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Improving CT Safety

Improving CT Safety

CT is a powerful diagnostic technology, but it is also associated with risks. Ionizing radiation can damage cells and act as a weak carcinogen. The challenge is to find the optimal x-ray dose for each CT exam. “About 80 million CTs are performed each year in the United States,” says John M. Boone, PhD. “The higher the dose, the better the images, but we also want the lowest possible dose so that patients are protected from unnecessary radiation exposure. The key is to find the balance between acceptable image quality and acceptable doses.” New Strategies The Journal of the American College of Radiology (JACR) recently devoted an entire issue to CT safety. Dr. Boone and other specialists from the University of California, Davis contributed three studies to the special issue. In one of the JACR papers, the need to improve dose calculations was discussed. Manufacturers use phantoms along with instruments to measure radiation, but different companies use phantoms of different sizes, making comparisons problematic in some cases. To prevent these problems, a new metric, the size-specific dose estimate (SSDE), is recommended. “SSDEs can provide a better way to estimate patient doses and can help compare scanners from different companies,” says Dr. Boone. SSDEs may also address the need to more accurately estimate CT doses from a range of patient sizes, especially in pediatric patients. The second JACR paper addressed the challenges of optimizing different CT machines. Automatic exposure protocols must be set up, but this can vary doses based on tissue thickness. “Transferring these settings between machines can be difficult and time consuming,” Dr. Boone says. To overcome this...

Risk Factors for In-Hospital Falls After Orthopedic Surgery

Research has shown that in-hospital falls can increase morbidities and complications, prolong hospitaliza­tions, and increase healthcare costs. In-hospital falls are problematic for surgeons too because they can lead to wounds bursting open, meaning that patients may require revision surgery or develop wound infections. Although it has been surmised that orthopedic surgeries can put patients at risk for in-hospital falls, few studies have evaluated the risk for these falls in this particular patient group. New Research on In-Hospital Falls In the June 2012 Journal of Arthroplasty, my colleagues and I studied in-hospital falls in patients undergoing orthopedic procedures in greater depth using data from AHRQ’s Nationwide Inpatient Sample. The database provides information on nearly 20% of all hospitalizations in the United States. It allows for the appropriate study of relatively rare events—such as in-hospital falls— surrounding surgery. “Our study data can also be used to design or fine tune in-hospital fall prevention programs.” We analyzed data between 1998 and 2007 in patients who had undergone a total hip or knee replacement. The rate of patients who fell during in-hospital recovery was 0.85% for the study period, but the rate increased over time, jumping from 0.4% to 1.3% during the 10-year period. This suggests the problem may be growing, perhaps because of more man­datory reporting protocols or because this patient population is getting sicker, which can increase fall risks. An important aspect of our study was to identify character­istics that put patients at greater risk for in-hospital falls. Patients were more likely to fall if they were male, older, belonged to a racial minority, or underwent a revision joint replacement surgery....

Measuring Preventable Harm

Although the healthcare community has expressed a strong desire to measure safety outcomes, accomplishing this feat has been challenging due to poor investment in the basic science of patient safety. There is a need for basic science because it can allow for better understanding of the causes of harm, help in designing and pilot testing interventions to reduce harm, and enable researchers to evaluate the effects of harm. To advance the science of measuring safety outcomes, it’s critical to separate and distinguish preventable harm from inevitable harm. In healthcare, the term preventable harm differs substantially from that in other industries. Despite receiving evidence-based medical therapies, some patients will inevitably die or sustain complications and problems that are preventable are likely to change over time. It’s important to consider strategies that tease apart preventable harm from inevitable harm, such as: Assuming all harm is preventable (high sensitivity, low specificity). Adjusting for preventability (low sensitivity, low specificity). Linking care received to outcomes (high specificity, low sensitivity). Assessing Potential Strategies Virtually all harm has been labeled as inevitable for decades by clinicians, but recent efforts by payers (eg, CMS) have aimed to label all harm as preventable. This strategy could be appropriate when evidence suggests that most harmful events are preventable. However, the problem is most measures of harm are missing one or several of the required validity components. Most harms are preventable to some degree, but we don’t have evidence to tell us how much. Another strategy could be to use risk-adjustment models to account for preventable and inevitable harm. Such models typically adjust for severity of illnesses, patient demographics, comorbid...
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