Establishing a culture of highly reliable quality care

Reliability is the likelihood that a process will perform a required function without failure, consistent over time and personnel changes. In the rapidly evolving healthcare landscape, reliably delivering excellent surgical care demands a comprehensive and systematic approach. Accomplishing this task is beyond the reach of any individual clinician, administrator, or leader. The team must work together to establish a highly reliable quality care culture that serves as the foundation for safe, patient-centered practice. High reliability thus inherently relies on transdisciplinary collaboration, with every level of clinical, administrative, and regulatory team members actively communicating, supporting each other, and building trust in each other's expertise. Here, we discuss the fundamentals of establishing a highly reliable quality care culture. We outline the key principles of a highly reliable organization - preoccupation with failure, sensitivity to operations, reluctance to oversimplify, commitment to resilience, and deference to expertise - and the characteristics of teams that can effectively implement these principles. We discuss the importance of standardization, continuous process and outcome measurement, and setting collective goals. And finally, we exemplify these fundamentals through a brief case study. In outlining these foundational concepts for today's care, we also look forward to the impact of big data, artificial intelligence, and interconnectedness on our future continuous quality improvement efforts. Within the myriad complexities of surgical care, there are bound to be adverse outcomes, but by instilling a culture of highly reliable quality care, we can do our best to minimize their frequency, mitigate their harm, and optimize outcomes.

Accuracy of Trauma Surgeons Prospective Estimation of the Injury Severity Score: A Pilot Study

Injury Severity Score (ISS) has limited utility as a prospective predictor of trauma outcomes as it is currently scored by abstractors post-discharge. This study aimed to determine accuracy of ISS estimation at time of admission. Attending trauma surgeons assessed the Abbreviated Injury Scale of each body region for patients admitted during their call, from which estimated ISS (eISS) was calculated. The eISS was considered concordant to abstracted ISS (aISS) if both were in the same category: mild (<9), moderate (9-15), severe (16-25), or critical (>25). Ten surgeons completed 132 surveys. Overall ISS concordance was 52.2%; 87.5%, 30.8%, 34.8%, and 61.7% for patients with mild, moderate, severe, and critical aISS, respectively; unweighted k = .36, weighted k = .69. This preliminarily supports attending trauma surgeons' ability to predict severity of injury in real time, which has important clinical and research implications.

Improving Statewide Post-Operative Sepsis Performance Measurement Using Hospital Risk Adjustment Within a Surgical Collaborative

Background: The Georgia Quality Improvement Program (GQIP) surgical collaborative participating hospitals have shown consistently poor performance in the post-operative sepsis category of National Surgical Quality Improvement Program data as compared with national benchmarks. We aimed to compare crude versus risk-adjusted post-operative sepsis rankings to determine high and low performers amongst GQIP hospitals. Patients and Methods: The cohort included intra-abdominal general surgery patients across 10 collaborative hospitals from 2015 to 2020. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) sepsis definition was used among all hospitals for case abstraction and NSQIP data were utilized to train and validate a multivariable risk-adjustment model with post-operative sepsis as the outcome. This model was used to rank GQIP hospitals by risk-adjusted post-operative sepsis rates. Rankings between crude and risk-adjusted post-operative sepsis rankings were compared ordinally and for changes in tertile. Results: The study included 20,314 patients with 595 cases of post-operative sepsis. Crude 30-day post-operative sepsis risk among hospitals ranged from 0.81 to 5.11. When applying the risk-adjustment model which included: age, American Society of Anesthesiology class, case complexity, pre-operative pneumonia/urinary tract infection/surgical site infection, admission status, and wound class, nine of 10 hospitals were re-ranked and four hospitals changed performance tertiles. Conclusions: Inter-collaborative risk-adjusted post-operative sepsis rankings are important to present. These metrics benchmark collaborating hospitals, which facilitates best practice exchange from high to low performers.

Generalizability of COBRA: A Parsimonious Perioperative Venous Thromboembolism Risk Assessment Model

INTRODUCTION

Standardized use of venous thromboembolism (VTE) risk assessment models (RAMs) in surgical patients has been limited, in part due to the cumbersome workflow addition required to use available models. The COBRA score-capturing cancer diagnosis, (old) age, body mass index, race, and American Society of Anesthesiologists Physical Status score-has been reported as a potentially automatable VTE RAM that circumvents the cumbersome workflow addition that most RAMs represent. We aimed to test the ability of the COBRA model to effectively risk-stratify patients across various populations.

METHODS

Patients were included from the 2014-2019 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Participant Use Data File for two hospitals, representing colorectal, endocrine, breast, transplant, plastic, and general surgery services. COBRA score was calculated for each patient using preoperative characteristics. We calculated negative predictive value (NPV) for VTE outcomes and compared the COBRA score to NSQIP's expected VTE rate for all patients, between the two hospitals, and between subspecialty service lines.

RESULTS

Of the 10,711 patients included, those with COBRA <4 (31%) had projected median VTE rate of 0.21% (interquartile range, 0.09-0.68%; mean, 0.54%). Patients with higher scores (69%) had median rate of 0.88% (0.26-2.07%; 1.46%); relative rate 2.7. The median projected VTE rates for patients identified as low risk were 0.21% and 0.16% and as high risk were 0.87% and 0.89% at hospitals one and 2, respectively. The median projected VTE rates for patients identified as low risk were 0.17%, 0.61%, and 0.08% and as high risk were 0.52%, 1.43%, and 0.18% among general, colorectal, and endocrine surgery patients, respectively. COBRA had NPV of 0.995 and sensitivity of 0.871 as compared to NPV 0.997 and sensitivity 0.857 of the NSQIP model.

CONCLUSIONS

The COBRA score is concordant with the traditional gold standard NSQIP VTE RAM and demonstrates interhospital and service-specific generalizability, although performance was limited in especially low-risk patients. The model adequately risk-stratifies surgical patients preoperatively, potentially providing clinical decision support for perioperative workflows.

A Self-Sustaining Antibiotic Prophylaxis Program to Reduce Surgical Site Infections

Background: Our multi-institutional healthcare system had a higher-than-expected surgical site infection (SSI) rate. We aimed to improve our peri-operative antibiotic administration process. Gap analysis identified three opportunities for process improvement: standardized antibiotic selection, standardized second-line antibiotic agents for patients with allergies, and feedback regarding antibiotic administration compliance. Hypothesis: Implementation of a multifaceted quality improvement initiative including a near-real-time pre-operative antibiotic compliance feedback tool will improve compliance with antibiotic administration protocols, subsequently lowering SSI rate. Methods: A compliance feedback tool designed to provide monthly reports to all anesthesia and surgical personnel was implemented at two facilities, in September 2017 and December 2018. Internal case data were tracked for antibiotic compliance through June 2021, and these data were merged with American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data at the case level to provide process and outcome measures for SSIs. Implementation success was evaluated by comparing protocol compliance and risk-adjusted rates of superficial and deep SSI before and after the quality improvement implementation. Results: A total of 20,385 patients were included in this study; 11,548 patients in the pre-implementation and 8,837 in the post-implementation groups. Baseline patient and operative characteristics were similar between groups, except the post-implementation group had a higher median expected SSI rate (2.2% vs. 1.6%). Post-implementation, antibiotic protocol compliance increased from 86.3% to 97.6%, and superficial and deep SSIs decreased from 2.8% to 1.9% (p < 0.001). The odds of superficial and deep SSI in patients in the post-implementation group was 0.69 (0.57, 0.83) times the odds of superficial and deep SSI in pre-implementation patients while adjusting for age, gender, diabetes mellitus, American Society of Anesthesiologists Physical Status (ASA) classification, wound class, smoking, and chronic obstructive pulmonary disease (COPD). Observed-to-expected ratios of superficial and deep SSI decreased from 0.82 to 0.48 after the intervention. Conclusions: Surgical antibiotic prophylaxis standardization and providing near-real-time individualized feedback resulted in sustained improvement in peri-operative antibiotic compliance rates and reduced superficial and deep SSIs.

Epidemiology and Post-Discharge Resource Utilization of Isolated Traumatic Brain Injury in Geriatric Patients

Benchmark data on traumatic brain injury (TBI) are potentially confounded by morbidity and rehabilitation needs associated with coincident extracranial injuries. Using data on isolated head injuries from 13 trauma centers in Georgia over 3 years, we studied the epidemiology and natural history of isolated TBI in geriatric vs non-geriatric patients in order to identify potential areas for quality improvement. We identified 8 512 patients, 3 895 of whom were geriatric. Geriatric patients had higher baseline comorbidity burden, mostly presented after ground level falls, had higher mortality despite equivalent ICU admission rates, and had higher rates of post-discharge resource utilization than non-geriatric counterparts. Geriatric patients are more likely to require post-discharge services and/or facility placement, regardless of pre-injury functional status. These data highlight the importance of streamlined protocols that place an early focus on post-discharge needs and goals of care, informed by cohort-specific prognosis data.

Which Procedures Contribute Most to the System-Wide Burden of Postoperative Venous Thromboembolism?

BACKGROUND

While clinical risk assessment models examine patient-level characteristics that portend morbidity, there is a paucity of literature exploring which procedures contribute most to the system-wide burden of venous thromboembolism (VTE). We aimed to identify highly contributory procedures as potential targets for quality improvement.

METHODS

All patients in the 2020 National Surgical Quality Improvement Program (NSQIP) Public User File were included. Current Procedural Terminology (CPT) codes were analyzed individually and grouped by National Healthcare Safety Network groupings. We counted prevalence of VTE and calculated VTE rate for each CPT and for each grouping.

RESULTS

Of 902,968 included patients, 7501 (.83%) sustained postoperative VTE. Of 2748 unique CPT codes, VTE occurred for 762 (28%). Twenty procedure codes (.7%) contributed 39% of the total VTE. VTE rates of these procedures ranged from high-volume procedures with low VTE rates such as laparoscopic cholecystectomy (.25%) and laparoscopic hysterectomy (.32%) to lower volume procedures with high VTE rate such as Hartmann's procedure (4.32%), Whipple procedure (3.85%), and distal pancreatectomy (3.82%). The CPT grouping with the most VTE was colon surgeries (1275/7501).

DISCUSSION

A small number of procedures contributes to the system-wide burden of VTE. High-risk procedures are important targets for standardized prophylaxis protocols. For low-risk procedures, careful attention should be paid to patient-specific factors that may increase VTE risk such as obesity, cancer, or limited mobility, as many common procedures contribute greatly to the systemic burden of VTE. Overall, surveillance can perhaps be targeted on a smaller number of procedures, allowing for more efficient use of quality improvement resources.

Straining to Put the Pieces Together: The Molecular Structure of (E)-1-Chloro-1,2-difluoroethylene-Acetylene from Microwave Spectroscopy

The microwave, rotational spectrum between 5.6 and 19.7 GHz of the gas-phase heterodimer formed between acetylene and (E)-1-chloro-1,2-difluoroethylene is obtained using both broadband, chirped-pulse and narrow band, Balle-Flygare Fourier transform microwave spectrometers. The structure of the complex is determined from the rotational constants obtained via the analysis of the spectra for the normal isotopologue of the complex and three isotopically substituted species: the singly substituted ³⁷Cl isotopologue, obtained in natural abundance, and two isotopologues singly substituted with ¹³C, obtained using an isotopically enriched HC¹³CH sample. The acetylene forms a hydrogen bond with the fluorine atom on singly halogenated carbon and a secondary interaction with the hydrogen atom on that same carbon. The angle strain induced in forming the secondary interaction is offset by the favorable electrostatics of the hydrogen bond to fluorine. Comparisons with acetylene complexes of 1,1,2-trifluoroethylene and cis-1,2-difluoroethylene show the effects of halogen substitution at the remote carbon on this bonding motif.

Outcomes of same admission cholecystectomy and endoscopic retrograde cholangiopancreatography for common bile duct stones: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND

The optimal timing for cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) stones is unknown. We hypothesized that a delay between procedures would correlate with more biliary complications and longer hospitalizations.

METHODS

We prospectively identified patients who underwent same admission cholecystectomy after ERCP for CBD stones from 2016 to 2019 at 12 US medical centers. The cohort was stratified by time between ERCP and cholecystectomy: ≤24 hours (immediate), >24 to ≤72 hours (early), and >72 hours (late). Primary outcomes included operative duration, postoperative length of stay, (LOS), and hospital LOS. Secondary outcomes included rates of open conversion, CBD explorations, biliary complications, and in-hospital complications.

RESULTS

For the 349 patients comprising the study cohort, 33.8% (n = 118) were categorized as immediate, 50.4% (n = 176) as early, and 15.8% (n = 55) as late. Rates of CBD explorations were lower in the immediate group compared with the late group (0.9% vs. 9.1%, p = 0.01). Rates of open conversion were lower in the immediate group compared with the early group (0.9% vs. 10.8%, p < 0.01) and in the immediate group compared with the late group (0.9% vs. 10.9%, p < 0.001). On a mixed-model regression analysis, an immediate cholecystectomy was associated with a significant reduction in postoperative LOS (β = 0.79; 95% confidence interval, 0.65-0.96; p = 0.02) and hospital LOS (β = 0.68; 95% confidence interval, 0.62-0.75; p < 0.0001).

CONCLUSION

An immediate cholecystectomy following ERCP correlates with a shorter postoperative LOS and hospital LOS. Rates of CBD explorations and conversion to open appear more common after 24 hours.

LEVEL OF EVIDENCE

Therapeutic, level III.

Development of a Novel Preoperative Venous Thromboembolism Risk Assessment Model

INTRODUCTION

Standardization of preoperative venous thromboembolism (VTE) risk assessment remains challenging due to variation in risk assessment models (RAMs) and the cumbersome workflow addition that most RAMs represent. We aimed to develop a parsimonious RAM that is automatable and actionable within the preoperative workflow.

METHODS

We performed a case-controlled review of all 18 VTE cases reported over a 12-month period and 171 matched controls included in an institutional National Surgical Quality Improvement Project (NSQIP) data set. We examined the predictive value of the Caprini, Padua, and NSQIP RAMs. We identified the 5 most impactful risk factors in VTE development by contribution to the known RAMs. We compared the predictive ability of cancer, age, body mass index, black race, and American Society of Anesthesiologists Physical Status (ASA-PS) score, to the Caprini, Padua, and NSQIP RAMs for VTE outcomes. Finally, we evaluated concordance between each of the models.

RESULTS

The Caprini Score was found to be 88.9% sensitive and 32.7% specific using a threshold of 5. The Padua score was found to be 61.1% sensitive and 47.4% specific using a threshold of 4. The novel 5-factor RAM was found to be 94.4% sensitive and 38.0% specific using a threshold of 4. The Caprini and Padua models were discordant in 26% of patients.

DISCUSSION

Cumbersome manual data entry contributes to the ongoing challenge of standardized VTE risk assessment and prophylaxis. Universally documented information and patient demographics can be utilized to create clinical decision support tools that can improve the efficiency of perioperative workflow and improve the quality of care.

Neuropsychologic changes in primary hyperparathyroidism after parathyroidectomy from a dual-institution prospective study

BACKGROUND

The impact of parathyroidectomy on neuropsychiatric symptoms in primary hyperparathyroidism remains poorly defined. The validated scales Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 can be used to assess depression and anxiety, respectively. Our aim was to prospectively characterize the changes in neuropsychiatric symptoms after parathyroidectomy.

METHODS

Patients undergoing parathyroidectomy and thyroidectomy (control) from two institutions between 2014 and 2019 were prospectively administered a questionnaire assessing neuropsychiatric symptoms before and after surgery. Paired t tests compared preoperative with postoperative neuropsychiatric symptoms and t tests compared differences in neuropsychiatric symptoms between parathyroidectomy and thyroidectomy.

RESULTS

A total of 244 patients underwent parathyroidectomy and 161 underwent thyroidectomy. We observed improvement in neuropsychiatric symptoms after parathyroidectomy (6.2 [5.0-7.4], P < .01). Preoperatively, neuropsychiatric symptoms were more prevalent in patients undergoing parathyroidectomy when compared with thyroidectomy (11.2 ± 11.5 vs 7.5 ± 8.2, P < .01); however, after surgery there was no difference between the two groups (5.1 ± 7.1 vs 5.4 ± 7.2, P = .59). Preoperatively, 27.5% and 18.0% of patients endorsed moderate to severe depression and anxiety, which fell to 8.2% and 5.3%, respectively, (P < .01) after surgery.

CONCLUSION

Patients undergoing parathyroidectomy showed significant improvement in neuropsychiatric symptoms after surgery. Neuropsychiatric symptoms are more prevalent in patients with primary hyperparathyroidism. Neuropsychiatric symptoms should be assessed in all patients with primary hyperparathyroidism and should be considered a relative indication for parathyroidectomy.

Use, Perceived Usability, and Barriers to Implementation of a Patient Safety Dashboard Integrated within a Vendor EHR

BACKGROUND

Preventable adverse events continue to be a threat to hospitalized patients. Clinical decision support in the form of dashboards may improve compliance with evidence-based safety practices. However, limited research describes providers' experiences with dashboards integrated into vendor electronic health record (EHR) systems.

OBJECTIVE

This study was aimed to describe providers' use and perceived usability of the Patient Safety Dashboard and discuss barriers and facilitators to implementation.

METHODS

The Patient Safety Dashboard was implemented in a cluster-randomized stepped wedge trial on 12 units in neurology, oncology, and general medicine services over an 18-month period. Use of the Dashboard was tracked during the implementation period and analyzed in-depth for two 1-week periods to gather a detailed representation of use. Providers' perceptions of tool usability were measured using the Health Information Technology Usability Evaluation Scale (rated 1-5). Research assistants conducted field observations throughout the duration of the study to describe use and provide insight into tool adoption.

RESULTS

The Dashboard was used 70% of days the tool was available, with use varying by role, service, and time of day. On general medicine units, nurses logged in throughout the day, with many logins occurring during morning rounds, when not rounding with the care team. Prescribers logged in typically before and after morning rounds. On neurology units, physician assistants accounted for most logins, accessing the Dashboard during daily brief interdisciplinary rounding sessions. Use on oncology units was rare. Satisfaction with the tool was highest for perceived ease of use, with attendings giving the highest rating (4.23). The overall lowest rating was for quality of work life, with nurses rating the tool lowest (2.88).

CONCLUSION

This mixed methods analysis provides insight into the use and usability of a dashboard tool integrated within a vendor EHR and can guide future improvements and more successful implementation of these types of tools.

Potential of an Electronic Health Record-Integrated Patient Portal for Improving Care Plan Concordance during Acute Care

BACKGROUND

Care plan concordance among patients and clinicians during hospitalization is suboptimal.

OBJECTIVE

This article determines whether an electronic health record (EHR)-integrated patient portal was associated with increased understanding of the care plan, including the key recovery goal, among patients and clinicians in acute care setting.

METHODS

The intervention included (1) a patient portal configured to solicit a single patient-designated recovery goal and display the care plan from the EHR for participating patients; and (2) an electronic care plan for all unit-based nurses that displays patient-inputted information, accessible to all clinicians via the EHR. Patients admitted to an oncology unit, including their nurses and physicians, were enrolled before and after implementation. Main outcomes included mean concordance scores for the overall care plan and individual care plan elements.

RESULTS

Of 457 and 283 eligible patients approached during pre- and postintervention periods, 55 and 46 participated in interviews, respectively, including their clinicians. Of 46 postintervention patients, 27 (58.7%) enrolled in the patient portal. The intention-to-treat analysis demonstrated a nonsignificant increase in the mean concordance score for the overall care plan (62.0-67.1, adjusted p = 0.13), and significant increases in mean concordance scores for the recovery goal (30.3-57.7, adjusted p < 0.01) and main reason for hospitalization (58.6-79.2, adjusted p < 0.01). The on-treatment analysis of patient portal enrollees demonstrated significant increases in mean concordance scores for the overall care plan (61.9-70.0, adjusted p < 0.01), the recovery goal (30.4-66.8, adjusted p < 0.01), and main reason for hospitalization (58.3-81.7, adjusted p < 0.01), comparable to the intention-to-treat analysis.

CONCLUSION

Implementation of an EHR-integrated patient portal was associated with increased concordance for key care plan components. Future efforts should be directed at improving concordance for other care plan components and conducting larger, randomized studies to evaluate the impact on key outcomes during transitions of care.

CLINICAL TRIALS IDENTIFIER

NCT02258594.

Phantom Sensation-Underreported Sensory Outcome Following Intercostal-to-Musculocutaneous Nerve Transfer

BACKGROUND

Intercostal-to-musculocutaneous nerve transfer is commonly performed in patients with brachial plexus avulsion injuries. As techniques have improved since its inception in 1963, most patients now experience some level of motor function improvement of their affected arm. While motor outcomes are well described, there is a paucity of literature describing sensory outcomes. It is thus difficult to gauge surgical success with respect to sensory function, and there is a necessity to share clear expectations with patients regarding intended or unintended postoperative sensation.

CASE DESCRIPTION

In this case report, we describe an unintended sensory outcome of this procedure. Three years after the operation, our patient experiences a "phantom sensation" on his chest when he is touched on the lateral forearm in the distribution of the lateral antebrachial cutaneous nerve. This outcome can be explained with review of the anatomy before and after the operation. The persistence of this adverse outcome suggests limitations in sensory cortical neuroplasticity.

CONCLUSIONS

It is important to be aware of potential sensory complications in intercostal-to-musculocutaneous nerve transfer. Although this complication is known, it is often overlooked and underreported. Complications such as this should be emphasized in order to set expectations for patients and guide evaluation of sensory outcomes in a future study.

A web-based and mobile patient-centered ''microblog'' messaging platform to improve care team communication in acute care

Communication in acute care settings is fragmented and occurs asynchronously via a variety of electronic modalities. Providers are often not on the same page with regard to the plan of care. We designed and developed a secure, patient-centered "microblog" messaging platform that identifies care team members by synchronizing with the electronic health record, and directs providers to a single forum where they can communicate about the plan of care. The system was used for 35% of patients admitted to a medical intensive care unit over a 6-month period. Major themes in messages included care coordination (49%), clinical summarization (29%), and care team collaboration (27%). Message transparency and persistence were seen as useful features by 83% and 62% of respondents, respectively. Availability of alternative messaging tools and variable use by non-unit providers were seen as main barriers to adoption by 83% and 62% of respondents, respectively. This approach has much potential to improve communication across settings once barriers are addressed.

Strategies for Managing Mobile Devices for Use by Hospitalized Inpatients

Despite the potential advantages, implementation of mobile devices and ongoing management pose challenges in the hospital environment. Our team implemented the PROSPECT (Promoting Respect and Ongoing Safety through Patient-centeredness, Engagement, Communication and Technology) project at Brigham and Women's Hospital. The goal of PROSPECT is to transform the hospital environment by providing a suite of e-tools to facilitate teamwork among nurses, physicians, patients and to engage patients and care partners in their plan of care. In this paper, we describe the device-related decisions and challenges faced including device and accessory selection, integration, information and device security, infection control, user access, and ongoing operation and maintenance. We relate the strategies that we used for managing mobile devices and lessons learned based on our experiences.

A web-based, patient-centered toolkit to engage patients and caregivers in the acute care setting: a preliminary evaluation

We implemented a web-based, patient-centered toolkit that engages patients/caregivers in the hospital plan of care by facilitating education and patient-provider communication. Of the 585 eligible patients approached on medical intensive care and oncology units, 239 were enrolled (119 patients, 120 caregivers). The most common reason for not approaching the patient was our inability to identify a health care proxy when a patient was incapacitated. Significantly more caregivers were enrolled in medical intensive care units compared with oncology units (75% vs 32%; P < .01). Of the 239 patient/caregivers, 158 (66%) and 97 (41%) inputted a daily and overall goal, respectively. Use of educational content was highest for medications and test results and infrequent for problems. The most common clinical theme identified in 291 messages sent by 158 patients/caregivers was health concerns, needs, preferences, or questions (19%, 55 of 291). The average system usability scores and satisfaction ratings of a sample of surveyed enrollees were favorable. From analysis of feedback, we identified barriers to adoption and outlined strategies to promote use.