Browsing by Subject "Patient Transfer"
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Item The Adult Spina Bifida Patient: Does a Delay in Referral Impact Urodynamic Findings and Clinical Outcomes? Recommendations for Transition of Care(2017-01-17) Eastman, Jessica; Lemack, Gary; Harris, Catherine; Howard, CatherineINTRODUCTION: Improvements in the management of children with myelomeningocele have resulted in an influx of such patients, many of whom have complex neurogenic bladder conditions, to adult urologists. We reviewed the presenting symptoms, urodynamic findings, and changes in clinical management of adults with spina bifida, specifically focusing on the relationship between the delay in urological follow-up and clinical outcomes. METHODS: All patients with neurological conditions that presented for urologic evaluation at a tertiary referral center have been prospectively entered into a database since 2000. Data from patients with spina bifida including, bladder management, chief complaint, urodynamic findings (UDS), surgical interventions and upper tract imaging were analyzed. RESULTS: Of the 1110 patients in the database, 60 patients with spina bifida were identified (51.7% male, 48.3% female). Median age at presentation was 33 (16-64). The majority of patients presented for symptom evaluation (75%) vs. establishing care (25%). The most common presenting symptoms were incontinence (n=18, 30%) and urinary tract infection (UTI) (n=15, 25%). Patients who had documented prior urologic evaluation were assessed for the interval to presentation (n=53). Patients were classified as having their last evaluation within the preceding 12 months (n=23, 43.3%), between 12 and 24 months (n=17, 32%), between 2 and 5 years (n=11, 20.8%) or greater than 5 years prior (n=2, 3.8%). Patients were significantly more likely to present within 12 months of their last evaluation if they were symptomatic (p=0.022). Patients presenting more than one year from their last evaluation were more likely to have DO (p=0.0215), though neither altered compliance nor DESD were associated with delay in diagnosis. As seen with children, the UDS diagnosis of impaired compliance was significantly associated with abnormal imaging findings (p=0.0328). Overall, 42% of this cohort required intervention following referral, and urologic workup including urodynamics altered clinical management in 58.9% of patients. CONCLUSION: Spina Bifida patients continue to require close surveillance into adulthood, and this evaluation must include urodynamic testing. Additionally, there is indication that patients who delay care are more likely to have UDS abnormalities that might necessitate changes in management strategies. We advocate follow-up of less than 12 months between adult urology clinics or within one year after pediatric surveillance has terminated.Item Designing an Audit and Feedback System to Drive Handoff Redesign and Implementation(2021-03-18) Dao, Anthony Quang; Reed, W. Gary; Greilich, Philip; Lynch, IsaacBACKGROUND: 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.Item Facilitating Image Sharing for Patients Transferred to a Tertiary Care Center Through Process Assessment and Identification of Quality Indicators in Order to Improve Quality of Patient Care, Reduce Healthcare Costs, and Reduce Reimaging(2017-04-03) Patel, Roshni; Reed, W. Gary; Greilich, Philip; Brewington, CeceliaBACKGROUND: lifeIMAGE allows for images to be uploaded from a CD and permanently stored in PACS and also facilitates the transfer of images online via cloud-based sharing without the transfer of CDs. However, the current use of lifeIMAGE in imaging transfers remains poorly understood. Thus the aim of this study was to assess the current state of imaging transfers and ultimately to improve medical imaging handovers for patients transferred from outside hospitals to Clements University Hospital (UT Southwestern's tertiary care center) through the use of lifeIMAGE. METHODS: The Plan Do Study Act method of quality improvement was used for this project. Based on our process mapping, we created a two-pronged intervention: the first focusing on increasing online imaging transfers from outside facilities via Cloud Connection, and the second focusing on assessing and improving knowledge of uploading images from CDs. Baseline assessment included pulling data from lifeIMAGE analytics to assess the current use of lifeIMAGE, reviewing 9 months of transfer logs before the intervention, and conducting a resident survey before the intervention. INTERVENTION: The first component of the intervention involved improving the current transfer of images from outside hospitals via cloud-based image sharing, without the use of CDs. This involved reviewing transfer logs to identify which outside facilities to focus on, providing the facilities with a document explaining their options for transferring images via lifeIMAGE, and scheduling meetings with these outside facilities to work towards a collaborative effort for the online transfer of images. The second component of the intervention involved uploading images from CDs to lifeIMAGE. A survey of residents was conducted to determine healthcare providers' current practice related to medical imaging handover for patients transferred with a CD and to evaluate knowledge of uploading images. This was followed by presenting a brief PowerPoint tutorial on uploading images from CD to lifeIMAGE to Internal Medicine residents at noon conference and posting instructions on the IM Resident blog and website. RESULTS: Of the recorded transfers spanning 9 months (Dec 2015-Aug 2016) from 371 different outside facilities (after excluding hospitals within the UT Southwestern system), United Regional Health Care System Wichita Falls and Dallas VA Medical Center were the facilities that transferred the most patients to CUH: 93 (3.63%) and 52 (3.32%), respectively. 68.2% of the surveyed residents expressed that at least half of transferred patients present with a CD containing images, and 72.7% of residents expressed that repeat imaging was required in at least half of the patients because they were transferred without imaging. 61.4% of resident respondents did not know how to upload CD images to lifeIMAGE. Of the residents who knew how to upload CD images to lifeIMAGE, the majority of this group (82%) endorsed uploading images themselves. When asked to describe the current process after receiving a CD containing images, 34% of surveyed residents reported directly importing images from the CDs into lifeIMAGE; 30% of residents reported sending CDs to radiology to upload; 25% reported viewing the images on CDs without import them. CONCLUSIONS: Creating a workflow diagram and assessing baseline data through lifeIMAGE Analytics and through the resident survey improved documentation and understanding of the current state of medical imaging transfers at Clements University Hospital. This study identified that cloud-based image sharing is an underutilized capability of lifeIMAGE. It further helped narrow the scope of the intervention by identifying the two sending hospitals with the highest volume of image transfers so that we could work to increase utilization of cloud-based transfers at these institutions. Based on the resident survey data exposing knowledge as a major barrier, we presented a short tutorial to the residents during noon conference detailing how to upload images to lifeIMAGE and push the images to PACS and created a brief instruction guide that was emailed to the residents as well as posted to the IM Resident website and IM blog for future access. The survey data also indicated that the process for uploading imaging from CDs was highly variable among residents, supporting the need for an intervention to standardize practice. Future PDSA cycles will be needed to assess the impact of our interventions.Item Transitions of care: research, implementation science, and public policy(2021-10-01) Kripalani, Sunil