Lisa M. McElroy

The extent and predictors of waiting time geographic disparity in kidney transplantation in the United States

Background Waiting time to deceased donor kidney transplant varies greatly across the United States. This variation violates the final rule, a federal mandate, which demands geographic equity in organ allocation for transplantation. Methods Retrospective analysis of the United States Renal Data System and United Network for Organ Sharing database from 2000 to 2009. Median waiting time was calculated for each of the 58 donor service areas (DSA) in the United States. Multivariate regression was performed to identify DSA predictors for long waiting times to kidney transplantation. Results The median waiting time varied between the 58 DSAs from 0.61 to 4.57 years, ranging from 0.59 to 5.17 years for standard criteria donor kidneys and 0.41 to 4.69 years for expanded criteria donor kidneys. The disparity in waiting time between the DSAs grew from 3.26 years (range, 0.41–3.67) in 2000 to 4.72 years (range, 0.50–5.22) in 2009. In DSAs with longer waiting times, there were significantly more patients suffering from end-stage renal disease and more patients listed for kidney transplant, lower kidney procurement rates, and higher transplant center competition. Patients were more likely black, sensitized, with lower educational attainment and less likely to waitlist outside of their DSA of residence. Donor organs used in DSAs with long waiting times were more likely hepatitis C positive and had a higher kidney donor profile index. Graft and patient survival at 5 years was worse for deceased donor kidney transplant, but rates for living donor kidney transplant were higher. Conclusion Our analysis demonstrates significant and worsening geographic disparity in waiting time for kidney transplant across the DSAs. Increase in living donor kidney transplant and use of marginal organs has not mitigated the disparity. Changes to the kidney allocation system might be required to resolve this extensive geographic disparity in kidney allocation.

Staging chest computed tomography and positron emission tomography in patients with pancreatic adenocarcinoma: utility or futility?

OBJECTIVES This study was conducted to determine if routine staging chest computed tomography (CT) or positron emission tomography (PET) scanning alters the clinical management of patients with newly diagnosed pancreatic adenocarcinoma. METHODS All new pancreas cancers seen in medical oncology, radiation oncology and surgery from 1 June 2008 to 20 June 2010 were retrospectively reviewed. Patients with metastatic disease on chest CT or PET, that had been unsuspected on initial imaging, were identified. RESULTS Pancreatic adenocarcinoma was present in 247 consecutive patients. Abdominal CT demonstrated metastases in 108 (44%) and localized disease in 139 (56%) patients. Chest CT and PET were not performed in 15 (11%) of these 139 patients. In the remaining 124 patients, CT imaging suggested resectable disease in 46, borderline resectable disease in 52 and locally advanced disease in 26 patients. Chest CT demonstrated an unsuspected lymphoma in one patient with borderline resectable disease and PET identified extrapancreatic disease in two patients with locally advanced disease. Chest CT and PET added no information in 121 (98%) of the 124 patients. CONCLUSIONS The addition of chest CT and PET to high-quality abdominal CT is of little clinical utility; additional sites of metastasis are rarely found. As the quality of abdominal imaging declines, the yield from other imaging modalities will increase. Dedicated pancreas-specific abdominal CT remains the cornerstone of initial staging in suspected or biopsy-proven pancreatic cancer.

Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study

BACKGROUND Operating room (OR) to the intensive care unit (ICU) handoffs are known sources of medical error, yet little is known about the relationship between process failures and patient harm. METHODS Interviews were conducted with clinicians involved in the OR-to-ICU handoff to characterize the relationship between handoff process failures and patient harm. Qualitative analysis was used to inductively identify key themes. RESULTS A total of 38 interviews were conducted. Dominant themes included early communication from the OR to the ICU, team member participation in the handoff, and relationships between clinicians; clinician perspectives varied depending substantially on role within the team. CONCLUSIONS The findings suggest that ambiguous roles and conflicting expectations of team members during the OR-to-ICU handoff can increase risk of patient harm. Future studies should investigate early postoperative ICU care as outcome markers of handoff quality and the effect of interprofessional education on clinician adherence to interventions.

The role of technology in clinician-to-clinician communication

Incomplete, fragmented and poorly organised communications contribute to more than half the errors that lead to adverse and sentinel events. Meanwhile, communication software and devices with expanding capabilities are rapidly proliferating and being introduced into the healthcare setting. Clinicians face a large communication burden, which has been exacerbated by the additional challenge of selecting a mode of communication. In addition to specific communication devices, some hospitals have implemented advanced technological systems to assist with communication. However, few studies have provided empirical evidence of the specific advantages and disadvantages of the different devices used for communication. Given the increasing quantities of information transmitted to and by clinicians, evaluations of how communication methods and devices can improve the quality, safety and outcomes of healthcare are needed.

A meta-analysis of complications following deceased donor liver transplant

BACKGROUND Liver transplantation is a complex surgery associated with high rates of postoperative complications. While national outcomes data are available, national rates of most complications are unknown. DATA SOURCES A systematic review of the literature reporting rates of postoperative complications between 2002 and 2012 was performed. A cohort of 29,227 deceased donor liver transplant recipients from 74 studies was used to calculate pooled incidences for 17 major postoperative complications. CONCLUSIONS This is the first comprehensive review of postoperative complications after liver transplantation and can serve as a guide for transplant and nontransplant clinicians. Efforts to collect national data on complications, such as through the National Surgical Quality Improvement Program, would improve the ability to provide patients with informed consent, serve as a tool for individual center performance monitoring, and provide a central source against which to measure interventions aimed at improving patient care.

Observation for assessment of clinician performance: a narrative review

Background Video recorded and in-person observations are methods of quality assessment and monitoring that have been employed in high risk industries. In the medical field, observations have been used to evaluate the quality and safety of various clinical processes. This review summarises studies utilising video recorded or in-person observations for assessing clinician performance in medicine and surgery. Methods A search of MEDLINE (PubMed) was conducted using a combination of medical subject headings (MeSH) terms. Articles were included if they described the use of in-person or video recorded observations to assess clinician practices in three categories: (1) teamwork and communication between clinicians; (2) errors and weaknesses in practice; and (3) compliance and adherence to interventions or guidelines. Results The initial search criteria returned 3215 studies, 223 of which were identified for full text review. A total of 69 studies were included in the final set of literature. Observations were most commonly used in data dense and high risk environments, such as the emergency department or operating room. The most common use was for assessing teamwork and communication factors. Conclusions Observations are useful for the improvement of healthcare delivery through the identification of clinician lapses and weaknesses that affect quality and safety. Limitations of observations include the Hawthorne effect and the necessity of trained observers to capture and analyse the notes or videos. The comprehensive, subtle and sensitive information observations provided can supplement traditional quality assessment methods and inform targeted interventions to improve patient safety and the quality of care.

The Effect of the Statewide Sharing Variance on Geographic Disparity in Kidney Transplantation in the United States

BACKGROUND AND OBJECTIVES The Statewide Sharing variance to the national kidney allocation policy allocates kidneys not used within the procuring donor service area (DSA), first within the state, before the kidneys are offered regionally and nationally. Tennessee and Florida implemented this variance. Known geographic differences exist between the 58 DSAs, in direct violation of the Final Rule stipulated by the US Department of Health and Human Services. This study examined the effect of Statewide Sharing on geographic allocation disparity over time between DSAs within Tennessee and Florida and compared them with geographic disparity between the DSAs within a state for all states with more than one DSA (California, New York, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective analysis from 1987 to 2009 was conducted using Organ Procurement and Transplant Network data. Five previously used indicators for geographic allocation disparity were applied: deceased-donor kidney transplant rates, waiting time to transplantation, cumulative dialysis time at transplantation, 5-year graft survival, and cold ischemic time. RESULTS Transplant rates, waiting time, dialysis time, and graft survival varied greatly between deceased-donor kidney recipients in DSAs in all states in 1987. After implementation of Statewide Sharing in 1992, disparity indicators decreased by 41%, 36%, 31%, and 9%, respectively, in Tennessee and by 28%, 62%, 34%, and 19%, respectively in Florida, such that the geographic allocation disparity in Tennessee and Florida almost completely disappeared. Statewide kidney allocations incurred 7.5 and 5 fewer hours of cold ischemic time in Tennessee and Florida, respectively. Geographic disparity between DSAs in all the other states worsened or improved to a lesser degree. CONCLUSIONS As sweeping changes to the kidney allocation system are being discussed to alleviate geographic disparity--changes that are untested run the risk of unintended consequences--more limited changes, such as Statewide Sharing, should be further studied and considered.

Failure mode and effects analysis: a comparison of two common risk prioritisation methods

Background Failure mode and effects analysis (FMEA) is a method of risk assessment increasingly used in healthcare over the past decade. The traditional method, however, can require substantial time and training resources. The goal of this study is to compare a simplified scoring method with the traditional scoring method to determine the degree of congruence in identifying high-risk failures. Methods An FMEA of the operating room (OR) to intensive care unit (ICU) handoff was conducted. Failures were scored and ranked using both the traditional risk priority number (RPN) and criticality-based method, and a simplified method, which designates failures as ‘high’, ‘medium’ or ‘low’ risk. The degree of congruence was determined by first identifying those failures determined to be critical by the traditional method (RPN≥300), and then calculating the per cent congruence with those failures designated critical by the simplified methods (high risk). Results In total, 79 process failures among 37 individual steps in the OR to ICU handoff process were identified. The traditional method yielded Criticality Indices (CIs) ranging from 18 to 72 and RPNs ranging from 80 to 504. The simplified method ranked 11 failures as ‘low risk’, 30 as medium risk and 22 as high risk. The traditional method yielded 24 failures with an RPN ≥300, of which 22 were identified as high risk by the simplified method (92% agreement). The top 20% of CI (≥60) included 12 failures, of which six were designated as high risk by the simplified method (50% agreement). Conclusions These results suggest that the simplified method of scoring and ranking failures identified by an FMEA can be a useful tool for healthcare organisations with limited access to FMEA expertise. However, the simplified method does not result in the same degree of discrimination in the ranking of failures offered by the traditional method.

Early Postoperative Emergency Department Care of Abdominal Transplant Recipients.

Background Research on posttransplant care has predominantly focused on predictors of readmission with little attention to emergency department (ED) visits. The goal of this study was to describe early postoperative ED care of transplant recipients. Methods A secondary database analysis of adult patients who underwent abdominal organ transplantation between January 1, 2008, and December 31, 2013, and sought ED care within 1 year after transplantation was conducted. Survival was compared using the Kaplan-Meier method with log-rank test. Cox proportional hazards regression analysis was performed to adjust for pertinent covariates Results A total of 1900 abdominal organ transplants were performed during the study period. Of these, 37% (N = 711) transplant recipients sought care in the ED (1343 total visits) with 1.89 mean ED visits per recipient. Of recipients seen in the ED, 58% received a kidney transplant and 28% received a liver transplant, with 45% of recipients presenting within the first 60 postoperative days. The most common chief complaints were gastroenterological (17%) and abnormal laboratory values or vital signs (17%). In total, 74% of recipients were readmitted and 50% of admitted patients were discharged in less than 24 hours. Transplant recipients with ED visits had lower 3-year graft (81% vs 87%; P < 0.001) and patient (89% vs 93%; P = 0.002) survival. Conclusions Transplant recipients have a high frequency of ED visits in the first posttransplantation year and high rates of subsequent hospital admission. Further investigation is needed to understand what drives recipient presentation to the ED and create care models that achieve the best outcomes.

A Pilot Study to Explore the Safety of Perioperative Postpyloric Enteral Nutrition

BACKGROUND The practice of holding enteral nutrition (EN) 8 hours prior to surgery is common. We hypothesized that it was safe to continue postpyloric EN, and we developed an institutional practice pattern to investigate our hypothesis. METHODS Our pilot study included intubated patients in the surgical intensive care unit at Froedtert Memorial Lutheran Hospital who received EN via a nasojejunal (NJ) feeding tube and underwent 1 or more surgical procedures. Demographic, illness, and injury information were collected as well as length of time to NJ placement, time to initiation of EN, EN interruptions, and complications. Additional hours of EN were calculated by totaling the number of hours a patient received EN past midnight on the day of surgery. RESULTS A total of 14 patients with mean (SD) age 44.3 (19.9) were included. Patients had a mean (SD) Injury Severity Score (ISS) of 26.1 (9.2) on admission and underwent a total of 38 operations following placement of a feeding tube. The most frequent operation performed was an orthopedic procedure (n = 17; 46.1%). The mean (SD) length of EN interruptions for a single procedure was 222.4 (206.9) minutes. Patients received an additional 11.9 (4.7) hours of EN over the course of their hospitalization and an additional 1064.9 (490) kcal/d per operation. There were no adverse events. CONCLUSION Perioperative continuation of postpyloric EN is feasible in some critically ill surgical patients and can result in additional calories provided. A multidisciplinary approach and an institutional policy can increase the likelihood of meeting nutrition goals in these patients.