Naama Neeman

Effect of Institution-Wide Policy of Colonoscopy Withdrawal Time ≥7 Minutes on Polyp Detection

BACKGROUND & AIMS Practice guidelines recommend that endoscopists spend at least 7 minutes examining the colonic mucosa during colonoscopy withdrawal to optimize polyp yield. The aim of this study was to determine if the implementation of an institution-wide policy of colonoscopy withdrawal time > or = 7 minutes was associated with an increase in colon polyp detection. METHODS All 42 endoscopists at our institute were asked to attain a colonoscopy withdrawal time of at least 7 minutes. Compliance with 7-minute withdrawal time was recorded for all nontherapeutic colonoscopies. Polyp detection ratio (number of polyps detected divided by number of colonoscopies performed) was computed. Regression models were used to assess the association between compliance with 7-minute withdrawal time and polyp detection. RESULTS During the study period, 23,910 colonoscopies were performed. The average age of patients was 56.8 years, and 54% were female. Colon cancer screening or surveillance was the indication for 42.5% of colonoscopies. At the beginning of the study, the polyp detection ratio was 0.48. Compliance with 7-minute withdrawal time for nontherapeutic procedures increased from 65% at the beginning of the initiative to almost 100%. However, no increase in polyp detection ratio was noted over the same period for all polyps (slope, 0.0006; P = .45) or for polyps 1-5 mm (slope, 0.001; P = .26), 6-9 mm (slope, 0.002; P = .43), or > or = 10 mm (slope, 0.006; P = .13). No association was detected when only colonoscopies performed for screening or surveillance were analyzed. CONCLUSIONS An institution-wide policy of colonoscopy withdrawal time > or = 7 minutes had no effect on colon polyp detection.

The Incidence and Cost of Unexpected Hospital Use After Scheduled Outpatient Endoscopy

BACKGROUND Data on complications of gastrointestinal endoscopic procedures are limited. We evaluated prospectively the incidence and cost of hospital visits resulting from outpatient endoscopy. METHODS We developed an electronic medical record-based system to record automatically admissions to the emergency department (ED) within 14 days after endoscopy. Physicians evaluated all reported cases for relatedness of the ED visit to the prior endoscopy based on predetermined criteria. RESULTS We evaluated 6383 esophagogastroduodenoscopies (EGDs) and 11 632 colonoscopies (7392 for screening and surveillance). Among these, 419 ED visits and 266 hospitalizations occurred within 14 days after the procedure. One hundred thirty-four (32%) of the ED visits and 76 (29%) of the hospitalizations were procedure related, whereas 31 complications were recorded by standard physician reporting (P < .001). Procedure-related hospital visits occurred in 1.07%, 0.84%, and 0.95% of all EGDs, all colonoscopies, and screening colonoscopies, respectively. The mean costs were

An alerting system improves adherence to follow-up recommendations from colonoscopy examinations.

1403 per ED visit and

Perspective: a road map for academic departments to promote scholarship in quality improvement and patient safety.

10 123 per hospitalization based on Medicare standardized rates. Across the overall screening/surveillance colonoscopy program, these episodes added

Enculturation of Unsafe Attitudes and Behaviors: Student Perceptions of Safety Culture

48 per examination. CONCLUSIONS Using a novel automated system, we observed a 1% incidence of related hospital visits within 14 days of outpatient endoscopy, 2- to 3-fold higher than recent estimates. Most events were not captured by standard reporting, and strategies for automating adverse event reporting should be developed. The cost of unexpected hospital visits postendoscopy may be significant and should be taken into account in screening or surveillance programs.

HIV quality of care assessment at an academic hospital: outcomes and lessons learned.

BACKGROUND & AIMS Systems are available to ensure that results of tests are communicated to patients. However, lack of adherence to recommended follow-up evaluation increases risk for adverse health outcomes and medical or legal issues. We tested the effectiveness of a novel follow-up system for patients due for surveillance colonoscopy examinations. METHODS Electronic medical records from colonoscopies performed 5 years prior were reviewed to identify individuals due for a repeat surveillance colonoscopy examination. Patients were assigned to groups that received the standard of care or a newly developed follow-up system that included a letter to the primary care provider, 2 letters to the patient, and a telephone call to patients who had not yet scheduled an examination by the procedure due date. The primary end point was the percentage of patients who scheduled or completed the colonoscopy examination within 6 months of the due date. Secondary end points included detection rate for adenomas, sex- and ethnicity-specific follow-up rates, and patient satisfaction. RESULTS Of 2609 patient records reviewed, 830 (31.8%) were found to be due for a surveillance colonoscopy examination in the study period. At the conclusion of the study, 241 (44.7%) patients in the intervention arm had procedures scheduled or completed, compared with 66 (22.6%) in the control group (P < .0001). The follow-up system appeared particularly effective among non-white patients; patients reported general satisfaction with the reminder program. CONCLUSIONS A simple protocol of letters and a telephone call to patients who are due for colonoscopy examinations significantly improved adherence to endoscopic follow-up recommendations. This work provides justification for the creation of reminder systems to improve patient adherence to medical recommendations.

Complementary Telephone Strategies to Improve Postdischarge Communication

The fields of quality improvement and patient safety (QI/PS) continue to grow with greater attention and awareness, increased mandates and incentives, and more research. Academic medical centers and their academic departments have a long-standing tradition for innovation and scholarship within a multifaceted mission to provide patient care, educate the next generation, and conduct research. Academic departments are well positioned to lead the science, education, and application of QI/PS efforts nationally. However, meaningful engagement of faculty and trainees to lead this work is a major barrier. Understanding and developing programs that foster QI/PS work while also promoting a scholarly focus can generate the incentives and acknowledgment to help elevate QI/PS into the academic mission. Academic departments should define and articulate a QI/PS strategy, develop individual and departmental capacity to lead scholarly QI/PS programs, streamline and support access to data, share information and improve collaboration, and recognize and elevate academic success in QI/PS. A commitment to these goals can also serve to cultivate important collaborations between academic departments and their respective medical centers, divisions, and training programs. Ultimately, the elevation of QI/PS into the academic mission can improve the quality and safety of our health care delivery systems.

Quality Improvement and Patient Safety Activities in Academic Departments of Medicine

Purpose Safety culture may exert an important influence on the adoption and learning of patient safety practices by learners at clinical training sites. This study assessed students’ perceptions of safety culture and identified curricular gaps in patient safety training. Method A total of 170 fourth-year medical students at the University of California, San Francisco, were asked to complete a modified version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture in 2011. Students responded on the basis of either their third-year internal medicine or surgery clerkship experience. Responses were recorded on a five-point Likert scale. Percent positive responses were compared between the groups using a chi-square test. Results One hundred twenty-one students (71% response rate) rated “teamwork within units” and “organizational learning” highest among the survey domains; “communication openness” and “nonpunitive response to error” were rated lowest. A majority of students reported that they would not speak up when witnessing a possible adverse event (56%) and were afraid to ask questions if things did not seem right (55%). In addition, 48% of students reported feeling that mistakes were held against them. Overall, students reported a desire for additional patient safety training to enhance their educational experience. Conclusions Assessing student perceptions of safety culture highlighted important observations from their clinical experiences and helped identify areas for curricular development to enhance patient safety. This assessment may also be a useful tool for both clerkship directors and clinical service chiefs in their respective efforts to promote safe care.

A “Smart” Heart Failure Sheet: Using Electronic Medical Records to Guide Clinical Decision Making

Rapid changes in HIV treatment guidelines and antiretroviral therapy drug safety data add to the increasing complexity of caring for HIV-infected patients and amplify the need for continuous quality monitoring. The authors created an electronic HIV database of 642 patients who received care in the infectious disease (ID) and general medicine clinics in their academic center to monitor HIV clinical performance indicators. The main outcome measures of the study include process measures, including a description of how the database was constructed, and clinical outcomes, including HIV-specific quality improvement (QI) measures and primary care (PC) measures. Performance on HIV-specific QI measures was very high, but drug toxicity monitoring and PC-specific QI performance were deficient, particularly among ID specialists. Establishment of HIV QI data benchmarks as well as standards for how data will be measured and collected are needed and are the logical counterpart to treatment guidelines.

An Educational Intervention for Providers to Promote Bone Health in High-Risk Older Patients

P w t v t u t p d i c Adverse events after hospital discharge are common and often preventable, representing a vulnerable time for patients. Hospitals are challenged to provide patients with a communication safety net postdischarge compared with ambulatory practices. Dedicated transitional care programs have tried to address this gap, focusing on specific diagnoses or selected high-risk populations, such as older adults. However, adoption of communication strategies targeting all discharged patients is still lacking despite its potential to prevent adverse events and reduce readmissions.