Mixed methods evaluation of a specialty-specific system to promote physician engagement in safety and quality reporting in a large academic health system.

BACKGROUND: Incident reporting systems (IRS) can improve care quality and patient safety, yet their impact is limited by clinician engagement. Our objective was to assess barriers to reporting in a hospital-wide IRS and use data to inform ongoing improvement of a specialty-specific IRS embedded in the electronic health record targeting anaesthesiologists. METHODS: This quality improvement (QI) evaluation used mixed methods, including qualitative interviews, faculty surveys and user data from the specialty-specific IRS. We conducted 24 semi-structured interviews from January to May 2023 in a large academic health system in Northern California. Participants included adult and paediatric anaesthesiologists, operating room nurses, surgeons and QI operators, recruited through convenience and snowball sampling. We identified key themes and factors influencing engagement, which were classified using the Systems Engineering Initiative for Patient Safety framework. We surveyed hospital anaesthesiologists in January and May 2023, and characterised the quantity and type of reports submitted to the new system. RESULTS: Participants shared organisation and technology-related barriers to engagement in traditional system-wide IRSs, many of which the specialty-specific IRS addressed-specifically those related to technological access to the system. Barriers related to building psychological safety for those who report remain. Survey results showed that most barriers to reporting improved following the specialty-specific IRS launch, but limited time remained an ongoing barrier (25 respondents out of 44, 56.8%). A total of 964 reports with quality/safety concerns were submitted over the first 8 months of implementation; 47-76 unique anaesthesiologists engaged per month. The top safety quality categories of concern were equipment and technology (25.9%), clinical complications (25.3%) and communication and scheduling (19.9%). CONCLUSIONS: These findings suggest that a specialty-specific IRS can facilitate increased physician engagement in quality and safety reporting and complement existing system-wide IRSs.

Tigecycline as salvage treatment of febrile neutropenia in patients with haematological malignancies-a retrospective single-centre analysis of 200 cases.

Tigecycline has been used to treat patients with febrile neutropenia (FN). This study aims to analyse the effectiveness of tigecycline as salvage treatment of FN. Patients records from 09/2004 to 04/2019 were reviewed. Cases were eligible if fever persisted/recurred (p/r-FN) after 3 days of second-line treatment with a carbapenem, and were divided into three groups: switch to tigecycline (TGC group), switch to other antibiotics (OAB group), and no switch (W&W group). The primary endpoint was response rate (defervescence for ≥ 7 days or at least until discharge); the key secondary endpoint was 30-day mortality rate. Two hundred cases from 176 patients (median 59 years; 53.5% men) treated were included, mostly acute myeloid leukaemias (61.0%). 45.5% of cases were in the TGC group (in combination with an anti-pseudomonal antibiotic, mostly ceftazidime [95.6%]); 35.5% were in the OAB and 19.0% in the W&W group. There was no significant difference in response rates (TGC, 73.6%; OAB, 62.0%; W&W, 78.9%; p = 0.12) or 30-day mortality rates (TGC, 7.7%; OAB, 7.0%; W&W, 5.3%; p = 0.94). Tigecycline plus an anti-pseudomonal antibiotic does not improve response or 30-day mortality rate compared to other antibiotics in patients with p/r-FN. Also, in some cases, no switch in antibiotics may be necessary at all.

Rate of occurrence of respiratory complications in patients who undergo shoulder arthroplasty with a continuous interscalene brachial plexus block and associated risk factors.

INTRODUCTION: Continuous interscalene nerve block techniques are an effective form of targeted non-opioid postoperative analgesia for shoulder arthroplasty patients. One of the limiting risks, however, is potential phrenic nerve blockade with resulting hemidiaphragmatic paresis and respiratory compromise. While studies have focused on block-related technical aspects to limit the incidence of phrenic nerve palsy, little is known about other factors associated with increased risk of clinical respiratory complications in this population. METHODS: A single-institution retrospective cohort study was conducted using electronic health records from adult patients who underwent elective shoulder arthroplasty with continuous interscalene brachial plexus blocks (CISB). Data collected included patient, nerve block, and surgery characteristics. Respiratory complications were categorized into four groups (none, mild, moderate, and severe). Univariate and multivariable analyses were conducted. RESULTS: Among 1025 adult shoulder arthroplasty cases, 351 (34%) experienced any respiratory complication. These 351 were subdivided into 279 (27%) mild, 61 (6%) moderate, and 11 (1%) severe respiratory complications. In an adjusted analysis, patient-related factors were associated with an increased likelihood of respiratory complication: ASA Physical Status III (OR 1.69, 95% CI 1.21 to 2.36); asthma (OR 1.59, 95% CI 1.07 to 2.37); congestive heart failure (OR 1.99, 95% CI 1.19 to 3.33); body mass index (OR 1.06, 95% CI 1.03 to 1.09); age (OR 1.02, 95% CI 1.00 to 1.04); and preoperative oxygen saturation (SpO2). For every 1% decrease in preoperative SpO2, there was an associated 32% higher likelihood of a respiratory complication (OR 1.32, 95% CI 1.20 to 1.46, p<0.001). CONCLUSIONS: Patient-related factors that can be measured preoperatively are associated with increased likelihood of respiratory complications after elective shoulder arthroplasty with CISB.

Low skeletal muscle mass is a predictor of treatment related toxicity in oncologic patients. A meta-analysis.

BACKGROUND & AIMS: The purpose of this meta-analysis was to summarize the published data regarding associations between occurrence of severe treatment related toxicity and low skeletal muscle mass (LSMM) in oncologic patients and to perform a meta-analysis based on a large sample. METHODS: MEDLINE, Cochrane, and SCOPUS databases were screened for associations between LSMM and treatment related toxicity in oncologic patients up to June 2021. Overall, 48 studies met the inclusion criteria. The following data were extracted: authors, year of publication, study design, number of patients, influence of LSMM on treatment toxicity (odds ratios and confidence intervals). The methodological quality of the involved studies was checked according to the QUADAS instrument. The meta-analysis was undertaken by using RevMan 5.4 software. DerSimonian and Laird random-effects models with inverse-variance weights were used to account for the heterogeneity between the studies. RESULTS: The included 48 studies comprised 4803 patients with different malignant diseases. LSMM occurred in 1966 patients (40.9%). LSMM was associated with therapy toxicity (simple logistic regression) with an odds ratio OR = 2.19, CI95%= (1.78-2.68). LSMM was associated with DLT in patients underwent curative treatment (16 studies, 2381 patients) with OR = 2.48, CI95%= (1.77-3.48). LSMM predicted DLT in patients underwent palliative chemotherapy (30 studies, 2337 patients)with OR = 2.06, CI95%= (1.56-2.74). In the subgroups received different palliative therapies, relationships between LSMM and DLT were as follows: conventional chemotherapies (7 studies, 600 patients) OR = 2.14, CI95%= (1.38-3.31); different kinases inhibitors (13 studies, 906 patients) OR = 3.08, CI95%= (1.87-5.09); checkpoint inhibitors (7 studies, 557 patients) OR = 1.30, CI95%= (0.79-2.11). CONCLUSIONS: LSMM is an essential factor of treatment toxicity in oncologic patients. Association between LSMM and DLT is strongest in patients received therapy with kinases inhibitors. The influence of LSMM on DLT is lowest in patients underwent treatment with checkpoint inhibitors. The presence of LSMM should be included into radiological reports and provided to oncologists to optimize chemotherapy. LSMM should be included into dose calculation for chemotherapy.

Automated text messaging follow-up for patients who receive peripheral nerve blocks.

BACKGROUND: Routine follow-up of patients who receive a nerve block for ambulatory surgery typically consists of a phone call from a regional anesthesia clinician. This process can be burdensome for both patients and clinicians but is necessary to assess the efficacy and complication rate of nerve blocks. METHODS: We present our experience developing an automated system for completing follow-up via short message service text messaging and our preliminary results using it at three clinical sites. The system is built on REDCap, a secure online research data capture platform developed by Vanderbilt University and currently available worldwide. RESULTS: Our automated system queried patients who received a variety of nerve block techniques, assessed patient-reported nerve block duration, and surveyed patients for potential complications. Patient response rate to text messaging averaged 91% (higher than our rates of daily phone contact reported previously) for patients aged 18 to 90 years. CONCLUSIONS: Given the wide availability of REDCap, we believe this automated text messaging system can be implemented in a variety of health systems at low cost with minimal technical expertise and will improve both the consistency of patient follow-up and the service efficiency of regional anesthesia practices.

Pain management in the orthopaedic trauma patient: Non-opioid solutions.

When treating pain in the orthopaedic trauma patient opioids have classically represented the mainstay of treatment. They are relatively inexpensive and modestly effective for basic pain management. However, they are fraught with considerable side effects as well as the very high risk of addiction. Their use in pain management has been implicated in the opioid epidemic. For this reason, as well as their only moderate efficacy, alternative modes of treatment have been sought for both the patient with isolated limb trauma and the patient with poly trauma. We review alternative treatment methods in pain management for those with isolated limb trauma and poly trauma. These methods include topical agents, as well as non steroidal anti-inflammatory medications, acetaminophen, gabapetoids, intravenous agents, varying degrees of local anesthetic infiltration and peripheral nerve blocks, and the newer modality of fascial plane blocks. Often, it is a combination of these analgesic modalities that gives the most optimum treatment for the trauma patient. This also, more frequently than not, must be individually tailored to the patient, as no two patients act the same in this regard. It is therefore of importance that the physician managing such patients's pain be experienced and well-versed in all these treatment modalities. We also provide a basic stepwise algorithm we have found useful in treating those with single extremity or single site trauma versus those patients with poly trauma and resultant multiple sources as pain generators. It is hoped that this breakdown of the different modalities along with a better understanding of each modality's potential benefits and indications will aid the surgeon in providing better care to patients following orthopedic trauma.

Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach.

BACKGROUND: The Agency for Healthcare Research and Quality has adopted iatrogenic pneumothorax (IAP) as a Patient Safety Indicator. In 2006, in response to a low performance ranking for IAP rate from the University Healthsystem Consortium (UHC), the authors established a multidisciplinary team to reduce our institution's IAP rate. Root-cause analysis found that subclavian insertion of central venous catheterization (CVC) was the most common procedure associated with IAP OBJECTIVE: Our short-term goal was a 50% reduction of both CVC-associated and all-cause IAP rates within 18 months, with long-term goals of sustained reduction. DESIGN: Observational study. SETTING: Academic tertiary care hospital. PATIENTS: Consecutive inpatients from 2006 to 2014. INTERVENTION: Our multifaceted intervention included: (1) clinical and documentation standards based on evidence, (2) cognitive aids, (3) simulation training, (4) purchase and deployment of ultrasound equipment, and (5) feedback to clinical services. MEASUREMENTS: CVC-associated IAP, all-cause IAP rate. RESULTS: We achieved both a short-term (years 2006 to 2008) and long-term (years 2006 to 2008-2014) reduction in our CVC-associated and all-cause IAP rates. Our short-term reduction in our CVC-associated IAP was 53% (P = 0.088), and our long-term reduction was 85% (P < 0.0001). Our short-term reduction in the all-cause IAP rate was 26% (P < 0.0001), and our long-term reduction was 61% (P < 0.0001). CONCLUSIONS: A multidisciplinary team, focused on evidence, patient safety, and standardization, can use a set of multifaceted interventions to sustainably improve patient outcomes for several years after implementation. Our hospital was in the highest performance UHC quartile for all-cause IAP in 2012 to 2014.

Cost and turn-around time display decreases inpatient ordering of reference laboratory tests: a time series.

OBJECTIVE: Reference tests, also known as send-out tests, are commonly ordered laboratory tests with variable costs and turn-around times. We aim to examine the effects of displaying reference laboratory costs and turn-around times during computerised physician order entry (CPOE) on inpatient physician ordering behaviour. DESIGN: We conducted a prospective observational study at a tertiary care hospital involving inpatient attending physicians and residents. Physician ordering behaviour was prospectively observed between September 2010 and December 2012. An intervention was implemented to display cost and turn-around time for reference tests within our CPOE. We examined changes in the mean number of monthly physician orders per inpatient day at risk, the mean cost per order, and the average turn-around time per order. RESULTS: After our intervention, the mean number of monthly physician orders per inpatient day at risk decreased by 26% (51 vs 38, p<0.0001) with a decrease in mean cost per order (US$146.50 vs US$134.20, p=0.0004). There were no significant differences in mean turn-around time per order (5.6 vs 5.7 days, p=0.057). A stratified analysis of both cost and turn-around time showed significant decreases in physician ordering. The intervention projected a mean annual savings of US$330 439. Reference test cost and turn-around time variables were poorly correlated (r=0.2). These findings occurred in the setting of non-significant change to physician ordering in a control cohort of non-reference laboratory tests. CONCLUSIONS: Display of reference laboratory cost and turn-around time data during real-time ordering may result in significant decreases in ordering of reference laboratory tests with subsequent cost savings.