Neuroinvasive Bacillus cereus Infection in Immunocompromised Hosts: Epidemiologic Investigation of 5 Patients With Acute Myeloid Leukemia.

Background: Bacillus cereus is a ubiquitous gram-positive rod-shaped bacterium that can cause sepsis and neuroinvasive disease in patients with acute leukemia or neutropenia. Methods: A single-center retrospective review was conducted to evaluate patients with acute leukemia, positive blood or cerebrospinal fluid test results for B cereus, and abnormal neuroradiographic findings between January 2018 and October 2022. Infection control practices were observed, environmental samples obtained, a dietary case-control study completed, and whole genome sequencing performed on environmental and clinical Bacillus isolates. Results: Five patients with B cereus neuroinvasive disease were identified. All patients had acute myeloid leukemia (AML), were receiving induction chemotherapy, and were neutropenic. Neurologic involvement included subarachnoid or intraparenchymal hemorrhage or brain abscess. All patients were treated with ciprofloxacin and survived with limited or no neurologic sequelae. B cereus was identified in 7 of 61 environmental samples and 1 of 19 dietary protein samples-these were unrelated to clinical isolates via sequencing. No point source was identified. Ciprofloxacin was added to the empiric antimicrobial regimen for patients with AML and prolonged or recurrent neutropenic fevers; no new cases were identified in the ensuing year. Conclusions: B cereus is ubiquitous in the hospital environment, at times leading to clusters with unrelated isolates. Fastidious infection control practices addressing a range of possible exposures are warranted, but their efficacy is unknown and they may not be sufficient to prevent all infections. Thus, including B cereus coverage in empiric regimens for patients with AML and persistent neutropenic fever may limit the morbidity of this pathogen.

What Went Right? A Mixed-Methods Study of Positive Feedback Data in a Hospital-Wide Mortality Review Survey.

BACKGROUND: Toxic work culture contributes to healthcare worker burnout and attrition, but little is known about how healthcare organizations can systematically create and promote a culture of civility and collegiality. OBJECTIVE: To analyze peer-to-peer positive feedback collected as part of a systematized mortality review survey to identify themes and recognition dynamics that can inform positive organizational culture change. DESIGN: Convergent mixed-methods study design. PARTICIPANTS: A total of 388 physicians, 212 registered nurses, 64 advanced practice providers, and 1 respiratory therapist at four non-profit hospitals (2 academic and 2 community). INTERVENTION: Providing optional positive feedback in the mortality review survey. MAIN MEASURES: Key themes and subthemes that emerged from positive feedback data, associations between key themes and positive feedback respondent characteristics, and recognition dynamics between positive feedback respondents and recipients. KEY RESULTS: Approximately 20% of healthcare workers provided positive feedback. Three key themes emerged among responses with free text comments: (1) providing extraordinary patient and family-centered care; (2) demonstrating self-possession and mastery; and (3) exhibiting empathic peer support and effective team collaboration. Compared to other specialties, most positive feedback from medicine (70.2%), neurology (65.2%), hospice and palliative medicine (64.3%), and surgery (58.8%) focused on providing extraordinary patient and family-centered care (p = 0.02), whereas emergency medicine (59.1%) comments predominantly focused on demonstrating self-possession and mastery (p = 0.06). Registered nurses (40.2%) provided multidirectional positive feedback more often than other clinician types in the hospital hierarchy (p < 0.001). CONCLUSIONS: Analysis of positive feedback from a mortality review survey provided meaningful insights into a health system's culture of teamwork and values related to civility and collegiality when providing end-of-life care. Systematic collection and sharing of positive feedback is feasible and has the potential to promote positive culture change and improve healthcare worker well-being.

Financial Impact of a Radiology Safety Net Program for Resolution of Clinically Necessary Follow-up Imaging Recommendations.

OBJECTIVE: Health care safety net (SN) programs can potentially improve patient safety and decrease risk associated with missed or delayed follow-up care, although they require financial resources. This study aimed to assess whether the revenue generated from completion of clinically necessary recommendations for additional imaging (RAI) made possible by an IT-enabled SN program could fund the required additional labor resources. METHODS: Clinically necessary RAI generated October 21, 2019, to September 24, 2021, were tracked to resolution as of April 13, 2023. A new radiology SN team worked with existing schedulers and care coordinators, performing chart review and patient and provider outreach to ensure RAI resolution. We applied relevant Current Procedural Terminology, version 4 codes of the completed imaging examinations to estimate total revenue. Coprimary outcomes included revenue generated by total performed examinations and estimated revenue attributed to SN involvement. We used Student's t test to compare the secondary outcome, RAI time interval, for higher versus lower revenue-generating modalities. RESULTS: In all, 24% (3,243) of eligible follow-up recommendations (13,670) required SN involvement. Total estimated revenue generated by performed recommended examinations was $6,116,871, with $980,628 attributed to SN. Net SN-generated revenue per 1.0 full-time equivalent was an estimated $349,768. Greatest proportion of performed examinations were cross-sectional modalities (CT, MRI, PET/CT), which were higher revenue-generating than non-cross-sectional modalities (x-ray, ultrasound, mammography), and had shorter recommendation time frames (153 versus 180 days, P < .001). DISCUSSION: The revenue generated from completion of RAI facilitated by an IT-enabled quality and safety program supplemented by an SN team can fund the required additional labor resources to improve patient safety. Realizing early revenue may require 5 to 6 months postimplementation.

Patient and System Factors Associated With Completed Follow-Up of Probably Benign (BI-RADS 3) Breast Imaging Findings.

OBJECTIVE: Evaluate patient factors and health system test ordering and scheduling processes associated with completed BI-RADS 3 breast imaging follow-up. METHODS: Retrospective review of reports from January 1, 2021, to July 31, 2021, identified BI-RADS 3 findings corresponding to unique patient encounters (index examinations). The electronic health record was queried for patient, examination, and health system ordering or scheduling data including follow-up order status (order placed, performed; order placed, scheduled, but not performed; order placed, unscheduled; no order placed); ordering provider specialty and health system affiliation (primary care versus other, internal versus external to health system); and ordering department (radiology staff versus referring physician staff). Patient home addresses were categorized by area deprivation index (University of Wisconsin's Neighborhood Atlas). Univariable and multivariable analysis identified patient, examination, and ordering or scheduling factors associated with completed follow-up imaging within 15 months of BI-RADS 3 assessment. RESULTS: There were 3,104 unique BI-RADS 3 assessments, 2,561 (82.5%) with completed BI-RADS 3 follow-up within 15 months of study examination. In multivariable analysis, factors associated with incomplete follow-up included ultrasound (odds ratio [OR] 0.48; 95% confidence interval [95% CI] 0.38-0.60; P < .001) and MRI (OR 0.71; 95% CI 0.50-1.00; P = .049) versus mammogram; patients living in the highest disadvantaged neighborhoods (OR 0.70; 95% CI 0.50-0.98; P = .04); patients <40 years (OR 0.14; 95% CI 0.11-0.19; P < .001); Asian race (OR 0.55; 95% CI 0.37-0.81; P = .003); order placement >3 months (OR, 0.05; 95% CI 0.02-0.16; P < .001) after index examination or scheduling >6 months after order placement (OR, 0.35; 95% CI 0.14-0.87; P = .02); order placement by breast oncology or breast surgery departments (OR 0.35; 95% CI 0.17-0.73; P = .01) versus radiology department. DISCUSSION: Incomplete BI-RADS 3 follow-up is associated with ultrasound or MRI, most socioeconomically disadvantaged patients, younger patients, Asian race, delayed order entry, and follow-up examination ordering and scheduling by non-radiology departments.

A Quality Improvement Intervention Leveraging a Safety Net Model for Surveillance Colonoscopy Completion.

Systems to address follow-up testing of clinically positive surveillance colonoscopy results are lacking. The impact of an ambulatory safety net (ASN) intervention on rates of colonoscopy completion was assessed. The ASN team identified patients using an electronic registry, conducted patient outreach, coordinated care, and tracked colonoscopy completion. In all, 701 patients were captured in the ASN program: 58.1% (407/701) had possible barriers to follow-up colonoscopy completion, with rates of 80.1% (236/294) if no barrier, and 40.9% (287/701) overall. Colonoscopy completion likelihood increased with prior polypectomy (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.3), and decreased with White race (OR, 0.5; 95% CI, 0.3-0.9), increased inpatient visits (OR, 0.6; 95% CI, 0.4-0.9), more outreach attempts (OR, 0.6; 95% CI, 0.5-0.7), and fair/poor/inadequate preparation (OR, 0.4; 95% CI, 0.2-0.7) in logistic regression models. An ASN model for quality improvement promotes colonoscopy completion rates and identifies patient barriers.

Electronic Health Record Transition and Impact on Screening Test Follow-Up.

INTRODUCTION: Nonurgent clinically significant test results (CSTRs) are a common cause of missed and delayed diagnoses. However, little is known about the impact of electronic health record (EHR) transitions on CSTR follow-up. This study examines follow-up rates for three CSTRs (incidental pulmonary nodules [IPNs]), prostate-specific antigen [PSA], and Pap smears) before and after EHR transition. METHODS: This is a retrospective cohort study at an urban tertiary medical center using an interrupted time series (ITS) design to assess monthly changes in CSTR follow-up-defined as completion of computed tomography chest imaging 5 to 13 months after first mention of an IPN in a radiology report; completion of a follow-up PSA test, urology visit, or prostate biopsy within 6 months of the first reported PSA > 4; or completion of a colposcopy or gynecology visit within 6 months of a first reported abnormal Pap smear. Patients were included with first-onset abnormal CSTRs for IPN, PSAs > 4, or abnormal Pap smears occurring in the 24 months before and after the EHR transition. RESULTS: There were no significant differences in follow-up in the IPN or the Pap smear ITS models. In the PSA ITS model, follow-up was significantly decreasing (p = 0.0133) in the preintervention period, and there was a significant change in trend from intervention to postintervention (p = 0.0279). CONCLUSION: EHR transition reversed a decreasing trend over time for PSA test follow-up, while IPN and Pap smear follow-up trends did not change significantly. Effects of EHR transition may differ by test studied.

A Multidisciplinary Intervention to Improve Care for High-Risk COPD Patients.

Chronic obstructive pulmonary disease (COPD) exacerbations contribute to both costs and patient morbidity. The authors designed a quality project to improve care for high-risk COPD patients admitted with an exacerbation. An electronic medical record report was used to target admitted high-risk COPD patients for an intervention that included pulmonary and respiratory therapy consults, post-discharge phone calls from a patient navigator, referrals to palliative services when appropriate, and bedside delivery of medications. The control population was a similar group of patients at a community partner hospital who received usual care. In all, 157 unique patients were enrolled over 16 months; referrals to palliative care services increased and rates of outpatient follow-up improved. There was no difference in readmissions or emergency department visits between the 2 groups. Better coordination of outpatient care and attention to psychosocial burdens were identified as possible targets for future interventions.

Factors Associated With Optimal Follow-up in Women With BI-RADS 3 Breast Findings.

OBJECTIVE: Assess rate of and factors associated with optimal follow-up in patients with BI-RADS 3 breast findings. METHODS: This Institutional Review Board-approved, retrospective cohort study, performed at an academic medical center, included all women undergoing breast imaging (ultrasound and mammography) in 2016. Index reports for unique patients with an assessment of BI-RADS 3 (retrieved via natural language processing) comprised the study population. Patient-specific and provider-related features were extracted from the Research Data Warehouse. The Institutional Cancer Registry identified patients diagnosed with breast cancer. Optimal follow-up rate was calculated as patients with follow-up imaging on the same breast 3 to 9 months from the index examination among patients with BI-RADS 3 assessments. Univariate analysis and multivariable logistic regression determined features associated with optimal follow-up. Malignancy rate and time to malignancy detection were recorded. RESULTS: Among 93,685 breast imaging examinations, 64,771 were from unique patients of which 2,967 had BI-RADS 3 findings (4.6%). Excluding patients with off-site index examinations and those with another breast examination <3 months from the index, 1,125 of 1,511 patients (74%) had optimal follow-up. In univariate and multivariable analysis, prior breast cancer was associated with optimal follow-up; younger age, Hispanic ethnicity, divorced status, and lack of insurance were associated with not having optimal follow-up. Malignancy rate was 0.86%, and mean time to detection was 330 days. DISCUSSION: Follow-up of BI-RADS 3 breast imaging findings is optimal in only 74% of women. Further interventions to promote follow-up should target younger, unmarried women, those with Hispanic ethnicity, and women without history of breast cancer and without insurance coverage.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer.

BACKGROUND: An ambulatory safety net (ASN) is an innovative organizational intervention for addressing patient safety related to missed and delayed diagnoses of abnormal test results. ASNs consist of a set of tools, reports and registries, and associated work flows to create a high-reliability system for abnormal test result management. METHODS: Two ASNs implemented at an academic medical center are described, one focusing on colon cancer and the other on lung cancer. Data from electronic registries and chart reviews were used to evaluate the effectiveness of the ASNs, which were defined as follows: colon cancer-the proportion of patients who were scheduled for or completed a colonoscopy following safety net team outreach to the patient; lung cancer-the proportion of patients for whom the safety net was able to identify and implement appropriate follow-up, as defined by scheduled or completed chest CT. RESULTS: The effectiveness of the colon cancer ASN was 44.0%, and the effectiveness of the lung cancer ASN was 56.9%. The ASNs led to the development of registries to address patient safety, fostered collaboration among interdisciplinary teams of clinicians and administrative staff, and created new work flows for patient outreach and tracking. CONCLUSION: Two ASNs were successfully implemented at an academic medical center to address missed and delayed recognition of abnormal test results related to colon cancer and lung cancer. The ASNs are providing a framework for development of additional safety nets in the organization.

Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework.

PURPOSE: The aim of this study was to measure diagnostic imaging safety events reported to an electronic safety reporting system and assess steps at which they occurred within the diagnostic imaging workflow and contributing sociotechnical factors. METHODS: The authors evaluated all electronic safety reporting system reports related to diagnostic imaging during calendar year 2015 at an academic medical center with 50,000 admissions, 950,000 ambulatory visits, and 680,000 diagnostic imaging studies annually. Each report was assigned a harm score ranging from 0 to 4 by the reporter; scores of 2 (minor harm) to 4 (death) were classified as "potential harm." Two reviewers manually classified reports into steps involved in the diagnostic imaging chain and sociotechnical factors per the Systems Engineering Initiative for Patient Safety framework. The κ coefficient was used to measure interreviewer agreement on 10% of reports. The percentage of reports that could cause "potential harm" was compared for each step and sociotechnical factor using χ2 analysis. RESULTS: Of 11,570 safety reports submitted in 2015, 854 (7%) were related to diagnostic imaging. Although the most common step was imaging procedure (54% of reports), potential harm occurred more in result communication (odds ratio, 2.36; P = .05). Person factors most commonly contributed to safety reports (71%). Potential harm occurred more in safety reports that were related to tasks compared with person factors (odds ratio, 5.03; P < .0001). The κ coefficient was 0.79. CONCLUSIONS: Safety events were related to diagnostic imaging in 7% of reported events. Potential harm occurred primarily during imaging procedure and result communication. Safety events were attributed to multifactorial sociotechnical factors. Further work is necessary to decrease safety events related to diagnostic imaging.

Impact of a Health Information Technology Intervention on the Follow-up Management of Pulmonary Nodules.

Lung cancer is the leading cause of cancer deaths in the USA. The most common abnormalities suspicious for lung cancer on CT scan include pulmonary nodules. Recommendations to improve care for patients with pulmonary nodules require follow-up management. However, transitions in care, especially for patients undergoing transitions to ambulatory care sites from the emergency department (ED) and inpatient settings, can exacerbate failures in follow-up testing and compromise patient safety. We evaluate the impact of a discharge module that includes follow-up recommendations for further management of pulmonary nodules on the study outcome and follow-up management of patients with pulmonary nodules within 1 year after discharge. After IRB approval, we collected data on all patients undergoing chest or abdominal CT exams over a 12-month baseline and 12-month intervention period at an academic medical center. The inpatient discharge module was implemented in November 2011; the ED module was implemented in May 2012. Multivariable logistic regression was performed to account for care setting, imaging modality, recommendations, and patient demographics. Implementation of a discharge module resulted in improved follow-up of patients with pulmonary nodules within 1 year after discharge (OR = 1.64, p = 0.01); the ED implementation resulted in better follow-up compared to the inpatient module (OR = 2.24, p < 0.01). Twenty-seven percent of patients with pulmonary nodules received follow-up management, which, although significantly improved from the 18% baseline, remains low. An electronic discharge module is associated with improved follow-up management of patients with pulmonary nodules, and may be combined with interventions to further improve management of these patients.

Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center.

BACKGROUND: Conferences, processes, and/or meetings in which adverse events and near misses are reviewed within clinical programs at a single academic medical center were identified. METHODS: Leaders of conferences, processes, or meetings-"process leaders"-in which adverse events and near misses were reviewed were surveyed. RESULTS: On the basis of responses from all 45 process leaders, processes were classified into (1) Morbidity and Mortality Conferences (MMCs), (2) Quality Assurance (QA) Meetings, and (3) Educational Conferences. Some 22% of the clinical programs used more than one of these three processes to identify and review adverse events and near misses, while 10% had no consistent participation in any of them. Explicit criteria for identifying and selecting cases to be reviewed were used by 58% of MMCs and 69% of QA Meetings. The explicit criteria used by MMCs and QA Meetings varied widely. Many MMCs (54%, 13/24), QA Meetings (54%, 7/13), and Educational Conferences (70%, 7/10) did not review all the adverse events or near misses that were identified, and several MMCs (46%, 6/13), QA Meetings (29%, 2/7), and Educational Conferences (57%, 4/7) had no other process within their clinical program by which to review these remaining cases. CONCLUSIONS: There was wide variation regarding how clinical programs identify and review adverse events and near misses within the MMCs, QA Meetings, and Educational Conferences, and some programs had no such processes. A well-designed, coordinated process across all clinical areas that incorporates accepted approaches for event analysis may improve the quality and safety of patient care.