Comparison of Two Preoperative Inspiratory Muscle Training Programs to Prevent Pulmonary Complications in Patients Undergoing Esophagectomy: A Randomized Controlled Pilot Study

Background

Postoperative pulmonary complications (PPCs) are the most commonly reported complications after esophagectomy. The aim of this study was to examine the effect and feasibility of preoperative inspiratory muscle training-high intensity (IMT-HI), and IMT-endurance (IMT-E) on the incidence of PPCs in patients following esophagectomy for esophageal cancer (EC).

Method

A single-blind, randomized, clinical pilot study was conducted between 2009 and 2012. Forty-five participants were assigned to either IMT-HI or IMT-E. Effectiveness was assessed by analyzing PPCs, length of hospital stay (LOS), duration of mechanical ventilation, stay on the intensive care unit, and number of reintubations. Maximal inspiratory pressure and lung function changes were recorded pre- and post-training. Feasibility was assessed by IMT-related adverse events, training compliance, and patients’ satisfaction.

Results

Thirty-nine patients could be analyzed, 20 patients in the IMT-HI arm and 19 patients in the IMT-E arm. The incidence of PPCs differed significantly between groups and was almost three times lower for the IMT-HI group (4 vs. 11 patients; p = 0.015). Other differences in favor of the IMT-HI group were LOS (13.5 vs. 18 days; p = 0.010) and number of reintubations (0 vs. 4 patients; p = 0.030). Both interventions proved to be equally feasible.

Conclusion

Preoperative IMT-HI showed to be a promising, effective, and feasible intervention to reduce PPCs in EC patients undergoing esophagectomy. Further research with a larger sample size is recommended.     

A Computerized Order Entry System Was Adopted with High User Satisfaction at an Orthopedic Teaching Hospital

Background

Computerized provider order entry (CPOE) has been considered essential for the reduction of medical errors and increased patient safety. Assessment of staff perception regarding a CPOE system is important for satisfaction and adoption. Incorporation of user feedback can greatly improve the functionality of a system and promote user satisfaction.

Questions/Purposes

This study aims to develop an informatics staff satisfaction survey instrument and to understand what components of computerized prescriber order entry (CPOE) contribute to staff satisfaction and its variability over time.

Methods

The 22-question survey was developed by a multidisciplinary group and focused on patient data including demographics, orders, medications, laboratory, and radiology data. The questions were designed to understand if clinicians (1) could easily access the information needed to properly take care of patients, (2) could act upon the information once acquired, (3) could obtain the information clearly, and (4) were alerted to potential errors. The survey was distributed just prior to “go-live,” 6 and 12 months after go-live. Responses were given on a five-point Likert scale.

Results

The survey results post-implementation showed user satisfaction with CPOE. Satisfaction regarding the ease of obtaining orders, medication, and lab data had a significant improvement at 6 and 12 months post-implementation, p < 0.001. Satisfaction that the computerized order entry system provided information needed to take care of their patients improved, p < 0.01. At 1 year post-implementation, user satisfaction declined from 6 months earlier but still demonstrated an overall increase in satisfaction from pre-implementation.

Conclusion

Compared prior to go-live, clinicians are satisfied or very satisfied across multiple spheres and multiple disciplines. At all time points, clinicians were able to obtain information required to take care of their patients. However, post-go-live, it was easier to obtain and act upon as well as more clear and understandable.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9377-1) contains supplementary material, which is available to authorized users.     

Physical therapists’ perception of workplace ethics in an evolving health-care delivery environment: a cross-sectional survey

Physical therapists are trained and obligated to deliver optimal health care and put patients first above all else. In the changing health-care environment, health-care organizations are grappling with controlling cost and increasing revenues. Moral distress may be created when physical therapists’ desire to provide optimal care conflicts with their organization’s goals to remain financially viable or profitable. Moral distress has been associated with low perception of ethical environment, professional burnout, and high turnover in organizations. This study identified groups who may be vulnerable to low perception of organizational ethical environment and identified self-reported strategies to remedy these perceptions. An ethics environment questionnaire was mailed to a random sample of 1200 physical therapists in Georgia. Respondents (n = 340) were analyzed by age, workplace setting, and position in organization. Therapists working in skilled nursing/assisted living environments scored the lowest on the questionnaire and voiced concerns regarding their ethical work environments. Owners and executives perceived their organizations to be more ethical than front-line clinicians. Respondent concerns included high productivity standards, aggressive coding/billing policies, decreased reimbursement, and increased insurance regulation. Possible solutions included more frequent communication between management and clinicians about ethics, greater professional autonomy, and increased training in business ethics and finance.     

Long-term Results of Comprehensive Clubfoot Release Versus the Ponseti Method: Which Is Better?

Background

Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child.

Questions/purposes

We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot.

Methods

This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics.

Results

Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01).

Conclusions

Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function.

Level of Evidence

Level III, prognostic study.