Engaging the Front Line: Tapping into Hospital-Wide Quality and Safety Initiatives.

Healthcare increasingly is moving from volume- to value-based care, with an emphasis on linking a larger percentage of payments to the quality of care provided. There is a renewed interest in designing a focused, strategic approach to quality and safety education and engagement of trainees in hospital-wide quality, safety, and patient experience initiatives. Hospitals, trainees, and patients benefit as a result of engaging frontline learners in these activities. Hospitals can leverage the intelligence from the front line to contribute to improved hospital safety, increased employee and patient engagement, and better identification of vulnerable areas of safety risks. Trainees benefit from increased engagement by acquiring fundamentals in quality and safety; are able to satisfy Clinical Learning Environment Review recommendations; have an opportunity to practice a number of skill sets (leadership, communication, collaboration); and complete quality and safety hands-on projects. Patients benefit from a more engaged work force, safer environment for their healthcare, and an improved overall experience. In this article, the current state of the Johns Hopkins Department of Anesthesiology and Critical Care Medicine's efforts to engage its front line in quality, safety, and patient experience initiatives that are in evolutionary phases of implementation is presented. Evolutionary concepts relate to the Johns Hopkins Health System and the aim of its training program to continuously improve and innovate.

Association Between Early Speech-Language Pathology Consultation and Pneumonia After Cardiac Surgery.

PURPOSE: Patients undergoing cardiac surgery are reported to be at higher risk for oropharyngeal dysphagia and aspiration, which may predispose them to respiratory complications such as pneumonia. Speech-language pathology consultation facilitates early identification of swallowing difficulties providing appropriate and timely interventions during the postoperative period. This study explores the association between pneumonia and timing of speech-language pathology order entry and evaluation following cardiac surgery. METHOD: A retrospective study was performed on adults who underwent cardiac surgery in a tertiary care center, from July 2016 through December 2019. Patients with preexisting tracheostomy upon admission for cardiac surgery were excluded. The medical records of patients who had speech-language pathology consultation orders for swallowing concerns were analyzed in order to compare the timing of speech-language pathology order entry, completion of speech-language pathology evaluation, and incidence of pneumonia during hospitalization following cardiac surgery. RESULTS: During the study period, 3,168 patients underwent cardiac surgery, of which 2,864 patients met the inclusion criteria. Speech-language pathology was ordered for 473 cases (16.5%), and clinical swallow evaluation (CSE) was completed by speech-language pathology in 419 patients (88.6%), of which 309 patients were suspected to have dysphagia (73.7%). Among the 2,391 patients without speech-language pathology consultation, pneumonia was reported in 34 patients (1.42%). Pneumonia was reported in 53 patients in the speech-language pathology cohort, of which 43 patients (13.9%) were suspected to have dysphagia. Patients with pneumonia had significantly longer median time (20.0 hr, range: 4.9-26.7) from speech-language pathology orders to completion of CSE, compared to those without pneumonia (13.2 hr, range: 3.2-22.4, p = .025). There was no significant difference in the median time from extubation to speech-language pathology consultation order time in patients with pneumonia versus those without pneumonia. Patients with pneumonia were observed to have prolonged, although not statistically significant, median time from extubation to CSE (70.4 hr, range: 21.2-215) compared to those without pneumonia (42.2 hr, range: 19.5-105.8, p = .066). CONCLUSIONS: Patients without pneumonia in the postoperative period were observed to have shorter median time from extubation to speech-language pathology evaluation. Future studies are needed to further understand the impact of early speech-language pathology consultation and incidence of pneumonia in this population.

Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration.

BACKGROUND: Confirmation of match between patient and blood product remains a manual process in most operating rooms (ORs), and documentation of dual-signature verification remains paper based in most medical institutions. A sentinel event at Johns Hopkins Hospital in which a seriously ill patient undergoing an emergent surgical procedure was transfused with a unit of incompatible red blood cells that had been intended for another patient in an adjacent OR led the hospital to conduct a quality improvement project to improve the safety of intraoperative blood component transfusions. METHODS: A multidisciplinary quality improvement project team led a four-phase implementation of bedside bar code transfusion verification (BBTV) for intraoperative blood product administration. Manual random sample audits of blood component transfusions were used to examine accuracy of documentation from July 2014 through June 2016. After the transition to the Epic anesthesia information management system (AIMS) in July 2016, automated Epic reports were generated to provide population-level audits. RESULTS: After initiation of BBTV and the addition of Epic AIMS, compliance with obtaining three metrics on documentation of patient identification (two electronic signatures, start and stop times of transfusion, and blood volume transfused) was improved during a one-year period to > 96%. Pre-Epic audits had shown a mean compliance of only 86%, mainly reflecting a lack of paper blood component requisitions. CONCLUSION: By implementing BBTV and using a novel intraoperative documentation process within the Epic AIMS, a safer process of blood transfusion in the ORs was initiated and documentation improved.

A Comparison of Helminth Faunas of Cope's Gray ( Hyla chrysoscelis ) and Green ( Hyla cinerea ) Treefrogs in Areas of Recent Niche Overlap.

This study compares the helminth faunas between Cope's gray treefrogs ( Hyla chrysoscelis ) and green treefrogs ( Hyla cinerea ), in areas where they have recently overlapped due to range expansion by H. cinerea , to determine whether or not 2 species of frogs with a high degree of similarity in many of their life history traits also exhibit similarities in the composition of their helminth assemblages. Results of this study did not find significant differences in helminth species diversity when sympatric and allopatric populations of the same species of frog were compared. There was, however, a significant difference in helminth diversity among sympatric populations of H. chrysoscelis and H. cinerea , and this difference was in large part attributable to the significantly higher abundance of the gastrointestinal nematode Cosmocercoides variabilis among H. chrysoscelis . Additional studies will be required to determine whether the observed patterns are due to differences in arrival time, perch locations within the chorus, or parasite-mediated competition.

A survey of postnatal debriefing.

BACKGROUND: The evidence for postnatal debriefing generally lacks clarification of what postnatal debriefing constitutes. This is true of the recommendation in the United Kingdom for midwives to undertake 'active postnatal debriefing' (Department of Health 1999). AIM: The study aimed to explore current practice and describe the provision of postnatal debriefing in two health regions of England. METHODS: A descriptive survey using cohort sampling was undertaken using a self-report questionnaire which was sent to each maternity unit in the two regions (n = 46). A response rate of 93% (n = 43) was obtained. The questionnaire collected information about the maternity units and their provision of 'postnatal debriefing'. A list of debriefing descriptors formed the basis of the questionnaire, and comprised activities that various authors had included in their definitions of debriefing. RESULTS: Responses indicated that 38 (88%) of maternity units offered women an opportunity to 'debrief' by discussing their experiences of maternity care. The provision of this service fell into three distinct sub-groups: firstly, those who provided a service which is in keeping with debriefing, however not all the maternity units actually called their service debriefing; secondly, those who provided a service which is fundamental postnatal care, usually called routine postnatal care; thirdly, those who provided a service which was inconsistent and neither debriefing nor postnatal care. This inconsistency was also reflected in the names chosen for the service. CONCLUSIONS: The findings of this study support previous claims that confusion about postnatal debriefing continues. Recommendations for practice are made with the intention of promoting a consistent approach; this would also enable further research and evaluation to be conducted.

Replacement of recipient stromal/mesenchymal cells after bone marrow transplantation using bone fragments and cultured osteoblast-like cells.

Abstract We present our experience on treatment of three children with potentially fatal diseases using a unique protocol for non-myeloablative bone marrow transplantation. The protocol was designed to promote engraftment of bone marrow stromal/mesenchymal cells (SC/MSCs) based on the knowledge from preclinical models over the last three decades. Accordingly, our protocol is the first to test the use of bone fragments as an ideal vehicle to transplant such cells residing in the bone core. Because of the paucity of knowledge for optimum transplantation of SC/MSCs in humans, we used a multifaceted approach and implanted bone fragments both intraperitoneally and directly into bone on day 0 of BMT. We also infused cultured donor osteoblast-like cells intravenously post-BMT. We were able to achieve high levels of stroma cell engraftment as defined by molecular analyses of bone biopsy specimens.