Browsing by Subject "Patient Care Team"

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Co-Surgeons in Breast Reconstructive Microsurgery: What Do They Bring to the Table?
(2019-03-18) Haddock, Nicholas T.; Kayfan, Samar; Pezeshk, Ronnie A.; Teotia, Sumeet S.; Kayfan, Samar; Teotia, Sumeet S.; Haddock, Nicholas T.; Rozen, Shai
INTRODUCTION: Current research within other surgical specialties suggests that a co-surgeon approach may reduce operative times and complications associated with complex bilateral procedures, possibly leading to improved patient and surgical outcomes. We sought to evaluate the role of the co-surgery team and its development in free flap breast reconstruction. METHODS: A retrospective review of free-flap breast reconstruction by two surgeons from 2011-2016 was conducted. We analyzed 128 patients who underwent bilateral-DIEP breast. Surgical groups were: single-surgeon reconstruction (SSR; 35 patients), Co-Surgery where both surgeons are present for entire reconstruction (CSR-I; 69 patients), and Co-Surgery reconstruction where co-surgeons appropriately assist in two concurrent or staggered cases (CSR-II; 24 patients). Efficiency data collected was OR time and patient length-of-stay (LOS). The rate of flap-failure, return to OR, infection, wound breakdown, seroma, hematoma and PE/DVT were compared. RESULTS: Single-surgeon reconstruction had significantly longer OR time (678 vs 485 minutes, p< 0.0001), LOS (5 vs 3.9 days, p<0.001), higher wound occurrences of the umbilical site that required surgical correction [11.4 percent (n=4) versus 1.5 percent,(n=1); p<0.043] compared to CSR-I. Similarly, SSR had significantly longer average OR time (678 vs 527 minutes p< 0.0001), average LOS (5 days vs 4 days, p=0.0005) when compared to CSR-II. There were no total increased patient related complications associated with co-surgery (CSR- I or II). CONCLUSION: The addition of a Co-surgeon, even with concurrent surgery, reduces operative time, average patient LOS, and post-operative complications. This work lends a strong credence that Co-surgery model is associated with increased operative efficiency.
Deep brain stimulation enhances control and restores valued personality characteristics
(2022-11-08) Kubu, Cynthia S.
Questions related to what constitutes personality, and how those conceptualizations interface with notions of self, identity, and autonomy, have fascinated psychologists, philosophers, and ethicists for hundreds of years. Since 2008, several studies have asserted that deep brain stimulation (DBS) results in patients’ loss of control, particularly related to undesired personality changes. Inherent in this argument is the thesis that DBS negatively impacts patients’ identity, autonomy, and personality. Our lab has relied on empirical methods to examine questions related to control in patients who undergo DBS to treat motor symptoms. Our data refute the claims that DBS results in a loss of control. We rely on the American philosophical tradition of pragmatism to conduct our work, particularly the emphasis on different ways of knowing, including the perspectives of various disciplines as well as different stakeholders in understanding, studying, and ultimately implementing practices based on good data.
Designing an Audit and Feedback System to Drive Handoff Redesign and Implementation
(2021-03-18) Dao, Anthony Quang; Reed, W. Gary; Greilich, Philip; Lynch, Isaac
BACKGROUND: Following the handoff efficacy pilot that was implemented 6 quarters ago at Clements University Hospital, a new measurement system needs to be implemented for preparation of a diffusion pilot to 4-6 additional units. At present there is no such system to monitor and provide feedback to key stakeholders. An Epic based clarity report was identified as a potential measurement system and this project revolved around the feasibility, acceptability, and appropriateness of implementing such a system. A survey was sent out to identify top handoff outcomes to be included in the system and to assess the feasibility of the system. From preliminary results, it was understood that it is possible to successfully implement an acceptable, appropriate, and feasible measurement system. LOCAL PROBLEM: Information loss during care transfers, or "handoffs", can disrupt care coordination and lead to adverse events, especially in high risk, error prone environments like the perioperative setting. Clements University Hospital piloted the redesign and implementation of a structured handoff process to Enhance Communication for Handoffs from the Operating room to the Intensive Care Unit (ECHO-ICU) to improve team-based communication and care. As a result of this successful efficacy pilot, an implementation science-based approach is being taken to prepare for widespread adoption of inpatient handoff redesign. This requires the development of an acceptable and feasible audit and feedback system to support the work led by an inter-professional, unit-based change team guided by institutional subject matter experts. Previous attempts to relay feedback to the original units from the efficacy pilot were unresponsive and slow, leading to disengagement of the stakeholders. This project will attempt to make this process easier, timelier, and scalable. The aim of this project is to reduce the time it takes to perform and Audit and Feedback by 50% by May 2021. METHODS: An initial literature review was performed to identify candidate important outcome measures related to successful handoffs. To assess acceptability, the primary stakeholders were surveyed on what they identified as the most important outcome measures related to handoffs. Feasibility was assessed by determining end users' personal motivation level for entering critical data into the electronic medical record and the complexity of generating an automated report by data specialists from Epic, enterprise, and clinical data registries. Data was collected using multiple methods, including a REDCap survey, small group discussions, and individual interviews. The top three voted upon measures will be added as new data fields into Epic for data collection. RESULTS: The outcomes deemed most important by the survey were all team members present during handoff, the receiving team feeling capable of meeting patient needs, and unanticipated postoperative events. Using these measures of meaning, a prototype dashboard audit and feedback system was designed for use in future efforts. By using participatory design, usability was addressed by focusing on feasibility, acceptability, and fidelity. The guidance team will work with the unit-based change team for handoff redesign and implementation of this audit and feedback. Initially, the feedback will occur quarterly, but each unit will determine their preferred feedback period. CONCLUSIONS: The next steps of this project will be to pilot this prototype with other handoff redesign efforts to collect usability data and assess whether the prototype remains feasible, acceptable, and fidelity. This prototype hopes to align with the University Hospital handoff diffusion pilot within 4 to 6 clinical units. Acceptability and feasibility are leading indicators of successful of widespread adoption, penetration, and sustainability. These latter implementation measure will be applied to future work from this project team.
A Four-Year Experience at a Level I Pediatric Trauma Center: 2009-2012
(2015-01-26) Stevens, Audrey; Renkes, Rachel; Burkhalter, Lorrie; Foglia, Robert
BACKGROUND: In the United States, trauma is the leading cause of death and disability in children. Annually 140,000 children are seen in the Emergency Department(ED) at our single Level-I verified pediatric trauma center. 12,000 -13,000 are due to trauma, with approximately 1,400 admissions. We reviewed the trauma experience at our hospital to assess its impact based upon the management, outcome, and hospital charges for these patients. METHODS: With IRB approval, the hospital Trauma Registry was accessed to identify the severity of injury, management and outcomes for patients admitted from Jan. 2009 - Dec. 2012. Data points included age, gender, Trauma Activation (TA), Injury Severity Score (ISS), admit service, ICU admission, length of stay (LOS), operative need, mortality, and hospital charges. ED deaths were excluded. RESULTS: There were 5,514 trauma admissions, 8.18% of all of the 67,429 hospital admissions; 60% were boys and 40% girls. Age was 6.82±4.41 years, and ISS was 8.21±7.54. 54% had a minor ISS (0-7), 32% moderate (8-15), 9.5% severe (16-24), and 5.2% very severe (>24). TAs were called in 1346(24.4%) patients, 1014(75.3%) ALERTs and 332(24.7%) STATs. 2607 (47.3%) patients required an operation. The majority of patients were assigned to Pediatric Surgery (44%) and Orthopedic Surgery (41%). Trauma ICU admissions were 14.2% of all trauma admissions, comparable to all hospital ICU admissions at 17.4%. The trauma ICU LOS was 3.59±5.64 days; this doubled to 7.02±15.96 days for all hospital ICU admissions. The trauma LOS was 2.48±4.57 days; again, this doubled to 5.17±10.31 days for all hospital patients. There were 64 trauma deaths (1.16%). The trauma cohort accounted for $188,472,675 of hospital charges, which was 4.3% of all hospital charges ($4,375,099,917) for four years. The average charge per trauma patient was $36,746 vs. $65,324 for all admits. CONCLUSION: If trauma were a single disease, it would be the third most frequent admission diagnosis. The trauma population is heterogeneous; 24% of the trauma patients required TA, 14% ICU admission, 47% needed surgery, and 46% had a moderate or higher ISS. The mortality rate of 1.16% is less than the national average of 2.26%. Hospital charges and the LOS (total and ICU) for trauma patients were half that of all patients. The lower cost may be due to an efficient use of resources, management, and care of trauma patients. Our patient management and hospital charges for these trauma patients, coupled with good outcomes, may be a model for other hospital admissions and other trauma programs.
The Impact of Portable Electronic Devices on Attending Rounding Behaviors of Inpatient Internal Medicine Teams at an Academic Medical Center
(2014-02-04) Locke, Cameron; Suss, Adina; Barker, Blake; Moran, Brett; Wagner, James
INTRODUCTION: The advancement of mobile technologies is changing the way medicine is practiced. Portable devices give health care professionals access to electronic resources and patient health records without restricting them to stationary computers. However, little exists in the literature on how these devices impact the rounding behavior of health care teams at academic medical centers. There is general concern that the EHR will compel caregivers to spend less time with their patients; there is significant evidence in a prior unpublished study to support this unintended consequence. In this study the authors sought to identify whether the availability of tablet computers to inpatient internal medicine teams would combine the best of both previous rounding behaviors. METHODS: Research was conducted over a period of 28 days, consisting of observation of internal medicine teams randomized into intervention, who were provided with tablet computers, and control groups. Two observers recorded behaviors on a standardized checklist, which included domains of patient care, EHR use, and distractions. RESULTS: 323 patient encounters were recorded in the context of eighteen health care teams, fourteen control (160 encounters) and four intervention (163 encounters). General characteristics of each arm of the study are summarized below: Variable Control Intervention p-value Tablet Used (y/n) 18.13% 50.31% < 0.0001 Tablet Use Count 0.29 1.18 < 0.0001 Total Tech Use Count 2.01 2.00 0.3637 Tablet Distraction Count 0 0.26 < 0.0001 Total Distraction Count 1.84 2.60 0.0045 % Rounds on Wards 34.38% 71.17% < 0.0001 Time per Patient (minutes) 12.37 10.62 0.0118 Time at Bedside (minutes) 3.28 3.71 0.6358 DISCUSSION: Tablet possession is associated with increased ward rounding with the same level of access to EHR as would be offered by room rounding, shorter time spent discussing each patient, but increased time spent at the patient's bedside. This constellation of findings may suggest increased efficiency. Intervention teams experienced more distractions than control teams, as is expected due to the increased amount of ward rounding. However, the tablets themselves contributed to the number of distractions. These results can shed light on the role that tablet computers will play as we enter the electronic age of medicine.
Improving Teamwork Competencies and Patient Handovers of Students in the Emergency Medicine Clinical Learning Environment
(2024-05) Lokesh, Nidhish; Reed, W. Gary; Greilich, Philip; Pierce, Ava E.
BACKGROUND: Communication failures contribute to significant teamwork failures causing adverse events for patients and providers, especially during patient handovers when providers transition care of patients to each other. Teamwork education has been shown to improve knowledge, skills, and communication in prelicensure learners. Despite knowledge of the problem and potential solutions, as well as requirements and recommendations by national medical accreditation and oversight agencies, there exists a gap in standardized teamwork education and assessment. The Emergency Department is a setting rife with inherent barriers to teamwork with a high frequency of patient handovers. LOCAL PROBLEM: At UT Southwestern, students used to have limited opportunities to improve teamwork in structured ways during their time on the clinical wards. In response, the institution developed and is implementing an educational quality enhancement plan - TeamFIRST - with the goal of developing a competency-based teamwork education (CBTE) strategy for students that is progressive, interprofessional, and continuous through the pre-clerkship, clerkship, and post-clerkship phases of medical school. Module 4 out of the 5 modules TeamFIRST developed focuses on improving teamwork competencies specifically in the clinical learning environment, i.e. during clinical rotations in most students' second years and beyond. This includes the Emergency Medicine clinical rotation, which most students undergo at Parkland Memorial Hospital, the busiest emergency department in the nation, as well as at other local Emergency Departments like Clements University Hospital and Presbyterian Dallas. Until now, the Emergency Medicine clinical rotation at UT Southwestern did not have any formal handover or teamwork education, despite being the clinical setting in which teamwork and handovers arguably provide the most value. METHODS: Continuous Quality Improvement (QI) and Implementation Science tools and methodologies were used in the study of the current state of handovers in the ED and in the design of interventions to implement effective handovers. Define-Measure-Analyze-Design-Verify methodology was used to iterate our interventions. Interviews with stakeholders were conducted to determine critical needs, learn about the main drivers for intervention, and map the current state of the ED clerkship rotation so that a suitable educational module could be developed. These stakeholders mainly included faculty, course directors, residents, and students in the Emergency Medicine rotation as well as members of TeamFIRST. Shared requirements from stakeholders included focusing on improving handovers, limiting time commitment due to already busy schedules, and mixing virtual with in-person education. Information was also gathered on the state of different handover types in the ED to design assessment tools that captured the critical components. TeamFIRST identified nine of the twelve Teamwork Competencies - Structured Communication, Closed Loop Communication, Asking Clarifying Questions, Sharing Unique Information, Mutual Trust, Team Mental Models, Mutual Performance Monitoring, Obstacles to Teamwork, and Psychological Safety - for the Module 4 interventions to address. Working in concert with TeamFIRST and the Emergency Medicine stakeholders, we developed a teamwork education curriculum that integrated into the existing Emergency Medicine clerkship rotation and focused specifically on improving patient handovers. Each teamwork competency was explored to differing degrees among the spectrum of inform, demonstrate, practice, and feedback. We selected various process, outcome, and balancing measures such as impact (effectiveness), fidelity of activities, acceptability and appropriateness, and feasibility. Impact of the curriculum was measured by assessing students' knowledge, confidence in skills, and attitudes on the teamwork competencies. Both quantitative and qualitative data was collected. Statistical methods such as Z test of proportion and Mann-Whitney U test were used to analyze pre- and post- data to determine any significant changes. INTERVENTIONS: The teamwork curriculum initially designed for the Emergency Medicine clerkship rotation (the "test" phase, designated "Curriculum 1.0") had three main aspects: a pre-orientation, asynchronous, virtual educational module on teamwork and handovers, integrated handover practice and assessment throughout the rotation, integrated teamwork participation/observation, reflection, and debriefing during the rotation. The pre-orientation module was designed with a pre-assessment to determine students' capacities before being exposed to the material and a post-assessment to measure changes in knowledge and receive feedback after going through the didactic curriculum that covered the teamwork competencies and dedicated a full section to patient handovers. The handover practice was scattered throughout teaching shifts, simulation center cases and a dedicated handover station, and while working on regular emergency department shifts with accompanying assessment tools made to allow residents and faculty to evaluate student handovers and provide learners feedback. Lastly, students participated in and observed teamwork instances throughout their rotation and were encouraged to note these experiences down in a Teamwork Competency Journal so they could reflect and debrief on them in a group session late in the rotation. Finally, an end-of-rotation assessment was administered to capture changes in knowledge, skills, and attitudes, as well as feedback on acceptability, appropriateness, and feasibility. Whereas feasibility data were derived from the qualitative feedback, fidelity to the learning activities were assessed quantitatively. These interventions were first tested with a non-representative student sample outside of the EM rotation at the end of the summer 2020 and during field tests in Spring 2021 to improve the process and optimize the interventions. The official, representative test within the clerkship, "Curriculum 1.0", began in June 2021 and ran through March 2023 (22 months total). "Curriculum 2.0", the more streamlined version, is our pilot phase, and has been running from April 2023 through the present. RESULTS: We had 124 students participate in the Curriculum 1.0 test over 13 rotation blocks and collected qualitative and quantitative data on acceptability, appropriateness, fidelity, feasibility, and impact. So far, the curriculum has shown to be effective in improving knowledge (significant in 5/8 categories, p<0.05) and confidence in teamwork skills (significant in 11/11 categories, p<0.05). Also, students have deemed the curriculum acceptable and appropriate (all average ratings >4/5). However, some learning activities were deemed less feasible, and the fidelity (completion as intended) of different activities was low (48% completion or less). Feedback was generally positive, with common themes being that the handover education and practice were useful and relevant, the teamwork debrief was excellent, and the course was unique. Negative feedback commonly addressed a lack of clarity in communication about the curriculum requirements and the need for more active student roles. CONCLUSION: Overall, the impact and acceptability/appropriateness of Curriculum 1.0 were high, feasibility of the curriculum was moderate, and fidelity was low. Some of the key takeaways include that our stakeholders found the education to be effective and valuable, a combination of asynchronous and synchronous learning seemed the most feasible and acceptable, and that the time pressures on our EM residents and faculty are high. Going forward, we will continue to pilot the streamlined "Curriculum 2.0", which has already shown to be more feasible and sustainable, to improve the experience for learners and instructors, improve data collection, and focus on getting students more practice on patient handovers.
The Relationship Between Interdisciplinary Team Cohesion and Burnout in Cognitive Rehabilitation
(August 2021) Cassill, Carolyn Kuniko; Anise, Mary; Robbins, Mona; Marquez de la Plata, Carlos; Kinney, Robert; Reese, Caitlin
BACKGROUND: The healthcare system at large is currently experiencing unprecedented amounts of burnout (Jalili et al., 2021; Reith, 2018). Researchers are working to identify risk and protective factors (Cañadas-De la Fuente et al., 2015; Seidler et al., 2014) of burnout that might be used as points of intervention (Awa et al., 2010; Demerouti, 2015). One potential protective factor of burnout that has not been explored is interpersonal team cohesion of the interdisciplinary team. (Hellyar et al., 2019). The purpose of this study was to determine if interpersonal team cohesion was inversely related to burnout in healthcare providers. METHODS: Emails and flyers with links to an online survey were sent to direct care staff in a cognitive rehabilitation setting. The convenience sample included 53 participants who completed the survey. Participants answered questions regarding burnout, interpersonal team functioning, depression, anxiety, and stress. Demographic variables associated with burnout were also included (Cañadas-De la Fuente et al., 2015; Shanafelt et al., 2015). RESULTS: Twenty-six participants reported symptoms consistent with burnout. All of these participants endorsed experiencing emotional exhaustion, but no one endorsed experiencing depersonalization or diminished professional accomplishment. As such, all analyses used emotional exhaustion to examine burnout. Multiple regression was used to determine if interpersonal team cohesion predicted emotional exhaustion. While the overall model was significant (F (6,42) = 12.55, p < .001, R2 = .64), only stress ( = 0.68, p < .001) and depression ( = 0.34, p = .047) were significant predictors of emotional exhaustion. Further analysis revealed that interpersonal team cohesion did significantly predict emotional exhaustion, but only with stress included as a partial mediator. CONCLUSIONS: The hypothesis that interpersonal team cohesion and burnout were inversely related to each other proved to be an oversimplification. Results of this study show that stress serves as a partial mediator between interpersonal functioning of interpersonal team cohesion and burnout, with lower team cohesion resulting in higher stress, which in turn results in higher levels of burnout. This implies that both interpersonal functioning of the interdisciplinary team and stress can be used as points of intervention for reducing or preventing burnout.