Use of High-Fidelity Simulation to Enhance Interdisciplinary Collaboration and Reduce Patient Falls.

OBJECTIVES: This pilot study aimed to determine the effect of nurse/physician interdisciplinary team training on patient falls. Specifically, we evaluated team training in a simulation center as a method for targeting and minimizing breakdowns in perceptions of respect, collaboration, communication, and role misunderstanding behaviors between care disciplines. METHODS: Registered nurses (RNs) were randomly assigned to participate. Residents were divided into groups and assigned based on their availability and clinical responsibility. All participants completed a demographic form, the Professional Practice Environment Assessment Scale (PPEAS), and the Mayo High Performance Teamwork Scale (MHPTS) after consenting and before participation in simulation training. The PPEAS and the MHPTS were readministered at 2 and 6 months after the simulation experience. Differences in MHPTS and PPEAS scores between the baseline and 2- and 6-month assessments were analyzed; fall rates over time were evaluated using Cochran-Armitage trend tests. RESULTS: After the team training exercises, teamwork as measured by the MHPTS improved significantly at both 2 and 6 months (P = 0.01; P < 0.001) compared with baseline measurement. Practice environment subscores, with the exception of positive organizational characteristics, also increased when measured 6 months after training. The primary outcome, reduction in anticipated patient falls, improved significantly (P = 0.02) over the course of the study. CONCLUSIONS: Results of this pilot study show that team training exercises result in improvement in both patient safety (anticipated patient falls) and team member perception of their work environment. If validated by other studies, improvement in this patient safety metric would represent an important benefit of simulation and team training.

Using Bundled Interventions to Reduce Surgical Site Infection After Major Gynecologic Cancer Surgery.

OBJECTIVE: To investigate whether implementing a bundle, defined as a set of evidence-based practices performed collectively, can reduce 30-day surgical site infections. METHODS: Baseline surgical site infection rates were determined retrospectively for cases of open uterine cancer, ovarian cancer without bowel resection, and ovarian cancer with bowel resection between January 1, 2010, and December 31, 2012, at an academic center. A perioperative bundle was prospectively implemented during the intervention period (August 1, 2013, to September 30, 2014). Prior established elements were: patient education, 4% chlorhexidine gluconate shower before surgery, antibiotic administration, 2% chlorhexidine gluconate and 70% isopropyl alcohol coverage of incisional area, and cefazolin redosing 3-4 hours after incision. New elements initiated were: sterile closing tray and staff glove change for fascia and skin closure, dressing removal at 24-48 hours, dismissal with 4% chlorhexidine gluconate, and follow-up nursing phone call. Surgical site infection rates were examined using control charts, compared between periods using χ or Fisher exact test, and validated against the American College of Surgeons National Surgical Quality Improvement Program decile ranking. RESULTS: The overall 30-day surgical site infection rate was 38 of 635 (6.0%) among all cases in the preintervention period, with 11 superficial (1.7%), two deep (0.3%), and 25 organ or space infections (3.9%). In the intervention period, the overall rate was 2 of 190 (1.1%), with two organ or space infections (1.1%). Overall, the relative risk reduction in surgical site infection was 82.4% (P=.01). The surgical site infection relative risk reduction was 77.6% among ovarian cancer with bowel resection, 79.3% among ovarian cancer without bowel resection, and 100% among uterine cancer. The American College of Surgeons National Surgical Quality Improvement Program decile ranking improved from the 10th decile to first decile; risk-adjusted odds ratio for surgical site infection decreased from 1.6 (95% confidence interval 1.0-2.6) to 0.6 (0.3-1.1). CONCLUSION: Implementation of an evidence-based surgical site infection reduction bundle was associated with substantial reductions in surgical site infection in high-risk cancer procedures.

Pressure Ulcer Prevention: Where Practice and Education Meet.

This article describes the processes used to implement a pressure ulcer management program in a Midwest academic medical center, which led to a decrease in reportable pressure ulcers. A learning needs assessment was completed, and a workgroup was formed to address the learning needs. Methods, materials, and processes included lectures, technology-enhanced learning, and interactive stations with mannequins and pressure ulcer moulages. The processes and outcome measures used to measure effectiveness of the program are discussed.

Enhanced recovery after surgery in microvascular breast reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have been shown in multiple surgical specialties to decrease hospital length of stay (LOS) after surgery, but they have not been described for patients undergoing microvascular breast reconstruction. STUDY DESIGN: A standardized ERAS pathway was developed through multidisciplinary collaboration which addressed all phases of surgical care for patients undergoing free-flap breast reconstruction using an abdominal donor site. Two surgeons used the ERAS pathway, and results were compared with a historical cohort of the same 2 surgeons' patients treated by traditional care after surgery (TRAS). All patients underwent surgery between September 2010 and September 2013. The primary outcome measure was hospital LOS. RESULTS: A total of 100 patients were analyzed: 49 in the ERAS cohort, and 51 in the TRAS cohort, with a total of 181 flaps. Mean hospital LOS was shorter with ERAS than TRAS (3.9 vs 5.5 days; P<0.001). Total inpatient postoperative opioid usage for the first 3 days, in oral morphine equivalents, was less for ERAS than TRAS (167.3 vs 574.3 mg; P<0.001), a decrease of 71%, with similar pain scores for the 2 groups. Overall 30-day major complication rates were not significantly different between the groups (P=0.21). CONCLUSIONS: The initiation of an ERAS pathway significantly decreased hospital LOS in our study. The pathway also significantly decreased the amount of opioids used postoperatively by 71%, without a consequent increase in patient-reported pain.

Enhanced recovery in gynecologic surgery.

OBJECTIVE: To investigate the effects of enhanced recovery (a multimodal perioperative care enhancement protocol) in patients undergoing gynecologic surgery. METHODS: Consecutive patients managed under an enhanced recovery pathway and undergoing cytoreduction, surgical staging, or pelvic organ prolapse surgery between June 20, 2011, and December 20, 2011, were compared with consecutive historical controls (March to December 2010) matched by procedure. Wilcoxon rank-sum, χ, and Fisher's exact tests were used for comparisons. Direct medical costs incurred in the first 30 days were obtained from the Olmsted County Healthcare Expenditure and Utilization Database and standardized to 2011 Medicare dollars. RESULTS: A total of 241 enhanced recovery women in the case group (81 cytoreduction, 84 staging, and 76 vaginal surgery) were compared with women in the control groups. In the cytoreductive group, patient-controlled anesthesia use decreased from 98.7% to 33.3% and overall opioid use decreased by 80% in the first 48 hours with no change in pain scores. Enhanced recovery resulted in a 4-day reduction in hospital stay with stable readmission rates (25.9% of women in the case group compared with 17.9% of women in the control group) and 30-day cost savings of more than $7,600 per patient (18.8% reduction). No differences were observed in rate (63% compared with 71.8%) or severity of postoperative complications (grade 3 or more: 21% compared with 20.5%). Similar, albeit less dramatic, improvements were observed in the other two cohorts. Ninety-five percent of patients rated satisfaction with perioperative care as excellent or very good. CONCLUSIONS: Implementation of enhanced recovery was associated with acceptable pain management with reduced opioids, reduced length of stay with stable readmission and morbidity rates, good patient satisfaction, and substantial cost reductions. LEVEL OF EVIDENCE: II.