Bradley Monash

Interdisciplinary Development and Implementation of Communication Checklist for Postoperative Management of Pediatric Airway Patients

Objective. The authors describe their multidisciplinary experience in applying the Institute of Health Improvement methodology to develop a protocol and checklist to reduce communication error during transfer of care for postoperative pediatric surgical airway patients. Preliminary outcome data following implementation of the protocol and checklist are also presented. Study Design. Prospective study from July 1, 2009, to February 1, 2011. Setting. Tertiary care center. Subjects. One hundred twenty-six pediatric airway patients who required coordinated care between Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital. Methods. Two sentinel events involving airway emergencies demonstrated a critical need for a standardized, comprehensive instrument that would ensure safe transfer of care. After development and implementation of the protocol and checklist, an initial pilot period on the first set of 9 pediatric airway patients was reassessed. Subsequent prospective 11-month follow-up data of 93 pediatric airway patients were collected and analyzed. Results. A multidisciplinary pediatric team developed and implemented a formalized, postoperative checklist and transfer protocol. After implementation of the checklist and transfer protocol, prospective analysis showed no adverse events from miscommunication during transfer of care over the subsequent 11-month period involving 93 pediatric airway patients. Conclusion. There has been very little written in the quality and safety patient literature about coordinating effective transfer of care between the pediatric surgical and medical subspecialty realms. After design and implementation of a simple, electronically based transfer-of-care checklist and protocol, the number of postsurgical pediatric airway information transfer and communication errors decreased significantly.

The Prevalence of Social and Behavioral Topics and Related Educational Opportunities During Attending Rounds

Purpose To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced. Method This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes—prevalence of SBS topic discussions and rate of positive responses to discussions—were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors. Results Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams’ responses were positive. Services varied with respect to learner- and patient-centeredness, with most services above average for learner-centered, and below average for patient-centered behaviors. Conclusions Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patient-centered behaviors.

Improving attending rounds: Qualitative reflections from multidisciplinary providers

Abstract Background. Attending rounds, the time for the attending physician and the team to discuss the team’s patients, take place at teaching hospitals every day, often with little standardization. Objective. This hypothesis-generating qualitative study sought to solicit improvement recommendations for standardizing attending rounds from the perspective of a multi-disciplinary group of providers. Methods. Attending physicians, housestaff (residents and interns), medical students, nurses and pharmacists at an academic medical center participated in a quality improvement initiative between January and April 2013. Participants completed an individual or focus group interview or an e-mail survey with three open-ended questions: (1) What are poor or ineffective practices for attending rounds? (2) How would you change attending rounds structure and function? (3) What do you consider best practices for attending rounds? We undertook content analysis to summarize each clinical stakeholder group’s improvement recommendations. Results. Sixty stakeholders participated in our study including 23 attending hospitalists, 24 housestaff, 7 medical students, 2 pharmacists and 4 nurses. Key improvement recommendations included (1) performing a pre-rounds huddle, (2) planning of the visit schedule based on illness or pending discharge, (3) real-time order writing, (4) patient involvement in rounds with shared decision-making, (5) bedside nurse inclusion and (6) minimizing interruption of intern or student presentations. Conclusions. The practice improvement recommendations identified in this study will require deliberate systems changes and training to implement, and they warrant rigorous evaluation to determine their impact on the clinical and educational goals of rounds.

Standardized attending rounds to improve the patient experience: A pragmatic cluster randomized controlled trial

BACKGROUND: At academic medical centers, attending rounds (AR) serve to coordinate patient care and educate trainees, yet variably involve patients. OBJECTIVE: To determine the impact of standardized bedside AR on patient satisfaction with rounds. DESIGN: Cluster randomized controlled trial. SETTING: 500‐bed urban, quaternary care hospital. PATIENTS: 1200 patients admitted to the medicine service. INTERVENTION: Teams in the intervention arm received training to adhere to 5 AR practices: 1) pre‐rounds huddle; 2) bedside rounds; 3) nurse integration; 4) real‐time order entry; 5) whiteboard updates. Control arm teams continued usual rounding practices. MEASUREMENTS: Trained observers audited rounds to assess adherence to recommended AR practices and surveyed patients following AR. The primary outcome was patient satisfaction with AR. Secondary outcomes were perceived and actual AR duration, and attending and trainee satisfaction. RESULTS: We observed 241 (70.1%) and 264 (76.7%) AR in the intervention and control arms, respectively, which included 1855 and 1903 patient rounding encounters. Using a 5‐point Likert scale, patients in the intervention arm reported increased satisfaction with AR (4.49 vs 4.25; P = 0.01) and felt more cared for by their medicine team (4.54 vs 4.36; P = 0.03). Although the intervention shortened the duration of AR by 8 minutes on average (143 vs 151 minutes; P = 0.052), trainees perceived intervention AR as lasting longer and reported lower satisfaction with intervention AR. CONCLUSIONS: Medicine teams can adopt a standardized, patient‐centered, time‐saving rounding model that leads to increased patient satisfaction with AR and the perception that patients are more cared for by their medicine team.

Fecal occult blood testing in hospitalized patients with upper gastrointestinal bleeding

&NA; The “Things We Do for No Reason” (TWDFNR) series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

The third hand: low rates of stethoscope hygiene on general medical services.

Hand hygiene is a proven and guideline-recommended safety practice, although clinicians and particularly physicians are unreliable at performing it. Like hands, stethoscopes can carry pathogens from patient to patient. In 1 study, stethoscopes were as likely to be contaminated after use with methicillin-resistant Staphylococcus aureus–positive patients as the provider’s hands. Furthermore, like hands, stethoscopes can be effectively decolonized with alcohol. However, although hand hygiene rates have been extensively studied, and hand hygiene has been linked to reductions in nosocomial infection, stethoscope hygiene is less well studied and emphasized less by guidelines. Several surveys have documented low self-reported compliance with stethoscope hygiene. Of 150 healthcare workers, 48% reported stethoscope hygiene between daily and weekly, 37% did stethoscope hygiene monthly, and 7% did stethoscope hygiene annually or never. Of 1401 doctors asked about their stethoscope hygiene beliefs and practices, 76% believed that stethoscopes could transmit infection, but only 24% reported cleaning their scopes regularly. Moreover, of 308 students, 22% had never done stethoscope hygiene, and <4% did it consistently. However, we were unable to find any data on observed rates of stethoscope hygiene. Thus, we observed student and trainee physician stethoscope hygiene performance during hospital medicine rotations as part of the baseline data-collection phase of a quality-improvement effort linked to hand hygiene efforts.

Tissue Isn't the Issue

A 43-year-old man with a history of asplenia, hepatitis C, and nephrolithiasis reported right-flank pain. He described severe, sharp pain that came in waves and radiated to the right groin, associated with nausea and nonbloody emesis. He noted “pink urine” but no dysuria. He had 4prior similar episodes during which he had passed kidney stones, although stone analysis had never been performed. He denied having fevers or chills. The patient had been involved in a remote motor vehicle accident complicated by splenic laceration, for which he underwent splenectomy. He was appropriately immunized. The patient also suffered from bipolar affective disorder and untreated chronic hepatitis C infection with no evidence of cirrhosis. He smoked one pack of tobacco per day for the last 10 years and reported distant alcohol and methamphetamine use.

The Authors Reply, “What Can Be Done to Maintain Positive Patient Experience and Improve Residents’ Satisfaction?” and “Standardized Attending Rounds to Improve the Patient Experience: A Pragmatic Cluster Randomized Controlled Trial”

We thank Talrai et al. for their comments in response to our randomized controlled trial evaluating the impact of standardized rounds on patient, attending, and trainee satisfaction. We agree that many factors beyond rounding structure contribute to resident satisfaction, including those highlighted by the authors, and would enthusiastically welcome additional research in this realm.

What's the Purpose of Rounds? A Qualitative Study Examining the Perceptions of Faculty and Students

BACKGROUND: Rounds are a critical activity on any inpatient service, but there is little literature describing the purpose of rounds from the perspective of faculty and trainees in teaching hospitals. OBJECTIVE: To evaluate and compare the perceptions of pediatric and internal medicine attendings and medical students regarding the purpose of inpatient attending rounds. METHODS: The authors conducted 10 semistructured focus groups with attendings and medical students in the spring of 2014 at 4 teaching hospitals. The protocol was approved by the institutional review boards at all institutions. The authors employed a grounded theory approach to data collection and analysis, and data were analyzed by using the constant‐comparative method. Two transcripts were read and coded independently by 2 authors to generate themes. RESULTS: Forty‐eight attendings and 31 medical students participated in the focus groups. We categorized 218 comments into 4 themes comprised of 16 codes representing what attendings and medical students believed to be the purpose of rounds. These themes included communication, medical education, patient care, and assessment. CONCLUSIONS: Our results highlight that rounds serve 4 purposes, including communication, medical education, patient care, and assessment. Importantly, both attendings and students agree on what they perceive to be the many purposes of rounds. Despite this, a disconnect appears to exist between what people believe are the purposes of rounds and what is happening during rounds.

Thinking Outside the Checkbox

A 34-year-old, previously healthy Japanese man developed a dry cough. He did not have dyspnea, nasal discharge, sore throat, facial pain, nasal congestion, or postnasal drip. His symptoms persisted despite several courses of antibiotics (from different physicians), including clarithromycin, minocycline, and levofl oxacin. A chest x-ray after 2 months of symptoms and a noncontrast chest computed tomography (CT) after 4 months of symptoms were normal, and bacterial and mycobacterial sputum cultures were sterile. Treatment with salmeterol and fl uticasone was ineffective.