Dennis M. Manning

Gaining efficiency and satisfaction in the handoff process

BACKGROUND Handoffs, or transfers of patient care responsibility, occur frequently on hospitalist teams. The reliability and efficiency of the handoff process is a national and local concern. Most studies in the literature regard physicians-in-training. We studied the morning handoff process of hospitalist teams comprised of staff physicians and nurse practitioner and/or physician assistants. METHODS An improvement team observed morning handoffs. Four problems were identified: unpredictable start and finish times, inefficiency, poor environment (hallway noise and distracting in-room conversations), and poor communication. The team restructured the process and observed post-intervention behavior at 15 and 90 days. A participant-provider survey was conducted before and after the intervention regarding wasted time, total time-in-report, and satisfaction with the process. RESULTS Pre-intervention 60.5% of providers (23/38) believed morning handoff was performed in a timely fashion compared to 100% (15/15) post-intervention (P = 0.005). Average time spent in morning report was 11 minutes, compared to 5 minutes after the intervention (P < 0.0028). Pre-intervention 6.5 minutes were believed wasteful, compared to 0.5 minutes post-intervention (P < 0.0001). CONCLUSIONS This study identifies deficiencies in the handoff process that were addressed by enhancing the physical environment (smaller room, noise reduction, closed door), assigned seating (visual cues by table tent cards), non-clinicians providing printed materials, standardization of written updates, team times (consistent & precise daily time for each team report), culture change including deference of attention to team receiving report with opportunity for questions, and minimization of side conversations. This intervention package resulted in an improvement in satisfaction and timeliness of clinicians involved.

Information Transfer at Hospital Discharge: A Systematic Review.

Supplemental digital content is available in the text. Background Prompt, complete, and accurate information transfer at the time of discharge between hospital-based and primary care providers (PCPs) is needed for the provision of safe and effective care. Purpose of the Study To evaluate timeliness, quality, and interventions to improve timeliness and quality of hospital discharge summaries. Data Sources PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, and Scopus database published in English between January 2007 and February 2014 were searched. We also hand-searched bibliographies of relevant articles. Study Selection Observational studies investigating transfer of information at hospital discharge (n = 7) and controlled studies evaluating interventions to improve timeliness and quality of discharge information (n = 12) were included. Data Extraction We extracted data on availability, timeliness, and content of hospital discharge summaries and on the effectiveness of interventions targeting discharge summaries. Results of studies are presented narratively and using descriptive statistics. Data Synthesis Across the studies, discharge summaries were completed within 48 hours in a median of 67% and were available to PCPs within 48 hours only 55% of the time. Most of the time, discharge summaries included demographics, primary diagnosis, hospital course, and discharge instructions. However, information was limited to pending test results (25%), diagnostic tests performed (60%), and postdischarge medications (78%). In 6 interventional studies, implementation of electronic discharge summaries was associated with improvement in timeliness but not quality. Conclusions Delayed or insufficient transfer of discharge information between hospital-based providers and PCPs remains common. Creation of electronic discharge summaries seems to improve timeliness and availability but does not consistently improve quality.

Learning from every death

The concepts of peer review and the venerable morbidity and mortality conference are familiar improvement approaches to health care providers. These 2 entities are typically provider or patient centric and are not typically extended within hospitals and health systems as a tool for organizational learning for care process or system failures. Out of a desire to deepen our understanding and accelerate learning about quality and safety opportunities in our hospitals, Mayo Clinic embarked on journey to analyze the stories of all patient deaths. This paper illuminates the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System (Rochester, MN).

Home alone: Assessing mobility independence before discharge

Hospitalists are often confronted with discharge planning responsibility and decisions for elderly patients who live alone. The absence of an in-home helper (spouse, partner, or care-giver) reduces the margin of safety and resilience to any new debility. Research has documented that during hospital stays elderly patients tend to become deconditioned, even if there is no new specific neurologic or motor deficit. In the patient whose pre-hospital mobility independence is not robust, and perhaps marginally compensated, inpatient stays for any diagnosis may result in critical decrements in mobility independence. The present study is an effort to design a bedside tool for the hospitalist by which to discern, or screen, for such debility. The tool is a hierarchical performance test we named I-MOVE (Independent Mobility Validation Examination). It is a quick series of bedside mobility requests to demonstrate capability of fundamental movements critical to independent living. We describe manner in which I-MOVE can be performed. Moreover, we describe the face validity and the high interrater reliability (> 0.90 intra-class correlation coefficient) of two RNs who independently administered and scored I-MOVE for 41 patients on a General Medical Care Unit. Although not yet studied in correlation with outcomes, nor with validated mobility assessment tools, we believe I-MOVE can serve as a useful extension of the nurses assessment, or the Hospitalists physical examination. Discerning the continued capability of mobility independence is a desirable, on-going insight for discharge planning of the elderly patient who resides alone.

Risk Factors for Excessive Anticoagulation Among Hospitalized Adults Receiving Warfarin Therapy Using a Pharmacist-Managed Dosing Protocol

To identify specific risk factors for excessive anticoagulation, defined as an international normalized ratio (INR) higher than 5, in hospitalized adults receiving warfarin therapy using a pharmacist‐managed dosing protocol.

Going Beyond Administrative Data: Retrospective Evaluation of an Algorithm Using the Electronic Health Record to Help Identify Bleeding Events Among Hospitalized Medical Patients on Warfarin

To reliably assess quality, a standardized electronic approach is needed to identify bleeding events. The study aims were the following: (1) clinically validate an electronic health record–based algorithm for bleeding and (2) assess interrater results to determine validity and reliability. Data were analyzed before and after implementation of a pharmacist-managed warfarin protocol. Bleeding was based on ≥2 of 3 criteria: (1) diagnosis indicating bleeding, (2) lab value decrease suggesting bleeding, and (3) blood product use. All suspected bleeds (234) and a sample (58) not meeting criteria were compared with clinical review. There were 234 bleeding cases identified electronically. Reviewer agreement was 78.2% (κ = 0.565). Algorithm sensitivity was 93.9% and positive predictive value 46.2%. Algorithm identification was least accurate for those with only 2 criteria but good for those with all criteria. This study supports using multiple electronic criteria to identify bleeding events. However, cases having exactly 2 criteria may require manual review for validation.

ACEi/ARB for systolic heart failure: Closing the quality gap with a sustainable intervention at an academic medical center

BACKGROUND National guidelines recommend angiotensin converting enzyme inhibitor (ACEi) or angiotensinogen receptor blocker (ARB) therapy for patients with left ventricular systolic dysfunction (LVSD), including those with symptomatic heart failure (HF). However, guideline adherence has not been optimal. The goal of this quality improvement project is to devise and implement a sustainable care-delivery model in a 920-bed academic hospital center that would improve ACEi/ARB adherence before hospital discharge. METHODS The Model of intervention is: (1) a computer-based daily screening program; (2) inpatient pharmacist e-flag message; and (3) alerts for inpatient care teams. Its operating algorithm: If eligible adult HF/LVSD inpatients are not on ACEi or ARB nor documentation of contraindications, a flag alert is generated; deficiency is confirmed by a pharmacist and conveyed to the patient-care teams; if alert is acted on and care brought into adherence, the screening program would not re-flag the same patients the succeeding day; if not, the patients would be re-flagged daily until reaching adherence. We compared ACEi/ARB adherence before, during, and after the intervention. RESULTS Baseline performance (percentage of eligible HF/LVSD patients receiving ACEi/ARB) was 87.5%. After implementation of the Model the ACEi/ARB adherence rate at the time of hospital discharge rose to 96.7% (P < 0.002) and was sustained for 21 months without needing additional personnel. CONCLUSIONS A carefully designed, computer-based care-delivery model is highly efficient and sustainable for enhancing ACEi/ARB adherence.

Reflective Practice: A Tool for Readmission Reduction.

Factors intrinsic to local practice, but not captured by the medical record, contribute to readmissions. Frontline providers familiar with their practice systems can identify these. The objective was to decrease 30-day hospital readmissions. The intervention involved retrospective review by hospitalists of their own patients’ readmissions, using reflective practice guided by a chart review tool. Subjects were patients discharged by hospitalists and readmitted to a tertiary care academic medical center. Hospitalists reviewed 193 readmissions of 170 patients. Factors contributing to readmission were grouped under patient characteristics, operational factors, and care transition. After reflection, physicians scheduled earlier follow-up appointments while nurse practitioners and physician assistants improved discharge instructions. Readmissions decreased during the review period, and the decrease sustained for one year after the review period. Hospitalists reflected on and identified local practice factors that contributed to their own patients’ 30-day readmissions. Reflective practice may be an effective strategy to decrease hospital readmissions.

Decline in ACEI/ARB Prescribing as Heart Failure Core Metrics Improve During Computer-Based Clinical Decision Support.

Computer-based clinical decision-support systems are effective interventions to improve compliance with guidelines and quality measures. However, understanding of their long-term impact, including unintended consequences, is limited. The authors assessed the clinical impact of the sequential implementation of 2 such systems to improve the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) in inpatients with heart failure. Compliance with the core measure improved from 91.0% at baseline to 93.6% with the Pharmacy Care (P-Care) Rule and to 96.4% with the Centricity-Blaze (CE-Blaze) Rule. At the same time, prescriptions for ACEIs/ARBs documented in the hospital discharge summary decreased from 83.2% at baseline to 75.8% with the P-Care rule and to 64.1% with the CE-Blaze Rule. The inpatient mortality rate and the 30-day readmission rate did not change significantly. Better documentation of contraindications in the electronic medical record seems to account for the core measure improvement, even as ACEI/ARB therapy has unexpectedly declined.

Psychiatric Manifestations of Hyperammonemic Encephalopathy Following Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) is considered to be the optimal surgical treatment in the morbidly obese patient and the most common weight loss procedure in the United States. In this case report we describe the life threatening complication of hyperammonemic encephalopathy and its psychiatric presentation in a gastric bypass patient. Hyperammonemic encephalopathy is an extremely uncommon syndrome but also a severe complication of RYGB with only a small number of case reports and high reports of mortality. Early and accurate diagnosis can be easily missed, leading to even further increased morbidity and mortality. Hyperammonemic encephalopathy related to RYGB is a syndrome characterized by life threatening metabolic and laboratory disturbances and associated changes in mental status. Our patient presented with decreased oral intake, malnutrition, weight loss, progressive confusion, markedly diminished memory, and gait instability to an inpatient medical hospitalization. She was found to have the following metabolic derangements including elevated ammonia and orotic acid, deceased ceruloplasmin and albumin, as well as deficiencies in zinc, copper, and selenium. This led to a mental status decline including the inability to respond to verbal stimuli or speak. She was treated with lactulose, rifaximin, levocarnitine, vitamin supplementation, and her ammonia levels began to decline. A naso-jejunal tube was endoscopically placed for enteral feedings, and her mental status began to improve. Over the next two weeks she gradually improved with normalizing of her mental status as evidenced by a Montreal Cognitive Assessment score of 27 out of 30 on day of discharge.