Sumant R Ranji

“July Effect”: Impact of the Academic Year-End Changeover on Patient Outcomes: A Systematic Review

BACKGROUND It is commonly believed that the quality of health care decreases during trainee changeovers at the end of the academic year. PURPOSE To systematically review studies describing the effects of trainee changeover on patient outcomes. DATA SOURCES Electronic literature search of PubMed, Educational Research Information Center (ERIC), EMBASE, and the Cochrane Library for English-language studies published between 1989 and July 2010. STUDY SELECTION Title and abstract review followed by full-text review to identify studies that assessed the effect of the changeover on patient outcomes and that used a control group or period as a comparator. DATA EXTRACTION Using a standardized form, 2 authors independently abstracted data on outcomes, study setting and design, and statistical methods. Differences between reviewers were reconciled by consensus. Studies were then categorized according to methodological quality, sample size, and outcomes reported. DATA SYNTHESIS Of the 39 included studies, 27 (69%) reported mortality, 19 (49%) reported efficiency (length of stay, duration of procedure, hospital charges), 23 (59%) reported morbidity, and 6 (15%) reported medical error outcomes; all studies focused on inpatient settings. Most studies were conducted in the United States. Thirteen (33%) were of higher quality. Studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover. Studies examining morbidity and medical error outcomes were of lower quality and produced inconsistent results. LIMITATIONS The review was limited to English-language reports. No study focused on the effect of changeovers in ambulatory care settings. The definition of changeover, resident role in patient care, and supervision structure varied considerably among studies. Most studies did not control for time trends or level of supervision or use methods appropriate for hierarchical data. CONCLUSION Mortality increases and efficiency decreases in hospitals because of year-end changeovers, although heterogeneity in the existing literature does not permit firm conclusions about the degree of risk posed, how changeover affects morbidity and rates of medical errors, or whether particular models are more or less problematic. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.

Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis.

Background:Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often inappropriately prescribed. Research Design and Methods:We searched the Cochrane Collaborations Effective Practice and Organisation of Care database, supplemented by MEDLINE and manual review of article bibliographies. We included randomized trials, controlled before-after studies, and interrupted time series. Two independent reviewers abstracted all data, and disagreements were resolved by consensus and discussion with a third reviewer. The primary outcome was the absolute reduction in the proportion of patients receiving antibiotics. Results:Forty-three studies reporting 55 separate trials met inclusion criteria. Most studies (N = 38) addressed prescribing for acute respiratory infections (ARIs). Among the 30 trials eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7% [interquartile range (IQR), 6.6–13.7%] over 6 months median follow-up. No single QI strategy or combination of strategies was clearly superior. However, active clinician education strategies trended toward greater effectiveness than passive strategies (P = 0.096). Compared with studies targeting specific conditions or patient populations, broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, with savings of 17–117 prescriptions per 1000 person-years. Study methodologic quality was fair. Conclusions:QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains. Strategies using active clinician education and targeting management of all ARIs (rather than single conditions in single age groups) may yield larger reductions in community-level antibiotic use.

Improving antibiotic selection : A systematic review and quantitative analysis of quality improvement strategies

Objective:We sought to assess which interventions are most effective at improving the prescribing of recommended antibiotics for acute outpatient infections. Design and Methods:We undertook a systematic review with quantitative analysis of the Cochrane Registry Effective Practice and Organization of Care (EPOC) database, supplemented by MEDLINE and hand-searches. Inclusion criteria included clinical trials with contemporaneous or strict historical controls that reported data on antibiotic selection in acute outpatient infections. The effect size of studies with different intervention types were compared using nonparametric statistics. To maximize comparability between studies, quantitative analysis was restricted to studies that reported absolute changes in the amount of or percent compliance with recommended antibiotic prescribing. Results:Twenty-six studies reporting 33 trials met inclusion criteria. Most interventions used clinician education alone or in combination with audit and feedback. Among the 22 comparisons amenable to quantitative analysis, recommended antibiotic prescribing improved by a median of 10.6% (interquartile range [IQR] 3.4–18.2%). Trials evaluating clinician education alone reported larger effects than interventions combining clinician education with audit and feedback (median effect size 13.9% [IQR 8.6–21.6%] vs. 3.4% [IQR 1.8–9.7%], P = 0.03). This result was confounded by trial sample size, as trials having a smaller number of participating clinicians reported larger effects and were more likely to use clinician education alone. Active forms of education, sustained interventions, and other features traditionally associated with successful quality improvement interventions were not associated with effect size and showed no evidence of confounding the association between clinician education-only strategies and outcome. Conclusions:Multidimensional interventions using audit and feedback to improve antibiotic selection were less effective than interventions using clinician education alone. Although confounding may partially account for this finding, our results suggest that enhancing the intensity of a focused intervention may be preferable to a less intense, multidimensional approach.

Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review

Background Adverse drug events (ADEs) are a major cause of morbidity in hospitalised and ambulatory patients. Computerised provider order entry (CPOE) combined with clinical decision support systems (CDSS) are being widely implemented with the goal of preventing ADEs, but the effectiveness of these systems remains unclear. Methods We searched the specialised database Agency for Healthcare Research and Quality (AHRQ) Patient Safety Net to identify reviews of the effect of CPOE combined with CDSS on ADE rates in inpatient and outpatient settings. We included systematic and narrative reviews published since 2008 and controlled clinical trials published since 2012. Results We included five systematic reviews, one narrative review and two controlled trials. The existing literature consists mostly of studies of homegrown systems conducted in the inpatient setting. CPOE+CDSS was consistently reported to reduce prescribing errors, but does not appear to prevent clinical ADEs in either the inpatient or outpatient setting. Implementation of CPOE+CDSS profoundly changes staff workflow, and often leads to unintended consequences and new safety issues (such as alert fatigue) which limit the systems safety effects. Conclusions CPOE+CDSS does not appear to reliably prevent clinical ADEs. Despite more widespread implementation over the past decade, it remains a work in progress.

The Housestaff Incentive Program: improving the timeliness and quality of discharge summaries by engaging residents in quality improvement

Background Quality improvement has become increasingly important in the practice of medicine; however, engaging residents in meaningful projects within the demanding training environment remains challenging. Methods We conducted a year-long quality improvement project involving internal medicine residents at an academic medical centre. Resident champions designed and implemented a discharge summary improvement bundle, which employed an educational curriculum, an electronic discharge summary template, regular data feedback and a financial incentive. The timeliness and quality of discharge summaries were measured before and after the intervention. Residents and faculty were surveyed about their perceptions of the project; primary care providers were surveyed about their satisfaction with hospital provider communication. Results With implementation of the bundle, the average time from patient discharge to completion of the discharge summary fell from 3.5 to 0.61 days (p<0.001). The percentage of summaries completed on the day of discharge rose from 38% to 83% (p<0.001) and this improvement was sustained for 6 months following the end of the project. The percentage of summaries that included all recommended elements increased from 5% to 88% (p<0.001). Primary care providers reported a lower likelihood of discharge summaries being unavailable at the time of outpatient follow-up (38% to 4%, p<0.001). Residents reported that the systems changes, more than the financial incentive, accounted for their behaviour change. Conclusions Our discharge summary improvement project provides an instructive example of how residents can lead clinically meaningful quality improvement projects.

Rapid Response Systems in Adult Academic Medical Centers

A survey suggests that the academic medical centers with successful rapid response system programs defined each call as a chance to save a life, as well as an educational opportunity to increase the knowledge of nurses, interns, and residents throughout the institution.

Implementing Patient Safety Interventions in Your Hospital: What to Try and What to Avoid

Hospitalists play an important role in improving patient safety through clinical expertise and leadership in hospital quality improvement activities. The evidence base in patient safety remains incomplete, despite an increasing body of published research in recent years. Thus, physicians must consider other factors in addition to the strength of evidence supporting a practice when deciding which patient safety interventions to implement. These factors include the prevalence of the safety problem targeted, the potential for unintended consequences of the intervention, the costs and complexity of implementing the intervention, and the potential of the intervention to generate momentum for further safety initiatives. In this article, the authors define a framework for evaluating patient safety interventions and discuss specific interventions hospitalists should consider.

Transitional Care Strategies From Hospital to Home: A Review for the Neurohospitalist

Hospitals are challenged with reevaluating their hospital’s transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients from hospital to home. Despite the increasing attention to transitional care, there are few published studies that have shown significant reductions in readmission rates, particularly for patients with stroke and other neurologic diagnoses. Successful hospital-initiated transitional care programs include a “bridging” strategy with both predischarge and postdischarge interventions and dedicated transitions provider involved at multiple points in time. Although multicomponent strategies including patient engagement, use of a dedicated transition provider, and facilitation of communication with outpatient providers require time and resources, there is evidence that neurohospitalists can implement a transitional care program with the aim of improving patient safety across the continuum of care.

Shifting indirect patient care duties to after hours in the era of work hours restrictions.

Purpose Few data describe how often residents defer indirect patient care tasks to after hours or show whether residents report this time in duty hours logs. Thus, the authors examined how often residents perform one such task, discharge dictation, outside scheduled hours. Method The authors tracked all discharge summaries dictated by internal medicine residents at a single teaching hospital from January to June 2009. They determined the length and timing of discharge dictations by querying the hospital voice-dictation system. Definite work hours violations occurred when residents completed dictations on the postcall day after reaching mandated duty hours limits or on scheduled days off. Potential work hours violations arose when residents dictated after 6 pm or during the month subsequent to their rotation. The authors compared the number of residents they determined to have incurred duty hours violations with the number self-reporting violations. Results The authors obtained data on 1,152 dictations performed by 39 residents. Residents spent a mean 6.5 hours dictating per month, averaging 13 minutes per dictation. Using objective criteria, the authors determined that the majority of residents (32; 82%) incurred definite duty hours violations. Far fewer (2; 5%) self-reported violations. Team census, total time spent dictating, and dictation length were associated with dictating during restricted hours. Conclusions Indirect patient care tasks, such as dictating discharge summaries, may contribute substantially to unrecognized duty hours violations. Accurate and objective ways to assess resident workflow can help create effective solutions for resident efficiency and inform changes to resident schedules.

Physical Examination Education in Graduate Medical Education—A Systematic Review of the Literature

ABSTRACTOBJECTIVESThere is widespread recognition that physical examination (PE) should be taught in Graduate Medical Education (GME), but little is known regarding how to best teach PE to residents. Deliberate practice fosters expertise in other fields, but its utility in teaching PE is unknown. We systematically reviewed the literature to determine the effectiveness of methods to teach PE in GME, with attention to usage of deliberate practice.DATA SOURCESWe searched PubMed, ERIC, and EMBASE for English language studies regarding PE education in GME published between January 1951 and December 2012.STUDY ELIGIBILITY CRITERIASeven eligibility criteria were applied to studies of PE education: (1) English language; (2) subjects in GME; (3) description of study population; (4) description of intervention; (5) assessment of efficacy; (6) inclusion of control group; and (7) report of data analysis.STUDY APPRAISAL AND SYNTHESIS METHODSWe extracted data regarding study quality, type of PE, study population, curricular features, use of deliberate practice, outcomes and assessment methods. Tabulated summaries of studies were reviewed for narrative synthesis.RESULTSFourteen studies met inclusion criteria. The mean Medical Education Research Study Quality Instrument (MERSQI) score was 9.0 out of 18. Most studies (n = 8) included internal medicine residents. Half of the studies used resident interaction with a human examinee as the primary means of teaching PE. Three studies “definitely” and four studies “possibly” used deliberate practice; all but one of these studies demonstrated improved educational outcomes.LIMITATIONSWe used a non-validated deliberate practice assessment. Given the heterogeneity of assessment modalities, we did not perform a meta-analysis.CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGSNo single strategy for teaching PE in GME is clearly superior to another. Following the principles of deliberate practice and interaction with human examinees may be beneficial in teaching PE; controlled studies including these educational features should be performed to investigate these exploratory findings.