The Minnesota Medical Operations Coordination Center: A COVID-19 Statewide Response to Ensure Access to Critical Care and Medical-Surgical Beds.

BACKGROUND: COVID-19 led to unprecedented inpatient capacity challenges, particularly in ICUs, which spurred development of statewide or regional placement centers for coordinating transfer (load-balancing) of adult patients needing intensive care to hospitals with remaining capacity. RESEARCH QUESTION: Do Medical Operations Coordination Centers (MOCC) augment patient placement during times of severe capacity challenges? STUDY DESIGN AND METHODS: The Minnesota MOCC was established with a focus on transfer of adult ICU and medical-surgical patients; trauma, cardiac, stroke, burn, and extracorporeal membrane oxygenation cases were excluded. The center operated within one health care system's bed management center, using a dedicated 24/7 telephone number. Major health care systems statewide and two tertiary centers in a neighboring state participated, sharing information on system status, challenges, and strategies. Patient volumes and transfer data were tracked; client satisfaction was evaluated through an anonymous survey. RESULTS: From August 1, 2020, through March 31, 2022, a total of 5,307 requests were made, 2,008 beds identified, 1,316 requests canceled, and 1,981 requests were unable to be fulfilled. A total of 1,715 patients had COVID-19 (32.3%), and 2,473 were negative or low risk for COVID-19 (46.6%). COVID-19 status was unknown in 1,119 (21.1%). Overall, 760 were patients on ventilators (49.1% COVID-19 positive). The Minnesota Critical Care Coordination Center placed most patients during the fall 2020 surge with the Minnesota Governor's stay-at-home order during the peak. However, during the fall 2021 surge, only 30% of ICU patients and 39% of medical-surgical patients were placed. Indicators characterizing severe surge include the number of Critical Care Coordination Center requests, decreasing placements, longer placement times, and time series analysis showing significant request-acceptance differences. INTERPRETATION: Implementation of a large-scale Minnesota MOCC program was effective at placing patients during the first COVID-19 pandemic fall 2020 surge and was well regarded by hospitals and health systems. However, under worsening duress of limited resources during the fall 2021 surge, placement of ICU and medical-surgical patients was greatly decreased.

Rapid implementation of a medical student rotation in health systems operations and remote patient care in response to COVID-19.

Medical schools initially removed students from clinical rotations at the outset of COVID-19 for safety reasons when students were eager to help and health systems needed personnel. In response, we rapidly implemented an innovative 2-week rotation for medical students to participate in health systems operations and care through remote efforts including triage and resource allocation. The curriculum also contained online self-paced educational modules covering topics including ethics, crisis standards of care, and modeling. As the health system needs shifted, so too did learners' work. One hundred and twenty-five 3rd and 4th-year students completed the experience over 10 months. Learner satisfaction, confidence, and knowledge assessed through pre- and post-rotation surveys showed statistically significant and educationally meaningful improvement. A near uniform change greater than 1 point (on a 5-point scale) was demonstrated upon rotation completion. Blending health systems and educational structures to meet the needs of both creates unique opportunities to educate students in new ways.

A 12-hospital prospective evaluation of a clinical decision support prognostic algorithm based on logistic regression as a form of machine learning to facilitate decision making for patients with suspected COVID-19.

OBJECTIVE: To prospectively evaluate a logistic regression-based machine learning (ML) prognostic algorithm implemented in real-time as a clinical decision support (CDS) system for symptomatic persons under investigation (PUI) for Coronavirus disease 2019 (COVID-19) in the emergency department (ED). METHODS: We developed in a 12-hospital system a model using training and validation followed by a real-time assessment. The LASSO guided feature selection included demographics, comorbidities, home medications, vital signs. We constructed a logistic regression-based ML algorithm to predict "severe" COVID-19, defined as patients requiring intensive care unit (ICU) admission, invasive mechanical ventilation, or died in or out-of-hospital. Training data included 1,469 adult patients who tested positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) within 14 days of acute care. We performed: 1) temporal validation in 414 SARS-CoV-2 positive patients, 2) validation in a PUI set of 13,271 patients with symptomatic SARS-CoV-2 test during an acute care visit, and 3) real-time validation in 2,174 ED patients with PUI test or positive SARS-CoV-2 result. Subgroup analysis was conducted across race and gender to ensure equity in performance. RESULTS: The algorithm performed well on pre-implementation validations for predicting COVID-19 severity: 1) the temporal validation had an area under the receiver operating characteristic (AUROC) of 0.87 (95%-CI: 0.83, 0.91); 2) validation in the PUI population had an AUROC of 0.82 (95%-CI: 0.81, 0.83). The ED CDS system performed well in real-time with an AUROC of 0.85 (95%-CI, 0.83, 0.87). Zero patients in the lowest quintile developed "severe" COVID-19. Patients in the highest quintile developed "severe" COVID-19 in 33.2% of cases. The models performed without significant differences between genders and among race/ethnicities (all p-values > 0.05). CONCLUSION: A logistic regression model-based ML-enabled CDS can be developed, validated, and implemented with high performance across multiple hospitals while being equitable and maintaining performance in real-time validation.

Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care.

BACKGROUND: After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world. RESEARCH QUESTION: A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality. STUDY DESIGN AND METHODS: TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence. RESULTS: Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. INTERPRETATION: A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.

Responding to COVID-19 Through Interhospital Resource Coordination: A Mixed-Methods Evaluation.

OBJECTIVES: The COVID-19 pandemic stressed hospital operations, requiring rapid innovations to address rise in demand and specialized COVID-19 services while maintaining access to hospital-based care and facilitating expertise. We aimed to describe a novel hospital system approach to managing the COVID-19 pandemic, including multihospital coordination capability and transfer of COVID-19 patients to a single, dedicated hospital. METHODS: We included patients who tested positive for SARS-CoV-2 by polymerase chain reaction admitted to a 12-hospital network including a dedicated COVID-19 hospital. Our primary outcome was adherence to local guidelines, including admission risk stratification, anticoagulation, and dexamethasone treatment assessed by differences-in-differences analysis after guideline dissemination. We evaluated outcomes and health care worker satisfaction. Finally, we assessed barriers to safe transfer including transfer across different electronic health record systems. RESULTS: During the study, the system admitted a total of 1209 patients. Of these, 56.3% underwent transfer, supported by a physician-led System Operations Center. Patients who were transferred were older (P = 0.001) and had similar risk-adjusted mortality rates. Guideline adherence after dissemination was higher among patients who underwent transfer: admission risk stratification (P < 0.001), anticoagulation (P < 0.001), and dexamethasone administration (P = 0.003). Transfer across electronic health record systems was a perceived barrier to safety and reduced quality. Providers positively viewed our transfer approach. CONCLUSIONS: With standardized communication, interhospital transfers can be a safe and effective method of cohorting COVID-19 patients, are well received by health care providers, and have the potential to improve care quality.

Overcoming gaps: regional collaborative to optimize capacity management and predict length of stay of patients admitted with COVID-19.

OBJECTIVE: Ensuring an efficient response to COVID-19 requires a degree of inter-system coordination and capacity management coupled with an accurate assessment of hospital utilization including length of stay (LOS). We aimed to establish optimal practices in inter-system data sharing and LOS modeling to support patient care and regional hospital operations. MATERIALS AND METHODS: We completed a retrospective observational study of patients admitted with COVID-19 followed by 12-week prospective validation, involving 36 hospitals covering the upper Midwest. We developed a method for sharing de-identified patient data across systems for analysis. From this, we compared 3 approaches, generalized linear model (GLM) and random forest (RF), and aggregated system level averages to identify features associated with LOS. We compared model performance by area under the ROC curve (AUROC). RESULTS: A total of 2068 patients were included and used for model derivation and 597 patients for validation. LOS overall had a median of 5.0 days and mean of 8.2 days. Consistent predictors of LOS included age, critical illness, oxygen requirement, weight loss, and nursing home admission. In the validation cohort, the RF model (AUROC 0.890) and GLM model (AUROC 0.864) achieved good to excellent prediction of LOS, but only marginally better than system averages in practice. CONCLUSION: Regional sharing of patient data allowed for effective prediction of LOS across systems; however, this only provided marginal improvement over hospital averages at the aggregate level. A federated approach of sharing aggregated system capacity and average LOS will likely allow for effective capacity management at the regional level.

Building the Bridge to Quality: An Urgent Call to Integrate Quality Improvement and Patient Safety Education With Clinical Care.

Current models of quality improvement and patient safety (QIPS) education are not fully integrated with clinical care delivery, representing a major impediment toward achieving widespread QIPS competency among health professions learners and practitioners. The Royal College of Physicians and Surgeons of Canada organized a 2-day consensus conference in Niagara Falls, Ontario, Canada, called Building the Bridge to Quality, in September 2016. Its goal was to convene an international group of educational and health system leaders, educators, frontline clinicians, learners, and patients to engage in a consensus-building process and generate a list of actionable strategies that individuals and organizations can use to better integrate QIPS education with clinical care.Four strategic directions emerged: prioritize the integration of QIPS education and clinical care, build structures and implement processes to integrate QIPS education and clinical care, build capacity for QIPS education at multiple levels, and align educational and patient outcomes to improve quality and patient safety. Individuals and organizations can refer to the specific tactics associated with the 4 strategic directions to create a road map of targeted actions most relevant to their organizational starting point.To achieve widespread change, collaborative efforts and alignment of intrinsic and extrinsic motivators are needed on an international scale to shift the culture of educational and clinical environments and build bridges that connect training programs and clinical environments, align educational and health system priorities, and improve both learning and care, with the ultimate goal of achieving improved outcomes and experiences for patients, their families, and communities.

Clinical and Educational Outcomes of an Integrated Inpatient Quality Improvement Curriculum for Internal Medicine Residents.

BACKGROUND: Integrating teaching and hands-on experience in quality improvement (QI) may increase the learning and the impact of resident QI work. OBJECTIVE: We sought to determine the clinical and educational impact of an integrated QI curriculum. METHODS: This clustered, randomized trial with early and late intervention groups used mixed methods evaluation. For almost 2 years, internal medicine residents from Dartmouth-Hitchcock Medical Center on the inpatient teams at the White River Junction VA participated in the QI curriculum. QI project effectiveness was assessed using statistical process control. Learning outcomes were assessed with the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and through self-efficacy, interprofessional care attitudes, and satisfaction of learners. Free text responses by residents and a focus group of nurses who worked with the residents provided information about the acceptability of the intervention. RESULTS: The QI projects improved many clinical processes and outcomes, but not all led to improvements. Educational outcome response rates were 65% (68 of 105) at baseline, 50% (18 of 36) for the early intervention group at midpoint, 67% (24 of 36) for the control group at midpoint, and 53% (42 of 80) for the late intervention group. Composite QIKAT-R scores (range, 0-27) increased from 13.3 at baseline to 15.3 at end point (P < .01), as did the self-efficacy composite score (P < .05). Satisfaction with the curriculum was rated highly by all participants. CONCLUSIONS: Learning and participating in hands-on QI can be integrated into the usual inpatient work of resident physicians.

Exemplary Care and Learning Sites: A Model for Achieving Continual Improvement in Care and Learning in the Clinical Setting.

PROBLEM: Current models of health care quality improvement do not explicitly describe the role of health professions education. The authors propose the Exemplary Care and Learning Site (ECLS) model as an approach to achieving continual improvement in care and learning in the clinical setting. APPROACH: From 2008-2012, an iterative, interactive process was used to develop the ECLS model and its core elements--patients and families informing process changes; trainees engaging both in care and the improvement of care; leaders knowing, valuing, and practicing improvement; data transforming into useful information; and health professionals competently engaging both in care improvement and teaching about care improvement. In 2012-2013, a three-part feasibility test of the model, including a site self-assessment, an independent review of each site's ratings, and implementation case stories, was conducted at six clinical teaching sites (in the United States and Sweden). OUTCOMES: Site leaders reported the ECLS model provided a systematic approach toward improving patient (and population) outcomes, system performance, and professional development. Most sites found it challenging to incorporate the patients and families element. The trainee element was strong at four sites. The leadership and data elements were self-assessed as the most fully developed. The health professionals element exhibited the greatest variability across sites. NEXT STEPS: The next test of the model should be prospective, linked to clinical and educational outcomes, to evaluate whether it helps care delivery teams, educators, and patients and families take action to achieve better patient (and population) outcomes, system performance, and professional development.

The Quality and Safety Educators Academy: fulfilling an unmet need for faculty development.

Educating physician trainees in the principles of quality improvement (QI) and patient safety (PS) is a national imperative. Few faculty are trained in these disciplines, and few teaching institutions have the resources and infrastructure to develop faculty as instructors of these skills. The authors designed a 3-day, in-person academy to provide medical educators with the knowledge and tools to integrate QI and PS concepts into their training programs. The curriculum provided instruction in quality and safety, curriculum development and assessment, change management, and professional development while fostering peer networking, mentorship, and professional development. This article describes the characteristics, experiences, and needs of a cross-sectional group of faculty interested in acquiring skills to help them succeed as quality and safety educators. It also describes the guiding principles, curriculum blueprint, program evaluation, and lessons learned from this experience which could be applied to future faculty development programs in quality and safety education.

Efficacy of peer-assisted learning across residencies for procedural training in dermatology.

BACKGROUND: With new care models such as the medical home, there is an expanding need for primary care providers to be trained in dermatologic procedures. Yet, many internal medicine residency program graduates feel unprepared to perform these procedures. The aim of this study was to evaluate the effect of a structured peer-assisted learning approach to improve residents' knowledge and skills related to common dermatologic assessment techniques. METHODS: Eight medicine-dermatology resident educators, with a faculty member, facilitated dermatologic procedure workshops for 28 internal medicine and medicine-pediatrics resident learners. Learners completed preworkshop and postworkshop surveys, assessing their knowledge and skill levels as well as the efficacy of the resident educators and the educational value of the workshop as a whole. RESULTS: All learners were able to properly demonstrate the techniques at the workshop's conclusion. The median sum score of self-reported knowledge increased from 3 to 9.5 (scale, 0-10; P < .001). The median sum score of self-reported skills increased from 10 to 16 (scale, 4-20; P < .001). Resident educators were favorably evaluated by their peers, and 96% of participants rated the experience as being of high educational value. CONCLUSION: Peer-assisted learning is effective in teaching dermatologic procedures in graduate medical education. Resident learners found peer-assisted learning to be beneficial and rated their peer teachers highly. Further studies should focus on outcomes in practice, looking at the number of dermatologic procedures performed by learners, as well as the effects on resident educators.

Integrating the science of team training: guidelines for continuing education.

The provision of high-quality, efficient care results from the coordinated, cooperative efforts of multiple technically competent health care providers working in concert over time, spanning disciplinary and professional boundaries. Accordingly, the role of medical education must include the development of providers who are both expert clinicians and expert team members. However, the competencies underlying effective teamwork are only just beginning to be integrated into medical school curricula and residency programs. Therefore, continuing education (CE) is a vital mechanism for practitioners already in the field to develop the attitudes, behaviors (skills), and cognitive knowledge necessary for highly reliable and effective team performance.The present article provides an overview of more than 30 years of evidence regarding team performance and team training in order to guide, shape, and build CE activities that focus on developing team competencies. Recognizing that even the most comprehensive and well-designed team-oriented CE programs will fail unless they are supported by an organizational and professional culture that values collaborative behavior, ten evidence-based lessons for practice are offered in order to facilitate the use of the science of team-training in efforts to foster continuous quality improvement and enhance patient safety.

What women want from their physicians: a qualitative analysis.

BACKGROUND: Despite increased efforts to improve the education of trainees in women's health, little information exists about what women want from their healthcare providers. Existing information from studies focuses on patient care and medical knowledge rather than on all six competencies mandated by the Accreditation Council of Graduate Medical Education (ACGME). OBJECTIVES: To identify what adult female patients want their physicians to know and be able to do in all ACGME competency areas in order to guide development of graduate women's health curricula. METHODS: We conducted two focus groups with 18 volunteer adult female patients and one focus group with 5 community advocates. Questions addressed all six competency areas. The same female researcher moderated all three sessions. Two researchers analyzed session transcriptions for themes. RESULTS: Female patients and community advocates consistently stressed the need for their physicians to be able to navigate the healthcare system and to be their advocates. They also noted the need for physicians skilled in working with patients from a variety of cultures and for developing and maintaining respectful doctor-patient relationships, including good interpersonal communication. CONCLUSIONS: Patients' expectations of physicians extend beyond medical knowledge and patient care into the areas of communication, systems-based practice, and professionalism. Curricular changes in women's health at the postgraduate level should emphasize skills in these competencies, and needs assessment processes would do well to include patient viewpoints in the future.

Implementing change in health professions education: stakeholder analysis and coalition building.

The challenges facing the health sciences education fields are more evident than ever. Professional health sciences educators have more demands on their time, more knowledge to manage, and ever-dwindling sources of financial support. Change is often necessary to either keep programs viable or meet the changing needs of health education. This article outlines a simple but powerful three-step tool to help educators become successful agents of change. Through the application of principles well known and widely used in business management, readers will understand the concepts behind stakeholder analysis and coalition building. These concepts are part of a powerful tool kit that educators need in order to become effective agents of change in the health sciences environment. Using the example of curriculum change at a school of veterinary medicine, we will outline the three steps involved, from stakeholder identification and analysis to building and managing coalitions for change.

Instruments for evaluating education in evidence-based practice: a systematic review.

CONTEXT: Evidence-based practice (EBP) is the integration of the best research evidence with patients' values and clinical circumstances in clinical decision making. Teaching of EBP should be evaluated and guided by evidence of its own effectiveness. OBJECTIVE: To appraise, summarize, and describe currently available EBP teaching evaluation instruments. DATA SOURCES AND STUDY SELECTION: We searched the MEDLINE, EMBASE, CINAHL, HAPI, and ERIC databases; reference lists of retrieved articles; EBP Internet sites; and 8 education journals from 1980 through April 2006. For inclusion, studies had to report an instrument evaluating EBP, contain sufficient description to permit analysis, and present quantitative results of administering the instrument. DATA EXTRACTION: Two raters independently abstracted information on the development, format, learner levels, evaluation domains, feasibility, reliability, and validity of the EBP evaluation instruments from each article. We defined 3 levels of instruments based on the type, extent, methods, and results of psychometric testing and suitability for different evaluation purposes. DATA SYNTHESIS: Of 347 articles identified, 115 were included, representing 104 unique instruments. The instruments were most commonly administered to medical students and postgraduate trainees and evaluated EBP skills. Among EBP skills, acquiring evidence and appraising evidence were most commonly evaluated, but newer instruments evaluated asking answerable questions and applying evidence to individual patients. Most behavior instruments measured the performance of EBP steps in practice but newer instruments documented the performance of evidence-based clinical maneuvers or patient-level outcomes. At least 1 type of validity evidence was demonstrated for 53% of instruments, but 3 or more types of validity evidence were established for only 10%. High-quality instruments were identified for evaluating the EBP competence of individual trainees, determining the effectiveness of EBP curricula, and assessing EBP behaviors with objective outcome measures. CONCLUSIONS: Instruments with reasonable validity are available for evaluating some domains of EBP and may be targeted to different evaluation needs. Further development and testing is required to evaluate EBP attitudes, behaviors, and more recently articulated EBP skills.