Efforts of hospital system wound care teams to reduce hospital acquired pressure ulcers

New reimbursement policies developed by the Centers for Medicare and Medicaid Services (CMS) are revolutionizing the health care landscape in America. The policies focus on clinical quality and patient outcomes. As part of the new policies, certain hospital acquired conditions have been identified by Medicare as "reasonably preventable". Beginning October 1, 2008, Medicare will no longer reimburse hospitals for these conditions developed after admission, pressure ulcers are among the most common of these conditions.^ In this practice-based culminating experience the objective was to provide a practical account of the process of program development, implementation and evaluation in a public health setting. In order to decrease the incidence of pressure ulcers, the program development team of the hospital system developed a comprehensive pressure ulcer prevention program using a "bundled" approach. The pressure ulcer prevention bundle was based on research supported by the Institute for Healthcare Improvement, and addressed key areas of clinical vulnerability for pressure ulcer development. The bundle consisted of clinical processes, policies, forms, and resources designed to proactively identify patients at risk for pressure ulcer development. Each element of the bundle was evaluated to ensure ease of integration into the workflow of nurses and clinical ancillary staff. Continued monitoring of pressure ulcer incidence rates will provide statistical validation of the impact of the prevention bundle. ^

A comparative analysis of hospital -based physician monitoring systems

The purpose of the multiple case-study was to determine how hospital subsystems (such as physician monitoring and credentialing; quality assurance; risk management; and peer review) were supporting the monitoring of physicians? Three large metropolitan hospitals in Texas were studied and designated as hospitals #1, #2, and #3. Realizing that hospital subsystems are a unique entity and part of a larger system, conclusions were made on the premises of a quality control system, in relation to the tools of government (particularly the Health Care Quality Improvement Act (HCQIA)), and in relation to itself as a tool of a hospital.^ Three major analytical assessments were performed. First, the subsystems were analyzed as to their "completeness"; secondly, the subsystems were analyzed for "performance"; and thirdly, the subsystems were analyzed in reference to the interaction of completeness and performance.^ The physician credentialing and monitoring and the peer review subsystems as quality control systems were most complete, efficient, and effective in hospitals #1 and #3. The HCQIA did not seem to be an influencing factor in the completeness of the subsystem in hospital #1. The quality assurance and risk management subsystem in hospital #2 was not representative of completeness and performance and the HCQIA was not an influencing factor in the completeness of the Q.A. or R.M. systems in any hospital. The efficiency (computerization) of the physician credentialing, quality assurance and peer review subsystems in hospitals #1 and #3 seemed to contribute to their effectiveness (system-wide effect).^ The results indicated that the more complete, effective, and efficient subsystems were characterized by (1) all defined activities being met, (2) the HCQIA being an influencing factor, (3) a decentralized administrative structure, (4) computerization an important element, and (5) staff was sophisticated in subsystem operations. However, other variables were identified which deserve further research as to their effect on completeness and performance of subsystems. They include (1) medical staff affiliations, (2) system funding levels, (3) the system's administrative structure, and (4) the physician staff "cultural" characteristics. Perhaps by understanding other influencing factors, health care administrators may plan subsystems that will be compatible with legislative requirements and administrative objectives. ^

Images of a groundwater flow system in Nicaragua

Conceptualization of groundwater flow systems is necessary for water resources planning. Geophysical, hydrochemical and isotopic characterization methods were used to investigate the groundwater flow system of a multi-layer fractured sedimentary aquifer along the coastline in Southwestern Nicaragua. A geologic survey was performed along the 46 km2 catchment. Electrical resistivity tomography (ERT) was applied along a 4.4 km transect parallel to the main river channel to identify fractures and determine aquifer geometry. Additionally, three cross sections in the lower catchment and two in hillslopes of the upper part of the catchment were surveyed using ERT. Stable water isotopes, chloride and silica were analyzed for springs, river, wells and piezometers samples during the dry and wet season of 2012. Indication of moisture recycling was found although the identification of the source areas needs further investigation. The upper-middle catchment area is formed by fractured shale/limestone on top of compact sandstone. The lower catchment area is comprised of an alluvial unit of about 15 m thickness overlaying a fractured shale unit. Two major groundwater flow systems were identified: one deep in the shale unit, recharged in the upper-middle catchment area; and one shallow, flowing in the alluvium unit and recharged locally in the lower catchment area. Recharged precipitation displaces older groundwater along the catchment, in a piston flow mechanism. Geophysical methods in combination with hydrochemical and isotopic tracers provide information over different scales and resolutions, which allow an integrated analysis of groundwater flow systems. This approach provides integrated surface and subsurface information where remoteness, accessibility, and costs prohibit installation of groundwater monitoring networks.