Free and paid medical assistance in the United States News : Part 5

Changing the Work Environment in ICUs to Achieve Patient-Focused Care: Response to a Flawed Health System

The decision of the AACN to establish standards for healthy work environments grew from a strategic planning process in which the association identified the three most important issues facing its members and critical care nurses at large on which the voice and actions of the AACN would have the greatest effect. A healthy work environment was one of those issues and was judged to be so influential that the failure to address it would result in deleterious effects for every aspect of critical care practice. A task force and national review panel led by past AACN president Connie Barden developed the standards that were launched at a Washington, DC, press conference in January 2005. More than 30,000 copies of the standards were downloaded from the AACN Web site in the first month after their release; the number of copies downloaded now exceeds 120,000. These standards are guiding the transformation of the care environment in many institutions across the United States. comments
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Changing the Work Environment in ICUs to Achieve Patient-Focused Care

Changing the Work Environment in ICUs to Achieve Patient-Focused CareThe landmark Institute of Medicine (IOM) document To Err Is Human: Building a Safer Health System1 transformed the way we think about patients safety. By making public the dangers that patients face when they enter the current health-care system, the IOM used its influence effectively to call for dramatic transformations in the way we evaluate errors and changed the focus of error prevention from individual punishment to one of system redesign. In Crossing the Quality Chasm: A New Health System for the Twenty-First Century,2 the IOM then attacked the dysfunctional processes of our past and current health-care systems (eg, pervasive poor communication and noninterdisciplinary, often isolationist decision-making behavior). By focusing on effective team performance, data-driven analysis of system failures, and continuous process improvements to reduce risk, the IOM called for a revolution in the way we communicate with each other, anticipate and modify patients’ risk, and evaluate our effectiveness.
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Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: Recommendation

Our findings would support the concept that while longitudinal structural abnormalities are clearly seen with HRCT, their longitudinal functional significance is less clear-cut. Other imaging techniques such as hyperpolarized He MRI may prove a useful alternative in obtaining longitudinal functional information. We recently evaluated He MRI in CF adults and found it to be a strong correlate of structural HRCT abnormalities and a stronger correlate of spirometry than HRCT. We envisage, although currently hypothetical, that spirometry, He MRI, and HRCT may work synergistically to provide longitudinal functional and structural information in CF. add comment
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Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: Conclusion

Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: ConclusionClearly there were differences between the Irish and Swedish cohorts in longitudinal progression, with the annual change in CT score equal to + 1.6% and FEV1 equal to — 0.4%, compared to – 2.7% and -2.3% in the Irish cohort, respectively. For individual HRCT abnormalities, de Jong et al found no change in mucus plugging over time in their adult patients in contrast to our results in which mucus plugging worsened predominantly in the group with mildly impaired lung function. Such discrepancies may be related to differences in treatment or in patient populations. Some European centers have followed a more aggressive policy of early antibiotic intervention from time of diagnosis, which may influence decline in spirometry results over time. More info

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Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: Discussion

Severity of bronchiectasis, extent of mucus plugging, sacculations/abscesses, generations of bronchial divisions involved, and air trapping demonstrated systematic differences between readers on Bland and Altman plots. Observer 1 scored extent of mucus plugging and air trapping worse on average than observer 2, and this was more pronounced for mild scores. Observer 2 scored severity of bronchiectasis, sacculations/abscesses, and generations of bronchial divisions involved worse on average than observer 1. For severity of bronchiectasis and generations of bronchial divisions involved, this was more pronounced for moderate scores; for sacculations/abscesses, this was more pronounced for severe scores. Reading here
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Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: HRCT Findings for All Patients

Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: HRCT Findings for All PatientsOn an annual basis, all spirometric variables except RV deteriorated significantly (Table 4). Almost all individual HRCT parameters also deteriorated, with the exception of acinar nodules, mosaic perfusion, and thickening of interlobular septa (Fig 1, bottom, B). Air trapping, collapse/consolidation, mucus plugging, peribronchial thickening, severity and extent of bronchiectasis, generations of bronchial divisions involved, and HRCT total score declined significantly faster than FEV1. FEF25-75 declined at a rate of – 5.1% per year. However, air trapping and extent of bronchiectasis declined significantly faster, at – 5.3 per year and – 6.5% per year, respectively (p < 0.001). Six patients showed stable spirometry results (annual change, 1.4% per year) but worsening HRCT scores (annual change, 6.6% per year). Reading here
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Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: Results

Mean age of the patients increased by 4 years (Table 2). Mean BMI remained stable, but four patients had BMIs < 18.5 kg/m2 at time 1, indicating malnourishment. Genotype was available for 37 patients. Forty-four percent of patients were homozygous and 36% were heterozygous for the AF508 mutation. All spirometry measurements except RV deteriorated significantly. Mean FEV1 was 81.8 ± 24.9% of predicted at time 1, indicating a group with overall mild lung impairment (Fig 1, top, A). This decreased by 11.7% between PFT-1 and PFT-2 (42 ± 7 months). Sixteen patients had mild lung function abnormalities, with mean FEV1 decreasing from 102.1 ± 14.5 to 87.5 ± 18.2%. Nineteen patients had moderate lung function abnormalities, with mean FEV1 decreasing from 69.8 ± 6.0 to 59.5 ± 15.8%. Four patients had severe lung function abnormalities, with mean FEV1 decreasing from 34.0 ± 2.7 to 30.5 ± 2.6%.

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Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: Longitudinal Measurements and Statistical Calculations

Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: Longitudinal Measurements and Statistical CalculationsThe initial HRCT and spirometry findings obtained at time 1 are reported as HRCT-1 and PFT-1, and follow-up HRCT and spirometry findings obtained at time 2 are reported as HRCT-2 and PFT-2. Median time interval was 42 ± 16 months (range, 19 to 73 months). The annual rate of change in HRCT score (AHRCT) was calculated for each patient as follows: (HRCT-2 — HRCT-1)/individual time interval for each patient. A positive AHRCT value indicated a worsening in HRCT appearances. Similarly, the annual rate of change in PFT score (APFT) was calculated for each patient as follows: (PFT-2 — PFT-1)/individ-ual time interval for each patient. A negative APFT value indicated a worsening in spirometry results. http://www.medicines-for-diabetes.com/
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Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: Sputum

Areas of hyperlucency with hypovascularity defined mosaic perfusion on inspiratory scans. Areas of hyperlucency on expiratory images defined air trapping. The total score was derived by adding the scores for each abnormality, and ranged from 0 to 37. For scoring purposes, the average of the two observers’ individual scores were calculated. Absolute total scores were converted to percentages of the potential total maximum score. The extent and severity of abnormalities were scored as in Table 1.
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Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: HRCT Protocol and Scoring

Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: HRCT Protocol and ScoringOf the two observers, one observer (J.M.) was a senior chest radiologist with > 20 years experience. The other observer (J.D.) was a thoracic clinical fellow in chest radiology with 2 years experience scoring HRCT. A consensus meeting was held prior to formal scoring to standardize scoring between observers. HRCT scans were scored over a 2-week time period.
Images were scored using a modified Bhalla scoring system. Modifications included additional HRCT abnormalities described in CF lung disease since the original publication by Bhalla et al. Abnormalities were defined according to recommendations of the nomenclature committee of the Fleischner society. Bronchiectasis was defined as a bronchus with an internal diameter larger then its accompanying pulmonary artery, lack of tapering of the bronchial lumen for > 2 cm, and visualization of a bronchus within 1 cm of the costal pleura. Peribronchial thickening was defined by a bronchial wall > 1 mm in thickness. Mucus plugging was identified by visualizing plugs in large airways or by the presence of tree-in-bud peripherally.

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