Browsing by Subject "Quality Improvement"
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Item Benchmarking Surgical Quality: Cholecystectomy at a Safety-Net Hospital(2017-04-03) Byrd, Jacqueline Noelle; Reed, W. Gary; Choti, Michael; AbdelFattah, KareemBACKGROUND: Rates of conversion from laparoscopic to open cholecystectomy in the U.S. have been reported to be 5 to 10%. This study aims to benchmark conversion rate and identify preoperative factors that are predictive of conversion at a large, safety-net hospital. OBJECTIVE: To identify preoperative factors predictive of conversion from laparoscopic to open cholecystectomy for improved risk-adjustment of conversion as a quality indicator METHODS: The data for all patients who underwent laparoscopic and converted cholecystectomies from 2007 to 2015 were retrospectively abstracted from the electronic medical records of a public, teaching hospital. Variability in conversion rate was assessed over the time period captured in the study cohort. Univariate and multivariate logistic regression were used to identify the factors that are significantly associated with conversion. RESULTS: We identified 9,008 patients: 84.0% were female, 77.8% were Hispanic, and 75.2% were uninsured, with a median age of 37 years old. American Society of Anesthesiologists (ASA) 3 and 4 constituted 10.5% of patients. The majority (81.8%) of cases were performed between 7 a.m. and 3 p.m. There were 451 converted cholecystectomies across all case types - a conversion rate of 5.0%. On multivariable analysis, predictors of conversion were male gender (odds ratio (OR)=2.68; 95% confidence interval (CI): 2.09-3.43), increased age (OR=1.02; 95% CI: 1.02-1.03), diabetes mellitus (OR=1.42; 95% CI: 1.04-1.95), increased BMI (OR=1.018; 95% CI: 1.001-1.03), increased WBC count (OR=1.034; 95% CI: 1.01-1.06), and increased alkaline phosphatase (OR=1.002; 95% CI: 1.001-1.003). CONCLUSION: This is the largest single institution study to present a risk predictor for cholecystectomy conversion. The proposed risk score includes gender, diabetes mellitus, age, case type, BMI and two lab values - white blood cell count and alkaline phosphatase. These variables are readily available to providers pre-operatively, enabling application of this risk score to patient education and surgical planning.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 Development and Implementation of Audit and Feedback for Patient Blood Management(2020-05-01T05:00:00.000Z) Vishwanath, Aishwarya; Reed, W. Gary; Greilich, Philip; Lysikowski, JerzyBACKGROUND: Red blood cell (RBC) transfusions, a common perioperative procedure, are overused nationwide¹ despite their association with numerous adverse postoperative outcomes² and often unnecessary administration. Patient blood management (PBM) programs respond to these trends by promoting responsible and restrictive transfusion to reduce unnecessary transfusions and overuse. LOCAL PROBLEM: RBC transfusion is an overused procedure in cardiac surgery at a major academic medical center. Sources of overuse include the use of transfusions for avoidable indications and variability in transfusion practice between physicians within service lines. METHODS: Physician surveys and interviews were conducted to understand the current state of transfusion practice and identify metrics of meaning for a blood utilization audit and feedback system, a potential future component to a PBM program. Retrospective review of cardiac and noncardiac thoracic surgical cases were conducted to establish baseline RBC transfusion rates. Following the development and implementation of an audit and feedback system for cardiovascular and thoracic anesthesiology and surgery, analysis was conducted to detect any effect on the population at hand. INTERVENTIONS: The development of an audit and feedback system regularly reporting departmental and physician-specific trends in RBC transfusion practice aimed to inspire constructive self- evaluation and group discussion on areas of improvement. RESULTS: Anemia and RBC transfusion are highly prevalent in cardiac surgery and are associated with the increased incidence of adverse postoperative outcomes. Variability exists among service line physicians in terms of adherence to evidence-based restrictive transfusion guidelines. Physician feedback supports an audit and feedback system and strongly advocates for risk-adjusted peer comparisons and granular feedback regarding transfusion trends. Though the implementation of the audit and feedback system did not have a significant effect on various process and outcomes measures, it may be associated with an increase in single-unit transfusion orders. CONCLUSIONS: Data-driven audit and feedback, developed with physician collaboration and support, may be able to reduce avoidable RBC transfusions and improve perioperative transfusion practice by promoting thoughtful reflection and constructive conversation about current departmental trends and peer comparisons. However, such an effect may only be possible when the site at hand has enough capacity and infrastructure to support a widespread initiative.Item Development of the Liang Handover Assessment Tool for Simulation (L-HATS)(2020-05-01T05:00:00.000Z) Liang, Tyler; Greilich, Philip; Phelps, Eleanor; Reed, W. GaryINTRODUCTION: Clinical handovers are critical to patient safety and outcomes. Handover simulation prepares healthcare students for handoffs in the clinical setting upon graduation. UT Southwestern has developed a longitudinal handover educational curriculum in which student handovers will be assessed. Although valid and reliable tools exist for assessing clinical handovers, assessment tools adapted for the undergraduate simulation environment currently do not exist. Our objective was to develop a reliable and valid assessment tool that could be used by scholarly healthcare students to assess undergraduate simulated handovers throughout the longitudinal handover education curriculum. METHODS: A literature review was conducted to identify critical elements of high-quality, effective handovers. Following the tool's creation, we underwent several PDSA cycles to optimize the tool for medical student evaluation and ease of grading. Grader inclusion criteria were students who had completed the transition to clerkship (T2C) handover activity. A training curriculum was developed to train graders on proper use of the tool and to promote reliable grading with the tool. 62 pre-clinical student handovers were conducted in the simulation setting and recorded. The handovers were stratified into three levels (low, intermediate, and high quality), and 10 handovers were selected from each of the three levels for grading (30 handovers total). Each handover was scored by four clerkship medical students "graders". Two-way random effects intra-class correlation coefficients (ICC) were used to establish inter-rater reliability and inter-rater agreement among graders using the tool. Three external handover experts were used to establish the tool's validity using face validity. RESULTS: The product of this project is Liang Handover Assessment Tool for Simulation (L-HATS) which evaluated three domains: handover content, handover process, and language with a maximum score of 28. Two-way random effects ICC for agreement was 0.804, 95% CI [0.601, 0.906]. Two-way random effects ICC for reliability was 0.866, 95% CI [0.765, 0.930]. Three external handover experts have sufficiently validated the tool. CONCLUSIONS: The L-HATS had good to excellent inter-rater reliability and agreement. The L-HATS is the first reliable and valid handover assessment tool used for undergraduate simulation education. By using a two-way random effects model, the results suggest that the tool can be used in settings outside of the T2C handover simulation activity. Having good to excellent absolute agreement suggests that the tool is suitable for assigning grades. Future studies include comparing faculty vs student grading of handovers as well as evaluating the tool in the clinical setting.Item Evaluating the Effectiveness of a Teledermatology on System Utilization in a Safety-Net Public Health and Hospital System(2020-05-01T05:00:00.000Z) Wu, Lawrence Wen; Dominguez, Arturo R.; Chong, Benjamin F.; Hynan, Linda S.BACKGROUND: Teledermatology is a potentially useful and cost-effective modality for triaging patients in a primary care setting. However, the effect of teledermatology on health system utilization in a safety net hospital system has not been studied. OBJECTIVE: To determine the effect teledermatology on dermatological-problem related healthcare system utilization. Our hypothesis was that teledermatology would be associated with decreased dermatological-problem related healthcare system utilization. METHODS: The design is a retrospective cohort study comparing patients referred by Parkland Community Outpatient Clinics (COPC) primary care providers for dermatology evaluation during Fiscal Year 2016 (October 1st, 2015 and September 30th, 2016): 1) Patients evaluated through SAF teledermatology, 2). Patients from COPCs that did not have teledermatology available to them and were referred for a face-to-face visit. 3.) Patients from the COPCs in cohort 1 that had teledermatology available but were referred for a face-to-face visit instead. Data from 6 months prior to originating encounter and 18 months post originating encounter were measured. Statistical analysis with binary categorical repeated measures for a saturated model analyzed for significant variations in utilization. Health system utilization was measured at primary care clinics, dermatology and other specialty care clinics, urgent care clinic, and Emergency Room visits at Parkland Memorial Hospital. We compared the demographic, diagnostic, and clinical management data of the 3 cohorts. We measured sex, age, race/ethnicity, health care coverage, and diagnostic category for all 3 cohorts. The patients were classified as either having an inflammatory or neoplastic skin condition. The primary outcome was the percentage of patients with at least 1 visit in a 6-month time interval. Secondary outcomes measured were referral treatment capture rate, time to definitive treatment, and teledermatology response time. RESULTS: There were 809 total participants comprising the 3 cohorts, which were 64% female and with a mean age of 50.4 years. Baseline characteristics among groups were similar except for a higher proportion of eczematous conditions in the teledermatology cohort. Over the 24 month study period, total health system utilization, defined as the percentage of patients with at least 1 visit in each 6-month time interval measured over 4 intervals, was significantly greater for patients with inflammatory conditions receiving a face-to-face referral from both teledermatology and non-teledermatology-utilizing clinics compared to patients receiving teledermatology consults. There are no significant differences all combined, dermatology, and PCP clinic utilization between the face-to-face referrals from teledermatology and non-teledermatology-utilizing groups. CONCLUSION: This study provides evidence for the potential effectiveness of teledermatology improving access to care and reducing system utilization for patients with an inflammatory skin condition in a large safety-net public hospital system. There was no significant difference in utilization in patients with a neoplastic condition. Our results suggest additional benefits of utilizing a teledermatology system in a safety net hospital system.Item Improving cardiac care at Parkland: lessons learned from the quality improvement front line(2014-01-09) Das, Sandeep R.Item Improving Clinic Flow at an Academic, Safety-Net, Surgical Oncology Clinic(2019-04-01) Tran, Matthew; Reed, W. Gary; Phelps, Eleanor; Rabaglia, JenniferBACKGROUND: A high-volume, academic, safety-net, surgical oncology ambulatory clinic sees patients twice a week. As healthcare systems move towards pay-for-performance, maximum workflow and efficiency become critical to both patient access to care and experience. LOCAL PROBLEM: The clinic has inefficiencies causing excessive delays leading to high patient dwell times, which negatively affect patient and provider satisfaction. The purpose of this study is to use quality improvement tools to decrease these wait times. METHODS: Quality improvement tools, lean, and DMAIC (define, measure, analyze, improve, control) methodology was used to guide the project. The baseline for the clinic was established with patient dwell times, defined as patient check-in to check-out in the Epic system. A value stream map was created to identify value-add and non-value-add steps. Time studies, interviews, and Pareto charts were designed to assess top non-value-add times. Root cause analysis with a fishbone diagram was used to identify areas of opportunity for interventions. A prioritization matrix was generated to evaluate the most effective solutions, and the interventions were chosen after discussion with clinic staff. After their implementation, data were collected prospectively: Epic tracked dwell time data, and Press Ganey gathered patient satisfaction scores. The datasets before (March 2016 - March 2017) and after (April 2017 - April 2018) the intervention was compared using statistical analysis including t-tests and control charts. INTERVENTIONS: Two interventions were chosen: (1) Patients were pre-assigned to residents before clinic start time to reduce the time they spent reviewing the patient chart before the patient visit. (2) A centralized supply cart was introduced to improve clinic flow for procedures. RESULTS: During the pre-intervention period from March 2016 to March 2017, the Press Ganey survey reported a patient satisfaction score of 87 (n=27). This score is about two standard deviations below the benchmark of 93 (n=1,243). During the post-intervention period of April 2017 - April 2018, the Press Ganey score increased to 88 (n=23), but the response rate was <1%. During the pre-intervention, the mean dwell time in the clinic was 140.67 minutes (n=572) and 123.02 minutes (n=2,802) for new and follow-up patients, respectively. The post-intervention mean dwell times in the clinic were 117.35 minutes (n=589) and 110.64 minutes (n=2,137) for new and follow-up patients, or about a 17% and 10% reduction respectively. The reductions in dwell time were statistically significant with a p-value of <0.001. The control chart also revealed a special cause variation due to the intervention, which represented a trend of decreasing dwell times for patients. CONCLUSION: Quality improvement tools can be successfully used in this specific setting to streamline clinic flow and improve efficiency to reduce patient dwell times. The next steps are to continue collecting more robust data and iteratively refining the interventions. As the clinic continues to evolve other interventions will be considered for implementation. The success of these solutions can transfer to other clinics in the academic hospital.Item Improving Intra-Operative Parathyroid Hormone Result Times at the University Hospitals(2022-05) Wang, Virginia Y.; Reed, W. Gary; Nwariaku, Fiemu; Holt, Shelby A.Intra-operative parathyroid hormone (ioPTH) levels are the current gold standard for assessing completeness of resection in parathyroidectomy surgery. Due to the time-sensitive nature of these results, delays in processing ioPTH samples lead to non-value-added time (NVAT) in the operating room, which generates unnecessary financial burdens and potential safety hazards for both patients and the hospital system. Baseline analysis of data from 191 parathyroidectomy cases performed by the UT Southwestern Endocrine Surgery Group at Clements University Hospital (CUH) and the Outpatient Surgery Center (OSC) between September 2020 and April 2021 identified a statistically significant delay in the sample-to-lab interval time in cases at the OSC (mean of 27 minutes) compared to cases at CUH (mean of 8 minutes). The need for a lab courier at the OSC is likely a major contributor to this NVAT, as the OSC does not have an in-house lab. Though altering the lab infrastructure to make in-house ioPTH processing at the OSC would be the most effective way to equalize the delay, it was also infeasible within the time constraints of this project given the depth of high-level decision-making this would necessitate. I chose to focus instead on optimizing parathyroidectomy case preparation. I worked with CUH OR nursing clinical leads to modify the Epic template text of surgeon preference cards, which OR nursing staff use to prepare for cases. Analysis of pre- and post-change data from 43 parathyroidectomy cases performed in February and March of 2022 at CUH revealed post-change special cause variation in both the sample-to-lab and lab-to-result interval times. Moving forward, many other interventions are available to continue to improve team communication and knowledge sharing and protocolize contingency plans; further work also remains to be done to address logistical constraints at the OSC on an institutional level.Item Improving Nutritional Counseling in Hyderabad, India: A Pilot Study(2019-03-29) Kotamraju, Swetha; Reed, W. Gary; Patterson, Abigail M.; Phelps, Mary E.BACKGROUND: If not addressed before the age of five, pediatric undernutrition can lead to irreversible long term health effects, including death. Mild to moderate pediatric undernutrition specifically contributes to 83% of malnutrition-related deaths in children. India has one of the world's largest prevalence rates for mild to moderate pediatric undernutrition. In India, improving nutritional counseling for caregivers of undernourished children is the most effective and sustainable way to reduce the prevalence of pediatric undernutrition. LOCAL PROBLEM: Staff at the Niloufer Hospital nutritional counseling center in Hyderabad, India were concerned that their counseling sessions were not aligned with international guidelines for these sessions and consistent between patients. It was unknown how reliable these sessions were. Therefore, the aim of this study was to increase the reliability of the evidence-based practice for nutritional counseling given at a nutritional center in Hyderabad, India by 25% by March 2017. Reliability was defined as how often counseling sessions followed 100% of international guidelines appropriate for a given patient. METHODS: The quality improvement methodologies of DMAIC (Define-Measure-Analyze-Improve-Control) and PDSA (Plan-Do-Study-Act) were used. The design and improvement of the interventions was carried out with PDSA cycles within the larger DMAIC methodology. During the define phase, a project charter was established and it was found that locally adapted WHO-UNICEF counseling guidelines were the best practice for this setting. During the measure phase, observation of counseling sessions showed that the sessions were given orally by nurses, without visual aids, and were inconsistent from patient to patient. A study to measure reliability and compliance of current practices and future intervention was created. Compliance is the percentage of topics covered out of the total topics listed in the age-appropriate guidelines for a given session. Guidelines were grouped into three age groups: under six months, six months to 35 months and three years to five years. Baseline reliability and compliance scores were collected in the analyze phase. During the improve phase, checklists and subsequently, flipcharts, were created as interventions to improve counseling using multiple PDSA cycles for each intervention. Reliability and compliance scores were collected for sessions using each intervention. INTERVENTIONS: The first intervention created was a checklist, a low-cost tool shown to improve long-term compliance with standardized medical processes. The content of the final checklists was adopted from the WHO-UNIFEF guidelines that served as a standard for this setting. A checklist was made for each of the three age groups. The second intervention created was a flipchart, which is a booklet with illustrations and corresponding talking points on opposite pages. It is the most common visual aid used in nutritional counseling worldwide. The final version of the flipcharts was created by using infographics adopted from a UNICEF nutritional counseling flipchart for India and supplemental images created by the local staff. The talking points of the flipchart were based on the checklists created earlier in the study. A flipchart was created for each of the three age groups. RESULTS: Counseling reliability did not increase with either intervention and was 0% for all age groups during all phases. However, counseling compliance increased with both. All results are reported for the age groups in the following order: under six months, six months to 35 months, and three years to five years. The average counseling compliance during the baseline phase were 20.6% (SD=4.1), 24.2% (SD= 8.2), and 28.9% (SD = 5.2). The average counseling compliance during the checklist phase were 56.8% (SD = 7.8), 57.8% (SD = 13.8), and 57.7% (SD = 10.5). The average counseling compliance during the flipchart phase were 64.6% (SD= 7.3), 57.8% (SD = 10.3), and 70.8% (SD = 7.8).The largest increase in average compliance was between the baseline and flipchart phase and was 44.0%, 33.9%, and 41.9%. A one-way ANOVA with post-hoc comparisons compared the effect of the interventions on compliance during each phase. For the youngest and oldest group, the mean compliance during the checklist and flipchart phase was found to be significantly different than for the baseline phase and from each other. For the middle group, the mean compliance during the checklist and flipchart phase was found to be significantly different than for the baseline phase but not from each other. CONCLUSION: This pilot study showed that both checklists and flipcharts can improve compliance in this setting though neither helped achieve the target reliability. Flipcharts were a more successful and advantageous intervention than the checklists for increasing compliance. Additionally, this study demonstrated that quality improvement framework used was an effective model to develop sustainable interventions in low resource settings. Further studies are needed to determine if these interventions can be improved and expanded to wider use.Item Improving Physician Behavior with an Obstetric Dashboard(2018-03-29) Xiong, Katherine Brenda; Reed, W. Gary; Horsager-Boehrer, Robyn; Phelps, EleanorOVERVIEW: A major complication of vaginal births is severe perineal laceration, and it is now an obstetric quality measure (AHRQ and The Joint Commission). One major risk factor of anal sphincter lacerations is episiotomy. National quality benchmarks recommend restricted use of episiotomy (in the absence of an indication like shoulder dystocia), with a recommended benchmark rate of less than 5.0% (Leapfrog) to reduce the occurrence of severe anal sphincter injuries. AIM STATEMENT: The aim of the primary phase was to reduce the episiotomy utilization by individual providers outside of the national benchmark by 10% and reduce the institutional rate by at least 25.0% in 6 months. The aim of the second phase was to reduce the frequency of severe perineal lacerations by 25% at CUH in 6 months. MEASURES OF SUCCESS: Incidence rate of episiotomy utilization by specific providers in spontaneous vaginal deliveries without shoulder dystocia and the incidence rate of severe perineal laceration in spontaneous vaginal deliveries without shoulder dystocia. INTERVENTIONS: In the primary phase, we instituted scheduled notifications of providers' episiotomy utilization rates using a physician dashboard. For our second project, heat pack application in the late first stage of labor was instituted. RESULTS: Following dashboard implementation, there was significant reduction in the institutional rate of episiotomy (9.0% pre-intervention vs. 2.7% post-intervention, p<0.001). However, no significant reduction in the frequency of severe perineal lacerations was observed (2.42% pre-intervention vs. 1.14% post-intervention, p=0.08). In the second study, we found the baseline incidence rate of severe perineal laceration to be 3.06% with no significant change in the incidence rate following initiation of our heat pack intervention (3.47% in the last quarter, p= 0.20). CONCLUSIONS AND NEXT STEPS: When variation in physician performance exists, utilization of a physician dashboard comparing individual provider behavior to peers can result in a significant improvement in provider and institutional performance on specific metrics.Item Improving Protocol Adherence in Central Line Placements(2022-05-01T05:00:00.000Z) Roy, Mathews Francis; Goff, Kristina L.; Yager, Ashley; Reed, W. GaryBACKGROUND: The placement of central lines is a very common exercise in medicine. Central lines are required for everything from acute trauma scenarios to long term cancer treatments. However, this ubiquitous procedure has several morbid complications that are not uncommon. Possible complications include infection, catheter misplacement, arterial puncture, hematoma, pneumothorax, and death[1]. Not only are the complications severe they are also quite prevalent with a complication rate of 15 to 25 percent[2]. LOCAL PROBLEM: Due to a concern for the rates of central line infections across campuses at the University of Texas Southwestern Medical Center (UTSW) there was a project underway to create a standardized central line placement protocol for all departments in the system. This protocol was taught to all incoming residents on a simulation session day. However, because a significant period of time can pass between central line training and the clinical practice of placing central lines, the rate of resident retention and adherence to the standardized procedure for central line placement is unknown. This report describes the results of a QI experiment meant to reduce the rate of catheter associated blood stream infections and ensure better resident protocol adherence at UTSW medical center using checklists and visual aids to ensure implementation of the standardized protocols. METHODS: The study was split into three phases. The first phase examined the baseline knowledge of UTSW residents regarding the placement of central lines and found the nursing position regarding possible interventions. The residents were interviewed regarding the standardized UTSW protocol and asked to detail the steps of placing a central line. The results were used to analyses areas of weakness in protocol adherence. Based on the results of the interviews, a checklist and visual aid were created highlighting key steps to ensure the adherence to the protocol. In phase two, to evaluate the feasibility of incorporating a checklist and CVA into the original CVC insertion methodology, a simulated pilot was conducted, and a survey was completed by the participants to determine how staff perceived the use of these new tools. In phase three after analyzing the ability to integrate the checklist and visual aid in a simulated setting, the utility of using a checklist to improve CVC insertions was tested by conducting a pilot study on real patients. During the pilot, CVCs placed in the ICU were observed by a medical student with the bedside nurse's participation and real time completion of the checklist RESULTS: Phase 1: It was found that there were significant variations in the average adherence between departments and training years. On average, post graduate year (PGY)3s did better than PGY2s. Furthermore, it was found that 50% of missed steps were caused by only 8 out 36 questions and 75% of mistakes were caused by just 15 out of 36 questions. Phase 2: Simulated pilot Survey results showed that all participants felt that their team successfully followed the standardized placement method. The participants also said that the implemented huddle helped to create teamwork and organization, and that it could easily be incorporated into the normal workflow. Phase 3: In-practice pilot All trial participants were asked for feedback regarding the perceived benefit of the process. Results were very positive with most participants saying that they thought that the new workflow was helpful and easy to implement. Analysis of the completed checklists show that participants were able to complete the forms without issue ensuring that complete adherence to the standardized protocol was possible. CONCLUSIONS: By interviewing residents to understand areas of difficulties and going through a multistep approach to ensure safety and efficacy of interventions, this project provides insight into the possible gaps in resident procedure adherences and retention of the UTSW protocol. It then also provides an intervention that strengthen the memory of the preforming physician and a layer of oversight to ensure that even if a mistake is made it is quickly corrected. The general concepts of simulation trials prior to clinical application and utilization of a checklist and cognitive visual aid can be applied not only to central lines at UTSW, but to many different procedures across multiple hospital systems.Item Improving survival & reducing racial disparities in cardiac arrest(2023-05-19) Girotra, SaketItem 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.Item Improving the Reliability of the Clements University Hospital OR to CV-ICU Patient Handover Observer Training Program(2017-04-03) Thangada, Neela D; Reed, W. Gary; Greilich, Philip; Barker, BlakeOR to CV-ICU patient handovers reflect high risk clinical scenarios where providers must transfer patient care responsibilities in the safest possible way. These post-sternotomy handovers are error prone, as providers must exchange patient information in a busy and chaotic environment while simultaneously stabilizing the often tenuous patient who requires hemodynamic and cardiopulmonary support. At UT Southwestern's University hospital, patient handoffs and transitions of care have less than a 50% approval rating per HSOPS data, suggesting a serious need for improving patient handovers. The Clements University Hospital (CUH) OR to CV-ICU observer training program was developed to train a cohort of clinicians who can evaluate post-sternotomy handovers and subsequently make recommendations for improving these handovers. The aim of this project is to improve the reliability and user satisfaction of the existing CUH OR to CV-ICU patient handover observer training program by January 2017. The performance results of the six observers who underwent the first iteration of the observer training program were reviewed. All six observers achieved greater than 80% agreement with the faculty expert, or master key, in their evaluation of handover scenarios from the training videos, suggesting an adequate understanding of how to evaluate a OR to CV-ICU handover. However, observers did not achieve a sufficient inter-rater reliability, with a suboptimal average Fleiss' kappa of 0.65. Since sufficient percent agreement and inter-rater reliability are both required to deem observers appropriately trained, these six observers did not meet the criteria to become 'trained observers.' To understand observers' challenges and overall satisfaction with the training program, a focus group analysis was performed. Elements critical-to-quality for the observer were identified, which included better teaching of handover best practice requirements so observers can more confidently evaluate the handovers.Item Investigation of Practice Facilitator Workflows for Enrollment Enhancement in ICD-Pieces Study(2018-03-22) Sakai, Mark; Reed, W. Gary; Vazquez, Miguel A.; Oliver, GeorgeBACKGROUND: Care for patients with multi-morbidities is challenging and often suboptimal. Earlier detection of patients with coexisting Chronic Kidney Disease (CKD), diabetes and hypertension served by our health care systems will allow us to institute appropriate care for the right patient at the right time with the right intervention thereby providing the greatest benefit. Implementation of interventions to treat CKD, diabetes, and hypertension and to treat associated conditions should reduce cardiovascular mortality and morbidity, improve clinical status, and reduce hospitalization and costs. A collaborative model approach to care for patients with multiple chronic conditions using the unique and novel technology platform provided by Pieces (Parkland intelligent e-coordination and evaluation system) is being investigated via pragmatic clinical trial. OBJECTIVE: The main hypothesis is that patients with CKD, hypertension and diabetes who receive care with a collaborative model of primary care-subspecialty care enhanced by novel information technology (Pieces) will have fewer hospitalizations, readmissions, CV events and deaths than patients receiving standard medical care. METHODS: The study employs a prospective stratified cluster randomization design involving four healthcare systems which are the stratum: Parkland Healthcare Systems, Texas Health Resources (THR), North Texas Veterans Affairs, and ProHealth Connecticut. Each of the four healthcare systems are unique in the populations that they serve, the electronic medical records that they utilize, and the qualifications of the practice facilitators that they employ. Practice facilitators at each of the participating sites received training on how to leverage the enhanced resources provided by Pieces. The practice facilitators are a crucial link that ensure consistent incorporation of Pieces technology into the care of patients selected for the intervention group of the study. The four unique practice facilitator workflows were diagrammed and proofed for accuracy. Challenges in the process identified by the practice facilitator were also cataloged. Similarities and differences noted in the workflows allowed the identification of the highest yield areas for improvement. Comparison of each of the four unique workflows to the original, "generic" workflow as well as to each other helped identify challenges consistent across all of the systems as well as ones unique to each system. RESULTS: The major challenge identified by each practice facilitator was the accuracy of the generated confirmed and candidate patient lists that they have been receiving. This led to decreased patient enrollments and resulted in the practice facilitators performing a manual survey of each patient. The inaccuracy of the lists was an indictment of the patient selection algorithm and leads one to question if all candidate patients were being identified. Other challenges identified by every practice facilitator included initial resistance from PCPs, missed appointments, and obtaining labs prior to appointments. Individually, each practice facilitator identified challenges that were unique to their situation. These challenges included the inability to sign lab orders, high overall workloads for pharmacists, and the inability to determine if PCPs had taken note of protocol recommendations. CONCLUSION: Investigation and comparison of the practice facilitator workflows at each of the four healthcare systems aided in the identification of shortfalls and challenges that have hindered the patient enrollment process. These workflows will be useful in future pragmatic studies that utilize the EMR in the identification of a patient population. It is also generally instructive for studies that seek to utilize EMRs to identify patient populations. Despite the theoretical efficacy of informatics application in healthcare, there is still much progress to be made in this arena. Nevertheless, the study as a whole will be an important part of the growing collection of pragmatic trials due to their increased external validity compared to traditional explanatory trials. It will also ultimately be a valuable learning tool in the construct and execution of future pragmatic trials and hopefully demonstrate that a collaborative model of primary care-subspecialty care that leverages information technology can improve the quality of patient care.Item Looking Back on Creating a COVID Telemedicine(2022-05-01T05:00:00.000Z) Murtuza, Mohammad Imran; Reed, W. Gary; Croft, Carol; Phelps, EleanorBACKGROUND: In March 2020, the Dallas Fort Worth (DFW) Metroplex experienced a surge in acute COVID-19 infections. At that time, no consistent protocols existed for follow-up of discharged patients with COVID-19 from the William P. Clements Jr. University Hospital at the University of Texas Southwestern Medical Center (UTSW). Simultaneously, medical students were suspended from in-person clinical activities to limit viral spread. In response to these events, a telemedicine elective was created to provide timely and high-quality telehealth follow-up for recently discharged COVID-19 patients from April of 2020 to July of 2020. METHODS: The pilot team, consisting of several second- through fourth-year medical students, developed a call script that included warning signs and symptoms, CDC guidelines for isolation, and primary care physician referral information. COVID-19 patients discharged from the Emergency Department and inpatient services were identified and assigned to student callers. All patients were discussed with an attending physician, who was available if an acute issue arose. The elective also included education on the SBAR handover technique, telehealth education, updated COVID-19 literature, and CDC guidelines. RESULTS: Improvement was noted in students' ability to identify patients who required escalation of care, as seen by over 60% of patients who were advised to return to ED required hospital admission. Statistically significant improvement was observed in the students' degree of feeling informed about the current state of COVID-19 and their degree of comfort with interviewing patients over the phone. DISCUSSION: This elective provided quality virtual healthcare to COVID-19 patients while allowing medical students to progress in their medical education and participate in patient care. This elective was an example of an early adopter of telemedicine in COVID-19 follow up. Now two years into the COVID-19 pandemic, the CDC, NIH, and health systems all around the United States have made virtual visits commonplace when treating patients with COVID-19 and beyond.Item The M&M conference: let's stop sugar-coating the facts(2022-06-03) Desai, ShivaniItem Non-Home Discharge and Prolonged Length of Stay after Cytoreductive Surgery and HIPEC(2018-01-23) Burguete, Daniel; Mokdad, Ali A.; Augustine, Martin M.; Minter, Rebecca; Mansour, John C.; Choti, Michael A.; Polanco, PatricioINTRODUCTION: The ability to preoperatively anticipate prolonged length of stay (PLOS) or transition to an extended care facility (non-home discharge, i.e., NHD) may facilitate discussion of patient expectations and improve utilization of hospital resources. No data has been reported on the rate and risk factors associated with NHD and PLOS in patients following cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for peritoneal carcinomatosis. The aim of this study is to identify risk factors for NHD and PLOS following CRS/HIPEC in a national cohort of patients. METHODS: Patients that underwent CRS/HIPEC from 2011-2012 were identified from the National Surgical Quality Improvement Project (NSQIP) dataset. NHD/PLOS and home discharge (within 30 days) groups were compared using Pearsonメs chi-squared test and two-sample t-test with unequal variances. A univariate analysis was used to compare patient demographics, diagnosis, comorbidities, CCI, operative details and types of resection and post-operative complications among both groups. A multivariate analysis was used to identify independent predictors of NHD and PLOS. RESULTS: A total of 556 CRS/HIPEC patients were identified, 44 (7.9%) of which were not discharged to home within 30 days. From these 44 patients, 12 were discharged to a skilled care facility and 11 were discharged to a rehabilitation facility, accounting for a NHD rate of 4.1%. Twenty-one patients remained hospitalized at ~30 days accounting for a PLOS rate of 3.7% On univariate analysis, advancing age, COPD, HTN, and low preoperative albumin were identified as preoperative risk factors for NHD/PLOS (p<0.05). On multivariate analysis, age ≥ 65, pre-op albumin < 3.0 g/dL, and having a multi-visceral resection were identified as independent predictors of NHD/PLOS. If all three predictors are met preoperatively, the probability of NHD/PLOS is 30.2%. CONCLUSION: In this national cohort of patients, advanced age, hypoalbuminemia, and multi-visceral resection constituted the main risk factors for NHD/PLOS following CRS/HIPEC. Timely identification of these risk factors may facilitate preoperative discussions with patients, and improve discharge planning and resource utilization.Item Optimizing Faculty Recruitment for Quality Enhancement Plan Programs at UT Southwestern(2020-03-18) Bordas, Jozsef Taksony; Reed, W. Gary; Greilich, Philip; Michael, MeghanBACKGROUND: Patient handovers serve as a major source of preventable adverse patient outcomes in healthcare settings. While standardization of this process can help reduce error, no consensus exists as to the best method of improving handover education. One potential method would focus on optimizing the recruitment of faculty scholars as leaders of new courses, thereby providing strong leadership as well as reducing recruitment and retention costs for institutions. Improved handover education will ensure that future physicians are prepared to work as effective members of healthcare teams and as a result improve patient care and safety. LOCAL PROBLEM: At UT Southwestern, the Team FIRST initiative seeks to improve handover education through creating new courses addressing this topic. However, faculty will need to be successfully recruited to ensure their success. Current faculty recruitment practices need to be identified in order to guide the optimal approach for maximizing the number of faculty scholars identified among potential candidates for course leadership. METHODS: Based on the emphasis of incorporating simulation education into the new educational activities comprising Team FIRST, learning communities at UT Southwestern utilizing simulation education were identified and faculty in either recruiter or recruit roles in each were identified. These faculty would serve as the source of data on current recruitment practices. Two sets of questions were created and used to guide 30-minute standardized interviews with the selected faculty in five different learning communities at UT Southwestern. Questions focused on outlining motivators and deterrents for position acceptance, ideal characteristics of candidates, steps in the recruitment process, and faculty development opportunities available after hire. Questions were revised as appropriate to improve the yield of pertinent data. The data from each interview was used to create a process map outlining the recruitment process for each educational program. These along with summaries of the question responses were sent back to interviewed faculty for verification of accuracy. Process maps were compared to identify general patterns in recruitment at UT Southwestern, and the responses to the other questions were tabulated for easy comparison and review. The patterns identified based on the data collected were used to create an application that will be used for faculty recruitment for the Team FIRST educational activities in upcoming years. INTERVENTIONS: The interventions used included the interview questions asked of faculty, which served to obtain data on and outline current recruitment practices at UT Southwestern. This information was then used to create an application for the newly created educational activities comprising Team FIRST, which will be evaluated to determine its reliability in identifying highly-invested faculty scholars from among the potential faculty candidates. RESULTS: Recruiters sought individuals with previous experience related to the position they were seeking and used student evaluations of faculty members to evaluate the quality of their previous engagements. Recruiters also emphasized enthusiasm, motivation, and realistic expectations as additional ideal characteristics. Recruiters identified financial incentives, opportunities for career development and advancement, and contribution to student growth as potential motivators for accepting a position, while time constraints and limited financial compensation were identified as deterrents. From the recruit perspective, an interest in teaching, departmental and student advocacy, and innovation served as both ideal characteristics and motivators for seeking a position while a lack of time, promotion, and tenure opportunities served as deterrents. The first step of faculty recruitment processes at UT Southwestern was the identification of a potential candidate either by invitation by higher-level faculty involved in the program or due to expressed interest by the candidate in the program which then led to their compilation into a list for consideration for the position. Once a current position opened, or new positions were created due to expansion of the program, the candidate's suitability for the position was assessed using an application often requiring endorsement from the department chair. Once an individual was selected, they would receive onboarding training to prepare them for the position in the program. CONCLUSION: Through multiple discussions with faculty in various learning communities, general pattern and trends in faculty recruitment practices at UT Southwestern were outlined. Based on these similarities, ideal faculty recruit characteristics were identified that could be used to guide the creation of an application for to help with the faculty recruitment process for the educational activities that make up Team FIRST. Through using this application and revising it as needed to improve the rate at which faculty scholars are identified, faculty recruitment can be optimized to ensure strong leadership for new courses aiming to improve patient handover education.Item Reduce infections together in everyone: a concept and a hospital program(2018-09-07) Sreeramoju, Pranavi