Novel combined patient instruction and discharge summary tool improves timeliness of documentation and outpatient provider satisfaction.

BACKGROUND: Incomplete or delayed access to discharge information by outpatient providers and patients contributes to discontinuity of care and poor outcomes. OBJECTIVE: To evaluate the effect of a new electronic discharge summary tool on the timeliness of documentation and communication with outpatient providers. METHODS: In June 2012, we implemented an electronic discharge summary tool at our 145-bed university-affiliated Veterans Affairs hospital. The tool facilitates completion of a comprehensive discharge summary note that is available for patients and outpatient medical providers at the time of hospital discharge. Discharge summary note availability, outpatient provider satisfaction, and time between the decision to discharge a patient and discharge note completion were all evaluated before and after implementation of the tool. RESULTS: The percentage of discharge summary notes completed by the time of first post-discharge clinical contact improved from 43% in February 2012 to 100% in September 2012 and was maintained at 100% in 2014. A survey of 22 outpatient providers showed that 90% preferred the new summary and 86% found it comprehensive. Despite increasing required documentation, the time required to discharge a patient, from physician decision to discharge note completion, improved from 5.6 h in 2010 to 4.1 h in 2012 (p = 0.04), and to 2.8 h in 2015 (p < 0.001). CONCLUSION: The implementation of a novel discharge summary tool improved the timeliness and comprehensiveness of discharge information as needed for the delivery of appropriate, high-quality follow-up care, without adversely affecting the efficiency of the discharge process.

Using A3 thinking to improve the STAT medication process.

BACKGROUND: Although the term STAT conveys a sense of urgency, it is sometimes used to circumvent a system that may be too slow to accomplish tasks in a timely manner. We describe a quality-improvement project undertaken by a US Department of Veterans Affairs (VA) hospital to improve the STAT medication process. METHODS: We adapted A3 Thinking, a problem-solving process common in Lean organizations, to our problem. In the discovery phase, a color-coded flow map of the existing process was constructed, and a real-time STAT order was followed in a modified "Go to the Gemba" exercise. In the envisioning phase, the team brainstormed to come up with as many improvement ideas as possible, which were then prioritized based on the anticipated effort and impact. The team then identified initial experiments to be carried out in the experimentation phase; each experiment followed a standard Plan-Do-Study-Act cycle. RESULTS: On average, the number of STAT medications ordered per month decreased by 9.5%. The average time from STAT order entry to administration decreased by 21%, and time from medication delivery to administration decreased by 26%. Improvements were also made in technician awareness of STAT medications and nurse notification of STAT medication delivery. CONCLUSIONS: Adapting A3 Thinking for process improvement was a low-cost/low-tech option for a VA facility. The A3 Thinking process led to a better understanding of the meaning of STAT across disciplines, and promoted a collaborative culture in which other hospital-wide problems may be addressed in the future.

Effect of ionized serum calcium on outcomes in acute kidney injury needing renal replacement therapy: secondary analysis of the acute renal failure trial network study.

BACKGROUND: Hypocalcemia is very common in critically ill patients. While the effect of ionized calcium (iCa) on outcome is not well understood, manipulation of iCa in critically ill patients is a common practice. We analyzed all-cause mortality and several secondary outcomes in patients with acute kidney injury (AKI) by categories of serum iCa among participants in the Acute Renal Failure Trial Network (ATN) Study. METHODS: This is a post hoc secondary analysis of the ATN Study which was not preplanned in the original trial. Risk of mortality and renal recovery by categories of iCa were compared using multiple fixed and adjusted time-varying Cox regression models. Multiple linear regression models were used to explore the impact of baseline iCa on days free from ICU and hospital. RESULTS: A total of 685 patients were included in the analysis. Mean age was 60 (SD=15) years. There were 502 male patients (73.3%). Sixty-day all-cause mortality was 57.0%, 54.8%, and 54.4%, in patients with an iCa<1, 1-1.14, and ≥1.15 mmol/L, respectively (p=0.87). Mean of days free from ICU or hospital in all patients and the 28-day renal recovery in survivors to Day 28 were not significantly different by categories of iCa. The hazard for death in a fully adjusted time-varying Cox regression survival model was 1.7 (95% CI: 1.3-2.4) comparing iCa<1 to iCa≥1.15 mmol/L. No outcome was different for levels of iCa>1 mmol/L. CONCLUSION: Severe hypocalcemia with iCa<1 mmol/L independently predicted mortality in patients with AKI needing renal replacement therapy.

A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center.

We assessed the impact of a quality improvement intervention to reduce urinary catheter use and associated urinary tract infections (UTIs) at a single hospital. After implementation, UTIs were reduced by 39% ([Formula: see text]). Additionally, we observed a slight decrease in catheter use and the number of catheters without an appropriate indication.