ACR Appropriateness Criteria® Epigastric Pain.

Epigastric pain can have multiple etiologies including myocardial infarction, pancreatitis, acute aortic syndromes, gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, and hiatal hernia. This document focuses on the scenarios in which epigastric pain is accompanied by symptoms such as heartburn, regurgitation, dysphagia, nausea, vomiting, and hematemesis, which raise suspicion for gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, or hiatal hernia. Although endoscopy may be the test of choice for diagnosing these entities, patients may present with nonspecific or overlapping symptoms, necessitating the use of imaging prior to or instead of endoscopy. The utility of fluoroscopic imaging, CT, MRI, and FDG-PET for these indications are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Impact of localizing physicians to hospital units on nurse-physician communication and agreement on the plan of care.

BACKGROUND: A significant barrier to communication among patient care providers in hospitals is the geographic dispersion of team members. OBJECTIVE: To determine whether localizing physicians to specific patient care units improves nurse-physician communication and agreement on patients' plans of care. METHODS: We conducted structured interviews of a cross-sectional sample of nurses and physicians before and after an intervention to localize physicians to specific patient care units. Interviews characterized patterns of nurse-physician communication and assessed understanding of patients' plans of care. Two internists reviewed responses and rated nurse-physician agreement on six aspects of the plan of care as none, partial, or complete agreement. RESULTS: Three hundred eleven of 342 (91%) and 291 of 294 (99%) patients' nurses and 301 of 342 (88%) and 285 of 294 (97%) physicians completed the interview during the pre- and post-localization periods. Two hundred nine of 285 (73%) patients were localized to physicians' designated patient care units in the post-localization period. After localization, a higher percentage of patients' nurses and physicians was able to correctly identify one another (93% vs. 71%; p < 0.001 and 58% vs. 36%; p < 0.001, respectively). Nurses and physicians reported more frequent communication after localization (68% vs. 50%; p < 0.001 and 74% vs. 61%; p < 0.001, respectively). Nurse-physician agreement was significantly improved for two aspects of the plan of care: planned tests and anticipated length of stay. CONCLUSIONS: Although nurses and physicians were able to identify one another and communicated more frequently after localizing physicians to specific patient care units, there was little impact on nurse-physician agreement on the plan of care.

Implementation of unit-based interventions to improve teamwork and patient safety on a medical service.

In a prior study involving 2 medical units, Structured Interdisciplinary Rounds (SIDRs) improved teamwork and reduced adverse events (AEs). SIDR was implemented on 5 additional units, and a pre- versus postintervention comparison was performed. SIDR combined a structured format for communication with daily interprofessional meetings. Teamwork was assessed using the Safety Attitudes Questionnaire (score range = 0-100), and AEs were identified using queries of information systems confirmed by 2 physician researchers. Paired analyses for 82 professionals completing surveys both pre and post implementation revealed improved teamwork (mean 76.8 ± 14.3 vs 80.5 ± 11.6; P = .02), which was driven mainly by nurses (76.4 ± 14.1 vs 80.8 ± 10.4; P = .009). The AE rate was similar across study periods (3.90 vs 4.07 per 100 patient days; adjusted IRR = 1.08; P = .60). SIDR improved teamwork yet did not reduce AEs. Higher baseline teamwork scores and lower AE rates than the prior study may reflect a positive cultural shift that began prior to the current study.

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.

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.

Hospitalized patients' understanding of their plan of care.

OBJECTIVE: To evaluate hospitalized patients' understanding of their plan of care. PATIENTS AND METHODS: Interviews of a cross-sectional sample of hospitalized patients and their physicians were conducted from June 6 through June 26, 2008. Patients were asked whether they knew the name of the physician and nurse responsible for their care and specific questions about 6 aspects of the plan of care for the day (primary diagnosis, planned tests, planned procedures, medication changes, physician services consulted, and the expected length of stay). Physicians were interviewed and asked about the plan of care in the same fashion as for the patients. Two board-certified internists reviewed responses and rated patient-physician agreement on each aspect of the plan of care as none, partial, or complete agreement. RESULTS: Of 250 eligible patients, 241 (96%) agreed to be interviewed. A total of 233 (97%) of 241 physicians completed the interview, although sample sizes vary because of missing data elements. Of 239 patients, 77 (32%) correctly named at least 1 of their hospital physicians, and 143 patients (60%) correctly named their nurses. For each aspect of care, patients and physicians lacked agreement on the plan of care in a large number of instances. Specifically, there was no agreement between patients and physicians on planned tests or procedures for the day in 87 (38%) of 231 [corrected] instances and in 22 (10%) of 231 [corrected] instances. Complete agreement on the anticipated length of stay occurred in only 85 (39%) of 218 instances. CONCLUSION: A substantial portion of hospitalized patients do not understand their plan of care. Patients' limited understanding of their plan of care may adversely affect their ability to provide informed consent for hospital treatments and to assume their own care after discharge.

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

BACKGROUND: Deficits in information transfer between inpatient and outpatient physicians are common and potentially dangerous. OBJECTIVE: To evaluate the effect of a newly-created electronic discharge summary. DESIGN AND PARTICIPANTS: Pre-post evaluation of discharge summaries using a survey of outpatient physicians and a medical records review. MEASUREMENTS: Outpatient physicians' ratings of satisfaction with discharge summaries before and after implementation of an electronic discharge summary using a 5-point Likert scale (1 = very dissatisfied; 5 = very satisfied). Additionally, 196 randomly selected discharge summaries before and after implementation were rated for timeliness and presence of 16 key content areas by 3 internists. RESULTS: Two hundred and twenty-six of 416 (54%) and 256 of 397 (64%) outpatient physicians completed the baseline and postimplementation surveys. Satisfaction with quality and timeliness of discharge summaries improved with the use of the electronic discharge summary (mean quality rating 3.04 versus 3.64; P < 0.001, mean timeliness rating 2.59 versus 3.34; P < 0.001). A higher percentage of electronic discharge summaries were completed within 3 days of discharge as compared with dictated discharge summaries (44.8% versus 74.1%; P < 0.001). Several elements of the discharge summary were present more often with the electronic discharge summary, including discussion of follow-up issues (52.0% versus 75.8%; P = 0.001), pending test results (13.9% versus 46.3%; P < 0.001), and information provided to the patient and/or family (85.1% versus 95.8%; P = 0.01). CONCLUSIONS: The use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries.