Using Broken Windows Theory as the Backdrop for a Proactive Approach to Threat Identification in Health Care.

OBJECTIVES: Historically, health care has relied on error management techniques to measure and reduce the occurrence of adverse events. This study proposes an alternative approach for identifying and analyzing hazardous events. Whereas previous research has concentrated on investigating individual flow disruptions, we maintain the industry should focus on threat windows, or the accumulation of these disruptions. This methodology, driven by the broken windows theory, allows us to identify process inefficiencies before they manifest and open the door for the occurrence of errors and adverse events. METHODS: Medical human factors researchers observed disruptions during 34 trauma cases at a Level II trauma center. Data were collected during resuscitation and imaging and were classified using a human factors taxonomy: Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis (RIPCHORD-TWA). RESULTS: Of the 576 total disruptions observed, communication issues were the most prevalent (28%), followed by interruptions and coordination issues (24% each). Issues related to layout (16%), usability (5%), and equipment (2%) comprised the remainder of the observations. Disruptions involving communication issues were more prevalent during resuscitation, whereas coordination problems were observed more frequently during imaging. CONCLUSIONS: Rather than solely investigating errors and adverse events, we propose conceptualizing the accumulation of disruptions in terms of threat windows as a means to analyze potential threats to the integrity of the trauma care system. This approach allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.

A Data-Driven Approach to Team Training for Nurses in a Level II Trauma Center.

This prospective investigation describes the process of designing a targeted, data-driven team training aimed at reducing identified process inefficiencies or flow disruptions (FDs) that threaten the optimal delivery of trauma care. Trained researchers observed and classified FDs during 34 trauma cases in a Level II trauma center. Multidisciplinary trauma personnel generated interventions to identified issues using the human factors intervention matrix (HFIX). This article focuses on one intervention: a formal trauma nurse training program centered around leadership, teamwork, and communication. The training was well perceived and was found to have a significant impact on participant knowledge of course content; t (65) = -13.92, p ≤ .01. By using hospital-specific data to drive intervention development from multidisciplinary team members, it is possible to develop effective solutions aimed at addressing individual threats.

Proactive Safety Management in Trauma Care: Applying the Human Factors Analysis and Classification System.

INTRODUCTION: This article examines the reliability of the Human Factors Analysis and Classification System (HFACS) for classifying observational human factors data collected prospectively in a trauma resuscitation center. METHODS: Three trained human factors analysts individually categorized 1,137 workflow disruptions identified in a previously collected data set involving 65 observed trauma care cases using the HFACS framework. RESULTS: Results revealed that the framework was substantially reliable overall (κ = 0.680); agreement increased when only the preconditions for unsafe acts were investigated (κ = 0.757). Findings of the analysis also revealed that the preconditions for unsafe acts category was most highly populated (91.95%), consisting mainly of failures involving communication, coordination, and planning. CONCLUSION: This study helps validate the use of HFACS as a tool for classifying observational data in a variety of medical domains. By identifying preconditions for unsafe acts, health care professionals may be able to construct a more robust safety management system that may provide a better understanding of the types of threats that can impact patient safety.

Real-World Clinical Quality Improvement for Complex Abdominal Wall Reconstruction.

INTRODUCTION: Traditional methods of clinical research may not be adequate to improve the value of care for patients undergoing abdominal wall reconstruction (AWR). These patients are prone to high complication rates and high costs. Here, we describe a clinical quality improvement (CQI) effort to enhance outcomes for patients undergoing AWR. MATERIALS AND METHODS: CQI was applied for the entire care cycle for consecutive patients who underwent AWR from August 2011-September 2015. Initiatives for improving value during this period included use of long-term resorbable synthetic mesh as well as administration of preoperative bilateral transversus abdominus plane (TAP), and intraoperative abdominal wall blocks using long-acting bupivacaine as a part of a multimodal regimen. Outcomes data that measure value in the context of AWR were collected to compare outcomes for the patients who received TAP blocks only, TAP and intraoperative blocks, and those who received no block. RESULTS: One hundred and two patients who had AWR for abdominal wall pathology were included. Outcomes including total opioid use, duration of stay and opioid use in the postanesthesia care unit (PACU), length of hospital stay (LOS), major wound complications, and costs, all improved over time. Specifically, PACU opioid use, total opioid use, and LOS were decreased in the two groups that received blocks versus a group that did not have any type of block. CONCLUSIONS: CQI program implementation in patients undergoing AWR resulted in measurable improvement of value-based outcomes over time. A CQI effort applied to the entire patient cycle of care should be routinely utilized.

A Clinical Quality Improvement (CQI) Project to Improve Pain After Laparoscopic Ventral Hernia Repair.

Patients who undergo laparoscopic ventral hernia repair can have significant post-operative pain and discomfort from both somatic pain due to mesh fixation and visceral pain due to CO2 insufflation pressure. In an attempt to improve outcomes, a Clinical Quality Improvement (CQI) project was implemented by a multi-disciplinary hernia team. CQI tools were applied for consecutive patients who underwent laparoscopic ventral hernia repair from June 2012 through September 2015 (39 months). Initiatives for improved patient outcomes during this period included the administration of a transversus abdominis plane (TAP) block and/or an intra-operative block with long-acting local anesthetic first, and then a low pressure pneumoperitoneum (LPP) system was implemented later in the project. One-hundred-twenty patients who underwent a laparoscopic ventral/incisional hernia repair were included in the analysis. Fifty-three patients had no block and had conventional insufflation at 15 mmHg (No Block-No LPP group). Outcomes for this group included a median time in the Post-Anesthesia Care Unit (PACU) of 126 minutes, a median length of stay of 4.0 days, a median use of opioid morphine equivalents (MEQ) in the PACU of 10.0, and a total use of opioid MEQ for the entire hospital stay of 100.0. Thirty-seven patients had blocks with a long-acting local anesthetic and conventional insufflation at 15 mmHg (Block only group). Outcomes for this group showed improvement for all outcomes, but none were statistically significant. Thirty patients had blocks with a long-acting local anesthetic and a low pressure pneumoperitoneum system with a standard pressure of 8 mmHg. Outcomes for this group included a median time in PACU of 83.6 minutes, a median length of stay of 1.5 days, a median amount of opioid use in the PACU of 5.0 MEQ, and a median use of opioid use for the entire hospital stay of 26.0 MEQ. All of these outcomes were statistically significant improvements compared with the No Block-No LPP and Block only groups. Implementation of a CQI program, including long-acting local anesthetic blocks and a low pressure pneumoperitoneum system as part of a multi-modal pain strategy for patients who underwent laparoscopic ventral hernia repair, was associated with decreased PACU time, decreased length of stay, and less opioid use in the PACU and for the entire hospital stay.

Can Abdominal Wall Reconstruction Be Safely Performed Without Drains?

The use of closed suction drains in the abdominal wall is a common practice in abdominal wall reconstruction (AWR) operations. Drains can be a conduit for bacteria and can cause pain and discomfort for patients after surgery. A single hernia program has implemented the principles of clinical quality improvement in an attempt to improve outcomes for hernia patients. An attempt at a process improvement was implemented to eliminate the use of drains in AWR by adapting the technique. A total of 102 patients undergoing AWR were included between 8/11 and 9/15 (49 months). Compared with the group before the attempt at eliminating the use of abdominal wall drains (8/11-9/13), the group of patients after the implementation of the attempted process improvement (9/13-9/15) had less wound and pulmonary complications, a shorter hospital stay, less time in the postanesthesia care unit, and less opioid use in the postanesthesia care unit as well as for the entire hospital stay. In this group of AWR patients, an attempt at process improvement that eliminated the use of drains led to improved outcomes. Abdominal wall drains may be able to be safely eliminated with appropriate technique adaptation for AWR.

Otolaryngology training during paediatric residency: A survey of paediatricians in Canada.

INTRODUCTION: There is a significant overlap between paediatrics and otolaryngology relating to clinical practice of the two specialties. A lack of cross-training has been identified in previous studies, but the specifics have not been established. The present study was directed at paediatricians in Canada, and examined the need for mandatory otolaryngology training during paediatric residency. METHODS: Surveys were mailed out to paediatricians in Canada who had completed residency within the past 20 years. Guidelines for the mailing procedure were regulated by the Royal College of Physicians and Surgeons of Canada. A cover letter, survey form and return envelope were included in the package. Data were tabulated and described using descriptive statistics. RESULTS: Six hundred sixty-six surveys were mailed; the response rate was 48%. Seventy-three per cent of paediatricians indicated that otolaryngology training should be mandatory during paediatric residency. Seventy-nine per cent of general paediatricians and 68% of subspecialists also believed that it should be mandatory training. Seventy per cent of paediatricians indicated that clinical experience was the best format for otolaryngology training, the other options being lectures or rotations. Postgraduate year 2 was the most preferred year for this training. For paediatricians who indicated mandatory training, 45% indicated that it could not replace something else, 38% said that it could replace another experience and the remainder were undecided. The respondents provided helpful commentary. INTERPRETATION: The majority of surveyed paediatricians in Canada believe that otolaryngology training should be mandatory during paediatric residency. There was also a general consensus relating to the format (clinical experience) and the duration (two to four weeks) of the training.

Deficiencies of cross-training between pediatrics and otolaryngology: a survey of specialists in Canada.

OBJECTIVE: Conditions relating to the ear, nose and throat are very frequent problems encountered by general pediatricians. Similarly, a major percentage of patients seen and operated on by the general otolaryngologist are of the pediatric age group. The pilot study demonstrated that pediatric program directors of both specialties in Canada have identified a deficiency of cross-training and desire the need for more cross-training. The aim of this study was to survey practicing physicians of both specialties for their input. METHODS: Surveys were sent to a large cross-section of pediatricians and otolaryngologists in Canada. They were asked to complete a questionnaire relating to their training experience, their desired training, important topics and general comments. Demographic data were collected including generalist versus sub-specialist, the year that residency was completed and country of training. Results were tabulated and analyzed. RESULTS: The response rate was high, being 70.6% and 76.2% for pediatricians and otolaryngologists, respectively. One hundred percent of pediatricians indicated that formal training by otolaryngologists was necessary, while 95% of otolaryngologists indicate a need for formal training by pediatricians during residency. Pediatricians desire more training using all three educational venues, namely lectures, clinics and rotations. While they are receiving lectures more often, they indicate that clinics are the most important mode of education. Otolaryngologists desire more formal training by pediatricians in the areas of lectures and clinics. They indicate the most important mode of education is lectures. There was no significant difference between generalists and sub-specialists or based on country of training for either group. There is some indication, in both specialties, of an increase of cross-training occurring within the past five years. CONCLUSIONS: This study has shown that there is a perceived deficiency of cross-training between the two specialties. Both pediatricians and otolaryngologists have indicated that they need more formal cross-training. This is a very important area to address, as this study relates directly to the optimum health of children in Canada and worldwide.

Age-related differential expression of apoptosis-related genes in conjunctival epithelial cells.

PURPOSE: To investigate whether the expression of apoptosis-related genes in normal conjunctival epithelial cells is age-related (as a prerequisite to assessing whether dysregulation of apoptosis may be involved during degenerative diseases). METHODS: Differential expression of apoptosis-related genes (e.g. apoptosis protease-activating factor 1 [Apaf-1]; caspases [casp] 3, 5, 8 and 9; Bad, Bax, Bcl-2, Bim, c-myc, Bag-1, as well as p53) was assessed by reverse transcription-polymerase chain reaction (RT-PCR). Samples were obtained from impression cytology (IC) specimens taken from 50 healthy subjects. Group A comprised 27 subjects aged 19-32 years and group B included 23 subjects aged 53-84 years. RESULTS: Reverse transcription-PCR revealed the detection of apoptosis-related m-RNAs as follows (group A compared to group B): Apaf-1 0%/0%; Bcl-2 0%/35%; Bim 0%/9%; Bag-1 0%/9%; p53 0%/4%; casp-3 11%/52%; casp-5 59%/48%; casp-8 44%/22%; casp-9 4%/9%; Bax 81%/52%; Bad 96%/56%, and c-myc 89%/96%. CONCLUSION: The data show an age-related expression of apoptosis-related genes such as casp-3, Bad, Bax and Bcl-2 in normal conjunctival cells. These results provide basic information which will help us understand the expression pattern of apoptotic genes during physiological ageing of the conjunctiva and the possible dysregulation of apoptotic genes during acute and chronic diseases such as dry eye disease, allergic conjunctivitis or cicatrizing conjunctivitis.

Deficiencies of cross-training between pediatrics and otolaryngology.

OBJECTIVE: Conditions relating to the ear, nose and throat are very frequent problems encountered by general pediatricians. Similarly, a major percentage of patients seen and operated on by the general otolaryngologist are of the pediatric age group. It is my hypothesis that there is a deficiency of cross-training between these two specialties. METHODS: All pediatric and otolaryngology program directors in Canada were contacted by mail. They were asked to complete a questionnaire regarding the need for further cross-training, what training their residents are presently receiving, and clinical entities that needed more attention. RESULTS: Data were tabulated and analyzed. 62.5% of pediatric program directors and 83.3% of otolaryngology program directors responded. All pediatric program directors indicated a need for teaching by otolaryngologists for their residents and 90% identified an area of deficiency in training. Similarly, 90% of otolaryngology program directors indicated a need for teaching by pediatricians for their residents and 89% of those identified an area of deficiency in training. CONCLUSIONS: These results suggest that there is a deficiency in cross-training between pediatrics and otolaryngology.