Why can't we improve turnover time? A systematic review.

BACKGROUND: Despite substantial efforts to reduce operating room (OR) turnover time (TOT), delays remain a frustration to physicians, staff, and hospital leadership. These efforts have employed many systems and human factor-based approaches with variable results. A deeper dive into methodologies and their applicability could lead to successful and sustained change. The aim of this study was to conduct a systematic review to evaluate relevant research focused on improving OR TOT and clearly defining measures of successful intervention. MATERIAL AND METHODS: A systematic review of OR TOT interventions implemented between 1980 through October 2022 was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Research databases included: 1) PubMed; 2) Web of Science; and 3) OVID Medline. RESULTS: A total of 38 articles were appropriate for analysis. Most employed a pre/post intervention approach (29, 76.3%), the remaining utilized a control/intervention approach. Nine intervention methods were identified: the majority included a process redesign bundle (24, 63%), followed by overlapping induction, dedicated unit/team/space feedback, financial incentives, team training, education, practice guidelines, and redefinition of roles/responsibilities. Studies were further categorized into one of two groups: (1) those that utilized predetermined interventions based on anecdotal experience or prior literature (18, 47.4%) and (2) those that conducted a prospective analysis on baseline data to inform intervention development (20, 52.6%). DISCUSSION: There are significant variability in the methodologies utilized to improve OR TOT; however, the most effective solutions involved process redesign bundles developed from a prospective investigation of the clinical work-system.

A Human Factors Approach to Vaginal Retained Foreign Objects.

STUDY OBJECTIVE: This study aimed to apply a structured human factors analysis to understand conditions contributing to vaginal retained foreign objects (RFOs). DESIGN: All potential vaginal RFO events from January 1, 2000, to May 21, 2019, were analyzed by trained human factors researchers. Each narrative was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare. SETTING: An 890-bed, academic medical center in Southern California. PATIENTS: Patients who underwent a vaginal procedure in which a vaginal RFO-related event occurred were included in this study. However, no patient information was included, and only the relevant details from their procedures were included. INTERVENTIONS: No interventions were developed or implemented. MEASUREMENTS AND MAIN RESULTS: Over the 19-year period, 45 events were reported. The most common items were vaginal packing and vaginal sponges (53.33%). Less frequently retained items involved broken instruments (20.20%). Most cases were laparoscopic hysterectomies or vaginal deliveries. Based on the Human Factors Analysis and Classification System, 75 contributing factors were identified, consisting primarily of preconditions for unsafe acts (communication challenges, coordination breakdowns and issues with the design of tools/technology) and unsafe acts (errors). CONCLUSION: Although rare, vaginal RFOs do occur. The top 2 contributing factors were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.

Enhancing POLST Completion in a Hospital Setting: An Interdisciplinary Approach.

EXECUTIVE SUMMARY: With increased therapeutic capabilities in healthcare today, many patients with multiple progressive comorbidities are living longer. They experience recurrent hospitalizations and often undergo procedures that are not aligned with their personal goals. That is why it is essential to discuss and document healthcare preferences prior to an acute event when significant interventions could occur, especially for patients with serious and progressive illness. Completion of an advance directive and a physician order for life-sustaining treatment (POLST) supports provision of goal-concordant care. Further, for patients who have do not attempt resuscitation (DNAR) orders or are diagnosed with advanced dementia, having a POLST is essential. This may be best accomplished with hospitalization discharge plans. Our 896-bed academic medical center, Cedars-Sinai Medical Center, launched a quality initiative in 2015 to complete POLSTs for patients being discharged with DNAR status or with dementia returning to a skilled nursing facility. As part of interdisciplinary progression of care rounds, emphasis was placed on those patients for whom POLST completion was indicated. Proactive, facilitated discussions with patients, family members, and attending physicians were initiated to support POLST completion. The completed forms were then uploaded to the electronic health record. Individual units and physicians received regular feedback on POLST completion rates, and the data were later shared at medical staff quality improvement meetings.During the initiative, POLST completion rates for DNAR patients discharged alive rose from 41% in fiscal year (FY) 2014 to 75% in FY 2019. Similar improvement was seen for patients with dementia discharged to skilled nursing facilities, regardless of code status (rising from 14% in FY 2014 to 54% in FY 2019). Subsequently, we have expanded our efforts to include early discussion and completion of these advanced care planning documents for patients recently diagnosed with high mortality cancers (ovarian, pancreatic, lung, glioblastoma), focusing on the completion of advanced care planning documentation and palliative care referrals.

Extracorporeal Membrane Oxygenation Appropriateness: An Interdisciplinary Consensus-Based Approach.

We describe a quality improvement initiative aimed at achieving interdisciplinary consensus about the appropriate delivery of extracorporeal membrane oxygenation (ECMO). Interdisciplinary rounds were implemented for all patients on ECMO and addressed whether care was consistent with a patient's minimally acceptable outcome, maximally acceptable burden, and relative likelihood of achieving either. The rounding process was associated with decreased days on venoarterial ECMO, from a median of 6 days in 2014 (first quartile [Q1]-third quartile [Q3], 3-10) to 5 days in 2015 (Q1-Q3, 2.5-8) and in 2016 (Q1-Q3, 1-8). Our statistical methods do not allow us to conclude that this change was due to our intervention, and it is possible that the observed decreases would have occurred whether or not the rounding process was implemented.

Timing of Chemical Thromboprophylaxis and Deep Vein Thrombosis in Major Colorectal Surgery: A Randomized Clinical Trial.

OBJECTIVE: To identify the optimal timing of perioperative chemical thromboprophylaxis (CTP) and incidence of occult preoperative deep vein thrombosis (OP-DVT) in patients undergoing major colorectal surgery. BACKGROUND: There is limited Level 1 data regarding the optimal timing of CTP in major colorectal surgery and the incidence of OP-DVT remains unclear. Both issues influence the occurrence of venous thromboembolism (VTE) and may impact Medicare reimbursement because of penalties for hospital-acquired conditions. METHODS: Patients undergoing major colorectal surgery underwent preoperative lower extremity venous duplex (LEVD) immediately before surgery. Those without OP-DVT were randomized to preoperative or postoperative CTP with 5000 units of subcutaneous heparin. Patients underwent repeat LEVD in the recovery room and on postoperative day 2. Outcome measures included early (48-hrs) and overall (30-days) postoperative VTE, bleeding complications, and OP-DVT. RESULTS: Eighteen patients (4.2%) had OP-DVT and were excluded. The randomized group included 376 patients (51.6% female) with mean age of 52.7 ±â€Š17.6 years. No pulmonary embolism occurred. There was no significant difference in preoperative versus postoperative CTP with respect to early postoperative DVT [3/184 (1.6%) vs 5/192 (2.6%); P = 0.72], DVT at 30 days (1.6% vs 3.6%; P = 0.34) or bleeding complications requiring reoperation (0.5% vs 1.6%; P = 0.62). CONCLUSIONS: The risk of OP-DVT is higher than that of perioperative DVT after colorectal surgery and preoperative screening LEVD should be considered to identify and treat patients at risk for pulmonary embolism. Preoperative and postoperative CTP are equally safe in protecting against VTE. CMS should account for these factors when assigning financial disincentives for perioperative VTE. TRIAL REGISTRATION: Clinicaltrials.gov #NCT01976988.

Efficacy and Safety of Glutamine-supplemented Parenteral Nutrition in Surgical ICU Patients: An American Multicenter Randomized Controlled Trial.

OBJECTIVE: To determine whether glutamine (GLN)-supplemented parenteral nutrition (PN) improves clinical outcomes in surgical intensive care unit (SICU) patients. SUMMARY BACKGROUND DATA: GLN requirements may increase with critical illness. GLN-supplemented PN may improve clinical outcomes in SICU patients. METHODS: A parallel-group, multicenter, double-blind, randomized, controlled clinical trial in 150 adults after gastrointestinal, vascular, or cardiac surgery requiring PN and SICU care. Patients were without significant renal or hepatic failure or shock at entry. All received isonitrogenous, isocaloric PN [1.5 g/kg/d amino acids (AAs) and energy at 1.3× estimated basal energy expenditure]. Controls (n = 75) received standard GLN-free PN (STD-PN); the GLN group (n = 75) received PN containing alanyl-GLN dipeptide (0.5 g/kg/d), proportionally replacing AA in PN (GLN-PN). Enteral nutrition (EN) was advanced and PN weaned as indicated. Hospital mortality and infections were primary endpoints. RESULTS: Baseline characteristics, days on study PN and daily macronutrient intakes via PN and EN, were similar between groups. There were 11 hospital deaths (14.7%) in the GLN-PN group and 13 deaths in the STD-PN group (17.3%; difference, -2.6%; 95% confidence interval, -14.6% to 9.3%; P = 0.66). The 6-month cumulative mortality was 31.4% in the GLN-PN group and 29.7% in the STD-PN group (P = 0.88). Incident bloodstream infection rate was 9.6 and 8.4 per 1000 hospital days in the GLN-PN and STD-PN groups, respectively (P = 0.73). Other clinical outcomes and adverse events were similar. CONCLUSIONS: PN supplemented with GLN dipeptide was safe, but did not alter clinical outcomes among SICU patients.

High-value care in the surgical intensive care unit: effect on ancillary resources.

BACKGROUND: Changes in health care policies have influenced transformations in hospital systems to be cost-efficient while maintaining robust outcomes. This is particularly important in intensive care units where significant resources are used to care for critically ill patients. We sought to determine whether high-value care processes (HVCp) implemented in a surgical intensive care unit (SICU) have an impact on commonly used ancillary tests. MATERIALS AND METHODS: An implementation phase using a Lean Six Sigma approach was performed in October 2014 at a 24-bed large academic center SICU with aims to decrease orders of excessive daily laboratory tests and X-rays. The HVCp implemented included use of daily checklists, staff education, and visual reminders emphasizing the importance of appropriate laboratory tests and chest X-rays. Preintervention (July 2014-October 2014) and post-intervention (November 2014-June 2015) phases were compared. RESULTS: Average SICU census, case mix index (4.3 versus 4.4, P = 0.57), all patient refined severity of illness (3.2 versus 3.2, P = 0.91), and SICU mortality (7.1% versus 5.1%, P = 0.18) were similar in both phases. A significant reduction of excessive laboratory tests was evident after the implementation period. Eight hundred sixty-five arterial blood gases/mo were obtained in the preintervention phase compared with 420 arterial blood gases/mo after intervention (P = 0.004), representing a 51.4% reduction. Similar results were obtained with complete blood counts, basic metabolic profiles, coagulation profiles, and chest X-rays (12%, 17.8%, 30.2%, and 20.3% reductions, respectively), a total estimated cost savings of $59,137/mo and prevention of excess phlebotomy of approximately 4 L of blood/mo. CONCLUSIONS: By implementing an HVCp including a checklist, visual reminders, and provider education, we significantly reduced the use of commonly ordered ancillary tests in the SICU without affecting outcomes, resulting in an annual cost savings of $710,000.

Understanding ultrarare adverse events - Lessons learned from a twelve-year review of intraoperative deaths at an academic medical center.

BACKGROUND: Intraoperative death (ID) is rare, the incidence remains challenging to quantify and learning opportunities are limited. We aimed to better define the demographics of ID by reviewing the longest single-site series. METHODS: Retrospective chart reviews, including a review of contemporaneous incident reports, were performed on all ID between March 2010 to August 2022 at an academic medical center. RESULTS: Over 12 years, 154 IDs occurred (∼13/year, average age: 54.3 years, male: 60%). Most occurred during emergency procedures (n = 115, 74.7%), 39 (25.3%) during elective procedures. Incident reports were submitted in 129 cases (84%). 21 (16.3%) reports cited 28 contributing factors including challenges with coordination (n = 8, 28.6%), skill-based errors (n = 7, 25.0%), and environmental factors (n = 3, 10.7%). CONCLUSIONS: Most deaths occurred in patients admitted from the ER with general surgical problems. Despite expectations for incident reporting, few provided actionable information on ergonomic factors which might help identify improvement opportunities.

'Physician advocates': a novel strategy for improving the value of hospital care by employing hospitalists part time to support non-hospitalist physicians.

BACKGROUND AND OBJECTIVE: At many hospitals, private-practice physicians still admit their own patients and are accustomed to autonomy in clinical practice. This creates challenges for hospital's efforts to improve the efficiency, quality, and value of care. Experienced inpatient-focused physicians - 'Physician Advocates' - could act as liaisons between private practitioners and the fast-paced inpatient microsystem. METHODS: We conducted a controlled pre-post ('differences-in-differences') analysis at an academic medical center where private-practice physicians care for about 40% of medical inpatients and hospitalist groups care for 60%. In the intervention, 'Physician Advocates' participated in daily multidisciplinary 'Progression of Care Rounds,' offering suggestions to increase care quality for private-practice physicians' patients. Controls were cared for by a large, well-established hospitalist group, which convened separate, unchanged multidisciplinary rounds. Outcomes were length of stay (LOS; primary outcome), 30-day readmissions, and inpatient mortality. RESULTS: In a risk-adjusted analysis of 31,632 medical inpatients, LOS declined by 4 hours more from the baseline period to the post-intervention period in the intervention group relative to the control group (ratio: 0.96, 95% CI: 0.93-0.99, p = 0.004). Readmissions declined 22% more in the intervention group (OR: 0.78, 95% CI: 0.63-0.97, p = 0.023). Mortality was unchanged (OR: 1.23, 95% CI: 0.78-1.93 p-value = 0.378). CONCLUSION: Among inpatients cared for by private practitioners, adding Physician Advocates to multidisciplinary rounds was associated with improved LOS and reduced readmissions - measures of efficiency and value. The Physician Advocates approach should be tested in diverse health systems because it allows hospitals to leverage the expertise of on-site clinicians while respecting the traditional private-practice care model, in which primary care physicians manage their hospitalized patients.

Surgical Supply Cost Awareness Is Associated With Lower Costs: A Single-Center Experience.

Surgeons are often unfamiliar with the costs of surgical instrumentation and supplies. We hypothesized that surgeon cost feedback would be associated with a reduction in cost. A multidisciplinary team evaluated surgical supply costs for laparoscopic appendectomies of 7 surgeons (surgeons A-G) at a single-center academic institution. In the intervention, each surgeon was debriefed with their average supply cost per case, their partner's average supply cost per case, the cost of each surgical instrument/supply, and the cost of alternatives. In addition, the laparoscopic appendectomy tray was standardized to remove extraneous instruments. Pre-intervention (March 2017-February 2018) and post-intervention (March 2018-October 2018) costs were compared. Pre-intervention, the surgeons' average supply cost per case ranged from $754-$1189; when ranked from most to least expensive, surgeon A > B > C > D > E > F > G. Post-intervention, the surgeons' average supply cost per case ranged from $676 to $846, and ranked from surgeon G > D > F > C > E > B > A. Overall, the average cost per case was lower in the post-intervention group ($854.35 vs. $731.11, P < .001). This resulted in savings per case of $123.24 (14.4%), to a total annualized savings of $29 151.

Role of heat shock protein and cytokine expression as markers of clinical outcomes with glutamine-supplemented parenteral nutrition in surgical ICU patients.

BACKGROUND: Nutrients, such as glutamine (GLN), have been shown to effect levels of a family of protective proteins termed heat shock proteins (HSPs) in experimental and clinical critical illness. HSPs are believed to serve as extracellular inflammatory messengers and intracellular cytoprotective molecules. Extracellular HSP70 (eHSP70) has been termed a chaperokine due to ability to modulate the immune response. Altered levels of eHSP70 are associated with various disease states. Larger clinical trial data on GLN effect on eHSP expression and eHSP70's association with inflammatory mediators and clinical outcomes in critical illness are limited. OBJECTIVE: Explore effect of longitudinal change in serum eHSP70, eHSP27 and inflammatory cytokine levels on clinical outcomes such as pneumonia and mortality in adult surgical intensive care unit (SICU) patients. Further, evaluate effect of parenteral nutrition (PN) supplemented with GLN (GLN-PN) versus GLN-free, standard PN (STD-PN) on serum eHSP70 and eHSP27 concentrations. METHODS: Secondary observational analysis of a multicenter clinical trial in 150 adults after cardiac, vascular, or gastrointestinal surgery requiring PN support and SICU care conducted at five academic medical centers. Patients received isocaloric, isonitrogenous PN, with or without GLN dipeptide. Serum eHSP70 and eHSP27, interleukin-6 (IL-6), and 8 (IL-8) concentrations were analyzed in patient serum at baseline (prior to study PN) and over 28 days of follow up. RESULTS: eHSP70 declined over time in survivors during 28 days follow-up, but non-survivors had significantly higher eHSP70 concentrations compared to survivors. In patients developing pneumonia, eHSP70, eHSP27, IL-8, and IL-6 were significantly elevated. Adjusted relative risk for hospital mortality was reduced 75% (RR = 0.25, p = 0.001) for SICU patients with a faster decline in eHSP70. The area under the receiver operating characteristic curve was 0.85 (95% CI: 0.76 to 0.94) for the final model suggesting excellent discrimination between SICU survivors and non-survivors. GLN-PN did not alter eHSP70 or eHSP27 serum concentrations over time compared to STD-PN. CONCLUSION: Our results suggest that serum HSP70 concentration may be an important marker for severity of illness and likelihood of recovery in the SICU. GLN-supplemented-PN did not increase eHSP70.

Differences in salivary habituation to a taste stimulus in bariatric surgery candidates and normal-weight controls.

BACKGROUND: Previous studies show that slower habituation to taste stimuli is associated with reduced rates of satiation and greater energy intake. This study compared rates of salivary habituation to gustatory presentations of lemon juice in 34 severely obese bariatric surgery candidates [48.8 +/- 7.9 years, 85% female, body mass index (BMI) = 47.4 +/- 7.5 kg/m(2)] and 18 normal-weight controls (48.4 +/- 9.5 years, 88.9% female, BMI = 22.7 +/- 1.2 kg/m(2)). METHODS: Parotid saliva was collected from cotton rolls positioned in the oral cavity during two baseline water trials and ten lemon juice trials. Data were condensed into trial blocks, representing mean values for the two baseline water trials and each of five pairs of lemon juice trials (i.e., blocks 1-5). Salivary change across lemon juice trials was calculated by subtracting values for blocks 1 through 5 from baseline. RESULTS: A significant interaction of group (bariatric surgery candidates/normal-weight controls) by blocked trials [F (4, 200) = 3.0; p < 0.05] indicated that the groups differed in their pattern of salivary responding, with bariatric surgery candidates' salivation (grams) failing to decrease significantly over the five blocked trials (-0.47 +/- 0.18, p = 0.12), unlike that of the normal-weight controls (-1.30 +/- 0.25, p < 0.001). CONCLUSION: These findings suggest that severely obese participants' rate of salivary habituation to a taste stimulus is delayed compared to normal-weight controls. This provides support that satiation in bariatric surgery candidates is impaired, possibly leading to increased energy intake and positive energy balance.

Variability in Critical Care-Related Charge Markups in Medicare Patients.

Charge markups for health care are variable and inflated several times beyond cost. Using the 2015 Medicare Provider Fee-For-Service Utilization and Payment Data file, we identified providers who billed for critical care hours and related procedures, including CPR, EKG interpretation, central line placement, arterial line placement, chest tube/thoracentesis, and emergent endotracheal intubation. Markup ratios (MRs), defined as the amount charged divided by the amount allowable, were calculated and compared; 42.1 per cent of physicians billing for critical care-related services were specialized in emergency medicine (EM). EM had the highest overall MR (median 4.99, IQR 3.60-6.88) and provided most of the services. MRs differed between genders in select cases (critical care hours: anesthesiology, EM, internal medicine, pulmonary and critical care medicine; CPR, pulmonary and critical care medicine; chest tube placement/thoracentesis, internal medicine). These differences in MR did not correspond to higher rates of Medicare allowable amounts (P = NS). In conclusion, charge markups significantly varied by physician specialty. EM physicians had the highest MRs for most critical care-related services, including critical care hours, EKG interpretation, CPR, central venous line placement, and emergent endotracheal intubation. EM physicians also provided most of these services. Charge markups are associated with adverse consequences and represent potential targets for cost containment and consumer protection.

Choosing Wisely clinical decision support adherence and associated inpatient outcomes.

OBJECTIVES: To determine whether utilization of clinical decision support (CDS) is correlated with improved patient clinical and financial outcomes. STUDY DESIGN: Observational study of 26,424 patient encounters. In the treatment group, the provider adhered to all CDS recommendations. In the control group, the provider did not adhere to CDS recommendations. METHODS: An observational study of provider adherence to a CDS system was conducted using inpatient encounters spanning 3 years. Data comprised alert status (adherence), provider type (resident, attending), patient demographics, clinical outcomes, Medicare status, and diagnosis information. We assessed the associations between alert adherence and 4 outcome measures: encounter length of stay, odds of 30-day readmission, odds of complications of care, and total direct costs. The associations between alert adherence and the outcome measures were estimated using 4 generalized linear models that adjusted for potential confounders, such as illness severity and case complexity. RESULTS: The total encounter cost increased 7.3% (95% CI, 3.5%-11%) for nonadherent encounters versus adherent encounters. We found a 6.2% (95% CI, 3.0%-9.4%) increase in length of stay for nonadherent versus adherent encounters. The odds ratio for readmission within 30 days increased by 1.14 (95% CI, 0.998-1.31) for nonadherent versus adherent encounters. The odds ratio for complications increased by 1.29 (95% CI, 1.04-1.61) for nonadherent versus adherent encounters. CONCLUSIONS: Consistent improvements in measured outcomes were seen in the treatment group versus the control group. We recommend that provider organizations consider the introduction of real-time CDS to support adherence to evidence-based guidelines, but because we cannot determine the cause of the associations between CDS interventions and improved clinical and financial outcomes, further study is required.