Indications and diagnostic outcome of antineutrophil cytoplasmic antibody testing in hospital medicine: a pattern of over-screening

Clinical Rheumatology - Antineutrophil cytoplasmic antibodies (ANCA) serology can aid in the diagnosis and classification of ANCA-associated vasculitides (AAV). However, it is often ordered in...     

Preferences for treatments to prevent rheumatoid arthritis in Canada and the influence of shared decision-making

Clinical Rheumatology - To elicit and compare preferences of patients and first-degree relatives and rheumatologists for preventive treatments for rheumatoid arthritis, understand the...     

Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review

BACKGROUND: Iatrogenic injuries related to medications are common, costly, and clinically significant. Computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) may reduce medication error rates. METHODS: We identified trials that evaluated the effects of CPOE and CDSSs on medication safety by electronically searching MEDLINE and the Cochrane Library and by manually searching the bibliographies of retrieved articles. Studies were included for systematic review if the design was a randomized controlled trial, a nonrandomized controlled trial, or an observational study with controls and if the measured outcomes were clinical (eg, adverse drug events) or surrogate (eg, medication errors) markers. Two reviewers extracted all the data. Discussion resolved any disagreements. RESULTS: Five trials assessing CPOE and 7 assessing isolated CDSSs met the criteria. Of the CPOE studies, 2 demonstrated a marked decrease in the serious medication error rate, 1 an improvement in corollary orders, 1 an improvement in 5 prescribing behaviors, and 1 an improvement in nephrotoxic drug dose and frequency. Of the 7 studies evaluating isolated CDSSs, 3 demonstrated statistically significant improvements in antibiotic-associated medication errors or adverse drug events and 1 an improvement in theophylline-associated medication errors. The remaining 3 studies had nonsignificant results. CONCLUSIONS: Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems. Research is needed to evaluate commercial systems, to compare the various applications, to identify key components of applications, and to identify factors related to successful implementation of these systems.     

Searching the health care literature efficiently: from clinical decision-making to continuing education

Searching the health care literature is an activity in which infection control professionals must routinely engage to seek evidence-based answers to specific practice questions and to stay abreast of developments in the field. Without the appropriate tools, the tremendous volume of clinical literature makes both of these daunting tasks. In this article, we illustrate techniques for searching MEDLINE efficiently, both as a means of answering particular clinical questions and for generating periodic updates on topics of general interest. With use of a specific example relevant to infection control, we demonstrate the identification of appropriate Medical Subject Headings terms that capture a given question or topic and the development of effective searches with use of these terms. We also touch on the advantages of targeting systematic reviews and meta-analyses in searching for evidence and staying abreast of the literature in general.     

The impact of adverse events in the intensive care unit on hospital mortality and length of stay

Background  

Adverse events (AEs) are patient injuries caused by medical care. Previous studies have reported increased mortality rates and prolonged hospital length of stay in patients having an AE. However, these studies have not adequately accounted for potential biases which might influence these associations. We performed this study to measure the independent influence of intensive care unit (ICU) based AEs on in-hospital mortality and hospital length of stay.     

Physician's management of suspected vitamin B12 deficiency.

A retrospective study was undertaken to audit physician's management of patients with a low serum level of vitamin B12 who were admitted to a university-affiliated teaching hospital during 1 year. Among the 34 patients 13 were proved to have pernicious anemia or vitamin B12 malabsorption, but for 12 of them there were unnecessary delays (several days or weeks) before initiation of investigation and therapy. An additional six patients, who had low serum levels of vitamin B12 and macrocytosis, most likely had true vitamin B12 deficiency, but proper investigation was not done and they did not receive any vitamin B12 or folic acid therapy. In another nine cases unexplained low serum levels of vitamin B12 were not properly investigated, and the patients either did not receive any vitamin B12 therapy or received it without proper documentation of a deficiency. Suggestions for facilitating early detection, investigation and treatment of megaloblastic anemia or vitamin B12 deficiency are given.     

Evidence-based quality improvement: the state of the science

Routine practice fails to incorporate research evidence in a timely and reliable fashion. Many quality improvement (QI) efforts aim to close these gaps between clinical research and practice. However, in sharp contrast to the paradigm of evidence-based medicine, these efforts often proceed on the basis of intuition and anecdotal accounts of successful strategies for changing provider behavior or achieving organizational change. We review problems with current approaches to QI research and outline the steps required to make QI efforts based as much on evidence as the practices they seek to implement.