Patient-Centered Care Transitions After Injury Hospitalization: A Comparative Effectiveness Trial.

OBJECTIVE: The investigation aimed to compare two approaches to the delivery of care for hospitalized injury survivors, a patient-centered care transition intervention versus enhanced usual care. METHOD: This pragmatic comparative effectiveness trial randomized 171 acutely injured trauma survivors with three or more early postinjury concerns and high levels of emotional distress to intervention (I; n = 85) and enhanced usual care control (C; n = 86) conditions. The care transition intervention components included care management that elicited and targeted improvement in patients' postinjury concerns, 24/7 study team cell phone accessibility, and stepped-up care. Posttraumatic concerns, symptomatic distress, functional status, and statewide emergency department (ED) service utilization were assessed at baseline and over the course of the 12 months after injury. Regression analyses assessed intervention and control group outcome differences over time. RESULTS: Over 80% patient follow-up was attained at each time point. Intervention patients demonstrated clinically and statistically significant reductions in the percentage of any severe postinjury concerns expressed when compared to controls longitudinally (Wald chi-square = 11.29, p = 0.01) and at the six-month study time point (C = 74%, I = 53%; Fisher's exact test, p = 0.02). Comparisons of ED utilization data yielded clinically significant cross-sectional differences (one or more three- to six-month ED visits; C = 30.2%, I = 16.5%, [relative risk (95% confidence interval] C versus I = 2.00 (1.09, 3.70), p = 0.03) that did not achieve longitudinal statistical significance (F (3, 507) = 2.24, p = 0.08). The intervention did not significantly impact symptomatic or functional outcomes. CONCLUSIONS: Orchestrated investigative and policy efforts should continue to evaluate patient-centered care transition interventions to inform American College of Surgeons' clinical guidelines for U.S. trauma care systems.

Effect of Standardized Handoff Curriculum on Improved Clinician Preparedness in the Intensive Care Unit: A Stepped-Wedge Cluster Randomized Clinical Trial.

Importance: Clinician miscommunication contributes to an estimated 250 000 deaths in US hospitals per year. Efforts to standardize handoff communication may reduce errors and improve patient safety. Objective: To determine the effect of a standardized handoff curriculum, UW-IPASS, on interclinician communication and patient outcomes. Design, Setting, and Participants: This cluster randomized stepped-wedge randomized clinical trial was conducted from October 2015 to May 2016 at 8 medical and surgical intensive care units at 2 hospital systems within an academic tertiary referral center. Participants included residents, fellows, advance-practice clinicians, and attending physicians (n = 106 clinicians, with 1488 handoff events over 8 months) and data were collected from daily text message-based surveys and patient medical records. Exposures: The UW-IPASS standardized handoff curriculum. Main Outcomes and Measures: The primary aim was to assess the effect of the UW-IPASS handoff curriculum on perceived adequacy of interclinician communication. Patient days of mechanical ventilation, intensive care unit length of stay, reintubations within 24 hours, and order workflow patterns were also analyzed. Mixed-effects logistic regression was used to compute odds ratios and confidence intervals with adjustment for location, time period, and clinician. Results: A total of 63 residents and advance practice clinicians, 13 fellows, and 30 attending physicians participated in the study. During the control period, clinicians reported being unprepared for their shift because of a poor-quality handoff in 35 of 343 handoffs (10.2%), while UW-IPASS-period residents reported being unprepared in 53 of 740 handoffs (7.2%) (odds ratio, 0.19; 95% CI, 0.03-0.74; P = .03). Compared with the control phase, the perceived duration of handoffs among clinicians using UW-IPASS was unchanged (+5.5 minutes; 95% CI, 0.34-9.39; P = .30). Early morning order entry decreased from 106 per 100 patient-days in the control phase to 78 per 100 patient-days in the intervention period (-28 orders; 95% CI, -55 to -4; P = .04). Overall, UW-IPASS was not associated with any changes in intensive care unit length of stay, duration of mechanical ventilation, or the number of reintubations. Conclusions and Relevance: The UW-IPASS standardized handoff curriculum was perceived to improve intensive care provider preparedness and workflow. IPASS-based curricula represent an important step forward in communication standardization efforts and may help reduce communication errors and omissions. Trial Registration: isrctn.org Identifier: ISRCTN14209509.

Technology Use, Preferences, and Capacity in Injured Patients at Risk for Posttraumatic Stress Disorder.

OBJECTIVE: This investigation comprehensively assessed the technology use, preferences, and capacity of diverse injured trauma survivors with posttraumatic stress disorder (PTSD) symptoms. METHOD: A total of 121 patients participating in a randomized clinical trial (RCT) of stepped collaborative care targeting PTSD symptoms were administered baseline one-, three-, and six-month interviews that assessed technology use. Longitudinal data about the instability of patient cell phone ownership and phone numbers were collected from follow-up interviews. PTSD symptoms were also assessed over the course of the six months after injury. Regression analyses explored the associations between cell phone instability and PTSD symptoms. RESULTS: At baseline, 71.9% (n = 87) of patients reported current cell phone ownership, and over half (58.2%, n = 46) of these patients possessed basic cell phones. Only 19.0% (n = 23) of patients had no change in cell phone number or physical phone over the course of the six months postinjury. In regression models that adjusted for relevant clinical and demographic characteristics, cell phone instability was associated with higher six-month postinjury PTSD symptom levels (p < 0.001). CONCLUSIONS: Diverse injured patients at risk for the development of PTSD have unique technology use patterns, including high rates of cell phone instability. These observations should be strongly considered when developing technology-supported interventions for injured patients with PTSD.

Pragmatic (trial) informatics: a perspective from the NIH Health Care Systems Research Collaboratory.

Pragmatic clinical trials (PCTs) are research investigations embedded in health care settings designed to increase the efficiency of research and its relevance to clinical practice. The Health Care Systems Research Collaboratory, initiated by the National Institutes of Health Common Fund in 2010, is a pioneering cooperative aimed at identifying and overcoming operational challenges to pragmatic research. Drawing from our experience, we present 4 broad categories of informatics-related challenges: (1) using clinical data for research, (2) integrating data from heterogeneous systems, (3) using electronic health records to support intervention delivery or health system change, and (4) assessing and improving data capture to define study populations and outcomes. These challenges impact the validity, reliability, and integrity of PCTs. Achieving the full potential of PCTs and a learning health system will require meaningful partnerships between health system leadership and operations, and federally driven standards and policies to ensure that future electronic health record systems have the flexibility to support research.

A nationwide survey of trauma center information technology leverage capacity for mental health comorbidity screening.

BACKGROUND: Despite evidence that electronic medical record (EMR) information technology innovations can enhance the quality of trauma center care, few investigations have systematically assessed United States (US) trauma center EMR capacity, particularly for screening of mental health comorbidities. STUDY DESIGN: Trauma programs at all US level I and II trauma centers were contacted and asked to complete a survey regarding health information technology (IT) and EMR capacity. RESULTS: Three hundred ninety-one of 525 (74%) US level I and II trauma centers responded to the survey. More than 90% of trauma centers reported the ability to create custom patient tracking lists in their EMR. Forty-seven percent of centers were interested in automating a blood alcohol content screening process; only 14% reported successfully using their EMR to perform this task. Marked variation was observed across trauma center sites with regard to the types of EMR systems used as well as rates of adoption and turnover of EMR systems. CONCLUSIONS: Most US level I and II trauma centers have installed EMR systems; however, marked heterogeneity exists with regard to EMR type, available features, and turnover. A minority of centers have leveraged their EMR for screening of mental health comorbidities among trauma inpatients. Greater attention to effective EMR use is warranted from trauma accreditation organizations.

Achieving and sustaining automated health data linkages for learning systems: barriers and solutions.

INTRODUCTION: Delivering more appropriate, safer, and highly effective health care is the goal of a learning health care system. The Agency for Healthcare Research and Quality (AHRQ) funded enhanced registry projects: (1) to create and analyze valid data for comparative effectiveness research (CER); and (2) to enhance the ability to monitor and advance clinical quality improvement (QI). This case report describes barriers and solutions from one state-wide enhanced registry project. METHODS: The Comparative Effectiveness Research and Translation Network (CERTAIN) deployed the commercially available Amalga Unified Intelligence System™ (Amalga) as a central data repository to enhance an existing QI registry (the Automation Project). An eight-step implementation process included hospital recruitment, technical electronic health record (EHR) review, hospital-specific interface planning, data ingestion, and validation. Data ownership and security protocols were established, along with formal methods to separate data management for QI purposes and research purposes. Sustainability would come from lowered chart review costs and the hospital's desire to invest in the infrastructure after trying it. FINDINGS: CERTAIN approached 19 hospitals in Washington State operating within 12 unaffiliated health care systems for the Automation Project. Five of the 19 completed all implementation steps. Four hospitals did not participate due to lack of perceived institutional value. Ten hospitals did not participate because their information technology (IT) departments were oversubscribed (e.g., too busy with Meaningful Use upgrades). One organization representing 22 additional hospitals expressed interest, but was unable to overcome data governance barriers in time. Questions about data use for QI versus research were resolved in a widely adopted project framework. Hospitals restricted data delivery to a subset of patients, introducing substantial technical challenges. Overcoming challenges of idiosyncratic EHR implementations required each hospital to devote more IT resources than were predicted. Cost savings did not meet projections because of the increased IT resource requirements and a different source of lowered chart review costs. DISCUSSION: CERTAIN succeeded in recruiting unaffiliated hospitals into the Automation Project to create an enhanced registry to achieve AHRQ goals. This case report describes several distinct barriers to central data aggregation for QI and CER across unaffiliated hospitals: (1) competition for limited on-site IT expertise, (2) concerns about data use for QI versus research, (3) restrictions on data automation to a defined subset of patients, and (4) unpredictable resource needs because of idiosyncrasies among unaffiliated hospitals in how EHR data are coded, stored, and made available for transmission-even between hospitals using the same vendor's EHR. Therefore, even a fully optimized automation infrastructure would still not achieve complete automation. The Automation Project was unable to align sufficiently with internal hospital objectives, so it could not show a compelling case for sustainability.

Review of influential articles in surgical education: 2002-2012.

BACKGROUND: Exploring the trends in surgical education research offers insight into concerns, developments, and questions researchers are exploring that are relevant to teaching and learning in surgical specialties. OBJECTIVE: We conducted a review of the surgical education literature published between 2002 and 2012. The purpose was 2-fold: to provide an overview of the most frequently cited articles in the field of surgical education during the last decade and to describe the study designs and themes featured in these articles. METHODS: Articles were identified through Web of Science by using "surgical education" and "English language" as search terms. Using a feature in Web of Science, we tracked the number of citations of any publication. Of the 800 articles produced by the initial search, we initially selected 23 articles with 45 or more citations, and ultimately chose the 20 articles that were most frequently cited for our analysis. RESULTS: Analysis of the most frequently cited articles published in US journals between the years 2002-2012 identified 7 research themes and presented them in order of frequency with which they appear: use of simulation, issues in student/resident assessment, specialty choice, patient safety, team training, clinical competence assessment, and teaching the clinical sciences, with surgical simulation being the central theme. Researchers primarily used descriptive methods. CONCLUSIONS: Popular themes in surgical education research illuminate the information needs of surgical educators as well as topics of high interest to the surgical community.

ACGME case logs: Surgery resident experience in operative trauma for two decades.

BACKGROUND: Surgery resident education is based on experiential training, which is influenced by changes in clinical management strategies, technical and technologic advances, and administrative regulations. Trauma care has been exposed to each of these factors, prompting concerns about resident experience in operative trauma. The current study analyzed the reported volume of operative trauma for the last two decades; to our knowledge, this is the first evaluation of nationwide trends during such an extended time line. METHODS: The Accreditation Council for Graduate Medical Education (ACGME) database of operative logs was queried from academic year (AY) 1989-1990 to 2009-2010 to identify shifts in trauma operative experience. Annual case log data for each cohort of graduating surgery residents were combined into approximately 5-year blocks, designated Period I (AY1989-1990 to AY1993-1994), Period II (AY1994-1995 to AY1998-1999), Period III (AY1999-2000 to AY2002-2003), and Period IV (AY2003-2004 to AY2009-2010). The latter two periods were delineated by the year in which duty hour restrictions were implemented. RESULTS: Overall general surgery caseload increased from Period I to Period II (p < 0.001), remained stable from Period II to Period III, and decreased from Period III to Period IV (p < 0.001). However, for ACGME-designated trauma cases, there were significant declines from Period I to Period II (75.5 vs. 54.5 cases, p < 0.001) and Period II to Period III (54.5 vs. 39.3 cases, p < 0.001) but no difference between Period III and Period IV (39.3 vs. 39.4 cases). Graduating residents in Period I performed, on average, 31 intra-abdominal trauma operations, including approximately five spleen and four liver operations. Residents in Period IV performed 17 intra-abdominal trauma operations, including three spleen and approximately two liver operations. CONCLUSION: Recent general surgery trainees perform fewer trauma operations than previous trainees. The majority of this decline occurred before implementation of work-hour restrictions. Although these changes reflect concurrent changes in management of trauma, surgical educators must meet the challenge of training residents in procedures less frequently performed. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level IV.

Neonatal Informatics: Information Technology to Support Handoffs in Neonatal Care.

Communication failures during physician handoffs represent a significant source of preventable adverse events. Computerized sign-out tools linked to hospital electronic medical record systems and customized for neonatal care can facilitate standardization of the handoff process and access to clinical information, thereby improving communication and reducing adverse events. It is important to note, however, that adoption of technological tools alone is not sufficient to remedy flawed communication processes. OBJECTIVES: After completing this article, readers should be able to: Identify key elements of a computerized sign-out tool.Describe how an electronic tool might be customized for neonatal care.Appreciate that technological tools are only one component of the handoff process they are designed to facilitate.

Development and assessment of personal skills and aptitudes.

Professionalism is an inherent attribute to the practice of surgery. Historically, the importance of this quality arose later than the earliest three fundamental principles of medical knowledge, diagnostic ability, and technical skill. In the modern era, society has clearly come to require that its surgeons embrace professionalism as a fundamental principle. It now stands among the six core competencies that all United States training programs teach and measure. We define professionalism as the pursuit of excellence, the display of humanism, an altruistic commitment, and accountability to all interactions with society. Surgeons teach professionalism to their trainees every day, sometimes by formal curricula but more often by the unspoken and unsuspected modeling of behavior. These methods can be structured into a teaching program. To that program, active practice and engagement in continuous professionalism improvement ought to be added. In this way, a true method of professionalism training can be made that allows for formal assessment.

Resident education in 2011: three key challenges on the road ahead.

Two important changes in the past decade have altered the landscape of graduate medical education (GME) in the U.S. The national restrictions on trainee duty hours mandated by the Accreditation Council for Graduate Medical Education (ACGME) were the most visible and generated much controversy. Equally important is the ACGME Outcome Project, which mandates competency-based training. Both of these changes have unique implications for surgery trainees, who traditionally spent long hours caring for patients in the hospital, and who must be assessed in 2 broad domains: their medical care of pre- and postoperative patients, and their technical skill with procedures in and out of the operating room. This article summarizes 3 key challenges that lie ahead for surgical educators. First, the changes in duty hours in the past 7 years are summarized, and the conversation about added restrictions planned for July 2011 is reviewed. Next, the current state of the assessment of competency among surgical trainees is reviewed, with an outline of the challenges that need to be overcome to achieve widespread, competency-based training in surgery. Finally, the article summarizes the problems caused by increased reliance on handoffs among trainees as they compensate for decreased time in the hospital, and suggests changes that need to be made to improve safety and efficiency, including how to use handoffs as part of our educational evaluation of residents.

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

PURPOSE: To determine whether changing sign-out practices and decreasing the time spent in rounding and recopying patient data affect patient safety. Responding to limited resident duty hours, the University of Washington launched a computerized rounding and sign-out system ("UW Cores"). The system shortened duty hours by facilitating sign-out, decreasing rounding time, and sharply reducing the time spent in prerounds data recopying. METHOD: This 14-week, randomized, crossover study involved 14 inpatient resident teams (6 general surgery, 8 internal medicine) at two hospitals. The authors measured resident-reported deviations in expected care that occurred during cross-coverage, medical errors, and institutionally reported adverse drug events (ADEs). RESULTS: The mean number of resident-reported deviations from expected care per 1,000 patient-days did not differ significantly between the control and UW Cores groups: 14.29 and 13.81, respectively (P = .85). The mean number of reported incidents involving errors was 6.33 per 1,000 patient-days for the control group and 5.61 per 1,000 patient-days for the UW Cores group (P = .68). The odds ratio of a reported overnight medical error under the UW Cores system was 1.01 (95% CI: 0.64, 1.60; P = .96). The odds ratio of an ADE while a resident is on an intervention team was 1.10 (95% CI: 0.69, 1.74; P = .70). CONCLUSIONS: Managing information for sign-out and rounding with the UW Cores system, to reduce time spent in recopying patient data and in rounding on patients, improved continuity and enhanced resident efficiency without weakening systemic defenses against error or jeopardizing patient safety.

Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care.

OBJECTIVE: To determine the nature of surgeon information transfer and communication (ITC) errors that lead to adverse events and near misses. To recommend strategies for minimizing or preventing these errors. SUMMARY BACKGROUND DATA: Surgical hospital practice is changing from a single provider to a team-based approach. This has put a premium on effective ITC. The Information Transfer and Communication Practices (ITCP) Project is a multi-institutional effort to: 1) better understand surgeon ITCP and their patient care consequences, 2) determine what has been done to improve ITCP in other professions, and 3) recommend ways to improve these practices among surgeons. METHODS: Separate, semi-structured focus group sessions were conducted with surgical residents (n = 59), general surgery attending physicians (n = 36), and surgical nurses (n = 42) at 5 medical centers. Case descriptions and general comments were classified by the nature of ITC lapses and their effects on patients and medical care. Information learned was combined with a review of ITC strategies in other professions to develop principles and guidelines for re-engineering surgeon ITCP. RESULTS: : A total of 328 case descriptions and general comments were obtained and classified. Incidents fell into 4 areas: blurred boundaries of responsibility (87 reports), decreased surgeon familiarity with patients (123 reports), diversion of surgeon attention (31 reports), and distorted or inhibited communication (67 reports). Results were subdivided into 30 contributing factors (eg, shift change, location change, number of providers). Consequences of ITC lapses included delays in patient care (77% of cases), wasted surgeon/staff time (48%), and serious adverse patient consequences (31%). Twelve principles and 5 institutional habit changes are recommended to guide ITCP re-engineering. CONCLUSIONS: Surgeon communication lapses are significant contributors to adverse patient consequences, and provider inefficiency. Re-engineering ITCP will require significant cultural changes.

A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.

BACKGROUND: Adoption of limits on resident work hours prompted us to develop a centralized, Web-based computerized rounding and sign-out system (UWCores) that securely stores sign-out information; automatically downloads patient data (vital signs, laboratories); and prints them to rounding, sign-out, and progress note templates. We tested the hypothesis that this tool would positively impact continuity of care and resident workflow by improving team communication involving patient handovers and streamlining inefficiencies, such as hand-copying patient data during work before rounds ("prerounds"). STUDY DESIGN: Fourteen inpatient resident teams (6 general surgery, 8 internal medicine) at two teaching hospitals participated in a 5-month, prospective, randomized, crossover study. Data collected included number of patients missed on resident rounds, subjective continuity of care quality and workflow efficiency with and without UWCores, and daily self-reported prerounding and rounding times and tasks. RESULTS: UWCores halved the number of patients missed on resident rounds (2.5 versus 5 patients/team/month, p = 0.0001); residents spent 40% more of their prerounds time seeing patients (p = 0.36); residents reported better sign-out quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree). UWCores halved the portion of prerounding time spent hand-copying basic data (p < 0.0001); it shortened team rounds by 1.5 minutes/patient (p = 0.0006); and residents reported finishing their work sooner using UWCores (82.1% agree or strongly agree). CONCLUSIONS: This system enhances patient care by decreasing patients missed on resident rounds and improving resident-reported quality of sign-out and continuity of care. It decreases by up to 3 hours per week (range 1.5 to 3) the time used by residents to complete rounds; it diverts prerounding time from recopying data to more productive tasks; and it facilitates meeting the 80-hour work week requirement by helping residents finish their work sooner.

Organizing the transfer of patient care information: the development of a computerized resident sign-out system.

BACKGROUND: The problem of safe and efficient transfer of care has increased over the years as new and complex diagnostic tools and more complex treatment options became available. Traditionally, residents ensured continuity of care by working long hours and minimizing the transfer of significant diagnostic or therapeutic responsibilities to other providers. The new 80-hour workweek has curtailed that practice and increased the pressure on trainees for workflow efficiency. We report on a study of information-handling routines among residents for the separate tasks of transfer of care ("sign-out") and daily patient care work (ward work). Using these results, an institution-wide computerized system was developed to centralize information-handling tasks and facilitate the management and transfer of patient care information. STUDY DESIGN: House staff from 31 resident-run inpatient and consult services at 2 teaching hospitals described current methods of maintaining patient information used during ward rounds and during sign-out. A subgroup of 28 residents then participated in the design of a computerized resident sign-out system to centralize patient information and produce lists for rounding and transferring care duties. Accuracy, flexibility, and portability were identified as key elements by the design team. RESULTS: Analysis of the type of information handled by residents caring for inpatients at our institution demonstrated common elements across many services. Most services used a paper patient list to manage both nightly sign-out and daily ward work, which required repeated recopying of patient data during the day. Utilizing medical information systems tools and rapid application development concepts, we constructed a computerized resident sign-out system ("UWCores"). This system combines the patient sign-out and daily ward work information in one central location. We believed this would improve the quality of information transferred during sign-out and enhance resident efficiency. During the design process, we identified rules that govern the type of clinical information that should be automatically versus manually updated. We observed an immediate acceptance by all residents and services that tried the system. CONCLUSIONS: This study shows that by combining downloaded patient data from hospital systems with resident-entered patient details, a computerized resident sign-out system can be a feasible, powerful, and popular tool. While its effect on patient safety and resident efficiency await the results of further studies, our study shows that this tool rapidly captured the attention of resident physicians and became widely used as a valuable means to centralize and organize sign-out and daily ward work information.