvements in patient safety.

34. Relatively high current utilization of practice reduced impact by one level.

35. Vigilance is required to monitor antibiotic overuse to prevent negative public health effects.

36. Study strength is rated as medium because randomized clinical trial data only applies to one disease process, although may be generalizable.

37. Medium vigilance for harm: although not studied, for certain cohorts the practice may be detrimental.

38. Study strength is rated as medium because randomized clinical trial data only applies to one disease process, although may be generalizable.

39. Tight perioperative glucose control requires major shift in practice style, increased vigilance, more coordination between nurses and physicians, and perhaps new policies regarding nursing care for diabetics.

40. Effect size high, but more impressive decrease in "failed insertion attempts" than in more clinically relevant complications. Also, there is some heterogeneity in study results, and there are two different technologies assessed (plain ultrasound vs. US with doppler), and the results vary.

41. Theoretical risk that additional manipulation/handling could increase infection risk; also concern regarding impact on providers' abilities to place catheters emergently when ultrasound guidance is not available.

42. Insufficient information about retained sponges: the event is highly concerning and often morbid when occurs, but the only data on frequency are from case reports.

43. Low potential impact because anesthesia complications are already so uncommon; also difficult to determine impact of current use of some version of this practice (e.g., low opportunity possible due to current utilization).

44. Low potential impact because anesthesia complications are already so uncommon; also difficult to determine impact of current use of some version of this practice (e.g., low opportunity possible due to current utilization).

45. Although there has been a very large randomized trial of pulse oximetry, other studies covered additional aspects of intraoperative monitoring and were generally of lower study design quality.

46. Pulse oximetry study showed no benefit, but major potential methodologic problems, such as secular trends. Complications that monitoring are designed to find are very unusual, so even a large trial may have been under-powered to detect important effects.

47. Because the patient safety target is reduction of unnecessary restraints, there are multiple outcomes of interest. Although reducing unnecessary restraints does not seem to increase the risk of falls, it raises other concerns regarding disconnected IVs, elopement risk, etc., which have not been fully evaluated.

48. Probably low, as categorized, but there is a theoretical risk that patients will not receive as much attention from nurses and other providers.

49. Medium cost based on relatively widespread implementation of bed alarms required to impact all patients who may potentially benefit. May also impact nursing workload and staffing needs.

50. Possibly higher cost if large numbers of patients would benefit from wearing hip protectors. There is also the question of whether these costs are borne by system/insurers or patients themselves.

51. Implementation complexity in the hospital may be low, but implementation outside of the hospital might involve large educational campaign directed at patients who could benefit from practice.

52. Studies compare a variety of special bedding materials to standard beds. Effect size for one special bed option versus another is not known. Unclear which particular surface works best.

53. Effect size varies since heterogeneous outcomes, perhaps in part related to the variety of interventions, some of which involved both inpatient and outpatient components.

54. Effect size varies due to heterogeneous results, which depend in part on the outcomes of interest (i.e., functional outcomes vs. mortality).

55. Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

56. Total cost, of course, depends on the extent of utilization (e.g., all patients versus only targeted patients). Cost-effectiveness analyses demonstrate the importance of targeting appropriate patients.

57. Outcome is level 2, only one study for N-acetylcystine.

58. Varies according to specific nutritional support practice. Robust findings for early enteral nutrition in critically ill and post-surgical patients.

59. Vigilance for harm is medium because of potential risk of increasing ventilator-associated pneumonia, and also because of possible overuse since high-risk groups are now better defined.

60. Depends on specific intervention; standing orders have the highest effectiveness.

61. Harm concern low, except one recent study (see Chapter 36) showed trend toward harm in HIV-positive patients.

62. Although some studies were randomized control trials, they did not look at all clinically relevant outcomes to ensure that practice was safe. Under-powered to assess whether diagnostic capability not impaired.

63. Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

64. Only studied for post-operative pain; may not apply more generally.

65. Some speculation that care may be fragmented when applied broadly, beyond post-operative patients.

66. Some of the positive results may be attributable to factors other than the intervention. Concern about underlying population changing (e.g., secular trends).

67. Study strength is medium despite a number of studies, because of variation in practices (e.g., various measures of nurse staffing, models of care). Chapter was designed to generalize across practices regarding nursing structure versus outcomes; evidence is not structured to tell effect on patient safety, and there are no benchmarks/thresholds for nurse staffing levels.

68. Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

69. Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-healthcare industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the healthcare literature.

70. Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-healthcare industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the healthcare literature.

71. Although alarms are ubiquitous in the hospital, it is unclear how many adverse events might be improved by improvements in alarm systems.

72. Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-healthcare industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the healthcare literature.

73. Costs are shared among a variety of payors including outpatient pharmacy.

74. Cost would vary based on interventions considered-some low-tech, paper-based, or pocket computers; higher cost for full-scale computerized systems.

75. Although one randomized trial performed, the outcomes reported were only indirectly related to patient safety outcomes.

76. Somewhat unclear, but errors due to misidentification can be grave.

77. Cost varies based on specific system and level of implementation.

78. Impact is a function of how widely the practice can be used (ICU vs. ward teams vs. operating room).

79. Insufficient information outside of anesthesia about volume of human factors errors amenable to training approaches.

80. Limited studies with small numbers of participant and with different simulators lead to concerns about generalizability.

81. Effect unclear since few studies with comparable simulators, and evaluated with mostly Level 3 outcomes.

82. Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-healthcare industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the healthcare literature.

83. Fixed shift may be more costly and difficult to implement than forward rotation.

84. Most evidence available outside of medicine; study strength not rated. These practices, drawn largely from non-healthcare industries, were not fully rated because of their unique nature and their relatively small evidentiary base in the healthcare literature.

85. Restructuring patient care to allow for napping while minimizing discontinuities could be expensive.

86. Study strength is borderline-medium with three Level 3 studies.

87. Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

88. Cost for video disks—assumes that off-the-shelf products exist for common procedures; would be higher if an institution has to build its own systems.

89. Cost would be lower for healthcare organizations that already rely on computers for care management.

90. Rated as low, but this practices requires behavior change on the part of the provider. Therefore, it may be more difficult to implement because its success largely rests on education (see Chapter 54) and acceptance.

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