Development of the Illinois Surgical Quality Improvement Collaborative (ISQIC): Implementing 21 Components to Catalyze Statewide Improvement in Surgical Care.

INTRODUCTION: In 2014, 56 Illinois hospitals came together to form a unique learning collaborative, the Illinois Surgical Quality Improvement Collaborative (ISQIC). Our objectives are to provide an overview of the first three years of ISQIC focused on (1) how the collaborative was formed and funded, (2) the 21 strategies implemented to support quality improvement (QI), (3) collaborative sustainment, and (4) how the collaborative acts as a platform for innovative QI research. METHODS: ISQIC includes 21 components to facilitate QI that target the hospital, the surgical QI team, and the peri-operative microsystem. The components were developed from available evidence, a detailed needs assessment of the hospitals, reviewing experiences from prior surgical and non-surgical QI Collaboratives, and interviews with QI experts. The components comprise 5 domains: guided implementation (e.g., mentors, coaches, statewide QI projects), education (e.g., process improvement (PI) curriculum), hospital- and surgeon-level comparative performance reports (e.g., process, outcomes, costs), networking (e.g., forums to share QI experiences and best practices), and funding (e.g., for the overall program, pilot grants, and bonus payments for improvement). RESULTS: Through implementation of the 21 novel ISQIC components, hospitals were equipped to use their data to successfully implement QI initiatives and improve care. Formal (QI/PI) training, mentoring, and coaching were undertaken by the hospitals as they worked to implement solutions. Hospitals received funding for the program and were able to work together on statewide quality initiatives. Lessons learned at one hospital were shared with all participating hospitals through conferences, webinars, and toolkits to facilitate learning from each other with a common goal of making care better and safer for the surgical patient in Illinois. Over the first three years, surgical outcomes improved in Illinois. DISCUSSION: The first three years of ISQIC improved care for surgical patients across Illinois and allowed hospitals to see the value of participating in a surgical QI learning collaborative without having to make the initial financial investment themselves. Given the strong support and buy-in from the hospitals, ISQIC has continued beyond the initial three years and continues to support QI across Illinois hospitals.

Value-based syncope evaluation and management: Perspectives of health care professionals on readiness, barriers and enablers.

BACKGROUND: Syncope is a common condition seen in the emergency department. Given the multitude of etiologies, research exists on the evaluation and management of syncope. Yet, physicians' approach to patients with syncope is variable and often not value based. The 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope includes a focus on unnecessary medical testing. However, little research assesses implementation of the guidelines. METHODS: Mixed methods approach was applied. The targeted provider specialties include emergency medicine, hospital medicine and cardiology. The Evidence-based Practice Attitude Scale-36 and the Organizational Readiness to Change Assessment surveys were distributed to four different hospital sites. We then conducted focus groups and key informant interviews to obtain more information about clinicians' perceptions to guideline-based practice and barriers/facilitators to implementation. Descriptive statistics and bivariate analyses were used for survey analysis. Two-stage coding was used to identify themes with NVivo. RESULTS: Analysis of surveys revealed that overall attitude toward evidence-based practices was moderate and implementation of new guidelines were seen as a burden, potentially decreasing compliance. There were differences across hospital settings. Five common themes emerged from interviews: uncertainty of a syncope diagnosis, rise of consumerism in health care, communication challenge with patient, provider differences in standardized care, and organizational processes to change. CONCLUSIONS: Despite recommendations for the use of syncope guidelines, adherence is suboptimal. Overcoming barriers to use will require a paradigm shift. A multifaceted approach and collaborative relationships are needed to adhere to the Guidelines to improve patient care and operational efficiency.

Evaluation of Changes in Quality Improvement Knowledge Following a Formal Educational Curriculum Within a Statewide Learning Collaborative.

OBJECTIVE: Our objectives were to (1) develop a curriculum based upon participants' needs, (2) evaluate baseline QI knowledge of the Illinois Surgical Quality Improvement Collaborative (ISQIC) members, and (3) evaluate the effectiveness of the educational curriculum. DESIGN: The Surgeon Champion (SC), Surgical Clinical Reviewer (SCR), and QI Designee at each ISQIC hospital completed a QI curriculum containing online modules and in-person trainings. A surgical adaptation of QI-KAT, a validated QI knowledge assessment with multiple-choice and free-response sections, was administered pre- and postcurriculum. Three blinded educators scored each exam using a rubric-based scoring tool (54 total points). SETTING: The ISQIC is a 52-hospital learning collaborative. Generally, ISQIC participants had little prior formal training or experience with quality improvement. RESULTS: Among 52 hospitals, 144 pretests and 112 post-tests were collected. Mean scores increased from 66% (35.6 points) to 77% (41.6 points; p < 0.001). Across all hospitals, all participant groups scored higher on the post-test (SCs 15%, SCRs 21%, QI Designees 17%). There was no significant difference in post-test mean scores among different team members: SCs 44 points, SCRs 42 points, QI Designees 44 points, (p = 0.76). When the post-test scores were aggregated at the hospital level, hospitals with new surgical QI programs improved more than hospitals with established programs (new 18%, established 11%, p < 0.05). CONCLUSIONS: QI knowledge significantly improved after completion of the ISQIC curriculum. These data support the value of formalized curricula to rapidly advance QI knowledge and application skills as a foundation for implementing QI initiatives.

Simplification of the HOSPITAL score for predicting 30-day readmissions.

OBJECTIVE: The HOSPITAL score has been widely validated and accurately identifies high-risk patients who may mostly benefit from transition care interventions. Although this score is easy to use, it has the potential to be simplified without impacting its performance. We aimed to validate a simplified version of the HOSPITAL score for predicting patients likely to be readmitted. DESIGN AND SETTING: Retrospective study in 9 large hospitals across 4 countries, from January through December 2011. PARTICIPANTS: We included all consecutively discharged medical patients. We excluded patients who died before discharge or were transferred to another acute care facility. MEASUREMENTS: The primary outcome was any 30-day potentially avoidable readmission. We simplified the score as follows: (1) 'discharge from an oncology division' was replaced by 'cancer diagnosis or discharge from an oncology division'; (2) 'any procedure' was left out; (3) patients were categorised into two risk groups (unlikely and likely to be readmitted). The performance of the simplified HOSPITAL score was evaluated according to its overall accuracy, its discriminatory power and its calibration. RESULTS: Thirty-day potentially avoidable readmission rate was 9.7% (n=11 307/117 065 patients discharged). Median of the simplified HOSPITAL score was 3 points (IQR 2-5). Overall accuracy was very good with a Brier score of 0.08 and discriminatory power remained good with a C-statistic of 0.69 (95% CI 0.68 to 0.69). The calibration was excellent when comparing the expected with the observed risk in the two risk categories. CONCLUSIONS: The simplified HOSPITAL score has good performance for predicting 30-day readmission. Prognostic accuracy was similar to the original version, while its use is even easier. This simplified score may provide a good alternative to the original score depending on the setting.

Evaluation of a novel mentor program to improve surgical care for US hospitals.

OBJECTIVE: To evaluate a novel mentor program for 27 US surgeons, charged with improving quality at their respective hospitals, having been paired 1:1 with 27 surgeon mentors through a state-wide quality improvement (QI) initiative. DESIGN: Mixed-methods utilizing quantitative surveys and in-depth semi-structured interviews. SETTING: The Illinois Surgical Quality Improvement Collaborative (ISQIC) utilized a novel Mentor Program to guide surgeons new to QI. PARTICIPANTS: All mentor-mentee pairs received the survey (n = 27). Purposive sampling identified a subset of mentors (n = 8) and mentees (n = 4) for in-depth semi-structured interviews. INTERVENTION: Surgeons with expertise in QI mentored surgeons new to QI. MAIN OUTCOME MEASURES: (i) Quantitative: self-reported satisfaction with the mentor program; (ii) Qualitative: key themes suggesting actions and strategies to facilitate mentorship in QI. RESULTS: Mentees expressed satisfaction with the mentor program (n = 24, 88.9%) and agreed that mentorship is vital to ISQIC (n = 24, 88.9%). Analysis of interview data revealed four key themes: (i) nuances of data management, (ii) culture of quality and safety, (iii) mentor-mentee relationship and (iv) logistics. Strategies from these key themes include: utilize raw data for in-depth QI understanding, facilitate presentations to build QI support, identify opportunities for in-person meetings and establish scheduled conference calls. The mentor's role required sharing experiences and acting as a resource. The mentee's role required actively bringing questions and identifying barriers. CONCLUSIONS: Mentorship plays a vital role in advancing surgeon knowledge and engagement with QI in ISQIC. Key themes in mentorship reflect strategies to best facilitate mentorship, which may serve as a guide to other collaboratives.

International Validity of the HOSPITAL Score to Predict 30-Day Potentially Avoidable Hospital Readmissions.

IMPORTANCE: Identification of patients at a high risk of potentially avoidable readmission allows hospitals to efficiently direct additional care transitions services to the patients most likely to benefit. OBJECTIVE: To externally validate the HOSPITAL score in an international multicenter study to assess its generalizability. DESIGN, SETTING, AND PARTICIPANTS: International retrospective cohort study of 117 065 adult patients consecutively discharged alive from the medical department of 9 large hospitals across 4 different countries between January 2011 and December 2011. Patients transferred to another acute care facility were excluded. EXPOSURES: The HOSPITAL score includes the following predictors at discharge: hemoglobin, discharge from an oncology service, sodium level, procedure during the index admission, index type of admission (urgent), number of admissions during the last 12 months, and length of stay. MAIN OUTCOMES AND MEASURES: 30-day potentially avoidable readmission to the index hospital using the SQLape algorithm. RESULTS: Overall, 117 065 adults consecutively discharged alive from a medical department between January 2011 and December 2011 were studied. Of all medical discharges, 16 992 of 117 065 (14.5%) were followed by a 30-day readmission, and 11 307 (9.7%) were followed by a 30-day potentially avoidable readmission. The discriminatory power of the HOSPITAL score to predict potentially avoidable readmission was good, with a C statistic of 0.72 (95% CI, 0.72-0.72). As in the derivation study, patients were classified into 3 risk categories: low (n = 73 031 [62.4%]), intermediate (n = 27 612 [23.6%]), and high risk (n = 16 422 [14.0%]). The estimated proportions of potentially avoidable readmission for each risk category matched the observed proportion, resulting in an excellent calibration (Pearson χ2 test P = .89). CONCLUSIONS AND RELEVANCE: The HOSPITAL score identified patients at high risk of 30-day potentially avoidable readmission with moderately high discrimination and excellent calibration when applied to a large international multicenter cohort of medical patients. This score has the potential to easily identify patients in need of more intensive transitional care interventions to prevent avoidable hospital readmissions.

The Prevalence of Inpatients at 33 U.S. Hospitals Appropriate for and Receiving Referral to Palliative Care.

BACKGROUND: The extent of unmet need for palliative care in U.S. hospitals remains largely unknown. We conducted a multisite cross-sectional, retrospective point prevalence analysis to determine the size and characteristics of the population of inpatients at 33 U.S. hospitals who were appropriate for palliative care referral, as well as the percentage of these patients who were referred for and/or received palliative care services. We also conducted a qualitative assessment of barriers and facilitators to referral, focusing on organizational characteristics that might influence palliative care referral practices. METHODS: Patients appropriate for palliative care referral were defined as adult (≥18 years) patients with any diagnosis of a poor-prognosis cancer, New York Heart Association class IV congestive heart failure, or oxygen-dependent chronic obstructive pulmonary disease who had inpatient status in 1 of 33 hospitals on May 13, 2014. Qualitative assessment involved interviews of palliative care team members and nonpalliative care frontline providers. RESULTS: Nearly 19% of inpatients on the point prevalence day were deemed appropriate for palliative care referral. Of these, approximately 39% received a palliative care referral or services. Delivery of palliative care services to these patients varied widely among participating hospitals, ranging from approximately 12% to more than 90%. Factors influencing differences in referral practices included nonstandardized perceptions of referral criteria and variation in palliative care service structures. CONCLUSION: This study provides useful information to guide providers, administrators, researchers, and policy experts in planning for optimal provision of palliative care services to those in need.

"SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis.

BACKGROUND: When errors occur with adverse events or near misses, root cause analysis (RCA) is the standard approach to investigate the "how" and "why" of system vulnerabilities. However, even for facilities experienced in conducting RCAs, the process can be fraught with inconsistencies; provoke discomfort for participants; and fail to lead to meaningful, focused discussions of system issues that may have contributed to events. In 2009 University of Kentucky HealthCare Lexington developed a novel rapid approach to RCAs-colloquially called "SWARMing"--to establish a consistent approach to investigate adverse or other undesirable events. METHODS: In SWARMs, which are conducted without unnecessary delay after an event, an interdisciplinary team undertakes thoughtful analysis of events reported by frontline staff. The SWARM process consist of five key steps: (1) introductory explanation of the process; (2) introduction of everyone in the room; (3) review of the facts that prompted the SWARM; (4) discussion of what happened, with investigation of the underlying systems factors; and (5) conclusion, with proposed focus areas for action and assignment of task leaders with specific deliverables and completion dates. RESULTS: Since its implementation, incident reporting increased by 52%-from an average of 608 incidents per month (June-December 2011) to an average of 923 per month (January-May 2014). The overall health system experienced a 37% decrease in the observed-to-expected mortality ratio-from 1.17 (October 2010) to 0.74 (April 2015). CONCLUSION: SWARMs, more than an error-analysis exercise or simple RCA, represent an organizational-messaging, culture-changing, and capacity-building effort to address the challenges of creating and implementing processes that serve to promote transparency and a culture of safety.

Underlying reasons associated with hospital readmission following surgery in the United States.

IMPORTANCE: Financial penalties for readmission have been expanded beyond medical conditions to include surgical procedures. Hospitals are working to reduce readmissions; however, little is known about the reasons for surgical readmission. OBJECTIVE: To characterize the reasons, timing, and factors associated with unplanned postoperative readmissions. DESIGN, SETTING, AND PARTICIPANTS: Patients undergoing surgery at one of 346 continuously enrolled US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) between January 1, 2012, and December 31, 2012, had clinically abstracted information examined. Readmission rates and reasons (ascertained by clinical data abstractors at each hospital) were assessed for all surgical procedures and for 6 representative operations: bariatric procedures, colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair, and lower extremity vascular bypass. MAIN OUTCOMES AND MEASURES: Unplanned 30-day readmission and reason for readmission. RESULTS: The unplanned readmission rate for the 498,875 operations was 5.7%. For the individual procedures, the readmission rate ranged from 3.8% for hysterectomy to 14.9% for lower extremity vascular bypass. The most common reason for unplanned readmission was surgical site infection (SSI) overall (19.5%) and also after colectomy or proctectomy (25.8%), ventral hernia repair (26.5%), hysterectomy (28.8%), arthroplasty (18.8%), and lower extremity vascular bypass (36.4%). Obstruction or ileus was the most common reason for readmission after bariatric surgery (24.5%) and the second most common reason overall (10.3%), after colectomy or proctectomy (18.1%), ventral hernia repair (16.7%), and hysterectomy (13.4%). Only 2.3% of patients were readmitted for the same complication they had experienced during their index hospitalization. Only 3.3% of patients readmitted for SSIs had experienced an SSI during their index hospitalization. There was no time pattern for readmission, and early (≤7 days postdischarge) and late (>7 days postdischarge) readmissions were associated with the same 3 most common reasons: SSI, ileus or obstruction, and bleeding. Patient comorbidities, index surgical admission complications, non-home discharge (hazard ratio [HR], 1.40 [95% CI, 1.35-1.46]), teaching hospital status (HR, 1.14 [95% CI 1.07-1.21]), and higher surgical volume (HR, 1.15 [95% CI, 1.07-1.25]) were associated with a higher risk of hospital readmission. CONCLUSIONS AND RELEVANCE: Readmissions after surgery were associated with new postdischarge complications related to the procedure and not exacerbation of prior index hospitalization complications, suggesting that readmissions after surgery are a measure of postdischarge complications. These data should be considered when developing quality indicators and any policies penalizing hospitals for surgical readmission.

Identification of process measures to reduce postoperative readmission.

BACKGROUND: Readmission rates after intestinal surgery have been notably high, ranging from 10 % for elective surgery to 21 % for urgent/emergent surgery. Other than adherence to established strategies for decreasing individual postoperative complications, there is little guidance available for providers to work toward reducing their postoperative readmission rates. STUDY DESIGN: Processes of care that may affect postoperative readmissions were identified through a systematic literature review, assessment of existing guidelines, and semi-structured interviews with individuals who have expertise in hospital readmissions and surgical quality improvement. Eleven experts ranked potential process measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology. RESULTS: Of 49 proposed process measures, 34 (69 %) were rated as valid. Of the 34 valid measures, two measures addressed care in the preoperative period. These included evaluation of patient's comorbidities, providing written instruction detailing the anticipated perioperative course, and communication with the patient's referring or primary care doctor. A measure addressing perioperative care stated that institutions should have a standardized perioperative care protocol. Additional measures focused on discharge instructions and communication. CONCLUSIONS: An expert panel identified several aspects of care that are considered essential to quality patient care and important to reducing postoperative readmissions.

Patient experiences after hospitalizations for elective surgery.

BACKGROUND: Little is known from patients' perspective about the quality of postdischarge care and the causes of rehospitalization after elective surgery. METHODS: A prospective observational cohort study was conducted. RESULTS: Of 400 patient participants, 374 completed the 30-day follow-up questionnaire (completion rate, 94%). Half of all unplanned rehospitalizations (experienced by 13% of patients) and nonrehospitalization emergency department visits (experienced by 6%) occurred within 10 days of discharge. Patients used emergency departments and were rehospitalized at facilities near their homes (mean distance traveled, 12.1 mi). The most common primary reason for rehospitalization was postoperative complications, according to patient report, clinical records, and administrative data. Poor perceived care coordination was associated with higher readmission risk. CONCLUSIONS: Patients perceive surgical complications as dominating the reasons for rehospitalizations after elective surgery. Strategies to improve care quality around elective surgery at referral centers should target the discharge process and the coordinated management of postoperative complications through care received at regional hospitals.

Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events.

BACKGROUND: Research supports medical record review using screening triggers as the optimal method to detect hospital adverse events (AE), yet the method is labour-intensive. METHOD: This study compared a traditional trigger tool with an enterprise data warehouse (EDW) based screening method to detect AEs. We created 51 automated queries based on 33 traditional triggers from prior research, and then applied them to 250 randomly selected medical patients hospitalised between 1 September 2009 and 31 August 2010. Two physicians each abstracted records from half the patients using a traditional trigger tool and then performed targeted abstractions for patients with positive EDW queries in the complementary half of the sample. A third physician confirmed presence of AEs and assessed preventability and severity. RESULTS: Traditional trigger tool and EDW based screening identified 54 (22%) and 53 (21%) patients with one or more AE. Overall, 140 (56%) patients had one or more positive EDW screens (total 366 positive screens). Of the 137 AEs detected by at least one method, 86 (63%) were detected by a traditional trigger tool, 97 (71%) by EDW based screening and 46 (34%) by both methods. Of the 11 total preventable AEs, 6 (55%) were detected by traditional trigger tool, 7 (64%) by EDW based screening and 2 (18%) by both methods. Of the 43 total serious AEs, 28 (65%) were detected by traditional trigger tool, 29 (67%) by EDW based screening and 14 (33%) by both. CONCLUSIONS: We found relatively poor agreement between traditional trigger tool and EDW based screening with only approximately a third of all AEs detected by both methods. A combination of complementary methods is the optimal approach to detecting AEs among hospitalised patients.

Assessment of teamwork during structured interdisciplinary rounds on medical units.

BACKGROUND: Interdisciplinary rounds (IDR) provide a means to assemble hospital team members and improve collaboration. Little is known about teamwork during IDR. OBJECTIVE: To evaluate and characterize teamwork during IDR. DESIGN: Cross-sectional observational study. SETTING: Six medical units which had implemented structured interdisciplinary rounds (SIDR). MEASUREMENTS: We adapted the Observational Teamwork Assessment for Surgery (OTAS) tool, a behaviorally anchored rating scale shown to be reliable and valid in surgical settings. OTAS provides scores ranging from 0 to 6 (0 = problematic behavior; 6 = exemplary behavior) across 5 domains (communication, coordination, cooperation/backup behavior, leadership, and monitoring/situational awareness) and for prespecified subteams. Two researchers conducted direct observations using the adapted OTAS tool. RESULTS: We conducted 7-8 independent observations for each unit (total = 44) and 20 joint observations. Inter-rater reliability was excellent at the unit level (Spearman's rho = 0.75), and good across domains (rho = 0.53-0.68) and subteams (rho = 0.53-0.76) with the exception of the physician subteam, for which it was poor (rho = 0.35). Though teamwork scores were generally high, we found differences across units, with a median (interquartile range [IQR]) 4.5 (3.9-4.9) for the lowest and 5.4 (5.3-5.5) for the highest performing unit (P < 0.01). Domain scores differed, with leadership receiving the lowest (median [IQR] = 5.0 [4.6-5.3]), and cooperation/backup behavior and monitoring/situational awareness receiving highest scores (median [IQR] = 5.4 [5.0-5.5] and 5.4 [5.0-5.7]). Differences across subteams were of borderline significance (P = 0.05). CONCLUSIONS: The adapted OTAS instrument demonstrated acceptable reliability for assessing teamwork during SIDR across units, domains, and most subteams. Variation in performance suggests a need to improve consistency of teamwork and emphasizes the importance of leadership.

Hospitalists' lack of knowledge of the Confusion Assessment Method: a barrier to systematic validated delirium surveillance.

INTRODUCTION: Delirium is frequently missed by inpatient health care providers despite the existence of a highly sensitive and specific assessment for delirium, the Confusion Assessment Method (CAM). The CAM, due to its test characteristics and ease of use, is an ideal physician instrument for systematic inpatient delirium screening; however, little is known about hospitalists' knowledge of the CAM. METHODS: A short survey with items assessing respondents' perceptions of delirium detection, familiarity and proficiency with the CAM, and knowledge of the CAM algorithm was administered at a regional hospital medicine conference. Participants included a group of hospital medicine providers comprised of physicians (79.9%), nurse practitioners (7.2%), and physician assistants (12.9%). Results in the form of counts, percentages, and distributions of Likert scale responses and multiple-choice questions were reported. RESULTS: Of 157 surveys distributed, 94% (n = 147) were returned. Approximately 3 of 4 of providers (77%) reported encountering delirium at least once per week, with 45% reporting encountering delirium more than once per week. Yet, 82% had never used or heard of the CAM; only 3 respondents felt proficient with its use. Of the knowledge items, 4 respondents were able to correctly indicate the 4 clinical features of the CAM. Only 1 respondent was able to answer all knowledge items correctly. The respondents also agreed that nurses have an important role in delirium detection (65%), delirium diagnosis is often delayed (68%), and reported that not knowing patients' baseline cognitive status (53%) and having difficulty separating delirium from dementia or psychiatric illnesses (25%) were important challenges to delirium diagnosis. CONCLUSION: Hospital medicine providers who responded to the survey reported encountering delirium often in their clinical practice; however, they also reported poor familiarity with and demonstrated poor knowledge of the CAM. These results suggest a potential barrier to systematic inpatient delirium screening and support increased delirium education and the use of validated delirium assessments among hospitalists.

Potential role of comanagement in "rescue" of surgical patients.

OBJECTIVES: To evaluate the effect of medical comanagement on outcomes of hospitalized surgical patients who had postoperative complications. STUDY DESIGN: Retrospective cohort study. METHODS: We used clinical and administrative data at a large urban hospital to conduct a cohort study of select surgical hospitalizations in 2008 and 2009. We identified patients who suffered postoperative complications using measures developed by the University Health System Consortium. Bivariate and multivariate regression analyses were used to determine the associations of postoperative comanagement with inpatient mortality, length of stay, and cost in surgical patients who had postoperative complications. RESULTS: From 21,728 total surgical hospitalizations, we identified 4040 hospitalizations involving primary procedures (mainly orthopedic and neurosurgical) that were associated with comanagement at least 25% of the time. After excluding cases with missing data, 501 hospitalizations (13.8%) involved a patient who suffered at least 1 postoperative complication. Patient characteristics between the comanaged (n = 297) and non-comanaged (n = 204) hospitalizations were well matched. Medical comanagement was associated with fewer in-hospital deaths (odds ratio 0.23, 95% confidence interval 0.05-0.99) in adjusted analysis. Comanaged compared with non-comanaged hospitalizations were associated with shorter stay (-2.6 days, P <.01) without significant differences in total cost. CONCLUSIONS: Comanagement of patients who had perioperative complications was associated with lower mortality, suggesting that comanagement may facilitate effective rescue among medically complex surgical patients.

Quality of care and outcomes in women hospitalized for heart failure.

BACKGROUND: Although women account for a significant proportion of heart failure (HF) hospitalizations, data on the quality of care and in-hospital outcomes in women are limited. METHODS AND RESULTS: We examined The Joint Commission performance measures, other quality metrics, length of stay, and in-hospital mortality in women using 99 841 HF admissions (January 2005 to June 2009) at 248 hospitals participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Women accounted for 50% of the HF admissions and were older (mean age, 74±14 versus 69±14 years), more likely to have hypertension (77% versus 72%), and less likely to have coronary disease (44% versus 53%) or renal insufficiency (18% versus 23%) than men (all P<0.001). The presenting symptoms were similar to men, but women had higher admission systolic blood pressure (mean, 144±31 versus 137±30 mm Hg; P<0.001) and ejection fraction (mean, 0.44±0.17% versus 0.34±0.16%; P<0.001). After adjustment for baseline differences, eligible women were less likely than men to have measurement of left ventricular function (adjusted odds ratio [OR], 0.81; 95% CI, 0.76 to 0.86) and to receive anticoagulation for atrial fibrillation (adjusted OR, 0.91; 95% CI, 0.86 to 0.96) or implantable cardioverter-defibrillators (adjusted OR, 0.70; 95% CI, 0.65 to 0.75) but were as likely to receive discharge instructions, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, ß-blockers, and smoking cessation counseling at discharge. Although the median length of stay was 4 days, women were more likely than men to be hospitalized >4 days (adjusted OR, 1.13; 95% CI, 1.10 to 1.16) and >7 days (adjusted OR, 1.07; 95% CI, 1.04 to 1.11). Women had comparable in-hospital mortality to men (adjusted OR, 1.05; 95% CI, 0.96 to 1.14). CONCLUSIONS: Compared to men, women hospitalized for HF differ in many clinical characteristics and length of stay but have similar clinical presentations, receive similar quality of care for most but not all measures, and experience similar in-hospital mortality.

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

BACKGROUND: Effective collaboration and teamwork is essential to providing safe hospital care. The objective of this study was to assess the effect of an intervention designed to improve interdisciplinary collaboration and lower the rate of adverse events (AEs). METHODS: The study was a controlled trial of an intervention, Structured Inter-Disciplinary Rounds, implemented in 1 of 2 similar medical teaching units in a tertiary care academic hospital. The intervention combined a structured format for communication with a forum for regular interdisciplinary meetings. We conducted a retrospective medical record review evaluating 370 randomly selected patients admitted to the intervention and control units (n = 185 each) in the 24 weeks after and 185 admitted to the intervention unit in the 24 weeks before the implementation of Structured Inter-Disciplinary Rounds (N = 555). Medical records were screened for AEs. Two hospitalists confirmed the presence of AEs and assessed their preventability and severity in a masked fashion. We used multivariable Poisson regression models to compare the adjusted incidence of AEs in the intervention unit to that in concurrent and historic control units. RESULTS: The rate of AEs was 3.9 per 100 patient-days for the intervention unit compared with 7.2 and 7.7 per 100 patient-days, respectively, for the concurrent and historic control units (adjusted rate ratio, 0.54; P = .005; and 0.51; P = .001). The rate of preventable AEs was 0.9 per 100 patient-days for the intervention unit compared with 2.8 and 2.1 per 100 patient-days for the concurrent and historic control units (adjusted rate ratio, 0.27; P = .002; and 0.37; P = .02). The low number of AEs rated as serious or life-threatening precluded statistical analysis for differences in rates of events classified as serious or serious and preventable. CONCLUSION: Structured Inter-Disciplinary Rounds significantly reduced the adjusted rate of AEs in a medical teaching unit.

The association between night or weekend admission and hospitalization-relevant patient outcomes.

INTRODUCTION: Nights and weekends represent a potentially high-risk time for hospitalized patients. Data regarding night or weekend admission and its impact on outcomes is limited. We studied the association between night or weekend admission and outcomes. METHODS: We reviewed 857 admissions to the general medicine services from the emergency department (ED) at our tertiary care hospital for demographic information, time and day of admission, and hospitalization-relevant outcomes (length of stay [LOS], hospital charges, intensive care unit [ICU] transfer during hospitalization, repeat ED visit within 30 days, readmission within 30 days, and poor outcome [ICU transfer, cardiac arrest, or death] within the first 24 hours of admission). Outcomes were compared between groups using univariate and multivariate modeling. RESULTS: Complete data for analysis were available for 824 patients. A total of 58% of patients were admitted at night and 22% were admitted during the weekend. Patients admitted at night as compared to those admitted during the day had similar a LOS (4.1 vs. 4.3, P = 0.38), hospital charges (25,200 vs. 27,500, P = 0.17), ICU transfer during hospitalization (3% vs. 6%, P = 0.06), 30 day repeat ED visit (22% vs. 20%, P = 0.42), 30 day readmission (20% vs. 17%, P = 0.23), and poor outcomes within 24 hours of admission (1% vs. 2%, P = 0.15). Patients admitted during the weekend as compared to those admitted during the week had lower hospital charges and lower likelihood of an ICU transfer but were otherwise similar. CONCLUSION: Night or weekend admission was not associated with worse hospitalization-relevant outcomes at our tertiary care hospital.