General improvements versus interruptive or non-interruptive alerts in the blood order set: study protocol for a randomized control trial to improve packed red blood cell utilization.

BACKGROUND: Blood transfusions can serve as a life-saving treatment, but inappropriate blood product transfusions can result in patient harm and excess costs for health systems. Despite published evidence supporting restricted packed red blood cell (pRBC) usage, many providers transfuse outside of guidelines. Here, we report a novel prospective, randomized control trial to increase guideline-concordant pRBC transfusions comparing three variations of clinical decision support (CDS) in the electronic health record (EHR). METHODS: All inpatient providers at University of Colorado Hospital (UCH) who order blood transfusions were randomized in a 1:1:1 fashion to the three arms of the study: (1) general order set improvements, (2) general order set improvements plus non-interruptive in-line help text alert, and (3) general order set improvements plus interruptive alert. Transfusing providers received the same randomized order set changes for 18 months. The primary outcome of this study is the guideline-concordant rate of pRBC transfusions. The primary objective of this study is to compare the group using the new interface (arm 1) versus the two groups using the new interface with interruptive or non-interruptive alerts (arms 2 and 3, combined). The secondary objectives compare guideline-concordant transfusion rates between arm 2 and arm 3 as well as comparing all of arms of the study in aggregate to historical controls. This trial concluded after 12 months on April 5, 2022. DISCUSSION: CDS tools can increase guideline-concordant behavior. This trial will examine three different CDS tools to determine which type is most effective at increasing guideline-concordant blood transfusions. TRIAL REGISTRATION: Registered on ClinicalTrials.gov 3/20/21, NCT04823273 . Approved by University of Colorado Institutional Review Board (19-0918), protocol version 1 4/19/2019, approved 4/30/2019.

Promoting appropriate midline catheter and PICC placement through implementation of an EHR-based clinical decision support tool: An interrupted time-series analysis.

BACKGROUND: Inappropriate use of peripherally inserted central catheters (PICCs), including multilumen PICCs, may increase the risk of patient complications. OBJECTIVE: Implement computerized decision support to: (a) increase the use of midline catheters over PICCs when appropriate and (b) decrease PICC lumens when a PICC is necessary. DESIGNS: Quasi-experimental, interrupted time series. SETTING: Single tertiary academic medical center. PATIENTS: Hospitalized adults who received a midline or PICC during clinical care. INTERVENTION: Decision support on appropriate vascular access device choice via a set of electronic orders embedded within the electronic health record. MEASUREMENTS: Proportion of midline catheter and single-lumen PICCs placed between January 2, 2017 and November 19, 2017 (preintervention) versus November 20, 2017 to December 1, 2019 (postintervention). RESULTS: A total of 8758 midline and PICCs were inserted during the study period. A statistically significant increase in the insertion of midline catheters was observed during the intervention (p = .006). In parallel, single-lumen PICC insertion as a proportion of all PICCs also increased after the intervention (p = .035). Results were consistent across multiple disciplines, including internal medicine, surgery, and intensive care. After considering the hospital census, total PICC and midline utilization rates and rates of complications did not change over time. However, an increase in catheter exchanges from less to more invasive devices occurred. CONCLUSIONS: In this single-center study, the implementation of electronic decision support to inform appropriate catheter use led to a more appropriate midline catheter and single-lumen PICC insertion. Dissemination of this single, effective intervention to examine efficacy in other hospital settings would be welcomed.

User-Centered Design to Reduce Inappropriate Blood Transfusion Orders.

BACKGROUND: To improve blood transfusion practices, we applied user-centered design (UCD) to evaluate potential changes to blood transfusion orders. OBJECTIVES: The aim of the study is to build effective transfusion orders with different designs to improve guideline adherence. METHODS: We developed three different versions of transfusion orders that varied how information was presented to clinicians ordering blood transfusions. We engaged 14 clinicians (residents, advanced practice providers [APPs], and attending physicians) from different specialties. We used the think aloud technique and rapid qualitative analysis to generate themes to incorporate into our modified orders. RESULTS: Most end-users who participated in the semi-structured interviews preferred the interruptive alert design plus behavioral nudges (n = 8/14, 57%). The predominant rationale was that the in-line alert was not visually effective in capturing the end-user's attention, while the interruptive alert forced a brief stop in the workflow to consider the guidelines. All users supported the general improvements, though for different reasons, and as a result, the general improvements remained in the designs for the forthcoming trial. CONCLUSION: The user experience uncovered through the think aloud approach produced a clear and rich understanding of potentially confounding factors in the initial design of different intervention versions. Input from end-users guided the creation of all three designs so each was addressing human factors with parity, which ensured that the results of our study reflected differences in interruptive properties of the alerts and not differences in design.

Dig Deeper: A Case Report of Finding (and Fixing) the Root Cause of Add-On Laboratory Failures.

BACKGROUND: Venipunctures and the testing they facilitate are clinically necessary, particularly for hospitalized patients. However, excess venipunctures lead to patient harm, decreased patient satisfaction, and waste. OBJECTIVES: We sought to identify contributors to excess venipunctures at our institution, focusing on electronic health record (EHR)-related factors. We then implemented and evaluated the impact of an intervention targeting one of the contributing factors. METHODS: We employed the quality improvement (QI) methodology to find sources of excess venipunctures, specifically targeting add-on failures. Once an error was identified, we deployed an EHR-based intervention which was evaluated with retrospective pre- and postintervention analysis. RESULTS: We identified an error in how the EHR evaluated the ability of laboratories across a health system to perform add-on tests to existing blood specimens. A review of 195,263 add-on orders placed prior to the intervention showed that 165,118 were successful and 30,145 failed, a failure rate of 15.4% (95% confidence interval [CI]: 15.1-15.6). We implemented an EHR-based modification that changed the criteria for add-on testing from a health-system-wide query of laboratory capabilities to one that incorporated only the capabilities of laboratories with feasible access to existing patient samples. In the 6 months following the intervention, a review of 87,333 add-on orders showed that 77,310 were successful, and 10,023 add-on orders failed resulting in a postintervention failure rate of 11.4% (95% CI: 11.1, 11.8) (p < 0.001). CONCLUSION: EHR features such as the ability to identify possible add-on tests are designed to reduce venipunctures but may produce unforeseen negative effects on downstream processes, particularly as hospitals merge into health systems using a single EHR. This case report describes the successful identification and correction of one cause of add-on laboratory failures. QI methodology can yield important insights that reveal simple interventions for improvement.

A Novel Hospital Medicine Training Track for Internal Medicine Residents: Description and Program Evaluation of the First 15 Years.

Background: The growth of hospital medicine has resulted in a parallel growth of hospital medicine training within internal medicine residency programs (IMRPs), but the experience and outcomes of these training offerings have not yet been described. Objective: To describe the first dedicated hospitalist track and the program evaluation data. Methods: The University of Colorado Hospitalist Training Track (HTT) is a 3-year track within the IMRP with robust inpatient clinical training, specialized didactics, experiential improvement work, and career mentorship. We collected data on graduates' current practices and board certification pass rates. To further evaluate the track, we electronically sent a cross-sectional survey to 124 graduates from 2005 to 2019 to identify current practice settings, graduate roles, and assessment of the training track. Results: Among 124 graduates, 97 (78.2%) practice hospital medicine, and the board certification pass rate was slightly higher than the overall IMRP pass rate for those graduating classes. Sixty-two (50%) graduates responded to the survey. Among respondents, 50 (80.6%) currently practice hospital medicine and 34 (54.8%) practice in an academic setting. The majority (50, 80.6%) hold leadership roles and are involved in a variety of scholarship, educational, and operational projects. Dedicated clinical training, didactics, and mentorship were valued by respondents. Conclusions: This represents the first description and program evaluation of a HTT for IM residents. A dedicated HTT produces graduates who choose hospital medicine careers at high rates and participate in a wide variety of leadership and nonclinical roles.

A Systems-Based Morbidity and Mortality Conference Was Associated With a Transient Reduction in ECG Completion Times.

BACKGROUND AND OBJECTIVES: During its monthly morbidity and mortality conference (MMC), the University of Colorado Division of Cardiology reviewed a "near-miss" patient safety event involving the delayed completion of a Stat-priority (ie, statim, meaning high priority) electrocardiogram (ECG). Because critical and interprofessional stakeholders participated in the conference, we hypothesized that the MMC would be associated with reduced ECG completion times. METHODS: Data were collected for in-hospital ECGs performed at the University of Colorado Hospital between January 1, 2017, and June 30, 2018. An interrupted time series analysis was used to estimate the immediate and ongoing impact of the MMC (held on February 28, 2018) on ECG completion times, stratified by order priority (Stat, Now, or Routine). The percentage of delayed Stat-priority ECGs was analyzed as a secondary outcome. RESULTS: Before the MMC, ECG completion times were stable for all order priorities ( P > .2), but the proportion of delayed Stat-priority ECGs increased from 5% in January 2017 to 20% in February 2018 ( P < .01). The MMC was associated with an immediate reduction in average daily ECG completion times for Routine (-18.4 minutes, P = .03) and Now (-8 minutes, P = .024) priority ECGs. No reduction was seen for Stat ECGs ( P = .97), though the percentage of delayed Stat ECGs stopped increasing ( P = .63). In the post-MMC period, completion times for Routine-priority ECGs increased and approached pre-MMC levels. CONCLUSIONS: The MMC was associated with an immediate, but temporary, improvement in ECG completion times. Although the observed clinical benefit of the MMC is novel, these data support the need for more durable reforms to sustain initial improvements.

Advancing Diversity, Equity, and Inclusion in Hospital Medicine.

BACKGROUND: In nearly all areas of academic medicine, disparities still exist for women and underrepresented minorities (URMs). OBJECTIVES: Develop a strategic plan for advancing diversity, equity, and inclusion (DEI); implement and evaluate the plan, specifically focusing on compensation, recruitment, and policies. DESIGN, SETTING, PARTICIPANTS: Programmatic evaluation conducted in the division of hospital medicine (DHM) at a major academic medical center involving DHM faculty and staff. MEASUREMENTS: (1) Development and implementation of strategic plan, including policies, processes, and practices related to key components of DEI program; (2) assessment of specific DEI outcomes, including plan implementation, pre-post salary data disparities based on academic rank, and pre-post disparities for protected time for similar roles. RESULTS: Using information gathered from a focus group with DHM faculty, an iterative strategic plan for DEI was developed and deployed, with key components of focus being institutional structures, our people, our environments, and our core mission areas. A director of DEI was established to help oversee these efforts. Using a two-phase approach, salary disparities by rank were eliminated. Internally funded protected time was standardized for leadership roles. A data dashboard has been developed to track high-level successes and areas for future focus. CONCLUSION: Using a systematic evidence-based approach with key stakeholder involvement, a division-wide DEI strategy was developed and implemented. While this work is ongoing, short-term wins are possible, in particular around salary equity and development of policies and structures to promote DEI.

Teaching Students to Transform: The Health Innovations Scholars Program 6 Years Later.

Training in leadership and health system transformation is increasingly important in undergraduate medical education in order to develop a pipeline of engaged physicians dedicated to transforming health care. Despite this growing need, it is unclear whether current leadership training methods have long-term impact on students' career trajectory. The authors analyzed career outcomes from 6 years of the Health Innovations Scholars Program (HISP) to better understand how the program affected the 46 graduates' future involvement in health system transformation and leadership. Eighty-eight percent of the graduates remained involved in quality improvement, 70% held leadership positions, 31% participated in health innovation, and 15% participated in patient safety initiatives. Project involvement of the graduates represented both primary and secondary catalysts for health system change, leading to 28 unique catalyst events. HISP is a model for directing trainees' career trajectory toward engagement in health system leadership and redesign.

Ambulatory Clinician's Guide to Inpatient Service: An Innovative Rapid Onboarding Strategy for the COVID-19 Pandemic.

BACKGROUND AND SIGNIFICANCE: When hospitals are subject to prolonged surges in patients, such as during the coronavirus disease 2019 (COVID-19) pandemic, additional clinicians may be needed to care for the rapid increase of acutely ill patients. How might we quickly prepare a large number of ambulatory-based clinicians to care for hospitalized patients using the inpatient workflow of the electronic health record (EHR)? OBJECTIVES: The aim of the study is to create a successful training intervention which prepares ambulatory-based clinicians as they transition to inpatient services. METHODS: We created a training guide with embedded videos that describes the workflow of an inpatient clinician. We delivered this intervention via an e-mail hyperlink, a static hyperlink inside of the EHR, and an on-demand hyperlink within the EHR. RESULTS: In anticipation of the first peak of inpatients with COVID-19 in April 2020, the training manual was accessed 261 times by 167 unique users as clinicians anticipated being called into service. As our institution has not yet needed to deploy ambulatory-based clinicians for inpatient service, usage data of the training document is still pending. CONCLUSION: We intend that our novel implementation of a multimedia, highly accessible onboarding document with access from points inside and outside of the EHR will improve clinician performance and serve as a helpful example to other organizations during the COVID-19 pandemic and beyond.

Expanding Training in Quality Improvement and Patient Safety Through a Multispecialty Graduate Medical Education Curriculum Designed for Fellows.

Introduction: Although the Accreditation Council for Graduate Medical Education requires quality improvement and patient safety (QIPS) training for fellow-level trainees, this experience is often insufficient due to lack of faculty time and expertise within fellowship training programs. We developed a centralized GME curriculum targeted to an integrated, multispecialty audience of fellow-level trainees with the goal of promoting leadership and scholarship in QIPS. Methods: The University of Colorado implemented the Fellows' Quality and Safety Academy, a three-seminar curriculum in patient safety and health systems improvement. As most participants had prior training in QIPS during medical school or residency, educational strategies emphasized application of QIPS concepts through focused didactic content review paired with small-group case-based exercises and coaching of experiential project work to promote content mastery as well as practice of leadership and scholarship strategies. Results: Since the curriculum's inception in 2017, there have been 106 participants in the Foundations in Patient Safety seminar, 49 participants in the Adverse Events Into Quality Improvement seminar, and 48 participants in the Quality in Academics seminar. These participants represented 44 separate fellowship disciplines from both adult and pediatric subspecialties. Learners reported improved attitudes and confidence and demonstrated objective knowledge acquisition across QIPS content domains. Discussion: Our pedagogical approach of centralizing QIPS training and harnessing faculty expertise to teach fellow-level trainees across specialties through interdisciplinary collaboration and interactive project-based work is an effective strategy to promote development of QIPS competencies during fellowship training.

Biomechanical evaluation of shear force vectors leading to injury of the biceps reflection pulley: a biplane fluoroscopy study on cadaveric shoulders.

BACKGROUND: The clinical importance of the biceps reflection pulley (BRP), which stabilizes the long head of the biceps tendon (LHB) as it exits the joint, has been shown. However, there is controversy on the pathomechanism of injury to the BRP. The angular orientation of the LHB relative to its origin and distal course changes with joint positions and may place the BRP at risk for injury. PURPOSE: To measure the course of the LHB in common arm positions and to determine the shear and normal (stabilizing) force vectors as well as the excursion of the LHB. STUDY DESIGN: Descriptive laboratory study. METHODS: The LHBs of 8 fresh-frozen cadaveric shoulders were marked with arthroscopically injected microbeads and mounted in a custom-built shoulder rig. Data for neutral arm position, forward flexion, and abduction were collected in internal, neutral, and external rotation using biplane fluoroscopy. Bone and LHB position were reconstructed in 3 dimensions. RESULTS: The shear component of the resulting vector was significantly higher during internal (28.4% +/- 18.1%) compared with external rotation (18.9% +/- 9.7%; P = .0157) and was highest in neutral arm position with internal rotation (39.2% +/- 12.7%) and forward flexion with neutral rotation (36.2% +/- 10.7%). The normal force vector, stabilizing the LHB, was significantly higher in abduction (55.2% +/- 9.6%) compared with forward flexion (39.1% +/- 12.4%; P <.0001) and neutral positions (39.1% +/- 11.4%; P <.0001). The LHB excursion was significantly lower for neutral arm positions (0.7 +/- 6.0 mm) compared with forward flexion (12.6 +/- 8.3 mm; P <.0001) and abduction (12.0 +/- 6.5 mm; P <.0001). CONCLUSION: Increased shear load at forward flexion with internal or neutral arm rotation and internal rotation at neutral arm position may cause injury to the BRP. Additionally, a sawing mechanism caused by the 12-mm linear excursion combined with a load of the LHB through the BRP during elevation may also lead to lesions. CLINICAL RELEVANCE: Knowledge of the pathomechanisms of BRP injury may help in developing specific treatment and rehabilitation strategies as well as tests for physical examination.