Effectiveness of Healthcare Delivery, Quality, and Safety a Patient Education Bundle on Venous Thromboembolism Prophylaxis Administration by Sex.

INTRODUCTION: Venous thromboembolism (VTE) is a frequent cause of preventable harm among hospitalized patients. Many prescribed prophylaxis doses are not administered despite supporting evidence. We previously demonstrated a patient-centered education bundle improved VTE prophylaxis administration broadly; however, patient-specific factors driving nonadministration are unclear. We examine the effects of the education bundle on missed doses of VTE prophylaxis by sex. METHODS: We performed a post-hoc analysis of a nonrandomized controlled trial to evaluate the differences in missed doses by sex. Pre-intervention and intervention periods for patients admitted to 16 surgical and medical floors between 10/2014-03/2015 (pre-intervention) and 04/2015-12/2015 (intervention) were compared. We examined the conditional odds of (1) overall missed doses, (2) missed doses due to patient refusal, and (3) missed doses for other reasons. RESULTS: Overall, 16,865 patients were included (pre-intervention 6853, intervention 10,012), with 2350 male and 2460 female patients (intervention), and 6373 male and 5682 female patients (control). Any missed dose significantly reduced on the intervention floors among male (odds ratio OR 0.55; 95% confidence interval CI, 0.44-0.70, P < 0.001) and female (OR 0.59; 95% CI, 0.47-0.73, P < 0.001) patients. Similar significant reductions ensued for missed doses due to patient refusal (P < 0.001). Overall, there were no sex-specific differences (P-interaction >0.05). CONCLUSIONS: Our intervention increased VTE prophylaxis administration for both female and male patients, driven by decreased patient refusal. Patient education should be applicable to a wide range of patient demographics representative of the target group. To improve future interventions, quality improvement efforts should be evaluated based on patient demographics and drivers of differences in care.

Nonadministration of pharmacologic venous thromboembolism prophylaxis is less common in hospitalized patients with COVID-19.

INTRODUCTION: The incidence of venous thromboembolism (VTE) in patients hospitalized with COVID-19 is higher than most other hospitalized patients. Nonadministration of pharmacologic VTE prophylaxis is common and is associated with VTE events. Our objective was to determine whether nonadministration of pharmacologic VTE prophylaxis is more common in patients with COVID-19 versus other hospitalized patients. MATERIALS AND METHODS: In this retrospective cohort analysis of all adult patients discharged from the Johns hopkins hospital between Mar 1 and May 12, 2020, we compared demographic, clinical characteristics, VTE outcomes, prescription and administration of VTE prophylaxis between COVID-19 positive, negative, and not tested groups. RESULTS: Patients tested positive for COVID-19 were significantly older, and more likely to be Hispanic, have a higher median body mass index, have longer hospital length of stay, require mechanical ventilation, develop pulmonary embolism and die (all p < 0.001). COVID-19 patients were more likely to be prescribed (aOR 1.51, 95% CI 1.38-1.66) and receive all doses of prescribed pharmacologic VTE prophylaxis (aOR 1.48, 95% CI 1.36-1.62). The number of patients who missed at least one dose of VTE prophylaxis and developed VTE was similar between the three groups (p = 0.31). CONCLUSIONS: It is unlikely that high rates of VTE in COVID-19 are due to nonadministration of doses of pharmacologic prophylaxis. Hence, we should prioritize research into alternative approaches to optimizing VTE prevention in patients with COVID-19.

What Does Venous Thromboembolism Mean in the National Surgical Quality Improvement Program?

BACKGROUND: Venous thromboembolism (VTE) affects an estimated 350,000 to 600,000 individuals and causes approximately 100,000 deaths annually in the United States. Postoperative VTE is a core measure reported by The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP). The objective of this research was to assess the validity of VTE events reported by NSQIP. MATERIALS AND METHODS: This is a retrospective analysis using NSQIP data from January 2006 through December 2018 and the electronic health record system data from five adult hospitals in the Johns Hopkins Health System. We included patients aged 18 years and older with a VTE event identified in our NSQIP data set. The main outcome measure was the proportion of valid VTE events, defined as concordant between the NSQIP data set and medical chart review for clinical documentation. RESULTS: Of 474 patients identified in our NSQIP database with a VTE, 26 (5.5%) did not meet the strict NSQIP definition of VTE. Nine had a preoperative history of DVT and no new postoperative event, seven had a negative workup for VTE, six had a peripheral arterial thrombus, two did not receive or refused therapy, one had an aortic thrombus, and one had a venous thrombosis in a surgical flap. CONCLUSIONS: We identified a considerable number of surgical patients misclassified as having a VTE in NSQIP, when did not truly. This highlights the need to improve definition specificity and standardize processes involved in data extraction, validation, and reporting to provide unbiased data for use in quality improvement.

Individualized Performance Feedback to Surgical Residents Improves Appropriate Venous Thromboembolism Prophylaxis Prescription and Reduces Potentially Preventable VTE: A Prospective Cohort Study.

OBJECTIVE: To investigate the effect of providing personal clinical effectiveness performance feedback to general surgery residents regarding prescription of appropriate venous thromboembolism (VTE) prophylaxis. BACKGROUND: Residents are frequently charged with prescribing medications for patients, including VTE prophylaxis, but rarely receive individual performance feedback regarding these practice habits. METHODS: This prospective cohort study at the Johns Hopkins Hospital compared outcomes across 3 study periods: (1) baseline, (2) scorecard alone, and (3) scorecard plus coaching. All general surgery residents (n = 49) and surgical patients (n = 2420) for whom residents wrote admission orders during the first 9 months of the 2013-2014 academic year were included. Outcomes included the proportions of patients prescribed appropriate VTE prophylaxis, patients with preventable VTE, and residents prescribing appropriate VTE prophylaxis for every patient, and results from the Accreditation Council for Graduate Medical Education resident survey. RESULTS: At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis and only 45% of residents prescribed appropriate prophylaxis for every patient. During the scorecard period, appropriate VTE prophylaxis prescription significantly increased to 95.4% (P < 0.001). For the scorecard plus coaching period, significantly more residents prescribed appropriate prophylaxis for every patient (78% vs 45%, P = 0.0017). Preventable VTE was eliminated in both intervention periods (0% vs 0.35%, P = 0.046). After providing feedback, significantly more residents reported receiving data about practice habits on the Accreditation Council for Graduate Medical Education resident survey (87% vs 38%, P < 0.001). CONCLUSIONS: Providing personal clinical effectiveness feedback including data and peer-to-peer coaching improves resident performance, and results in a significant reduction in harm for patients.

Sustaining Reliability on Accountability Measures at The Johns Hopkins Hospital.

BACKGROUND: In 2012 Johns Hopkins Medicine leaders challenged their health system to reliably deliver best practice care linked to nationally vetted core measures and achieve The Joint Commission Top Performer on Key Quality Measures ®program recognition and the Delmarva Foundation award. Thus, the Armstrong Institute for Patient Safety and Quality implemented an initiative to ensure that ≥96% of patients received care linked to measures. Nine low-performing process measures were targeted for improvement-eight Joint Commission accountability measures and one Delmarva Foundation core measure. In the initial evaluation at The Johns Hopkins Hospital, all accountability measures for the Top Performer program reached the required ≥95% performance, gaining them recognition by The Joint Commission in 2013. Efforts were made to sustain performance of accountability measures at The Johns Hopkins Hospital. METHODS: Improvements were sustained through 2014 using the following conceptual framework: declare and communicate goals, create an enabling infrastructure, engage clinicians and connect them in peer learning communities, report transparently, and create accountability systems. One part of the accountability system was for teams to create a sustainability plan, which they presented to senior leaders. To support sustained improvements, Armstrong Institute leaders added a project management office for all externally reported quality measures and concurrent reviewers to audit performance on care processes for certain measure sets. CONCLUSIONS: The Johns Hopkins Hospital sustained performance on all accountability measures, and now more than 96% of patients receive recommended care consistent with nationally vetted quality measures. The initiative methods enabled the transition of quality improvement from an isolated project to a way of leading an organization.

Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.

BACKGROUND: Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS: We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS: Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS: DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

Maintaining and sustaining the On the CUSP: stop BSI model in Hawaii.

BACKGROUND: Hawaii joined the On the CUSP: Stop BSI national effort in the United States in 2009 (CUSP stands for Comprehensive Unit-based Safety Program). In the initial 18-month study evaluation, adult ICUs decreased central line-associated bloodstream infection (CLABSI) rates by 61%. The impact of a series of novel strategies/tools in reducing infections and sustaining the collaborative in ICUs and non-ICUs in Hawaii was assessed. METHODS: This cohort collaborative consisted of 20 adult ICUs and 18 nonadult ICUs in 16 hospitals. Hawaii developed and implemented six tools between July 2010 and August 2011: a tool to investigate CLABSIs, a video to address cultural barriers, a standardized dressing change kit, a map of the cohort's journey, a 12-strategies leadership dashboard, and a geometric plot of consecutive infection-free days. The primary outcome measure was overall CLABSI rates (mean infections per 1,000 catheter-days). RESULTS: A comparison of baseline data from 28 ICUs with 12-quarter (36-month) postimplementation data indicated that the CLABSI rate decreased across the entire state: overall, 1.57 to 0.29 infections/1,000 catheter-days; adult ICUs, 1.49 to 0.25 infections/1,000 catheter-days; nonadult ICUs, 2.54 to 0.33 infections/1,000 catheter-days, non-ICUs (N= 14), 4.52 to 0.25 infections/1,000 catheter-days, and PICU/NICU (N = 4), 2.05 to 0.53 infections/1,000 catheter-days. Days between CLABSIs in the adult ICUs statewide increased from a median of 5 days in 2009 to 70 days in 2011. DISCUSSION: Hawaii successfully spread the program beyond adult ICUs and implemented a series of tools for maintenance and sustainment. Use of the tools shaped a culture around the continued belief that CLABSIs can be eradicated, and infections further reduced.

A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units*.

OBJECTIVES: To determine the causal effects of an intervention proven effective in pre-post studies in reducing central line-associated bloodstream infections in the intensive care unit. DESIGN: We conducted a multicenter, phased, cluster-randomized controlled trial in which hospitals were randomized into two groups. The intervention group started in March 2007 and the control group started in October 2007; the study period ended September 2008. Baseline data for both groups are from 2006. SETTING: Forty-five intensive care units from 35 hospitals in two Adventist healthcare systems. INTERVENTIONS: A multifaceted intervention involving evidence-based practices to prevent central line-associated bloodstream infections and the Comprehensive Unit-based Safety Program to improve safety, teamwork, and communication. MEASUREMENTS AND RESULTS: We measured central line-associated bloodstream infections per 1,000 central line days and reported quarterly rates. Baseline average central line-associated bloodstream infections per 1,000 central line days was 4.48 and 2.71, for the intervention and control groups (p = .28), respectively. By October to December 2007, the infection rate declined to 1.33 in the intervention group compared to 2.16 in the control group (adjusted incidence rate ratio 0.19; p = .003; 95% confidence interval 0.06-0.57). The intervention group sustained rates <1/1,000 central line days at 19 months (an 81% reduction). The control group also reduced infection rates to <1/1,000 central line days (a 69% reduction) at 12 months. CONCLUSIONS: This study demonstrated a causal relationship between the multifaceted intervention and the reduced central line-associated bloodstream infections. Both groups decreased infection rates after implementation and sustained these results over time, replicating the results found in previous, pre-post studies of this multifaceted intervention and providing further evidence that most central line-associated bloodstream infections are preventable.

Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center.

BACKGROUND: Briefings and debriefings, previously shown to be a practical and feasible strategy to improve interdisciplinary communication and teamwork in the operating room (OR), was then assessed as a strategy to prospectively surface clinical and operational defects in surgical care--and thereby prevent patient harm. METHODS: A one-page, double-sided briefing and debriefing tool was used by surgical teams during cases at the William Beaumont Hospital Royal Oak (Royal Oak, Michigan) campus to surface clinical and operational defects during the study period (October 2006-May 2010). Defects were coded into six categories (with each category stratified by briefing or debriefing period) during the first six months, and refinement of coding resulted in expansion to 16 defect categories and no further stratification. A provider survey was used in January 2008 to interview a sample of 40 caregivers regarding the perceived effectiveness of the tool in surfacing defects. FINDINGS: The teams identified a total of 6,202 defects--an average of 141 defects per month--during the entire study period. Of 2,760 defects identified during the six-defect coding period, 1,265 (46%) surfaced during briefings, and the remaining 1,495 (54%) during debriefings. Equipment (48%) and communication (31%) issues were most prominent. Of 3,442 defects identified during the 16-defect coding period, the most common were Central Processing Department (CPD) instrumentation (22%) and Communication/Safety (15%). Overall, 70 (87%) of the 80 responses were in agreement that briefings were effective for surfacing defects, as were 59 (76%) of the 78 responses for debriefings. CONCLUSIONS: Briefings and debriefings were a practical and effective strategy to surface potential surgical defects in the operating rooms of a large medical center.

Using the Opportunity Estimator tool to improve engagement in a quality and safety intervention.

Teams throughout the United States participating in a program to reduce central line-associated bloodstream infections (CLABSIs) are using the Opportunity Estimator. This web-based tool translates CLABSI-related data into "opportunity estimates" of the patient lives and money that could be saved by reducing these infections.

Lessons Learned From Rapid Deployment of 100% Mortality Review for Patients With COVID-19 Across a Health System.

Mortality review is one approach to systematically examine delivery of care and identify areas for improvement. Health system leaders sought to ensure hospitals were adapting to the rapidly changing medical guidance for COVID-19 and delivering high-quality care. Thus, all patients with a COVID-19 diagnosis within the 6-hospital system who died between March and July 2020 were reviewed within 72 hours. Concerns for preventability advanced review to level 2 (content experts) or 3 (hospital leadership). Reviews included available autopsy and cardiac arrest data. Overall health system mortality for COVID-19 patient admissions was 12.5% and mortality for mechanically ventilated patients was 34.4%. Significant differences in mortality rates were observed among hospitals due to demographic variations in patient populations at hospitals. Mortality reviews resulted in the dissemination of evolving knowledge among sites using an electronic medical record order set, implementation of proning teams, and development of checklists for converting COVID-19 floors and units.

Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial.

Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.

Assessing and improving safety climate in a large cohort of intensive care units.

OBJECTIVES: To evaluate the impact of a comprehensive unit-based safety program on safety climate in a large cohort of intensive care units participating in the Keystone intensive care unit project. DESIGN/SETTING: A prospective cohort collaborative study to improve quality of care and safety culture by implementing and evaluating patient safety interventions in intensive care units predominantly in the state of Michigan. INTERVENTIONS: The comprehensive unit-based safety program was the first intervention implemented by every intensive care unit participating in the collaborative. It is specifically designed to improve the various elements of a unit's safety culture, such as teamwork and safety climate. We administered the validated Safety Attitudes Questionnaire at baseline (2004) and after 2 yrs of exposure to the safety program (2006) to assess improvement. The safety climate domain on the survey includes seven items. MEASUREMENTS AND MAIN RESULTS: Post-safety climate scores for intensive care units. To interpret results, a score of <60% was in the "needs improvement" zone and a ≥10-point discrepancy in pre-post scores was needed to describe a difference. Hospital bed size, teaching status, and faith-based status were included in our analyses. Seventy-one intensive care units returned surveys in 2004 and 2006 with 71% and 73% response rates, respectively. Overall mean safety climate scores significantly improved from 42.5% (2004) to 52.2% (2006), t = -6.21, p < .001, with scores higher in faith-based intensive care units and smaller-bed-size hospitals. In 2004, 87% of intensive care units were in the "needs improvement" range and in 2006, 47% were in this range or did not score ≥10 points or higher. Five of seven safety climate items significantly improved from 2004 to 2006. CONCLUSIONS: A patient safety program designed to improve teamwork and culture was associated with significant improvements in overall mean safety climate scores in a large cohort of 71 intensive care units. Research linking improved climate scores and clinical outcomes is a critical next step.

Overview of progress in patient safety.

In the 11 years since the Institute of Medicine reported ubiquitous problems with the quality and safety of patient care in the United States, efforts been made to improve health care. Obstetrics and gynecology has made some improvements; however, similar to other areas of health care, progress has been slow. The major deterrents are complexities in our health care system and culture and an immature science of safety and quality that makes measurement and evaluation of progress difficult. This article describes the efforts that have been made in obstetrics and gynecology to identify causes or factors that contribute to adverse outcomes, to develop measures of quality and safety, and to make improvements. It also offers a framework to help organize patient safety research and improvement. Finally, this article offers ways the American Congress of Obstetricians and Gynecologists can organize and support future work.

Republished paper: assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

OBJECTIVES To describe the authors' hospital-wide efforts to improve safety climate at a large academic medical centre. DESIGN AND SETTING A prospective cohort study used multiple interventions to improve hospital-wide safety climate. 144 clinical units in an urban academic medical centre are included in this analysis. Interventions The comprehensive unit-based safety programme included steps to identify hazards, partner units with a senior executive to fix hazards, learn from defects, and implement communication and teamwork tools. Hospital-level interventions were also implemented. Main outcome measures Safety climate was assessed annually using the safety attitudes questionnaire. The safety culture goal was to meet or exceed the 60% minimum positive score or improve the score by ≥10 points. RESULTS Response rates were 77% (2006) and 79% (2008). For safety climate, 55% of units in 2006 and 82% in 2008 achieved the culture goal. For teamwork climate, 61% of units in 2006 and 83% in 2008 achieved the culture goal. The mean safety climate improvement (difference score) for 79 units at or above 60% in 2006 was 0.201 in 2008; the mean improvement for the 65 units below the threshold was 18.278. The mean teamwork climate improvement (difference score) for the 89 units at or above 60% in 2006 was 0.452 in 2008; the mean improvement for the 55 units below the threshold was 16.176. Climate scores improved significantly from 2006 to 2008 in every domain except stress recognition. CONCLUSIONS Hospital-wide interventions were associated with improvements in safety climate at a large academic medical centre.

Systematic Undercoding of Diagnostic Procedures in National Inpatient Sample (NIS): A Threat to Validity Due to Surveillance Bias.

BACKGROUND AND OBJECTIVES: Health services research often relies on readily available data, originally collected for administrative purposes and used for public reporting and pay-for-performance initiatives. We examined the prevalence of underreporting of diagnostic procedures for acute myocardial infarction (AMI), deep venous thrombosis (DVT), and pulmonary embolism (PE), used for public reporting and pay-for-performance initiatives. METHOD: We retrospectively identified procedures for AMI, DVT, and PE in the National Inpatient Sample (NIS) database between 2012 and 2016. From January 1, 2012, through September 30, 2015, the NIS used the International Classification of Diseases, Ninth Revision (ICD-9) coding scheme. From October 1, 2015, through December 31, 2016, the NIS used the International Classification of Diseases, Tenth Revision (ICD-10) coding scheme. We grouped the data by ICD code definitions (ICD-9 or ICD-10) to reflect these code changes and to prevent any confounding or misclassification. In addition, we used survey weighting to examine the utilization of venous duplex ultrasound scan for DVT, electrocardiogram (ECG) for AMI, and chest computed tomography (CT) scan, pulmonary angiography, echocardiography, and nuclear medicine ventilation/perfusion () scan for PE. RESULTS: In the ICD-9 period, by primary diagnosis, only 0.26% (n = 5930) of patients with reported AMI had an ECG. Just 2.13% (n = 7455) of patients with reported DVT had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 1.92% (n = 12 885) had pulmonary angiography, 3.92% (n = 26 325) had CT scan, 5.31% (n = 35 645) had cardiac ultrasound scan, and 0.45% (n = 3025) had scan. In the ICD-10 period, by primary diagnosis, 0.04% (n = 345) of reported AMI events had an ECG and 0.91% (n = 920) of DVT events had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 2.08% (n = 4805) had pulmonary angiography, 0.63% (n = 1460) had CT scan, 1.68% (n = 3890) had cardiac ultrasound scan, and 0.06% (n = 140) had scan. Small proportions of diagnostic procedures were observed for any diagnoses of AMI, DVT, or PE. CONCLUSIONS: Our findings question the validity of using NIS and other administrative databases for health services and outcomes research that rely on certain diagnostic procedures. Unfortunately, the NIS does not provide granular data that can control for differences in diagnostic procedure use, which can lead to surveillance bias. Researchers and policy makers must understand and acknowledge the limitations inherent in these databases, when used for pay-for-performance initiatives and hospital benchmarking.

Audit and Feedback to Surgery Interns and Residents on Prescribing Risk-Appropriate Venous Thromboembolism Prophylaxis.

OBJECTIVE: To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. DESIGN: Prospective cohort study. SETTING: The Johns Hopkins Hospital, an urban academic medical center. PARTICIPANTS: All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. INTERVENTION: Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. RESULTS: During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). CONCLUSIONS AND RELEVANCE: Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.

Needlestick injuries among surgeons in training.

BACKGROUND: Surgeons in training are at high risk for needlestick injuries. The reporting of such injuries is a critical step in initiating early prophylaxis or treatment. METHODS: We surveyed surgeons in training at 17 medical centers about previous needlestick injuries. Survey items inquired about whether the most recent injury was reported to an employee health service or involved a "high-risk" patient (i.e., one with a history of infection with human immunodeficiency virus, hepatitis B or hepatitis C, or injection-drug use); we also asked about the perceived cause of the injury and the surrounding circumstances. RESULTS: The overall response rate was 95%. Of 699 respondents, 582 (83%) had had a needlestick injury during training; the mean number of needlestick injuries during residency increased according to the postgraduate year (PGY): PGY-1, 1.5 injuries; PGY-2, 3.7; PGY-3, 4.1; PGY-4, 5.3; and PGY-5, 7.7. By their final year of training, 99% of residents had had a needlestick injury; for 53%, the injury had involved a high-risk patient. Of the most recent injuries, 297 of 578 (51%) were not reported to an employee health service, and 15 of 91 of those involving high-risk patients (16%) were not reported. Lack of time was the most common reason given for not reporting such injuries among 126 of 297 respondents (42%). If someone other than the respondent knew about an unreported injury, that person was most frequently the attending physician (51%) and least frequently a "significant other" (13%). CONCLUSIONS: Needlestick injuries are common among surgeons in training and are often not reported. Improved prevention and reporting strategies are needed to increase occupational safety for surgical providers.

Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit.

BACKGROUND: A culture of teamwork and learning from mistakes are universally acknowledged as essential factors to improve patient safety. Both are part of the Comprehensive Unit-based Safety Program (CUSP), which improved safety in intensive care units but had not been evaluated in other inpatient settings. METHODS: CUSP was implemented beginning in February 2008 on an 18-bed surgical floor at an academic medical center to improve patient safety, nurse/physician collaboration, and safety on the unit. This unit admits three to six patients per day from up to eight clinical services. RESULTS: Staff implemented several interventions to reduce safety hazards and improve culture. Surgical patients admitted to one clinical service were cohorted on this unit to increase physician presence. A team-based goals sheet was implemented to improve communication and coordination of daily goals of care. Nurses were included on rounds to form an interdisciplinary team. Five of six culture domain scores demonstrated significant improvements from 2006 and 2007 to 2008. There was a 27% nurse turnover rate in 2006 and a 0% turnover rate in 2007 and 2008. CONCLUSIONS: Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on a surgical inpatient unit after implementing a safety program. As part of the CUSP process, staff described safety hazards and then as a team designed and implemented several interventions. CUSP is sufficiently structured to provide a strategy for health care organizations to improve culture and learn from mistakes, yet is flexible enough for units to focus on risks that they perceive as most important, given their context. Broad use of this program throughout health systems could arguably produce substantial improvements in patient safety.