Development of a Web-Based Nonoperative Small Bowel Obstruction Treatment Pathway App.

OBJECTIVE: An electronic pathway for the management of adhesive small bowel obstruction (SBO) was built and implemented on top of the electronic health record. The aims of this study are to describe the development of the electronic pathway and to report early outcomes. METHODS: The electronic SBO pathway was designed and implemented at a single institution. All patients admitted to a surgical service with a diagnosis of adhesive SBO were enrolled. Outcomes were compared across three time periods: (1) patients not placed on either pathway from September 2013 through December 2014, (2) patients enrolled in the paper pathway from January 2017 through January 2018, and (3) patients enrolled in the electronic pathway from March through October 2018. The electronic SBO pathway pulls real-time data from the electronic health record to prepopulate the evidence-based algorithm. Outcomes measured included length of stay (LOS), time to surgery, readmission, surgery, and need for bowel resection. Comparative analyses were completed with Pearson's chi-squared, analysis of variance, and Kruskal-Wallis tests. RESULTS: There were 46 patients enrolled in the electronic pathway compared with 93 patients on the paper pathway, and 101 nonpathway patients. Median LOS was lower in both pathway cohorts compared with those not on either pathway (3 days [range 1-11] vs. 3 days [range 1-27] vs. 4 days [range 1-13], p = 0.04). Rates of readmission, surgery, time to surgery, and bowel resection were not significantly different across the three groups. CONCLUSION: It is feasible to implement and utilize an electronic, evidence-based clinical pathway for adhesive SBOs. Use of the electronic and paper pathways was associated with decreased hospital LOS for patients with adhesive SBOs.

COVID-19 infections among HCWs exposed to a patient with a delayed diagnosis of COVID-19.

We report on COVID-19 risk among HCWs exposed to a patient diagnosed with COVID-19 on day 13 of hospitalization. There were 44 HCWs exposed to the patient before contact and droplet precautions were implemented: of these, 2 of 44 (5%) developed COVID-19 potentially attributable to the exposure.

Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt.

IMPORTANCE: Death due to preventable medical error is a leading cause of death, with varying estimates of preventable death rates (14%-56% of total deaths based on national extrapolated estimates, 3%-11% based on single-centre estimates). Yet, how best to reduce preventable mortality in hospitals remains unknown. OBJECTIVE: In this article, we detail lessons learnt from implementing a hospital-wide, automated, real-time, electronic mortality reporting system that relies on the opinions of front-line clinicians to identify opportunities for improvement. We also summarise data obtained regarding possible preventability, systems issues identified and addressed, and challenges with implementation. We outline our process of survey, evaluation, escalation and tracking of opportunities identified through the review process. METHODS: We aggregated and analysed 7 years of review data regarding deaths, review responses categorised by ratings of possible preventability and inter-rater reliability of possible preventability. A qualitative analysis of reviews was performed to identify care delivery opportunities and institutional response. RESULTS: Over the course of 7 years, 7856 inpatient deaths occurred, and 91% had at least one review completed. 5.2% were rated by front-line clinicians as potentially being preventable (likely or possibly), and this rate was consistent over time. However, there was only slight inter-rater agreement regarding potential preventability (Cohen's kappa=0.185). Nevertheless, several major systems-level opportunities were identified that facilitated care delivery improvements, such as communication challenges, need for improved end-of-life care and interhospital transfer safety. CONCLUSIONS: Through implementation, we found that a hospital-wide mortality review process that elicits feedback from front-line providers is feasible, and provides valuable insights regarding potential preventable mortality and prioritising actionable opportunities for care delivery improvements.

Patient and Provider-Identified Factors Contributing to Surgical Readmission After Colorectal Surgery.

PURPOSE: Nearly one in seven surgical patients is readmitted to the hospital within 30 days of discharge. Few studies have identified patient-centric factors that raise the risk of both preventable and nonpreventable postoperative readmissions. MATERIALS AND METHODS: Over 6 months in 2012, 48 colorectal surgical patients were identified on re-admission within 30 days of discharge. We prospectively obtained information on the patient's and primary surgeon's views on factors that contributed to readmission, and compiled data to produce an external list of contributing factors. A standard cost analysis was performed. RESULTS: 48 colorectal surgery patients participated, and 47 were included in this patient-centric evaluation of factors leading to readmission. The three primary readmission diagnoses included dehydration, fever, and ileus or small bowel obstruction. Of all readmissions, 23% were considered to be preventable. 38% of patients had scheduled follow-up appointments that were documented in the medical record at the time of discharge. Providers identified several factors contributing to readmission including difficulty understanding discharge plan, medication management and premature discharge. Per patient, the cost of preventable readmission was $15,366 (±20%; $12,293-$18,439). Total preventable cost was $169,025 (±20%; $135,220-$202,829). CONCLUSIONS: The ability to obtain an outpatient postoperative appointment and the understanding of their own postoperative care were the most commonly identified barriers. Interventions to help reduce unnecessary readmissions include a standard discharge process and coordinator, and routine (<7 days) postdischarge outpatient appointments. Successful reduction of preventable readmissions would result in approximately $3.6 million in cost savings per 1,000 colorectal readmissions.

Implementation of Measures to Improve SCIP Perioperative Beta-Blocker Compliance: Quality and Financial Implications.

INTRODUCTION: The Surgical Care Improvement Project (SCIP) was launched in 2005. One of the SCIP metrics includes perioperative beta-blocker guideline (CARD-2), which measures the percentage of patients on a pre-operative beta-blocker with continued use in the perioperative period. Compliance is intended to decrease rates of acute myocardial infarction (AMI) and cardiac mortality among high-risk patients. We desired to create low cost, standardized processes on an institutional level to improve compliance with the SCIP CARD-2 metric. METHODS: We assessed the impact of interventions on provider compliance with the SCIP CARD-2 metric and on simulated impact on institutional cost. RESULTS: We were able to improve CARD-2 compliance at one hospital within a year of intervention implementation. The hospital decreased its losses due to noncompliance in FY 2014 by $27 273. DISCUSSION: A relatively low cost intervention, aimed at educating providers that utilized existing infrastructure resulted in improved SCIP beta-blocker compliance. Changes in the reimbursement system made at the time of publication demonstrate that reimbursement measures are constantly in flux; tailored interventions based upon our successes may still produce similar results.

A Single-Center Multidisciplinary Initiative to Reduce Catheter-Associated Urinary Tract Infection Rates: Quality and Financial Implications.

INTRODUCTION: Catheter-associated urinary tract infection (CAUTI) is an important patient safety issue that is responsible for an estimated 449334 annual infections, with an average direct cost of $790-$1200 per infection. In total, the cost associated with CAUTI is estimated to be $115 million to $1.82 billion annually. METHODS: We conducted an internal revenue analysis with a standard sensitivity analysis to assess the impact of a low-cost CAUTI reduction program on direct costs to the hospital over four years. The interventions included the formation of a multidisciplinary CAUTI reduction task force, formal data collection in all ICUs, staff education, and new electronic order sets with decision support. RESULTS: During the initial intervention period, the infection rate per 1000 catheter days decreased from 5.4 to 1.5. In the second year of the program, the infection rate increased to 4.6. After additional interventions were launched, infection rates decreased to 2.2. Cost savings per 1000 catheter days (±20%) during the initial intervention were $4501 ($3600-$5401). DISCUSSION: Our intervention demonstrated that provider education and electronic documentation prompts were followed by a significant decrease in catheter utilization, that in turn was followed by lower infection rates. Decreased emphasis on intervention goals were followed by an increase in CAUTI rates. Our subsequent interventions suggest that upward trends may be reversible.

A multidisciplinary three-phase approach to improve the clinical utility of patient safety indicators.

PURPOSE: The AHRQ Patient Safety Indicators (PSIs) are used for calculation of risk-adjusted postoperative rates for adverse events. The payers and quality consortiums are increasingly requiring public reporting of hospital performance on these metrics. We discuss processes designed to improve the accuracy and clinical utility of PSI reporting in practice. METHODS: The study was conducted at a 793-bed tertiary care academic medical center where PSI processes have been aggressively implemented to track patient safety events at discharge. A three-phased approach to improving administrative data quality was implemented. The initiative consisted of clinical review of all PSIs, documentation improvement, and provider outreach including active querying for patient safety events. RESULTS: This multidisciplinary effort to develop a streamlined process for PSI calculation reduced the reporting of miscoded PSIs and increased the clinical utility of PSI monitoring. Over 4 quarters, 4 of 41 (10%) PSI-11 and 9 of 138 (7%) PSI-15 errors were identified on review of clinical documentation and appropriate adjustments were made. CONCLUSION: A multidisciplinary, phased approach leveraging existing billing infrastructure for robust metric coding, ongoing clinical review, and frontline provider outreach is a novel and effective way to reduce the reporting of false-positive outcomes and improve the clinical utility of PSIs.

Description of a multidisciplinary initiative to improve SCIP measures related to pre-operative antibiotic prophylaxis compliance: a single-center success story.

BACKGROUND: The Surgical Care Improvement Project (SCIP) was launched in 2005. The core prophylactic perioperative antibiotic guidelines were created due to recognition of the impact of proper perioperative prophylaxis on an estimated annual one million inpatient days and $1.6 billion in excess health care costs secondary to preventable surgical site infections (SSIs). An internal study was conducted to create low cost, standardized processes on an institutional level to improve compliance with prophylactic antibiotic administration. METHODS: We assessed the impact of auditing and notifying providers of SCIP errors on overall compliance with inpatient antibiotic guidelines and on net financial gain or loss to a large tertiary center between March 1st 2010 and September 31st 2013. We hypothesized that direct physician-to-physician feedback would result in significant compliance improvements. RESULTS: Through physician notification, our hospital was able to significantly improve SCIP compliance and emphasis on patient safety within a year of intervention implementation. The hospital earned an additional $290,612 in 2011 and $209,096 in 2012 for re-investment in patient care initiatives. CONCLUSIONS: Provider education and direct notification of SCIP prophylactic antibiotic dosing errors resulted in improved compliance with national patient improvement guidelines. There were differences between the anesthesiology and surgery department feedback responses, the latter likely attributed to diverse surgical department sub-divisions, frequent changes in resident trainees and supervising attending staff, and the comparative ability. Provider notification of guideline non-compliance should be encouraged as standard practice to improve patient safety. Also, the hospital experienced increased revenue for re-investment in patient care as a secondary result of provider notification.

Process measures to improve perioperative prophylactic antibiotic compliance: quality and financial implications.

The Surgical Care Improvement Project (SCIP) was launched in 2005. The core prophylactic perioperative antibiotic guidelines were created because of recognition of the impact of proper perioperative prophylaxis on an estimated annual 1 million inpatient days and $1.6 billion in excess health care costs that are secondary to preventable surgical site infections. There is a need to create low-cost, standardized processes on an institutional level to improve compliance with prophylactic antibiotic administration. The impact of interventions on provider compliance with SCIP inpatient antibiotic guidelines and net financial gain or loss to a large tertiary center were assessed. A single hospital was able to significantly improve their SCIP compliance and emphasis on patient safety within a year of intervention implementation. The hospital earned an additional $290,612 in 2011 and $209,096 in 2012 for reinvestment in patient safety initiatives. Low-cost interventions aimed at educating providers that utilize existing infrastructure result in improved SCIP compliance and patient safety. As a secondary gain, there were hundreds of thousands of dollars in annual cost savings. The impact of compliance on infection rates is inferred but requires further study.