Surgery and Anesthesia Preoperative "Virtual Huddle": A Pilot Trial to Enhance Communication across the Drape

OBJECTIVES

 Effective communication between surgeons and anesthesiologists is critical for high-quality, safe, and efficient perioperative patient care. Despite widespread implementation of surgical safety checklists and time-outs, ineffective team communication remains a leading cause of patient safety events in the operating room. To promote effective communication, we conducted a pilot trial of a "virtual huddle" between anesthesiologists and surgeons.

METHODS

 Attending anesthesiologists and surgeons at an academic medical center were recruited by email to participate in this feasibility trial. An electronic health record-based smartphone application was utilized to create secure group chats among trial participants the day before a surgery. Text notifications connected a surgeon/anesthesiologist pair in order to introduce colleagues, facilitate a preoperative virtual huddle, and enable open-ended, text message-based communication. A 5-point Likert scale-based survey with a free-text component was used to evaluate the utility of the virtual huddle and usability of the electronic platform.

RESULTS

 A total of 51 unique virtual huddles occurred between 16 surgeons and 12 anesthesiologists over 99 operations. All postintervention survey questions received a positive rating (range: 3.50/5.00-4.53/5.00) and the virtual huddle was considered to be easy to use (4.47/5.00), improve attending-to-attending communication (4.29/5.00), and improve patient care (4.22/5.00). There were no statistically significant differences in the ratings between surgery and anesthesia. In thematic analysis of qualitative survey results, Participants indicated the intervention was particularly useful in interdisciplinary relationship-building and reducing room turnover. The huddle was less useful for simple, routine cases or when participation was one sided.

CONCLUSION

 A preoperative virtual huddle may be a simple and effective intervention to improve communication and teamwork in the operating room. Further study and consideration of broader implementation is warranted.

Surgical pit crew: initiative to optimise measurement and accountability for operating room turnover time

BACKGROUND AND OBJECTIVES

Turnover time (TOT), defined as the time between surgical cases in the same operating room (OR), is often perceived to be lengthy without clear cause. With the aim of optimising and standardising OR turnover processes and decreasing TOT, we developed an innovative and staff-interactive TOT measurement method.

METHODS

We divided TOT into task-based segments and created buttons on the electronic health record (EHR) default prelogin screen for appropriate staff workflows to collect more granular data. We created submeasures, including 'clean-up start', 'clean-up complete', 'set-up start' and 'room ready for patient', to calculate environmental services (EVS) response time, EVS cleaning time, room set-up response time, room set-up time and time to room accordingly.

RESULTS

Since developing and implementing these workflows, measures have demonstrated excellent staff adoption. Median times of EVS response and cleaning have decreased significantly at our main hospital ORs and ambulatory surgery centre.

CONCLUSION

OR delays are costly to hospital systems. TOT, in particular, has been recognised as a potential dissatisfier and cause of delay in the perioperative environment. Viewing TOT as one finite entity and not a series of necessary tasks by a variety of team members limits the possibility of critical assessment and improvement. By dividing the measurement of TOT into respective segments necessary to transition the room at the completion of one case to the onset of another, valuable insight was gained into the causes associated with turnover delays, which increased awareness and improved accountability of staff members to complete assigned tasks efficiently.

Ransomware Attack Associated With Disruptions at Adjacent Emergency Departments in the US

Importance

Cyberattacks on health care delivery organizations are increasing in frequency and sophistication. Ransomware infections have been associated with significant operational disruption, but data describing regional associations of these cyberattacks with neighboring hospitals have not been previously reported, to our knowledge.

Objective

To examine an institution's emergency department (ED) patient volume and stroke care metrics during a month-long ransomware attack on a geographically proximal but separate health care delivery organization.

Design, Setting, and Participants

This before and after cohort study compares adult and pediatric patient volume and stroke care metrics of 2 US urban academic EDs in the 4 weeks prior to the ransomware attack on May 1, 2021 (April 3-30, 2021), as well as during the attack and recovery (May 1-28, 2021) and 4 weeks after the attack and recovery (May 29 to June 25, 2021). The 2 EDs had a combined mean annual census of more than 70 000 care encounters and 11% of San Diego County's total acute inpatient discharges. The health care delivery organization targeted by the ransomware constitutes approximately 25% of the regional inpatient discharges.

Exposure

A month-long ransomware cyberattack on 4 adjacent hospitals.

Main Outcomes and Measures

Emergency department encounter volumes (census), temporal throughput, regional diversion of emergency medical services (EMS), and stroke care metrics.

Results

This study evaluated 19 857 ED visits at the unaffected ED: 6114 (mean [SD] age, 49.6 [19.3] years; 2931 [47.9%] female patients; 1663 [27.2%] Hispanic, 677 [11.1%] non-Hispanic Black, and 2678 [43.8%] non-Hispanic White patients) in the preattack phase, 7039 (mean [SD] age, 49.8 [19.5] years; 3377 [48.0%] female patients; 1840 [26.1%] Hispanic, 778 [11.1%] non-Hispanic Black, and 3168 [45.0%] non-Hispanic White patients) in the attack and recovery phase, and 6704 (mean [SD] age, 48.8 [19.6] years; 3326 [49.5%] female patients; 1753 [26.1%] Hispanic, 725 [10.8%] non-Hispanic Black, and 3012 [44.9%] non-Hispanic White patients) in the postattack phase. Compared with the preattack phase, during the attack phase, there were significant associated increases in the daily mean (SD) ED census (218.4 [18.9] vs 251.4 [35.2]; P < .001), EMS arrivals (1741 [28.8] vs 2354 [33.7]; P < .001), admissions (1614 [26.4] vs 1722 [24.5]; P = .01), patients leaving without being seen (158 [2.6] vs 360 [5.1]; P < .001), and patients leaving against medical advice (107 [1.8] vs 161 [2.3]; P = .03). There were also significant associated increases during the attack phase compared with the preattack phase in median waiting room times (21 minutes [IQR, 7-62 minutes] vs 31 minutes [IQR, 9-89 minutes]; P < .001) and total ED length of stay for admitted patients (614 minutes [IQR, 424-1093 minutes] vs 822 minutes [IQR, 497-1524 minutes]; P < .001). There was also a significant increase in stroke code activations during the attack phase compared with the preattack phase (59 vs 102; P = .01) as well as confirmed strokes (22 vs 47; P = .02).

Conclusions and Relevance

This study found that hospitals adjacent to health care delivery organizations affected by ransomware attacks may see increases in patient census and may experience resource constraints affecting time-sensitive care for conditions such as acute stroke. These findings suggest that targeted hospital cyberattacks may be associated with disruptions of health care delivery at nontargeted hospitals within a community and should be considered a regional disaster.

A Novel Fellowship in Perioperative Administration, Quality and Informatics: A Pilot Experience for Training Surgical Leaders

Value-based, outcome-oriented care supported with innovative technology is the future of surgery. We established a novel fellowship in Perioperative Administration, Quality, and Informatics. The aim is to equip future surgeon scholars with the requisite knowledge base and skillset to serve as institutional leaders capable of transforming surgical healthcare delivery. The model was designed as a project-based, "operations-focused" education with supplemental didactics and mentored by surgical leaders and institutional executives. We describe our initial experience, successes, and challenges such that a similar model may be replicated elsewhere.

The Clinical Information Systems Response to the COVID-19 Pandemic

OBJECTIVE

The year 2020 was predominated by the coronavirus disease 2019 (COVID-19) pandemic. The objective of this article is to review the areas in which clinical information systems (CIS) can be and have been utilized to support and enhance the response of healthcare systems to pandemics, focusing on COVID-19.

METHODS

PubMed/MEDLINE, Google Scholar, the tables of contents of major informatics journals, and the bibliographies of articles were searched for studies pertaining to CIS, pandemics, and COVID-19 through October 2020. The most informative and detailed studies were highlighted, while many others were referenced.

RESULTS

CIS were heavily relied upon by health systems and governmental agencies worldwide in response to COVID-19. Technology-based screening tools were developed to assist rapid case identification and appropriate triaging. Clinical care was supported by utilizing the electronic health record (EHR) to onboard frontline providers to new protocols, offer clinical decision support, and improve systems for diagnostic testing. Telehealth became the most rapidly adopted medical trend in recent history and an essential strategy for allowing safe and effective access to medical care. Artificial intelligence and machine learning algorithms were developed to enhance screening, diagnostic imaging, and predictive analytics - though evidence of improved outcomes remains limited. Geographic information systems and big data enabled real-time dashboards vital for epidemic monitoring, hospital preparedness strategies, and health policy decision making. Digital contact tracing systems were implemented to assist a labor-intensive task with the aim of curbing transmission. Large scale data sharing, effective health information exchange, and interoperability of EHRs remain challenges for the informatics community with immense clinical and academic potential. CIS must be used in combination with engaged stakeholders and operational change management in order to meaningfully improve patient outcomes.

CONCLUSION

Managing a pandemic requires widespread, timely, and effective distribution of reliable information. In the past year, CIS and informaticists made prominent and influential contributions in the global response to the COVID-19 pandemic.

Rapid response to COVID-19: health informatics support for outbreak management in an academic health system

OBJECTIVE

To describe the implementation of technological support important for optimizing clinical management of the COVID-19 pandemic.

MATERIALS AND METHODS

Our health system has confirmed prior and current cases of COVID-19. An Incident Command Center was established early in the crisis and helped identify electronic health record (EHR)-based tools to support clinical care.

RESULTS

We outline the design and implementation of EHR-based rapid screening processes, laboratory testing, clinical decision support, reporting tools, and patient-facing technology related to COVID-19.

DISCUSSION

The EHR is a useful tool to enable rapid deployment of standardized processes. UC San Diego Health built multiple COVID-19-specific tools to support outbreak management, including scripted triaging, electronic check-in, standard ordering and documentation, secure messaging, real-time data analytics, and telemedicine capabilities. Challenges included the need to frequently adjust build to meet rapidly evolving requirements, communication, and adoption, and to coordinate the needs of multiple stakeholders while maintaining high-quality, prepandemic medical care.

CONCLUSION

The EHR is an essential tool in supporting the clinical needs of a health system managing the COVID-19 pandemic.

Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting

BACKGROUND

The status of implementation of medication reconciliation across hospitals is variable to date; the degree to which hospitalists are involved is not known.

METHODS

To better describe the current state of medication reconciliation implementation, we conducted a survey of attendees of the 2006 Society of Hospital Medicine national meeting.

RESULTS

We identified a lack of uniformity across hospitals with respect to the degree of process implementation. Hospitalists were involved in design and implementation in a majority of cases, and felt that medication reconciliation would likely have a positive impact on patient safety. Tertiary care academic centers were more likely to use physicians to perform medication reconciliation, whereas community hospitals were more likely to involve nurses as well. Pharmacist participation in the medication reconciliation process was found to be quite low. Process and outcome measures were used infrequently. Patients' lack of medication knowledge and absence of preadmission medication information were cited most frequently as barriers to implementation of medication reconciliation.

CONCLUSIONS

Implementation of medication reconciliation is complex and challenging. Medication information is often incomplete, and elements of the medication reconciliation process result in increased time demands on providers. Current implementation efforts often have physicians and nurses "share" responsibility for compliance, and pharmacists are underutilized in medication reconciliation processes. Hospitalists have thus far played a substantial role in process design and implementation, and should continue to lead the way in advancing efforts to successfully implement medication reconciliation.