Multidisciplinary handoffs improve perceptions of communication.

BACKGROUND: Communication errors during handoffs are a leading cause of sentinel events. The Accreditation Council for Graduate Medical Education 2011 duty hour standards (DHS) increase the frequency of handoffs. OBJECTIVE: The goal of this study was to determine if a multidisciplinary group handoff bundle improves communication while working within the 2011 DHS. METHODS: During 1-month pilot programs of the 2011 DHS, 2 groups were observed. Group A adopted a multidisciplinary group handoff bundle, including presence of residents and charge nurses, a standardized mnemonic in verbal and written form, and resident training. Group B received only a mnemonic pocket card. Residents completed preintervention and postintervention Likert scale surveys to assess handoff perceptions. Within-group preintervention to postintervention changes were analyzed by using the signed rank test. Measuring communication errors, an institutional tool was used to track unanticipated patient occurrences (UPOs) postintervention for both groups. RESULTS: Significant improvements for the preintervention to postintervention surveys regarding the perceptions of quality of handoffs received, effective and efficient delivery of handoffs, comfort in giving handoffs, and handoff practices focusing on safety (all, P ≤ .05) were observed in group A. There were no significant changes in group B. Overall, 17% of collected group A UPO forms and 11% of group B UPO forms had at least 1 UPO recorded. The most common reason for a UPO was unaddressed nursing concerns. CONCLUSIONS: A multidisciplinary group of residents and charge nurses and a handoff bundle was associated with improved resident perceptions of handoffs and communication within the 2011 DHS.

Effects of the 2011 duty hour restrictions on resident education and learning from patient admissions.

OBJECTIVE: In July 2011, new duty hour limits for resident physicians were instituted to address concerns about the effects of sleep deprivation on patient care and trainee experience. We sought to evaluate potential educational impacts of these duty hour changes with regard to learning and frequency of attending interactions during patient admissions. METHODS: Forty-nine residents on general pediatric teams participated in a prospective observational cohort study. Intervention residents (n = 23) worked a shift-based schedule compliant with new requirements. Control residents (n = 26) were on call every fourth night and compliant with 2003 work hour limits. Faculty members were present 16 hours daily. Resident surveys assessed learning from admissions (frequency of attending interaction and perceived learning during admissions). Data were analyzed with generalized linear mixed models to account for multiple responses from each resident. RESULTS: Intervention interns and seniors were less likely to present admissions to faculty during morning rounds, but there were no differences between intervention and control groups in percentage of admissions discussed with faculty at any time. Perceived learning from admissions was not different between the 2 groups. CONCLUSIONS: Faculty-resident interaction decreased during morning rounds; however, overall attending contact did not, suggesting inpatient teaching approaches must adapt to meet learners' needs throughout the workday.

Effect of a face sheet tool on medical team provider identification and family satisfaction.

Resident duty hour restrictions may expose families to more trainees during hospitalization and hinder recognition of medical team members. This may negatively impact family satisfaction. Our study sought to determine the effects of a face sheet tool on families' identification and satisfaction rating of the medical team. One of 2 general pediatric units at a large academic center was assigned to intervention; the other served as the concurrent control. Families on the intervention unit were given a face sheet tool with medical team members' photos and role descriptions. Upon discharge, caregivers matched names, photos, and roles to providers they encountered, answered a 10-question satisfaction survey, and answered an overall hospital experience satisfaction question. Caregivers encountered a median of 8 (range, 3-14) medical team members. Caregivers in the intervention group were more likely to correctly identify providers by name (median correct, 25% vs 11% for controls; P < 0.01) and provider roles (median correct, 50% vs 25%; P < 0.01). No significant difference was noted between groups for overall satisfaction. A face sheet tool helped caregivers identify their child's care providers' names and roles, although identification remained poor.

Oral antibiotics at discharge for children with acute osteomyelitis: a rapid cycle improvement project.

BACKGROUND: Substantial evidence demonstrates comparable cure rates for oral versus intravenous therapy for routine osteomyelitis. Evidence adoption is often slow and in our centre virtually all patients with osteomyelitis were discharged on intravenous therapy. OBJECTIVE: For patients with acute osteomyelitis admitted to the hospital medicine service, we aimed to increase the proportion of cases discharged on oral antibiotics to at least 70%. METHODS: The setting for our observational time series study was a large academic children's hospital. The model for improvement and plan-do-study-act cycles were used to test, refine and implement interventions identified through our key driver diagram. Our multifaceted intervention included a shared decision-making tool, an order set in our electronic health record, and education to faculty and trainees. We also included an identify and mitigate intervention to target providers caring for children with osteomyelitis in near-real time and reinforce the evidence-based recommendations. Data were analysed on an annotated g-chart of osteomyelitis cases between patients discharged on intravenous antibiotics. Structured chart review was used to identify treatment failures as well as length of stay and hospital charges in preintervention and postintervention groups. RESULTS: The osteomyelitis cases between patients discharged on intravenous antibiotics increased from a median of 0 preintervention to a maximum of 9 cases following our identify and mitigate intervention. The direction and magnitude of successive improvements observed satisfied criteria for special cause variation. Improvement has been sustained for 1 year. Treatment failure and complications were uncommon in preintervention and postintervention phases. No significant differences in length of stay or charges were detected. CONCLUSIONS: Even for uncommon conditions, rapid and sustained evidence adoption is possible using quality improvement methods.

Pediatric hospitalist perceptions of the impact of duty hour changes on education and patient care.

OBJECTIVE: The goal of this study was to measure the impact of the new 2011 Accreditation Council for Graduate Medical Education duty hour standards (DHS) on education, patient care, and overall satisfaction as perceived by pediatric hospitalist faculty. METHODS: We undertook a nonrandomized but controlled study of 23 pediatric hospitalist faculty members during a trial of the new DHS in 2011. During the intervention (January), residents piloted schedules that complied with the new DHS, and in the control period (February), resident schedules complied with previous DHS. Daily surveys solicited faculty perceptions of the amount and quality of teaching provided, time with patients, quality of patient care, and overall faculty satisfaction. Faculty were also surveyed on their years of experience as a hospitalist and clinical teaching activity. Multiple logistic regression analysis with generalized estimating equations was used to examine outcome associations after adjusting for census and accounting for multiple attending reports. RESULTS: Census volumes were higher in the control group. During the intervention, faculty were less likely to rate their quality of teaching (odds ratio [OR]: 0.40 [95% confidence interval (CI): 0.18-0.88]) and overall satisfaction with the shift (OR: 0.23 [95% CI: 0.08-0.66]) as good/excellent compared with controls. During the intervention, more years of experience as a hospitalist were associated with rating quality of patient care provided as good/excellent (OR: 1.77 [95% CI: 1.23-2.54]). CONCLUSIONS: Faculty were less likely to rate their quality of teaching and overall satisfaction as good/excellent during a trial of the 2011 DHS. In addition, more experienced faculty were more likely to rate the quality of care highly.

Evaluating the impact of interactive and entertaining educational conferences.

Adult learning theory suggests that meaningful engagement impacts learning. To evaluate the impact of resident-led interactive conferences on satisfaction, engagement and knowledge acquisition. A prospective study at a paediatric academic institution compared educational conferences in two formats. Control conferences were PowerPoint(®) lectures and intervention conferences included multimedia, audience participation and faculty mentorship. Learner and presenter satisfaction and learner engagement were assessed by post-conference surveys. Knowledge was assessed via pre- and post-conference open-ended questions; matched pre- and post-questions were analyzed. Control and intervention groups' satisfaction and engagement were compared using the Wilcoxon rank-sum test. Comparison of proportion of learners with improved post-conference knowledge score was analyzed with the Chi square test. There were 181 control and 170 intervention surveys collected. Learners' median satisfaction (4 vs. 5, p = .03) and engagement (4 vs. 5, p < .01) ratings improved in the intervention group. Presenters rated audience engagement higher during the intervention conferences (median 3 vs. 4, p = .01). Knowledge acquisition, compared for matched surveys only, was not significantly different between the groups. Learner and presenter satisfaction and learner engagement were higher for the interactive format. While knowledge acquisition was unchanged, greater satisfaction encourages the use of interactive conferences.

Rapid adoption of Lactobacillus rhamnosus GG for acute gastroenteritis.

BACKGROUND AND OBJECTIVES: A 2007 meta-analysis showed probiotics, specifically Lactobacillus rhamnosus GG (LGG), shorten diarrhea from acute gastroenteritis (AGE) by 24 hours and decrease risk of progression beyond 7 days. In 2005, our institution published a guideline recommending consideration of probiotics for patients with AGE, but only 1% of inpatients with AGE were prescribed LGG. The objective of this study was to increase inpatient prescribing of LGG at admission to >90%, for children hospitalized with AGE, within 120 days. METHODS: This quality improvement study included patients aged 2 months to 18 years admitted to general pediatrics with AGE with diarrhea. Diarrhea was defined as looser or ≥ 3 stools in the preceding 24 hours. Patients with complex medical conditions or with presumed bacterial gastroenteritis were excluded. Admitting and supervising clinicians were educated on the evidence. We ensured LGG was adequately stocked in our pharmacies and updated an AGE-specific computerized order set to include a default LGG order. Failure identification and mitigation were conducted via daily electronic chart review and e-mail communication. Primary outcome was the percentage of included patients prescribed LGG within 18 hours of admission. Intervention impact was assessed with run charts tracking our primary outcome over time. RESULTS: The prescribing rate increased to 100% within 6 weeks and has been sustained for 7 months. CONCLUSIONS: Keys to success were pharmacy collaboration, use of an electronic medical record for a standardized order set, and rapid identification and mitigation of failures. Rapid implementation of evidence-based practices is possible using improvement science methods.

Survey of academic pediatric hospitalist programs in the US: organizational, administrative, and financial factors.

BACKGROUND: Many pediatric academic centers have hospital medicine programs. Anecdotal data suggest that variability exists in program structure. OBJECTIVE: To provide a description of the organizational, administrative, and financial structures of academic pediatric hospital medicine (PHM). METHODS: This online survey focused on the organizational, administrative, and financial aspects of academic PHM programs, which were defined as hospitalist programs at US institutions associated with accredited pediatric residency program (n = 246) and identified using the Accreditation Council for Graduate Medical Education (ACGME) Fellowship and Residency Electronic Interactive Database. PHM directors and/or residency directors were targeted by both mail and the American Academy of Pediatrics Section on Hospital Medicine LISTSERV. RESULTS: The overall response rate was 48.8% (120/246). 81.7% (98/120) of hospitals reported having an academic PHM program, and 9.1% (2/22) of hospitals without a program reported plans to start a program in the next 3 years. Over a quarter of programs provide coverage at multiple sites. Variability was identified in many program factors, including hospitalist workload and in-house coverage provided. Respondents reported planning increased in-house hospitalist coverage coinciding with the 2011 ACGME work-hour restrictions. Few programs reported having revenues greater than expenses (26% single site, 4% multiple site). CONCLUSIONS: PHM programs exist in the majority of academic centers, and there appears to be variability in many program factors. This study provides the most comprehensive data on academic PHM programs and can be used for benchmarking as well as program development.

Utilizing improvement science methods to improve physician compliance with proper hand hygiene.

OBJECTIVE: In 2009, The Joint Commission challenged hospitals to reduce the risk of health care-associated infections through hand hygiene compliance. At our hospital, physicians had lower compliance rates than other health care workers, just 68% on general pediatric units. We used improvement methods and reliability science to increase compliance with proper hand hygiene to >95% by inpatient general pediatric teams. METHODS: Strategies to improve hand hygiene were tested through multiple plan-do-study-act cycles, first by 1 general inpatient medical team and then spread to 4 additional teams. At the start of each rotation, residents completed an educational module and posttest about proper hand hygiene. Team compliance data were displayed daily in the resident conference room. Real-time identification and mitigation of failures by a hand-washing champion encouraged shared accountability. Organizational support ensured access to adequate hand hygiene supplies. The main outcome measure was percent compliance with acceptable hand hygiene, defined as use of an alcohol-based product or hand-washing with soap and turning off the faucet without using fingers or palm. Compliance was defined as acceptable hand hygiene before and after contact with the patient or care environment. Covert bedside observers recorded at least 8 observations of physicians' compliance per day. RESULTS: Physician compliance with proper hand hygiene improved to >95% within 6 months and was sustained for 11 months. CONCLUSIONS: Instituting a hand-washing champion for immediate identification and mitigation of failures was key in sustaining results. Improving physician compliance with proper hand hygiene is achievable and a first step in decreasing health care-associated infections.

Improved documentation and care planning with an asthma-specific history and physical.

OBJECTIVE: The objective was to determine the effect of an electronic asthma-specific inpatient history and physical (H&P) template on documented history and improvements in care plans. METHODS: This was a before-after comparison of history and care plan documentation following implementation of a new H&P template. The template was implemented in May 2011. A retrospective review of the electronic health record was completed for 304 consecutive patients (2-16 years of age) admitted for asthma June to September 2010 and 242 admitted June to September 2011. Elements reviewed included asthma severity classification, utilization history (previous oral steroids, emergency visits, hospitalizations, intensive care admissions, and intubations), and environmental history (exposure to cockroaches, rodents, and mold). Assessed changes in care plans included social work or asthma-related subspecialty consult and change in controller medications. Patients from 2011 were compared with those from 2010 by using ttest and chi2 statistics with adjustment for confounders by use of logistic regression. Interrupted time-series analyses assessed variability in documentation over time. RESULTS: In 2011, the new H&P template was used in 74% of encounters. Compared with patients seen preimplementation, documentation in those seen after implementation was more likely to include severity classification (71% vs 44%; P < .0001), complete utilization history (73% vs 12%; P < .0001), and environmental history (66% v. 2%; P < .0001). Documentation became more consistent over time. Changes in care planning were also more common after implementation (63% vs 49%; P = .0006). CONCLUSIONS: A structured H&P template for asthma led to more complete and less variable documentation of important history and likely led to enhancements in care plans.