Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative.

BACKGROUND: Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. The authors embarked on a professional practice initiative to attain documented train-of-four ratios greater than or equal to 0.90 in all patients for improved patient outcomes through reducing residual paralysis. METHODS: The authors utilized equipment trials, educational videos, quantitative monitors in all anesthetizing locations, and electronic clinical decision support with real-time alerts, and initiated an ongoing professional practice metric. This was a retrospective assessment (2016 to 2020) of train-of-four ratios greater than or equal to 0.9 that were documented before extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients who received a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes. RESULTS: From pre- to postimplementation, more patients were assigned American Society of Anesthesiologists Physical Status III to V, fewer were inpatients, the rocuronium average dose was higher, and more patients had a prereversal train-of-four count less than 4. Manually reviewed anesthesia records (n = 2,807) had 2 of 172 (1%) cases with documentation of train-of-four ratios greater than or equal to 0.90 in November 2016, which was fewer than the cases in December 2020 (250 of 269 [93%]). Postimplementation (February 1, 2020, to December 31, 2020), sugammadex (650 of 935 [70%]), neostigmine (195 of 935 [21%]), and no reversal (90 of 935 [10%]) were used to attain train-of-four ratios greater than or equal to 0.90 in 856 of 935 (92%) of patients. In the electronically searched medical charts (n = 20,181), postimplementation inpatients had shorter postanesthesia care unit lengths of stay (7% difference; median [in min] [25th, 75th interquartile range], 73 [55, 102] to 68 [49, 95]; P < 0.001), pulmonary complications were less (43% difference; 94 of 4,138 [2.3%] to 23 of 1,817 [1.3%]; P = 0.010; -1.0% difference [95% CI, -1.7 to -0.3%]), and hospital length of stay was shorter (median [in days] [25th, 75th], 3 [2, 5] to 2 [1, 4]; P < 0.001). CONCLUSIONS: In this professional practice initiative, documentation of train-of-four ratios greater than or equal to 0.90 occurred for 93% of patients in a busy clinical practice. Return-of-strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes.

Feasibility and safety of a rapid-access transient ischemic attack clinic.

BACKGROUND: In the United States, patients with transient ischemic attacks (TIAs) are commonly admitted to the hospital despite evidence that low-risk TIA patients achieve improved outcomes at lower costs at specialized rapid-access TIA clinics (RATCs). LOCAL PROBLEM: All patients experiencing TIAs at a hospital system in the Pacific Northwest were being admitted to the hospital. This project aimed to implement an RATC to relocate care for low-risk TIA patients, showing feasibility and safety. METHODS: Following implementation of the RATC, a retrospective chart review was performed. Outcomes included days to RATC; days to magnetic resonance imaging (MRI); final diagnosis; stroke-related admissions and deaths within 90 days of the RATC visit. INTERVENTIONS: From 2016 to 2018, implementation of an RATC included patient triage tools; multidisciplinary collaboration between departments; a direct scheduling pathway; and emphasis on stroke prevention. RESULTS: Ninety-nine patients were evaluated in the RATC, 69% (69/99) were referred from the emergency department. Sixty-six percent of patients were seen in the TIA clinic in 2 days or less, 19% at 3 days, and 15% at 4 days or more. Mean days to TIA clinic was 2.5 days (SD 2.4). Mean days (SD) to MRI was 2.1 days (SD 2.3). Forty-eight percent (48/99) had a final diagnosis of probable TIA, followed by 32% (32/99) who had other diagnoses; 15% (15/99) migraine variant; 4% (4/99) with stroke. Two percent (2/99) of patients had a stroke-related admission within 90 days, another 2% (2/99) died of non-stroke-related causes within 90 days of the RATC visit. CONCLUSIONS: Utilization of RATCs is feasible and safe. Nurse practitioners are integral in delivering this innovative, cost-effective model of care.

Coupling Lean and Experience-Based Design for Measuring and Incorporating Patient Emotional Experience Into the Redesign of Health Care.

BACKGROUND AND OBJECTIVES: Incorporation of Lean into health care requires consideration of the patient and other customer experience of care as well as final health outcomes. We incorporate experience-based design (EBD) into our Lean management method to assess the experience of care, guide redesign of care processes, and assess the effectiveness of quality improvement on the care experience. Foundational to EBD is identification of "touch points," moments in the health care delivery process where a patient has a strong positive or negative emotional response that has the potential to alter the way patients feel about their overall care experience. METHODS: EBD proceeds sequentially from qualitative assessment of customer experience and touch points (through observations and interviews); semiquantitatively assessing the experience across many patients (through EBD questionnaires); engaging in codesign with patients (through improvement teams and events); and reassessing the care experience after improvement (through follow-up EBD questionnaires). The use of project-specific (EBD) emotion word questionnaires enables assessment of change over time. These EBD questionnaires are developed ad hoc for each care improvement effort, to reflect the specific high emotion touch points patients identify for that care process, and therefore pose unique validity and reliability challenges. We have previously validated a set of emotion words that form the library from which questionnaire designers select the relevant emotion word choices. In addition, to assess consistency of measurement in the absence of any improvement, we performed a repeated-measures study deploying the same EBD questionnaire to different groups of patients, separated by a 60-day interval in the absence of any quality improvement work. RESULTS: We apply EBD across the health care enterprise, including patients and family caregivers, as well as staff members. Examples where EBD has been incorporated into care redesign have included; outpatient care for pancreatic cancer patients; clinic visits in rheumatology; delirium care for hospital inpatients; and the orientation process for newly hired advanced practice providers. Our reliability data demonstrate that moderate differences in scores on the EBD questionnaire (up to 19 percentage points) may reflect random variability, but differences of greater magnitude reflect actual changes in the patient experience. CONCLUSIONS: In summary, experience-based design has promise as a methodology to incorporate patient experience within a Lean management structure. EBD can aid with health care redesign, defining the emotional touch points that are foundational to the experience of care, enabling targeting of quality improvement efforts, and assessing change.

Using Lean tools to improve the efficiency of awake fibreoptic intubation setup.

BACKGROUND: Awake fibreoptic intubation is a complex advanced airway technique used by anaesthesiologists in the management of a difficult airway. The time to setup this important procedure can be significant which may dissuade its use by some providers. In our institution, the awake intubation setup process was highly variable and error prone. METHODS: We deployed Lean methods to improve the efficiency and accuracy of the awake fibreoptic intubation setup process. A 2-day improvement event with a multidisciplinary team addressed the setup process, tested solutions and created standard work documents. Twenty awake fibreoptic intubation simulations were conducted before and after the intervention to quantify gains in setup efficiency and error reduction. RESULTS: Variability in the setup process, including clinical locations visited, was reduced through creating a standardised process. The average time to for an awake fibreoptic intubation setup was reduced by approximately 50%, from 23 min to 11 min (p<0.001). In addition, awake fibreoptic intubation equipment set out without error increased in the postintervention simulations from 59% to 85% (p=0.003). CONCLUSION: Using Lean tools, we were able to make the setup of awake fibreoptic intubation not only more efficient, but also more accurate. A similar methodological approach may have value for other complex anaesthesia procedures.

MRI and muscle enzymes do not support the diagnosis of local anesthetic myotoxicity: a descriptive case series.

BACKGROUND: The presence of thigh muscle edema as characterized by increased signal intensity on MRI has been used to support the diagnosis of presumed local anesthetic-induced myotoxicity reported after total knee arthroplasty (TKA) with continuous adductor canal block (CACB). However, neither postoperative baseline imaging appearance nor muscle enzyme values have been described in conjunction with this clinical scenario. Thus, the usefulness of MRI or enzymatic biomarkers of muscle injury for supporting the diagnosis of local anesthetic myotoxicity is unknown. METHODS: This descriptive case series documents postoperative MRI appearance of the ipsilateral upper leg, plus preoperative and postoperative creatine phosphokinase and aldolase values in volunteer patients who underwent uncomplicated TKA with CACB. RESULTS: In 27 volunteer patients with no postsurgical evidence of clinically relevant myotoxicity, anterior thigh muscle edema was universally evident on imaging (n=12) and muscle enzyme values (n=19) were normal or only slightly elevated. CONCLUSIONS: The non-specificity of these findings suggests that MRI and near normal muscle enzyme levels are of limited diagnostic value when there is clinical suspicion of local anesthetic myotoxicity in the setting of TKA with CACB. TRIAL REGISTRATION NUMBER: NCT04821245.

Opportunistic Screening of Patients for Hepatic Steatosis: Clinical Follow-Up and Diagnostic Yield.

PURPOSE: Hepatic steatosis is a common incidental finding on abdominal imaging that is not always reported or recognized as having clinical significance. Because of its association with liver disease, cirrhosis, and diabetes, the aim of this study was to bring attention to this finding and provide clinical guidance to referring clinicians by inserting standardized text into radiology reports of patients with incidentally detected hepatic steatosis. METHODS: Patients with incidentally discovered hepatic steatosis on abdominal ultrasound or CT had standard text inserted into the impression sections of their diagnostic imaging reports. A total of 1,256 patients whose reports were tagged between April 2016 and September 2017 were retrospectively identified and their electronic medical records reviewed to determine subsequent acknowledgment in the medical record or clinical action in response to the tagged report. Information regarding patient demographics, the type of provider who ordered the examination, and the acuity of the examination results was also recorded. RESULTS: Acknowledgment and subsequent clinical action were more likely in patients whose examinations was ordered by primary care providers, whose examination results were not urgent, and who were in the ultrasound group. The overall diagnostic yield in patients who underwent clinical evaluation was nonalcoholic fatty liver disease in 70%, nonalcoholic steatohepatitis in 6%, and alcoholic hepatitis in 17%. CONCLUSIONS: Opportunistic screening for incidental hepatic steatosis on abdominal CT and ultrasound is feasible, with substantial yield for patients with clinically important entities including nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

Association of Use of Contract Nurses With Hospitalized Patient Pressure Injuries and Falls.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) and falls are outcomes sensitive to quality of nursing care. Use of contract (traveler) nurses varies among organizations, but there is little research on the effect of contract nurses on nurse-sensitive outcomes. OBJECTIVES: To explore the relationship between use of contract nurses and two key nurse-sensitive outcomes, HAPIs and falls. RESEARCH DESIGN: This was a cross-sectional study of unit-level nursing, patient, and hospital factors versus HAPIs and falls from a national nursing data consortium from 2015 to 2016. We used cluster analysis to identify similar units, and compared outcomes between clusters. SUBJECTS: 605 nursing units in 166 hospitals, 3.2 patients per nurse, and 5.3% contract nurses. MEASURES: Prevalence and incidence of HAPIs and number of falls, adjusted by patient days. RESULTS: For both prevalence and incidence of HAPIs, there was a statistically significant difference between the five independent cluster groups (p = .012 and p = .001, respectively). The cluster with the highest percentage of nurse travelers (>7%) had the highest HAPI prevalence (0.84%) and incidence (0.055 per 1,000 patient days) despite higher nurse staffing, compared to HAPI prevalence of 0.32% and incidence of 0.017 per 1,000 patient days in the cluster with the lowest percentage of nurse travelers (<2%). We did not identify a consistent relationship between use of contract nurses and falls. CONCLUSIONS: Use of contract nurses was associated with higher HAPI prevalence and incidence, independent of staffing levels. CLINICAL RELEVANCE: Our results suggest that institutions should either minimize the use of contract nurses, or engage in extensive training to confirm that contract nurses have understanding of the institutional practices around HAPIs.

Clinical Decision Support: Opportunity or Armageddon?

OBJECTIVE. The objective of this article is to discuss clinical decision support (CDS) and the article by Palen and colleagues in this issue of AJR. CONCLUSION. The Palen et al. study provides strong evidence to date that CDS can lead to improvement in imaging appropriateness scores. However, the relevance of appropriateness scores in clinical practice is unknown and CDS is potentially highly disruptive to workflow, and therefore research into its true impact on clinical care is essential.

The Relationship Between Medicare Outpatient Efficiency Measure OP8 and Lumbar MRI Utilization.

INTRODUCTION: Quality-based reporting and payment are predicated on using valid metrics. We sought to determine the relationship between widely used lumbar imaging quality metric OP8 and underlying quality as measured through actual utilization of lumbar MRI. METHODS: We performed a multi-institutional cross-sectional study using hospital-level billing data from a major commercial insurance company, including 23 Washington State hospitals from July 1, 2014, to June 30, 2015, with more than 25 eligible visits. For each hospital, we determined the OP8 score using the CMS published specifications. We calculated actual utilization rate from the proportion of patients visiting primary care (internal medicine or family medicine, including physicians, nurse practitioners, and physician assistants) for uncomplicated low back pain who underwent lumbar MRI. For both measures, patients under age 18 or with complicated conditions (eg, infection, cancer, inflammatory arthropathy) were excluded. OP8 scores and utilization were compared using linear regression and correlation coefficients. RESULTS: Hospital scores ranged from 28.0% to 55.3% on OP8 and from 0.7% to 4.2% on MRI utilization (with lower scores indicating better performance). There was no association between score on OP8 and actual utilization of lumbar MRI across hospitals in Washington State (attributable risk 0.00016, 95% confidence interval: -0.00026, 0.00059, P = .43). DISCUSSION: Widely used imaging efficiency measure OP8 does not correlate with actual utilization of lumbar MRI. Better OP8 scores reflect use of antecedent conservative therapy regardless of whether MRI is overutilized. OP8 scores may be worse for institutions with aggressive control of inappropriate imaging.

Improving the Electronic Capture of Advance Care Directives in a Healthcare Delivery System.

OBJECTIVES: To determine the effectiveness of a multifaceted quality improvement intervention in outpatient clinics at an integrated healthcare delivery system on capture rate of advance directives (ADs) in the electronic medical record (EMR). DESIGN: Interrupted time series analysis with control groups between January 2010 and June 2015. SETTING: Oncology, nephrology, and primary care outpatient clinics in an integrated healthcare delivery system. PARTICIPANTS: All individuals aged 65 and older with at least one office visit in any outpatient clinic in the care delivery system (n = 77,350 with 502,446 office visits). INTERVENTION: A series of quality improvement interventions to improve rates of advance care planning discussions and capture of those discussions in the EMR between 2010 and 2014. MEASUREMENTS: Capture rate of ADs in the EMR. RESULTS: Visits in the intervention primary care clinic were twice as likely to mention ADs in the EMR (53.4%) than visits in nonintervention primary care clinics (26.5%). Visits in the intervention oncology clinic were more than eight times as likely to mention ADs in the EMR (49.3% vs 6.0%), and visits in the intervention nephrology clinic were 2.5 times as likely to mention ADs (15.4% vs 6.0%) than visits in other specialty clinics. CONCLUSIONS: A series of quality improvement interventions to increase discussions about advance care planning and capture of advance care directives in the EMR significantly increased the rate of capture in primary care and specialty care outpatient settings.

Changes in Provider Prescribing Patterns After Implementation of an Emergency Department Prescription Opioid Policy.

BACKGROUND: Prescription opioid-associated abuse and overdose is a significant cause of morbidity and mortality in the United States. Opioid prescriptions generated from emergency departments (EDs) nationwide have increased dramatically over the past 20 years, and opioid-related overdose deaths have become an epidemic, according to the Centers for Disease Control and Prevention. OBJECTIVE: Our aim was to determine the effectiveness of implementing a prescription policy for opioids on overall opioid prescribing patterns in a hospital ED. METHODS: The ED provider group of an academic, non-university-affiliated urban hospital with 23,000 annual patient visits agreed to opioid prescribing guidelines for chronic pain with the goal of limiting prescriptions that may be used for abuse or diversion. These guidelines were instituted in the ED through collaborative staff meetings and educational and training sessions. We used the electronic medical record to analyze the number and type of opioid discharge prescriptions during the study period from 2006-2014, before and after the prescribing guidelines were instituted in the ED. RESULTS: The number of patients discharged with a prescription for opioids decreased 39.6% (25.7% to 15.6%; absolute decrease 10.2%; 95% confidence interval [CI] 9.6-10.7; p < 0.001) after the intervention. The improvements were sustained 2.5 years after the intervention. Decreases were seen in all major opioids (hydrocodone, oxycodone, hydromorphone, and codeine). The number of pills per prescription also decreased 14.8%, from 19.5% to 16.6% (absolute decrease 2.9; 95% CI 2.6-3.1; p < 0.001). CONCLUSIONS: Implementation of an ED prescription opioid policy was associated with a significant reduction in total opioid prescriptions and in the number of pills per prescription.

Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of an Evidence-Based Clinical Care Pathway.

STUDY DESIGN: Quality improvement with before and after evaluation of the intervention. OBJECTIVE: To improve lumbar spine postoperative care and quality outcomes through a series of Lean quality improvement events designed to address root causes of error and variation. SUMMARY OF BACKGROUND DATA: Lumbar spine fusion procedures are common, but highly variable in process of care, outcomes, and cost. METHODS: We implemented a standardized lumbar spine fusion clinical care pathway through a series of Lean quality improvement events. The pathway included an evidence-based electronic order set; a patient visual tool; and multidisciplinary communication, and was designed to delineate expectations for patients, staff, and providers. To evaluate the effectiveness of the intervention, we performed a quality improvement study with before and after evaluation of consecutive patients from January 2012 to September 2014. Outcomes were hospital length of stay and quality measures before and after the April 1, 2013 intervention. Data were analyzed with chi-square and t tests for before and after comparisons, and were explored graphically for temporal trends with statistical process control charts. RESULTS: Our study population was 458 patients (mean 65 years, 65% women). Length of stay decreased from 3.9 to 3.4 days, a difference of 0.5 days (CI 0.3, 0.8, P < 0.001). Discharge disposition also improved with 75% (183/244) being discharged to home postintervention versus 64% (136/214) preintervention (P = 0.002). Urinary catheter removal also improved (P = 0.003). Patient satisfaction scores were not significantly changed. CONCLUSION: Applying Lean methods to produce standardized clinical pathways is an effective way of improving quality and reducing waste for lumbar spine fusion patients. We believe that quality improvements of this type are valuable for all spine patients, to provide best care outcomes at lowest cost. LEVEL OF EVIDENCE: 4.

Meaningful use of the electronic patient portal - Virginia Mason's journey to create the perfect online patient experience.

We present a case study of Virginia Mason Medical Center's successful implementation of the online patient portal. The organization exceeded its Meaningful Use 2 View/Download/Transmit targets and national benchmarks, with over 70% of unique patient encounters being provided timely online access to their health information, over 50% viewing, downloading, and transmitting health information electronically, and potential cost savings to the institution. Key lessons learned in our implementation process were.

Using Experience-Based Design to Improve the Care Experience for Patients With Pancreatic Cancer.

PURPOSE: Despite the importance of the patient care experience to quality and outcome, the literature detailing the care experience in patients with pancreatic cancer is limited. METHODS: To elicit the experience of patients with pancreatic cancer for care redesign, we deployed experience-based design, an emerging methodology based on identification of events of high emotional content, known as touch points, to delineate qualitatively what matters most to patients and families. We defined touch points through direct observations, interviews, and a focus group. We then used experience questionnaires to measure emotional content and develop an experience map to graphically display the fluctuating emotional journey through the care processes. Study subjects were patients with pancreatic cancer who were cared for at Virginia Mason Medical Center, family caregivers, and staff. Redesign was initiated through an all-day improvement event in September 2013. RESULTS: During 2013 and 2014, we cared for 485 new patients with pancreatic cancer, the majority of whom had local disease at diagnosis. The response rate for the experience questionnaire was 23% (117 of 500 questionnaires distributed). The experience-based design results were often contrary to staff preconceptions of the care experience for patients with pancreatic cancer, and contributed to redesign in three key areas: understanding and documenting patient goals and values, providing better resources for caregivers/families, and improving care coordination and support services. CONCLUSION: Experience-based design enabled us to understand the care experience and associated emotional content for patients with pancreatic cancer and their caregivers. This knowledge then supported care redesign targeted at areas of high negative emotional content.

Engaging Frontline Leaders and Staff in Real-Time Improvement.

BACKGROUND: The relationship of staff satisfaction and engagement to organizational success, along with the integral influence of frontline managers on this dimension, is well established in health care and other industries. To specifically address staff engagement, Virginia Mason Medical Center, an integrated, single-hospital health system, developed an approach that involved leaders, through the daily use of standard work for leaders, as well as staff, through a Lean-inspired staff idea system. METHODS: Kaizen Promotion Office (KPO) staff members established three guiding principles: (1) Staff engagement begins with leader engagement; (2) Integrate daily improve- ment (kaizen) as a habitual way of life not as an add-on; and (3) Create an environment in which staff feel psycho- logically safe and valued. Two design elements--Standard Work for Leaders (SWL) and Everyday Lean Ideas (ELIs) were implemented. RESULTS: For the emergency department (ED), an early adopter of the staff engagement work, the challenge was to apply the guiding principles to improve staff engagement while improving quality and patient and staff satisfaction, even as patient volumes were increasing. Daily huddles for the KPO staff members and weekly leader rounds are used to elicit staff ideas and foster ELIs in real time. Overall progress to date has been tracked in terms of staff satisfaction surveys, voluntary staff turnover, adoption of SWL, and testing and implementation of staff ideas. For example, voluntary turnover of ED staff decreased from 14.6% in 2011 to 7.5% in 2012, and 2.0% in 2013. Organizationwide, at least 800 staff ideas are in motion at any given time, with finished ones posted in an idea supermarket website. CONCLUSION: A leadership and staff engagement approach that focuses on SWL and on capturing staff ideas for daily problem solving and improvement can contribute to organization success and improve the quality of health care delivery.

The Success and Failure of a Radiology Quality Metric: The Case of OP-10.

PURPOSE: Medical quality metrics can serve various functions, including promoting quality improvement efforts within a medical system, and providing a basis for comparing quality among institutions. OP-10, an imaging efficiency quality measure based on the number of CT scans of the abdomen performed both with and without contrast is broadly used and publically reported, but it has not been investigated in actual practice. METHODS: In this project, we report on both a successful quality improvement effort built around measurement of OP-10, and on the identified potential limitations of OP-10 itself for comparing among institutions. We performed two quality improvement interventions in 2012 and 2014 directed at OP-10, encompassing building of institutional practice standards via creating multidisciplinary consensus, educating radiologists and clinicians, revising CT protocols, and providing performance measurement and feedback. Results were extracted from the radiology information system and analyzed using interrupted time series segmented regression and statistical process control charts. RESULTS: The proportion of inappropriate abdominal CT scans with and without contrast under OP-10 decreased, from 3,041 of 13,855 (21.9%) to 691 of 6,006 (11.5%) (P < .0001). However, 262 of 691 (37.8%) of the CT scans labeled as potential overuse by OP-10 could be considered appropriate under national guidelines. These discordant cases clustered in specific clinical areas (eg, urology and hepatology), indicating potential for bias against centers that serve referral populations in these areas. CONCLUSIONS: We conclude that OP-10 can be useful to drive internal quality improvement efforts but is potentially biased when used for interinstitutional comparisons.