Impact of an Asynchronous Spaced Education Learning Intervention on Emergency Medicine Clinician Opioid Prescribing.

Introduction Opioid prescribing has contributed to the opioid crisis and education has focused on improved opioid stewardship. We aimed to evaluate the impact of an asynchronous high-quality education to change emergency medicine (EM) clinician opioid prescribing. Methods We conducted a retrospective cohort study of a spaced-education intervention in EM clinicians who work at an urban, university-affiliated academic medical center emergency department. We developed opioid prescribing educational content and investigated whether prescriber participation in a novel asynchronous educational program, QuizTime, was associated with a change in EM clinician opioid prescribing practices and whether those prescribing practice changes would be maintained. The primary outcome was the frequency of opioid prescriptions by attributable emergency department discharges. We compared the frequency during the post-intervention period, 24 months following QuizTime education (July 2018 - June 2020) to the baseline period (November 2016 - March 2018). The secondary outcomes were total morphine milligram equivalent (MME) and the number of tablets dispensed per prescription. We analyzed the outcomes by EM clinicians' level of participation in QuizTime education. Results During the study period, there was an overall reduction in opioid prescribing per attributable emergency department discharge (p < 0.001). Among the 45 prescribers who enrolled in QuizTime, there was a significant reduction of 4.3 (95% CI: 3.9, 4.6, p < 0.001) opioid prescriptions per 100 ED discharges in the post-intervention period compared to baseline. Among the 11 non-enrollees, there was a significant reduction of 2.4 (95% CI: 1.7, 3.1, p < 0.001) opioid prescriptions per 100 emergency department discharges in the post-intervention period compared to baseline. The prescribers enrolled in QuizTime had a significantly larger reduction in prescriptions compared to those who did not enroll (p < 0.001). A decreasing trend of total MME and the number of tablets dispensed was observed (p < 0.001). However, there was insufficient evidence to show a reduction in the number of tablets dispensed or MME per day. Conclusion EM clinician participation in the QuizTime Pain Management educational program was associated with a nearly two-fold decrease in opioid prescriptions per emergency department discharge compared to peers who chose not to enroll.

Improving Mortality Attribution in Otolaryngology - Head and Neck Surgery.

OBJECTIVE/HYPOTHESIS: Mortality attribution can have significant implications for reimbursement, hospital/department rankings, and perceptions of safety. This work seeks to compare the accuracy of externally assigned diagnosis-related group (DRG)-based service line mortality attribution in otolaryngology to an internal review process that assigns mortality to the teams that cared for a patient during hospitalization. STUDY DESIGN: Retrospective case series. METHODS: Mortality events at Vanderbilt University Medical Center (VUMC) from 2012 to 2018 were compared. Included events were assigned to the otolaryngology service line (OSL) via the following methods: an external agency (Vizient) using DRG, utilization management assignment based on the service that provided care at admission (admission service), discharge (discharge service), or throughout hospitalization (major service line), or through the internal VUMC mortality review committee. Internal review was considered the standard for comparison. RESULTS: Of the 28 mortality events assigned to OSL by the DRG-based external method, nine (32%) were actually attributable to OSL. Of the 23 total mortality events attributable to OSL at our institution, external DRG-based review captured nine (39%). The designation of major service during hospitalization was correct 95% of the time and captured 87% of mortality events. Differences between external and internal attribution methods were statistically significant (P < .001). CONCLUSIONS: DRG-based models are frequently utilized but can be inaccurate when attributing mortality for an individual otolaryngology department. Otolaryngology mortalities appear to be captured and assigned more accurately by assigning deaths to the service that renders the majority of care during hospitalization. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1805-E1810, 2021.

Sustained improvement in hand hygiene adherence: utilizing shared accountability and financial incentives.

OBJECTIVE: To evaluate the impact of an institutional hand hygiene accountability program on healthcare personnel hand hygiene adherence. DESIGN: Time-series design with correlation analysis. SETTING: Tertiary care academic medical center, including outpatient clinics and procedural areas. PARTICIPANTS: Medical center healthcare personnel. METHODS: A comprehensive hand hygiene initiative was implemented in 2 major phases starting in July 2009. Key facets of the initiative included extensive project planning, leadership buy-in and goal setting, financial incentives linked to performance, and use of a system-wide shared accountability model. Adherence was measured by designated hand hygiene observers. Adherence rates were compared between baseline and implementation phases, and monthly hand hygiene adherence rates were correlated with monthly rates of device-associated infection. RESULTS: A total of 109,988 observations were completed during the study period, with a sustained increase in hand hygiene adherence throughout each implementation phase (P < .001) as well as from one phase to the next (P < .001), such that adherence greater than 85% has been achieved since January 2011. Medical center departments were able to reclaim some rebate dollars allocated through a self-insurance trust, but during the study period, departments did not achieve full reimbursement. Hand hygiene adherence rates were inversely correlated with device-associated standardized infection ratios (R(@) = 0.70). CONCLUSIONS: Implementation of this multifaceted, observational hand hygiene program was associated with sustained improvement in hand hygiene adherence. The principles of this program could be applied to other medical centers pursuing improved hand hygiene adherence among healthcare personnel.

Template of patient-specific summaries facilitates education and outcomes in paediatric cardiac surgery units.

OBJECTIVES: Few educational opportunities exist in paediatric cardiac critical care units (PCCUs). We introduced a new educational activity in the PCCU in the form of of patient-specific summaries (TPSS). Our objective was to study the role of TPSS in the provision of a positive learning experience to the multidisciplinary clinical team of PCCUs and in improving patient-related clinical outcomes in the PCCU. METHODS: Prospective educational intervention with simultaneous clinical assessment was undertaken in PCCU in an academic children's hospital. TPSS was developed utilizing the case presentation format for upcoming week's surgical cases and delivered once every week to each PCCU clinical team member. Role of TPSS to provide clinical education was assessed using five-point Likert-style scale responses in an anonymous survey 1 year after TPSS provision. Paediatric cardiac surgery patients admitted to the PCCU were evaluated for postoperative outcomes for TPSS provision period of 1 year and compared with a preintervention period of 1 year. RESULTS: TPSS was delivered to 259 clinical team members including faculty, fellows, residents, nurse practitioners, nurses, respiratory therapists and others from the Divisions of Anesthesia, Cardiology, Cardio-Thoracic Surgery, Critical Care, and Pediatrics working in the PCCU. Two hundred and twenty-four (86%) members responded to the survey and assessed the role of TPSS in providing clinical education to be excellent based on mean Likert-style scores of 4.32 ± 0.71 in survey responses. Seven hundred patients were studied for the two time periods and there were no differences in patient demographics, complexity of cardiac defect and surgical details. The length of mechanical ventilation for the TPSS period (57.08 ± 141.44 h) was significantly less when compared with preintervention period (117.39 ± 433.81 h) (P < 0.001) with no differences in length of PCICU stay, hospital stay and mortality for the two time periods. CONCLUSIONS: Provision of TPSS in a paediatric cardiac surgery unit is perceived to be beneficial in providing clinical education to multidisciplinary clinical teams and may be associated with improved clinical outcome.

Standardization of case reviews (morbidity and mortality rounds) promotes patient safety.

The morbidity and mortality conference (M&M) is a long-standing practice in medicine. Originally created to identify errors and improve care, the primary focus of M&M has moved toward an emphasis on education of trainees. A structured format for the M&M conference can help the interdisciplinary team address causes of adverse patient outcomes and identify opportunities for systems improvement.

Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance*.

OBJECTIVE: To determine whether structured handover tool from operating room to pediatric cardiac intensive care unit following cardiac surgery is associated with a reduction in the loss of information transfer and an improvement in the quality of communication exchange. In addition, whether this tool is associated with a decrease in postoperative complications and an improvement in patient outcomes in the first 24 hrs of pediatric cardiac intensive care unit stay. DESIGN: Prospective observational clinical study. SETTING: Pediatric cardiac intensive care unit of an academic medical center. PATIENTS: Pediatric cardiac surgery patients over a 3-yr period. Evaluation of communication and patients studied for two time periods: verbal handover (July 2007-June 2009) and structured handover (July 2009-June 2010). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two anonymous surveys administered to the entire clinical team of the pediatric cardiac intensive care unit evaluated loss of information transfer for each of the two handover processes. Quality of structured handover tool was evaluated by Likert scale responses in the second survey. Patient complications including cardiopulmonary resuscitation, mediastinal reexploration, placement on extracorporeal membrane oxygenation, development of severe metabolic acidosis, and number of early extubations in the first 24-hr pediatric cardiac intensive care unit stay were compared for the two time periods. Survey results showed the general opinion that the structured handover tool was of excellent quality to enhance communication (Likert scale: 4.4 ± 0.7). In addition, the tool was associated with a significant reduction (p < .001) in loss of information for every category of patient clinical care including patient, preoperative, anesthesia, operative, and postoperative details and laboratory values. Patient data revealed significant decrease (p < .05) for three of the four major complications studied and a significant increase (p < .04) in the number of early extubations following introduction of our standardized handover tool. CONCLUSIONS: In this setting, a standardized handover tool is associated with a decrease in the loss of patient information, an improvement in the quality of communication during postoperative transfer, a decrease in postoperative complications, and an improvement in 24-hr patient outcomes.