Fall 2009 - Volume 13 Number 4

Original Articles

Computed Tomography Angiography in Patients Evaluated for Acute Pulmonary Embolism with Low Serum D-dimer Levels: A Prospective Study
Lana Hirai Gimber, MPH;
 Travis R Ing; 
Jayme M Takahashi, MD; 
Torrey L Goodman, MD
; Hyo-Chun Yoon, MD, PhD
In this prospective observational study of Emergency Department patients with possible pulmonary embolism (PE) who underwent pulmonary computed tomography angiography (CTA), the CTA findings positive for acute embolism should be viewed with caution, especially if the suspected PE is in a distal segmental or subsegmental artery in a patient with a serum D-dimer level of ≤ 1.0 μg/ml.

Service Score Segmentation of Diverse Populations to Improve Patient and Physician Satisfaction—A Multicase Quality Improvement Study.
David Newhouse, MD, MPH
The changing demographic picture in California creates a complex challenge for physicians, facilities, and an organization. In response, one strategy is a service improvement program, with demonstrated successful outcomes that combines patient satisfaction "service scores"; data segmentation by ethnicity, sex and age; and data analysis, which recognizes the demographic subsets at which physicians excel and are weak. Five case examples are described, including clinicians interacting with Chinese patients, African-American patients, and young females, and two department level interventions in urology and internal medicine.

Reducing Collusion Between Family Members and Clinicians of Patients Referred to the Palliative Care Team
James Alvin Low, MBBS, FRCP; Sim Lai Kiow, SRN; Norhisham Main, MBBS, MRCP; Koh Kim Luan, SRN; Pang Weng Sun, MBBS, FRCP; May Lim, SRN
The deeply entrenched Asian cultural practice of collusion—a secret agreement made between clinicians and family members to hide the diagnosis of a serious or life-threatening illness from a patient—was studied by the Palliative Care Team. Between December 2004 and June 2008, 655 patients with advanced-stage cancers were referred to the team. Beginning in February 2005, with the implementation of awareness measures, the team was able to maintain an average awareness rate of 80% of patients.

Decreasing Adverse Events through Night Talks: An Interdisciplinary, Hospital-Based Quality
Improvement Project

Christine White, MD, MAT; Javier Gonzalez del Rey, MD, MEd
The majority of medical adverse events are secondary to errors in communication. Review of nonoperative adverse events at Cincinnati Children's Hospital Medical Center in 2007 found that 57% were related to failure to recognize abnormal vital signs and to communicate or to address parents' or nurses' concerns. The initiation of Night Talks—a late-evening review of patients' status by physicians and nurses—reduced near misses in neurosurgical patients to zero in 201 days, a 5360% change.

Staff Solutions for Noise Reduction in the Workplace
Alison Connor, RN, BSN, NE-BC; Elizabeth Ortiz, RN
A comprehensive noise-reduction project was initiated in response to low patient-satisfaction scores on an inpatient neuroscience unit. Before project initiation, decibel readings (dB) were as high as 78.1 dB (standard recommended levels are 40 dB). Postproject satisfaction scores rose to the 95th percentile by July 2008.

Developing a Unit-Based Family Advocacy Board on a Pediatric Intensive Care Unit
Christine McMullan, MPA; Margaret Parker, MD, FCCM; Jeralyn Sigwart, RN, MS, PNP
A pediatric intensive care unit developed a family advocacy board to assist staff in providing patient- and family-centered care. Questions asked pediatric critical care staff related to patients and families as advisors showed a statistically significant improvement postimplementation. Staff perception of the level of family involvement during and after anesthesia induction increased from 42% to 78%, and during resuscitation increased from 28% to 90%.

Case Studies

Peripartum Cardiomyopathy: Case Reports
Mary Wang, MD
Postpartum Cardiomyopathy is a dilated cardiomyopathy defined as systolic cardiac heart failure in the last month of pregnancy or within five months of delivery. The symptoms that differentiate it from those of normal pregnancy and postpartum are chest pain, dyspnea on exertion, rales, and cough. This disorder carries a high mortality rate.

Gastric Antral Vascular Ectasia (Watermelon Stomach)--An Enigmatic and Often-Overlooked Cause of Gastrointestinal Bleeding in the Elderly
Hien Nguyen, MD
Connie Le, MD 
Hanh Nguyen, MD
Gastric Antral Vascular Ectasia (GAVE) syndrome is characterized endoscopically by "watermelon stripes." Without cirrhosis, patients are 71% female, average age 73, presenting with occult blood loss leading to transfusion-dependent chronic iron-deficiency anemia, severe acute upper gastrointestinal bleeding, and nondescript abdominal pain.

Clinical Medicine

The B-SMART Appropriate Medication-Use Process: A Guide for Clinicians to Help Patients-- Part 2: Adherence, Relationships, and Triage
Elizabeth Oyekan, PharmD, FCSHP; Ananda Nimalasuriya, MD; John Martin, MD; Ron Scott, MD; R James Dudl, MD; Kelley Green, RN, PhD
Part 2 of the B-SMART process--a guide to appropriate medication use--describes: adherence tools and reminders, relationships, and triage. Elements include: involving patients in the decision making, simplifying dosage regimens, education about the medication, self-management training, ongoing reinforcement and motivation, and positive relationships.

Image Diagnosis: Interesting Computed Tomography Scans from the Emergency Department
Gus M Garmel, MD, FACEP, FAAEM
Three examples of intracranial hemorrhage are described and visualized on computed tomography scans: subdural, subarachnoid, and intraparenchymal hemorrhage.

Corridor Consult
What Do I Do with My Morbidly Obese Patient? A Detailed Case Study of Bariatric Surgery in Kaiser Permanente Southern California
Pouya Shafipour MS, MD; Jack K Der-Sarkissian, MD; Fadi N Hendee, MD; Karen J Coleman, MS, PhD
Most bariatric surgery studies have shown excellent weight-loss rates for up to two years after surgery, and that most patients maintain the loss for up to ten years. This article summarizes the bariatric surgery process through a detailed case study of how Kaiser Permanente Southern California screens, prepares, and follows patients.

Corridor Consult

A Practical Drug Allergy Update: What You Need to Know About Drug Allergies But Did Not Learn in Medical School
Eric Macy, MD, MS
The majority of adverse drug reactions are nonallergic. Of 275 individuals who reported ten or more drug "allergies," 92% were women (mean age 67 years), and 60% had a diagnosis of depression or serious mental illness. The single most important thing that clinicians can do is not to use antibiotics outside the setting of bacterial infections.


No Respect: Research in Quality, Safety, and Process Improvement
Ilan S Rubinfeld, MD, MBA; H Mathilda Horst, MD
The need for good quality and safety research has never been more imperative, but even as it is encouraged it is suppressed through institutional bias and inertia. This commentary explores implications of the application of pure science standards at the sharp end of clinical practice, where the down-and-dirty street-level improvement work happens.

Health Care Delivery Performance: Service, Outcomes, and Resource Stewardship
Michelle Cowing, PhD; Carrie M Davino-Ramaya, MD; Krishnan Ramaya, PhD; Joseph Szmerekovsky, PhD
As competition intensifies within the health care industry, patient satisfaction and service quality are providing the evidentiary basis for patient outcomes. We propose a conceptual model of three interrelated areas--service, health outcomes, and resource stewardship--all affected by the clinician-patient relationship, and from the perspectives of the health care organization, clinician, and patient, to define a more comprehensive measure of health care delivery performance.

Patient–Physician Language Concordance: A Strategy for Meeting the Needs of Spanish-Speaking Patients in Primary Care
Michael H Kanter, MD; Karyn M Abrams, MBA; Maria R Carrasco, MD; Nancy H Spiegel; Ralph S Vogel, PhD; Karen J Coleman, PhD
Patients need to communicate with a language-concordant physician, not simply an interpreter, to receive the best medical care, bond with the physician, and be satisfied with the care experience. A Spanish Language Task Force addressed the issue of Spanish-speaking patients visiting Primary Care Departments. Not all physicians who self-identify as Spanish-speaking truly speak fluently. Once an individual assessment is completed, then a plan for concordance can be made.


High Satisfaction: Thank You Survey Respondents!
Tom Janisse, MD
The Permanente Journal (TPJ)conducted its fifth reader survey and found continued high satisfaction. Of the 2910 respondents--70% physicians, 15% clinicians, 11% nurses, 4% academics, researchers, leaders, and managers--33% rated TPJ "excellent," 49% "good," 12% "average," 4% "fair," and 2% "poor." Reader comments and requests are cited with 2009 actions, including new electronic capabilities.

Narrative Medicine

From Microscope to Comfy Chair: Imaging Control in Interview Situations
Susan Fairbairn; Gavin Fairbairn
This presents a simple model as a series of metaphorical images--microscope, picture frame, mirror, and two comfy chairs--that correspond to points on a continuum of levels of control exerted by interviewers, and a second continuum, from low to high empathy.

Book Reviews

The Color Atlas of Family Medicine
Review by Susan Christenson, MD

Doctors As Patients
Review by Vincent J Felitti, MD, FACP

Soul of the Healer

"Two Floats"
James Sens

"Peace and Prayers 
in Bhutan"
Anita Kulkarni, MD

"Mystery Valley"
Eric Brody, MD

"Thermophilic Bacteria"
Gary Larsen, MS

"Left Bank, Paris"
Ira Levy, MD

Original Literary Art

Virginia Night Pastoral
Kelly Sievers, CRNA

On the Cover

Gloria Yu, MD,


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