Michelle C. Nguyen

Our New Reality of Public Reporting: Shame Rather Than Blame?

he number of organizations issuing reports on hosTpital and physician quality performance has increased markedly over the past decade. Differences in the measures, data sources, and scoring methodologies produce contradictory results that lead to confusion for the public, providers, and governing boards, and impair the public’s ability to make well-informed choices about health care providers [1]. This variability continues today and points to concerns about validity and the ultimate reliability of the measures used by these groups. The hospital community and surgeons as a whole support the principle of accountability through public reporting of health care performance data. However, performance data that are inappropriately collected, analyzed, and displayed may add more confusion than clarity to the health care quality question [1]. For data to be understood and for results to be comparable, publicly reported data should adhere to a set of guiding principles. With that goal in mind, the Association of American Medical Colleges (AAMC) convened a panel of experts in 2012 and 2013 to develop a set of guiding principles that can be used to evaluate quality reports. The principles were organized into three broad categories: purpose, transparency, and validity. Under the domain of purpose, the AAMC recognized that public reporting and performance measurement should occur for a variety of reasons, including consumer education, provider quality improvement, and purchaser decision making. Relative to transparency, the AAMC believed that methodologic details should be clearly discerned as they can impact both providers’ performance data and the appropriate interpretation of the data. Transparency also requires that all information necessary to understand the data be available to and interpretable by the reader. Limitations in data collection and methodology as well as relevant financial interests should always be disclosed in language that is discernable. Lastly, validity of the data must ensure that the methodology, data collection, scoring, and benchmarks produce an accurate reflection of the characteristic being measured and reflect the care being provided by the hospital or physician. These guiding principles were expanded and proposed by the AAMC to facilitate adherence and to ensure appropriate interpretation of

Mortality and readmission of outcomes after discharge from the surgical intensive care unit to long-term, acute-care hospitals

Background. Patients with prolonged hospitalizations in the surgical intensive care unit often have ongoing medical needs that require further care at long‐term, acute‐care hospitals upon discharge. Setting expectations for patients and families after protracted operative intensive care unit hospitalization is challenging, and there are limited data to guide these conversations. The purpose of this study was to determine patient survival and readmission rates after discharge from the surgical intensive care unit directly to a long‐term, acute‐care hospital. Methods. All patients who were admitted to the surgical intensive care unit at an academic, tertiary care medical center from 2009–2014 and discharged directly to long‐term, acute‐care hospitals were retrospectively reviewed. Patients represented all surgical subspecialties excluding cardiac and vascular surgery patients. Primary outcomes included 30‐day readmission, and 1‐ and 3‐year mortality rates following discharge. Results. In total, 296 patients were discharged directly from the surgical intensive care unit to a long‐term, acute‐care hospital during the study period. There were 190 men (64%) and mean age was 61 ± 16 years. Mean duration of stay in the surgical intensive care unit was 27 ± 17 days. The most frequent complication was prolonged mechanical ventilation (277, 94%) followed by pneumonia (139, 47%), sepsis (78, 26%), and acute renal failure (32, 11%); 93% of patients required tracheostomy and enteral feeding access prior to discharge, and 19 patients (6%) were newly dependent on hemodialysis. The readmission rate was 20%. There were 86 deaths within 1 year from discharge (29%) with an overall 3‐year mortality of 32%. In a multiple logistic regression analysis, a history of end‐stage renal disease had a greater odds of readmission (odds ratio 6.07, P = .028). Patients with history of cancer had greater odds of 1‐ and 3‐year mortality (odds ratio = 2.99, P = .028 and odds ratio 2.56, P = .053, respectively), and patients with a neurologic diagnosis had greater odds of 3‐year mortality (odds ratio 4.69, P = .031). Readmission significantly increased the odds of 1‐ and 3‐year mortality (odds ratio 3.12, P = .020 and odds ratio 2.90, P = .027, respectively). Patients who had both private insurance and Medicare had greater odds of 1‐ and 3‐year mortality (odds ratio 10.39, P = .005 and odds ratio 10.65, P = .004, respectively). Conclusion. Patients who are discharged to long‐term, acute‐care hospitals have prolonged hospitalizations with high complication rates. These patients have high readmission and 1‐year mortality rates. Patients and families should be counseled regarding these outcomes related to post–intensive care unit recovery after discharge to a long‐term, acute‐care hospital to allow for realistic expectations of survival after prolonged intensive care unit hospitalization.

Development of a Prehospital Tranexamic Acid Administration Protocol

Abstract Objective: Early administration of tranexamic acid (TXA) has been shown to reduce all-cause mortality and death secondary to trauma. Our objective was to develop a collaborative prehospital TXA administration protocol between a ground EMS and academic medical center. Methods: Physicians, pharmacists, and EMS and fire department personnel developed a prehospital TXA administration protocol between a local fire and EMS center with a Midwest tertiary care health system based on results from the CRASH-2 Trial. The protocol was initiated March 27, 2013 and the first dose of TXA was administered in September 2013. Results: Since September 2013, nineteen trauma patients received TXA. Survival rate was 89% (17/19); 2 patients expired immediately following arrival to the trauma bay. Seven patients did not receive the in-hospital maintenance dose due to the following: 3/7 (43%) due to miscommunication of pre-TXA administration; 2/7 (29%) did not meet inclusion criteria for TXA protocol; 1/7 (14%) due to protocol noncompliance; 1/7 (14%) due to a chaotic situation with an unstable patient. Conclusions: Prehospital TXA protocol based on the CRASH-2 trial is safe and feasible. The first dose of TXA administered under this protocol marks the first ground EMS administration in the USA. Conceivably, this will pose as a model to other trauma centers that receive patients from outlying areas without immediate access to care. Large multi-institutional analyses need to be performed to evaluate survival benefits of prehospital TXA administration protocol.

What's New in Academic Medicine? Retained surgical items: Is “zero incidence” achievable?

Dear Readers, Retained surgical items (RSIs) are designated as “never events” or sentinel events that are considered to be totally preventable.[1] A sentinel event is defined as a patient safety event that reaches a patient and results in death, permanent harm, or severe temporary. In 1996, the Joint Commission adopted a formal Sentinel Event Policy, which details serious adverse events and their respective prevention strategies.[2] RSI incidence was added to the Sentinel Event Policy on June 2005, and its incidence reached a peak of 188 cases in 2011, surpassing the incidence of wrong‐patient, wrong site, and wrong procedure events which were the most frequently reported events in 2008 and 2009.[3] These numbers only represent a small proportion of actual events given the voluntary nature of reporting to The Joint Commission. The true incidence of RSIs is unknown, however, estimates range from one in every 1000–1500 abdominal procedures to one in every 8000–18,000 inpatient procedures annually in the USA.[4,5] The most common RSIs include soft goods (sponges and towels), un‐retrieved device components or fragments, stapler components, parts of laparoscopic trocars, guide wires, catheters, and pieces of drains, needles and other sharps, and instruments (most commonly malleable retractors).[6] RSIs can lead to complications including pain, sepsis, intestinal obstruction, prolonged length of stay, and rarely death.[7‐9] Not only do RSIs harm the patient, but they also add significantly to the average total cost of caring for the patient ranging up to

Daily review of AHRQ patient safety indicators has important impact on value-based purchasing, reimbursement, and performance scores

200,000 or more per incident which covers legal defense, indemnity payments, and surgical costs not reimbursed by the Centers for Medicare and Medicaid Services.[10]

Clinical Effectiveness of Negative Pressure Wound Therapy Following Surgical Resection of Sternoclavicular Joint Infection: A Case Report.

Background. The Patient Safety Indicators (PSIs) Composite (PSI 90) of the Agency for Healthcare Research and Quality has been found to have low positive predictive values. Because scores can affect hospital reimbursement and ranking, our institution designed a review process to ensure accurate data and incur minimal penalties under the Hospital Value‐Based Purchasing Program. Methods. A multidisciplinary team was assembled to review PSI 90 within a performance period. The positive predictive value of each PSI was calculated. Weight‐adjusted PSI rates were used to recalculate the PSI 90 Performance Period Index Value (PPIV). The adjusted PPIV was used to estimate what the achievement points and financial impact would have been if PSI review had not been implemented. Differences in PPIV, achievement points, and financial impact before and after PSI review were calculated. Results. A total of 1,470 cases were flagged for PSI over a 2‐year period. The positive predictive value was 63.3%. Refuting 36.7% of PSIs resulted in a decrease in the PPIV from 0.696 to 0.508, an increase in achievement points from 5 to 10, resulting in a decreased net loss of

Postpartum Invasive Group A Streptococcus Infection: Case Report and Mini-review

111,773. Conclusion. Multidisciplinary review processes are practical and effective in identifying false‐positive patient safety events. The real‐time process affects hospital performance and resultant Medicare reimbursement substantially.

Changes in the burnout profile of chairs of academic departments of obstetrics and gynecology over the past 15 years

Septic arthritis of the sternoclavicular joint (SCJ) is a rare condition accounting for 0.5% of bone and joint infections. The majority of cases require joint resection and advancement flaps to provide coverage to the resulting wound defect. However, in the setting of an infected wound space, surgeons are often inclined to allow wound healing by secondary intention. Negative pressure wound therapy (NPWT) can be an important adjunct to promote and shorten wound healing time following SCJ resection.

The Link Between Clinically Validated Patient Safety Indicators and Clinical Outcomes

The overall incidence of postpartum invasive group A streptococcal (GAS) disease is low in the United States. However, postpartum women are much more likely to develop GAS disease than nonpregnant women. Additionally, postpartum GAS has the potential to develop into a severe disease and a delay in diagnosis can have deadly consequences. This case describes a patient with invasive postpartum endometritis in the setting of diastases of the pubic symphysis. Sepsis secondary to the endometritis develops along with bilateral pneumonia. This case characterizes some of the typical and atypical symptoms a patient with invasive postpartum GAS can present with. Further, it outlines the timely identification of the disease and its appropriate treatment to prevent a potentially disastrous outcome.

Relative value unit transformation: Our new reality of worth

BACKGROUND: While many studies have documented the high prevalence of burnout in practicing physicians and medical trainees, fewer reports describe burnout in academic leaders. In 2002, we observed a moderate‐high to high level of burnout in 41.4% of chairs of academic departments of obstetrics and gynecology. OBJECTIVE: The purpose of this study was to identify trends in burnout and associated factors in today’s obstetrics and gynecology chairs as they face complex changes to the current health care environment. STUDY DESIGN: This was a cross‐sectional study. A survey was developed based on the questionnaire used in our first investigation and sent electronically to all members of the Council of University Chairs of Obstetrics and Gynecology. Burnout was measured using an abbreviated Maslach Burnout Inventory‐Human Sciences Survey. In addition to demographic data, we assessed perceived stressors, job satisfaction, spousal/partner support, self‐efficacy, depression, suicidal ideation, and stress management. RESULTS: The response rate was 60% (84/139). Almost 30% of chairs were women, increased from 7.6% in 2002. Hospital and department budget deficits and loss of key faculty remain major stressors noted by participants. The Maslach Burnout Inventory results have changed dramatically over the past 15 years. Today’s chairs demonstrated less burnout but with an “ineffective” profile. Subscale scores for emotional exhaustion and depersonalization were reduced but >50% reported low personal accomplishment. Spousal support remained important in preventing burnout. CONCLUSION: Chairs of academic departments of obstetrics and gynecology continue to face significant job‐related stress. Burnout has decreased; however, personal accomplishment scores have also declined most likely due to administrative factors that are beyond the chairs’ perceived control.