The prevalence of COVID-19 in healthcare personnel in an adult and pediatric academic medical center.

BACKGROUND: It is vital to know which healthcare personnel (HCP) have a higher chance of testing positive for severe acute respiratory syndrome coronavirus 2 (COVID-19). METHODS: A retrospective analysis was conducted at Stanford Children's Health (SCH) and Stanford Health Care (SHC) in Stanford, California. Analysis included all HCP, employed by SCH or SHC, who had a COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) test resulted by the SHC Laboratory, between March 1, 2020 and June 15, 2020. The primary outcome was the RT-PCR percent positivity and prevalence of COVID-19 for HCP and these were compared across roles. RESULTS: SCH and SHC had 24,081 active employees, of which 142 had at least 1 positive COVID-19 test. The overall HCP prevalence of COVID-19 was 0.59% and percent positivity was 1.84%. Patient facing HCPs had a significantly higher prevalence (0.66% vs 0.43%; P = .0331) and percent positivity (1.95% vs 1.43%; P = .0396) than nonpatient facing employees, respectively. Percent positivity was higher in food service workers (9.15%), and environmental services (5.96%) compared to clinicians (1.93%; P < .0001) and nurses (1.46%; P < .0001), respectively. DISCUSSION AND CONCLUSION: HCP in patient-facing roles and in support roles had a greater chance of being positive of COVID-19.

Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship.

Health systems in low-income and middle-income countries (LMICs) have a high burden of medical errors and complications, and the training of local experts in patient safety is critical to improve the quality of global healthcare. This analysis explores our experience with the Duke Global Health Patient Safety Fellowship, which is designed to train clinicians from LMICs in patient safety, quality improvement and infection control. This intensive fellowship of 3-4 weeks includes (1) didactic training in patient safety and quality improvement, (2) experiential training in patient safety operations, and (3) mentorship of fellows in their home institution as they lead local safety programmes. We have learnt several lessons from this programme, including the need to contextualise training to local needs and resources, and to focus training on building interdisciplinary patient safety teams. Implementation challenges include a lack of resources and data collection systems, and limited recognition of the role of safety in global health contexts. This report can serve as an operational guide for intensive training in patient safety that is contextualised to global health challenges.

Pediatric Medication Safety in the Emergency Department.

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

National Quality Program Achieves Improvements in Safety Culture and Reduction in Preventable Harms in Community Hospitals.

BACKGROUND: Through an innovative affiliation, Duke University Health System (DUHS), a large and complex academic health system, and LifePoint Health® (LifePoint [LP]) collaborated to create a joint venture, DLP Healthcare (DLP) to measurably improve culture and quality and patient safety metrics in community hospitals across the United States. A structured approach to quality was developed in DLP hospitals and later refined and spread to all LP hospitals through the National Quality Program (NQP). METHODS: The NQP was designed to drive organizationwide performance improvement through use of a framework of leadership, performance improvement, and culture. A comprehensive quality assessment of each DLP and LP hospital led to the creation of a customized improvement plan that was specific to the performance level of individual hospitals and aligned with strategic organizational goals. The improvement process was data driven, managed with defined improvement methodologies and practices, and implemented in a culture that honors teamwork, mutual respect, accountability and provider well-being. RESULTS: Implementation of the NQP has led to significant improvements in patient safety metrics and in safety culture, which have now been sustained for more than seven years. Aggregate harm, as measured by administrative claims data-based harms per 1,000 inpatient-days, was reduced by 62.5% between January 2011 and December 2017, as compared to 2010 baseline data. CONCLUSION: The LP and Duke journey to achieve high reliability in community hospitals has yielded significant improvement in measures of patient safety and culture. The results are consistent with literature supporting the link between culture and overall performance.

Healthcare Affiliation Networks: A Unique Quality Partnership to Aid in Making Communities Healthier.

As the healthcare environment continues to evolve, many community hospitals of all sizes are finding it difficult to thrive and grow in the headwinds of increasing regulatory requirements, decreased reimbursements amidst healthcare reform efforts, increased requirements for efficiency, demands for improvement in the patient experience, and increasing penalties for lagging performance in patient safety and quality metrics. A unique partnership, involving an organization built upon expertise in operating community hospitals and an academic center with expertise in patient safety, quality, innovation, and care delivery, has provided a successful solution for a growing number of challenged community facilities. The purpose of this article is to demonstrate how using standardized patient safety, quality improvement processes, and high-reliability strategies in community hospitals has been supported and enhanced through the development of a healthcare affiliation network with an academic medical center. By developing this type of quality affiliation, hospitals across a broad spectrum of sizes and locations can achieve significant improvement in safety culture while demonstrating measureable advances in quality and safety and supporting their mission of "making communities healthier, together."

Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents.

OBJECTIVE: Teaching and evaluation of handovers are important requirements of graduate medical education (GME), but well-defined and effective methods have not been clearly established. Case-based computer simulations provide potential methods to teach, evaluate, and practice handovers. METHODS: Case-based computer simulation modules were developed. In these modules, trainees care for a virtual patient in a time-lapsed session, followed by real-time synthesis and handover of the clinical information to a partner who uses this information to continue caring for the same patient in a simulated night scenario, with an observer tallying included handover components. The process culminates with evaluator feedback and structured handover education. Surveys were used before and after module implementation to allow the interns to rate the quality of handover provided and record rapid responses and transfers to the ICU. RESULTS: Fifty-two pediatric and medicine/pediatric residents from 2 institutions participated in the modules. "Anticipatory guidance" elements of the handover were the most frequently excluded (missing at least 1 component in 77% of module handovers). There were no significant differences in the proportion of nights with rapid response calls (7.24% vs 12.79%, P=.052) or transfers to the ICU (7.76% vs 11.27%, P=.21) before and after module implementation. CONCLUSIONS: Case-based, computer-simulation modules are an easily implemented and generalizable mechanism for handover education and assessment. Although significant improvements in patient safety outcomes were not seen as a result of the educational module alone, novel techniques of this nature may supplement handover bundles that have been demonstrated to improve patient safety.

Why and when to use CT in children: perspective of a pediatric emergency medicine physician.

The Emergency Department is a risk-laden environment for clinicians caring for children. A number of factors can increase the risk of medical errors and adverse events, including lack of standardized medication dosing because of size variation in the pediatric age range, unique physical and developmental characteristics of children that affect treatment strategies, and the inability of young or non-verbal children to provide a medical history or to clearly communicate pain and other symptoms. The Emergency Department (ED) setting is often hectic and chaotic, with lots of interruptions. Many EDs lack the pediatric-specific supplies deemed essential for managing pediatric emergencies, and long hours or overnight shifts, while necessary for maintaining 24-hour emergency services, can cause provider fatigue that can lead to increased medical errors. It is in this environment that ED physicians make decisions about the use of CT scans in children, often without evidence-based guidelines to help them weigh risks and benefits. Although recent efforts have raised the awareness of the risk of exposure to radiation, many pediatric providers and families lack adequate information to guide decisions about the use of CT. Pediatricians and emergency physicians need to collaborate with radiologists to maintain current knowledge of the risks and benefits of CT scans, to advocate for pediatric protocols and evidence-based guidelines, and to engage families in decisions regarding the evaluation and treatment of pediatric patients in the Emergency Department.

Developing physicians as catalysts for change.

Failures in care coordination are a reflection of larger systemic shortcomings in communication and in physician engagement in shared team leadership. Traditional medical care and medical education neither focus on nor inspire responses to the challenges of coordinating care across episodes and sites. The authors suggest that the absence of attention to gaps in the continuum of care has led physicians to attempt to function as the glue that holds the health care system together. Further, medical students and residents have little opportunity to provide feedback on care processes and rarely receive the training and support they need to assess and suggest possible improvements.The authors argue that this absence of opportunity has driven cynicism, apathy, and burnout among physicians. They support a shift in culture and medical education such that students and residents are trained and inspired to act as catalysts who initiate and expedite positive changes. To become catalyst physicians, trainees require tools to partner with patients, staff, and faculty; training in implementing change; and the perception of this work as inherent to the role of the physician.The authors recommend that medical schools consider interprofessional training to be a necessary component of medical education and that future physicians be encouraged to grow in areas outside the "purely clinical" realm. They conclude that both physician catalysts and teamwork are essential for improving care coordination, reducing apathy and burnout, and supporting optimal patient outcomes.

A closer look at associations between hospital leadership walkrounds and patient safety climate and risk reduction: a cross-sectional study.

Leadership walkrounds (WRs) are widely used in health care organizations to improve patient safety. This retrospective, cross-sectional study evaluated the association between WRs and caregiver assessments of patient safety climate and patient safety risk reduction across 49 hospitals in a nonprofit health care system. Linear regression analyses using units' participation in WRs were conducted. Survey results from 706 hospital units revealed that units with ≥ 60% of caregivers reporting exposure to at least 1 WR had a significantly higher safety climate, greater patient safety risk reduction, and a higher proportion of feedback on actions taken as a result of WRs compared with those units with <60% of caregivers reporting exposure to WRs. WR participation at the unit level reflects a frequency effect as a function of units with none/low, medium, and high leadership WR exposure.

Standardizing and Evaluating Transitions of Care in the Era of Duty Hour Reform: One Institution's Resident-Led Effort.

BACKGROUND: Compliance with the Accreditation Council for Graduate Medical Education duty hour standards may necessitate more frequent transitions of patient responsibility. INTERVENTION: We created a multidisciplinary Patient Safety and Quality Council with a Task Force on Handoffs (TFH), engaging residents at a large, university-based institution. METHODS: The TFH identified core content of effective handoffs and patterned institutional content on the SIGNOUTT mnemonic. A web-based module highlighting core content was developed for institutional orientation of all trainees beginning summer 2011 to standardize handoff education. The TFH distributed handoff material and catalogued additional program initiatives in teaching and evaluating handoffs. A standard handoff evaluation tool, assessing content, culture, and communication, was developed and "preloaded" into the institution-wide electronic evaluation system to standardize evaluation. The TFH developed questions pertaining to handoffs for an annual institutional survey in 2011 and 2012. Acceptability of efforts was measured by program participation, and feasibility was measured by estimating time and financial costs. RESULTS: Programs found the TFH's efforts to improve handoffs acceptable; to date, 13 program-specific teaching initiatives have been implemented, and the evaluation tool is being used by 5 programs. Time requirements for TFH participants average 2 to 3 h/mo, and financial costs are minimal. More residents reported having education on handoffs (58% [388 of 668] versus 42% [263 of 625], P < .001) and receiving adequate signouts (69% [469 of 680] versus 61% [384 of 625], P  =  .004) in the 2012 survey, compared with 2011. CONCLUSIONS: Use of a multispecialty resident leadership group to address content, education, and evaluation of handoffs was feasible and acceptable to most programs at a large, university-based institution.

Evaluation of a nurse-led safety program in a critical care unit.

This implementation of a formalized safety program in a critical care unit highlights the importance of the "voice of the caregiver," as it relates to patient safety. This nurse-led program featured executive walkrounds and a multidisciplinary core team whose goal was to prioritize and resolve safety issues identified during the 6-month study period. Unit nurses' scores on the Safety Attitudes Questionnaire remained stable from July 2011 to February 2012. Staff identified 77 safety issues during executive walkrounds; 57% were resolved during the study period. Results indicate the clinical significance of nurse-led patient safety programs.

Implementation of the Josie King Care Journal in a pediatric intensive care unit: a quality improvement project.

The Care Journal is a tool developed by the Josie King Foundation to promote interactive exchange among providers and patients/families. The Care Journal was implemented in a pediatric intensive care unit, and surveys were administered to assess perceptions about use. Parents who used the Care Journal and nursing staff found it to be a useful tool that improved communication, made parents feel more knowledgeable and empowered, and improved parents' overall perception of the hospital stay.

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.

With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Duke's internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.

Implementation of condition help: family teaching and evaluation of family understanding.

Partnering with families to deliver safe care includes teaching how to activate the rapid response team (RRT) if their hospitalized child's condition worsens. Condition Help (Condition H) is how families call the RRT. Pediatric nurses used scripted Condition H teaching and follow-up surveys to evaluate family understanding about Condition H. Although there were only 2 Condition H calls during the study period, 53% to 90% of families received Condition H teaching, and family understanding was greater than 75%.

Teamwork training with nursing and medical students: does the method matter? Results of an interinstitutional, interdisciplinary collaboration.

OBJECTIVES: The authors conducted a randomised controlled trial of four pedagogical methods commonly used to deliver teamwork training and measured the effects of each method on the acquisition of student teamwork knowledge, skills, and attitudes. METHODS: The authors recruited 203 senior nursing students and 235 fourth-year medical students (total N = 438) from two major universities for a 1-day interdisciplinary teamwork training course. All participants received a didactic lecture and then were randomly assigned to one of four educational methods didactic (control), audience response didactic, role play and human patient simulation. Student performance was assessed for teamwork attitudes, knowledge and skills using: (a) a 36-item teamwork attitudes instrument (CHIRP), (b) a 12-item teamwork knowledge test, (c) a 10-item standardised patient (SP) evaluation of student teamwork skills performance and (d) a 20-item modification of items from the Mayo High Performance Teamwork Scale (MHPTS). RESULTS: All four cohorts demonstrated an improvement in attitudes (F(1,370) = 48.7, p = 0.001) and knowledge (F(1,353) = 87.3, p = 0.001) pre- to post-test. No educational modality appeared superior for attitude (F(3,370) = 0.325, p = 0.808) or knowledge (F(3,353) = 0.382, p = 0.766) acquisition. No modality demonstrated a significant change in teamwork skills (F(3,18) = 2.12, p = 0.134). CONCLUSIONS: Each of the four modalities demonstrated significantly improved teamwork knowledge and attitudes, but no modality was demonstrated to be superior. Institutions should feel free to utilise educational modalities, which are best supported by their resources to deliver interdisciplinary teamwork training.

Blending technology and teamwork for successful management of product recalls.

Patient safety programs have been developed in many hospitals to reduce the risk of harm to patients. Proactive, real-time, and retrospective risk-reduction strategies should be implemented in hospitals, but patient safety leaders should also be cognizant of the risks associated with thousands of products that enter the hospital through the supply chain. A growing number of recalls and alerts related to these products are received by health care facilities each year, through a recall process that is fraught with challenges. Despite the best efforts of health care providers, weaknesses and gaps in the process lead to delays, fragmentation, and disruptions, thus extending the number of days patients may be at risk from potentially faulty or misused products. To address these concerns, Duke Medicine, which comprises an academic medical center, two community hospitals, outlying clinics, physicians' offices, and home health and hospice, implemented a Web-based recall management system. Within three months, the time required to receive, deliver, and close alerts decreased from 43 days to 2.74 days. To maximize the effectiveness of the recall management process, a team of senior Duke Medicine leaders was established to evaluate the impact of product recalls and alerts on patient safety, to evaluate response action plans, and to provide oversight of patient and provider communication strategies. Alerts are now communicated more effectively and responded to in a more consistent and global manner. This comprehensive approach to product recalls is a critical component of a broader Duke Medicine strategy to improve patient safety.

Enhancing pediatric safety: assessing and improving resident competency in life-threatening events with a computer-based interactive resuscitation tool.

BACKGROUND: Though rare, allergic reactions occur as a result of administration of low osmolality nonionic iodinated contrast material to pediatric patients. Currently available resuscitation aids are inadequate in guiding radiologists' initial management of such reactions. OBJECTIVE: To compare radiology resident competency with and without a computer-based interactive resuscitation tool in the management of life-threatening events in pediatric patients. MATERIALS AND METHODS: The study was approved by the IRB. Radiology residents (n = 19; 14 male, 5 female; 19 certified in basic life support/advanced cardiac life support; 1 certified in pediatric advanced life support) were videotaped during two simulated 5-min anaphylaxis scenarios involving 18-month-old and 8-year-old mannequins (order randomized). No advance warning was given. In half of the scenarios, a computer-based interactive resuscitation tool with a response-driven decision tree was available to residents (order randomized). Competency measures included: calling a code, administering oxygen and epinephrine, and correctly dosing epinephrine. RESULTS: Residents performed significantly more essential interventions with the computer-based resuscitation tool than without (72/76 vs. 49/76, P < 0.001). Significantly more residents appropriately dosed epinephrine with the tool than without (17/19 vs. 1/19; P < 0.001). More residents called a code with the tool than without (17/19 vs. 14/19; P = 0.08). A learning effect was present: average times to call a code, request oxygen, and administer epinephrine were shorter in the second scenario (129 vs. 93 s, P = 0.24; 52 vs. 30 s, P < 0.001; 152 vs. 82 s, P = 0.025, respectively). All the trainees found the resuscitation tool helpful and potentially useful in a true pediatric emergency. CONCLUSION: A computer-based interactive resuscitation tool significantly improved resident performance in managing pediatric emergencies in the radiology department.

Imaging of acute appendicitis in children: EU versus U.S. ... or US versus CT? A North American perspective.

The timing, type, and technique of imaging evaluation of suspected appendicitis in children are all debated. This debate is both local and international. The fact is that choices in imaging evaluation will depend on both local and national influences, which are reasonable and to be expected. There still is a responsibility, though, for those involved with evaluation of patients with possible appendicitis to come to agreement about an appropriate diagnostic pathway that considers standards of care and available resources.

'Sleeping with the enemy?' Expectations and reality in imaging children in the emergency setting.

As an introduction to the ALARA conference titled "Building Bridges between Radiology and Emergency Medicine: Consensus Conference on Imaging Safety and Quality for Children in the Emergency Setting," it is important for us to understand the landscapes of both the pediatric radiology and emergency medicine subspecialties. Recognizing potentially different practice patterns, including perspectives on pediatric care, as well as shared and sometimes unique professional pressures, can help us identify common concerns and problems and facilitate the development of strategies aimed at correcting these issues.