Balancing Patient Safety Research Articles

Risk Factors for Bleeding and Clinical Ineffectiveness Associated With Clopidogrel Therapy: A Comprehensive Meta-Analysis.

Although clopidogrel is a frequently used antiplatelet medication to treat and prevent atherothrombotic disease, clinicians must balance its clinical effectiveness with the potential side effect of bleeding. However, many previous studies have evaluated beneficial and adverse factors separately. The objective of our study was to perform a comprehensive meta‐analysis of studies of clopidogrel’s clinical effectiveness and/or risk of bleeding in order to identify and assess all reported risk factors, thus helping clinicians to balance patient safety with drug efficacy. We analyzed randomized controlled trials (RCTs) of maintenance use in four stages: search for relevant primary articles; abstract and full article screening; quality assessment and data extraction; and synthesis and data analysis. Screening of 7,109 articles yielded 52 RCTs that met the inclusion criteria. Twenty‐seven risk factors were identified. “Definite risk factors” were defined as those with aggregated odds ratios (ORs) > 1 and confidence intervals (CIs) > 1 if analyzed in more than one study. Definite risk factors for major bleeding were concomitant aspirin use (OR 2.83, 95% CI 2.04–3.94) and long duration of clopidogrel therapy (> 6 months) (OR 1.74, 95% CI 1.21–2.50). Dual antiplatelet therapy, extended clopidogrel therapy, and high maintenance dose (150 mg/day) of clopidogrel were definite risk factors for any bleeding. Reduced renal function, both mild and severe, was the only definite risk factor for clinical ineffectiveness. These findings can help clinicians predict the risks and effectiveness of clopidogrel use for their patients and be used in clinical decision support tools.

RAMIFICATIONS OF A NURSING STRIKE ON OPERATING ROOM EFFICIENCY

A nursing strike represents an operational disruption from normal perioperative services. The impact a nursing strike has on a perioperative system has not been well studied. The purpose of this study was to evaluate the realized and unrealized financial and operational impacts a nursing strike has on perioperative services. This was a retrospective analysis conducted at an academic, rural medical center during a nursing strike. During the nursing strike, the hospital implemented measures to maintain patient safety and continue normal operations. Several operating room (OR) management and clinical productivity metrics were used to evaluate the realized and unrealized financial and operational impacts. First Case Start Delay times increased (+69%), Scheduling Error decreased (-42%), Clinical Productivity decreased (-6%), Total ASA units decreased (-44%), Productivity per Attending decreased (-55%), estimated missed revenue of $864,118, and missed expected profit of $432,059. The changes in overall OR workflow resulted in additional expenses, loss of individual productivity and concomitant lost revenue from cancelled cases. Some operational metrics improved. Tactical planning to maintain clinical operations during a strike must involve clinical directors and anesthesiology administrators. The primary directive should balance patient safety against long-term implications and account for unrealized costs.

MP66-11 HOW TO PREVENT PROSTATE BIOPSY COMPLICATIONS: TO AUGMENT OR TO SWAB?

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety III (MP66)1 Apr 2020MP66-11 HOW TO PREVENT PROSTATE BIOPSY COMPLICATIONS: TO AUGMENT OR TO SWAB? Lydia Glick*, Timothy M. Han, Christopher Caputo, Danielle Squadrito, Joon Yau Leong, Claudette Fonshell, Kaynaat Syed, John Danella, Serge Ginzburg, Thomas J. Guzzo, Thomas Lachoney, Jay D. Raman, Marc C. Smaldone, Robert Uzzo, Jeffrey Tomaszewski, Adam C. Reese, Edouard J. Trabulsi, Leonard G. Gomella, and Mark J. Mann Lydia Glick*Lydia Glick* More articles by this author , Timothy M. HanTimothy M. Han More articles by this author , Christopher CaputoChristopher Caputo More articles by this author , Danielle SquadritoDanielle Squadrito More articles by this author , Joon Yau LeongJoon Yau Leong More articles by this author , Claudette FonshellClaudette Fonshell More articles by this author , Kaynaat SyedKaynaat Syed More articles by this author , John DanellaJohn Danella More articles by this author , Serge GinzburgSerge Ginzburg More articles by this author , Thomas J. GuzzoThomas J. Guzzo More articles by this author , Thomas LachoneyThomas Lachoney More articles by this author , Jay D. RamanJay D. Raman More articles by this author , Marc C. SmaldoneMarc C. Smaldone More articles by this author , Robert UzzoRobert Uzzo More articles by this author , Jeffrey TomaszewskiJeffrey Tomaszewski More articles by this author , Adam C. ReeseAdam C. Reese More articles by this author , Edouard J. TrabulsiEdouard J. Trabulsi More articles by this author , Leonard G. GomellaLeonard G. Gomella More articles by this author , and Mark J. MannMark J. Mann More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000941.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate biopsies are the current gold standard for the diagnosis of prostate cancer, but there is a lack of consensus regarding optimal prophylactic approach for infection prevention. Urology guidelines suggest a single agent or targeted therapy based on rectal swab cultures, balancing patient safety with antibiotic stewardship. The goal of this study was to determine if one prophylaxis method was superior to another at preventing infectious outcomes. METHODS: Data collected from the Pennsylvania Urologic Regional Collaborative was analyzed for patient, prostate and biopsy characteristics. Special attention was paid to antibiotic prophylaxis pathway: patients received “Culture-Directed” (based on rectal swab culture), “Augmented” (baseline antibiotic + another based on local antibiogram) or no specific antibiotic pathway. A univariate and multivariate analysis assessed predictors of infectious outcome including fever, urinary tract infection or sepsis. A Chi-square test was used to compare association between each prophylaxis pathway and occurrence of emergency department visit or readmission secondary to biopsy complication within 30 days. RESULTS: Data from 11,941 biopsies was collected. Predictors of infectious outcomes included a history of diabetes. Type of antibiotic prophylaxis pathway was not predictive of infectious outcome on multivariate analysis (Table 1). Chi-square analysis revealed a significant association (p < 0.001) between prophylaxis pathway and both ED visit and readmission within 30 days (Table 2). CONCLUSIONS: Antibiotics pathway was not associated with infectious outcome. However, hospital readmission and ED visit following biopsy were associated with type of antibiotic prophylaxis pathway used. Emergency visits and readmission may be an additional way to capture adverse events. Efforts to integrate culture-directed prophylaxis into urologic practices should be considered to benefit patient outcomes and limit antibiotic resistance. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e987-e987 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lydia Glick* More articles by this author Timothy M. Han More articles by this author Christopher Caputo More articles by this author Danielle Squadrito More articles by this author Joon Yau Leong More articles by this author Claudette Fonshell More articles by this author Kaynaat Syed More articles by this author John Danella More articles by this author Serge Ginzburg More articles by this author Thomas J. Guzzo More articles by this author Thomas Lachoney More articles by this author Jay D. Raman More articles by this author Marc C. Smaldone More articles by this author Robert Uzzo More articles by this author Jeffrey Tomaszewski More articles by this author Adam C. Reese More articles by this author Edouard J. Trabulsi More articles by this author Leonard G. Gomella More articles by this author Mark J. Mann More articles by this author Expand All Advertisement PDF downloadLoading ...

‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing trainee failure while guarding patient safety

BackgroundLearning is in delicate balance with safety, as faculty supervisors try to foster trainee development while safeguarding patients. This balance is particularly challenging if trainees are allowed to experience the...

High-intensity interval training for patients with coronary artery disease: Finding the optimal balance

BackgroundThe optimal characteristics of high-intensity interval training (HIIT) for patients with coronary artery disease (CAD) within cardiac rehabilitation (CR) are unclear. We assessed a HIIT protocol designed to balance patient safety, efficacy and enjoyment. MethodsTwenty-nine patients with CAD completed 6-weeks (× 2 sessions per week) of HIIT within outpatient (phase 2) CR. HIIT comprised 15 repetitions × 30-seconds cycling at ∼85-90% maximum heart rate, interspersed with 30-seconds of active recovery. Key outcomes covered patient safety, efficacy (peak aerobic capacity, body composition, blood pressure and vascular function), and patient adherence and enjoyment. ResultsNo cardiovascular-related adverse events were reported in relation to HIIT sessions. Patients showed significant improvement in peak aerobic capacity (mean +12%, p < 0.001, effect size d = 0.38), blood pressure (brachial systolic -7mmHg, p < 0.001, d = -0.59) and total body fat (-4%, p < 0.001, d = -0.49). Central adaptations were prominent (aortic systolic BP -5mmHg, p = 0.001, d = -0.50; visceral fat -10%, p = 0.001, d = -0.41). Patient enjoyment of training was high (5.5 out of 7 using the Exercise Enjoyment Scale) and measures of affective state improved following training (assorted p < 0.018). ConclusionsThis HIIT protocol appears safe, effective and enjoyable for patients with CAD within CR. Improved aerobic fitness, blood pressure and body fat levels were observed indicating improved cardiovascular-risk. High patient enjoyment and improved mood suggest the HIIT could be sustainable for patients in the longer-term.

Nurses' decision‐making about intravenous administration set replacement: A qualitative study

To explore nurses' decision-making regarding intravenous administration set replacement for vascular access device infusions in paediatric and adult clinical settings. Intravenous administration sets are routinely replaced at regular intervals in clinical practice with the goal of preventing catheter-related bloodstream infection; however, emerging evidence is challenging traditional hang-time durations. Nurses' perceptions and contextual factors affecting decision-making for administration set replacement have not been assessed previously. Qualitative study using focus groups with contextualism methodology and inductive analysis. During November-December 2016, eight semi-structured focus groups were conducted with 38 nurses at two metropolitan hospitals in Queensland, Australia. Interviews were audio-recorded and transcribed. Two authors independently reviewed transcripts and extracted significant statements using Braun and Clarke's 7-step method of thematic analysis. The COREQ checklist provided a framework to report the study methods, context, findings, analysis and interpretation. Five key themes emerged from the analysis: (a) infection prevention, (b) physical safety, (c) patient preference, (d) clinical knowledge and beliefs, and (e) workload. Administration set replacement can be a complex task, particularly when patients have multiple infusions and incompatible medications. Nurses drew on perceptions of patient preference, as well as previous experience, knowledge of peer experts and local policies, to aid their decisions. Nurses use clinical reasoning to balance patient safety and preferences with competing workplace demands when undertaking administration set replacement. Nurses rely on previous experience, hospital and medication manufacturer policies, and peer experts to guide their practice. Nurses at times deviate from clinical guidelines in the interests of patient acuity, nurses' experience and workload. The findings of this study indicate nurses also balance considerations of patient preference and safety with these competing demands.

High-intensity Interval Training for Patients with Coronary Artery Disease: Finding the Optimal Balance

Abstract Background The optimal characteristics of high-intensity interval training (HIIT) for patients with coronary artery disease (CAD) within cardiac rehabilitation (CR) are unclear. We assessed a HIIT protocol designed to balance patient safety, efficacy and enjoyment. Methods Twenty-nine patients with CAD completed 6-weeks (× 2 sessions per week) of HIIT within outpatient (phase 2) CR. HIIT comprised 15 repetitions × 30-seconds cycling at ∼85-90% maximum heart rate, interspersed with 30-seconds of active recovery. Key outcomes covered patient safety, efficacy (peak aerobic capacity, body composition, blood pressure and vascular function), and patient adherence and enjoyment. Results No cardiovascular-related adverse events were reported in relation to HIIT sessions. Patients showed significant improvement in peak aerobic capacity (mean +12%, p Conclusions This HIIT protocol appears safe, effective and enjoyable for patients with CAD within CR. Improved aerobic fitness, blood pressure and body fat levels were observed indicating improved cardiovascular-risk. High patient enjoyment and improved mood suggest the HIIT could be sustainable for patients in the longer-term.

Interpretation and integration of the federal substance use privacy protection rule in integrated health systems: A qualitative analysis

BackgroundFederal regulations (42 CFR Part 2) provide special privacy protections for persons seeking treatment for substance use disorders. Primary care providers, hospitals, and health care organizations have struggled to balance best practices for medical care with adherence to 42 CFR Part 2, but little formal research has examined this issue. The aim of this study was to explore institutional variability in the interpretation and implementation of 42 CFR Part 2 regulations related to health systems data privacy practices, policies, and information technology architecture. MethodsThis was a cross-sectional qualitative study using purposive sampling to conduct interviews with privacy/legal officers (n = 17) and information technology specialists (n = 10) from 15 integrated healthcare organizations affiliated with three research nodes of the National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network (CTN). Trained staff completed a short survey and digitally recorded semi-structured qualitative interview with each participant. Interviews were transcribed and coded within Atlas.ti. Framework analysis was used to identify and organize key themes across selected codes. ResultsParticipants voiced concern over balancing patient safety with 42 CFR Part 2 privacy protections. Although similar standards of protection regarding release of information outside of the health system was described, numerous workarounds were used to manage intra-institutional communication and care coordination. To align 42 CFR Part 2 restrictions with electronic health records, health systems used sensitive note designation, “break the glass” technology, limited role-based access for providers, and ad hoc solutions (e.g., provider messaging). ConclusionsIn contemporary integrated care systems, substance-related EHR records (e.g., patient visit history, medication logs) are often accessible internally without specific consent for sharing despite the intent of 42 CFR Part 2. Recent amendments to 42 CFR Part 2 have not addressed information sharing needs within integrated care settings.

A SCORING SYSTEM TO DECIDE ICU ADMISSIONS IN PATIENTS WITH SUBSTANCE OVERDOSE

SESSION TITLE: Critical Care 2 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Patients presenting with substance overdose (recreational or prescription) are often admitted to the Intensive Care Unit (ICU). While ICU-level interventions are needed for some, many admitted to the ICU do not require these. To balance patient safety and judicious use of ICU resources, we studied the accuracy of a set of clinical criteria in identifying patients who may require ICU-level interventions. METHODS: We conducted an IRB-approved retrospective study at a large, academic medical center. Through electronic chart review, we identified all adult patients presenting with substance overdose over 1 year (7/1/16 – 6/30/17). Based on prior literature, cutoffs were set as follows for each of the key clinical criteria: respiratory rate (≤8 or ≥30 per minute), oxygen saturation (<90%), systolic blood pressure (<90 or >200 mmHg), Glasgow Coma Scale (GCS) score (<14) and QRS duration on electrocardiogram (>120 millisecond). ICU admission was said to be indicated if any of the above criteria were met. We recorded ICU-level interventions performed for patients, including mechanical ventilation, central venous access, hemodynamic infusions, cardiac pacing or arrhythmia management, or continuous renal replacement therapy. RESULTS: A total of 179 patients were identified with a median age of 42 years. 87 were men and 92 were female. Of these, 146 patients (81%) had one or more abnormal clinical criteria. Of the 179 patients, 36 (20%) received ICU-level interventions. Using these data, sensitivity of the criteria in identifying patients needing ICU care was 94.4%. The specificity was 21.6%. 99 patients were actually admitted to the ICU, of which 66 did not require any ICU-level intervention. Of these, the criteria would have accurately predicted that 11 (16.7%) did not need ICU admission. CONCLUSIONS: We found that a composite tool using multiple clinical criteria can be very sensitive in identifying patients who may benefit from ICU-level care. Of the patients actually admitted to the ICU, two-thirds did not require ICU-level interventions. Of these, this tool would have appropriately reduced 16.7% of ICU admissions, in a safe manner.Our results are similar to the sensitivity and specificity reported in the literature using composite variables to create a triaging tool for patients with substance overdose. CLINICAL IMPLICATIONS: While ICU care is potentially life-saving, it is resource-intensive. This study is an important step in the development of a tool to help triage patients with substance overdose or poisoning to the appropriate level of care. The tool used in this study is sensitive enough to safely screen patients in or out of the ICU. Once patients are screened using this tool, additional clinical judgment can then be used to decide whether ICU admission is warranted. This approach would reduce the number of ICU admissions without compromising patient safety. DISCLOSURES: No relevant relationships by Sumedh Hoskote, source=Web Response No relevant relationships by Shaun Noronha, source=Web Response No relevant relationships by Swathi Sangli, source=Web Response

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BackgroundPatient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. MethodsThis prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy. ResultsOf 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51–19.97) than planned admissions (OR: 2.32, 95% CI: 1.43–3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8–51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI. ConclusionsAfter risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Modernizing Clinical Trial Eligibility Criteria: Recommendations of the American Society of Clinical Oncology-Friends of Cancer Research HIV Working Group.

Purpose People with HIV are living longer as a result of effective antiretroviral therapy. Cancer has become a leading cause of morbidity and mortality in this patient population. However, studies of novel cancer therapeutics have historically excluded patients with HIV. Critical review of eligibility criteria related to HIV is required to accelerate development of and access to effective therapeutics for HIV-infected patients with cancer and make studies more generalizable to this patient population. Methods From January through April 2016, the HIV Working Group conducted a series of teleconferences; a review of 46 New Drug Applications from registration studies of unique agents studied in adults with cancer that led to the initial US Food and Drug Administration approval of that agent from 2011 to 2015; and a review of HIV-related eligibility criteria from National Cancer Institute-sponsored studies. Results were discussed and refined at a multistakeholder workshop held May 12, 2016. The HIV Working Group developed recommendations for eligibility criteria that focus on pharmacologic and immunologic considerations in this patient population and that balance patient safety, access to appropriate investigational agents, and study integrity. Results Exclusion of patients with HIV remains common in most studies of novel cancer agents. Models for HIV-related eligibility criteria in National Cancer Institute-sponsored studies are instructive. HIV infection itself should no longer be an exclusion criterion for most studies. Eligibility criteria related to HIV infection that address concurrent antiretroviral therapy and immune status should be designed in a manner that is appropriate for a given cancer. Conclusion Expanding clinical trial eligibility to be more inclusive of patients with HIV is justified in most cases and may accelerate the development of effective therapies in this area of unmet clinical need.

What factors influence attending surgeon decisions about resident autonomy in the operating room?

Educating residents in the operating room requires balancing patient safety, operating room efficiency demands, and resident learning needs. This study explores 4 factors that influence the amount of autonomy supervising surgeons afford to residents. We evaluated 7,297 operations performed by 487 general surgery residents and evaluated by 424 supervising surgeons from 14 training programs. The primary outcome measure was supervising surgeon autonomy granted to the resident during the operative procedure. Predictor variables included resident performance on that case, supervising surgeon history with granting autonomy, resident training level, and case difficulty. Resident performance was the strongest predictor of autonomy granted. Typical autonomy by supervising surgeon was the second most important predictor. Each additional factor led to a smaller but still significant improvement in ability to predict the supervising surgeon's autonomy decision. The 4 factors together accounted for 54% of decision variance (r=0.74). Residents' operative performance in each case was the strongest predictor of how much autonomy was allowed in that case. Typical autonomy granted by the supervising surgeon, the second most important predictor, is unrelated to resident proficiency and warrants efforts to ensure that residents perform each procedure with many different supervisors.

Organizational Perspectives on Rapid Response Team Structure, Function, and Cost: A Qualitative Study.

Understanding how an organization determines structure and function of a rapid response team (RRT), as well as cost evaluation and implications, can provide foundational knowledge to guide decisions about RRTs. The objectives were to (1) identify influencing factors in organizational development of RRT structure and function and (2) describe evaluation of RRT costs. Using a qualitative, ethnographic design, nurse executives and experts in 15 moderate-size hospitals were interviewed to explore their decision-making processes in determining RRT structure and function. Face-to-face interviews were audio recorded and transcribed verbatim and verified for accurateness. Using content analysis and constant comparison, interview data were analyzed. Demographic data were analyzed using descriptive statistics. The sample included 27 participants from 15 hospitals in 5 south-central states. They described a variety of RRT responders and functions, with the majority of hospitals having a critical care charge nurse attending all RRT calls for assistance. Others described a designated RRT nurse with primary RRT duties as responder to all RRT calls. Themes of RRT development from the data included influencers, decision processes, and thoughts about cost. It is important to understand how hospitals determine optimal structure and function to enhance support of quality nursing care. Determining the impact of an RRT on costs and benefits is vital in balancing patient safety and limited resources. Future research should focus on clarifying differences between team structure and function in outcomes as well as the most effective means to estimate costs and benefits.

Regulatory environment for clinical research: Recent past and expected future.

In the past few years, there have been numerous updates to policy and guidelines governing the conduct of clinical research in India. These measures were taken by regulators considering safety of Indian patients as the topmost priority although the overall regulatory environment became challenging. However, in the recent past, Indian regulations have evolved positively to favorably support clinical research in India while appropriately balancing patient safety as well. These regulatory changes are expected to bring newer innovative medicines to Indian patients at an earliest.

Nursing workers health and patient safety: the look of nurse managers.

Objective To understand the perception of nurse managers about the relationship between nursing workers health and patient safety. Method A qualitative survey was conducted using the social phenomenology approach of Alfred Schütz, accomplished through individual interviews with nine nurse managers from five Brazilian university hospitals. Results Nurse managers' perception of the relationship between nursing workers health and patient safety was evidenced in the following categories: "The suffering to balance workers health and patient safety" and "Interventions in everyday work life". Conclusion Managers' experience showed an everyday work life marked by suffering and concern, due to high rates of absenteeism and presenteeism resulting from illness and incapability of workers, and the need to ensure patient safety through qualified nursing care.

Reducing infection transmission in the playroom: Balancing patient safety and family-centered care

Family-centered care requires that institutions develop strategies to allow sibling visitors to hospitalized children while reducing risks of infectious disease transmission. Most guidelines recommend that siblings not be permitted to visit playrooms. This approach was not seen as consistent with family-centered care in our setting; therefore, in a pilot project we developed an approach for screening siblings with cooperation of families, child life specialists, the care team, and the infection prevention and control service. A literature review using CINAHL and PubMed databases (Medical Subject Heading terms: visitors to patients, child, infection, nosocomial, and siblings) from 2004-2014 did not uncover formal established methods for reducing playroom infectious disease exposures. Benchmarking with other Canadian centers revealed a diversity of approaches. Child life, the ward staff, and infection prevention and control at this center collaborated to develop a sibling screening strategy. The collaborative approach led to a process based on a screening form that is introduced to the family during admission. The process requires the cooperation of the admitting nurse, parents, and child life staff. In the first 2 years of the project, approximately 10% of screened siblings had a potentially communicable illness. A collaborative multidisciplinary approach based on family center care principles led to a process whereby siblings of hospitalized children can be allowed to visit playrooms, while reducing risk of infectious disease transmission.

Trends in technical and team simulations: Challenging the status Quo of surgical training

Traditional opportunistic and experiential surgical training can expose patients to excess risk of harm, particularly when new technology or surgical approaches are applied to highly complex operations. Declining birth rates, decreasing academic regionalization of complex neonatal procedures, duty hour restrictions, and the increasing need for highly specialized surgical skills all serve to further degrade the educational opportunities for surgical trainees. Even more concerning, practicing pediatric surgeons are also struggling with declines in neonatal surgical volumes, with fewer opportunities to maintain established cognitive, technical, and nontechnical skills in the operating room. In an effort to balance patient safety with a deeply rooted commitment to surgical education, surgical educators have developed a number of innovative educational strategies to achieve these goals.

Randomized, controlled pilot trial of bupropion for pregnant smokers: challenges and future directions.

The aim of the study is to conduct an initial pilot trial evaluating the feasibility, safety, and efficacy of bupropion for smoking cessation in pregnancy. A randomized, double-blind, parallel-group pilot study of bupropion versus placebo with 50 pregnant smokers was planned. Eligibility criteria were restrictive (e.g., 14-26 weeks' gestation; no psychiatric conditions or medications) due to the unknown safety, tolerability, and side effect profile of bupropion in pregnancy. Bayesian analyses were planned to provide probability of benefit. Significant challenges were encountered with regard to trial feasibility. Of 820 women screened, 112 were current smokers, but only 11 women were eligible and consented to participate in the study. Excluded women most often had a psychiatric disorder (23%); were outside the gestational range (14%); or declined to participate (11%). This initial attempt to evaluate bupropion for smoking cessation during pregnancy will inform future trial methodology. Because of the unknown safety profile, conservative eligibility criteria were used and resulted in a large portion of this high-risk, low-income smoker population being excluded from the trial, raising questions regarding broad applicability, and highlighting the need to balance patient safety and trial feasibility. Large multisite studies will likely be needed to conduct definitive pharmacotherapy studies.

The impact of the resident duty hour regulations on surgical patients’ perceptions of care

Implementation of the 2003 Accreditation Council for Graduate Medical Education (ACGME) resident duty regulations and access to publicly reported patient satisfaction measures have challenged administrators and clinicians to balance resident’s educational experience, patient care quality, and patients’ satisfaction and perceptions. A pre retrospective study design investigated association between implementation of ACGME regulations and patient satisfaction/perceptions using multinomial logistic – June 2005), who responded to surveys at an academic medical center. Patients gave lower ratings for physician interactions (patient-physician interaction time, clinical updates, a hour regulations. While the odds of patients rating related to time spent, kept informed, and friendliness/ courtesy) were higher rating “very good”, the overall rating of quality care improved post increased interaction of patients with other hospital personnel. To improve patient satisfacti perceptions, initiatives such as workload balancing, hand for care providers are recommended. Finally, residency programs and institutions need to develop strategies for implementation of current and future ACGME duty hour regulations so as to balance patient safety, patient percep and resident well-being.

Impact of Throughput Optimization on Intensive Care Unit Occupancy

Intensive care unit (ICU) resources are scarce, yet demand is increasing at a rapid rate. Optimizing throughput efficiency while balancing patient safety and quality of care is of utmost importance during times of high ICU utilization. Continuous improvement methodology was used to develop a multidisciplinary workflow to improve throughput in the ICU while maintaining a high quality of care and minimizing adverse outcomes. The research team was able to decrease ICU occupancy and therefore ICU length of stay by implementing this process without increasing mortality or readmissions to the ICU. By improving throughput efficiency, more patients were able to be provided with care in the ICU.