How complexity science can inform scale-up and spread in health care: understanding the role of self-organization in variation across local contexts.

Health care systems struggle to scale-up and spread effective practices across diverse settings. Failures in scale-up and spread (SUS) are often attributed to a lack of consideration for variation in local contexts among different health care delivery settings. We argue that SUS occurs within complex systems and that self-organization plays an important role in the success, or failure, of SUS.

Technologic advances in endotracheal tubes for prevention of ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is associated with high morbidity, mortality, and costs. Interventions to prevent VAP are a high priority in the care of critically ill patients requiring mechanical ventilation (MV). Multiple interventions are recommended by evidence-based practice guidelines to prevent VAP, but there is a growing interest in those related to the endotracheal tube (ETT) as the main target linked to VAP.

Hypocapnia and hypercapnia are predictors for ICU admission and mortality in hospitalized patients with community-acquired pneumonia.

Objective: The purpose of our study was to examine in patients hospitalized with community acquired pneumonia (CAP) the association between abnormal Pa CO 2 and ICU admission and 30-day mortality.

Methods: A retrospective cohort study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of CAP.

Same organization, same electronic health records (EHRs) system, different use: exploring the linkage between practice member communication patterns and EHR use patterns in an ambulatory care setting.

Objective: Despite efforts made by ambulatory care organizations to standardize the use of electronic health records (EHRs), practices often incorporate these systems into their work differently from each other. One potential factor contributing to these differences is within-practice communication patterns. The authors explore the linkage between within-practice communication patterns and practice-level EHR use patterns.

Late admission to the ICU in patients with community-acquired pneumonia is associated with higher mortality.

Background: Limited data are available on the impact of time to ICU admission and outcomes for patients with severe community acquired pneumonia (CAP). Our objective was to examine the association of time to ICU admission and 30-day mortality in patients with severe CAP.

Methods: A retrospective cohort study of 161 ICU subjects with CAP (by International Classification of Diseases, 9th edition, codes) was conducted over a 3-year period at two tertiary teaching hospitals.

Task overlap among primary care team members: an opportunity for system redesign?

This article presents the results of research on a systematic approach to the assignment of primary care work in the Veterans Health Administration. Based on a functional job analysis protocol, the study identified overlap in the performance of primary care tasks among multiple occupational groups as prima facie evidence of opportunities to reallocate work responsibilities. Results show that registered nurses, physicians, advanced practitioners, and licensed vocational nurses reported performing 60 percent to 97 percent of the same tasks, while clerks and health technicians appeared to be underutilized.

Antibiotic therapy and 48-hour mortality for patients with pneumonia.

Purpose: Although numerous articles have demonstrated that recommended empiric antimicrobial regimens are associated with decreased mortality at 30 days, there is controversy over whether appropriate antibiotic selection has a beneficial impact on mortality within the first 48 to 96 hours after admission. Our aim was to determine whether the use of guideline-concordant antibiotic therapy is associated with decreased mortality within the first 48 hours after admission for patients with pneumonia.

Methods: A retrospective cohort study was conducted at two tertiary teaching hospitals in San Antonio, Texas.

Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration?

Objectives: To identify the extent of inappropriate prescribing using criteria for proper use developed by the Agency for Healthcare Research and Quality (AHRQ) and dose-limitation criteria defined by Beers, as well as to describe duration of use and patient characteristics associated with inappropriate prescribing for older people.

Design: Retrospective national Veterans Health Administration (VA) administrative database analysis.

Setting: VA outpatient facilities during fiscal year 2000 (FY00).

Effects of guideline-concordant antimicrobial therapy on mortality among patients with community-acquired pneumonia.

Purpose: National practice guidelines have recommended specific initial empiric antimicrobial regimens for patients with community-acquired pneumonia. Our aim was to determine the association between the use of guideline-concordant antimicrobial therapy and 30-day mortality in patients with pneumonia.

Methods: We conducted a retrospective cohort study at two tertiary teaching hospitals.

Functional independence after major abdominal surgery in the elderly.

Background: Elders undergo approximately 40% of more than 1 million major abdominal operations annually. Yet evidence about recovery to preoperative levels of functional independence is limited. This study details course and predictors of functional recovery after elective major abdominal operations in the elderly.

Higher Hb level is associated with better early functional recovery after hip fracture repair.

Background: The benefits and indications for blood transfusion are controversial. One possible reason to transfuse is to improve functional recovery after major surgery. However, the data linking improved function with higher Hb concentration are limited.