ABCs of Hospitalized Patients: A Simple Before-After Study of a Communication Tool to Improve Quality of Inpatient Care.

OBJECTIVES: Within the past several years, innovative communication tools have been established as viable quality improvement mechanisms in health care. Meanwhile, the economic and societal burdens of hospital-acquired conditions (HACs) continue to rise. Various interventions have been attempted to reduce HACs. This study evaluated the effectiveness of a communication tool in reducing risk factors for HACs. METHODS: A communication tool aimed at reducing HAC risk factors was developed by an interdisciplinary team of physicians and nurses and tested in a simple before-after quality improvement study. It included 8 components: ambulation/fall risk, blood glucose greater than 200 mg/dL, central venous catheters, deep venous thrombosis prophylaxis, erosions of the skin/dermal ulcers, Foley/urinary catheters, got communication, and heart monitor/telemetry. This communication tool facilitated multidisciplinary communication. The nurses completed it nightly, and the physicians reviewed the communication tool each morning and, when appropriate, addressed components of care that were out of compliance with best practices. RESULTS: The use of the ABCs of Hospitalized Patients Communication Tool led to daily improvements with reduction in the percentage of patients with blood glucose greater than 200 mg/dL from 43.3% to 35.1%, reduction in the use of central venous catheters from 8.2% to 1.0% of patients, increase in the use of chemical deep venous thrombosis prophylaxis from 45.4% of patients to 56.7%, reduction in the use of urinary catheters from 27.6% to 13.2%, and decrease in use of telemetry from 67.5% to 55.1%. All of the results have P < 0.05. These improvements were sustained over time. CONCLUSIONS: Implementation of a multidisciplinary communication tool serves as a simple, resource-conscious, and customizable instrument to reduce the risk factors for developing HACs. This communication tool can be easily disseminated and used by other institutions.

Preoperative Testing for Urethral Sling Surgery for Stress Urinary Incontinence: Overuse, Underuse and Cost Implications.

PURPOSE: We identify areas of overuse and underuse in the preoperative evaluation of patients undergoing mid urethral sling surgery. We also estimate the effect of overuse of preoperative testing on health care costs. MATERIALS AND METHODS: We conducted a retrospective review of women who underwent sling surgery with or without concomitant prolapse repair between 2012 and 2013. Physician orders for preoperative electrocardiogram, chest x-ray, basic metabolic panel, complete blood count, coagulation studies and urinalysis were classified as appropriate or inappropriate based on summary guidelines from the American Academy of Family Physicians. The additional costs of inappropriate tests were estimated using the 2014 Medicare clinical laboratory and physician fee schedules. RESULTS: A total of 101 women who underwent mid urethral sling surgery were identified and 346 preoperative tests were ordered. Overall 76% of coagulation profiles, 73% of complete blood counts, 47% of basic metabolic panels, 39% of chest x-rays and 21% of electrocardiograms ordered did not have an appropriate clinical indication. In addition, 6% of electrocardiograms, 22% of chest x-rays and 10% of urinalyses were not ordered despite an appropriate indication. The estimated charges of overused tests were $1,844.15 for the cohort, or $18 per patient. CONCLUSIONS: Preoperative testing is overused as well as underused in patients undergoing sling surgery. The greatest variation occurred with the use of electrocardiograms, chest x-rays and urinalysis. Poor adherence to national guidelines leads to increased health care costs and warrants increased awareness in following evidence-based guidelines.

Safety, efficiency and learning curves in robotic surgery: a human factors analysis.

BACKGROUND: Expense, efficiency of use, learning curves, workflow integration and an increased prevalence of serious incidents can all be barriers to adoption. We explored an observational approach and initial diagnostics to enhance total system performance in robotic surgery. METHODS: Eighty-nine robotic surgical cases were observed in multiple operating rooms using two different surgical robots (the S and Si), across several specialties (Urology, Gynecology, and Cardiac Surgery). The main measures were operative duration and rate of flow disruptions-described as 'deviations from the natural progression of an operation thereby potentially compromising safety or efficiency.' Contextual parameters collected were surgeon experience level and training, type of surgery, the model of robot and patient factors. Observations were conducted across four operative phases (operating room pre-incision; robot docking; main surgical intervention; post-console). RESULTS: A mean of 9.62 flow disruptions per hour (95 % CI 8.78-10.46) were predominantly caused by coordination, communication, equipment and training problems. Operative duration and flow disruption rate varied with surgeon experience (p = 0.039; p < 0.001, respectively), training cases (p = 0.012; p = 0.007) and surgical type (both p < 0.001). Flow disruption rates in some phases were also sensitive to the robot model and patient characteristics. CONCLUSIONS: Flow disruption rate is sensitive to system context and generates improvement diagnostics. Complex surgical robotic equipment increases opportunities for technological failures, increases communication requirements for the whole team, and can reduce the ability to maintain vision in the operative field. These data suggest specific opportunities to reduce the training costs and the learning curve.