Flexible Medical Resident Duty Hours Did Not Pose Risks To Patients

MedicalResearch.com Interview with:

Jeffrey H. Silber, MD, PhDDirector, Center for Outcomes ResearchNancy Abramson Wolfson Endowed Chair in Health Services ResearchChildren's Hospital of PhiladelphiaProfessor of Pediatrics, Anesthesiology and Critical CarePerelman School of Medicine, University of PennsylvaniaProfessor of Health Care ManagementWharton School, University of Pennsylvania

Dr. Silber

Jeffrey H. Silber, MD, PhD
Director, Center for Outcomes Research
Nancy Abramson Wolfson Endowed Chair
Health Services Research
Children’s Hospital of Philadelphia
Professor of Pediatrics, Anesthesiology and Critical Care
Perelman School of Medicine, University of Pennsylvania
Professor of Health Care Management
Wharton School, University of Pennsylvania 

MedicalResearch.com: What is the background for this study?

Response: This was a year-long randomized trial that involved 63 internal medicine residency programs from around the US.  In 2015-2016, about half of the programs were randomized to follow the existing rules about resident duty hours that included restrictions on the lengths of shifts and the rest time required between shifts (the standard arm of the trial) and the other half of the programs didn’t have those shift length or rest period rules (the flexible arm of the trial).  We measured what happened to the patients cared for in those programs (the safety study), and other studies examined how much sleep the residents received, and how alert they were at the end of shifts (the sleep study), and previously we published on the educational outcomes of the interns.

To measure the impact on patient outcomes when allowing program directors the ability to use a flexible shift length for their interns, we compared patient outcomes after the flexible regimen went into place to outcomes the year before in the same program. We did the same comparison for the standard arm. Then we compared the difference between these comparisons. Comparing before and after the implementation of the trial within the same program allowed us to be more confident that a particularly strong or weak program, or a program with especially sick or healthy patients, would not throw off the results of the study. The trial was designed to determine, with 95% confidence, if the flexible arm did not do more than 1% worse than the standard arm. If this were true for the flexible arm, we could say the flexible regimen was “non-inferior” to the standard regimen.

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Family Input Improves Hospital Safety Surveillance

MedicalResearch.com Interview with:

Alisa Khan, MD, MPH Staff Physician Instructor in Pediatrics Boston Children's Hospital

Dr. Khan

Alisa Khan, MD, MPH
Staff Physician
Instructor in Pediatrics
Boston Children’s Hospital 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: ​Medical errors are known to be a leading cause of death in the United States. However, the true rate at which errors and adverse events occur in medicine is believed to be even higher than what has been found through the most rigorous patient safety studies.

Families are typically excluded from safety surveillance efforts, both in research and operationally in hospitals. We found that including families in safety reporting at four pediatric hospitals led to significantly higher error/adverse event detection rates, compared to the safety surveillance methodology typically considered most rigorous and highest yield in safety research. In addition, families reported errors/adverse events at similar rates as providers and at several-fold higher rates than the hospital incident reports which typically form the basis of operational hospital safety surveillance.
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Estimating Hospital-Related Deaths Due to Medical Error

MedicalResearch.com Interview wth:

Kevin Kavanagh, MD, MS Board Chairman of Health Watch USA

Dr. Kevin Kavanagh

Kevin Kavanagh, MD, MS
Board Chairman of Health Watch USA

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The genesis of our study was a desire to respond to a keynote speech at a major national patient safety conference which seemed to mitigate the problem of preventable hospital mortality in the United States.

Our main finding is that there is credible evidence indicating that the preventable hospital mortality rate is more than 160,000 per year. When one considers the events which were not captured, and that we did not count diagnostic errors or post-discharge presentation of events, this number can be projected to approximate or exceed 200,000.

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33% Rise In ‘Last-Resort’ Antibiotics Use in Hospitals

MedicalResearch.com Interview with:

James Baggs, PhD CDC

Dr. James Baggs

James Baggs, PhD
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention
Atlanta, Georgia

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We used medical claims data to estimate the amount of antibiotics used in US hospitals from 2006 – 2012. Data came from the Truven Health MarketScan Hospital Drug Database, which included about 300 hospitals and more than 34 million discharges. Antibiotic use in hospitals was very common with more than half of patients receiving at least one antibiotic during their hospital stay. Overall rates of antibiotic use in U.S. hospitals did not change over time; however, there were significant changes in the types of antibiotics prescribed.

Importantly, the types of antibiotics with the largest increases in use were the types of antibiotics often considered to be the most powerful. Of particular concern, there was a 37% rise in the use of carbapenems, commonly referred to as “last resort” antibiotics.

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AARP Discusses Medical Errors and Suggestions For Prevention

MedicalResearch.com Interview with:

Charlotte Yeh MD FACEP Chief Medical Officer AARP Services, Inc

Dr. Charlotte Yeh

Charlotte Yeh MD FACEP
Chief Medical Officer
AARP Services, Inc

Dr. Charlotte Yeh is the Chief Medical Officer for AARP Services, Inc . In her role, Dr. Yeh works with the independent carriers that make health-related products and services available to AARP members, to identify programs and initiatives that will lead to enhanced care for older adults.

Dr. Yeh has more than 30 years of healthcare experience – as a practitioner and Chief of Emergency Medicine at Newton-Wellesley Hospital and Tufts Medical Center, as the Medical Director for the National Heritage Insurance Company, a Medicare Part B claims contractor, and as the Regional Administrator for the Centers for Medicare and Medicaid Services in Boston.

In this interview, Dr. Yeh comments on the September 2016 AARP Bulletin feature that focuses on twelve common health care blunders and how they can be avoided.

MedicalResearch.com: What is the background for this report? How big is the problem of medical errors?

Dr. Yeh: Medical errors first became widely acknowledged in 1999 with the publication of the landmark study by the National Academy of Sciences (IOM), formerly called the Institute of Medicine (IOM), estimating as many as 98,000 hospital in-patient deaths per year were caused by medical errors. More recently, a study from Johns Hopkins noted that medical errors may claim as many as 251,000 lives per year.

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Hospitals Should Engage Patients and Families in Safety Efforts

MedicalResearch.com Interview with:

Dr. Alisa Khan, MD MPH Boston Children's Hospital Boston

Dr. Alisa Khan

Dr. Alisa Khan, MD MPH
Division of General Pediatrics
Boston Children’s Hospital
Department of Pediatrics, Harvard Medical School, Boston, Massachusetts

Medical Research: What is the background for this study? What are the main findings?

Dr. Khan: Medical errors, or mistakes in the process of caring for patients, occur frequently. While methods of detecting errors have improved, parents and families are not typically included in routine hospital safety monitoring systems. We found that nearly 1 in 11 parents reported their child had experienced a safety incident during hospitalization. Most of these reports were confirmed to be medical errors when reviewed by physicians, and many were not otherwise documented in the patient’s medical record.

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Mission of Safety Net Hospitals Prevents Streamlining Health Care

Richard S. Hoehn, MD Division of Transplant Surgery Department of Surgery, University of Cincinnati School of Medicine Cincinnati, OHMedicalResearch.com Interview with:
Richard S. Hoehn, MD
Division of Transplant Surgery
Department of Surgery
University of Cincinnati School of Medicine
Cincinnati, OH

Medical Research: What is the background for this study? What are the main findings?

Dr. Hoehn: Safety-net hospitals are hospitals that either have a stated purpose of maintaining an “open door policy” to all patients, regardless of their ability to pay, or simply have a significantly high burden of patients with Medicaid or no insurance. As healthcare policy and reimbursement change to focus on both “quality” metrics as well as cost containment, these hospitals may find themselves in a precarious situation. Current literature suggests that increased safety-net burden corresponds to inferior surgical outcomes. If this is true, safety-net hospitals will have inferior outcomes and suffer more financial penalties than other centers. This decrease in resources may adversely affect patient care, leading to even worse outcomes and further financial penalties, potentially creating a downward spiral that exacerbates disparities in surgical care that already exist in our country.

Medical Research: What are the main findings?

Dr. Hoehn: Our study analyzed 9 major surgical operations using the University HealthSystem Consortium clinical database, which represents 95% of academic medical centers in the United States. We sought to determine the effect of patient and hospital characteristics on the inferior outcomes at safety-net hospitals. As expected, we found that safety-net hospitals had higher rates of patients who were of black race, of lowest socioeconomic status, had government insurance, had extreme severity of illness, and needed emergent operations. They also had the highest rates of post-operative mortality, 30-day readmissions, and highest costs associated with care.

Next we performed a multivariate analysis controlling for patient age, race, socioeconomic status, and severity of illness, as well as hospital procedure-specific volume. Using this model, we found that the increased mortality and readmission rates at safety-net hospitals were somewhat reduced, but the increased costs were not affected. Safety-net hospitals still provided surgical care that was 23-35% more expensive, despite controlling for patient characteristics. This suggests that intrinsic hospital characteristics may be responsible for the increased costs at safety-net hospitals.

To further investigate this finding, we analyzed Medicare Hospital Compare data and found that safety-net hospitals performed worse on Surgical Care Improvement Project (SCIP) measures, had higher rates of reported surgical complications, and also had much slower measures of emergency department throughput (time from arrival to evaluation, treatment, admission, etc). This corresponded with our finding that hospital characteristics may be driving increased costs at safety-net hospitals.

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Communication During Handoffs Varies Greatly Among Hospital Teams

Alicia A. Bergman, Ph.D. Research Health Scientist VA Greater Los Angeles Healthcare System Center for the Study of Healthcare Innovation, Implementation & Policy North Hills, CA 91343MedicalResearch.com Interview with:
Alicia A. Bergman, Ph.D.
Research Health Scientist
VA Greater Los Angeles Healthcare System
Center for the Study of Healthcare Innovation, Implementation & Policy North Hills, CA 91343

 Medical Research: What is the background for this study? What are the main findings?

Dr. Bergman: The impetus for this study comes from several sources but most notably the IOM report of 2002 entitled, Crossing the Quality Chasm in which the IOM estimated that between 44,000 and 98,000 lives are lost each year due to preventable medical errors in the hospital.  The IOM further reported that 80% of all adverse outcomes in the hospital can be traced back to breakdowns in communication during handoffs and transfers of care.  A 2005 study by our VA research team found that only 7% of medical schools in the US teach the handoff as part of the formal curriculum. As such, handoffs represent a vulnerable gap in the quality and safety of patient care.

We were interested to know how end of shift handoffs in medicine, nursing, and surgery were enacted and audio and videotaped them in a single VA hospital. We found that there was a great deal of variation in how the handoffs were conducted and similar variations in the ways in which language was used to characterize technical and interpersonal aspects of care. We were especially interested in what we term “anticipatory management communication” and its functions during handoffs. While much technical information can easily be conveyed in the electronic medical record, some types of psychological or social information that are more informal in nature, such as “Mr. Smith’s been our problem child today,” do not lend themselves to being transmitted in the electronic medical record. However, such ‘heads up’ information and communication is often critical to understanding a patient’s context, course, and outcome of care. We also found that indirect anticipatory management communication was used among all dyads but more commonly among nurse dyads, with instructions and tasks implied and often inferential. We conclude that contextually sensitive information about anticipated events is best communicated directly (and ideally face-to-face), and that talk-backs and more explicit use of language can improve handoff quality, making them safer for patients.

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Effective Surgical Checklists Require Culture of Safety

E. Patchen Dellinger, M.D. Professor of Surgery University of Washington, Box 356410 Seattle, Washington MedicalResearch.com Interview with:
E. Patchen Dellinger, M.D.
Professor of Surgery
University of Washington
Seattle, Washington

Medical Research: What is the background for this study? What are the main findings?

Dr. Dellinger: We know from previous large studies that use of checklists is associated with improvements in patient morbidity and mortality. However, recent large studies have also shown that mandating teams to use the checklist without providing the support required for adequate implementation does not result in better outcomes. This report reviews findings from studies examining checklist compliance and use. We found that when compliance with the checklist is poor it is not as effective as when the checklist is carried out as it is intended. Checklist use appears to be a marker for institutional culture of safety, and organizations with a more robust safety culture may be more likely to use the checklist in an effective manner with resulting improvements in patient safety. Continue reading

Heart Attack: Off-Hours Stent Surgery Has Same Outcomes

Atsushi Sorita, MD, MPH Mayo Clinic, Division of Preventive Medicine Rochester, MN 55905.MedicalResearch.com Interview with:
Atsushi Sorita, MD, MPH

Mayo Clinic, Division of Preventive Medicine
Rochester, MN 55905.

 

Medical Research: What is the background for this study? What are the main findings?

Dr. Sorita: Prior studies have suggested that patients with heart attack who are admitted during off-hours (weekends, nights and holidays) have higher risk of death when compared with patients admitted during regular hours. In our study, we found that patients undergoing percutaneous coronary interventions for heart attack who were admitted during off-hours did not have higher mortality or readmission rates as compared with ones admitted during regular hours at a highly-integrated academic center in the United States.

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Serious Reportable Events Reduced By Standardized Safe Surgery Program

Terrence Loftus, MD, MBA, FACS Medical Director, Surgical Service & Clinical Resources Banner Health Phoenix, Arizona 85006Medical Research.com Interview with:
Terrence Loftus, MD, MBA, FACS
Medical Director, Surgical Service & Clinical Resources
Banner Health
Phoenix, Arizona 85006


Medical Research: What are the main findings of the study?

Dr. Loftus: This study demonstrated that a standardized safe surgery program effectively and systematically implemented across a diverse healthcare system resulted in a significant reduction in serious reportable events (SREs), thereby improving the quality of patient care and leading to significant cost avoidance.   For the purposes of the study, SREs were defined as any reported retained surgical item, wrong site, wrong patient or wrong procedure event. Following implementation of the Safe Surgery Program there was a 52% reduction in the SRE rate in the operating rooms and L&D areas in our system. The most dramatic change and greatest area of improvement was in wrong site events which demonstrated a 70% reduction for this type of serious reportable events.

This was achieved through a Safe Surgery Program which consisted of three main components.

  • The first component was patient focused procedures. These are steps designed to prevent wrong site, wrong patient or wrong procedure events.
  • The second component was sponge, sharp and instrument count procedures. These are steps designed to prevent retained surgical items.
  • The final component was monthly observational audits that were performed to assess program compliance. Continue reading

Longer Shifts and Overtime May Lead To Lower Quality and Safety of Nursing Care

Dr. Peter Griffiths PhD, RN Centre for Innovation and Leadership in Health Sciences University of Southampton, Southampton, UK MedicalResearch.com Interview with:
Dr. Peter Griffiths PhD, RN
Centre for Innovation and Leadership in Health Sciences
University of Southampton, Southampton, UK

Medical Research: What are the main findings of the study?

Dr. Griffiths: This study found that hospital nurses who are working on a 2 shift system, where care is provided by nurses working long shifts of 12-13 hours, report lower quality and safety of care than nurses who work a traditional three shift system where nurses typically work shifts of 8 hours. We also found that nurses who were working overtime reported lower quality and safety of care. We found that these shifts are common in some European countries – most notably Poland, Ireland and England.

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Improving Hand Hygiene Compliance With Red Flashing Lights

Dr. Gianni D'Egidio HBSc, MD, MEng Academic Division of Internal Medicine Ottawa Hospital, CanadaMedicalResearch.com Interview with:
Dr. Gianni D’Egidio HBSc, MD, MEng
Academic Division of Internal Medicine
Ottawa Hospital, Canada

Medical Research: What are the main findings of the study?

Dr. D’Egidio: Baseline hand hygiene compliance at our main entrance in our study was 12.4%.  We believe one of the main reasons for such an appalling low compliance was that individuals were distracted.  Visitors entering are often preoccupied with acquiring information to help them navigate a large and confusing environment given the multitude of signs, lights, announcements and other people.  Also, the majority of individuals entering have objects occupying their hands; keys, hand-held devices, coffee mugs, and during cold weather, gloves.  All this together contributes to poor compliance at our front entrance.

We hypothesized that a conspicuous flashing red light at 3 Hz (3 flashed per second) attached to alcohol hand dispensers located at our front entrance would attract an individual’s attention and hopefully increase compliance.  We measured hand hygiene compliance for 1-week periods from 07:30-08:30 before and after the implementation of our flashing lights.  We found that compliance increased by more than double to 25.3% (p<0.0001).
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Program Improves Post-Op Patient Safety At Community Hospitals

MedicalResearch.com Interview
Cristina B. Geltzeiler, MD
Knight Cancer Institute
Oregon Health & Science University
Portland, OR 97239-3098

Medical Research: What are the main findings of the study?

Dr. Geltzeiler: The main findings of the study are that implementing an Enhanced Recovery After Surgery (ERAS) program at a community hospital can be successfully implemented and can allow patients to recover quicker from their surgery with ongoing safety.

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Weekend Hospital Admissions Still Have Higher Mortality

Dr. Hiroshi Hoshijima Evidence-based Anesthsia Research Group Tohoku Universit y Graduate School of Dentistry, Dept of Anaesthesiology, Sendai, Japan,MedicalResearch.com Interview with:
Dr. Hiroshi Hoshijima
Evidence-based Anesthsia Research Group
Tohoku Universit y Graduate School of Dentistry,
Dept of Anaesthesiology, Sendai, Japan,


MedicalResearch: What are the main findings of the study?

Dr.  Hoshijima: Our systematic review shows that weekend admission is associated with higher mortality compared with weekday admission.Subgroup analysis revealed that patients admitted during the weekend were at a higher risk of death than weekday admission in patients in 5 categories (patients who had stroke; cardiovascular disease; upper gastrointestinal haemorrhage; medical disease; mixed medical and surgical disease.)
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Hospital Safety Tipping Point Reached At Well Below Full Occupancy

Professor Ludwig Kuntz Seminar for Business Administration and Health Care Management University of Cologne Albertus-Magnus-Platz 50923 Cologne GermanyMedicalResearch.com Interview with:
Professor Ludwig Kuntz
Seminar for Business Administration and Health Care Management University of Cologne Albertus-Magnus-Platz
50923 Cologne Germany

MedicalResearch.com: What are the main findings of the study?

Professor Kuntz:  We have identified the point at which hospitals begin to fail, resulting in deaths of critically ill patients. The Safety Tipping Point for hospitals occurs when they reach occupancy levels far below 100%, namely we identified a tipping point strongly at around 92 per cent [patient occupancy relative to ward capacity]. Our research therefore demonstrates conclusively that far from maximizing efficiency, exceeding a capacity “tipping point” on a hospital ward can have dire consequences. This has major implications for the way we think about capacity and stress in the workplace.
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Reduction in Surgical Residents Work Hours Did Not Improve Outcomes for Patients or Residents

dr_najma_ahmedMedicalResearch.com Interview with:
Dr. Najma Ahmed
Trauma and Acute Care Surgeon, St. Michael’s Hospital
Residency Training Director, General Surgery, University of Toronto

 

MedicalResearch.com: What are the main findings of this study:

Dr. Ahmed: The main findings if the study were that the recent reduction of resident duty hours to much less than 80 hours decreases health outcomes in patients, has adverse educational outcomes for residents and does not improve wellness in surgery.

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Venous Thromboembolism: Detection and Surveillance Bias

Mila Ju, MD Resident, Division of Vascular Surgery Northwestern University 676 N. Saint Clair St., Ste 650 Chicago, IL  60611MedicalResearch.com Interview with:
Mila Ju, MD
Resident, Division of Vascular Surgery
Northwestern University
676 N. Saint Clair St., Ste 650
Chicago, IL  60611


MedicalResearch.com: What are the main findings of the study?

Dr. Ju: By using combined data from Hospital Compare, American Hospital Association, and Medicare claims databases, we found that better hospital venous thromboembolism (VTE) prophylaxis adherence rates were weakly associated with worse risk-adjusted VTE event rates. Moreover, hospitals with higher intensity of detecting VTE with imaging studies (such as venous duplex, chest computer tomography, etc.) had more VTE events (13.5 in highest VTE imaging quartile vs 5.0 in lowest VTE imaging quartile) per 1000 discharges. Our study suggests that VTE rates might be influenced by surveillance bias and not reflecting the true quality of care provided by the hospitals.

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