midterm

the institute of medicine report in 1999 concluded that roughly 98,000 patients die each year due to what?

medical error

define pressure ulcers

localized areas of tissue damage or necrosis that develop bc of pressure over a bony prominence

traditionally the care and prevention of pressure ulcers has been left to who?

nursing … physicians play a more passive role by signing off nursing initiated orders

what is the current costs of providing care for 1 pressure ulcer?

$3500 - $60,000 depending on stage

define competency

ability or skill; skill needed to perform in a particular role, knowledge in particular domain or value that can be expressed in exaction or combo of all 3

describe competency in terms of a nurse taking care of a cancer patient

skill → placing IVs, listening to patient

knowledge → experience w chemo drugs, knowing what to look for

value → respect for patient’s feelings and preferences

define common competencies

those expected of all health practitioners

define complementary competencies

unique competencies that enhance the delivery of healthcare

define collaborative competencies

those that each profession needs to work together w others

list the 4 competency domains

1. value/ethics for interprofessional practice

2. roles/responsibilities

3. interprofessional communication

4. teams and teamwork

describe competency domain 1

values and ethics

• focus on values of relationships w patients, other professionals etc.

• work w individuals of other professions to maintain climate of mutual respect and shared values

describe competency domain 2

roles and responsibility

• understanding of how professional roles/responsibilities complement each other

• able to clearly describe one’s own professional role and responsibilities to team members and understand others’ roles in relation to one’s own

• each profession’s roles vary w/in legal boundaries and will change depending on specific care situation

describe competency domain 3

interprofessional communication

• communicating a readiness to work together assist in collaboration

  • being available, receptive, and willing to discuss - indicate readiness

• teamwork and team based competency for better patient centered care requires mastery of new communication technologies

describe competency domain 4

teams and teamwork

• cooperating in delivery of care and coordinating one’s care w other professionals so that gaps, redundancies and errors are avoided

• shared accountability, problem solving and decision making = characteristics of collaborative/effective teamwork

describe the cell walls of a gram positive bacterium

thick peptidoglycan layer that contains teichoic and lipoteichoic acids

• out to in - peptidoglycan → periplasmic space → plasma membrane

describe the cell walls of a gram negative bacterium

thin peptidoglycan layer and outer membrane that contains lipopolysaccharide, phospholipids, and proteins

• periplasmic space contain transport, degradative and cell wall synthetic proteins

• outer membrane joined to cytoplasmic membrane at adhesion points and is attached to peptidoglycan by lipoprotein links

• out to in - outer membrane → periplasmic space → peptidoglycan → peripalsmic space → plasma membrane

this gram stain is of a gram positive or negative bacteria?

positive

this gram stain is of a gram positive or negative bacteria?

negative

what is a risk factor of antibiotic use to treat C diff?

• disrupt barrier function of normal colonic flora, providing niche for C diff to multiply and elaborate toxins

• make it more virulent by increasing antibiotic resistance

the risk factor of antibiotic use to treat C diff is associated with what antibiotics?

fluoroquinolone (cipro, levofloaxcin) and clindamycin

why is age a risk factor of C. diff?

comorbidities and suppressed immune system

why is gastric acid suppression a risk factor for C diff?

PPI use *****

is C diff gram positive or gram negative?

gram positive anaerobic spore forming bacillus

C diff produces 2 toxins, describe them

A - enterotoxin that destroys tight cell junctions leading to increased permeability of the intestinal wall and thus diarrhea

B - cytotoxin that targets actin and destroys cellular cytoskeletons

C diff produces surface layer proteins which allows organisms to do what?

bind to intestinal epithelium and cause local damage

which toxin was found to be essential for C diff virulence?

B

what is the treatment of C diff?

stop inciting antibiotic, place in isolation precautions, oral vancomycin or fidaxomicin

recurrent refractory C diff is treated with what?

fecal transplant

how can we prevent/control C diff?

infection control to track and keep surveillance data, enforcing hand hygiene, contact precautions (bathroom in patient room, use of gloves and gowns), cleanliness of C diff patient rooms with sporicidal antiseptic agents, disposable equipment

what are the 4 phases of clinical trials?

1. assess drug safety and find dosage

2. efficacy and side effects

3. compare new treatment w current to see which is better

4. safety and efficacy

what is bezlotoxumab?

human IgG1 monoclonal antibody which binds to C diff toxin B and neutralizes it to prevent its toxic effects

what is actoxumab?

monoclonal antibody against C diff toxin A

How was the study organized in the “Bezlotoxumab for prevention of recurrent C diff infection” journal?

2 double blind randomized placebo controlled phase 3 trials

• 2000+ adults receiving standard of care oral antibiotics were randomized into 4 groups (bezlotoxumab, actoxumab, combo, and normal saline placebo)

rank the treatment groups from smallest infection recurrence to largest

actoxumab-bezlotoxumab → bezlotoxumab → actoxumab → placebo

the use of bezlotoxumab together with standard oral antibiotic therapy was associated with what result?

significantly lower rate of recurrent infection than oral antibiotic therapy alone

did the addition of actoxumab produce any significant results in the bezlotoxumab study?

no, it didn’t improve efficacy

who are hospitalists?

specialists in inpatient medicine who will be responsible for managing care of hospitalized patients in the same way that primary care physicians are responsible for managing care of outpatients

define patient centered care

providing care that is respectful of and responsive to individual patient preferences, needs, values and ensuring that patient values guide all clinical decisions

define patient experience

sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across continuum of care

how is patient experience measured and what does it measure?

measured by patient satisfaction survey and measures patients perception about communication w nurses and Drs, communication ab medicines, pain management, cleanliness and quietness, responsiveness of staff, discharge information and overall ranking

define patient engagement

actions taken by individuals to obtain greatest benefit from health care services available to them

• greater patient involvement in care

what are the hospitalist values?

concern for value of care, delivering patient centered care, ensuring safe and timely discharges, making accurate diagnosis, communicating clearly

what are the requirements to becoming a hospitalist?

MD or DO, 3 years in internal medicine or sometimes family medicine

• skills → those of internist

• knowledge → extensive medical knowledge to make diagnoses

what is the correlation between quality and cost?

improved quality is usually less expensive

hospitalists will be expected to embrace what?

concept of value and drive its use into everyday practice

define quality

safe, effective, efficient, equitable, patient centered

define cost

unit cost of care delivery by hospitalists

what is the equation for value?

value = quality/cost

define value for clinicians

decreasing overuse and inefficiency, while improving compliance w evidence based care

define value for patients

enriching the patient experience and concentrating on patient centered outcomes

give an example of something that is of high cost but produces high net benefit and high value

MRI for epidural abscess

give an example of something that is of high cost but produces low net benefit and low value

routine MRI for low back pain

give an example of something that is of low cost but produces high net benefit and high value

universal HIV screening

give an example of something that is of low cost but produces low net benefit and low value

preoperative testing prior to low risk surgery

endocarditis is an infection caused by what?

bacteria that enter the bloodstream and settle in heart lining, heart valve or blood vessel

how does endocarditis manifests itself?

mass of platelets, fibrin, microorganisms, and scant inflammatory cells

endocarditis most commonly involves what in the body?

heart valve

describe the mortality of endocarditis

high → 15-22% in hospital and 40% w/in 5 years

describe the endocarditis team

team led by cardiac surgeons that brings together cardiac surgeons, cardiologist, endocardiographers, and infectious disease specialists to discuss diagnosis and management of cases

describe the following of the endocarditis team

• intervention, primary endpoint, and secondary endpoint

• intervention = formation of team

• primary end pt. = impact of the team on the rate of all-cause in-hospital mortality

• secondary end pt. = evaluate effect of team on 6 month and 1 yr mortality, rate of surgery, time to surgery, duration of antibiotic treatment, length of hospital stay, occurrence of cardiac or neurological sequelae

what were the outcomes of the endocarditis team?

• significant reductions in time to surgical procedure, duration of antibiotic treatment and length of hospital stay

• found nonsignificant reductions in in-hopsital 6 month and 1 yr mortality rates

• team and surgery were independent factors linked to survival

what are the responsibilities and roles of a medical and health services manager?

• lead and manage healthcare organizations

• set and monitor organizational strategy

• monitor performance

• implement business functions of finance, HR management, information management, marketing, and environmental management

• concern over the fiscal health of organization

what are the education requirements for medical and health services managers?

• MPH, MHA, or MBA (maybe a hospital fellowship too)

• in smaller settings, bachelor’s degree is sufficient

• no licensing (except for nursing home administrators)

what is a consequence of no standard licensing for medical and health services managers?

substantial variability in the educational backgrounds and experiences

what are the values of medical and health services managers?

appreciate systems aspect of their work (understand how micro-decisions affect everything/one), loyal to their organization and its success, comfortable working in chain of command, value interpersonal skill and organizational political skill, and evidence based management (use of research evidence on management decision making)

occupational interests is defined as what?

preferences in work environment

• O*NET interests → realistic, investigative, artistic, social, enterprising, and conventional

define the realistic occupational interest from the O*NET program

involve work activities that include practical, hands on problems and solutions

• deal w plants, animals and real-world materials

• many of the occupations require working outside and don’t involve a lot of paperwork or working w others

define the investigative occupational interest from the O*NET program

working w ideas, and requires an extensive amt of thinking

• involve searching for facts and solving problems mentally

define the artistic occupational interest from the O*NET program

working w forms, designs and patterns

• require self-expression and work can be done w/o following clear set of rules

define the social occupational interest from the O*NET program

working with, communicating with and teaching people

• helping or providing service to others

define the enterprising occupational interest from the O*NET program

starting up and carrying out projects

• leading people and making many decisions

• require risk taking and often deal w business

define the conventional occupational interest from the O*NET program

following set procedures and routines

• working w data and details more than w ideas

• clear line of authority to follow

define accountable care organization

groups of Dr, hospitalists and other healthcare providers who come together voluntarily to give coordinated high quality care

define beneficiary

person that receives any of the benefits of insurance coverage

define capitation

payment of a fee to a healthcare provider providing services to a number of people, such that the amt paid is determined by the number of total patients

define coinsurance

amt a beneficiary must pay for medical care after they have met their deductible

• insurance company may pay for 80% of an approved amt and the patient will pay 20%

define copayment

flat fee that a beneficiary must pay each time they receive medical care

• patient may pay $10 for every dr visit, while insurance plan covers rest

define coverage limits

max amt that a health insurance plan may pay for certain healthcare services

• some polices may also have a max annual or lifetime coverage amt

• after any of these limits are reached, then the policyholder may have to pay for the remaining costs

define deductible

amt of the beneficiary must pay each year before their health insurance coverage plan begins paying

define exclusions/limitations

services that are not covered by a plan, must be clearly define in plan literature

define fee for service

payment system where healthcare services are unbundled and paid for separately

define formulary

insurance providers list of covered drugs

define health maintenance organization (HMO)

form of managed care in which all care is received from participating providers w/in the network

• referral from primary care provider needs to be obtained prior to seeing specialists

define health reimbursement account (HRA)

account established by employer to pay an employee’s medical expenses

• only the employer can contribute to HRA

define health savings account (HSA)

account established by an employer or individual to save $ toward medical expenses on a tax free basis

why do many small businesses don’t offer employer based insurance?

increased costs of premiums

describe private insurance

a growing market in which an employee will buy their own insurance bc their employer doesn’t offer it

• more expensive

define medicare

federal insurance for people over 65 years old regardless of medical history or income

describe the following of medicare part A

• description, coverage, premium payments, portion of benefit spending

hospital insurance plan largely financed through social security taxes from employers and employees

• coverage - hospital stays, skilled nursing facility stays, home health visits, and hospice care

• premium - most don’t pay as long as they or their spouse paid medicare taxes while working, if don’t qualify then they pay $441/month

• benefit spending - 31% of total

describe the following of medicare part B

• description, coverage, premium payments, portion of benefit spending

outpatient services insurance financed by federal taxes and monthly premium from beneficiaries

• coverage - ppl eligible for A and elect to pay B premium, Dr visits, outpatient services, home health visits, required equipment (wheelchair + walkers)

• premium - pay standard amt but can be adjusted based on income

• benefit spending - 20% of total

describe the following of medicare part C

• description, coverage, premium payments, portion of benefit spending

medicare advantage program, through which beneficiaries can enroll in private health plan and receive medicare covered benefits

• coverage - Part A,B and/or D services

• premium - determined by private health plan

• benefit spending - 22% of total

describe the following of medicare part D

• description, coverage, premium payments, portion of benefit spending

voluntary, subsidized outpatient prescription drug benefit

• coverage - outpatient prescription drugs

• premium - monthly premium that varies, include copayments/coinsurance

• benefit spending - 11% of total

define medicaid

largest health insurance program in US covering 1/5 people and 1/3 children

• administered by individual states w federal govt. support

• must be low income and a child, pregnant, adult w dependent children, have a severe disability or over 65 years old

describe the affordable care act

legislation aimed at decreasing number of uninsured

• intended to streamline healthcare delivery and improve healthcare outcomes

• expand medicaid coverage to those in poverty and establish state level health insurance exchanges

define medical ethics

rigorous academic discipline that combines philosophy, history, sociology and theology which helps clinicians navigate complex moral choices

what are the 4 widely accepted facets of medical ethics that constitute values of the field?

autonomy, beneficence, nonmaleficence and justice

define autonomy

patient has the right to refuse or choose their treatment

• necessary to empower patients to make informed decisions about their health

• informed consent, medical confidentiality, listening to patients/answering questions

describe beneficence

clinician should act in the best interest of the patient at all times

• provide net medical benefit to patients w minimal harm

• must be ablate provide best treatments possible and need rigorous effective education and training both before and during working

describe nonmaleficence

to do no harm

• all decisions must be made w respect to risks/harms that patient can face (physical, $$, psychological)

describe justice

fair and equitable distribution of limited healthcare resources

• moral obligation to act on basis of fair adjudication b/w competing claims