James D. Bramble

Team training can improve operating room performance

BACKGROUND This study was conducted to determine if team training using a federally sponsored team training program improves operating room (OR) performance and culture. METHODS The TeamSTEPPS program, a team training program designed and tested for health care applications, was provided to the OR staff. The training occurred over 2 months to all members of the OR team, including scrub technicians, nurses, certified registered nurse anesthetists, anesthesiologists, surgeons, and all anesthesiology and surgical resident staff. RESULTS After 9 months, there was a significant improvement in the OR staff team work (score 53.2 to 62.7; P < .05) and OR communications (score 47. 5 to 62.7; P < .05). There was significant improvement in OR first case starts (69% to 81%), Surgical Quality Improvement Program measures (antibiotic administration, 78% to 97% [P < .05]; venous thromboembolism administration, 74% to 91% [P < .05]; and beta blocker administration, 19.7% to 100%; P < .05) and patient satisfaction (willingness to recommend, 77% to 89.3% [P < .05]). NSQIP measured overall surgical morbidity and mortality, which were both significantly improved (mortality, 2.7% to 1% [P < .05]; morbidity, 20.2% to 11.0% [P < .05]), indicating a significant change in the overall OR culture. A year later, the data showed that factors linked to regulatory requirements, such as Surgical Quality Improvement Program measures linked to the time out remained improved while first case on time starts decreased (81% to 69%; P < .05), patient willingness to recommend decreased (89.3% to 80.8%; P < .05), surgical mortality increased (1% to 1.5%; P < .05), and surgical morbidity increased (11% to 13%; P < .05) reflecting a degree of culture deterioration which has persisted. CONCLUSION These data confirm that team training improves OR performance, but continued team training is required to provide sustained improved OR culture.

The relationship between physician practice characteristics and physician adoption of electronic health records

BACKGROUND Health information technologies, such as electronic health records (EHRs), can potentially improve patient safety in our health care system. The potential advantages include increased quality and more efficiency in the care of patients. Adoption of EHRs has been slow despite these advantages and a national call for EHR implementation. PURPOSES This article explores factors associated with the adoption of EHR systems using organizational theory to derive hypotheses as to why physicians would adopt EHRs. METHODOLOGY/APPROACH : A survey was administered to all office-based physicians in Nebraska and South Dakota using a modified Dillman technique between July and November 2007. The main outcome variable measured physician EHR adoption status at three levels: not planning to use an EHR, planning to use an EHR, and using an EHR. Factors associated with EHR status were analyzed using a multinomial logistic regression. FINDINGS Approximately 30% of physicians reported using an EHR in his or her practice. Physicians adopting EHRs were younger and had access to internal health information technologies support. In addition, working in an independent practice decreased the likelihood of physicians using and adopting EHRs. PRACTICE IMPLICATIONS This research provides further evidence of the barriers impeding EHR adoption. One such barrier includes the lack of access to internal information technology support staff versus having to outsource for technical support services. From a resource dependency perspective, barriers illustrated by this example may place undue dependencies on physicians if they pursue an EHR system. By addressing these barriers, physicians may be in a better position to adopt EHR system into his or her practice.

Patient Safety Perspectives of Providers and Nurses: The Experience of a Rural Ambulatory Care Practice Using an EHR With E‐prescribing

PURPOSE The purpose of this study was to identify and describe safety improvements and concerns indicated by providers and nurses in a rural community ambulatory care practice using an electronic health record with an e-prescribing feature (EHR with eRx). METHODS Two focus groups were conducted; 1 with providers and the other with nurses. Participants responded to questions and discussed their perceptions of safety improvements and concerns with use of an EHR with eRx. Transcripts were analyzed using sequential and continuous analytic methods. FINDINGS Three themes centered on efficiency and patient safety emerged from data analysis: (1) EHR with eRx adoption has led to new improvements and concerns for patient safety, (2) the EHR with eRx has affected efficiency in the clinic, and (3) EHR with eRx adoption has led to workarounds. CONCLUSIONS Concerns remain among providers and nurses regarding the use of EHR with eRx applications, although concerns differed between groups. Therefore, When EHR improvements are planned, it is important to consider the differing needs of the professionals who deliver care.

Description and evaluation of an interprofessional patient safety course for health professions and related sciences students

Objectives: The structure, process, and outcomes associated with planning, developing, and offering an interprofessional course on the foundations of patient safety is described, including how organizational, structural, cultural, and attitudinal barriers were overcome. Methods: Seventeen faculty members from 7 colleges and schools and medical center participated-from the fields of decision sciences and systems, dentistry, medicine, law, nursing, occupational therapy, pharmacy, physical therapy, social work, health care administration, and outcomes management in health systems. Student assessment included theme analysis of open-ended questions, descriptive analysis of multiple- response option questionnaires, and criterion-based assessment of student performance on case studies. Triangulation of student comments, final course evaluation, and student performance evaluations were performed to learn overarching themes of student experience with the course. Results: The students learned a different way of thinking, found the instructional design and active learning methods useful to learning, and felt prepared to solve problems in the future. Students believed that the content was an essential core knowledge for all health professionals (87%) and should be required for all health professions students (78%). Students achieved an application level of learning (77%) within the cognitive domain and the valuing level within the affective domain. Students agree (96%) that they can define and apply the basic principles and tenets of patient safety, including identification of tools needed to work effectively within the health system and to improve safety and strongly agree (100%) that they value patient safety as a professional practice framework. Conclusion: The universitywide implementation case may offer important lessons to others nationally in health care education.

Critical Care Transportation by Paramedics: A Cross-sectional Survey

OBJECTIVE The purpose of this study was to gather data from paramedics practicing in the critical care transport setting to guide development of the education, training, and clinical practices for certification as a critical care paramedic. METHODS A paper survey of 1991 randomly selected nationally registered (NREMT) paramedics was conducted. Nine paramedics with residences in small US Pacific Island territories were not included in the survey. RESULTS We received 610 responses (30.6%). Respondents that stated that they provided critical care transport services reported using pediatric skills and equipment the most and intracranial pressure monitoring the least. Paramedics served as the primary provider for pediatric patients (72.5%), 12-lead electrocardiogram (66.3%), intravenous infusion pump (76.7%), mechanical ventilator (66.9%), central line management (63.1%), and chest tube management (63.3%). Paramedics served in a team member capacity most often with neonatal isolette (71.8%), intra-aortic balloon pump (79.2%), and ICP monitoring (64.9%). The majority provided ground critical care transport (249) compared to 44 rotor-wing and 6 fixed-wing. Sixteen respondents reported serving as primary providers on combinations of ground, rotor-, and fixed-wing services. CONCLUSIONS Paramedics reported being the primary provider on the critical care transport team and performing skills while using equipment and administering medications that exceeded their education and training as paramedic and, at times, without the benefit of any additional education or training. National appreciation of this reality should spur development of standardized education, licensing or certification, and continuing education to prepare paramedics for their role as critical care medical providers.

Examining barriers to health information technology adoption

Results of a previous study showed that use of health information technology (HIT) significantly reduced potential medication prescribing errors. However, the results also revealed a less than 100% rate of HIT adoption by primary care physicians. The current study reports on personal interviews with participating physicians that explored the barriers they faced when attempting to fully adopt a particular HIT. Content analysis of qualitative interviews revealed three barrier themes: time, technology, and environment. Interviews also revealed two other areas of concern; specifically, the compatibility of the HIT with the physicians patient mix and the physicians own attitude toward the use of HIT. A theoretical model of technology acceptance and use is used to discuss and further explain the data derived from the physician interviews. With a better understanding of these issues, health care administrators can develop successful strategies for adoption of HIT across their health care organizations.

Privacy, security and the national health information network: A mixed methods case study of state-level stakeholder awareness

This mixed methods multiple case study examines the knowledge, understanding, and awareness of 25 health board/facility oversight managers and 20 health professional association directors about privacy and security issues important to achieving health information exchange (HIE) in the state of Nebraska. Within case analyses revealed that health board/facility oversight managers were unaware of key elements of the federal agenda; their concerns about privacy encompassed broad definitions both of what constituted a “health record” and “regulations centeredness.” Alternatively, health professional association leaders were keenly aware of national initiatives. Despite concerns about HIE, they supported information exchange believing that patient care quality and safety would improve. Cross-case analyses revealed a perceptual disconnect between board/facility oversight managers and professional association leaders; however, both favored HIE. Understanding state-level stakeholder perceptions helps us further understand our progress toward achieving the national health information interoperability goal. There is an ongoing need to assure adequate patient privacy protection. Licensure and facility boards at the state level are likely to have a major role in the assurance of patient protections through facility oversight and provider behavior. The need for these boards to take an active role in oversight of patient rights and protections is imminent. Similarly, professional associations are the major vehicles for post-graduate education of practicing health professionals. Their engagement is essential to maintaining health professions knowledge. States will need to understand and engage both of these key stakeholders to make substantial progress in moving the HIE agenda forward.

Resource use in treating alcohol- and drug-related diagnoses.

OBJECTIVE: This study examined the variations in hospital resource use in the treatment of alcohol and drug diagnoses. Specifically, the study tested 2 hypotheses: 1) patients treated in teaching hospitals will have shorter lengths of stay and lower hospital charges than patients treated in nonteaching hospitals; and 2) patients treated in hospitals with more experience treating these conditions will have shorter lengths of stay and lower hospital charges.DESIGN: A retrospective cross-sectional study design used data from the 1996 Health Care Utilization Project to test the proposed hypotheses.PATIENTS/PARTICIPANTS: The population for this study consisted of patients over 18 years old with an acute alcohol-or drug-related discharge diagnostic related group code.MEASUREMENT AND MAIN RESULTS: The variables of interest were teaching hospital status, as defined by the Council of Teaching Hospitals, and hospital experience, defined as the ratio of alcohol- and drug-related diagnoses to the hospital’s total admissions. Measures of hospital resource use included the patient’s length of stay and total hospital charges. Patients treated at hospitals with relatively more experience in treating alcohol- and drug-related diagnoses had 10.3% (

Interobserver reliability in the interpretation of diagnostic lumbar MRI and nuclear imaging

321) lower total charges (P=.017).CONCLUSIONS: Similar to research for high-volume surgical hospitals, these findings confirm that hospitals that have greater experience with complex medical conditions such as alcohol and drug intoxication and withdrawal may be more efficient. This important finding provides a rationale for further exploration of the key factors associated with higher quality and more efficient care for complex medical conditions.