Rescue Improvement Conference: A Novel Tool for Addressing Failure to Rescue.

OBJECTIVE: To understand the effectiveness of Rescue Improvement Conference, a forum that addresses FTR. SUMMARY OF BACKGROUND DATA: Every year over 150,000 patients die after elective surgery in the United States. FTR is the phenomenon whereby delayed recognition and/or response to serious surgical complications leads to a progressive cascade of adverse events culminating in death. Rescue Improvement Conference is an adapted version of the Ottawa-style morbidity and mortality conference, designed to address common contributors to FTR: ineffective communication and inadequate problem solving. METHODS: Mixed methods data were used to evaluate Rescue Improvement Conference, a bi-monthly forum that was first introduced in our academic medical center in 2018. Conference effectiveness data were collected via survey and open-text responses after 5 conferences between September 2018 and February 2020. We focused on 5 indicators of effectiveness: educational value, conference takeaways, discussion time, changes to surgical practice, and actionable opportunities for improvement. Twelve surgical faculty and house staff also provided feedback during semi-structured interviews. Qualitative data were analyzed using thematic analysis. RESULTS: Conference attendees (N = 140) felt that Rescue Improvement Conference was effective-all 5 indicators had mean scores above 5 on Likert scales. The qualitative data supports the quantitative findings, and 3 additional themes emerged: Rescue Improvement Conference enables the representation of diverse voices, promotes interdisciplinary collaboration, and encourages multilevel problem solving. CONCLUSIONS: Rescue Improvement Conference has the potential to support other surgical departments in developing system-level strategies to recognize and manage postoperative complications by providing stakeholders a forum to identify and discuss factors that contribute to FTR.

Improving Postoperative Rescue Through a Multifaceted Approach.

This article provides a better understanding of how interactions and relationships within hospital microsystems affect rescue. Through structured engagement of clinical champions, these rescue improvement tools may decrease rates of secondary and tertiary complications and enhance staff culture, confidence, and competence. The proposed 3-prong approach sheds light on how health care organizations can better sense, cope with, and respond to the unexpected and changing demands presented by clinically deteriorating postsurgical patients. These interventions lay the groundwork for the further development, testing, and implementation of larger scale rescue-focused initiatives, which could have a direct, population-level impact on mortality.

Understanding Interpersonal and Organizational Dynamics Among Providers Responding to Crisis.

Patient rescue occurs in phases: recognizing the problem, communicating the concern, and treating the complication. To help improve rescue, we sought to understand facilitators and barriers to managing postoperative complications. We used a criterion-based sample from a large academic medical center. Semistructured interviews (n = 57) were conducted, which were audio-recorded and transcribed verbatim. Thematic analysis and consensus coding was performed using NVivo 11. We used a framework matrix approach to synthesize our coding and identify themes that facilitate or impede rescue. Clinicians identified root causes for delays in care, such as recognizing patient deterioration, knowing whom to contact and when, and reaching the correct decision-making provider. This study identified significant variation in communication processes across providers caring for surgical patients. Targeted interventions aimed at improving and standardizing these aspects of communication may significantly influence the ability to effectively identify and escalate care for postoperative complications.

Using a dependent schedule to measure risky choice in male rats: Effects of d-amphetamine, methylphenidate, and methamphetamine.

Risky choice is the tendency to choose a large, uncertain reward over a small, certain reward, and is typically measured with probability discounting, in which the probability of obtaining the large reinforcer decreases across blocks of trials. One caveat to traditional procedures is that independent schedules are used, in which subjects can show exclusive preference for one alternative relative to the other. For example, some rats show exclusive preference for the small, certain reinforcer as soon as delivery of the large reinforcer becomes probabilistic. Therefore, determining if a drug increases risk aversion (i.e., decreases responding for the probabilistic alternative) is difficult (due to floor effects). The overall goal of this experiment was to use a concurrent-chains procedure that incorporated a dependent schedule during the initial link, thus preventing animals from showing exclusive preference for one alternative relative to the other. To determine how pharmacological manipulations alter performance in this task, male Sprague-Dawley rats (n = 8) received injections of amphetamine (0, 0.25, 0.5, 1.0 mg/kg), methylphenidate (0, 0.3, 1.0, 3.0 mg/kg), and methamphetamine (0, 0.5, 1.0, 2.0 mg/kg). Amphetamine (0.25 mg/kg) and methylphenidate (3.0 mg/kg) selectively increased risky choice, whereas higher doses of amphetamine (0.5 and 1.0 kg/mg) and each dose of methamphetamine impaired stimulus control (i.e., flattened the discounting function). These results show that dependent schedules can be used to measure risk-taking behavior and that psychostimulants promote suboptimal choice when this schedule is used. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Identifying Barriers and Facilitators to Nutrition and Physical Activity among Public Housing Residents Using Photovoice.

BACKGROUND: Weight management is a national health priority for health disparity-facing populations. There is a paucity of literature examining perceptions of diet and physical activity behaviors for weight management among public housing residents. Photovoice is a qualitative technique in which participants take photographs to document and discuss personal, social, and environmental factors around a particular topic. OBJECTIVES: To use photovoice to identify facilitators and barriers to weight management, including diet and physical activity behaviors, among urban public housing residents. METHODS: Four 2-hour sessions were held in each of four housing developments (16 total sessions). Participants were given three photo missions to take photographs of the meaning of health, facilitators, and barriers. Participants then discussed and wrote narratives of their most meaningful photographs. RESULTS: The majority of participants (n = 28) were obese (60%), female (82%), and African American or Black (71%) residents. Qualitative analysis of the transcripts revealed multiple facilitators and barriers that influenced weight management at the individual (e.g., self-control), interpersonal (e.g., peer influence), and community (e.g., access) levels. Additional themes that were specific to the housing development level included built environment at the development, feelings of community support, the development tenant/resident task force, and living conditions. CONCLUSIONS: Findings revealed multiple facilitators and barriers to healthy eating, physical activity, and weight management among public housing residents with additional factors influencing health within the housing development. Photovoice was a feasible method to engage community members in discussions and may be useful to inform multilevel interventions.

Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue.

Failure to rescue-mortality following a major surgical complication-is a key driver of variation in postoperative mortality. However, little is known about the impact of interpersonal and organizational dynamics, or microsystem factors, on failure to rescue. In a qualitative study of providers from hospitals with high and low rescue rates, we identified five key factors that providers believe influence the successful rescue of surgical patients: teamwork, action taking, psychological safety, recognition of complications, and communication. Near-uniform agreement existed on two targets for improvement: delayed recognition of developing complications and poor interprofessional communication and inability to express clinical concerns. To improve perioperative outcomes, hospitals and payers should shift their attention to improving early detection and effective communication of major complications.

Effects of GluN2B-selective antagonists on delay and probability discounting in male rats: Modulation by delay/probability presentation order.

The contribution of the GluN2B subunit of the NMDA receptor to impulsivity has recently been examined. Ro 63-1908, a highly selective antagonist for the GluN2B, decreases impulsive choice. Because the order in which delays are presented modulates drug effects in discounting procedures, one goal of the current study was to determine the effects of Ro 63-1908 in delay discounting procedures in which the delays to obtaining the large reinforcer either increase or decrease across the session. We also determined if Ro 63-1908 differentially alters risky choice in probability discounting procedures that use ascending/descending schedules. Male rats were trained in either delay (n = 24) or probability (n = 24) discounting in which the delay to/odds against reinforcement were presented in either ascending or descending order (n = 12 each schedule). Following training, rats received the GluN2B antagonists Ro 63-1908 (0-1.0 mg/kg) and CP-101,606 (0-3.0 mg/kg). In delay discounting, Ro 63-1908 (1.0 mg/kg), but not CP-101,606, decreased choice for the large reinforcer, but only when the delays decreased across the session. In probability discounting, Ro 63-1908 (0.3 mg/kg)/CP-101,606 (1.0 mg/kg) increased choice for the large reinforcer when the probability of obtaining this alternative decreased across the session, but Ro 63-1908 (1.0 mg/kg)/CP-101,606 (3.0 mg/kg) decreased choice when the probabilities increased. These results show that the GluN2B is a mediator of impulsive/risky choice, but the effects of GluN2B antagonists are dependent on the order in which delays/probabilities are presented. (PsycINFO Database Record (c) 2018 APA, all rights reserved).