Half-day Blocks Research Articles

Pediatric Endoscopy Blocks: Enhanced Efficiency and Endoscopist Satisfaction.

Endoscopic procedures are increasingly performed for children and adolescents and these interventions represent a central element of both pediatric gastroenterology (GI) care and revenues. It remains unclear, however, which scheduling paradigm maximizes efficiency of resource utilization and delivery of care in this arena. In this study, we evaluate the impact of shifting from shared endoscopy blocks to individual, provider-specific endoscopy blocks for scheduling endoscopic procedures in our tertiary care academic center. The implemented endoscopy block system involves a single endoscopist performing procedures in an allocated room for the entire half-day period of time, with most providers having 1-3.5 day blocks per month. We analyzed block fragmentation (multiple providers in a single block), block utilization, and procedure volume, comparing the 8-month period prior to implementation of the block system (pre-implementation period) with the 8-month period following implementation of the block system (post-implementation period). Provider satisfaction and perceptions were assessed by survey pre- and post-implementation. Standard descriptive statistics were utilized for analysis. In the pre- and post-implementation periods, 22 half-day blocks were allocated to pediatric GI. In the pre-implementation period, mean utilization of these blocks was 65.9% (range: 47%-77%). In the post-implementation period, mean % utilization was 79.8% (range: 64%-89%). Overall endoscopy procedure volume increased from 279 in the pre-implementation period to 419 in the post-implementation period. Provider perception of endoscopy efficiency was enhanced by the block system, with 68.4% of pediatric GI respondents rating endoscopy as "efficient" post-implementation (vs 19% pre-implementation) and 63.2% indicating that the block system directly enhanced efficiency. A total of 63.2% reported increased personal procedure volume and 84.2% reported perceived increase in overall procedure volume with block system implementation. Strategic approaches for scheduling endoscopic procedures carry the potential to enhance efficiency and experience for both providers and patients. Implementation of the endoscopy block system was associated with increased procedure volumes and block utilization as well as a more positive experience for the majority of providers. Schedule adjustments with analysis of associated efficiency and satisfaction metrics can optimize pediatric endoscopy practice.

Appropriate operating room time allocations and half-day block time for low caseload proceduralists, including anesthesiologist pain medicine physicians in the State of Florida

Study objectiveWe analyzed University of Iowa operating room data to estimate whether it would be economically rational to allocate, every two weeks, an operating room to anesthesiology pain medicine physicians or a half-day session to individual proceduralists. We investigated the generalizability of the results by studying anesthesiologist pain medicine physicians working at all hospitals and ambulatory surgery centers in the State of Florida. DesignObservational, cohort study of spinal neuromodulation procedures. MeasurementsHours of daily operating room time and cases by anesthesiologist pain medicine physicians at the University of Iowa, and in Florida in 2018. For each two-week period, we calculated the difference in hours between (1) the under-utilized time from allocating 8 h and (2) time-and-a-half times the over-utilized time from no allocated time. Main resultsThe mean greater cost from allocating 8 h vs 0 h equaled 3.89 h, significantly >0 (P = 0.0001, N = 77 periods). Sample mean activities were 0.79 cases and 1.64 h, <2.00 cases and 4.00 h, respectively (both P < 0.0001). Thus, no allocated time or block time should be planned.At least 76.6% (95% lower confidence limit) of Florida surgical facilities performing ≥1 neuromodulation procedures averaged <1.08 cases per two weeks. At least 89.6% of the facilities averaged <2 cases per two weeks. At least 88.8% of combinations of anesthesiologist and facility in Florida averaged fewer cases per two weeks than anesthesiologist proceduralists at the University of Iowa. At least 96.5% of the proceduralists averaged <2 cases per two weeks at each facility where they operated. ConclusionsAmong anesthesiologist proceduralists in Florida using operating room time for neurostimulator procedures, most perform too few cases weekly for the economically appropriate planning of block time. Few Florida facilities would have enough cases, even potentially, to warrant allocating operating room time.

Morning versus afternoon adenoma detection rate: a systematic review and meta-analysis.

Adenoma detection rate (ADR) is a quality marker of colonoscopy and operator performance. Prior studies evaluating the effect of an extended workday on the ADR reported variable outcomes that remain controversial. Given the variable results of prior studies and the potential legal implications of reduced ADR in the afternoon, we aimed to further evaluate this parameter and its effect on ADR. We performed a systematic review of the PubMed, CINAHL and Scopus electronic databases. Studies were included if they reported ADR in patients undergoing colonoscopy in the morning session and the afternoon session. Afternoon sessions included both sessions following a morning shift and half-day block shifts. Subgroup analyses were performed for ADR comparing morning and afternoon colonoscopies in a continuous workday, advanced ADRs (AADRs) and polyp detection rates (PDRs) were also compared. Thirteen articles with 17 341 (61.2%) performed in the morning session and 10 994 (38.8%) performed in the afternoon session were included in this study. There was no statistical significance in the ADR or AADR between morning and afternoon sessions, respectively [relative risk (RR) 1.06, 95% confidence interval (CI) 0.99-1.14] and (RR 1.19, 95% CI 0.95-1.5). Afternoon procedures had a significantly higher PDR than morning procedures (RR 0.93, 95% CI 0.88-0.98). ADR was not significantly influenced in the afternoon session when operators continued to perform procedures throughout the day or on a half-day block schedule.

Remote blood pressure monitoring and behavioral intensification for stroke: A randomized controlled feasibility trial.

Measuring blood pressure (BP) at home and remote monitoring can improve the patient's adherence to BP control and vascular outcomes. This study evaluated the feasibility of a trial regarding the effects of an intensive mobile BP management strategy versus usual care in acute ischemic stroke patients. A feasibility-testing, randomized, open-labeled controlled trial was conducted. Remote BP measurement, data transmission, storage, and centralized monitoring system were organized through a Bluetooth-equipped sphygmomanometer paired to the participants' smartphones. Participants were randomized equally into intensive management (behavioral intensification to measure BP at home by texting, direct telephone call, or breakthrough visit) and control (usual care) groups. The primary feasibility outcomes were: 1) recruitment time for the pre-specified number of participants, 2) retention of participants, 3) frequency of breakthrough visit calls, 4) response to breakthrough visit call, and 5) proportions satisfying BP measurement criteria. Sixty participants were randomly assigned to the intensive management (n = 31) and control (n = 29) groups, of which 57 participants were included in the primary analysis with comparable baseline characteristics. Recruitment time from the first to the last participant was 350 days, and 95% of randomized participants completed the final visit (intensive, 94%; control, 98%). Eight breakthrough visit calls were made to 7 participants (23%), with complete and immediate responses within 3 ± 4 days. The median of half-day blocks fulfilling the BP measurement criteria per patient were 91% in the intensive group and 83% in the control group (difference, 12.2; 95% confidence interval, 2.2-22.2). No adverse events related to the trial procedures were reported. The intensive monitoring, including remote BP measurement, data transfer, and centralized monitoring system, engaged with behavioral intensification was feasible if the patients complied with the intervention. However, the device utilized would need further improvement prior to a large trial.

536 Adenoma Detection Rate Is Higher in a.m. Colonoscopies Only When Performed in Full-Day Blocks: A Systematic Review and Meta-Analysis

INTRODUCTION: Colorectal cancer (CRC) is the fourth leading cause of malignancy in the US. Colonoscopy remains the most accurate tool for CRC screening. Adenoma detection rate (ADR) and polyp detection rate (PDR) are important quality indicators for colonoscopy and high rates are associated with decreased post-colonoscopy CRC. Colonoscopy performed in the afternoon has been reported to be associated with lower rates of ADR and PDR, however studies remain controversial. Our aim was to perform a systematic review and meta-analysis to evaluate the ADR and PDR between morning and afternoon colonoscopies. METHODS: We included trials comparing ADR or PDR between morning (AM) and afternoon (PM) colonoscopies. We searched Medline, Google Scholar, and Cochrane through May 2019. Eligible studies were searched for variables of interest. All statistical analyses were performed using the R Programming Language. Pooled rates of variables were reported as Odds ratio (OR) with 95% confidence interval and heterogeneity was reported as I2statistics. RESULTS: A total of 14 trials were eligible and included in the analysis. Colonoscopies were performed in full-day blocks in 3 studies and in half-day blocks in 5. There was a total of 18184 subjects in the AM group and 12326 in the PM group. ADR and PDR were significantly higher in the AM compared to the PM group only when performed in full-day blocks (OR = 1.25, 1.11-1.4; OR = 1.33, 1.13-1.58 respectively). Bowel prep adequacy was similar between the 2 groups (OR = 1.08, 0.8-1.45). There was substantial heterogeneity. CONCLUSION: Colonoscopy quality, as indicated by ADR and PDR is only affected when performing colonoscopies in full-day blocks with lower performance in the afternoon. Endoscopist fatigue, fellow participation and quality of bowel prep are important cofounders when comparing quality metrics in endoscopy. The difference between in ADR and PDR between studies is likely multifactorial, however scheduling colonoscopies in half-day shifts may prevent endoscopist fatigue and improve performance. Given the heterogeneity of the results, definite conclusions cannot be drawn and future randomized trials are needed.

A quality improvement project to increase compliance with diabetes measures in an academic outpatient setting

BackgroundAmerican Diabetes Association (ADA) sets annual guidelines on preventative measures that aim to delay the onset of severe diabetes mellitus complications. Compared to private internal medicine clinics, resident clinics provide suboptimal diabetic preventative care as evidenced by decreased compliance with ADA guidelines. The purpose of our study is to improve diabetic care in resident clinics through quality improvement (QI) projects, with A1C value as primary outcome and other ADA guidelines as secondary outcomes.MethodsOur resident clinic at Beaumont Hospital, Royal Oak consists of 76 residents divided in 8 teams. In November 2016, baseline data on ADA guideline measures was obtained on 538 patients with diabetes mellitus. A root cause analysis was conducted. 5 teams developed a QI intervention plan to improve their diabetes care and 3 teams served as comparisons without intervention plans. In November 2017, post-intervention data was collected.ResultsBaseline characteristics demonstrate mean age of intervention groups at 60.9 years and of comparison groups at 58.9 years. The change in A1C value from baseline to post-intervention was + 0.09 vs. + 0.322 in the intervention and comparison groups respectively (p = 0.174). As a group, the changes in secondary outcome measures were as follows: eye examinations (+ 5% in intervention vs. -7% in comparison, p < 0.01), foot examinations (+ 13% vs. + 5%, p = 0.09), lipid panel testing (+ 7% vs. -5%, p < 0.01), micro-albumin/creatinine ratio testing (+ 4% vs. + 1%, p = 0.03), and A1C testing (+8% vs. + 5%, p = 0.24).ConclusionsWhile the QI project did not improve A1C value, it did have significant improvement in several secondary outcomes within intervention groups. One resident team implemented an intervention involving protected half-day blocks to identify overdue examinations and consequently had the largest improvements, thus serving as a potential intervention to further study. Given our study results, we believe that QI interventions improve preventative care for patients with diabetes in resident clinics.

Attending Physicians' Perspectives of Resident Academic Half Day

Phenomenon: Academic health centers face significant challenges trying to improve medical education while meeting patient care needs. In response to problems with traditional forms of didactic education, many residency programs have transitioned to Academic Half Day (AHD), a curricular model in which learning is condensed into half-day blocks. In this model, trainees have protected educational time free from clinical responsibilities. However, an understanding of the impact on attending physicians and patient care when residents depart clinical sites for learning activities has not been well described. We sought to explore attending physicians’ perspectives when residents depart clinical sites to attend AHD. Approach: We performed a qualitative study with a grounded theory approach using individual semistructured interviews (December 2016–April 2017) of attending physicians who worked at inpatient and emergency department clinical sites from which residents departed to attend AHD. We used the constant comparative method, generating codes using an iterative approach and continuing sampling until saturation was reached. Major themes were identified and disagreements were resolved by consensus. Findings: Fifteen attending physicians from 6 clinical services were interviewed. Data analysis yielded 5 themes: emotional strain of workload, technology and systems challenges, patient safety and care concerns, disrupted resident learning, and the challenge to optimize resident education. Attending physicians, already working on busy services, felt frustrated and perceived having an increased workload when residents departed for AHD. They were concerned about safely entering orders in the electronic health record, impeded patient workflow, and further disruption of resident schedules already disrupted by duty hour restrictions and continuity clinic. Attending physicians described the importance of experiential learning from caring for patients and from structured didactic learning; however, the optimal balance was uncertain. Insights: We found that attending physicians experienced significant emotional strain, faced technological challenges, and were concerned about impeded workflow and patient safety when residents departed clinical sites for AHD. This is likely to be true whenever residents are pulled out of the clinical setting for any reason. Educators need to partner with hospital administrators to provide appropriate support for attending physicians when residents leave clinical sites, evaluate the effectiveness of different educational models, and determine how structured learning activities fit into the overall curriculum.

Profile of French general practitioners providing opportunistic primary preventive care--an observational cross-sectional multicentre study.

Preventive services provided opportunistically by GPs are insufficient. Reasons are most often gathered through GPs' self-reports, rather than through independent observation. To assess with passive observers, the degree to which French GPs opportunistically perform primary preventive care during routine consultation. Observational cross-sectional multicentre ancillary study of the French ECOGEN study. The study period extended from 28 November 2011 to 30 April 2012. The inclusion criteria were patients seen by GPs at surgery and home consultations in non-randomized pre-determined half-day blocks per week. The non-inclusion criteria were patient's refusal and consultations initially focused on primary prevention in response to patient's request (ancillary study's specific criterion). Using passive observers, data were collected based on the second version of International Classification of Primary Care. Preventive consultations were defined if at least one problem/diagnosis was considered by consensus as definitely related to primary prevention. For each one of the 128 participating GPs, aggregation of data was performed from all his/her consultations. Determinants of the proportion of preventive consultations per GP were assessed by multivariate linear regression. Considering 19003 consultations, the median proportion of preventive consultations per GP was 14.9% (range: 0-78.3%). It decreased with increased proportion of patients aged 18 or less (P = 0.006), with increased proportion of home visits (P = 0.008) and with increased proportion of consultations lasting under 10 minutes (P = 0.02). None of the GPs' personal characteristics were significantly associated. Primary preventive care activity was related to the characteristics of GPs' patients and practice organizational markers and not to GPs' personal characteristics.

Adenoma detection rate is not influenced by full-day blocks, time, or modified queue position

Recent studies have shown the adenoma detection rate (ADR) to decrease from endoscopist fatigue. Our primary objective was to evaluate the afternoon ADR in half-day versus full-day blocks. Secondary objectives were to determine whether time or complexity of prior procedures (modified queue position) influence ADR. Retrospective chart review on consecutive colonoscopies. Tertiary-care teaching hospital. This study involved all patients in our database who were over age 45 and who underwent screening and surveillance colonoscopies. ADR. A total of 3085 patients were included in the study, with an overall 31% ADR. Of these procedures, 2148 (70%) were done in the morning, and 937 (30%) were done in the afternoon (512 full-day block, 425 half-day block). By multivariate analysis, there was no difference in ADR between full-day blocks compared with afternoon-only blocks (35% vs 32%; odds ratio [OR] 1.1; 95% confidence interval [CI], 0.8-1.5; P = .2). For all afternoon colonoscopies, no decrease in ADR was noted with increasing queue position (P = .9) or time (P = .3). In addition, no difference was found comparing ADR between all afternoon colonoscopies versus morning colonoscopies (33% vs 30%; OR 1.1; CI, 1.0-1.3; P = .1). No difference was found for advanced adenomas and number of adenomas between either afternoon-only blocks versus afternoon colonoscopy in full-day blocks or morning versus all afternoon cases. Retrospective study; not all withdrawal times were recorded; trainees performed some of the procedures. Our data show that colonoscopy can be performed in full-day blocks and 30-minute slots without compromising ADR.

Adenoma Detection Rate Is Not Influenced by the Timing of Colonoscopy When Performed in Half-Day Blocks

Afternoon colonoscopies have recently been reported to be associated with lower adenoma detection rate (ADR), which was attributed to physician fatigue resulting from the same endoscopist performing procedures throughout the day. The aim of our study was to assess ADR in morning compared with afternoon colonoscopy performed in half-day blocks with different physicians. We evaluated the primary hypothesis that morning and afternoon ADRs would not differ significantly when performed in half-day blocks by different endoscopists. Data on all colonoscopies performed between January 2009 and December 2009 were obtained from our endoscopy database. All patients who underwent colonoscopies in 2009 for screening, surveillance, and family history of colon cancer/polyps were included in the study. Morning colonoscopies were defined as those that were performed from 0800 to 1200 hours. Afternoon colonoscopies were defined as those that were performed from 1300 to 1700 hours. Colonoscopies in each block were performed either by different endoscopists working in half-day (morning or afternoon) block schedules or by the same endoscopist working a full-day schedule. A total of 4,665 patients were included in the study. For endoscopists working the full-day, the afternoon ADR was significantly lower than the morning ADR (21 vs. 26.1%; odds ratio (OR)=0.75; 95% confidence interval (CI) 0.59, 0.96; P=0.02). Conversely, in the half-day group, there was no significant difference in ADR between afternoon and morning (27.6 vs. 26.6%; OR=1.05; 95% CI 0.88, 1.26; P=0.56). Performing colonoscopies in half-day blocks by different endoscopists increases the detection of adenomas in afternoon procedures, probably by reducing physician fatigue.

What can Actigraphy Add to the Concept of Labschool Design in Clinical Trials?

Pharmacological intervention with methylphenidate (MPH) is very common and helpful in the treatment of attention-deficit/ hyperactivity disorder (ADHD). It ameliorates inattention, impulsivity and hyperactivity and improves psychosocial functioning. The core symptoms of ADHD are problematic mainly in demanding structured situations such as in the classroom. It was argued that MPH does not only lead to a decrease of hyperactivity in these situations but may also result in a general dampening of motor activity during non-structured leisure time. Unfortunately, only few clinical trials have investigated this practically important issue and thus it is still a matter of debate. It follows that many parents hesitate to accept psychotropic drugs for their children. To elucidate this problem in the current study, not only overall behavioral ratings (half-day blocks) but also day-long actigraphy was applied during an analogue classroom setting, where structured and non-structured situations alternated over time. Fourty-nine children with ADHD were assessed for treatment effects of once-daily extended-release and twice daily immediate-release methylphenidate (MPH) as well as placebo. Both MPH regimes yielded improved behavioral ratings during morning and afternoon, while actigraphy showed reduced motor activity in structured situations, but not during leisure time. Furthermore, the movement information obtained with actigraphy during structured situations could be differentiated from the one gained with overall behavioral ratings. Thus, while behavioral ratings provide a valid estimate of the overall symptomatology, additional information gathered with actigraphy may help to differentiate the impact of medication on hyperactive movement in different situations during the day. This may reflect a more valid picture of a child's real life and improve the quality of clinical trials. Thus, both methods may be regarded as complementary for the assessment of drug effects in children with ADHD and should be a standard of further laboratory school protocols in clinical trials.