Improving and Maintaining On-Time Start Times for Nonelective Cases in a Major Academic Medical Center.

BACKGROUND: As health care expenditures continue to increase, thoughtful use of perioperative resources is important. Efforts to improve operating room (OR) efficiency often focus on increasing on-time first case starts to improve OR utilization, reduce subsequent delays, and reduce adverse events. One institution, with severely limited inpatient hospital capacity and an extensive daily add-on list of surgical cases, focused efforts to improve OR efficiency by improving on-time first case starts for unscheduled, nonemergent surgeries. METHODS: A multidisciplinary team was assembled to work together for this quality improvement (QI) initiative. The primary outcome measure was the percentage of cases starting on time. The team identified six key steps thought to contribute to on-time start performance. Data were collected for each of these process measures, and feedback was shared with stakeholders. RESULTS: By measuring adherence to and giving feedback about critical steps in the preoperative process, on-time starts improved from a baseline of 65% to 85% (p = 0.041). Sustained improvement was seen even after daily measurement ceased and the QI project was completed. CONCLUSION: Establishing a multidisciplinary team to improve timely care of unscheduled, nonelective surgical patients; identifying key elements necessary for on-time surgical case starts; and providing feedback to clinicians were associated with a sustained improvement in OR efficiency for a traditionally difficult-to-schedule patient population.

Bringing Perioperative Emergency Manuals to Your Institution: A "How To" from Concept to Implementation in 10 Steps.

BACKGROUND: Emergency manuals (EMs) are context-relevant sets of crisis checklists or cognitive aids designed to enable professional teams to deliver optimal care during critical events. Evidence from simulation and other high-risk industries have proven that use of these types of checklists can significantly improve event management and decrease omissions of key steps. However, simply printing and placing tools in operating rooms (ORs) is unlikely to be effective. How interventions are implemented influences whether clinicians actually change practice and whether patient care is affected. This article provides an in-depth description of a rigorous implementation plan with three goals: (1) place EMs in every anesthetizing location, (2) create interprofessional engagement, and (3) demonstrate that a majority of anesthesia clinicians would use the new tool in some way within the first year. METHODS: The implementation of EMs included 10 steps across four distinct phases. EM use was measured using an electronic quality assurance tool, with data collected after each case about whether and how the EM was used. RESULTS: During the six months following implementation, 67.0% of clinicians had used the manual, with 24.1% using it for clinical care and 9.2% using it during a critical event. CONCLUSION: This article presents a framework and detailed description of the steps a large academic institution followed in successfully implementing EMs. In conjunction with other available resources, those interested in introducing OR EMs at large, complex institutions may benefit from the experience shared in anticipating challenges and overcoming barriers to adoption.

Measuring and Improving the Quality of Preprocedural Assessments.

BACKGROUND: Preprocedural assessments are used by anesthesia providers to optimize perioperative care for patients undergoing invasive procedures. When these assessments are performed in advance by providers who are not caring for the patient during the procedure, there is an additional layer of complexity in ensuring that the workup meets the needs of the primary anesthesia care team. In this study, anesthesia providers were asked to rate the quality of preprocedural assessments prepared by other providers to evaluate anesthesia care team satisfaction. METHODS: Quality ratings for preprocedural assessments were collected from anesthesia providers on the day of surgery using an electronic quality assurance tool from January 9, 2014 to October 21, 2014. Users could rate assessments as "exemplary," "satisfactory," or "unsatisfactory." Free text comments could be entered for any of the quality ratings chosen. A reviewer trained in clinical anesthesia categorized all comments as "positive," "constructive," or "neutral" and conducted in-depth chart reviews triggered by 67 "constructive" comments submitted during the first 3 months of data collection to further subcategorize perceived deficiencies in the preprocedural assessments. In May 2014, providers were asked to participate in a midpoint survey and provide general feedback about the preprocedural process and evaluations. RESULTS: 37,611 procedures requiring anesthesia were analyzed. Of the 17,522 (46.6%) cases with a rated preprocedural assessment, anesthesia providers rated 3828 (21.8%) as "exemplary," 13,454 (76.8%) as "satisfactory," and 240 (1.4%) as "unsatisfactory." The monthly proportion of "unsatisfactory" ratings ranged from 3.1% to 0% over the study period, whereas the midpoint survey showed that anesthesia providers estimated that the number of unsatisfactory evaluations was 11.5%. Preprocedural evaluations performed on inpatients received significantly better ratings than evaluations performed on outpatients by the preadmission testing clinic or phone program (P < .0001). The most common reason given for "unsatisfactory" ratings was a perception of "missing information" (49.2%). Chart reviews revealed that inadequate documentation was in reality the most common deficiency in preprocedural evaluations (35 of 67 reviews, 52.2%). CONCLUSIONS: The overwhelming majority of preprocedural assessments performed at our institution were considered satisfactory or exemplary by day-of-surgery anesthesia providers. This was demonstrated by both the case-by-case ratings and midpoint survey. However, the perceived frequency of "unsatisfactory" evaluations was worse when providers were asked to reflect on the quality of preprocedural evaluations generally versus rate them individually. Analysis of comments left by providers allowed us to identify specific and actionable areas for improvement. This method can be used by other institutions to identify systemic deficiencies in the preprocedural evaluation process.

Increased peripheral IL-4 leads to an expanded virtual memory CD8+ population.

Memory-phenotype CD8(+) T cells can arise even in the absence of overt Ag stimulation. Virtual memory (VM) CD8(+) T cells are CD8(+) T cells that develop a memory phenotype in the periphery of wild-type mice in an IL-15-dependent manner. Innate CD8(+) T cells, in contrast, are memory-phenotype CD8(+) T cells that develop in the thymus in response to elevated thymic IL-4. It is not clear whether VM cells and innate CD8(+) T cells represent two independent T cell lineages or whether they arise through similar processes. In this study, we use mice deficient in Nedd4-family interacting protein 1 to show that overproduction of IL-4 in the periphery leads to an expanded VM population. Nedd4-family interacting protein 1(-/-) CD4(+) T cells produce large amounts of IL-4 due to a defect in JunB degradation. This IL-4 induces a memory-like phenotype in peripheral CD8(+) T cells that includes elevated expression of CD44, CD122, and Eomesodermin and decreased expression of CD49d. Thus, our data show that excess peripheral IL-4 is sufficient to cause an increase in the VM population. Our results suggest that VM and innate CD8(+) T cells may be more similar than previously appreciated.

Translational sciences approach to RSV vaccine development.

Respiratory syncytial virus (RSV) is a major cause of lower respiratory tract infections in infants and the elderly. Despite its relatively low degree of antigenic variation, it causes frequent reinfection throughout life. Clinical manifestations of RSV disease and the immune response to infection differ in infants and the elderly, suggesting that vaccines designed to protect these two populations may require different attributes. Here, the authors describe the translational approach of utilizing data from epidemiology studies performed in these populations, the use of RSV diagnostics in clinical practice, lessons learned from previous vaccine clinical trials and the success of palivizumab in prevention of RSV disease in premature and high-risk infants to aid the development of safe and effective RSV vaccines.

Gastrointestinal microbiota do not significantly contribute to T cell activation or GI inflammation in Ndfip1-cKO mice.

The bacteria inhabiting the mammalian gastrointestinal (GI) tract play a vital role in normal digestion and immune function. In a healthy host, the immune system is tolerant to gut bacteria and does not mount an effector response to bacteria-derived antigens. Loss of tolerance to intestinal microflora has been associated with inflammatory bowel disease (IBD) in both mice and humans. Mice lacking Ndfip1, an adaptor protein for E3 ubiquitin ligases of the Nedd4-family, in T cells (Ndfip1-cKO) develop a disease resembling IBD. Inflammation in these mice is characterized by increased activation of peripheral T cells, infiltration of eosinophils into the GI tract, and epithelial hypertrophy in the esophagus. We hypothesized that this intestinal inflammation in Ndfip1-cKO mice is caused by a loss of T-cell tolerance to bacterial antigens. Here, we show that treatment of Ndfip1-cKO mice with broad-spectrum antibiotics drastically reduced bacterial load in stool but had little effect on T-cell activation and did not affect eosinophil infiltration into the GI tract or epithelial hypertrophy in the esophagus. Thus, inflammation in Ndfip1-cKO mice is not caused by a loss of tolerance to intestinal microbiota. Rather, T cell activation and eosinophilia may instead be triggered by other environmental antigens.

Dynamic evolution of V1R putative pheromone receptors between Mus musculus and Mus spretus.

BACKGROUND: The mammalian vomeronasal organ (VNO) expresses two G-protein coupled receptor gene families that mediate pheromone responses, the V1R and V2R receptor genes. In rodents, there are ~150 V1R genes comprising 12 subfamilies organized in gene clusters at multiple chromosomal locations. Previously, we showed that several of these subfamilies had been extensively modulated by gene duplications, deletions, and gene conversions around the time of the evolutionary split of the mouse and rat lineages, consistent with the hypothesis that V1R repertoires might be involved in reinforcing speciation events. Here, we generated genome sequence for one large cluster containing two V1R subfamilies in Mus spretus, a closely related and sympatric species to Mus musculus, and investigated evolutionary change in these repertoires along the two mouse lineages. RESULTS: We describe a comparison of spretus and musculus with respect to genome organization and synteny, as well as V1R gene content and phylogeny, with reference to previous observations made between mouse and rat. Unlike the mouse-rat comparisons, synteny seems to be largely conserved between the two mouse species. Disruption of local synteny is generally associated with differences in repeat content, although these differences appear to arise more from deletion than new integrations. Even though unambiguous V1R orthology is evident, we observe dynamic modulation of the functional repertoires, with two of seven V1Rb and one of eleven V1Ra genes lost in spretus, two V1Ra genes becoming pseudogenes in musculus, two additional orthologous pairs apparently subject to strong adaptive selection, and another divergent orthologous pair that apparently was subjected to gene conversion. CONCLUSION: Therefore, eight of the 18 (~44%) presumptive V1Ra/V1Rb genes in the musculus-spretus ancestor appear to have undergone functional modulation since these two species diverged. As compared to the rat-mouse split, where modulation is evident by independent expansions of these two V1R subfamilies, divergence between musculus and spretus has arisen more by mutations within coding sequences. These results support the hypothesis that adaptive changes in functional V1R repertoires contribute to the delineation of very closely related species.