Valerie L. Katz, MD, FACS

• Assistant Professor of Clinical Surgery
• Weill Medical College of Cornell University
• Section Chief, Department of General Surgery
• Lincoln Medical and Mental Health Center
• Bronx, New York

Sydney gastritis diet peanut butter best purchase ranitidine, Australia: Australian Commission on Quality and Safety in Health Care; 2017 gastritis nsaids symptoms trusted ranitidine 150mg. Key Findings and Recommendations on Reporting and Learning Systems for Patient Safety Incidents Across Europe gastritis diet 2014 purchase genuine ranitidine line. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer gastritis bloating buy ranitidine 150 mg with visa. Safety Is Personal: Partnering with Patients and Families for the Safest Care; 2014 gastritis diet coconut water ranitidine 300mg amex. National Safety and Quali-ty Health Service Standard 2: Partnering with Consumers prepyloric gastritis definition ranitidine 300mg mastercard. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. An analysis of near misses identified by anesthesia providers in the intensive care unit. The impact of workload, safety climate, and safety tools on medical errors: a study of intensive care units. Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. The contribution of labelling to safe medication administration in anaesthetic practice. Evidencebased strategies for preventing drug administration errors during anaesthesia. Review article: improving drug safety for patients undergoing anesthesia and surgery. Infection prevention in anesthesia practice: a tool to assess risk and compliance. Incidence, characteristics, and predictive factors for medication errors in paediatric anaesthesia: a prospective incident monitoring study. Implementing quality improvement strategies to reduce healthcare-associated infections: a systematic review. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Medication safety in the operating room: literature and expert-based recommendations. American journal of medical quality: the official journal of the American College of Medical Quality. Association between implementation of a medical team training program and surgical mortality. The effects of crew resource management on teamwork and safety climate at Veterans Health Administration Facilities. Journal of healthcare risk management: the journal of the American Society for Healthcare Risk Management. The effect of two cognitive aid designs on team functioning during intraoperative anaphylaxis emergencies: a multicentre simulation study. Communication failures in the operating room: an observational classification of recurrent types and effects. Analysing action sequences: variations in action density in the administration of anaesthesia. Human factors research in anesthesia patient safety: techniques to elucidate factors affecting clinical task performance and decision making. Novel method of measuring the mental workload of anaesthetists during clinical practice. Plastic surgical nursing: official journal of the American Society of Plastic and Reconstructive Surgical Nurses. A national random sample survey about "truth-telling practices" in the perioperative setting in the United States. Production pressure and a culture of deviance in the insular operating room and the consequences of their "normalization": have we reached a hooper moment Do technical skills correlate with nontechnical skills in crisis resource management: a simulation study. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Effects of intraoperative reading on vigilance and workload during anesthesia care in an academic medical center. Quantitative description of the workload associated with airway management procedures. Prevalence of potentially distracting noncare activities and their effects on vigilance, workload, and nonroutine events during anesthesia care. Task complexity in emergency medical care and its implications for team coordination. Objective assessment of manual skills and proficiency in performing epidural anesthesia-video-assisted validation. Treatment of ventricular fibrillation during anaesthesia in an anaesthesia simulator. Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models. Analysis of the clinical behaviour of anaesthetists: recognition of uncertainty as a basis for practice. Reviewing intuitive decision-making and uncertainty: the implications for medical education. Columbus, Ohio: Cognitive Systems Engineering Laboratory Report, prepared for Anesthesia Patient Safety Foundation; 1991. Diagnosing "vulnerable system syndrome": an essential prerequisite to effective risk management. Prospective memory in dynamic environments: effects of load, delay, and phonological rehearsal. Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions. Human performance limitations (communication, stress, prospective memory and fatigue). Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. Fixation Errors in Dynamic and Complex Systems: Descriptive Forms, Psychological Mechanisms, Potential Countermeasures. Fixation errors: failures to revise situation assessment in dynamic and risky systems. Effects of trait anxiety and situational stress on attentional shifting are buffered by working memory capacity. A systematic review of retention of adult advanced life support knowledge and skills in healthcare providers. Importance of practical simulation training for troubleshooting the heart-lung machine. Journal of artificial organs: the official journal of the Japanese Society for Artificial Organs. Maintaining competence in the field: Learning about practice, through practice, in practice. Human factors in critical care: towards standardized integrated human-centred systems of work. Customization of a tool to assess Danish surgeons nontechnical skills in the operating room. Anaesthesia nontechnical skills: can anaesthetists be trained to reliably use this behavioural marker system in 1 day Evaluation of a simpler tool to assess nontechnical skills during simulated critical events. Human factors in the development of complications of airway management: preliminary evaluation of an interview tool. Patient Safety Curriculum, Topic 2: "Why applying human factors is important for patient safety The relationship between experience and mental workload in anaesthetic practice: an observational study. Differences in talking-to-theroom behaviour between novice and expert teams during simulated paediatric resuscitation: a quasi-experimental study. Evaluation of anesthesia residents using mannequin-based simulation: a multiinstitutional study. Performance of certified registered nurse anesthetists and anesthesiologists in a simulationbased skills assessment. Cardiac arrest from local anesthetic toxicity after a field block and transversus abdominis plane block: a consequence of miscommunication between the anesthesiologist and surgeon. The call, the save, and the threat: understanding expert help-seeking behavior during nonroutine operative scenarios. Delayed time to defibrillation after intraoperative and periprocedural cardiac arrest. The "call for help": intraoperative consultation and the surgeon-patient relationship. The use of cognitive task analysis to improve anesthesia skills training for postoperative extubation. Using a structured assessment tool to evaluate nontechnical skills of nurse anesthetists. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature. Team mental models and their potential to improve teamwork and safety: a review and implications for future research in healthcare. High-performing trauma teams: frequency of behavioral markers of a shared mental model displayed by team leaders and quality of medical performance. The application of evidence to clinical decision-making in anaesthesia as a means of delivering value to patients. Laptops and smartphones in the operating theatre - how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction Smartphone use habits of anesthesia providers during anesthetized patient care: a survey from Turkey. Effects of divided attention and operating room noise on perception of pulse oximeter pitch changes: a laboratory study. The role of practice in dual-task performance: toward workload modeling a connectionist/control architecture. Personal electronic device use in the operating room: a survey of usage patterns, risks and benefits. No interruptions please: impact of a No Interruption Zone on medication safety in intensive care units. Sustained attention performance during sleep deprivation: evidence of state instability. The risks and implications of excessive daytime sleepiness in resident physicians. Fatigue in anesthesia: implications and strategies for patient and provider safety. The national study of sleep-related behaviors of nurse anesthetists: personal and professional implications. Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Guided team self-correction: impacts on team mental models, processes, and effectiveness. Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team training. Developing and Enhancing Teamwork in Organisations: Evidence-Based Best Practices and Guidelines. Closed-loop communication improves task completion in pediatric trauma resuscitation. Handovers during anesthesia care: patient safety risk or opportunity for improvement A multidisciplinary handoff process to standardize the transfer of care between the intensive care unit and the operating room. Training in intraoperative handover and display of a checklist improve communication during transfer of care: an interventional cohort study of anaesthesia residents and nurse anaesthetists. Speaking up is related to better team performance in simulated anesthesia inductions: an observational study. Call-shift fatigue and use of countermeasures and avoidance strategies by certified registered nurse anesthetists: a national survey. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships Effects of intraoperative breaks on mental and somatic operator fatigue: a randomized clinical trial. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Improving alertness and performance in emergency department physicians and nurses: the use of planned naps. Everyday problem solving across the adult life span: solution diversity and efficacy.

Using statistical process control methods to trace small changes in perinatal mortality after a training program in a low-resource setting gastritis y dolor de espalda purchase ranitidine 300mg online. International journal for quality in health care: journal of the International Society for Quality in Health Care gastritis diet food recipes order ranitidine australia. Efficacy and Effectiveness of Simulation Based Training for Learning and Assessment in Health Care gastritis peptic ulcers symptoms buy ranitidine cheap online. Technology-enhanced simulation for health professions education: a systematic review and metaanalysis antral gastritis diet chart discount 300mg ranitidine. The pharmacology of simulation: a conceptual framework to inform progress in simulation research gastritis symptoms fever discount ranitidine 150mg with amex. Use of a highfidelity simulator to develop testing of the technical performance of novice anaesthetists diet bei gastritis 300 mg ranitidine. Systematic simulation-based team training in a Swedish intensive care unit: a diverse response among critical care professions. Competent and autonomous individuals can make affirmative choices about their medical care and refuse any medical treatments, including lifesaving care. Four elements of competent decision making are understanding, appreciation, reasoning, and evidence of a choice. Minor patients have varying degrees of decision-making capacity, and they may have legal rights to make certain decisions. Pediatric patients should be involved to the degree that they can be in medical decision making, particularly regarding elective therapy. Medical testing should follow the ethical principles of beneficence and nonmaleficence and should be based on clinically validated algorithms whenever possible. In general, the rights of pregnant women are weighed against the rights of fetuses in a decremental fashion as the fetus approaches and surpasses viable age. Laboring women are able to give informed consent, and the validity of "Ulysses directives" at the time of labor is ethically arguable. Coercing or using physical or chemical means to force competent patients to undergo treatment they are refusing is both unethical and illegal. Surrogate decision makers explicitly act in "substituted judgment" to provide what the patient would have wanted and are not being asked merely for their own preferences. Patients have moral and legal rights to refuse even life-sustaining therapy, including in the operating room. Terminal care requires special knowledge and experience on the part of the physician. Several interventions have special ethical implications-fluid and nutritional management; the administration of sedatives and/or narcotics that have the potential to hasten death; the institution of deep continuous sedation; the administration of neuromuscular blocking agents; and deactivating pacemakers, ventricular assist devices, and implanted cardioverter-defibrillators. Euthanasia is the administration of medication by someone other than the patient for the express purpose of causing death. Brain death is legally and medically defined as the point at which all cardiorespiratory function irreversibly ceases or all function of the whole brain irreversibly stops. The ethical conduct of research in human subjects follows three principles: (1) respect for autonomy, and the obligation to protect subjects with limited autonomy; (2) beneficence, with obligations to minimize risks, maximize benefits, and ensure that the research design is scientifically sound; and (3) justice, the obligation to treat each person with regard to what is morally right and to ensure fair distribution of benefits and burdens. Advances in understanding animal cognition have led most biologists to believe that many, if not all, animals are capable of feeling pleasure, pain, anticipation, and fear, and thus they experience both enjoyment and suffering. Allowing animal suffering because of pain, fear, sickness, or poor standards of care is a moral harm that must be avoided, mitigated, and weighed heavily against the benefits it produces. Medicine is a respected profession with codes of behavior and definite rules of conduct. In this view, the physician is a genuinely virtuous person with inherent qualities of competence, sincerity, confidentiality, and altruism, who naturally knows and does what is correct for the patient. The patient, uneducated about medicine, has to trust the physician to decide what is best. Western society and legal systems have changed substantially since paternalism flourished, giving way to practices based in the four "pillars" of medical ethics: respect for patient autonomy, beneficence, nonmaleficence, and justice. Many different ethical frameworks are applied in modern medicine, but two of the most prominent frameworks relevant to western medicine are utilitarian ethics and deontology. A "right" action produces the most good, based on a perspective that gives equal weight to the interests of all affected parties. Utilitarian theory is compelling but falls short in defining which benefits are most important. Is it the "good" that all reasonable people want or the "good" defined by the individual patient For example, what if the only way to win a war is to systematically torture children Outcomes of actions continue to accumulate over time- when on that continuum is it appropriate to determine that an action was right or wrong Utilitarian theory may be best when applied to analyzing broad-based policies, in decisions regarding rationing of resources, and when attempting to resolve conflicting ethical obligations between several equally interested parties. The premise of Kantian-based ethics (also called deontologic-or duty-based-theory) is that features of actions other than their consequences make them right or wrong. Furthermore, no person should use another exclusively as a means to an end, because each person is the end for which we should act. Kantian philosophy would forbid killing one innocent person to save another innocent person, for example. Individualism and autonomy are valued highly in Western society, and people tend to turn to Kantian philosophy when ethical questions arise that balance the authority of the physician against the goals and values of individual patients. The political tradition of the United States provides a clear underpinning to individual freedom, and at the beginning of the 20th century, the concept of the autonomy of patients began to emerge. Autonomy refers to the ability to choose without controlling interferences by others and without personal limitations that prevent meaningful choices, such as inadequate information or understanding. In the United States, this right is rooted in constitutional guarantees of privacy and noninterference. Competence and Capacity Autonomy to make medical decisions cannot exist in the absence of competence. In the United States, competence is a legal determination, and capacity describes the necessary skills to participate in medical decisions. Medication effects can variously impede competence, or improve it, depending on their effects and the context in which they are given. Older patients, patients suffering from mental impairment, and children are particularly vulnerable to having their participation in medical decisions inappropriately curtailed or denied because their capacity to participate is frequently underestimated. Hearing loss, expressive aphasia, and other neurologic impairments can create the false impression that capacity is impaired. Many minors have the ability to make medical decisions but may be mistakenly excluded from the decisionmaking process solely because of their age. Patients may be able to understand and make decisions about medical issues while being unable to manage their financial affairs, for example. Prejudice and paternalism permeate physician behavior in the informed consent process. With such high value placed in the United States on autonomy and self-determination, incompetency is, and should be, a difficult bar to leap over, requiring that only persons with impairments "that place them at the very bottom of the performance curve" should be declared incompetent. Claims that premedications automatically invalidate consent demonstrate a lack of understanding of the concept of competence. If it were true that benzodiazepines and narcotics, for example, automatically invalidate consent, then we would have to consider the consent of almost all chronic pain patients invalid. A patient who is in severe pain, for example, is unlikely to be able to focus on detailed risks and alternatives of a proposed procedure without first receiving medication. In that case, treatment of severe pain may actually improve competence during the informed consent process. How does the anesthesiologist determine if they are dealing with a competent patient Multiple reviews by competency consultants agree that there are several functional elements to competence: (1) Understanding - Can the patient receive and understand treatment-related information Elective surgery may have to be postponed until expert consultation for a determination of mental capacity or treatment of reversible conditions can occur. The subjective standard recognizes that some patients may have special needs for specific information, and when that need is obvious or has been brought to the attention of the physician, the information must be disclosed. A concert violinist may have a specific need to know about the potential for nerve damage from an axillary block, while an opera singer may need to know that intubation may adversely affect the voice. In obtaining informed consent, the anesthesiologist should always ask the patient if there are any special concerns regarding the anesthetic, or anything he or she would want the provider to know. In general, legal and ethical standards now require that the physician (1) accurately discuss the therapy and its potential alternative-including no therapy-and (2) disclose the common risks, because they are more likely to happen, and the serious risks, because the consequences are severe. The doctrine of therapeutic privilege is sometimes cited to avoid discussing risks, the reasoning being that discussing risks can psychologically or physically harm the patient by increasing stress. These studies show that patient stress is generally reduced after risk discussions19,20 and omission of such conversations is contrary to U. Physicians have ethical obligations to avoid exploiting their influence for the purpose of accomplishing their own ends. Although offering a rational basis for a medical choice is acceptable, it is always unethical to coerce or manipulate competent patients into decisions by presenting real or implied threats or by omitting or misrepresenting key information. In fact, such intentional manipulations are morally equivalent to lying to the patient, and thus invalidate the concept of informed consent entirely. Flawed informed consent processes have been cited, however, as evidence of a lack of quality of care by the physician, and are associated with poorer litigation outcomes for the physician. Informed refusal has concerns and requirements similar to those of informed consent. When patients refuse medical care or insist on what the physician believes to be suboptimal care, disclosure of the risks and benefits becomes even more important because these decisions may veer from options that are already widely accepted and for which the risks are believed to be lowest. It is easier to justify agreeing to the unusual preferences of a well-informed patient than to justify subjecting a poorly informed patient to unorthodox care. Despite full information, patients may sometimes request or demand care that is unreasonable, either because it will adversely affect the performance of a surgical procedure or because it would be associated with unreasonably high risks. When a patient demands a technique that is inappropriate or outside of the realm of reasonable practice, the anesthesiologist is under no ethical obligation to provide that care. Medical care of individuals who have never been autonomous relies on principles such as respect for human dignity, beneficence, avoidance of harm, and adherence to the principle of justice. Laws in each state define the age at which children become legally competent to make medical decisions (usually 18 years), but many younger children have the mental and emotional capacity to make medical decisions. Forcing such individuals to undergo treatments they do not want is unethical and could be illegal as well. However, the range of capability in children as young as 7 or 8 years old is wide. In one study, children 6 through 9 years of age who were invited to participate in influenza vaccine research asked pertinent questions about individual risks and benefits and whether their community and other children would benefit. The law recognizes that, tragically, some conditions for which a minor seeks therapy may even be the result of parental abuse and seeking parental permission for treatment may actually further endanger the minor. One quarter of pregnant teens are at risk for physical or sexual assault, and the most common perpetrator is a member of their family. Individuals interpret religious doctrines in light of their own spiritual contexts, and not all believers hold to the same tenets with identical fervor. Church doctrines, like medical practices, evolve over time, and practices that are acceptable at one time may not be years later. Moreover, any patient has the right to refuse blood transfusion therapy, regardless of whether this desire is founded in religious preference. Ideally, individuals of any age should be involved in medical decisions to the degree that their capacity allows. Children ages 7 to 17 have been shown to desire comprehensive perioperative information, including details of the procedure and anesthesia, risks, and complications. Recently, authors have suggested that informed consent rather than assent for medical research participation should be applied to children ages 12 and up. We generally undertake such tests precisely because we intend to help the patient (beneficence) or to use the information to minimize other risks (nonmaleficence). False-positive and false-negative results may either label patients as having a condition they do not have or inappropriately assure patients that they do not have a condition that they do. Erroneous results may lead either to further testing or to inappropriate and unnecessary therapy associated with further complications. Errors can also cause patients to be deprived of important therapy they would otherwise receive. Tests sometimes have accompanying physical complications, and they are certainly always associated with economic costs. Systematic over-testing increases the costs of health care for entire populations, unnecessarily burdening an already costly system, and diverting badly needed funds to unnecessary enterprise. Medical tests may involve problems of conflicts of interest if the ordering physician has an economic relationship with the entity that carries out the tests. Modern medicine is a science that incorporates theories that are expected to be consistent and generalizable. In general, nonsystematic clinical experience, anecdote, and untested theory are not sufficient grounds for clinical decision making. One Cochrane review, for example, found that administration of human albumin, a mainstay of therapy for treatment of shock, may be associated with increased mortality. In the words of Rogers, "those with the greatest burden of ill health are disenfranchised, as there is little research that is relevant to them, there is poor access to treatments, and attention is diverted from activities that might have a much greater impact on their health. Large population studies of many routine preoperative tests, such as coagulation screening,37 chest radiography,38 and electrocardiography,39 have, on the contrary, found that these tests increase costs without necessarily positively affecting outcomes and can even lead to detrimental outcomes. Seropositive women can experience marital breakup, abandonment, verbal abuse, and physical violence if their status is disclosed. Despite pervasive beliefs to the contrary, studies do not conclusively demonstrate that anesthetic agents lead to early fetal loss, and no anesthetics have been clearly associated with teratogenic effects.

The growing demand from patients gastritis diet ��� best order ranitidine, clinicians gastritis attack discount ranitidine 300 mg with visa, insurers gastritis gluten purchase ranitidine with visa, regulators gastritis with fever generic 300mg ranitidine with amex, accreditors gastritis diet alcohol cheap ranitidine 300mg on line, and purchasers for improved quality and safety in health care requires that anesthesiologists and members of the anesthesia team persistently evaluate the quality of care they provide gastritis prevention buy 300mg ranitidine free shipping. Clinicians have an enhanced ability to obtain feedback regarding performance in their daily work, in part because of the increasing use of information systems. The measurement system must fit into an improvement system; clinicians must have the will to work cooperatively to improve, and they must have ideas or hypotheses about changes to the current system of care. Also, the clinical team must have a model for testing changes and implementing those that result in improvements. Outcome measures, including in-hospital mortality rates, have been the basis for evaluating performance and quality. However, hospital mortality alone provides an incomplete picture of quality, does not include all domains of quality, and does not measure the overall success of the full cycle of care for a specific medical condition. Efforts to improve quality of care require development of valid, reliable, and practical measures of quality. Identification of clinical care that truly achieves excellence would be helpful not only to the administration of anesthesia, but also to health care overall. Developing a quality measure requires several steps: prioritizing the clinical area to evaluate; selecting the type of measure; writing definitions and designing specifications; developing data collection tools; pilot-testing data collection tools and evaluating the validity, reliability, and feasibility of measures; developing scoring and analytic specifications; and collecting baseline data. The best opportunities to improve quality of care and patient outcomes will most likely come not only from discovering new therapies, but also from discovering how to better deliver therapies that are already known to be effective. Safety is an integral part of quality that is focused on the prevention of error and patient harm. The airline industry is often lauded as an exemplar of safety because it has embraced important safety principles, including the standardization of routine tasks, the reduction of unnecessary complexity, and the creation of redundancies. Anesthesia care teams have also adopted these principles, although many opportunities remain to further bolster patient safety. Healthcare providers can organize their quality improvement and patient safety efforts around three key areas: (1) translating evidence into practice, (2) identifying and mitigating hazards, and (3) improving culture and communication. Although each of these areas requires different tools, they all help health care organizations evaluate progress in patient safety and quality. The need for improving quality and reducing the cost of health care has been highlighted repeatedly in the scientific literature and lay press. Improving care, minimizing variation, and reducing costs have increasingly become national priorities in many countries. Edwards Deming, scholar, professor, author, lecturer, and consultant to business leaders, corporations, and governments defined quality as "a predictable degree of uniformity and dependability with a quality standard suited to the customer. However, when the term quality is applied to health care, the subtleties and implications of treating a human being are of prime importance, as opposed to the concerns involved in producing consumer goods. Use of the term quality in the context of health care can sometimes lead to defensive attitudes, economic concerns, and even ethical debates. For example, a daughter may evaluate quality by the level of dignity and respect with which her elderly mother is treated by a nurse. A cardiac surgeon may see quality as a percentage of improvement in the function of a heart on which he or she has just operated. A business may judge quality by the timeliness and cost effectiveness of the care delivered to its employees and its effect on the bottom line. Finally, society may evaluate quality by the ability to deliver care to those who need it, regardless of their cultural or socioeconomic backgrounds. This definition of quality may have implications for both its measurement and its improvement. Government Department of Health and Human Services, which defines quality in public health as "the degree to which policies, programs, services, and research for the population increase desired health outcomes and conditions in which the population can be healthy. No patient or healthcare worker should be harmed by the healthcare system at any time, including during transitions of care and "off hours," such as nights or weekends. Errors may be categorized as either failure of an action to occur as planned, such as the administration of a wrong medication to a patient, or having the wrong plan altogether, such as misdiagnosing and subsequently mistreating a patient. If a complication does occur, medical staff should make full disclosure, provide assistance to the patient and family, and exercise due diligence in preventing any recurrences of the error. Effective medicine requires evidence-based decisions about treatment for individual patients, when such evidence exists. The best available evidence should be combined with clinical expertise and patient values in forming a treatment plan. With effective care, medical practitioners avoid underuse by providing a treatment to all who will benefit and avoid overuse by refraining from giving treatment to those unlikely to benefit. Patient-centered care is respectful of individual patient preferences, needs, and values and uses these factors to guide clinical decisions. The dramatic increase in access to health information on the Internet has resulted in more patients who are well informed and proactive in their care. Patient-centered care embraces this trend and shifts more of the power and control to patients and their families. Examples of patient-centered care include shared decision making, patient and family participation in rounds, patient ownership of medical records, schedules that minimize patient inconvenience, and unrestricted visitation hours. Furthermore, delays may not only affect patient satisfaction, but may impair timely diagnosis and treatment. For healthcare workers, delays in availability of equipment or information may decrease job satisfaction and the ability to perform their jobs adequately. Rising costs have increased scrutiny of waste in health care; this includes waste in labor, capital, equipment, supplies, ideas, and energy. Examples of efficiency measures include mean length of hospital stay, readmission rate, and mean cost of treatment for a diagnosis. The elimination of waste can result in better quality of care for patients at the same or lower cost. At the individual level, it means absence of discrimination based on factors such as age, gender, race, ethnicity, nationality, religion, educational attainment, sexual orientation, disability, or geographic location. These four aims include better care, better outcomes, lower cost, and better work life for the healthcare workforce. For example, a standard for overall mortality after cardiac surgery is less than 3%; however, is 3% (vs. Most standards are inherently arbitrary and often lack consensus among medical professionals. These systems often exist to flag certain cases or practitioners for intense review. Practitioners may regard this intense review as a punishment because only "failures" or "bad apples" are identified, and process failures are not connected with the outcome on every case. Systems within health care are a series of interlinked processes, each of which results in one or more outputs. A specification is an explicit, measurable statement regarding an important attribute of a process or the outcome it produces. The system then attempts to correct errors by fixing the process rather than the people. To quote Philip Crosby, "The system for causing quality is prevention, not appraisal. Edwards Deming wrote about two different types of knowledge: subject matter knowledge and profound knowledge. Subject matter knowledge is professional expertise, such as expertise in anesthesiology. The most significant improvement occurs where these two types of knowledge overlap. Deming divides profound knowledge into four different categories: appreciation of a system, the theory of knowledge, understanding variation, and psychology. A system is a network of interdependent components working together for a common aim. If this is the case, it is our responsibility to manage the system to get the results we want. We must have a theory behind our improvement work, not just data, if we are going to learn. Special cause variation is variation from causes that are not inherent to the process but arise from specific circumstances. Use data gathered from previous stages to build new knowledge and make predictions. Adopt the change, or use knowledge gained to plan or modify the next test of action. These measures provide the feedback that enables one to know whether or not the change is an improvement. However, not all projects have an easily quantifiable outcome and the outcome may be more qualitative. It is worth the time and effort to identify opportunities to translate goals into quantifiable outcomes if possible. The more intimate the understanding of a process and its key drivers, the higher the likelihood of generating successful changes. Improvement may require multiple cycles of preferably small tests of change over time. Through repeated cycles, increased knowledge is acquired, and actions are continuously modified or changed. Measures defined in the first part of the model help determine whether or not a change is a success. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. It is a structured, dynamic model that applies the scientific method to testing and implementing a change. Ideas for improvements may come from interviewing those involved or affected by the process, such as staff or patients. Two of these frameworks, Lean Production and Six Sigma, are briefly discussed here. Lean methodology has its roots in Japanese manufacturing, particularly in the Toyota Production System. Two notable examples of its use are Virginia Mason Medical Center and ThedaCare, Inc. Every step in a process is evaluated to differentiate those steps that add value from those that do not. If evaluating preoperative assessment, map the physical flow of a patient from the scheduling of a procedure through the day of surgery (history and physical, preoperative counseling, laboratory tests, imaging, consultations). In this process, all of the steps are accounted for, including the back-and-forth flow of the patient to the front desk, to the laboratory, and so on. Eliminate steps that do not add value to the overall process and are likely a poor use of time or effort on the part of the caregivers or the patient. Pursue perfection by continuing the process until you have achieved ultimate value with no waste. The transformation of Motorola in the 1980s from a struggling company to a high-quality, high-profit organization helped give rise to the Six Sigma methodology. Two key fundamental objectives of Six Sigma are a virtually errorfree process and a large focus on reducing variation. In a 1998 report, Chassin16 reported that hospitalized patients harmed by negligence were at a four sigma level (10,000/ million), patients inadequately treated for depression were at a two sigma level (580,000/million), and eligible heart attack survivors who failed to receive -adrenergic blockers were at a one sigma level (790,000/million). In contrast, Chassin found that anesthesiology was the one healthcare specialty that approached the six sigma level, with deaths caused by anesthesia as low as 5. One popular example of this is Lean Six Sigma, which combines improvements in flow and value with reduction in error and variation. The Value Framework in Health Care Since quality in health care is focused on patient outcomes, another approach to quality is the value framework. Hence, in health care, value is defined as the patient health outcomes achieved per dollar spent. Value includes goals already embraced by health care such as quality, safety, patient centeredness, and cost containment; the value framework allows for a way to integrate these goals. Because value is always defined around the customer, in the healthcare industry it is what matters most to patients, and unites the interests of all the stakeholders in the healthcare system. Thus, when value improves, not only do patients, payers, providers, and suppliers all benefit, but the economic sustainability of the healthcare system also improves. According to Porter, the failure to adopt value as the central goal in health care and the failure to measure it, are the most serious failures of the medical community. Thus, value is dependent on patient health outcomes and not the volume of services delivered. The only way to accurately measure value is to track individual patient outcomes and costs longitudinally over the full cycle of care, which can vary from 30 to 90 days for hospital care and 1 year for chronic care. While process measurement is an important component of improvement, it should not be substituted for measurement of patient outcomes. Outcomes, the numerator of the value equation, refer to the actual results of care in terms of patient health and should consist of a set of multidimensional outcomes that, when considered together, constitute patient benefit. Most physicians do not know the full costs of caring for a patient, thus they lack the information to make real efficiency improvements. Without a feedback loop that includes the outcomes achieved, providers lack the information they require to learn and improve. Third, outcomes such as infection rates may vary substantially by medical condition. Current cost measurement approaches have not only hampered our understanding of costs but also contributed to approaches involving cost-containment. A focus on cost-containment rather than value improvement can be dangerous and is often self-defeating. Two major problems associated with cost measurement include: (a) cost aggregation, wherein we often measure and accumulate costs based on how care is organized and billed for, that is, costs for departments, discrete service areas, and line items such as supplies or drugs and (b) cost allocation where the costs of healthcare delivery are shared costs, involving shared resources and as such are normally calculated as the average cost over all patients for a department. Finally, the perspective used to calculate costs matters and patient costs including lost work may not be included in the analysis.

Sleep deprivation causes bidirectional changes in brain activity and connectivity xylitol gastritis buy cheap ranitidine 150 mg, thereby mainly affecting attention and working memory gastritis duodenitis generic ranitidine 150mg visa, and an increased vulnerability to delirium in critically ill patients acute gastritis definition generic ranitidine 150mg line. Narcolepsy is divided into narcolepsy with or without cataplexy (sudden loss of muscle tone without loss of consciousness) chronic gastritis zinc buy ranitidine 150mg with amex. Pharmaceutical treatments of daytime sleepiness include amphetamines acute gastritis symptoms uk generic 300 mg ranitidine fast delivery, methylphenidate gastritis diet ������ 300mg ranitidine with mastercard, modafinil, or selegiline (also effective for treatment of cataplexy), and cataplexies can be treated using tricyclic antidepressants, selective serotonin reuptake inhibitors, or -hydroxybutyrate/sodium oxybate. Delayed emergence from anesthesia, postsurgical hypersomnia, and apneic episodes are in part related to an increased sensitivity to anesthetic drugs in narcolepsy patients. Medical treatment of narcolepsy should be maintained during the preoperative period. Patients with restless legs syndrome usually also complain about sensory symptoms in the legs. Isolated periodic limb movement during sleep is a rare symptom, commonly referred to as periodic limb movement disorder. The characteristic periodic episodes of repetitive limb movements during sleep occur most often in the lower extremities, but occasionally in the upper extremities. These movements can be associated with frequent arousals leading to sleep disruption, causing excessive daytime sleepiness, which often is the only symptom reported by the patients themselves in most cases. Furthermore, gabapentin enacarbil, levodopa with dopa decarboxylase inhibitor, or opioids can be used. Medication impairing the dopaminergic system (dopamine antagonists, neuroleptics, selective serotonin reuptake inhibitors, and tricyclic antidepressants, antihistamines, caffeine, alcohol, and nicotine) should be avoided, if possible. Exacerbation of restless legs syndrome may occur after general anesthesia,382 and the urge to move the limbs may be misinterpreted as agitation or delirium. Restless legs syndrome medication should be continued until the day of surgery, whenever appropriate. Drugs that block the central dopamine transmission, such as neuroleptics, should be avoided. In contrast, ketamine might be the superior anesthetic drug for patients with restless legs syndrome. The best way to provide symptom relief in patients with restless legs syndrome might be early mobilization after surgery. In patients who are not eligible for mobilization, compression treatment386 or intravenous administration of magnesium387 and physiostigmine388 have been shown to lead to relief of restless legs syndrome symptoms. Iron and ferritin blood levels should be monitored closely before, during, and after surgery, especially in surgical cases with iron loss. Chamberlin for her contribution to this chapter in the prior edition of this work. A Manual of Standardized Terminology, Techniques and Scoring Systems for Sleep Stages of Human Subjects. Obstructive sleep apnoea in adults: perioperative considerations: a narrative review. Regularly occurring periods of eye motility, and concomitant phenomena, during sleep. Theta and gamma coordination of hippocampal networks during waking and rapid eye movement sleep. Timing and consolidation of human sleep, wakefulness, and performance by a symphony of oscillators. 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