Distal anterior cerebral artery aneurysms treated with flow diversion: experience of a large-volume center and systematic review of the literature.

BACKGROUND: Evidence about the safety and the efficacy of flow diversion for distal anterior cerebral artery (DACA) aneurysms is scant. To provide further insight into flow diversion for aneurysms located at, or distal to, the A2 segment. METHODS: Consecutive patients receiving flow diversion for DACA aneurysms were retrieved from our prospective database (2014-2020). A PRISMA guidelines-based systematic review of the literature was performed. Aneurysm occlusion (O'Kelly-Marotta=OKM) and clinical outcomes were evaluated. RESULTS: Twenty-three patients and 25 unruptured saccular DACA aneurysms treated with flow diversion were included. Aneurysm size ranged from 2 mm to 9 mm (mean size 4.5 mm, SD ±1.6). Mean parent artery diameter was 1.8 mm (range, 1.2-3 mm, SD ±0.39). Successful stent deployment was achieved in all cases. Angiographic adequate occlusion (OKM C-D) at follow-up (14 months) was 79% (19/24 available aneurysms). No cases of aneurysm rupture or retreatment were reported. Univariate analysis showed a significant difference in diameter among aneurysms with adequate (4 mm) vs incomplete occlusion (7 mm) (P=0.006).There was one transient perioperative in-stent thrombosis, and three major events causing neurological morbidity: two stent thromboses (one attributable to the non-adherence of the patient to the antiplatelet therapy); and one acute occlusion of a covered calloso-marginal artery.Results from systematic review (12 studies and 107 A2-A3 aneurysms) showed 78.6% (95% CI=70-86) adequate occlusion, 7.5% (95% CI=3.6-14) complications, and 2.8%, (3/107, 95% CI=0.6-8.2) morbidity. CONCLUSIONS: Flow diversion among DACA aneurysms is effective, especially among small lesions. However, potential morbidity related to in-stent thrombosis and covered side branches should be considered when planning this strategy.

Clinical and Economic Outcomes of Genome Sequencing Availability on Containing a Hospital Outbreak of Resistant Escherichia coli in Australia.

OBJECTIVES: To evaluate the outbreak size and hospital cost effects of bacterial whole-genome sequencing availability in managing a large-scale hospital outbreak. METHODS: We built a hybrid discrete event/agent-based simulation model to replicate a serious bacterial outbreak of resistant Escherichia coli in a large metropolitan public hospital during 2017. We tested the 3 strategies of using whole-genome sequencing early, late (actual outbreak), or not using it and assessed their associated outbreak size and hospital cost. The model included ward dynamics, pathogen transmission, and associated hospital costs during a 5-month outbreak. Model parameters were determined using data from the Queensland Hospital Admitted Patient Data Collection (N = 4809 patient admissions) and local clinical knowledge. Sensitivity analyses were performed to address model and parameter uncertainty. RESULTS: An estimated 197 patients were colonized during the outbreak, with 75 patients detected. The total outbreak cost was A$460 137 (US$317 117), with 6.1% spent on sequencing. Without sequencing, the outbreak was estimated to result in 352 colonized patients, costing A$766 921 (US$528 547). With earlier detection from use of routine sequencing, the estimated outbreak size was 3 patients and cost A$65 374 (US$45 054). CONCLUSIONS: Using whole-genome sequencing in hospital outbreak management was associated with smaller outbreaks and cost savings, with sequencing costs as a small fraction of total hospital costs, supporting the further investigation of the use of routine whole-genome sequencing in hospitals.

Segurança do paciente em hospitais de grande porte / Patient safety in large hospitals

Objetivo: analisar a implementação da política nacional de segurança do paciente. Método: trata-se de um estudo quantitativo, descritivo e avaliativo de casos múltiplos em hospitais de grande porte. Informa-se que a coleta de dados constou de uma entrevista com o profissional responsável pelos Núcleos de Segurança do Paciente por meio de um formulário semiestruturado. Analisaram-se os dados pela estatística simples. Resultados: detalha-se que, dos 20 hospitais elegíveis, 12 (60%) participaram do estudo; todos os hospitais (100%) possuem núcleos constituídos, (91,7%) com Plano de Segurança do Paciente e (50%) contam com profissional com dedicação exclusiva. Implementaram-se, por mais da metade dos núcleos (58,3%), todos os protocolos obrigatórios, sendo identificação do paciente (83,3%) e higienização das mãos (83,3%) os mais frequentes. Revela-se que os percentuais de eventos adversos notificados foram: lesão por pressão (88,9%); queda do leito (77,8%) e erros de medicamentos (75%). Conclusão: conclui-se que os núcleos estudados não atendem totalmente às políticas regulatórias vigentes no país, merecendo, portanto, de adequações e de controle sanitário efetivo.(AU)

Objective: to analyze the implementation of the national patient safety policy. Method: this is a quantitative, descriptive and evaluative study of multiple cases in large hospitals. Please be informed that the data collection consisted of an interview with the professional responsible for the Patient Safety Centers using a semi-structured form. Data were analyzed using simple statistics. Results: it is detailed that, of the 20 eligible hospitals, 12 (60%) participated in the study; all hospitals (100%) have centers, (91.7%) have a Patient Safety Plan and (50%) have a professional with exclusive dedication. All mandatory protocols were implemented in more than half of the centers (58.3%), with patient identification (83.3%) and hand hygiene (83.3%) being the most frequent. It is revealed that the percentages of adverse events reported were: pressure injury (88.9%); bed falls (77.8%) and medication errors (75%). Conclusion: it is concluded that the centers studied do not fully comply with the regulatory policies in force in the country, therefore deserving adjustments and effective sanitary control.(AU)

Objetivo: analizar la implementación de la política nacional de seguridad del paciente. Método: se trata de un estudio cuantitativo, descriptivo y evaluativo de casos múltiples en grandes hospitales. Tenga en cuenta que la recopilación de datos consistió en una entrevista con el profesional responsable de los Centros de Seguridad del Paciente utilizando un formulario semiestructurado. Los datos se analizaron mediante estadísticas simples. Resultados: se observa que de los 20 hospitales elegibles, 12 (60%) participaron en el estudio. Se dice que todos los hospitales (100%) tienen centros constituidos, (91.7%) con un Plan de Seguridad del Paciente y (50%) tienen un profesional con dedicación exclusiva. Es de destacar que más de la mitad de los centros (58.3%) implementan todos los protocolos obligatorios, siendo la identificación del paciente (83.3%) y la higiene de manos (83.3%) las más frecuentes. Se observa que los porcentajes de eventos adversos informados fueron: lesión por presión (88,9%), caída de la cama (77,8%) y errores de medicación (75%). Conclusión: se informa que los centros estudiados no cumplen plenamente con las políticas regulatorias vigentes en el país, por lo que merecen ajustes y un control sanitario efectivo.(AU)

Organizational trust, employee commitment and job satisfaction in Turkish hospitals: implications for public policy and health.

BACKGROUND: Understanding relationships between factors that can affect organizational outcomes such as organizational trust, employee commitment and job satisfaction is important to foster healthy work conditions in organizations. AIMS: This study aimed to determine the perception of Turkish physicians about organizational trust, employee commitment and job satisfaction and determine the relationships between them. METHODS: A questionnaire was developed based on three standard survey instruments and given to 1679 doctors in four training and research hospitals in Istanbul, Turkey, in 2013. The Pearson correlation coefficient was calculated and regression analyses were conducted. RESULTS: A total of 304 doctors completed the survey (18.1% response rate). Most were males (57%), over 30 years old (62%) and specialists (82%). A strong positive correlation was found among the study variables (P ≤ 0.001). Regression analyses indicated that organizational trust was a significant predictor of job satisfaction and commitment. CONCLUSIONS: Policy-makers need to consider implementing interventions in the health care system to improve the working conditions of current and future doctors in Turkey, in order to attract and retain them and prevent health care labour force losses.

Racial and Ethnic Differences in 30-Day Hospital Readmissions Among US Adults With Diabetes.

Importance: Differences in readmission rates among racial and ethnic minorities have been reported, but data among people with diabetes are lacking despite the high burden of diabetes and its complications in these populations. Objectives: To examine racial/ethnic differences in all-cause readmission among US adults with diabetes and categorize patient- and system-level factors associated with these differences. Design, Setting, and Participants: This retrospective cohort study includes 272 758 adult patients with diabetes, discharged alive from the hospital between January 1, 2009, and December 31, 2014, and stratified by race/ethnicity. An administrative claims data set of commercially insured and Medicare Advantage beneficiaries across the United States was used. Data analysis took place between October 2016 and February 2019. Main Outcomes and Measures: Unplanned all-cause readmission within 30 days of discharge and individual-, clinical-, economic-, index hospitalization-, and hospital-level risk factors for readmission. Results: A total of 467 324 index hospitalizations among 272 758 adults with diabetes (mean [SD] age, 67.7 [12.7]; 143 498 [52.6%] women) were examined. The rates of 30-day all-cause readmission were 10.2% (33 683 of 329 264) among white individuals, 12.2% (11 014 of 89 989) among black individuals, 10.9% (4151 of 38 137) among Hispanic individuals, and 9.9% (980 of 9934) among Asian individuals (P < .001). After adjustment for all factors, only black patients had a higher risk of readmission compared with white patients (odds ratio, 1.05; 95% CI, 1.02-1.08). This increased readmission risk among black patients was sequentially attenuated, but not entirely explained, by other demographic factors, comorbidities, income, reason for index hospitalization, or place of hospitalization. Compared with white patients, both black and Hispanic patients had the highest observed-to-expected (OE) readmission rate ratio when their income was low (annual household income <$40 000 among black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; among Hispanic patients: OE ratio, 1.11; 95% CI, 1.07-1.16) and when they were hospitalized in nonprofit hospitals (black patients: OE ratio, 1.10; 95% CI, 1.08-1.12; among Hispanic patients: OE ratio, 1.08; 95% CI, 1.05-1.12), academic hospitals (black patients: OE ratio, 1.16; 95% CI, 1.13-1.20; Hispanic patients: OE ratio, 1.12; 95% CI, 1.06-1.19), or large hospitals (ie, with ≥400 beds; black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; Hispanic patients: OE ratio, 1.09; 95% CI, 1.04-1.14). Conclusions and Relevance: In this study, black patients with diabetes had a significantly higher risk of readmission than members of other racial/ethnic groups. This increased risk was most pronounced among lower-income patients hospitalized in nonprofit, academic, or large hospitals. These findings reinforce the importance of identifying and addressing the many reasons for persistent racial/ethnic differences in health care quality and outcomes.

Organizational transformation in health care: an activity theoretical analysis.

PURPOSE: Older patients are at high risk of hospital readmission, which has led to an increasing number of screening and intervention programs. Knowledge on implementing screening tools for preventing readmissions in emergency department (ED), where the primary focus is often the present-day flow of patients, is scant. The purpose of this paper is to explore whether a new screening tool for predicting readmissions and functional decline in medical patients>65 years of age could be implemented and its influence on cross-continuum collaborations between the primary and secondary sectors. DESIGN/METHODOLOGY/APPROACH: The study took place in an ED in Denmark, in collaboration with the surrounding municipalities. An evaluation workshop with nurses and leaders from the ED and the surrounding municipalities took place with the aim of investigating the organizational changes that occurred in daily practice after the implementation of the screening tool. The workshop was designed and analyzed using cultural historical activity theory (CHAT). FINDINGS: The results showed that it was possible to develop collaboration between the two sectors during the test period. However, the screening tool created different transformations for the municipality employees and in the ED. The contradictions indicated that the screening tool did not mediate a general and sustained transformation in the cross-continuum collaboration. RESEARCH LIMITATIONS/IMPLICATIONS: Screening tools are not objective, neutral or "acontexual" artifacts and must always be adapted to the local context and sectors. CHAT offers a perspective to understand the collective object when working with organizational transformations and implementation. PRACTICAL IMPLICATIONS: The study have shown that screening tools are not objective, neutral or "acontexual" artifacts and must always be adapted to the local context. This is called adaption process. This adaption requires time and resources that should be taken into consideration from the beginning of introduction of new screens. ORIGINALITY/VALUE: This paper contributes with knowledge about CHAT which offers a way to understand the leading collective object when working with organizational transformations and implementation. CHAT focuses not only on the structural changes but also on the cultural aspects of organizational changes, which is important if we want to reach a sustained change and implement the new screening tool in different sectors.

Technology Isn't the Half of It: Integrating Electronic Health Records and Infusion Pumps in a Large Hospital.

BACKGROUND: Although adoption of "smart" infusion pumps has improved intravenous medication administration safety, pump integration with electronic health records (EHRs) remains rare. Early-adopter hospitals have recently implemented intravenous clinical integration (IVCI) to allow bidirectional communication between their EHRs and infusion pumps. However, the challenges and strategies involved in IVCI implementation have not been described. METHODS: A qualitative description of one hospital's IVCI implementation was conducted. The research team interviewed 33 pharmacists, technologists, clinicians, nurse managers, educators, and organizational leaders; observed nurses on five units using EHR-integrated pumps; and attended nurse training. Interview notes and transcripts were analyzed to describe IVCI implementation, highlighting its effects on clinicians and the organization. RESULTS: Motivations for implementation included a culture of innovation, simultaneous pump and EHR upgrades, and belief that IVCI would improve patient safety. Proactive planning included a simultaneous go-live across selected units, financial investment, multidisciplinary planning teams, and clinical training. Challenges included lack of direct communication between EHR and pump vendors, nonstandardized unit-specific drug libraries, and unit- and nurse-specific variation in workflows for administering infusions. Mitigation strategies included serving as messenger between vendors, conducting hospitalwide efforts to standardize drug libraries and workflows, and standardizing organizational policies. Lessons learned included that IVCI adoption was as much a nursing workflow and organizational policy intervention as a technological implementation. CONCLUSION: Integrating infusion pumps and EHRs involves much more than installing new technologies. Hospitals considering IVCI should prepare to undertake significant simultaneous changes to organizational policies and clinician workflows.

A nationwide survey on involvement of clinical microbiologists in antibiotic stewardship programmes in large French hospitals.

Antibiotic stewardship programmes (ASP) are essential to tackle antibiotic resistance. Clinical microbiologists (CMs) play a key role in these programmes; however, few studies describe their actual involvement. Our objective was to explore CMs' involvement in French hospital ASP. In 2018, we conducted a survey among CMs working in large public French hospitals (600 acute care beds or more). The questionnaire focused on the following topics: microbiology department's characteristics, hospital ASP, and CMs' involvement in this programme, including their use of rapid diagnostic tests (RDT). Fifty/74 CMs answered (response rate 68%), with 68% working in a teaching hospital. CMs were leading the ASP in 6% of cases, and 57% of hospitals had a multidisciplinary antibiotic stewardship team. Most microbiology departments (92%) were using specific PCR, processed 24/7 in 74% of hospitals. More than half (58%) were using syndromic panel-based testing, 94% mass spectrometry, and 96% immunochromatographic/colorimetric RDT. Blood cultures were processed 24/7 in 44% of hospitals. CMs were involved in this. Finally, 42% of CMs wished to be more involved in their hospital's ASP, the most frequently reported barrier being lack of time (36%). CMs should be more involved in ASP. RDT are widely used, but not implemented in an optimal way.

Hand hygiene knowledge, training and practice: A cross-sectional study in a tertiary health institution, North-central Nigeria.

BACKGROUND: Hand hygiene (HH) is the single most important means of preventing hospital-acquired infections. We set out to determine the knowledge, training gaps, and practice of HH in a tertiary health institution in a resource constrained setting. METHODS: This cross-sectional study was conducted among health care workers in a 600-bed capacity tertiary health centre. The study was conducted between April and November 2013. A multi-stage randomized sampling method was used to self-administer 322 WHO HH knowledge questionnaires. Information on HH training in the past 3 years, knowledge and practice of HH were obtained, and data were analysed using Epi-Info version 3.5.1. RESULTS: A response rate of 98.5% was obtained for the HH knowledge assessment. Mean age of the study population was 39 ± 9.8. About 64% were females. Of all the respondents, only 16% had good knowledge of HH, 52% had moderate knowledge while 32% had poor knowledge. About 24% had formal training on HH. In terms of practice, only about 22% of the respondents self-reported routine practice of HH. CONCLUSIONS: The findings in this study suggest that there is sub-optimal HH knowledge, practice and training. It is imperative to improve the HH training and retraining of health care workers with a focus on attendants. Administrative controls and bold signage in healthcare institutions are also recommended.

Combination of lymphovascular invasion and the AJCC TNM staging system improves prediction of prognosis in N0 stage gastric cancer: results from a high-volume institution.

BACKGROUND: This study sought to explore whether lymphovascular invasion can affect the prognosis of patients with stage N0 gastric cancer and to evaluate the survival benefit of adjuvant chemotherapy for such patients. METHOD: From January 2006 to December 2011, a total of 2102 gastric cancer patients undergoing radical gastric resection were enrolled in this study. Homogeneity, discriminatory ability, and monotonicity of gradients in the combination of lymphovascular invasion and the 8th edition of the AJCC staging system and the 8th edition of the AJCC staging system alone were compared using linear trend χ2, likelihood ratio χ2 statistics, and Akaike information criterion (AIC) calculations. The Kaplan-Meier method and the log-rank test were used to analyze between-group differences in survival rate. RESULT: The median follow-up time of the whole group was 58 months, and the average age of the whole group was 63.9 years (range 21-89 years). The 3-year and 5-year overall survival rates in N0 patients with lymphovascular invasion were lower than those in N0 patients without lymphovascular invasion (3-year OS: 78.3% vs 92.5%, 5-year OS: 70.0% vs 88.3%, p < 0.001). A multivariate analysis showed that age (p < 0.001), lymphovascular invasion (p < 0.001), and pT (p < 0.001) were independent risk factors for the prognosis of N0 patients. Compared with the 8th edition of the AJCC staging system alone, the 8th AJCC staging system combined with lymphovascular invasion demonstrated a better linear trend χ2, likelihood ratio χ2 statistics, and AIC value (68.99 vs 58.58, 70.18 vs 58.36, 1473.38 vs 1485.04). In pT3N0M0 patients with lymphovascular invasion, the 3-year and 5-year overall survival rates of the adjuvant chemotherapy group were higher than those of the surgery alone group (3-year OS: 83.3% vs 68.2%, 5-year OS: 72.3% vs 50.0%, p = 0.048). CONCLUSION: Lymphovascular invasion is an independent prognostic factor in N0 patients. The 8th AJCC staging system combined with lymphovascular invasion can improve the accuracy of the AJCC staging system for N0 patients. Moreover, adjuvant chemotherapy improves the survival of pT3N0M0 patients with lymphovascular invasion.

Impact of repeated hospital accreditation surveys on quality and reliability, an 8-year interrupted time series analysis.

OBJECTIVE: To evaluate whether hospital re-accreditation improves quality, patient safety and reliability over three accreditation cycles by testing the accreditation life cycle model on quality measures. DESIGN: The validity of the life cycle model was tested by calibrating interrupted time series (ITS) regression equations for 27 quality measures. The change in the variation of quality over the three accreditation cycles was evaluated using the Levene's test. SETTING: A 650-bed tertiary academic hospital in Abu Dhabi, UAE. PARTICIPANTS: Each month (over 96 months), a simple random sample of 10% of patient records was selected and audited resulting in a total of 388 800 observations from 14 500 records. INTERVENTIONS: The impact of hospital accreditation on the 27 quality measures was observed for 96 months, 1-year preaccreditation (2007) and 3 years postaccreditation for each of the three accreditation cycles (2008, 2011 and 2014). MAIN OUTCOME MEASURES: The life cycle model was evaluated by aggregating the data for 27 quality measures to produce a composite score (YC) and to fit an ITS regression equation to the unweighted monthly mean of the series. RESULTS: The results provide some evidence for the validity of the four phases of the life cycle namely, the initiation phase, the presurvey phase, the postaccreditation slump and the stagnation phase. Furthermore, the life cycle model explains 87% of the variation in quality compliance measures (R2=0.87). The best-fit ITS model contains two significant variables (ß1 and ß3) (p≤0.001). The Levene's test (p≤0.05) demonstrated a significant reduction in variation of the quality measures (YC) with subsequent accreditation cycles. CONCLUSION: The study demonstrates that accreditation has the capacity to sustain improvements over the accreditation cycle. The significant reduction in the variation of the quality measures (YC) with subsequent accreditation cycles indicates that accreditation supports the goal of high reliability.

Improved survival of glioblastoma patients treated at academic and high-volume facilities: a hospital-based study from the National Cancer Database.

OBJECTIVE: The present study was designed to explore the association between facility type (academic center [AC] vs non-AC), facility volume (high-volume facility [HVF] vs low-volume facility [LVF]), and outcomes of glioblastoma (GBM) treatment. METHODS: Based on the National Cancer Database (NCDB), GBM patients were categorized by treatment facility type (non-AC vs AC) and volume [4 categories (G1-G4): < 5.0, 5.0-14.9, 15.0-24.9, and ≥ 25.0, cases/year]. HVF was defined based on the 90th percentile of annual GBM cases (≥ 15.0 cases/year). Outcomes include overall survival (OS), the receipt of surgery and adjuvant therapies, 30-day readmission/mortality, 90-day mortality, and prolonged length of inpatient hospital stay (LOS). Kaplan-Meier methods and accelerated failure time (AFT) models were applied for survival analysis, and multivariable logistic regression models were performed to compare differences in the receipt of treatment and related short-term outcomes by facility type and volume. RESULTS: A total of 40,256 GBM patients diagnosed between 2004 and 2014 were included. Patients treated at an AC & HVF experienced the longest survival (median OS: 13.3, 11.8, 11.1, and 10.3 months; time ratio [TR]: 1.00 [Ref.], 0.96, 0.92, and 0.89; for AC & HVF, AC & LVF, non-AC & HVF, and non-AC & LVF, respectively), regardless of care transition/treatment referral. Tumor resection, radiotherapy, and chemotherapy were most frequently utilized in AC & HVF. Prolonged LOS, 30-day readmission, and 90-day mortality were decreased by 20%, 22%, and 16% (p ≤ 0.001), respectively, at AC & HVF. CONCLUSIONS: This study provides evidence of superior outcomes when GBM patients are treated at AC and HVF. Standardization of health care across facility type and/or volume and comprehensive neuro-oncological care should be a potential goal in the management of GBM patients.

Toward the Design of an Engagement Tool for Effective Electronic Health Record Adoption.

As healthcare systems continue to expand their use of electronic health records (EHRs), barriers to robust and successful engagement with such systems by stakeholders remain tenacious. To this effect, this research presents the results of a survey tool utilizing both original and modified constructs from the Consolidated Framework for Implementation Research to assess key points of engagement barriers and potential points of intervention for stakeholders of EHRs in a large-scale healthcare organization (500-bed level II regional trauma center). Based on the extensive assessment, the paper presents recommendations for the utility of engagement process modeling and discusses how intervention opportunities can be used to mitigate engagement barriers.

Musculoskeletal complaints in healthcare personnel in hospital: An interdepartmental, cross-sectional comparison.

The objective of this study is to investigate musculoskeletal complaints (MSCs) in healthcare workers (HCWs) in 3 community hospital-based departments [internal medicine (IM), general surgery (GS), and emergency department (ED)] and its effects on the quality of work life (QWL) of hospital HCW.This prospective cross-sectional study was performed in the 700-bed community training hospital. All HCW staffed in 3 departments (IM, GS, ED) of the hospital were asked to respond to items in the study data sheet. Enrolled personnel were inquired about their demographic data, work history and schedule, and medical history. The 16-item Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) Turkish version was applied to evaluate MSC. A total of 216 HCW constituted the study sample and demographic characteristics, history, and clinical findings were analyzed.Among all, 103 personnel (47.7%) were women (n = 42, 41.1% in physicians, n = 57, 87.6% in nurses and n = 4, 8% in other HCW) (P = .000). A total of 173 personnel (79.7%) reported MSC in some part of their bodies. Female personnel had MSC significantly more commonly than males (chi-square = 40.7, P = .000). Numbers and percentages of the personnel with MSC in 3 departments (IM, GS, ED) were 51/61, 52/65, and 70/90, respectively (P = .67). Total QWL score of those without MSC was significantly higher than others (74.7 + -12 vs 63.2 + -15, respectively; t test, P = .000). Total frequency score of MSC as elicited via CMDQ was significantly higher in those without MSC compared to the others (8.1 + -7.6 vs 0.1 + -0.6, respectively, t test, P = .000).Female sex, high-income, university graduation, being a nurse or a physician, and older age impose risk for HCW in hospital with respect to having MSC. Presence of MSC affects QWL negatively.

A Multidisciplinary Handoff Process to Standardize the Transfer of Care Between the Intensive Care Unit and the Operating Room.

OBJECTIVE: Critically ill patients are at high risk for adverse events on transfer between intensive care unit and operating room. Patient safety concerns were raised within our institution during such transfers, and absence of a standardized patient handoff process was identified as an area of concern. METHODS: The current state of the patient transfer processes between the intensive care units (ICUs) and the operating rooms (ORs) was mapped and failure modes were identified. A multidisciplinary team was convened and a standardized handoff process and tool (checklist) was developed. Adherence to the process and care team satisfaction was assessed at the end of a 60-day pilot period. RESULTS: The process was successfully implemented hospital-wide covering all adult and pediatric ICUs. We observed a 90% compliance rate with ICU to the OR transfers and 95% compliance rate with transfers from OR to the ICU during the 60-day pilot period. The care team expressed overall satisfaction with the process and identified potential areas of improvement. CONCLUSION: A standardized patient handoff process between the ICU and the ORs can be successfully implemented in a large academic medical center. Universal application of this quality improvement tool can reduce patient harm, improve communication between providers, and enhance patient safety.

Patients discharged from the emergency department after referral for hospitalist admission.

OBJECTIVES: To describe the characteristics and outcomes of patients discharged from the emergency department (ED) by hospitalist physicians. STUDY DESIGN: Retrospective cohort study at a tertiary academic medical center. METHODS: We used consultation Current Procedural Technology codes to identify patients discharged from the ED after referral for hospitalist admission from April 2011 to April 2014. We report patient demographics and primary diagnoses. Main outcome measures included return to the ED, hospitalization, or mortality, all within 30 days. RESULTS: There were 710 discharges from the ED for 670 patients referred for hospitalist admission; 21.7% returned to the ED, 12.3% were hospitalized, and 0.4% died within 30 days. Chest pain was the most common diagnosis (38.2%); 18.1% of these patients returned to the ED within 30 days. Patients with the following 3 diagnoses returned to the ED most frequently: sickle cell disease (82.4%), alcohol-related diagnoses (43.5%), and abdominal pain (35.7%). In multivariate analysis, abdominal pain (odds ratio [OR], 3.2; P <.001) and alcohol dependence (OR, 3.1; P = .003) increased the odds of ED revisits, whereas syncope (OR, 0.23; P = .049) reduced the odds. Chest pain reduced the odds of hospitalization (OR, 0.37; P = .005). CONCLUSIONS: A majority of patients discharged from the ED after referral for hospitalist admission did not return to the ED within 30 days, and the 30-day hospitalization rate was low. Our data suggest that hospitalists can safely aid patients by reducing the costs and adverse outcomes associated with unnecessary hospitalization.

The TEND (Tomorrow's Expected Number of Discharges) Model Accurately Predicted the Number of Patients Who Were Discharged from the Hospital the Next Day.

BACKGROUND: Knowing the number of discharges that will occur is important for administrators when hospital occupancy is close to or exceeds 100%. This information will facilitate decision making such as whether to bring in extra staff, cancel planned surgery, or implement measures to increase the number of discharges. We derived and internally validated the TEND (Tomorrow's Expected Number of Discharges) model to predict the number of discharges from hospital in the next day. METHODS: We identified all patients greater than 1 year of age admitted to a multisite academic hospital between 2013 and 2015. In derivation patients we applied survival-tree methods to patient-day covariates (patient age, sex, comorbidities, location, admission urgency, service, campus, and weekday) and identified risk strata having unique discharge patterns. Discharge probability in each risk strata for the previous 6 months was summed to calculate each day's expected number of discharges. RESULTS: Our study included 192,859 admissions. The daily number of discharges varied extensively (median 139; interquartile range [IQR] 95-160; range 39-214). We identified 142 discharge risk strata. In the validation patients, the expected number of daily discharges strongly predicted the observed number of discharges (adjusted R2 = 89.2%; P < 0.0001). The relative difference between observed and expected number of discharges was small (median 1.4%; IQR -5.5% to 7.1%). CONCLUSION: The TEND model accurately predicted the daily number of discharges using information typically available within hospital data warehouses. Further study is necessary to determine if this information improves hospital bed management.

Impact of a quality-assessment dashboard on the comprehensive review of pharmacist performance.

PURPOSE: The impact of a quality-assessment dashboard and individualized pharmacist performance feedback on the adherence of order verification was evaluated. METHODS: A before-and-after study was conducted at a 1,440-bed academic medical center. Adherence of order verification was defined as orders verified according to institution-derived, medication-related guidelines and policies. Formulas were developed to assess the adherence of verified orders to dosing guidelines using patient-specific height, weight, and serum creatinine clearance values from the electronic medical record at the time of pharmacist verification. A total of 5 medications were assessed by the formulas for adherence and displayed on the dashboard: ampicillin-sulbactam, ciprofloxacin, piperacillin-tazobactam, acyclovir, and enoxaparin. Adherence of order verification was assessed before (May 1-July 31, 2015) and after (November 1, 2015-January 31, 2016) individualized performance feedback was given based on trends identified by the quality-assessment dashboard. RESULTS: There was a significant increase in the overall adherence rate postintervention (90.1% versus 91.9%, p = 0.040). Among the 34 pharmacists who participated, the percentage of pharmacists with at least 90% overall adherence increased postintervention (52.9% versus 70.6%, p = 0.103). Time to verification was similar before and after the study intervention (median, 6.0 minutes; interquartile range, 3-13 minutes). The rate of documentation for nonadherent orders increased significantly postintervention (57.1% versus 68.5%, p = 0.019). CONCLUSION: The implementation of the quality-assessment dashboard, educational sessions, and individualized performance feedback significantly improved pharmacist order-verification adherence to institution-derived, medication-related guidelines and policies and the documentation rate of nonadherent orders.