Application of analytic hierarchy process for measuring and comparing the global performance of intensive care units

Purpose: To develop a model for the global performance measurement of intensive care units (ICUs) and to apply that model to compare the services for quality improvement. Materials and Methods: Analytic hierarchy process, a multiple-attribute decision-making technique, is used in this study to evolve such a model. The steps consisted of identifying the critical success factors for the best performance of an ICU, identifying subfactors that influence the critical factors, comparing them pairwise, deriving their relative importance and ratings, and calculating the cumulative performance according to the attributes of a given ICU. Every step in the model was derived by group discussions, brainstorming, and consensus among intensivists. Results: The model was applied to 3 ICUs, 1 each in Barbados, Trinidad, and India in tertiary care teaching hospitals of similar setting. The cumulative performance rating of the Barbados ICU was 1.17 when compared with that of Trinidad and Indian ICU, which were 0.82 and 0.75, respectively, showing that the Trinidad and Indian ICUs performed 70% and 64% with respect to Barbados ICU. The model also enabled identifying specific areas where the ICUs did not perform well, which helped to improvise those areas. Conclusions: Analytic hierarchy process is a very useful model to measure the global performance of an ICU. © 2005 Elsevier Inc. All rights reserved.

Measuring the operational performance of intensive care units using the analytic hierarchy process approach

Purpose - The purpose of this study is to develop a performance measurement model for service operations using the analytic hierarchy process approach. Design/methodology/approach - The study reviews current relevant literature on performance measurement and develops a model for performance measurement. The model is then applied to the intensive care units (ICUs) of three different hospitals in developing nations. Six focus group discussions were undertaken, involving experts from the specific area under investigation, in order to develop an understandable performance measurement model that was both quantitative and hierarchical. Findings - A combination of outcome, structure and process-based factors were used as a foundation for the model. The analyses of the links between them were used to reveal the relative importance of each and their associated sub factors. It was considered to be an effective quantitative tool by the stakeholders. Research limitations/implications - This research only applies the model to ICUs in healthcare services. Practical implications - Performance measurement is an important area within the operations management field. Although numerous models are routinely being deployed both in practice and research, there is always room for improvement. The present study proposes a hierarchical quantitative approach, which considers both subjective and objective performance criteria. Originality/value - This paper develops a hierarchical quantitative model for service performance measurement. It considers success factors with respect to outcomes, structure and processes with the involvement of the concerned stakeholders based upon the analytic hierarchy process approach. The unique model is applied to the ICUs of hospitals in order to demonstrate its effectiveness. The unique application provides a comparative international study of service performance measurement in ICUs of hospitals in three different countries. © Emerald Group Publishing Limited.

A comprehensive approach to quality management of intensive care services

Purpose – The purpose of this paper is to develop a comprehensive framework for improving intensive care unit performance. Design/methodology/approach – The study introduces a quality management framework by combining cause and effect diagram and logical framework. An intensive care unit was identified for the study on the basis of its performance. The reasons for not achieving the desired performance were identified using a cause and effect diagram with the stakeholder involvement. A logical framework was developed using information from the cause and effect diagram and a detailed project plan was developed. The improvement projects were implemented and evaluated. Findings – Stakeholders identified various intensive care unit issues. Managerial performance, organizational processes and insufficient staff were considered major issues. A logical framework was developed to plan an improvement project to resolve issues raised by clinicians and patients. Improved infrastructure, state-of-the-art equipment, well maintained facilities, IT-based communication, motivated doctors, nurses and support staff, improved patient care and improved drug availability were considered the main project outputs for improving performance. The proposed framework is currently being used as a continuous quality improvement tool, providing a planning, implementing, monitoring and evaluating framework for the quality improvement measures on a sustainable basis. Practical implications – The combined cause and effect diagram and logical framework analysis is a novel and effective approach to improving intensive care performance. Similar approaches could be adopted in any intensive care unit. Originality/value – The paper focuses on a uniform model that can be applied to most intensive care units.

A comparative study to evaluate surface microbial contamination associated with copper-containing and stainless steel pens used by nurses in the critical care unit

A clinical study was undertaken to compare the surface microbial contamination associated with pens constructed of either a copper alloy or stainless steel used by nurses on intensive care units. A significantly lower level of microbial contamination was found on the copper alloy pens. Copyright © 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Managing healthcare performance in analytical framework

Purpose – The purpose of the paper is to develop an integrated framework for performance management of healthcare services. Design/methodology/approach – This study develops a performance management framework for healthcare services using a combined analytic hierarchy process (AHP) and logical framework (LOGFRAME). The framework is then applied to the intensive care units of three different hospitals in developing nations. Numerous focus group discussions were undertaken, involving experts from the specific area under investigation. Findings – The study reveals that a combination of outcome, structure and process-based critical success factors and a combined AHP and LOGFRAME-based performance management framework helps manage performance of healthcare services. Practical implications – The proposed framework could be practiced in hospital-based healthcare services. Originality/value – The conventional approaches to healthcare performance management are either outcome-based or process-based, which cannot reveal improvement measures appropriately in order to assure superior performance. Additionally, they lack planning, implementing and evaluating improvement projects that are identified from performance measurement. This study presents an integrated approach to performance measurement and implementing framework of improvement projects.

Neonatal enteral feeding tubes as loci for colonisation by members of the Enterobacteriaceae

Background The objective of this study was to determine whether neonatal nasogastric enteral feeding tubes are colonised by the opportunistic pathogen Cronobacter spp. (Enterobacter sakazakii) and other Enterobacteriaceae, and whether their presence was influenced by the feeding regime. Methods One hundred and twenty-nine tubes were collected from two neonatal intensive care units (NICU). A questionnaire on feeding regime was completed with each sample. Enterobacteriaceae present in the tubes were identified using conventional and molecular methods, and their antibiograms determined. Results The neonates were fed breast milk (16%), fortified breast milk (28%), ready to feed formula (20%), reconstituted powdered infant formula (PIF, 6%), or a mixture of these (21%). Eight percent of tubes were received from neonates who were 'nil by mouth'. Organisms were isolated from 76% of enteral feeding tubes as a biofilm (up to 107 cfu/tube from neonates fed fortified breast milk and reconstituted PIF) and in the residual lumen liquid (up to 107 Enterobacteriaceae cfu/ml, average volume 250 µl). The most common isolates were Enterobacter cancerogenus (41%), Serratia marcescens (36%), E. hormaechei (33%), Escherichia coli (29%), Klebsiella pneumoniae (25%), Raoultella terrigena (10%), and S. liquefaciens (12%). Other organisms isolated included C. sakazakii (2%),Yersinia enterocolitica (1%),Citrobacter freundii (1%), E. vulneris (1%), Pseudomonas fluorescens (1%), and P. luteola (1%). The enteral feeding tubes were in place between < 6 h (22%) to > 48 h (13%). All the S. marcescens isolates from the enteral feeding tubes were resistant to amoxicillin and co-amoxiclav. Of additional importance was that a quarter of E. hormaechei isolates were resistant to the 3rd generation cephalosporins ceftazidime and cefotaxime. During the period of the study, K. pneumoniae and S. marcescens caused infections in the two NICUs. Conclusion This study shows that neonatal enteral feeding tubes, irrespective of feeding regime, act as loci for the bacterial attachment and multiplication of numerous opportunistic pathogens within the Enterobacteriaceae family. Subsequently, these organisms will enter the stomach as a bolus with each feed. Therefore, enteral feeding tubes are an important risk factor to consider with respect to neonatal infections.

UK epidemic strains of meticillin-resistant Staphylococcus aureus in clinical samples from Malta

Since 1999, the European Antimicrobial Resistance Surveillance System (EARSS) has monitored the rise in infection due to a number of organisms, including meticillin-resistant Staphylococcus aureus (MRSA). The EARSS reported that MRSA infections within intensive care units account for 25-50% of infections in many central and southern European countries, these included France, Spain, Great Britain, Malta, Greece and Italy. Each country has defined epidemic MRSA (EMRSA) strains; however, the method of spread of these strains from one country to another is unknown. In this current study, DNA profiles of 473 isolates of MRSA collected from the UK and Malta were determined by PFGE. Analysis of the data showed that two countries separated by a large geographical distance had a similar DNA profile pattern. Additionally it was demonstrated that strains of EMRSA normally found in the UK were also found in the Maltese cohort (EMRSA 15 and 16). A distinct DNA profile was found in the Maltese cohort, which may be a local EMRSA, and accounted for 14.4% of all Maltese isolates. The appearance of the same MRSA and EMRSA profiles in two separate countries suggests that MRSA can be transferred out of their country of origin and potentially establish in a new locality or country.

Extent and nature of unlicensed and off-label medicine use in hospitalised children in Palestine

Objective of the study To determine the extent and nature of unlicensed/off-label prescribing patterns in hospitalised children in Palestine. Setting Four paediatric wards in two public health system hospitals in Palestine [Caritas children’s hospital (Medical and neonatal intensive care units) and Rafidia general hospital (Medical and surgical units)]. Method A prospective survey of drugs administered to infants and children <18 years old was carried out over a five-week period in the four paediatric wards. Main outcome measure Drug-licensing status of all prescriptions was determined according to the Palestinian Registered Product List and the Physician’s Desk Reference. Results Overall, 917 drug prescriptions were administered to 387children. Of all drug prescriptions, 528 (57.5%) were licensed for use in children; 65 (7.1%) were unlicensed; and 324 (35.3%) were used off-label. Of all children, 49.6% received off-label prescriptions, 10.1% received unlicensed medications and 8.2% received both. Seventy-two percent of off-label drugs and 66% of unlicensed drugs were prescribed for children <2 years. Multivariate analysis showed that patients who were admitted to the neonatal intensive care unit and infants aged 0–1 years were most likely to receive a greater number of off-label or unlicensed medications (OR 1.80; 95% CI 1.03–3.59 and OR 1.99; 95% CI 0.88–3.73, respectively). Conclusion The present findings confirmed the elevated prevalence of unlicensed and off-label paediatric drugs use in Palestine and strongly support the need to perform well designed clinical studies in children.

Estimating the scope for savings in referrals and drug prescription costs in the general Practice units of a UK primary care trust

This paper explores the potential for cost savings in the general Practice units of a Primary Care Trust (PCT) in the UK. We have used Data Envelopment Analysis (DEA) to identify benchmark Practices, which offer the lowest aggregate referral and drugs costs controlling for the number, age, gender, and deprivation level of the patients registered with each Practice. For the remaining, non-benchmark Practices, estimates of the potential for savings on referral and drug costs were obtained. Such savings could be delivered through a combination of the following actions: (i) reducing the levels of referrals and prescriptions without affecting their mix (£15.74 m savings were identified, representing 6.4% of total expenditure); (ii) switching between inpatient and outpatient referrals and/or drug treatment to exploit differences in their unit costs (£10.61 m savings were identified, representing 4.3% of total expenditure); (iii) seeking a different profile of referral and drug unit costs (£11.81 m savings were identified, representing 4.8% of total expenditure). © 2012 Elsevier B.V. All rights reserved.

Medicines reconciliation in comparison with NICE guidelines across secondary care mental health organisations

Background Medicines reconciliation-identifying and maintaining an accurate list of a patient's current medications-should be undertaken at all transitions of care and available to all patients. Objective A self-completion web survey was conducted for chief pharmacists (or equivalent) to evaluate medicines reconciliation levels in secondary care mental health organisations. Setting The survey was sent to secondary care mental health organisations in England, Scotland, Northern Ireland and Wales. Method The survey was launched via Bristol Online Surveys. Quantitative data was analysed using descriptive statistics and qualitative data was collected through respondents free-text answers to specific questions. Main outcomes measure Investigate how medicines reconciliation is delivered, incorporate a clear description of the role of pharmacy staff and identify areas of concern. Results Forty-two (52 % response rate) surveys were completed. Thirty-seven (88.1 %) organisations have a formal policy for medicines reconciliation with defined steps. Results show that the pharmacy team (pharmacists and pharmacy technicians) are the main professionals involved in medicines reconciliation with a high rate of doctors also involved. Training procedures frequently include an induction by pharmacy for doctors whilst the pharmacy team are generally trained by another member of pharmacy. Mental health organisations estimate that nearly 80 % of medicines reconciliation is carried out within 24 h of admission. A full medicines reconciliation is not carried out on patient transfer between mental health wards; instead quicker and less exhaustive variations are implemented. 71.4 % of organisations estimate that pharmacy staff conduct daily medicine reconciliations for acute admission wards (Monday to Friday). However, only 38 % of organisations self-report to pharmacy reconciling patients' medication for other teams that admit from primary care. Conclusion Most mental health organisations appear to be complying with NICE guidance on medicines reconciliation for their acute admission wards. However, medicines reconciliation is conducted less frequently on other units that admit from primary care and rarely completed on transfer when it significantly differs to that on admission. Formal training and competency assessments on medicines reconciliation should be considered as current training varies and adherence to best practice is questionable.

Data envelopment analysis model for the appraisal and relative performance evaluation of nurses at an intensive care unit

The appraisal and relative performance evaluation of nurses are very important and beneficial for both nurses and employers in an era of clinical governance, increased accountability and high standards of health care services. They enhance and consolidate the knowledge and practical skills of nurses by identification of training and career development plans as well as improvement in health care quality services, increase in job satisfaction and use of cost-effective resources. In this paper, a data envelopment analysis (DEA) model is proposed for the appraisal and relative performance evaluation of nurses. The model is validated on thirty-two nurses working at an Intensive Care Unit (ICU) at one of the most recognized hospitals in Lebanon. The DEA was able to classify nurses into efficient and inefficient ones. The set of efficient nurses was used to establish an internal best practice benchmark to project career development plans for improving the performance of other inefficient nurses. The DEA result confirmed the ranking of some nurses and highlighted injustice in other cases that were produced by the currently practiced appraisal system. Further, the DEA model is shown to be an effective talent management and motivational tool as it can provide clear managerial plans related to promoting, training and development activities from the perspective of nurses, hence increasing their satisfaction, motivation and acceptance of appraisal results. Due to such features, the model is currently being considered for implementation at ICU. Finally, the ratio of the number DEA units to the number of input/output measures is revisited with new suggested values on its upper and lower limits depending on the type of DEA models and the desired number of efficient units from a managerial perspective.

Ethanol intake of paediatric intensive care patients

Background - Limiting the amount of alcohol in children's medicines is advisable but as alcohol is the second most common solvent used in liquid preparations, paediatric patients with increased medication intake may be exposed to a considerable alcohol intake. Few medicines are specifically designed for children in Paediatric Intensive Care (PICU), and therefore adult formulations are frequently administered, with high medication use further exposing a PICU patient to undesired alcohol intake. Aims - This small pilot study aimed to examiine the intake of a sample of PICU patients, highlight common medicines used on PICU containing alcohol, provide alternatives where possible and where alternatives are not possible, provide the prescriber with a list of the higher alcohol containing medicines. Method - A retrospective medication chart review was undertaken as a two point snap shot. Data collected included age, weight, medications prescribed and the formulations used at time of the study. The patients' sedation score was recorded. The electronic medicine compendium (EMC) was consulted for any ethanol content for the commercially available products. The manufacturer was contacted for ethanol content of all ‘specials’ and any commercial products found to contain ethanol from the EMC. The PICU patient's daily intake of ethanol was calculated. The calculation was converted to an adult equivalent alcohol unit intake and although this method of conversion is crude and does not take physiological differences of adult and children into account, it was done in order to provide the clinician with commonly used terminology in deciding the risk to the patient. Results - Twenty-eight patients were prescribed a range of 69 different medications. Of the 69 medicines, 12 products were found to contain ethanol. Patient ages ranged from a 26 week premature infant to 15 years old, weights ranges from 0.7 kg to 45 kg. Only 2 out of the 28 patients did not receive ethanol containing medications, and most patients were prescribed at least two medicines containing ethanol. Daily ethanol intake uncorrected for weight ranged from 0.006 ml to 2.18 ml (median 0.26 ml). Converting this to adult units per week, alcohol intake ranged from 0.07 to 15.2 units (median 1.4 units). The two patients receiving above 15 units/week adult equivalent were prescribed an oral morphine weaning regimen, therefore the high alcohol exposure was short term. The most common drugs prescribed containing alcohol were found to be nystatin, ranitidine, furosemide and morphine. No commercially available alcohol-free oral liquid preparations were found for ranitidine, furosemide or morphine at the time of the study. Correlation of the sedation score against ethanol intake was difficult to analyse as most patients were actively sedated. Conclusions - Polypharmacy in PICU patients increases the exposure to alcohol. Some commercially available medicines provide excessive ethanol intake, providing the clinician with ethical, potentially economical dilemmas of prescribing an unlicensed medicine to minimise ethanol exposure. Further research is required to evaluate the scope of the problem, effects of exposure and provision of alcohol free formulations.

Using DEA to estimate potential savings at GP units at medical specialty level

The aim of this paper is to identify benchmark cost-efficient General Practitioner (GP) units at delivering health care in the Geriatric and General Medicine (GMG) specialty and estimate potential cost savings. The use of a single medical specialty makes it possible to reflect more accurately the medical condition of the List population of the Practice so as to contextualize its expenditure on care for patients. We use Data Envelopment Analysis (DEA) to estimate the potential for cost savings at GP units and to decompose these savings into those attributable to the reduction of resource use, to altering the mix of resources used and to those attributable to securing better resource 'prices'. The results reveal a considerable potential for savings of varying composition across GP units. © 2013 Elsevier Ltd.

Unused medicines with potential for misuse or abuse in primary care

To assess the quantity and nature of prescribed medicines with potential for misuse returned to community pharmacies and general practice surgeries. Setting Community pharmacies (n = 51, 85% total) and general practice surgeries (n = 42, 69%) within the boundaries of Eastern Birmingham Primary Care Trust, UK. Method Medicines returned spontaneously by patients to participating sites were collected over eight weeks in May and June 2003. Data were recorded for each medicinal item including: patient sex, recommended International Non-proprietary Name (rINN), strength, form, legal classification, quantity and number of doses per day. Medicines were categorised into BWF therapeutic groups. A 'medicinal item' was defined as the total number of dose units of a medicine of the same form, strength and date of issue, returned for a given patient. Key findings Medicines were returned from 910 patients comprising 3765 medicinal items (2782 (73.9%) prescription-only medicines and 356 (9.5%) controlled drugs). Substantial amounts of unused, prescribed medicines with potential to cause harm or for misuse were returned, with analgesics, psychoactive and antiepileptic agents comprising 19.4% of returned medicinal items. Medicines of note that were returned included paracetamol-containing medicines (16 630 tablets), morphine (56 g), diamorphine (4.3 g), tramadol (2840 tablets and capsules), benzodiazepines (677 tablets) and tricyclic antidepressants (2831 tablets). Conclusions Substantial quantities of prescribed medicines with potential to cause harm or be misused are routinely present in the community. The management of these unused medicines, and in particular controlled drugs, Is currently inadequate and further work is required to identify the legislative and patient-centred processes required to minimise the potential for these medicines to be misused or cause harm. © 2007 The Authors.

Productivity growth and efficiency measurements in fuzzy environments with an application to health care

Health care organizations must continuously improve their productivity to sustain long-term growth and profitability. Sustainable productivity performance is mostly assumed to be a natural outcome of successful health care management. Data envelopment analysis (DEA) is a popular mathematical programming method for comparing the inputs and outputs of a set of homogenous decision making units (DMUs) by evaluating their relative efficiency. The Malmquist productivity index (MPI) is widely used for productivity analysis by relying on constructing a best practice frontier and calculating the relative performance of a DMU for different time periods. The conventional DEA requires accurate and crisp data to calculate the MPI. However, the real-world data are often imprecise and vague. In this study, the authors propose a novel productivity measurement approach in fuzzy environments with MPI. An application of the proposed approach in health care is presented to demonstrate the simplicity and efficacy of the procedures and algorithms in a hospital efficiency study conducted for a State Office of Inspector General in the United States. © 2012, IGI Global.