Julius Yang

Sustained effectiveness of a primary-team-based rapid response system.

Objective:Laws and regulations require many hospitals to implement rapid-response systems. However, the optimal resource intensity for such systems is unknown. We sought to determine whether a rapid-response system that relied on a patient’s usual care providers, not a critical-care–trained rapid-response team, would improve patient outcomes. Design, Setting, and PatientsAn interrupted time-series analysis of over a 59-month period. Setting:Urban, academic hospital. Patients:One hundred seven-one thousand, three hundred forty-one consecutive adult admissions. Intervention:In the intervention period, patients were monitored for predefined, standardized, acute, vital-sign abnormalities or marked nursing concern. If these criteria were met, a team consisting of the patient’s existing care providers was assembled. Measurements and Main Results:The unadjusted risk of unexpected mortality was 72% lower (95% confidence interval 55%–83%) in the intervention period (absolute risk: 0.02% vs. 0.09%, p < .0001). The unadjusted in-hospital mortality rate was not significantly lower (1.9% vs. 2.1%, p = .07). After adjustment for age, gender, race, season of admission, case mix, Charlson Comorbidity Index, and intensive care unit bed capacity, the intervention period was associated with an 80% reduction (95% confidence interval 63%–89%, p < .0001) in the odds of unexpected death, but no significant change in overall mortality [odds ratio 0.91 (95% confidence interval 0.82–1.02), p = .09]. Analyses that also adjusted for secular time trends confirmed these findings (relative risk reduction for unexpected mortality at end of intervention period: 65%, p = .0001; for in-hospital mortality, relative risk reduction = 5%, p = .2). Conclusions:A primary-team–based implementation of a rapid response system was independently associated with reduced unexpected mortality. This system relied on the patient’s usual care providers, not an intensive care unit based rapid response team, and may offer a more cost-effective approach to rapid response systems, particularly for systems with limited intensivist availability.

Patient care transitions from the emergency department to the medicine ward: evaluation of a standardized electronic signout tool

OBJECTIVE To evaluate the impact of a new electronic handoff tool for emergency department to medicine ward patient transfers over a 1-year period. DESIGN Prospective mixed-methods analysis of data submitted by medicine residents following admitting shifts before and after eSignout implementation. SETTING University-based, tertiary-care hospital. PARTICIPANTS Internal medicine resident physicians admitting patients from the emergency department. INTERVENTION An electronic handoff tool (eSignout) utilizing automated paging communication and responsibility acceptance without mandatory verbal communication between emergency department and medicine ward providers. MAIN OUTCOME MEASURES (i) Incidence of reported near misses/adverse events, (ii) communication of key clinical information and quality of verbal communication and (iii) characterization of near misses/adverse events. RESULTS Seventy-eight of 80 surveys (98%) and 1058 of 1388 surveys (76%) were completed before and after eSignout implementation. Compared with pre-intervention, residents in the post-intervention period reported similar number of shifts with a near miss/adverse event (10.3 vs. 7.8%; P = 0.27), similar communication of key clinical information, and improved verbal signout quality, when it occurred. Compared with the former process requiring mandatory verbal communication, 93% believed the eSignout was more efficient and 61% preferred the eSignout. Patient safety issues related to perceived sufficiency/accuracy of diagnosis, treatment or disposition, and information quality. CONCLUSIONS The eSignout was perceived as more efficient and preferred over the mandatory verbal signout process. Rates of reported adverse events were similar before and after the intervention. Our experience suggests electronic platforms with optional verbal communication can be used to standardize and improve the perceived efficiency of patient handoffs.

Effect of a Systems Intervention on the Quality and Safety of Patient Handoffs in an Internal Medicine Residency Program

ABSTRACTBACKGROUNDPoor quality handoffs have been identified as a major patient safety issue.In residency programs, problematic handoffs may be an unintended consequence of duty-hour restrictions, and key data are frequently omitted from written handoffs because of the lack of standardization of content.OBJECTIVEDetermine whether an intervention that facilitates face-to-face communication supported by an electronic template improves the quality and safety of handoffs.DESIGNBefore-after trial.PARTICIPANTSThirty-nine interns providing nighttime coverage over 132 intern shifts, representing ∼9,200 handoffs.INTERVENTIONSTwo interventions were implemented serially—an alteration of the shift model to facilitate face-to-face verbal communication between the primary and nighttime covering physicians and an electronic template for the day-to-night handoff.MEASUREMENTSOverall satisfaction and handoff quality were measured using a survey tool administered at the end of each intern shift. Written handoff quality, specifically the documentation of key components, was also assessed before and after the template intervention by study investigators. Interns used the survey tool to report patient safety events related to poor quality handoffs, which were validated by study investigators.RESULTSIn adjusted analyses comparing intern cohorts with similar levels of training, overall satisfaction with the new handoff processes improved significantly (p < 0.001) post intervention. Verbal handoff quality (4/10 measures) and written handoff quality (5/6 measures) also improved significantly. Study investigators also found significant improvement in documentation of key components in the written handoff. Interns reported significantly fewer reported data omissions (p = 0.001) and a non-significant reduction in near misses (p = 0.056), but no significant difference in adverse events (p = 0.41) post intervention.CONCLUSIONSRedesign of shift models common in residency programs to minimize the number of handoffs and facilitate face-to-face communication, along with implementation of electronic handoff templates, improves the quality of handoffs in a learning environment.

A comprehensive new curriculum to teach and assess resident knowledge and diagnostic evaluation of musculoskeletal complaints

Musculoskeletal complaints are a common reason for primary care visits; however, many essential physical examination, diagnostic and treatment skills are not adequately taught. The objectives of the study were to create and implement a comprehensive clinical skills teaching model, and to evaluate its effects on residents’ knowledge and diagnostic skills. A comparison of cohorts who participated and did not participate in a musculoskeletal curriculum was undertaken. Second and third year medical residents participated in comprehensive curricula to teach and evaluate musculoskeletal skills. Sixty-seven attended the first of three lectures on the painful shoulder; 61 attended all three lectures and completed pre- and post-self assessment forms and tests. Three months later 26 of these residents and 10 controls participated in an OSCE examination. Thirty-nine medical residents attended the first of three lectures on the painful knee; 32 attended all three lectures and completed pre- and post-self assessment forms and tests. Seven of these residents and eight controls participated in an OSCE examination three months later. Both the shoulder and knee curricula were associated with a significant improvement in test scores (p < 0.0001), in self-assessment of physical examination, diagnostic and procedural skills (p < 0.0001), and in OSCE results (p < 0.005). It was concluded that the skills required for the diagnosis and treatment of common musculoskeletal complaints can be effectively taught and assessed using inexpensive and simple methods.

Bridging the Gap: A Framework and Strategies for Integrating the Quality and Safety Mission of Teaching Hospitals and Graduate Medical Education.

Integrating the quality and safety mission of teaching hospitals and graduate medical education (GME) is a necessary step to provide the next generation of physicians with the knowledge, skills, and attitudes they need to participate in health system improvement. Although many teaching hospital and health system leaders have made substantial efforts to improve the quality of patient care, few have fully included residents and fellows, who deliver a large portion of that care, in their efforts. Despite expectations related to the engagement of these trainees in health care quality improvement and patient safety outlined by the Accreditation Council for Graduate Medical Education in the Clinical Learning Environment Review program, a structure for approaching this integration has not been described. In this article, the authors present a framework that they hope will assist teaching hospitals in integrating residents and fellows into their quality and safety efforts and in fostering a positive clinical learning environment for education and patient care. The authors define the six essential elements of this framework—organizational culture, teaching hospital–GME alignment, infrastructure, curricular resources, faculty development, and interprofessional collaboration. They then describe the organizational characteristics required for each element and offer concrete strategies to achieve integration. This framework is meant to be a starting point for the development of robust national models of infrastructure, alignment, and collaboration between GME and health care quality and safety leaders at teaching hospitals.

A standardized, bundled approach to providing geriatric-focused acute care.

To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high‐risk medications.