Sustainability of a Multifaceted Intervention to Improve Surrogate Decision Maker Documentation for Hospitalized Adults.

Documenting surrogate decision makers (SDMs) is an important step in advance care planning (ACP) for hospitalized adults. The authors performed a quality improvement study of clinical and electronic health record (EHR) workflows aiming to increase SDM documentation for hospitalized adults. The intervention included an ACP education module, audit and feedback, as well as workflow and EHR adaptations. The authors prospectively tracked SDM documentation using control charts and used chart review to assess secondary outcome, process, and balancing measures. SDM documentation significantly increased from 69.5% to 80.2% ( P < 0.001) for intervention patients, sustained over 3 years, and was unchanged for control patients (34.6% to 36.3%; P = 0.355). There were no significant differences in secondary ACP outcomes in intervention or control patients. Clinical and EHR adaptations increased SDM documentation for hospitalized adults with minimal risk, although did not affect other ACP metrics. Future studies are needed to determine the effects of such changes on goal-concordant care.

The Mystery Dinner RCA: Using Gamification and Simulation to Teach Root Cause Analysis.

Introduction: Root cause analysis (RCA) is a widely utilized tool for investigating systems issues that lead to patient safety events and near misses, yet only 38% of learners participate in an interdisciplinary patient safety investigation during training. Common barriers to RCA education and participation include faculty time and materials, trainee time constraints, and learner engagement. Methods: We developed a simulated RCA workshop to be taught to a mix of medical and surgical specialties from over 11 GME programs and to third-year medical students. The workshop was a single 90-minute session formatted as a gamified mystery dinner including characters and sequentially revealed clues to promote engagement. Participant satisfaction and subjective knowledge, skills, and attitudes were assessed with a pre/post survey. Results: The workshop was completed by 134 learners between October 2018 and October 2019. The short workshop duration and premade simulation allowed a small number of faculty to train a wide variety of learners in various educational settings. Participants' presurvey (124 out of 134, 92%) versus postsurvey (113 out of 134, 84%) responses showed that attitudes about RCA were statistically improved across all domains queried, with an average effect size of 0.6 (moderate effect); 91% of participants would recommend this course to a colleague. Discussion: A 90-minute, gamified, simulated RCA workshop was taught to medical students and multiple GME specialties with subjective improvements in patient safety attitudes and knowledge while alleviating faculty time constraints in case development.

Hospital charges associated with "never events": comparison of anterior cervical discectomy and fusion, posterior lumbar interbody fusion, and lumbar laminectomy to total joint arthroplasty.

OBJECTIVE Beginning in 2008, the Centers for Medicare and Medicaid Service (CMS) determined that certain hospital-acquired adverse events such as surgical site infection (SSI) following spine surgery should never occur. The following year, they expanded the ruling to include deep vein thrombosis (DVT) and pulmonary embolism (PE) following total joint arthroplasty. Due to their ruling that "never events" are not the payers' responsibility, CMS insists that the costs of managing these complications be borne by hospitals and health care providers, rather than billings to health care payers for additional care required in their management. Data comparing the expected costs of such adverse events in patients undergoing spine and orthopedic surgery have not previously been reported. METHODS The California State Inpatient Database (CA-SID) from 2008 to 2009 was used for the analysis. All patients with primary procedure codes indicating anterior cervical discectomy and fusion (ACDF), posterior lumbar interbody fusion (PLIF), lumbar laminectomy (LL), total knee replacement (TKR), and total hip replacement (THR) were analyzed. Patients with diagnostic and/or treatment codes for DVT, PE, and SSI were separated from patients without these complication codes. Patients with more than 1 primary procedure code or more than 1 complication code were excluded. Median charges for treatment from primary surgery through 3 months postoperatively were calculated. RESULTS The incidence of the examined adverse events was lowest for ACDF (0.6% DVT, 0.1% PE, and 0.03% SSI) and highest for TKA (1.3% DVT, 0.3% PE, 0.6% SSI). Median inpatient charges for uncomplicated LL was $51,817, compared with $73,432 for ACDF, $143,601 for PLIF, $74,459 for THR, and $70,116 for TKR. Charges for patients with DVT ranged from $108,387 for TKR (1.5 times greater than index) to $313,536 for ACDF (4.3 times greater than index). Charges for patients with PE ranged from $127,958 for TKR (1.8 times greater than index) to $246,637 for PLIF (1.7 times greater than index). Charges for patients with SSI ranged from $168,964 for TKR (2.4 times greater than index) to $385,753 for PLIF (2.7 times greater than index). CONCLUSIONS Although incidence rates are low, adverse events of spinal procedures substantially increase the cost of care. Charges for patients experiencing DVT, PE, and SSI increased in this study by factors ranging from 1.8 to 4.3 times those for patients without such complications across 5 common spinal and orthopedic procedures. Cost projections by health care providers will need to incorporate expected costs of added care for patients experiencing such complications, assuming that the cost burden of such events continues to shift from payers to providers.

Co-immunization with multimeric scaffolds and DNA rapidly induces potent autologous HIV-1 neutralizing antibodies and CD8+ T cells.

To obtain proof of concept for HIV vaccines, we generated recombinant multimeric particles displaying the HIV-1 Envelope (Env) third hypervariable region (V3) as an N-terminal fusion protein on the E2 subunit of the pyruvate dehydrogenase complex of Geobacillus stearothermophilus. The E2 scaffold self-assembles into a 60-mer core that is 24 nm in diameter, with a molecular weight of 1.5 MDa, similar to a virus like particle with up to 60 copies of a heterologous protein accessible on the surface. Env(V3)-E2 multimers were tested alone and in combination with Env(gp160) DNA in mice and rabbits. Following two or more co-immunizations with Env(V3)-E2 and Env gp160 DNA, all 18 rabbits developed potent autologous neutralizing antibodies specific for V3 in six weeks. These neutralizing antibodies were sustained for 16 weeks without boosting, and comparable responses were obtained when lipopolysaccharide, a contaminant from expression in E. coli, was removed. Co-immunizations of Env(V3)-E2 and DNA expressing gp160 elicited moderate CD8-specific responses and Env-specific antibodies in mice. Co-immunization with DNA and E2 was superior to individual or sequential vaccination with these components in eliciting both neutralizing antibodies in rabbits and CD8(+) T cell responses in mice. Co-immunization with DNA and multimeric E2 scaffolds appears to offer a highly effective means of eliciting rapid, specific, and sustained immune responses that may be a useful approach for other vaccine targets.