ERAS: Safety checklists, antibiotics, and VTE prophylaxis.

The concept rested on several components that many of us have now tried to adopt or improve on, inclusive of a multidisciplinary team, a multimodal approach to anesthesia and preoperative preparedness, evidence-based approach to care protocols; and a change in management using interactive and continuous audit prior to and post-procedure. This article describes the development of ERAS protocols relative to checklist implementation, antibiotic use, and venous thromboembolism (VTE) prevention, how these ideas are developed and operationalized as well as how they are evolving and spreading across the care continuum to achieve sustained outcome improvements.

Outbreak of postpartum group a Streptococcus infections on a labor and delivery unit.

A healthcare-associated group A Streptococcus outbreak involving six patients, four healthcare workers, and one household contact occurred in the labor and delivery unit of an academic medical center. Isolates were highly related by whole genome sequencing. Infection prevention measures, healthcare worker screening, and chemoprophylaxis of those colonized halted further transmission.

Daily review of AHRQ patient safety indicators has important impact on value-based purchasing, reimbursement, and performance scores.

BACKGROUND: The Patient Safety Indicators (PSIs) Composite (PSI 90) of the Agency for Healthcare Research and Quality has been found to have low positive predictive values. Because scores can affect hospital reimbursement and ranking, our institution designed a review process to ensure accurate data and incur minimal penalties under the Hospital Value-Based Purchasing Program. METHODS: A multidisciplinary team was assembled to review PSI 90 within a performance period. The positive predictive value of each PSI was calculated. Weight-adjusted PSI rates were used to recalculate the PSI 90 Performance Period Index Value (PPIV). The adjusted PPIV was used to estimate what the achievement points and financial impact would have been if PSI review had not been implemented. Differences in PPIV, achievement points, and financial impact before and after PSI review were calculated. RESULTS: A total of 1,470 cases were flagged for PSI over a 2-year period. The positive predictive value was 63.3%. Refuting 36.7% of PSIs resulted in a decrease in the PPIV from 0.696 to 0.508, an increase in achievement points from 5 to 10, resulting in a decreased net loss of $111,773. CONCLUSION: Multidisciplinary review processes are practical and effective in identifying false-positive patient safety events. The real-time process affects hospital performance and resultant Medicare reimbursement substantially.

Strain differences in murine ventilatory behavior persist after urethane anesthesia.

Differences in breathing pattern between awake C57BL/6J (B6) and A/J mice are such that A/J mice breathe slower, deeper, and with greater variability than B6. We theorized that urethane anesthesia, by affecting cortical and subcortical function, would test the hypothesis that strain differences require a fully functional neuroaxis. We anesthetized B6 and A/J mice with urethane, placed them in a whole-body plethysmograph, and measured the durations of inspiration and expiration, respiratory frequency (Fr), and peak amplitude during exposure to room air (21% O2), hyperoxia (5 min, 100% O2), hypoxia (5 min, 8% O2), and posthypoxic reoxygenation (5 min, 100% O2). Breathing variability was assessed by calculating the coefficient of variation (CV) and by applying spatial statistics to Poincaré plots constructed from the timing and amplitude data. Even though Fr in anesthetized B6 and A/J mice was greater than that for unanesthetized animals, anesthetized A/J mice still breathed slower, deeper, and with greater variability than B6 mice at rest and during hyperoxia. During the fourth minute of hypoxia, Fr and its CV were not significantly different between strains. Even though Fr was similar between strains immediately after hypoxia, its CV was significantly greater for B6 than A/J mice. Posthypoxic Fr was significantly less than baseline Fr in B6 but not A/J mice, and the CV for posthypoxic Fr was greater for B6 but less for AJ mice compared with baseline CV. This difference in patterning was confirmed by spatial statistical analysis. We conclude that strain-specific differences in respiratory pattern and its variability are robust genetic traits. The neural substrate for these differences, at least partially, exists within subcortical structures generating the breathing pattern.

Developing a multidisciplinary robotic surgery quality assessment program.

The objective of this study was to test the feasibility of a novel quality-improvement (QI) program designed to incorporate multiple robotic surgical sub-specialties in one health care system. A robotic surgery quality assessment program was developed by The Ohio State University College of Medicine (OSUMC) in conjunction with The Ohio State University Medical Center Quality Improvement and Operations Department. A retrospective review of cases was performed using data interrogated from the OSUMC Information Warehouse from January 2007 through August 2009. Robotic surgery cases (n=2200) were assessed for operative times, length of stay (LOS), conversions, returns to surgery, readmissions and cancellations as potential quality indicators. An actionable and reproducible framework for the quality measurement and assessment of a multidisciplinary and interdepartmental robotic surgery program was successfully completed demonstrating areas for improvement opportunities. This report supports that standard quality indicators can be applied to multiple specialties within a health care system to develop a useful quality tracking and assessment tool in the highly specialized area of robotic surgery.

Development and assessment of quality improvement education for medical students at The Ohio State University Medical Center.

This study tested the feasibility of a quality improvement (QI) program that provided first and second year medical students with education in QI processes and demonstrate their utility within the framework of a real-world QI project. Medical students assessed the use of the Surgical Safety Checklist at The Ohio State University Medical Center. Before performing audits students were required to complete a self-paced online program that provided preliminary education in QI, patient safety, leadership, teamwork, and patient-centered care. A 2.5-hr orientation introduced basic operating room protocol, and the surgical checklist audit tool. Orientation included a multimedia simulation of checklist usage and a role-playing exercise simulating its use. Students completed pre- and postparticipation assessments. Results included an increased knowledge of QI methodology, an improved understanding of the evidence supporting the need for QI projects within health systems, and a greater awareness of available QI projects. Students' perspectives changed to indicate an increased belief that QI is the responsibility of all health professionals including physicians, administrators and other staff. This study concluded that QI education can be effectively disseminated to medical students early in their education using existing online tools and experiential QI projects, and can result in actionable QI data supporting hospital improvement initiatives.