Does housestaff discontinuity of care increase the risk for preventable adverse events?

Causes of care discontinuity in chronic outpatient care: A mixed method case study

BACKGROUND

While health systems are primarily designed for acute health issues, managing life-long conditions often results in chronic care discontinuity. This refers to situations where a chronic patient's planned care fails to actualise.

RESEARCH DESIGN

This study descriptively explores the reasons behind chronic care discontinuity in outpatient care.

DATA COLLECTION

Data was collected via interviews and a focus group with healthcare professionals, and a patient survey specifically targeting chronic abdominal patients.

ANALYSIS

Using grounded theorising the Discontinuity of Chronic Care (DoCC) framework was developed, to identify and categorise reasons behind chronic care discontinuity.

RESULTS

The framework reveals that reasons for discontinuity can be largely divided into healthcare system related factors-including caregiver, technological, and process challenges-and patient-related factors such as situational and internal psychological challenges.

CONCLUSIONS

The DoCC-framework provides a valuable tool for analysing various patient processes, offering healthcare managers insights to improve the management of chronic patient journeys. Additionally, it guides healthcare professionals to better focus their development efforts on challenges they have the capacity to address.

Inpatient topical glaucoma medication-ordering discrepancies: a study of frequency and risk factors for inaccurate reconciliation

OBJECTIVE

To describe the frequency of topical glaucoma medication-ordering discrepancies (MOD) during transitions of care and to explore factors that may be associated with an increased risk of MOD.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A random sample of adult patients with primary open-angle glaucoma (POAG) on at least 1 topical glaucoma medication admitted to any Cleveland Clinic facility between January 1, 2012, to January 1, 2023. Study patients must have had at least 1 visit with a Cole Eye Institute ophthalmologist-who diagnosed POAG and prescribed one or more topical glaucoma medications-within 12 months prior to admission.

METHODS

Charts were manually reviewed for discrepant prescriptions. Logistic regressions were employed to assess potential risk factors.

RESULTS

MOD was noted in 288 of 944 (30.5%) encounters. Patient demographics, hospital site, provider type, admitting service, and pharmacy verification did not alter the odds of MOD. Patients on 3 medications experienced MOD most frequently (41.2%) followed by 1 medication (29.3%) and then 2 medications (26.8%) (P = 0.032). Omission was the most common MOD type across all reconciliations followed by substitution, addition, and wrong eye MOD (23.8%, 9.1%, 3.3%, and 0.53%, respectively). Medication discrepancy in a previous hospitalization increased the odds of discrepancy in the next (OR 5.1, 95% CI [3.2-8.4]; P < 0.001). A discrepancy on admission significantly increased MOD rates at transfer and discharge (P < 0.001).

CONCLUSIONS

Glaucoma MOD occurred in approximately one-third of the inpatient encounters in this study, suggesting incongruence at transitions of care. Patients with inpatient MOD were significantly more likely to have an MOD in subsequent admissions.

Biased Language in Simulated Handoffs and Clinician Recall and Attitudes

Importance

Poor-quality handoffs can lead to medical errors when transitioning patient care. Biased language within handoffs may contribute to errors and lead to disparities in health care delivery.

Objective

To compare clinical information recall accuracy and attitudes toward patients among trainees in paired cases of biased vs neutral language in simulated handoffs.

Design, Setting, and Participants

Surveys administered from April 29 to June 15 and from July 20 to October 10, 2023, included 3 simulated verbal handoffs, randomized between biased and neutral, and measured clinical information recall, attitudes toward patients, and key takeaways after each handoff. Participants included residents in internal medicine, pediatrics, and internal medicine-pediatrics and senior medical students at 2 academic medical centers in different geographic regions of the US. Data were analyzed from November 2023 to June 2024.

Exposures

Each participant received 3 handoffs that were based on real handoffs about Black patients at 1 academic center. These handoffs were each randomized to either a biased or neutral version. Biased handoffs had 1 of 3 types of bias: stereotype, blame, or doubt. The order of handoff presentation was also randomized. Internal medicine and pediatrics residents received slightly different surveys, tailored for their specialty. Internal medicine-pediatrics residents received the pediatric survey. Medical students were randomly assigned the survey type.

Main Outcomes and Measures

Each handoff was followed by a clinical information recall question, an adapted version of the Provider Attitudes Toward Sickle Cell Patients Scale (PASS), and 3 free-response takeaways.

Results

Of 748 trainees contacted, 169 participants (142 residents and 27 medical students) completed the survey (23% overall response rate), distributed across institutions, residency programs, and years of training (95 female [56%]; mean [SD] age, 28.6 [2.3] years). Participants who received handoffs with blame-based bias had less accurate information recall than those who received neutral handoffs (77% vs 93%; P = .005). Those who reported bias as a key takeaway of the handoff had lower clinical information recall accuracy than those who did not (85% vs 93%; P = .01). Participants had less positive attitudes toward patients per PASS scores after receiving biased compared with neutral handoffs (mean scores, 22.9 [3.3] vs 25.2 [2.7]; P < .001). More positive attitudes toward patients were associated with higher clinical information recall accuracy (odds ratio, 1.12; 95% CI, 1.02-1.22).

Conclusions and Relevance

In this survey study of residents and medical students, biased handoffs impeded accurate transfer of key clinical information and decreased empathy, potentially endangering patients and worsening health disparities. Handoff standardization is critical to addressing racial bias and improving patient safety.

Streamlining Telecommunications Center and Interfacility Patient Throughput to a Pediatric Emergency Department by Utilizing an Electronic Handoff: A Quality Improvement Initiative

OBJECTIVE

Effective handoffs are critical for patient safety and high-quality care. The pediatric emergency department serves as the initial reception for patients where optimal communication is crucial. The complexities of interfacility handoffs can result in information loss due to lack of standardization. The aim of our project was a 50% reduction in monthly calls routed through the communication center from 157 to 78, for interfacility transfers to the emergency department from outpatient sites within our organization over a 1-year period, through utilization of an electronic handoff activity.

METHODS

We designed a quality improvement project in a tertiary care pediatric hospital to improve the process of interfacility transfer. The initiative aimed to streamline the transfer of patients from ambulatory, urgent care, and nurse triage encounters to the pediatric emergency department by using the electronic health record. The primary outcome measure was number of monthly calls received by the telecommunications center for these transfers.Our process measure was tracked by measuring the utilization of the electronic handoff. In addition, the number of safety events reported because of information lost through using the electronic handoff served as a balancing measure.

RESULTS

One year after the enterprise-wide rollout of the handoff, the telecommunications center was receiving an average of 29 calls per month versus 157 at time of study initiation, a decrease of 81.5%. Monthly usage increased from zero to an average of 544 during the same period. The project was continued after the initial 12-month data collection and demonstrated stability.

CONCLUSIONS

Our initiative facilitated the safe and efficient transfer of patients and streamlined workflows without sacrificing quality of patient care. Our telecommunications center has been freed up for other tasks with fewer interruptions during patient throughput. Next steps will analyze the encounters of transferred patients to further optimize patient flow at our organization.

The Impact of Intraoperative Anesthesiology Provider Handovers on Postoperative Complications After Hepatopancreatobiliary (HPB) Surgery

BACKGROUND

The objective of this study is to assess the possible association between intraoperative anesthesia team handovers and increased 90-day major complications following HPB surgery.

METHODS

This is a single-center retrospective cohort study of patients who underwent HPB surgery. Anesthesiologist handover (AH) occurred when a complete transfer of care to a receiving anesthesiologist. total anesthesia team handovers (TH) occurred when both anesthesiologist and supervised provider transferred care. The primary outcome was 90-day major complications, defined as an ACCORDION score of ≥ 3.

RESULTS

Ninety-day major complications occurred in 35 (21.6%) of TH and 96 (21.9%) of AH patients. With adjustment of other covariates, no significant association was found between AH (OR, 1.358, 95% CI, 0.935-1.973, p = 0.1079) or TH (OR, 1.157, 95% CI, 0.706-1.894, p = 0.5633) and 90-day major complications.

CONCLUSIONS

In a high-volume HPB center, anesthesia team handovers were not associated with an increased risk of patients having a major complication within 90 days after HPB surgery.

Secondary analysis of hand-offs in internal medicine using the I-PASS mnemonic

BACKGROUND

Miscommunications account for up to 80% of preventable medical errors. Mnemonics like I-PASS (Illness severity, Patient summary, Actions list, Situation awareness, Synthesis) have demonstrated a positive impact on reducing error rates. Currently, physicians at our hospital do not follow a specific structure during hand-offs. We aimed to compare current hand-offs without prior training to a gold standard and the I-PASS tool in terms of content and sequence.

METHODS

This study is a secondary analysis of data collected during a simulation study of a Friday evening hand-off to the night resident at University Hospitals of Geneva. Thirty physicians received a hand-off of four patients and managed two other patients through nursing pages at the start of the night shift, generating six sign-outs each, totaling 177 sign-outs. A focus group of three senior doctors defined the gold standard (GS) by consensus on the essential content of each sign-out. The analysis focused on the rates of relevance (ratio of information considered relevant by the GS) and completeness (proportion of transmitted elements out of all expected elements of the GS), and the distribution and sequence of the first four I-PASS categories.

RESULTS

Relevance and completeness rates were 37.2% ± 0.07 and 51.9% ± 0.1, respectively, with no significant difference between residents and supervisors. There was a positive correlation between total hand-off time and relevance (residents: R2 = 0.62; supervisors: R2 = 0.67) and completeness (residents: R2 = 0.32; supervisors: R2 = 0.56). The distribution of I-PASS categories was highly skewed in both the GS (I = 2%, P = 72%, A = 17%, S = 9%) and participants (I = 6%, P = 73%, A = 14%, S = 7%), with significant differences in categories A (p = 0.046) and I (p ≤ 0.001). Sequences of I-PASS categories generally followed a P-A-S-I pattern. The first S category was frequently absent, and only one participant began by announcing the case severity as suggested by I-PASS.

CONCLUSION

We identified gaps between current medical sign-outs in our institution's general internal medicine division and the I-PASS structure. We recommend implementing the I-PASS mnemonic, emphasizing the "I" category at the start and the "S" category to anticipate and prevent complications. Future studies should assess the impact of this recommendation, adapt the mnemonic elements to the context, and introduce specific hand-off training for senior medical students.

A qualitative study on the adoption of the new duty hour regulations among medical residents and faculty in Korea

Duty hour regulations (DHRs) were enforced in 2017 in Korea to prevent the detrimental effects of excessively prolonged working hours among medical residents. We investigated the adoption of and implications of the new DHRs among medical residents and faculty members. Semi-structured interviews were conducted with 15 medical residents and 9 faculty members across general surgery, internal medicine, obstetrics-gynecology, and pediatrics departments at Chonnam National University Hospital. Based on the constructivist grounded theory, we developed themes from the data by concurrent coding and analysis with theoretical sampling until data saturation. In addition, respondent validation was used to ensure accuracy, and all authors remained reflexive throughout the study to improve validity. The methods of DHRs adoption among residents and faculty members included the following 4 themes: DHRs improved work schedule, residents have more time to learn on their own, clinical departments have come to distribute work, organization members have strived to improve patient safety. Residents have undertaken initial steps towards creating a balance between personal life and work. Teamwork and shift within the same team are the transitions that minimize discontinuity of patient care considering patient safety. Teaching hospitals, including faculty members, should ensure that residents' work and education are balanced with appropriate clinical experience and competency-based training.

Information Challenges Associated With Accessing and Sharing of Patient Information in Disasters: A Qualitative Analysis

As disasters increase in frequency and severity, so too does the health impact on affected populations. Disasters exacerbate the already challenging health information-sharing landscape. A reduced capacity to access and share patient information may have negative impacts on providers' ability to care for patients individually and to address disaster health outcomes at the population level. Between October 2018 and July 2019, we conducted 21 semistructured interviews with physicians experienced in providing healthcare during disasters to understand the challenges related to patient information sharing in disaster responses. Key informants noted challenges with patient information management-including accessing, sharing, and transferring information-and that it was a barrier to providing effective clinical care in disasters. Three major areas were identified as challenges: (1) lack of systematic mechanisms for patient information sharing during disaster handoffs, (2) lack of access to a patient's past medical history, and (3) population-level impacts of patient information-sharing breakdowns in disasters. Reducing barriers to effective patient information sharing is a critical need during disasters. Requirements generally fall to overburdened clinicians, and novel solutions that ease this responsibility and leverage existing infrastructure should be explored. Work conducted during the COVID-19 pandemic may inform new solutions. Integrated approaches that support information sharing in real time will improve patient care at the individual level and can support operational improvements to current and future disaster responses.

Comparison of 30-day Readmission Rates and Inpatient Cardiac Procedures for Weekday Versus Weekend Hospital Admissions for Heart Failure

BACKGROUND

Whether the timing of hospital presentation impacts care delivery and clinical outcomes for patients hospitalized for heart failure (HF) remains a matter of debate. In this study, we examined all-cause and HF-specific 30-day readmission rates for patients who were admitted for HF on a weekend vs admitted for HF on a weekday.

METHODS AND RESULTS

We conducted a retrospective analysis using the 2010-2019 Nationwide Readmission Database to compare 30-day readmission rates among patients who were admitted for HF on a weekday (Monday to Friday) vs patients who were admitted for HF on a weekend (Saturday or Sunday). We also compared in-hospital cardiac procedures and temporal trends in 30-day readmission by day of index hospital admission. Among 8,270,717 index HF hospitalizations, 6,302,775 were admitted on a weekday and 1,967,942 admitted on a weekend. For weekday and weekend admissions, the 30-day all-cause readmission rates were 19.8% vs 20.3%, and HF-specific readmission rates were 8.1% vs 8.4%, respectively. Weekend admissions were independently associated with higher risk of all-cause (adjusted odds ratio [aOR] 1.04, 95% confidence interval [CI] 1.03-1.05, P < .001) and HF-specific readmission (aOR 1.04, 95% CI 1.03-1.05, P < .001). Weekend HF admissions were less likely to undergo echocardiography (aOR 0.95, 95% CI 0.94-0.96, P < .001), right heart catheterization (aOR 0.80, 95% CI 0.79-0.81, P < .001), electrical cardioversion (aOR 0.90, 95% CI 0.88-0.93, P < .001), or receive temporary mechanical support devices (aOR 0.84, 95% CI 0.79-0.89, P < .001). The mean length of stay was shorter for weekend HF admissions (5.1 days vs 5.4 days, P < .001). Between 2010 and 2019, 30-day all-cause (18.5% to 18.2%, trend P < .001) and HF-specific (8.4% to 8.3%, trend P < .001) readmission rates decreased among weekday HF admissions. Among weekend HF admissions, the HF-specific 30-day readmission rate decreased (8.8% to 8.7%, trend P < .001), but the all-cause 30-day readmission rate remained stable (trend P = .280).

CONCLUSIONS

Among patients hospitalized for HF, weekend admissions were independently associated with excess risk of 30-day all-cause and HF-specific readmission and a lower likelihood of undergoing in-hospital cardiovascular testing and procedures. The 30-day all-cause readmission rate has decreased modestly over time among patients admitted on weekdays, but has remained stable among patients admitted on weekends.

Association of Time of Day with Delays in Antimicrobial Initiation among Ward Patients with Hospital-Onset Sepsis

Rationale: Although the mainstay of sepsis treatment is timely initiation of broad-spectrum antimicrobials, treatment delays are common, especially among patients who develop hospital-onset sepsis. The time of day has been associated with suboptimal clinical care in several contexts, but its association with treatment initiation among patients with hospital-onset sepsis is unknown. Objectives: Assess the association of time of day with antimicrobial initiation among ward patients with hospital-onset sepsis. Methods: This retrospective cohort study included ward patients who developed hospital-onset sepsis while admitted to five acute care hospitals in a single health system from July 2017 through December 2019. Hospital-onset sepsis was defined by the Centers for Disease Control and Prevention Adult Sepsis Event criteria. We estimated the association between the hour of day and antimicrobial initiation among patients with hospital-onset sepsis using a discrete-time time-to-event model, accounting for time elapsed from sepsis onset. In a secondary analysis, we fit a quantile regression model to estimate the association between the hour of day of sepsis onset and time to antimicrobial initiation. Results: Among 1,672 patients with hospital-onset sepsis, the probability of antimicrobial initiation at any given hour varied nearly fivefold throughout the day, ranging from 3.0% (95% confidence interval [CI], 1.8-4.1%) at 7 a.m. to 13.9% (95% CI, 11.3-16.5%) at 6 p.m., with nadirs at 7 a.m. and 7 p.m. and progressive decline throughout the night shift (13.4% [95% CI, 10.7-16.0%] at 9 p.m. to 3.2% [95% CI, 2.0-4.0] at 6 a.m.). The standardized predicted median time to antimicrobial initiation was 3.2 hours (interquartile range [IQR], 2.5-3.8 h) for sepsis onset during the day shift (7 a.m.-7 p.m.) and 12.9 hours (IQR, 10.9-14.9 h) during the night shift (7 p.m.-7 a.m.). Conclusions: The probability of antimicrobial initiation among patients with new hospital-onset sepsis declined at shift changes and overnight. Time to antimicrobial initiation for patients with sepsis onset overnight was four times longer than for patients with onset during the day. These findings indicate that time of day is associated with important care processes for ward patients with hospital-onset sepsis. Future work should validate these findings in other settings and elucidate underlying mechanisms to inform quality-enhancing interventions.

Work like a Doc: A comparison of regulations on residents' working hours in 14 high-income countries

BACKGROUND

Medical residents work long, continuous hours. Working in conditions of extreme fatigue has adverse effects on the quality and safety of care, and on residents' quality of life. Many countries have attempted to regulate residents' work hours.

OBJECTIVES

We aimed to review residents' work hours regulations in different countries with an emphasis on night shifts.

METHODS

Standardized qualitative data on residents' working hours were collected with the assistance of experts from 14 high-income countries through a questionnaire. An international comparative analysis was performed.

RESULTS

All countries reviewed limit the weekly working hours; North-American countries limit to 60-80 h, European countries limit to 48 h. In most countries, residents work 24 or 26 consecutive hours, but the number of long overnight shifts varies, ranging from two to ten. Many European countries face difficulties in complying with the weekly hour limit and allow opt-out contracts to exceed it.

CONCLUSIONS

In the countries analyzed, residents still work long hours. Attempts to limit the shift length or the weekly working hours resulted in modest improvements in residents' quality of life with mixed effects on quality of care and residents' education.

Models of acute care for injured older patients-Australia and New Zealand practice

INTRODUCTION

The epidemiology of injured patients has changed, with an increasing predominance of severe injury and deaths in older (65 years and above) patients after low falls. There is little evidence of the models of care that optimise outcomes for injured older patients. This study aims to describe clinician perspectives of existing models of acute care for injured older patients in Australia and New Zealand.

METHODS

This cross-sectional online survey of healthcare professionals (HCP) managing injured older patients in Australia or New Zealand hospitals was conducted between November 2nd and December 12th, 2020. Recruitment was via survey link and snowball sampling to professional organisations and special interest groups via email and social media. HCP were asked, using a Likert scale, how likely four typical case vignettes were to be admitted to one of twelve options for ongoing care. Additional questions explored usual care components.

RESULTS

Participants (n=157) were predominantly Australian medical professionals in a major trauma service (MTS) or metropolitan hospital. The most common age defining "geriatric" was aged 65 years and older (43%). HCP described variability in the models and components of acute care for older injured patients in Australia and New Zealand. As a component of care, cognitive, delirium and frailty screening are occurring (60%, 61%, 46%) with HCP from non-major trauma services (non-MTS) reporting frailty and cognitive impairment screening more likely to occur in the emergency department (ED). Access to an acute pain service was more likely in a MTS. Participants described poor likelihood of a geriatrician (highest 16%) or physician (highest 12%) review in ED CONCLUSION: Despite a low response rate, HCP in Australia and New Zealand describe variability in acute care pathways for injured older patients. Given the change in epidemiology of injury towards older patients with low force mechanisms, models of acute injury care should be evaluated to define a cost-effective model and components of care that optimise patient-centred outcomes relevant to injured older patients. HCP described some factors they perceive to determine care, and outcomes of variability, offering guidance for future research and resource allocation in the Australia and New Zealand trauma system.

Association between physician continuity of care and patient outcomes in clinical teaching units: a cohort analysis

BACKGROUND

Hospital-based clinical teaching units (CTUs) are supervised by rotating attending physicians. Physician hand-offs in other contexts have been associated with worse patient outcomes, presumably through communication gaps. We aimed to determine the association between attending physician hand-offs on CTUs and patient outcomes including escalation of care, readmission and mortality.

METHODS

We conducted a retrospective, multicentre cohort study using data from 3 tertiary care hospitals in Calgary between Jan. 1, 2015, and Dec. 31, 2017. We included hospital admissions in the top 10 case-mix groups. Our exposure variable was the number of attending physicians seen by a patient. Outcome measures were admission to intensive care unit (ICU); inpatient 7- and 30-day mortality; and 7- and 30-day readmission rate. We used multivariable regression statistical models adjusted for patient age, sex, length of stay, Charlson Comorbidity Index, case-mix groups, senior resident presence, team handovers and team transfers.

RESULTS

Our cohort included 4324 unique patients. There were no significant differences in the incidence rate ratios (IRRs) of admission to ICU, inpatient 7- and 30-day mortality, and 7- and 30-day readmission rates among 1 or 2 physicians. However, we noted a significant increase in 30-day readmission rate (IRR 1.37, 95% confidence interval 1.05-1.78) in patients who had 3 or more attending physicians compared with those who had 1 attending physician.

INTERPRETATION

We found that 2 or more physician hand-offs on CTUs had a modestly greater association with patient readmission at 30 days. More research is needed to explore this finding and to evaluate associated patient and resource outcomes with physician hand-offs.

Safety Outcomes of Direct Discharge Home From ICUs: An Updated Systematic Review and Meta-Analysis (Direct From ICU Sent Home Study)

OBJECTIVE

To evaluate the impact of direct discharge home (DDH) from ICUs compared with ward transfer on safety outcomes of readmissions, emergency department (ED) visits, and mortality.

DATA SOURCES

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature from inception until March 28, 2022.

STUDY SELECTION

Randomized and nonrandomized studies of DDH patients compared with ward transfer were eligible.

DATA EXTRACTION

We screened and extracted studies independently and in duplicate. We assessed risk of bias using the Newcastle-Ottawa Scale for observational studies. A random-effects meta-analysis model and heterogeneity assessment was performed using pooled data (inverse variance) for propensity-matched and unadjusted cohorts. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach.

DATA SYNTHESIS

Of 10,228 citations identified, we included six studies. Of these, three high-quality studies, which enrolled 49,376 patients in propensity-matched cohorts, could be pooled using meta-analysis. For DDH from ICU, compared with ward transfers, there was no difference in the risk of ED visits at 30-day (22.4% vs 22.7%; relative risk [RR], 0.99; 95% CI, 0.95-1.02; p = 0.39; low certainty); hospital readmissions at 30-day (9.8% vs 9.6%; RR, 1.02; 95% CI, 0.91-1.15; p = 0.71; very low-to-low certainty); or 90-day mortality (2.8% vs 2.6%; RR, 1.06; 95% CI, 0.95-1.18; p = 0.29; very low-to-low certainty). There were no important differences in the unmatched cohorts or across subgroup analyses.

CONCLUSIONS

Very low-to-low certainty evidence from observational studies suggests that DDH from ICU may have no difference in safety outcomes compared with ward transfer of selected ICU patients. In the future, this research question could be further examined by randomized control trials to provide higher certainty data.

The Effect of Admission During the Weekend On In-Hospital Outcomes for Patients With Peripartum Cardiomyopathy

Background Previous studies have shown that patients with heart failure (HF) and cardiogenic shock (CS) have worse outcomes when admitted over the weekend. Since peripartum cardiomyopathy (PPCM) is a cause of CS and persisting HF, it is reasonable to extrapolate that admission over the weekend would also have deleterious effects on PPCM outcomes. However, the impact of weekend admission has not been specifically evaluated in patients with PPCM. Methods We analyzed the National Inpatient Sample (NIS) from 2016 to 2019. The International Classification of Diseases, tenth revision (ICD-10) codes were used to identify all admissions with a primary diagnosis of PPCM. The sample was divided into weekday and weekend groups. We performed a multivariate regression analysis to estimate the effect of weekend admission on specified outcomes. Results A total of 6,120 admissions met the selection criteria, and 25.3% (n=1,550) were admitted over the weekend. The mean age was 31.3 ± 6.4 years. There were no significant differences in baseline characteristics between study groups. After multivariate analysis, weekend admission for PPCM was not associated with in-hospital mortality, ventricular arrhythmias, sudden cardiac arrest, thromboembolic events, cardiovascular implantable electronic device placement, and mechanical circulatory support insertion. Conclusion In conclusion, although HF and CS have been associated with worse outcomes when admitted over the weekend, we did not find weekend admission for PPCM to be independently associated with worse clinical outcomes after multivariate analysis. These findings could reflect improvement in the coordination of care over the weekend, improvement in physician handoff, and increased utilization of shock teams.

Differential Impact of Work Overload on Physicians' Attention: A Comparison Between Residential Fields

OBJECTIVES

Medical errors cause tens of thousands of deaths annually and have a major impact on quality of care and management; however, it receives scant research and public awareness. This study aimed to examine the relation between workload-induced lack of sleep and attention failure, as indications for medical errors risk, among young residents.

METHODS

We performed an evaluation of young physicians by the Test of Variables of Attention, before and after a 24-hour shift.

RESULTS

Workload was manifested by 13% overall attention impairment at baseline, which increased to 34% with deficiencies below the normal range after the shift. Attention measures differed between physicians of each residential field at baseline, but to greater extent after the shift.

CONCLUSIONS

Traditional working schedule is strongly associated with attention failure. Based on the literature linking attention failures to medical errors, we suggest a regulatory change regarding residents' shift duration to decrease preventable errors.

Evaluating the reliability and validity of a questionnaire used to measure experiences of teamwork among student pharmacists in a quality improvement course

INTRODUCTION

The psychometric properties of instruments used to capture student pharmacists' perspectives of teamwork have not been well assessed. This study measured the reliability and validity of an instrument designed to assess teamwork experiences among student pharmacists in a quality improvement (QI) class at one United States pharmacy school.

METHODS

The psychometric properties of a previously conducted 17-item questionnaire (response options: "strongly agree," "agree," "disagree," or "strongly disagree") about second-year student pharmacists' teamworking experiences were assessed. A Rasch rating scale model was used to construct measures of teamwork experience. Principal component analysis (PCA) assessed unidimensionality. Item- and person-fit statistics were assessed. Construct and content validity and reliability were estimated utilizing student and item separation indices (SI) and reliability coefficients (RC).

RESULTS

Sixty student pharmacists were included. PCA conveyed a unidimensional construct. Four items with infit and outfit mean-squared values outside the suggested range were removed. Item responses "disagree" and "strongly disagree" were merged to improve scale functionality. The average person measure was 1.74 ± 2.03 logits. Student and item RC were 0.81 (SI = 2.04) and 0.97 (SI = 2.17), respectively. The easiest item endorsed was team's ability to reach consensus, while the most difficult item was interest to do collaborative work again. Mismatch of student experience and item difficulty level on the continuum scale suggested additional items are needed to match student teamwork experience.

CONCLUSION

The instrument demonstrated evidence of reliability and validity to measure student pharmacists' teamwork experience in a QI class, but additional instrument modifications are recommended.

The Impact of Resident Holdover Admissions on Length of Hospital Stay and Risk of Transfer to an Intensive Care Unit

OBJECTIVE

Implementation of residency duty hour standards has led to adoption of different staffing models, such as the "holdover" model, whereby nighttime teams admit patients and transfer their care to daytime teams who provide ongoing care. In contrast, nonholdover teams at our institution are responsible for both admitting patients and providing ongoing care. We sought to determine whether patients admitted by holdover teams experience worse outcomes than those admitted by nonholdover teams.

METHODS

This is a retrospective cohort study of patients admitted to the internal medicine hospital service at a quaternary care hospital from July 2013 to June 2015. Primary outcomes included hospital length of stay (LOS) and transfer to an intensive care unit within 72 hours of admission. Secondary outcomes were any transfer to an intensive care unit, in-hospital mortality, discharge to home (versus discharge to postacute care facility), and readmission to the health system within 30 days of discharge.

RESULTS

We analyzed 5518 encounters, 64% of which were admitted by a holdover team. Outcomes were similar between study groups, except the LOS, which was 5.5 hours longer for holdover encounters in unadjusted analyses (5.18 versus 4.95 days, P = 0.04) but not significantly different in adjusted analyses. The mean discharge time was 4:00 p.m. for both groups, whereas the mean admission times were 12:00 a.m. and 4:00 p.m. for holdover and nonholdover encounters, respectively.

CONCLUSIONS

Holdover encounters at our institution were not associated with worse patient safety outcomes. A small increase in LOS may have been attributable to holdover patients having earlier admission and identical discharge times.

Weekend admissions with ascites are associated with delayed paracentesis: A nationwide analysis of the 'weekend effect'

INTRODUCTION AND OBJECTIVES

Weekend admissions has previously been associated with worse outcomes in conditions requiring specialists. Our study aimed to determine in-hospital outcomes in patients with ascites admitted over the weekends versus weekdays. Time to paracentesis from admission was studied as current guidelines recommend paracentesis within 24h for all patients admitted with worsening ascites or signs and symptoms of sepsis/hepatic encephalopathy (HE).

PATIENTS

We analyzed 70 million discharges from the 2005-2014 National Inpatient Sample to include all adult patients admitted non-electively for ascites, spontaneous bacterial peritonitis (SBP), and HE with ascites with cirrhosis as a secondary diagnosis. The outcomes were in-hospital mortality, complication rates, and resource utilization. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models.

RESULTS

Out of the total 195,083 ascites/SBP/HE-related hospitalizations, 47,383 (24.2%) occurred on weekends. Weekend group had a higher number of patients on Medicare and had higher comorbidity burden. There was no difference in mortality rate, total complication rates, length of stay or total hospitalization charges between the patients admitted on the weekend or weekdays. However, patients admitted over the weekends were less likely to undergo paracentesis (OR 0.89) and paracentesis within 24h of admission (OR 0.71). The mean time to paracentesis was 2.96 days for weekend admissions vs. 2.73 days for weekday admissions.

CONCLUSIONS

We observed a statistically significant "weekend effect" in the duration to undergo paracentesis in patients with ascites/SBP/HE-related hospitalizations. However, it did not affect the patient's length of stay, hospitalization charges, and in-hospital mortality.

The Holy Month of Ramadan: Mass-Gathering Event Implications for Hospital Surge Capacity Planning in Saudi Arabia

OBJECTIVES

The goal of this study is to determine the impact of the Holy Month of Ramadan on emergency department (ED) and hospital resource utilization in comparison to the time of Hajj and the rest of the year, so as to better define future resource needs of hospitals responding to events of this large size and duration.

METHODS

A retrospective chart review was conducted of electronic medical records, ED visits, and hospital admissions during Ramadan, Hajj, and all other months over a three-year period on the Hijra calendar (1438-1440) or Gregorian (2016-2019). Primary outcomes were the change in the number of ED visits, hospital admissions, and intensive care unit (ICU) admissions during Ramadan in comparison to during Hajj and other months. Secondary outcomes included mortality; number of surgeries by specialty; and admissions to cardiac, respiratory, orthopedic, and neurosurgery wards.

RESULTS

During the three years, ED visits increased during Ramadan by 83.0%, 74.8%, and 40.3%, respectively, when compared to non-Hajj, non-Ramadan months. Hospital admissions rose by 21.05%, 50.96% and 48.22%. Combined ED and in-hospital mortality rose by 15.21%, 21.47%, and 1.39%. While there was a large increase in ICU admissions during Ramadan of 1440 (May 2019), this was not a trend seen in other years. Despite there only being two years of data for comparison, there was a trend towards increased admissions to all specialty wards. There was an average 46.69% increase in admissions to the general surgery ward during Ramadan months compared to other months, a 31.06% increase in admissions to the orthopedic surgery ward, and a 44.05% increase in admissions to the cardiac care unit.

CONCLUSIONS

Ramadan is associated with a significant increase in the population of Makkah (Mecca), Saudi Arabia. Despite this study only focusing on a three-year period, and some variables with only two years of data available, it demonstrates a significant increase in ED visits, hospital admissions, and mortality during Ramadan compared to non-Hajj/non-Ramadan months. During mass gatherings of this size, it would benefit local and regional hospital systems to devote increased resources to patient care, especially to the ED, to prevent morbidity and mortality.

Impact of intensive care unit admission during handover on mortality: propensity matched cohort study

OBJECTIVE

To investigate the impact of intensive care unit admission during medical handover on mortality.

METHODS

Post-hoc analysis of data extracted from a prior study aimed at addressing the impacts of intensive care unit readmission on clinical outcomes. This retrospective, single-center, propensity-matched cohort study was conducted in a 41-bed general open-model intensive care unit. Patients were assigned to one of two cohorts according to time of intensive care unit admission: Handover Group (intensive care unit admission between 6:30 am and 7:30 am or 6:30 pm and 7:30 pm) or Control Group (intensive care unit admission between 7:31 am and 6:29 pm or 7:31 pm and 6:29 am). Patients in the Handover Group were propensity-matched to patients in the Control Group at a 1:2 ratio.

RESULTS

A total of 6,650 adult patients were admitted to the intensive care unit between June 1st 2013 and May 31st 2015. Following exclusion of non-eligible participants, 5,779 patients (389; 6.7% and 5,390; 93.3%, Handover and Control Group) were deemed eligible for propensity score matching. Of these, 1,166 were successfully matched (389; 33.4% and 777; 66.6%, Handover and Control Group). Following propensity-score matching, intensive care unit admission during handover was not associated with increased risk of intensive care unit (OR: 1.40; 95%CI: 0.92-2.11; p=0.113) or in-hospital (OR: 1.23; 95%CI: 0.85-1.75; p=0.265) mortality.

CONCLUSION

Intensive care unit admission during medical handover did not affect in-hospital mortality in this propensity-matched, single-center cohort study.

Rural family physician perspectives on communication with urban specialists: a qualitative study

OBJECTIVE

Communication is a key competency for medical education and comprehensive patient care. In rural environments, communication between rural family physicians and urban specialists is an essential pathway for clinical decision making. The aim of this study was to explore rural physicians' perspectives on communication with urban specialists during consultations and referrals.

SETTING

Newfoundland and Labrador, Canada.

PARTICIPANTS

This qualitative study involved semistructured, one-on-one interviews with rural family physicians (n=11) with varied career stages, geographical regions, and community sizes.

RESULTS

Four themes specific to communication in rural practice were identified. The themes included: (1) understanding the contexts of rural care; (2) geographical isolation and patient transfer; and (3) respectful discourse; and (4) overcoming communication challenges in referrals and consultations.

CONCLUSIONS

Communication between rural family physicians and urban specialists is a critical task in providing care for rural patients. Rural physicians see value in conveying unique aspects of rural clinical practice during communication with urban specialists, including context and the complexities of patient transfers.

Initiation of a Night Float System in an Otolaryngology Residency: Resident Perception and Impact on Operative Volume

OBJECTIVES

Evaluate resident perception on implementation of a night float (NF) system to an otolaryngology residency program. We compared these perceptions to Accreditation Council for Graduate Medical Education (ACGME) case log data.

METHODS

A retrospective anonymous survey was sent to residents and alumni graduating between 2015 and 2023. Deidentified ACGME case log information was then examined for key indicator (KI) cases from post graduate year (PGY) 2 and PGY5.

RESULTS

Thirty (93.8%) residents and alumni responded. Residents with NF answered more positively compared to those without NF on following duty hour violations: 80-hour work week, 1-in-7 days off, 1 call every 3 days, adequate time between shifts, and allotted time after a 24-hour shift. Residents most commonly agreed that NF has improved patient care, resident education, and resident morale. Although residents with NF were neutral on PGY2 case volume effects, they disagreed that it affected overall case volume. The only KIs that differed for both PGY2 and PGY5s were airway cases (P = .004 vs P = .002) and bronchoscopy (P = .02 vs P = .006), which were significantly higher for those with NF. Thyroid surgery was the only KI higher for the residents without NF and spanned all PGY levels.

CONCLUSION

Residents and alumni agreed that NF implementation had a positive effect on duty hour violations. The NF system does not have significant impact on case volume.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Pediatric resident's perception of night float system compared to 24 hours system, a prospective study

BACKGROUND

The study aims to evaluate the perceptions of pediatric residents under the night float (NF) on-call system and its impact on well-being, education, and patient safety compared with the traditional 24-h on-call system.

METHODS

The study is prospective in nature and conducted on two pediatric resident training centers who apply the NF on-call system as a pilot project. Senior residents (PGY-3 and PGY-4) enrolled in the two training centers were invited to participate before and 6 months after the implementation of the change in the on-call system. A self-administered online questionnaire was distributed. Responses were rated using a five-point Likert-type scale (1 = strongly disagree; 5 = strongly agree). The items covered three main domains, namely, residents' well-being, ability to deliver healthcare, and medical education experience. Pre- and post-intervention scores were presented as means and compared by t-test for paired samples.

RESULTS

A total of 42 residents participated in the survey (female = 24; 57.1%). All participants were senior residents; 25 (59.6%) were third-year residents (PGY-3), whereas 17 (40.4%) were fourth-year residents (PGY-4). The participants reported that many aspects of the three domains were improved with the introduction of the NF system. The system was perceived to exert less adverse health effect on the residents (mean: 2.37 ± 1.01) compared with the 24-h on-call system (mean: 4.19 ± 0.60; P < 0.001). In addition, the NF system was perceived to lead to less exposure to personal harm and result in less negative impact on quality of care, better work efficiency, reduced potential for medical errors, more successful teaching, and less disruptions to other rotations compared with the 24 h on-call system (P < 0.001).

CONCLUSION

The perception of senior residents toward the 24-h on-call system pertains to negative impacts on well-being, education, and patient safety compared with on-call systems with restrictive duty hours, such as the NF system, which is perceived to be less harmful, to exert positive impacts on the quality of delivered healthcare services, and more useful from pedagogic aspect.

Does work time limit for resident physician affect short-term treatment outcome and hospital length of stay in patients with spontaneous intracerebral hemorrhage?: a two-year experience at a single training hospital in South Korea

Objective

To compare short-term treatment outcomes at hospital discharge and hospital length of stay (LOS) in patients with spontaneous intracerebral hemorrhage (sICH) before and after introduction of resident physician work time limit (WTL).

Methods

We retrospectively reviewed consecutive patients treated for sICH at our institution between 2016 and 2019. Then we dichotomized these patients into two groups, pre-WTL and post-WTL. We analyzed demographic elements and clinical features, and hospital length of stay (LOS). We evaluated short-term outcome using modified Rankin scale score at hospital discharge and then divided it into “good” and “poor” outcome groups. We subsequently, compared short-term treatment outcome and hospital LOS between the pre-WTL and post-WTL groups.

Results

Out of 779 patients, 420 patients (53.9%) were included in the pre-WTL group, and 359 (46.1%) in post-WTL. The mortality rate in sICH patients was higher in the post-WTL group (pre-WTL; 13.6% vs. post-WTL; 17.3%), but there was no statistically significant difference in short-term outcome including mortality (p=0.332) between the groups. The LOS also, was not significantly different between the two groups (pre-WTL; 19.0 days vs. post-WTL; 20.2 days) (p=0.341). The initial Glasgow Coma Scale score, personal stroke history, and mean age were the only independent outcome predicting factors for patients with sICH.

Conclusions

Some neurosurgeons may expect poorer outcome for sICH after implementation of the WTL of the K-MHW for resident physician however, enforcement of the WTL did not significantly influence the short-term outcome and hospital LOS for sICH in our hospital. Further well-designed multi-institutional prospective studies on the effects of WTL in sICH patient outcome, are anticipated.

The Trainee's Role in Patient Safety: Training Residents and Medical Students in Surgical Patient Safety

"The focus on patient safety offers a new framework not only for delivering health care but also for training physicians. Medical school and surgical graduate medical education must transition to a more holistic approach by teaching technical and nontechnical skills. Formalized safety curricula can be developed by adopting recommended guidelines and content from national and international organizations, existing validated practices of training programs, frequent simulation exercises, and objective evaluation tools."

Communicating Neurocritical Illness: The Anatomy of Misunderstanding

We talk, text, email all day. Do we perceive things correctly? Do we need to improve the way we communicate? It is a truism that providing insufficient information about a patient results in delays and errors in management. How can we best communicate urgent triage or urgent changes in the patient condition? There is no substitute for a face-to-face conversation but what would the receiving end want to know? One starting point for those practicing acute neurology and neurocritical care is a new mnemonic TELL ME (Time course, Essence, Laboratory, Life-sustaining interventions, Management, Expectation), which will assist physicians in standardizing their communication skills before they start a conversation or pick up a phone. These include knowing the time course (new and "out of the blue" or ongoing for some time); extracting the essentials (eliminating all irrelevancies); communicating what tests are known and pending (computerized tomography and laboratory); relaying how much critical support will be needed (secretion burden, intubation, vasopressors); knowing fully which emergency drugs have been administered (e.g., mannitol, antiepileptics, tranexamic acid), when transport is anticipated, and what can be expected in the following hours. Perfect orchestration in communication may be too much to ask, but we neurointensivists strive to convey information accurately and completely. Communication must be taught, learned, and practiced. This article provides guiding principles for a number of scenarios involving communication inside and outside the hospital.

The impact of nurses' and physicians' shift change on obstetrical outcomes

PURPOSE

To evaluate the effect around nurses' shift change and on-call physicians' shift change on obstetrical outcomes.

METHODS

A retrospective study of women who had an attempt of labor in a single-medical center, January 2006-December 2017. Obstetrical outcomes were compared between the time around nurses' shift change (6:00-8:00, 14:00-16:00, and 22:00-00:00) to the rest of the day, and between the time around on-call physicians' shift change (6:00-8:00, 14:00-16:00) to the rest of the day.

RESULTS

32,861 women were included, 7826 deliveries occurred during nurses' shift-change, and 25,035 deliveries occurred during the rest of the day. The groups had similar general and obstetrical characteristics, with no statistical difference in cesarean delivery rate (10% vs. 9.8%, P = 0.45) (Table 1). Nurses' shift change had no measurable effect on obstetrical outcomes, including induction of labor, preterm labor, 5-min-Apgar score and cord pH value, except PPH which was less likely to occur during nurses' shift change period (3.8% vs. 4.4%, P = 0.045) (Table 2). From 32,861 deliveries, 5155 deliveries occurred during on-call physicians' shift-change, and 27,706 deliveries occurred during the rest of the day. Induction\augmentation of labor and epidural analgesia were less likely to happen during on-call physicians' shift change (34.4% vs. 38%, P < 0.0001, 59.6% vs. 61.8%, P = 0.003, respectively) (Table 3). The two groups had similar obstetrical outcomes, without statistical difference in cesarean delivery rate (10% vs. 9.8%, P = 0.63) (Table 4). Table 1 General and obstetric characteristics of women giving birth during the time of nurses shift change versus during the rest of the day Variable Change of nurses shifts (n = 7826) All other hours of the day (n = 25,035) P value Maternal age, y 30.3 ± 5.1 30.2 ± 5.2 0.09 Gestational age at birth (weeks) 39.7 ± 1.09 39.8 ± 1.10 0.55 Nulliparity 2077 (35%) 7067 (37%) 0.01 Induction\augmentation of labor 2905 (37) 9368 (38) 0.62 Epidural analgesia 4746 (61) 15,396 (62) 0.16 Neonatal birth weight, g 3340 ± 422 3330 ± 423 0.06 Data is presented as mean ± S.D or N (%) Table 2 Maternal and neonatal adverse outcomes of women giving birth during the time of nurses shift change versus during the rest of the day Variable (%) Change of nurses shifts (n = 7826) All other hours of the day (n = 25,035) P value Vacuum assisted delivery 615 (7.9) 2002 (8.0) 0.69 Cesarean delivery 788 (10) 2443 (9.8) 0.45 Postpartum hemorrhage 294 (3.8) 1089 (4.4) 0.045 Third- and fourth-degree perineal laceration 106 (1.4) 372 (1.5%) 0.51 5-min Apgar score < 7 39 (0.5) 139 (0.6) 0.65 Umbilical pH < 7.2 170 (23) 580 (23) 0.96 Prolonged second stage 190 (2.5) 559 (2.2) 0.22 Maternal and fetal composite adverse outcome* 1309 (16.7%) 4219 (16.9%) 1.00 Data is presented as N (%) *Maternal and fetal composite adverse outcome was defined as the presence of any of the following: vacuum delivery, CD, prolonged second stage, postpartum hemorrhage, third and fourth degree perineal laceration, 5-min Apgar score < 7 and umbilical cord pH < 7.2 Table 3 General and obstetric characteristics of women giving birth during the time of the on-call physicians shift change versus during the rest of the day Variable Change of physicians shifts (n = 5155) All other hours of the day (n = 27,706) P value Maternal age, years 30.3 ± 5.1 30.2 ± 5.2 0.38 Gestational age at birth (weeks) 39.8 ± 1.09 39.8 ± 1.10 0.95 Nulliparity (%) 1303 (33.4) 7841 (37)  < 0.0001 Induction\augmentation of labor (%) 1769 (34.3) 10,504 (38)  < 0.0001 Epidural analgesia (%) 3067 (59.6) 17,075 (61.8) 0.003 Neonatal birth weight (gr) 3345 ± 416 3330 ± 424 0.019 Data is presented as mean ± S.D or N (%) Table 4 Maternal and neonatal adverse outcomes of women giving birth during the time of physicians on-call shift change versus during the rest of the day Variable (%) Change of physicians shifts (n = 5155) All other hours of the day (n = 27,706) P value Vacuum assisted delivery 397 (7.7) 2220 (8.0) 0.45 Cesarean delivery 517 (10.0) 2714 (9.8) 0.63 Postpartum hemorrhage 209 (4.1) 1174 (4.3) 0.54 Third- and fourth-degree perineal laceration 67 (1.3) 411 (1.5) 0.31 5-min Apgar score < 7 22 (0.5) 156 (0.6) 0.30 Umbilical pH < 7.2 94 (20.3) 656 (23.3) 0.15 Prolonged second stage 127 (2.5%) 622 (2.3%) 0.36 Maternal and fetal composite adverse outcome* 852 (16.5%) 4676 (16.9%) 1.00 Data is presented as N (%) *Maternal and fetal composite adverse outcome was defined as the presence of any of the following: vacuum delivery, CD, prolonged second stage, postpartum hemorrhage, third and fourth degree perineal laceration, 5-min Apgar score < 7 and umbilical cord pH < 7.2 CONCLUSION: Nurses' shift change and on-call physicians' shift change does not appear to be associated with an increase in adverse maternal or neonatal outcomes.

The information imperative: to study the impact of informational discontinuity on clinical decision making among doctors

Background

Informational discontinuity can have far reaching consequences like medical errors, increased re-hospitalization rates and adverse events among others. Thus the holy grail of seamless informational continuity in healthcare has been an enigma with some nations going the digital way.

Digitization in healthcare in India is fast catching up. The current study explores the components of informational continuity, its impact on clinical decision-making and captures the general perception among the doctors towards a digital solution.

Methods

Cross-sectional study with snowball sampling. A survey questionnaire was developed and validated through a pilot study, then circulated through online platforms. Responses from doctors were obtained through an online Google form for a period of 3 months and analyzed using SPSS 20. The categorical variables were analyzed using Chi-square test.

Results

1413 responses were obtained through a national level survey. Respondents were from a wide range of work experiences, locations, sectors, specialties and patient load. Components of patient records like clinical notes, investigation reports, previous diagnosis and treatment details were rated to be very important.

41% reported about half and 20% reported about 3/4th of their patients do not bring relevant records. Patients from rural areas, visiting state government hospitals and visiting general practitioners were less likely to bring relevant records during consultations.

The fallouts of not having timely relevant patient information of the patients include more time per patient, repeat investigations, difficulty to arrive at definitive diagnosis, difficulty to take further treatment decisions and impaired overall clinical decision making which were said to be significant by respondents across the spectrum. The benefits of having timely relevant patient information were also reported consistently across the spectrum.

An overwhelming proportion (83%), from across the spectrum, unequivocally expressed their willingness to use digital platforms for accessing patients’ relevant medical records.

Conclusion

Prevalence of informational discontinuity and its impact on clinical decision making is significant with definite benefits of having timely relevant medical history. There is strong willingness among the doctors to use digital solution(s) without any extra investment or effort on their part making customized solutions pertinent.

Training Nontechnical Skills in Ward Rounds to Improve Team Performance

OBJECTIVE

To assess the utility of simulated ward rounds to train healthcare professionals in nontechnical skills using a qualitative analysis of participant feedback.

DESIGN

We developed simulated scenarios to train members of the surgical healthcare team in nontechnical skills, derived from observations of real ward rounds. Participants performed the simulated ward rounds as a team, led by a Urology trainee. Scenarios were carried out using actors as patients, and a simulated "switchboard" for phone conversations. Throughout the scenarios, distractions were introduced and directed at different members of the participating team. Following each scenario, a whole group debrief took place to discuss and provide feedback on performances. All participants completed a 2-part feedback form comprising of questions answered on a Likert scale, as well as free-text responses.

SETTING

All simulations took place in a high-fidelity simulated ward bay. Observers were in a separate room, where the scenarios were projected on a screen in real-time.

PARTICIPANTS

Thirty-five healthcare professionals in the department of Urology attended this session. There was no restriction on professional background or seniority for attendees.

RESULTS

The qualitative thematic analysis revealed that participants commented positively on the type of scenarios, but would have preferred if more participants could partake in scenarios. The attendees also commended the use of debriefs between scenarios. Suggestions were also given regarding types of scenarios; and involved ensuring that participants are well briefed before each scenario.

CONCLUSIONS

This simulated ward round exercise was positively received by participants. The approach to derive scenarios from real ward round observations permitted a variety of the main themes of nontechnical skills to be tested, and improved the fidelity of the simulation. The reflections expressed by participants demonstrate a need for this training, and drives our initiative to raise awareness and develop nontechnical skills in a controlled environment, supported with transparent discussion and feedback.

Factors influencing digital review of pathology test results in an inpatient setting: a cross-sectional study

BACKGROUND

Delay or failure to view test results in a hospital setting can lead to delayed diagnosis, risk of patient harm, and represents inefficiency. Factors influencing this were investigated to identify how timeliness and completeness of test review could be improved through an evidence-based redesign of the use of clinical test review software.

METHODS

A cross-section of all abnormal hematology and biochemistry results which were published on a digital test review platform over a 3-year period were investigated. The time it took for clinicians to view these results, and the results that were not viewed within 30 days, were analyzed relative to time of the week, the detailed type of test, and an indicator of patient record data quality.

RESULTS

The majority of results were viewed within 90 min, and 93.9% of these results viewed on the digital platform within 30 days. There was significant variation in results review throughout the week, shown to be due to an interplay between technical and clinical workflow factors. Routine results were less likely to be reviewed, as were those with patient record data quality issues.

CONCLUSION

The evidence suggests that test result review would be improved by stream-lining access to the result platform, differentiating between urgent and routine results, improving handover of responsibility for result review, and improving search for temporary patient records. Altering the timing of phlebotomy rounds and a review of the appropriateness of routine test requests at the weekend may also improve result review rates.

Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts

BACKGROUND

The effects on patient safety of eliminating extended-duration work shifts for resident physicians remain controversial.

METHODS

We conducted a multicenter, cluster-randomized, crossover trial comparing two schedules for pediatric resident physicians during their intensive care unit (ICU) rotations: extended-duration work schedules that included shifts of 24 hours or more (control schedules) and schedules that eliminated extended shifts and cycled resident physicians through day and night shifts of 16 hours or less (intervention schedules). The primary outcome was serious medical errors made by resident physicians, assessed by intensive surveillance, including direct observation and chart review.

RESULTS

The characteristics of ICU patients during the two work schedules were similar, but resident physician workload, described as the mean (±SD) number of ICU patients per resident physician, was higher during the intervention schedules than during the control schedules (8.8±2.8 vs. 6.7±2.2). Resident physicians made more serious errors during the intervention schedules than during the control schedules (97.1 vs. 79.0 per 1000 patient-days; relative risk, 1.53; 95% confidence interval [CI], 1.37 to 1.72; P<0.001). The number of serious errors unitwide were likewise higher during the intervention schedules (181.3 vs. 131.5 per 1000 patient-days; relative risk, 1.56; 95% CI, 1.43 to 1.71). There was wide variability among sites, however; errors were lower during intervention schedules than during control schedules at one site, rates were similar during the two schedules at two sites, and rates were higher during intervention schedules than during control schedules at three sites. In a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors.

CONCLUSIONS

Contrary to our hypothesis, resident physicians who were randomly assigned to schedules that eliminated extended shifts made more serious errors than resident physicians assigned to schedules with extended shifts, although the effect varied by site. The number of ICU patients cared for by each resident physician was higher during schedules that eliminated extended shifts. (Funded by the National Heart, Lung, and Blood Institute; ROSTERS ClinicalTrials.gov number, NCT02134847.).

How to Increase the Burden on Trauma Centers: Implement the 80-hour Work Week

The 80-hour week was implemented in 2003 to improve outcomes and limit errors. We hypothesize that there has been no change in outcomes postimplementation of the restrictions. Outcomes were queried from the trauma registry from 1997 to 2002 (PRE) and 2004 to 2009 (POST). Primary outcomes were mortality, intensive care unit length of stay (ICU LOS), and length of stay (LOS). Patients were stratified based on demographics, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Score, base deficit). Outcomes were then compared PRE with POST. A total of 41,770 patients were admitted during the study period. The mean age was 38 years with most being male (73%) and blunt mechanism (78%). Although patients admitted in the POST period had a slightly higher blood pressure, they were older and had higher injury severity. ICU LOS, LOS, self-pay, and mortality were higher in the POST period. After adjusted analysis, admission in the POST period was no longer a predictor of mortality (odds ratio, 1.02; confidence interval, 0.92 to 1.14). Whereas patients were more slightly more injured in the POST period, the adjusted analysis shows no difference in mortality and both a longer LOS and ICU LOS. Whether the increase is the result of more severe injury in the POST period or less efficient disposition remains to be elucidated. This study adds to the mounting evidence that the implementation of the limits on work hours does not lead to better outcomes.

Checklist-styled Daily Sign-out Rounds Improve Hospital Throughput in a Major Trauma Center

The checklist concept has received much attention as a result of its ability to improve patient care by minimizing complications. We hypothesized daily sign-out rounds using a checklist, by improving team communication and consistency of clinical care, could lead to expedited throughput for patients at a major trauma center. A retrospective study examined patients admitted to a mature trauma center. Two time periods, PRE (September 2008 to January 2009) and POST (September 2009 to January 2010), were selected to match for seasonal variation in admission diagnosis. An organ system-based checklist was used during daily sign-out for all admitted trauma patients in the POST period. We examined discharge status, complications and rates, and intensive care unit (ICU) and overall hospital length of stay for differences. There were similar numbers of patients (824 PRE vs 798 POST) admitted in these two cohorts. We found no statistical differences in the incidence of complications or mortality rate. We did discover statistically significant differences in the median ICU days (2 PRE vs 1 POST, P = 0.007) as well as median hospital length of stay (2 days, interquartile differences Q1 to Q3 PRE [1 to 5] and POST [1 to 4] P = 0.000). These trends remained valid even among the severely injured (Injury Severity Score 16 or greater) with a hospital length of stay of 5 (PRE) versus 3 days (POST; P = 0.021). A simple, organ system-based checklist can be successfully adopted for daily sign-out round on a busy, multiprovider trauma service. We were able to expedite trauma patient throughput in both ICU and overall hospital stays with a trend toward decreasing mortality. This improved throughput may potentially translate into a cost saving for the hospital.

A Sociotechnical Framework for Safety-Related Electronic Health Record Research Reporting: The SAFER Reporting Framework

Electronic health record (EHR)-based interventions to improve patient safety are complex and sensitive to who, what, where, why, when, and how they are delivered. Success or failure depends not only on the characteristics and behaviors of individuals who are targeted by an intervention, but also on the technical characteristics of the intervention and the culture and environment of the health system that implements it. Current reporting guidelines do not capture the complexity of sociotechnical factors (technical and nontechnical factors, such as workflow and organizational issues) that confound or influence these interventions. This article proposes a methodological reporting framework for EHR interventions targeting patient safety and builds on an 8-dimension sociotechnical model previously developed by the authors for design, development, implementation, use, and evaluation of health information technology. The Safety-related EHR Research (SAFER) Reporting Framework enables reporting of patient safety-focused EHR-based interventions while accounting for the multifaceted, dynamic sociotechnical context affecting intervention implementation, effectiveness, and generalizability. As an example, an EHR-based intervention to improve communication and timely follow-up of subcritical abnormal test results to operationalize the framework is presented. For each dimension, reporting should include what sociotechnical changes were made to implement an EHR-related intervention to improve patient safety, why the intervention did or did not lead to safety improvements, and how this intervention can be applied or exported to other health care organizations. A foundational list of research and reporting recommendations to address implementation, effectiveness, and generalizability of EHR-based interventions needed to effectively reduce preventable patient harm is provided. The SAFER Reporting Framework is not meant to replace previous research reporting guidelines, but rather provides a sociotechnical adjunct that complements their use.

Application of electronic medical record-derived analytics in critical care: Rothman Index predicts mortality and readmissions in surgical intensive care unit patients

INTRODUCTION

The Rothman Index (RI) is an objective measurement of a patient's overall condition, automatically generated from 26 variables including vital signs, laboratory data, cardiac rhythms, and nursing assessments. The purpose of this study was to assess the validity of RI scores in predicting surgical ICU (SICU) readmission rates and mortality.

METHODS

We conducted a single-center retrospective analysis of surgical patients who were transferred from the SICU to the surgical floor from December 2014 to December 2016. Data included demographics, length of stay (LOS), mortality, and RI at multiple pretransfer and post-transfer time points.

RESULTS

A total of 1,445 SICU patients were transferred to the surgical floor; 79 patients (5.5%) were readmitted within 48 hours of transfer. Mean age was 52 years, and 67% were male. Compared to controls, patients readmitted to the SICU within 48 hours experienced higher LOS (29 vs. 11 days, p < 0.05) as well as higher mortality (2.5% vs. 0.6%, p < 0.05). Patients requiring readmission also had a lower RI at 72, 48, and 24 hours before transfer as well as at 24 and 48 hours after transfer (p < 0.05 for all). Rothman Index scores were categorized into higher-risk (<40), medium-risk (40-65), and lower-risk groups (>65); RI scores at 24 hours before transfer were inversely proportional to overall mortality (RI < 40 = 2.5%, RI 40-65 = 0.3%, and RI > 65 = 0%; p < 0.05) and SICU readmission rates (RI < 40 = 9%, RI 40-65 = 5.2%, and RI > 65 = 2.8%; p < 0.05). Patients transferred with RI scores greater than 83 did not require SICU readmission within 48 hours.

CONCLUSION

Surgical ICU patients requiring readmission within 48 hours of transfer have a significantly higher mortality and longer LOS compared to those who do not. Patients requiring readmission also have significantly lower pretransfer and post-transfer RI scores compared to those who do not. Rothman Index scores may be used as a clinical tool for evaluating patients before transfer from the SICU. Prospective studies are warranted to further validate use of this technology.

LEVEL OF EVIDENCE

Retrospective database review, level III.

Physicians' working time restriction and its impact on patient safety: an integrative review

BACKGROUND

Although shift work is a part of the physicians' routine, there is controversy on the length of shifts and adequate rest for safe professional practice. If on the one hand long working hours might have negative impact on patient safety by interfering with the psychological and physical functioning of physicians, on the other shorter working hours might impair the safety of patients due to interference with the continuity of care.

OBJECTIVE

To analyze the impact of restrictions to physicians' working hours on patient safety.

METHOD

Integrative literature review in which we surveyed studies on restriction to physicians' working time and patient safety included in databases National Library of Medicine (PubMed) and Scientific Electronic Library Online (SciELO) until May 2018. Thirty-five studies which met the inclusion criteria were included.

RESULTS

Patient safety outcomes analyzed in the included studies were mortality, adverse events, continuity of care, in-hospital complications, readmission rate and length of stay at hospital. Restriction to working time was associated with variable impact on patient safety indicators, but often did not modify their performance.

CONCLUSION

Restrictions to physicians' working time did not always improved patient safety indicators. Focusing on interventions which only seek to limit the workload of physicians might be insufficient to bring consistent improvement to patient care.

Resident Working Hour Restrictions Increased the Workload of the Medical Emergency Team: A Retrospective Observational Study

BACKGROUND

Restrictions to residents' working hours have been shown to increase the workload of other medical resources; few studies have measured the effects on medical emergency teams (METs).

OBJECTIVES

This study evaluated how limiting residents' working hours affected the workload of MET in a pulmonology unit.

METHODS

This retrospective observational study analyzed MET activity during periods before and after we limited the working hours of residents in our pulmonary unit to 88 h/wk: Period 1, March 2014 to February 2015; and Period 2, March 2015 to February 2016. Medical emergency team activities, dose (activations/1000 admissions), intensive care unit transfers, and mortality were compared between the two periods for weekdays and for weekends and holidays.

RESULTS

There were no significant differences between the two periods in MET dose (85.0 in Period 1 versus 91.3 in Period 2, P = 0.675), intensive care unit transfers (P = 0.828), 30-day mortality (P = 0.701), and 60-day mortality (P = 0.531). However, some activities increased significantly or near significantly in Period 2, including portable echocardiography (P < 0.001), arterial line insertion (P = 0.034), mechanical ventilation (P = 0.063), and fluid therapy (P = 0.220). These increases were greater for weekends and holidays than for weekdays.

CONCLUSIONS

Since December 2017, a specific law for improving the training environment and status of residents has been implemented and applied at all hospitals in Korea. This legal restriction to working hours raises concerns regarding other medical personnel and system improvements to ensure patient safety and care continuity.

Overnight cross-coverage on hospital medicine services: perceived workload based on patient census, pager volumes, and patient acuity

OBJECTIVE

Little is understood about what contributes to perceived workload for those providing overnight coverage to hospitalized patients overnight, which limits the ability to modify these factors or to proactively identify appropriate staffing levels. The objective of this study is to understand the major contributors to perceived overnight cross-coverage workload.

METHODS

Cross-covering advanced practice providers (APPs) in a large academic hospitalist group completed the National Aeronautics and Space Administration Task Load Index (NASA-TLX) at the end of each night shift. Other shift characteristics were collected, including patient load, assigned action items, watcher/unstable patients, newly admitted patients, number of units covered, total pages, peak pager density, rapid response team (RRT) activations, and intensive care unit (ICU) transfers.

RESULTS

For 14 APP participants, who completed 271 post-shift surveys, the mean (SD) patient load was 49.9 (6.4) patients per night, and providers received a mean (SD) of 40.8 (13.7) total pages per shift. Mean (SD) NASA-TLX score was 35.1 (19.0). In multivariate modeling, total pages, action items, and any RRT or ICU transfer were associated with significant increases in the mean NASA-TLX score, with estimated effect sizes of 0.5, 0.8, and 14.3, respectively, per 1-unit increase in each shift characteristic. The greatest cumulative contributor to perceived workload was total number of pages, followed by the presence of any RRT activation/ICU transfer, with estimated effect sizes of 20.4 and 14.9, respectively.

CONCLUSIONS

Total number of pages was the greatest contributor to perceived workload. This study suggests that quality improvement initiatives designed to improve pager communication may considerably improve provider-perceived workload.

Going the extra mile - cross-border patient handover in a European border region: qualitative study of healthcare professionals' perspectives

BACKGROUND

Cross-border healthcare is complex, increasingly frequent and causes potential risks for patient safety. In this context, cross-border handovers or the transfer of patients from one country to another deserves particular attention. Although general handover has been the topic of extensive research, little is known about the challenges of handover across national borders, especially as perceived by stakeholders. In this study, we aimed to gain insight into healthcare professionals' perspectives on cross-border handover and ways to support this.

METHODS

We conducted semistructured interviews with healthcare professionals (physicians, nurses, paramedics and administrative staff) in a European border region to investigate their perspectives on cross-border handover. The interviews were aimed to investigate settings of acute and planned handover. Informed by the theory of planned behaviour (TPB), interviews focused on participant perspectives. We summarised all interviews and inductively identified healthcare professionals' perspectives. We used elements of the TPB as sensitising concepts.

RESULTS

Forty-three healthcare professionals participated. Although respondents had neutral to positive attitudes, they often did not know very well what was expected of them or what influence they could have on improving cross-border handover. Challenges covered five themes: information transfer, language barriers, task division and education, policy and financial structures and cultural differences. To overcome these challenges, we proposed strategies such as providing tools and protocols, discussing and formalising collaboration, and organising opportunities to meet and get to know each other.

CONCLUSION

Healthcare professionals involved in cross-border handovers face specific challenges. It is necessary to take measures to come to a shared understanding while paying special attention to the above-mentioned challenges. Meeting in person around meaningful activities (eg, training and case discussions) can facilitate sharing ideas and community building.

Characteristics and determinants of high-risk unscheduled return visits to the emergency department

Background

High-risk unscheduled return visits (HRURVs), defined as return visits within 72 hours that require admission or die in the emergency department (ED) on representation, are a key quality metric in the ED. The objective of this study was to determine the incidence and describe the characteristics and predictors of HRURVs to the ED.

Methods

Case–control study, conducted between 1 November 2014 and 31 October 2015. Cases included all HRURVs over the age of 18 that presented to the ED. Controls were selected from patients who were discharged from the ED during the study period and did not return in the next 72 hours. Controls were matched to cases based on gender, age (±5 years) and date of presentation.

Results

Out of 38 886 ED visits during the study period, 271 are HRURVs, giving an incidence of HRURV of 0.70% (95% CI 0.62% to 0.78%). Our final analysis includes 270 HRURV cases and 270 controls, with an in-ED mortality rate of 0.7%, intensive care unit admission of 11.1% and need for surgical intervention of 22.2%. After adjusting for other factors, HRURV cases are more likely to be discharged with a diagnosis related to digestive system or infectious disease (OR 1.64, 95% CI 1.02 to 2.65 and OR 2.81, 95% CI 1.05 to 7.51, respectively). Furthermore, presentation to the ED during off-hours is a significant predictor of HRURV (OR 1.64, 95% CI 1.11 to 2.43) as is the presence of a handover during the patient visit (OR 1.68, 95% CI 1.02 to 2.75).

Conclusion

HRURV is an important key quality outcome metric that reflects a subgroup of ED patients with specific characteristics and predictors. Efforts to reduce this HRURV rate should focus on interventions targeting patients discharged with digestive system, kidney and urinary tract and infectious diseases diagnosis as well as exploring the role of handover tools in reducing HRURVs.

Effect of Standardized Handoff Curriculum on Improved Clinician Preparedness in the Intensive Care Unit: A Stepped-Wedge Cluster Randomized Clinical Trial

Importance

Clinician miscommunication contributes to an estimated 250 000 deaths in US hospitals per year. Efforts to standardize handoff communication may reduce errors and improve patient safety.

Objective

To determine the effect of a standardized handoff curriculum, UW-IPASS, on interclinician communication and patient outcomes.

Design, Setting, and Participants

This cluster randomized stepped-wedge randomized clinical trial was conducted from October 2015 to May 2016 at 8 medical and surgical intensive care units at 2 hospital systems within an academic tertiary referral center. Participants included residents, fellows, advance-practice clinicians, and attending physicians (n = 106 clinicians, with 1488 handoff events over 8 months) and data were collected from daily text message-based surveys and patient medical records.

Exposures

The UW-IPASS standardized handoff curriculum.

Main Outcomes and Measures

The primary aim was to assess the effect of the UW-IPASS handoff curriculum on perceived adequacy of interclinician communication. Patient days of mechanical ventilation, intensive care unit length of stay, reintubations within 24 hours, and order workflow patterns were also analyzed. Mixed-effects logistic regression was used to compute odds ratios and confidence intervals with adjustment for location, time period, and clinician.

Results

A total of 63 residents and advance practice clinicians, 13 fellows, and 30 attending physicians participated in the study. During the control period, clinicians reported being unprepared for their shift because of a poor-quality handoff in 35 of 343 handoffs (10.2%), while UW-IPASS-period residents reported being unprepared in 53 of 740 handoffs (7.2%) (odds ratio, 0.19; 95% CI, 0.03-0.74; P = .03). Compared with the control phase, the perceived duration of handoffs among clinicians using UW-IPASS was unchanged (+5.5 minutes; 95% CI, 0.34-9.39; P = .30). Early morning order entry decreased from 106 per 100 patient-days in the control phase to 78 per 100 patient-days in the intervention period (-28 orders; 95% CI, -55 to -4; P = .04). Overall, UW-IPASS was not associated with any changes in intensive care unit length of stay, duration of mechanical ventilation, or the number of reintubations.

Conclusions and Relevance

The UW-IPASS standardized handoff curriculum was perceived to improve intensive care provider preparedness and workflow. IPASS-based curricula represent an important step forward in communication standardization efforts and may help reduce communication errors and omissions.

Trial Registration

isrctn.org Identifier: ISRCTN14209509.

Quality improvement of medical records through internal auditing: a comparative analysis

Introduction

The systematic evaluation of the quality of medical records is crucial. Nevertheless, even if the improvement of medical records quality represents a priority for every health organization, it might be difficult to realize.

This is the first study to assess the efficacy of internal audit as a tool to improve the quality of medical records in hospital setting.

Methods

The program was carried out in a third level teaching hospital. Trained ad hoc evaluation teams carried out two retrospective assessments of quality of medical records using a random sampling strategy. The quality assessment was performed using a 48-items evaluation grid divided into 9 domains: General; Patient Medical History and Physical Examination; Daily Clinical Progress Notes; Daily Nursing Progress Notes; Drug Therapy Chart; Pain Chart; Discharge Summary; Surgery Register; Informed Consent. After the first evaluation of 1.460 medical records, an audit departmental program was set up. The second evaluation was carried out after the internal auditing for 1.402 medical records.

Results

Compared to the first analysis, a significant quality amelioration in all the sections of the medical chart was shown with the second analysis, with an increase of all the scores above 50%. The differences found for each section of medical records between the first and second analysis are all significant (p<0.01).

Conclusions

Internal audits are not just measurement activities but a necessary activity to support the organization in achieving its objectives and assessing the quality of clinical care and maintaining high quality professional performance

Handovers Among Staff Intensivists: A Study of Information Loss and Clinical Accuracy to Anticipate Events

OBJECTIVES

Handovers are associated with medical errors, and our primary objective is to identify missed diagnosis and goals immediately after a shift handover. Our secondary objective is to assess clinicians' diagnostic accuracy in anticipating clinical events during the night shift.

DESIGN

Single-center prospective observational cohort study.

SETTING

Thirty-bed tertiary ICU in Sao Paulo, Brazil.

PATIENTS

Three-hundred fifty-two patient encounters over 44 day-to-night handovers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used a multimethods approach to measure transmission of information among staff physicians on diagnoses and goals for the night shift. We surveyed clinicians immediately after a handover and identified clinical events through chart abstractions and interviews with clinicians the next morning. Nighttime clinicians correctly identified 454 of 857 diagnoses (53%; 95% CI 50-56) and 123 of 304 goals (40%; 95% CI, 35-46). Daytime clinicians were more sensitive (65% vs 46%; p < 0.01) but less specific (82% vs 91%; p < 0.01) than nighttime clinicians in anticipating clinical events at night, resulting in similar accuracy (area under the receiver operating characteristic curve, 0.74 [95% CI, 0.68-0.79] vs 0.68 [95% CI 0.63-0.74]; p = 0.09). The positive predictive value of both daytime and nighttime clinicians was low (13% vs 17%; p = 0.2). Gaps in diagnosis and anticipation of events were more pronounced in neurologic diagnoses.

CONCLUSIONS

Among staff intensivists, diagnoses and goals of treatment are either not conveyed or retained 50-60% of the cases immediately after a handover. Clinicians have limited ability to anticipate events, and the expectation that anticipatory guidance can inform handovers needs to be balanced against information overload. Handovers among staff intensivists showed more gaps in the identification of diagnostic uncertainty and for neurologic diagnoses, which could benefit from communication strategies such as cognitive checklists, prioritizing discussion of neurologic patients, and brief combined clinical examination at handover.