2011 John M. Eisenberg Patient Safety and Quality Awards. The effect of a novel Housestaff Quality Council on quality and patient safety. Innovation in patient safety and quality at the local level.

BACKGROUND: In 2008 New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, New York City, the largest not-for-profit, nonsectarian hospital in the United States, created and implemented a novel approach--the Housestaff Quality Council (HQC)--to engaging house-staff in quality and patient safety activities. METHODS: The HQC represented an innovative collaboration between the housestaff, the Department of Anesthesiology, the Division of Quality and Patient Safety, the Office of Graduate Medical Education, and senior leadership. As key managers of patient care, the housestaff sought to become involved in the quality and patient safety decision- and policy-making processes at the hospital. Its members were determined to decrease or minimize adverse events by facilitating multimodal communication, ensuring smart work flow, and measuring outcomes to determine best practices. The HQC, which also included frontline hospital staff or managers from areas such as nursing, pharmacy, and information technology, aligned its initiatives with those of the division of quality and patient safety and embarked on two projects--medication reconciliation and use of the electronic medical record. More than three years later, the resulting improvements have been sustained and three new projects--hand hygiene, central line-associated bloodstream infections, and patient handoffs--have been initiated. CONCLUSIONS: The HQC model is highly replicable at other teaching institutions as a complementary approach to their other quality and patient safety initiatives. However, the ability to sustain positive momentum is dependent on the ability of residents to invest time and effort in the face of a demanding residency training schedule and focus on specialty-specific clinical and research activities.

Provider Board Certification Status and Practice Patterns in Total Knee Arthroplasty.

PURPOSE: The presumption that board certification directly affects the quality of clinical care is a topic of ongoing discussion in medical literature. Recent studies have demonstrated disparities in patient outcomes associated with type of anesthesia provided for total knee arthroplasty (TKA); improved outcomes are associated with neuraxial (or regional) versus general anesthesia. Whether board-certified (BC) and non-board-certified (nBC) anesthesiologists make different choices in the anesthetic they administer is unknown. The authors sought to study potential associations of board certification status with anesthesia practice patterns for TKA. METHOD: The authors accessed records of anesthetics provided from 2010 to 2013 from the National Anesthesia Clinical Outcomes Registry database. They identified TKA cases using Clinical Classifications Software and Current Procedural Terminology codes. The authors divided practitioners into two groups: those who were BC and those who were nBC. For each of these groups, the authors compared the following: their patient populations, the hospitals in which they worked, the nature of their practices, and the anesthetics they administered to their patients. RESULTS: BC anesthesiologists provided care for 81.7% of 97,508 patients having TKA; 18.3% were treated by nBC anesthesiologists. BC anesthesiologists administered neuraxial/regional anesthesia more frequently than nBC anesthesiologists (41.4% versus 21.2%; P < .001). CONCLUSIONS: The rates at which regional/neuraxial anesthesia were administered for TKA were relatively low, and there were significant differences in practice patterns of BC and nBC anesthesiologists providing care for patients undergoing TKA. More research is necessary to understand the causes of these disparities.

Acute Pain Management/Regional Anesthesia.

Effective and efficient acute pain management strategies have the potential to improve medical outcomes, enhance patient satisfaction, and reduce costs. Pain management records are having an increasing influence on patient choice of health care providers and will affect future financial reimbursement. Dedicated acute pain and regional anesthesia services are invaluable in improving acute pain management. In addition, nonpharmacologic and alternative therapies, as well as information technology, should be viewed as complimentary to traditional pharmacologic treatments commonly used in the management of acute pain. The use of innovative technologies to improve acute pain management may be worthwhile for health care institutions.

Variability in anesthetic care for total knee arthroplasty: an analysis from the anesthesia quality institute.

Anesthetic practice utilization and related characteristics of total knee arthroplasties (TKAs) are understudied. The research team sought to characterize anesthesia practice patterns by utilizing National Anesthesia Clinical Outcomes Registry data of the Anesthesia Quality Institute. The proportions of primary TKAs performed between January 2010 and June 2013 using general anesthesia (GA), neuraxial anesthesia (NA), and regional anesthesia (RA) were determined. Utilization of anesthesia types was analyzed using anesthesiologist and patient characteristics and facility type. In all, 108 625 eligible TKAs were identified; 10.9%, 31.3%, and 57.9% were performed under RA, NA, and GA, respectively. Patients receiving RA had higher median age and higher frequency of American Society of Anesthesiology score ≥3 compared with those receiving other anesthesia types under study. Relative to GA (45.0%), when NA or RA were used, the anesthesiologist was more frequently board certified (75.5% and 62.1%, respectively; P < .0001). Anesthetic technique differences for TKAs exist, with variability associated with patient and provider characteristics.

Uvular injury during the perioperative period in patients undergoing general anesthesia.

OBJECTIVE: The purpose of this study was to evaluate the incidence and causes of uvular injury in the patients that received general anesthesia in the perioperative period. STUDY DESIGN: A 4-year retrospective review of cases of uvular injury and their resolution was conducted in adult patients who received general anesthesia at our institution. METHODS: An extensive review was conducted of the quality assurance (QA) database maintained by the Department of Anesthesiology at our tertiary academic medical center. The database was searched for cases of uvular injury that occurred in adult patients undergoing general anesthesia that between January 2007 and December 2010. The medical records of identified patients were then obtained to evaluate the presentation, treatment and ultimate resolution of injury. RESULTS: Ten cases of uvular injury were reported in the 28,788 general anesthetics conducted over a 3-year period in adult patients. This correlates to an incidence of 0.034%. Uvular injury occurred in mostly male patients (80%) during elective cases in the supine position. All cases were associated with endotracheal intubation. Additional objects, such as gastric tubes and esophageal temperature probes, were placed in the pharynx of 80% of these patients. Urologic procedures were associated with 50% of reported cases. Treatment ranged from observation to medical therapy. There were no permanent symptoms in any of the patients. CONCLUSION: Uvular injury is a relatively rare complication that occurs in patients during the perioperative period who receive general anesthesia. While endotracheal intubation is closely associated with this type of injury, further study is required to elucidate the mechanism and other associated etiologic factors.

Evaluation and treatment of perioperative corneal abrasions.

Purpose. To evaluate perioperative risk factors for corneal abrasion (CA) and to determine current care for perioperative CA in a tertiary care setting. Methods. Hospital-based, cross-sectional study. In Operating Room and Post-Anesthesia Care Units patients, a comparison of cases and controls was evaluated to elucidate risk factors, time to treatment, and most common treatments prescribed for corneal abrasions. Results. 86 cases of corneal abrasion and 89 controls were identified from the 78,542 surgical procedures performed over 2 years. Statistically significant risk factors were age (P = 0.0037), general anesthesia (P < 0.001), greater average estimated blood loss (P < 0.001), eyes taped during surgery (P < 0.001), prone position (P < 0.001), trendelenburg position (P < 0.001), and supplemental oxygen en route to and in the Post-Anesthesia Care Units (P < 0.001). Average time to complaint was 129 minutes. 94% of cases had an inpatient ophthalmology consult, with an average time to consult of 164 minutes. The most common treatment was artificial tears alone (40%), followed by combination treatment of antibiotic ointment and artificial tears (35.3%). Conclusions. Trendelenburg positioning is a novel risk factor for CA. Diagnosis and treatment of perioperative corneal abrasions by an ophthalmologist typically require three hours in the tertiary care setting.

An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.

At New York-Presbyterian Hospital, Weill Cornell Medical Center, an innovative approach to involving housestaff in quality and patient safety, policy and procedure creation, and culture change was led by the Department of Anesthesiology of the Weill Medical College of Cornell University. A Housestaff Quality Council was started in 2008 that has partnered with hospital leadership and clinical departments to engage the housestaff in quality and patient safety initiatives, resulting in measurable improvements in several patient care projects and enhanced working relationships among various clinical constituencies. Ultimately this attempt to change culture has found great success in fostering a relationship between the housestaff and the hospital in ways that have and will continue to improve patient care.

Perspective: call to action: it is time for academic institutions to appoint a resident quality and patient safety officer.

In meeting the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements, teaching hospitals often find it challenging to ensure effective involvement of housestaff in the area of quality and patient safety (QPS). Because housestaff are the frontline providers of care to patients, and medical errors occasionally occur based on their actions, it is essential for health care organizations to engage them in QPS processes.In early 2008 a Housestaff Quality Council (HQC) was established at New York-Presbyterian Hospital, Weill Cornell Medical Center, to improve QPS by engaging housestaff in policy and decision-making processes and to promote greater housestaff participation in QPS initiatives. It was quickly realized that the success of the HQC was highly contingent on alignment with the institution's overall QPS agenda. To this end, the position of resident QPS officer was created to strengthen the relationship between the hospital's strategic goals and the HQC. The authors describe the success of the resident QPS officers at their institution and observe that by appointing and supporting resident QPS officers, hospitals will be better able to meet their quality and safety goals, residency programs will be able to fulfill their required ACGME core competencies, and the overall quality and safety of patient care can be improved. Simultaneously, the creation of this position will help to create a new cadre of physician leaders needed to further the goals of QPS in health care.

Ten years after the IOM report: Engaging residents in quality and patient safety by creating a House Staff Quality Council.

Ten years after the 1999 Institute of Medicine report, it is clear that despite significant progress, much remains to be done to improve quality and patient safety (QPS). Recognizing the critical role of postgraduate trainees, an innovative approach was developed at New York-Presbyterian Hospital, Weill Cornell Medical Center to engage residents in QPS by creating a Housestaff Quality Council (HQC). HQC leaders and representatives from each clinical department communicate and partner regularly with hospital administration and other key departments to address interdisciplinary quality improvement (QI). In support of the mission to improve patient care and safety, QI initiatives included attaining greater than 90% compliance with medication reconciliation and reduction in the use of paper laboratory orders by more than 70%. A patient safety awareness campaign is expected to evolve into a transparent environment where house staff can openly discuss patient safety issues to improve the quality of care.