The Use of Performance Improvement Methods to Enhance Emergency Department Patient Satisfaction in the United States: A Critical Review of the Literature and Suggestions for Future Research

Objectives: The authors reviewed the evidence on performance improvement methods for increasing emergency department (ED) patient satisfaction to provide evidence-based suggestions for clinical practice.
Methods: Data sources consisted of searches through MEDLINE, CINAHL, PSYCHINFO, Cochrane Library, and Emergency Medicine Abstracts and a manual search of references. Articles were included if they reported a performance improvement intervention targeting patient satisfaction in the ED setting. Articles on studies not conducted in the United States or that failed to provide enough details to allow critical evaluation of the study were excluded. Two authors used structured evaluation criteria to independently review each retained study.
Results: Nineteen articles met all selection criteria. Three studies found varying levels of support for multicomponent interventions, predominantly focused on implementation of clinical practice guidelines for specific presenting complaints and process redesign. Sixteen studies evaluated single-component interventions, with the following having at least one supportive study: using alternating patient assignment to provider teams rather than "zone"-based assignment, enhancing provider communication and customer service skills, incorporating information delivery interventions (e.g., pamphlets, video) that target patient expectations, using preformatted charts, and establishing ED-based observation units for specific conditions such as asthma and chest pain.
Conclusions: There is modest evidence supporting a range of performance improvement interventions for improving ED patient satisfaction. Further work is needed before specific, evidence-based recommendations can be made regarding which process changes are most effective. Recommendations are made for improving the quality of performance improvement efforts in the ED setting.     

药物洗脱支架直接置入治疗A型和B_1型病变的临床观察

目的　评价直接置入药物洗脱支架 (CYPHERTM,codis)在A或B1 型病变的冠心病患者治疗中的安全性、可行性。方法　 6 2例接受CYPHERTM 支架直接置入的患者 (直接支架组 )和一般情况匹配的 5 1例球囊扩张后行冠脉支架术的患者 (常规支架组 ) ,比较两组的一般情况 ,冠脉造影及介入治疗即刻和临床随访结果。结果　直接支架组介入操作时间明显短于常规支架组 [(17.2± 8.6 )比 (2 6 .3± 7.1)min ,P <0 .0 1],直接支架组平均扩张压明显高于常规支架组 [(14± 3)比 (12± 1.9)atm ,P<0 .0 1],两组无一例发生介入治疗相关的严重心脏事件。随访期间两组严重心脏不良事件发生率无显著差异。结论　A或B1 型病变的冠心病患者CYPHERTM 支架直接置入术可缩短介入操作时间 ,即刻效果、并发症及中期临床随访与常规支架组差异无显著性意义     

Recognition performance and perceived quality of video enhanced for the visually impaired

Subjects with central field loss (CFL) individually selected enhancement parameters to improve visibility of static video images. The effect of enhancement on performance and on perceived quality of motion video was assessed. Performance, e.g. recognition of visual details, was assessed by having subjects answer questions regarding visual information contained in the video motion segments that were enhanced using the individually-selected parameters. Enhancement did not improve subject performance on questions about video content. This result might be due to a ceiling effect limitation of the performance assessment method. In a second procedure, subjects' continuous perceptions of quality (using an adjective-based rating scale) were made while the enhancement parameters were abruptly switched among multiple values; these included the individually-selected enhancements, as well as unenhanced, over-enhanced, and degraded segments. The results indicate that adaptive enhancement (individually-tuned using a static image) adds significantly to perceived image quality when viewing motion video. Subjects who selected stronger contrast enhancement also perceived the enhancement to provide a larger benefit in image quality.     

应用抗凝剂的心脏瓣膜置换患者接受胆道手术的术前处理

目的总结瓣膜置换患者行胆道手术的术前用药方法。方法对38例瓣膜置换后在服用华法令过程中因胆道疾病需行择期手术治疗的患者随机分为2组,肝功能正常组(A组)23例、肝功能不正常组(B组)15例均于术前3d停服华法令,B组术前12h肌注VitK110mg。术前无应用华法令历史的患者115例做为对照组。结果38例患者停药2d后A组血浆凝血酶原时间与对照组差异无显著意义,B组于术前12h肌注VitK110mg后,血浆凝血酶原时间与对照组相比差异也无显著性意义。结论瓣膜置换患者在抗凝期间行胆道手术,只要准备充分,围手术期是安全的。     

耐药性癫(癎)患者颞叶中细胞周期依赖性蛋白激酶5的表达

目的 研究细胞周期依赖性蛋白激酶5(cyclin dependent kinases 5,CDK5)在耐药性癫(癎)患者颞叶中的表达,探索其在耐药性癫(癎)发病机制中的作用.方法 收集耐药性癫(癎)患者术后脑组织,用荧光定量PCR、免疫组化和Western blot 3种检测方法从基因和蛋白水平分别测定CDK5在耐药性癫(癎)患者颞叶中的表达,并与对照组进行比较.结果 荧光定量PCR发现CDK5 mRAN比对照组明显增加,免疫组化检测显示这种基因的蛋白表达产物主要分布在神经元轴突和胶质细胞中,Western blot检测在相对分子质量35 000处有一蛋白条带,并且可见实验组(颞叶和海马中分别为1.4293±0.1839和2.0733±0.4738)高于对照组(颞叶和海马中分别为0.9680±0.4147和1.403±0.6163,P＜0.05).结论 CDK5在耐药性癫(癎)患者颞叶中表达增强,提示他们可能参与了耐药性癫(癎)的形成.     

Effects of stimulation and blockade of dopamine receptor subtypes on the discriminative stimulus properties of cocaine

The involvement of dopamine (DA) receptor subtypes in the behavioral effects of CNS stimulants was studied in rats trained to discriminate occaine from saline. In substitution tests, the stimulus effects of 10mg/kg of this substance generalized tod-amphetamine (0.25–1.0 mg/kg) and the selective D₂ against LY-171555 (0.05–0.25 mg/kg); but not to the D₁ agonist SKF-38393 (5.0–15.0 mg/kg); in combination tests, the D₁ antagonist Sch-23390 (0.0625–0.5 mg/kg) significantly blocked, and the D₂ antagonist spiperone (0.25–0.5 mg/kg) partially blocked the cocaine cue. These data suggest that the involvement of DA systems in the behavioral effects of cocaine is more complex than either D₁ or D₂ receptor activation; for example, the stimulus properties of this substance might involve both D₁ and D₂ receptor activation.Some of these results were presented at the meeting of the Society for Neuroscience, Toronto, 1988     

Applying item response theory to enhance health outcomes assessment

Background Health-related quality of life (HRQL) is an accepted outcome measure in patients with mood and anxiety disorders. Yet, surprisingly little attention has been paid to the determinants. In this paper we test the hypothesis that it is associated with personality traits while controlling for mental disorders. Methods A large sample of outpatients (n=640) with mood and anxiety disorders was studied. The empirically supported five factor model of normal personality traits was assessed using the NEO-FFI and includes: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Mental disorders were assessed with the CIDI, and HRQL with the SF-36. Results Regression analyses revealed that the NEO-FFI scores, with the exception of conscientiousness, were significantly associated with SF-36 subscales and summary scores, independently from the mental disorders. The percentage of explained variance due to the personality traits was highest for the subscales Vitality (10.0%), Mental Health (13.3%) and the Mental Health Summary Score (9.5%). Furthermore, specific personality traits were related to specific SF-36 subscales. Conclusions A low HRQL of patients with mood or anxiety disorders is not only determined by the disease or the current health but is also shaped by personality traits that are relatively stable throughout an individual's life time.     

The discriminative stimulus and subjective effects of d-amphetamine,phenmetrazine and fenfluramine in humans

The discriminative stimulus (DS) and subjective effects of d-amphetamine (AMP), phenmetrazine (PMT) and fenfluramine (FFL) were studied in a group of normal healthy adults. Subjects (N=27) were trained to discriminate between placebo and 10 mg AMP (PO). Fourteen of the subjects (discriminators) reliably learned the discrimination, whereas the other 13 did not. Nearly all discriminators labelled AMP as a stimulant, and AMP, relative to placebo, increased ratings of drug liking and general activity level, and produced typical stimulant-like subjective effects, as measured by the Profile of Mood States, the Addiction Research Center Inventory, and a series of visual analog scales. The discrimination accuracy of discriminators increased as a function of hour after drug ingestion, as did analog ratings of how certain subjects were that their discrimination responses were correct. Discriminators were tested with doses of PMT (25 and 50 mg) and FFL (20 and 40 mg) to determine whether the DS properties of these drugs would substitute for those of AMP. Both doses of PMT consistently substituted for AMP, and PMT produced subjective effects very similar to those of AMP. Conversely, neither dose of FFL consistently substituted for AMP, and FFL produced essentially no subjective effects. These findings are consistent with results from discrimination studies with other species, and provide further evidence of the validity of this procedure for studying the DS properties of drugs in humans. Offprint requests to: L.D. Chait     

病案质量问题与改进

病案作为记录医疗活动过程的重要载体,包含着各类丰富的信息。医疗服务质量评价有很多内容是通过病案实现的。作者分析了包括"三级医师查房"在内的20余项在病案中反映的医疗服务质量项目,指出影响质量判断的常见因素,并提出解决的对策与措施。