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Adoption of alternative financing strategies to increase the diffusion of picture archiving and communication systems into the radiology marketplace

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JOURNAL OF DIGITAL IMAGING 2000年第2期13卷 108-113页

作者： Reiner, B Siegel, E McKay, P Univ Maryland Amer Radiol Serv Leonardtown MD 20650 USA Vet Affairs Med Ctr Baltimore MD USA Univ Maryland Sch Med Baltimore MD 21201 USA Amer Radiol Serv Baltimore MD USA Natl Vet Affairs Headquarters Washington DC USA

The objective of the study was to evaluate current marketplace conditions and strategies employed by major picture archiving and communication systems (PACS) vendors in the creation of alternative financing strategies, to enhance the diffusion of filmless imaging. Data were collected from the major PACS vendors in the forms of survey questionnaires and review of existing leases. Topics evaluated in the survey included current financing options available, foreseeable changes in PACS financing, role of third-party financiers, and creation of risk-sharing arrangements. Generic leases were also reviewed evaluating the presence or absence of several key variables including technology obsolescence protection, hardware/software upgrades, end-of-term options, determination of fair market value, functionality/acceptance testing, uptime guarantees, and workflow management consulting. Eight of the 10 PACS vendors surveyed participated in the data collection. The vast majority of current PACS implementations (60% to 90%) occur through direct purchase, with conventional leasing (operating or capital) accounting for only 5% to 30% of PACS installations. The majority of respondents view fee-for-lease arrangements and other forms of risk sharing as increasing importance for future PACS financing. The specific targets for such risk-sharing arrangements consist of small hospital and privately owned imaging centers. Leases currently offered range in duration from 3 to 5 years and frequently offer technology obsolescence protection with upgrades, multiple end-of-term options, and some form of acceptance testing. A number of important variables frequently omitted from leases include uptime guarantees, flexibility in changing financing or vendors, and incorporation of expected productivity/operational efficiency gains. As vendors strive to increase the penetration of PACS into the radiology marketplace, there will be a shift from conventional financing (loan or purchase) to leasing. Fee-

关键词：费用分担成本及成本分析/统计学和数值数据经济学医院/统计学和数值数据筹资组织/经济学租赁财产/经济学卫生服务使用研究/经济学采购科医院/经济学放射科医院/经济学放射学信息系统/经济学人类

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Etomidate for procedural sedation in emergency medicine

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ANNALS OF EMERGENCY MEDICINE 2002年第6期39卷 592-598页

作者： Vinson, DR Bradbury, DR Kaiser Permanente Med Ctr Dept Emergency Med Roseville CA 95661 USA Kaiser Permanente Med Ctr Sacramento CA USA

Study objective: We describe and analyze the effectiveness and safety of etomidate for procedural sedation and evaluate the patient's perspective on effectiveness, side effects, and satisfaction. Methods: We conducted an observational retrospective study of all patients who received etomidate for procedural sedation over 2 years in 3 affiliated suburban emergency departments of a large group-model health maintenance organization. Data were abstracted from the ED records. Additionally, a patient questionnaire was prospectively administered by telephone. Results: Etomidate was used for sedation in 134 patients between 6 and 93 years of age during 150 procedures. The mean cumulative dose was 0.20 mg/kg. Adjunctive medication was used in 36 (23%) procedures Moderate sedation with verbal arousability was induced in 48 (32%) patients, and deep sedation with verbal unresponsiveness was induced in 102 (68%) patients, Full recovery to the preprocedural level of alertness was achieved within 30 minutes in 142 (95%) of procedures, Mean changes in systolic blood pressure, pulse rate, and oxygen saturation were clinically insignificant. There were 7 (4.7%;95% confidence interval [Cl] 1.9% to 9.4%) adverse events, including 5 (3.3%;95% Cl 1.1% to 7.6%) cases of oxygen desaturation below 94% in older patients (>55 years of age) who received slightly higher mean doses of etomidate (0.23 mg/kg). Four of these patients received brief assisted bag-valve-mask ventilation and recovered uneventfully;none required endotracheal intubation, The questionnaire was completed by 120 (90%) of 134 patients and involved 136 procedures. During 127 (93%) of these, etomidate was believed to be extremely effective in causing sleep, and for 127 (93%) it induced complete procedural amnesia, Only 5 (4%) patients experienced nausea or vomiting, Regarding willingness to receive etomidate for their next procedure, the patients' responses were favorable: extremely, 95%;moderately, 2%;slightly, 3%;and not at

关键词：清醒镇静急诊室医院/统计学和数值数据依托咪酯血流动力学催眠药和镇静药病人满意度回顾性研究青少年成年人老年人老年人 80以上儿童儿童学龄前女(雌)性人类男(雄)性中年人

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Antibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: A national study of hospital-based emergency departments

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ANNALS OF EMERGENCY MEDICINE 2000年第4期36卷 320-327页

作者： Stone, S Gonzales, R Maselli, J Lowenstein, SR Univ Colorado Hlth Sci Ctr Dept Surg Div Emergency Med Denver CO 80262 USA Univ Colorado Hlth Sci Ctr Div Internal Med Dept Med Denver CO 80262 USA

Study objective: Antibiotics are often used to treat viral upper respiratory tract infections, even though they are usually ineffective. However, frequent inappropriate antibiotic use contributes to the emergence of drug-resistant bacterial pathogens. This study used a national database to evaluate antibiotic use in treating upper respiratory tract infections in emergency departments. Methods: Data were obtained from the 1996 National Hospital Ambulatory Medical Care Survey. Antibiotic prescribing rates were examined for colds, upper respiratory tract infections, and acute bronchitis. Patients with comorbid conditions or secondary diagnoses, such as chronic obstructive pulmonary disease, pneumonia, sinusitis, and HIV, were excluded. Bivariate and multivariate analyses were used to assess predictors of antibiotic use. Results: Overall, there were an estimated 2.7 million ED visits for colds, upper respiratory tract infections, and bronchitis by children and adults in 1996. Antibiotics were prescribed for 24.2% (95% CI 18.9, 29.5) of patients with common colds and upper respiratory tract infections and for 42.2% (95% CI 35.2, 49.2) of patients with bronchitis. There were no significant associations between antibiotic use and patient race, sex, Hispanic ethnicity, geographic location, or source of payment. Antibiotics were prescribed less often by interns or residents than by staff or other physicians (odds ratio 0.43;95% CI 0.19, 0.98), and patients younger than 18 years were less likely to receive antibiotics than adults (odds ratio 0.32;95% CI 0.20, 0.52). Smokers were 4.3 (95% CI 2.2, 8.3) times more likely to receive antibiotics than nonsmokers. Conclusion: Antibiotics are commonly prescribed for ED patients with upper respiratory tract infections even though they are usually ineffective in otherwise healthy adults. Efforts should be made to reduce inappropriate antibiotic use for the sake of containing costs, preventing side effects, and limiting the spread of an

关键词：抗菌药/治疗应用支气管炎/药物疗法感冒/药物疗法药物利用/统计学和数值数据急诊室医院/统计学和数值数据国家卫生统计中心(美国) 中耳炎/药物疗法美国青少年成年人儿童女(雌)性人类男(雄)性

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Hospital admissions for rotavirus infection in the Netherlands

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CLINICAL INFECTIOUS DISEASES 2000年第3期31卷 698-704页

作者： de Wit, MAS Koopmans, MPG van der Blij, JF van Duynhoven, YTHP Natl Inst Publ Hlth & Environm Dept Infect Dis Epidemiol NL-3720 BA Bilthoven Netherlands Natl Inst Publ Hlth & Environm Res Lab Infect Dis NL-3720 BA Bilthoven Netherlands Med Ctr Alkmaar Netherlands

The development of a vaccine against rotavirus (RV) infection has necessitated the estimation of the number of hospitalizations for RV infection in the Netherlands. During 1998, pediatricians have reported all hospitalizations with RV infection and supplied information on the duration of admission, clinical picture, indication for admission, and treatment. Also, data from the National Disease Registry on hospitalizations for gastroenteritis (International Classification of Disease codes 006.6. 006.8, 009, and 558.9) and laboratory surveillance data for 1996-1998 were combined in a Linear regression model to indirectly estimate the incidence and proportion of hospitalizations attributable to RV infection. The direct estimate of admissions for RV infection in children aged <5 years was 0.9 per 1000, and the indirect estimate was 2.7 per 1000 in 1998 (1996, 3.4;1997, 1,6). The proportion of hospitalizations for gastroenteritis attributable to RV ranged from 32% in 1997 to 58% in 1996.

关键词：儿童住院/统计学和数值数据交叉感染/病毒学胃肠炎/流行病学胃肠炎/病毒学住院/统计学和数值数据发病率实验室医院/统计学和数值数据线性模型荷兰/流行病学病人出院/统计学和数值数据人群监测/方法轮状病毒感染/流行病学轮状病毒感染/病毒学时间因素儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性

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The effect of an education program on violence in the emergency department

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ANNALS OF EMERGENCY MEDICINE 2002年第1期39卷 47-55页

作者： Fernandes, CMB Raboud, JM Christenson, JM Bouthillette, F Bullock, L Ouellet, L Moore, CF St Pauls Hosp Dept Emergency Med Ctr Hlth Evaluat & Outcome Sci Vancouver BC V6Z 1Y6 Canada St Pauls Hosp Dept Occupational Hlth & Safety Vancouver BC V6Z 1Y6 Canada Univ British Columbia Dept Surg Vancouver BC V5Z 1M9 Canada Univ British Columbia Dept Hlth Care & Epidemiol Vancouver BC V5Z 1M9 Canada Canadian HIV Trials Network Vancouver BC Canada

Study objective: We examine whether a specific educational effort reduces emergency department violence in the short term and quantify the amount of violence in the ED. Methods: Cross-sectional prospective surveys were conducted at a tertiary referral center at baseline (1998) and at 3 and 6 months (1999) after the Prevention and Management of Aggressive Behavior Program (PMABP). ED staff on all shifts for 7 alternate days in a 2-week period were surveyed. We measured the total and mean number of physical and violent events per survey. A generalized estimating equation Poisson regression model examined the effect of the program on the numbers of physically and verbally violent events per shift per employee, after adjusting for other covariates. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Results: Physical violence events per survey at baseline, 3 months posttraining, and 6 months posttraining were 0.27, 0.10, and 0.21, respectively. The number of reported violent interactions at the same intervals were 49, 19, and 46 (adjusted OR 1.0, 0.35 [95% CI 0.15 to 0.84], and 0.79 [95% Cl 0.48 to 1.40]), respectively. Verbal violence events per survey at baseline, 3 months posttraining, and 6 months posttraining were 0.85, 0.31, and 0.51, respectively. The number of reported interactions involving verbal violence at the same intervals were 154, 58, and 69 (adjusted OR 1.0, 0,31 [95% CI 0.21 to 0.46], and 0.47 [95% Cl 0.33 to 0.66]), respectively. Conclusion: Violent events are frequent in the ED. Education programs may reduce the number of events at least temporarily but do not clearly reduce violence in the long term.

关键词：英属哥伦比亚/流行病学横断面研究急诊室医院/统计学和数值数据在职培训职业卫生病人教育(主题) 泊松分布方案评价前瞻性研究暴力/预防和控制暴力/统计学和数值数据人类

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Emergency department crowding: A point in time

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ANNALS OF EMERGENCY MEDICINE 2003年第2期42卷 167-172页

作者： Schneider, SM Gallery, ME Schafermeyer, R Zwemer, FL Univ Rochester Dept Emergency Med Rochester NY 14642 USA Carolinas Med Ctr Charlotte NC 28203 USA Amer Coll Emergency Phys Dallas TX USA

Study objective: This is a pilot study designed to assess the feasibility of a point prevalence study to assess the degree of crowding in hospital emergency departments (EDs). In addition, we sought to measure the degree of physical crowding and personnel shortage in our sample. Methods: A mail survey was sent to a random sample of 250 EDs chosen from a database compiled by the American College of Emergency Physicians of 5,064 EDs in the United States. In addition to demographic information, respondents were asked to count the patients and staff in their EDs at 7 Pm local time on Monday March 12,, 2001 (index time). Results: The response rate was 36%. At the index time, there was an average of 1.1 patients per treatment space, and 52% of EDs reported more than 1 patient per treatment space. There was also evidence of personnel shortage, with a mean of 4.2 patients per registered nurse and 49% of EDs having each registered nurse caring for more than 4 patients. There was a mean of 9.7 patients per physician. Sixty-eight percent of EDs had each physician caring for more than 6 patients. There was crowding present in all geographic areas and all hospital types (teaching-nonteaching status of the hospital). Consistent with the crowded conditions, 11% of institutions were on ambulance diversion and not accepting new acute patients. Delays in transfer of admitted patients out of the ED contributed to the physical crowding. Twenty-two percent of patients in the ED were already admitted and were awaiting transfer to an inpatient bed;73% of EDs were boarding 2 or more inpatients. The amount of crowding quantified by this point prevalence study was confirmed by the amount of crowding reported for the previous week: 48% of EDs were boarding inpatients during the previous week for a mean of 8.9 hours, 4.2 days per week;31% had been on diversion;59% had been routinely using their halls for patients;38% had been doubling their rooms;and 47% had been using nonclinical space for pa

关键词：病床利用率/统计学和数值数据横断面研究拥挤急诊室医院/统计学和数值数据可行性研究卫生服务研究医院病床数/统计学和数值数据室内设计和家俱/统计学和数值数据住院时间/统计学和数值数据医务人员医院/供应和分配需求估价护理人员医院/供应和分配病人转诊/统计学和数值数据人员配备和时间安排/统计学和数值数据医生行政负责人试点项目前瞻性研究时间因素美国人类

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Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma

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ANNALS OF EMERGENCY MEDICINE 2002年第3期40卷 287-293页

作者： Touger, M Gennis, P Nathanson, N Lowery, DW Pollack, CV Hoffman, JR Mower, WR Albert Einstein Coll Med Dept Emergency Med Jacobi Med Ctr Bronx NY 10461 USA Albert Einstein Coll Med Dept Radiol Jacobi Med Ctr Bronx NY 10461 USA Emory Univ Dept Emergency Med Atlanta GA 30322 USA Penn Hosp Dept Emergency Med Philadelphia PA 19107 USA Univ Calif Los Angeles Sch Med Ctr Emergency Med Los Angeles CA 90024 USA

Study objective: A decision instrument based on 5 clinical criteria has been shown to be highly sensitive in selecting patients who require cervical spine imaging after blunt trauma, while simultaneously reducing overall imaging. We examine the performance of this instrument in the elderly and explore some of the common features of geriatric cervical spine injury (CSI). Methods: The National Emergency X-radiography Utilization Study (NEXUS) was a prospective, observational, multicenter study conducted at 21 geographically diverse centers. We analyzed the performance of the NEXUS decision instrument among patients at least 65 years of age. Results: The study group consisted of 2,943 (8.6%) geriatric patients, representing 8.6% of the entire NEXUS sample. The rate of CSI was twice as great in these patients as it was in nongeriatric patients (4.59% versus 2.19%). Odontoid fractures were particularly common in geriatric patients, accounting for 20% of geriatric fractures compared with 5% of nongeriatric fractures. The frequency of patients meeting NEXUS criteria was similar in the 2 groups, with 14% of geriatric patients and 12.5% of nongeriatric patient classified as low risk. CSI occurred in only 2 low-risk geriatric patients, and these patients injuries met our preset definition of a clinically insignificant injury. The sensitivity of the NEXUS decision instrument for clinically significant injury in the geriatric group was therefore 100% (95% confidence interval 97.1% to 100%). Conclusion: The prevalence of CSI, and especially odontoid fracture, is relatively increased among geriatric patients with blunt trauma. The NEXUS decision instrument can be applied safely to these patients, with an expected reduction in cervical imaging comparable with that achieved in nongeriatric patients.

关键词：颈椎/诊断显像决策支持技术急诊室医院/统计学和数值数据老年人身心健康评价患病率前瞻性研究放射摄影术结果可重复性脊柱损伤/诊断显像脊柱损伤/流行病学美国/流行病学创伤非贯通性/诊断显像创伤非贯通性/流行病学成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Ability of laboratories to detect emerging antimicrobial resistance in nosocomial pathogens: a survey of Project ICARE laboratories

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DIAGNOSTIC MICROBIOLOGY AND INFECTIOUS DISEASE 2000年第1期38卷 59-67页

作者： Steward, CD Wallace, D Hubert, SK Lawton, R Fridkin, SK Gaynes, RP McGowan, JE Tenover, FC Ctr Dis Control & Prevent Hosp Infect Program Atlanta GA 30333 USA Emory Univ Rollins Sch Publ Hlth Atlanta GA 30322 USA

A proficiency testing project was conducted among 48 microbiology laboratories participating in Project ICARE Intensive Care Antimicrobial Resistance Epidemiology). All laboratories correctly identified the Staphylococcus aureus challenge strain as oxacillin-resistant and an Enterococcus faecium strain as vancomycin-resistant. Thirty-one (97%) of 32 laboratories correctly reported the Streptococcus pneumoniae strain as erythromycin-resistant. All laboratories testing the Pseudomonas aeruginosa strain against ciprofloxacin or ofloxacin correctly reported the organism as resistant. Of 40 laboratories, 30 (75%) correctly reported resistant MICs or zone sizes for the imipenem- and meropenem-resistant Serratia marcescens. For the extended-spectrum beta-lactamase (ESBL)-producing strain of Klebsiella pneumoniae, 18 (42%) of 43 laboratories testing ceftazidime correctly reported ceftazidime MICs in the resistant range. These results suggest that current testing generally produces accurate results, although some laboratories have difficulty detecting resistance to carbapenems and extended-spectrum cephalosporins. This highlights the need for monitoring how well susceptibility test systems in clinical laboratories detect emerging resistance. (C) 2000 Elsevier Science Inc. All rights reserved.

关键词：氨基糖苷类抗菌药/药理学抗感染药/药理学环丙沙星/药理学交叉感染/药物疗法交叉感染/微生物学交叉感染/预防和控制抗药性微生物肠球菌屎/药物作用红霉素/药理学亚胺培南/药理学实验室医院/标准实验室医院/统计学和数值数据氧氟沙星/药理学苯唑西林/药理学青霉素类/药理学假单胞菌铜绿/药物作用可重复性结果沙雷菌黏质/药物作用葡萄球菌金黄色/药物作用链球菌肺炎/药物作用噻烯霉素类/药理学万古霉素/药理学人类

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Second-generation antipsychotics in the emergency care setting. A prospective naturalistic study

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GENERAL HOSPITAL PSYCHIATRY 2000年第2期22卷 107-114页

作者： Raja, M Azzoni, A Osped Santo Spirito Sassia Serv Psichiatr Diag & Cura I-00136 Rome Italy

The objective of this subject was to examine the impact of the replacement of standard neuroleptics with atypical antipsychotic agents in an intensive psychiatric care unit. A mirror-image study was conducted. Cases admitted in the first semester of the year (when most of patients were treated with standard neuroleptics) were compared to cases admitted in the second semester of the year, when atypical antipsychotic agents were routinely utilized as first line treatment of patients with psychotic signs. Cases admitted in the first semester received a significantly higher daily dosage of antipsychotic drugs and more frequently received anticholinergics. In the second semester, a significantly higher number of patients received anticonvulsants, in particular valproate and gabapentin. There was no significant difference between the two groups of cases in the number of patients treated with antipsychotics, benzodiazepines, lithium, and carbamazepine and in the mean daily dose of benzodiazepines, lithium, carbamazepine, or valproate on the first day of hospitalization, the day of evaluation, and on discharge. On discharge, similar percentages of patients went home, were transferred to other Psychiatric Intensive Cave Units (PICUs) or to private clinics, or left our PICU against medical advice. The length of hospitalization was similar in the two groups. There was no significant difference in the rate of aggressive or violent behavior registered in the two groups of cases. The risk of increasing violence rates, lengthening hospitalization, and facilitating patients' noncompliance should not be major concerns for physicians prescribing second-generation antipsychotics in the emergency cave setting. Since these drugs have been shown to have at least similar efficacy (or greater efficacy in the case of clozapine) in the treatment of psychotic disorders as typical neuroleptics and to have a better side-effects profile, they should become first line treatment for patients with

关键词：急性病抗惊厥药/投药和剂量抗惊厥药/治疗应用抗精神病药/投药和剂量抗精神病药/治疗应用苯二氮|艹卓|类卡方分布氯丙嗪/治疗应用氯氮平/治疗应用运动障碍药物性咪唑类/治疗应用吲哚类/治疗应用重症监护病房/统计学和数值数据神经递质药/投药和剂量神经递质药/治疗应用哌仑西平/类似物和衍生物哌仑西平/治疗应用前瞻性研究精神病科医院/统计学和数值数据精神病/药物疗法利哌立酮/治疗应用治疗结果成年人女(雌)性人类男(雄)性中年人

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Syndromic analysis of computerized emergency department patients' chief complaints: An opportunity for bioterrorism and influenza surveillance

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ANNALS OF EMERGENCY MEDICINE 2003年第4期41卷 447-452页

作者： Irvin, CB Nouhan, PP Rice, K Wayne State Univ Sch Med Dept Emergency Med St John Hosp & Med Ctr Detroit MI USA

Study objective: Emergency department computerized triage logs might be useful for automated ED surveillance and potentially for early identification of bioterrorism events. We describe a Web-based surveillance program and its feasibility for surveillance. Methods: A Web-based surveillance program that receives computerized chief complaint data daily from a large academic urban teaching hospital and performs syndromic analysis on these data was developed. On the basis of preset limits, the Web-based surveillance program sends an alert e-mail message when the syndromic analysis reveals an increase in the number of patients in predefined symptom groups. The feasibility of this system was tested by using historical data during an influenza outbreak (December 1999 to January 2000) and applying the anthrax symptom group. Results: The Web-based surveillance program identified the influenza outbreak in the first week. Conclusion: Computerized triage logs might be a feasible method for bioterrorism and influenza surveillance. The Web-based nature of the surveillance program creates the opportunity for other hospitals to contribute data, potentially resulting in an automated network of ED computerized triage log surveillance.

关键词：医学科学研究中心炭疽/流行病学生物恐怖/统计学和数值数据肉毒中毒/流行病学疾病暴发流行/统计学和数值数据急诊室医院/统计学和数值数据可行性研究医院信息系统/统计学和数值数据医院教学医院市区流感人/流行病学病案系统计算机化/统计学和数值数据密执安/流行病学试点项目鼠疫/流行病学人群监测/方法方案评价敏感性与特异性天花/流行病学伤病员分拣土拉菌病/流行病学人类

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