Inter-provider Communication Research Articles

Improving outcomes in a high-output pediatric otolaryngology practice

ObjectivesTo identify factors associated with efficient operating room work flow on high volume pediatric otolaryngology days and the effects on provider and perceived parent satisfaction. MethodsRetrospective review was performed of a sample of 20 days with greater than 10 cases per day performed by a pediatric otolaryngologist operating in 2 rooms. Turnover time and complications were the main outcome measures. Providers from otolaryngology and anesthesia that participated in these days were surveyed regarding efficiency, safety, and satisfaction. Results223 cases were performed over 20 operative days. The average turnover time was significantly longer in “major” surgeries (p=0.03), cases with multispecialty involvement (p=0.01), cases requiring intubation (p<0.001), and in cases where a fellowship trained pediatric anesthesiologist (p=0.01) or CRNA was present (p<0.001). When comparing “fast” (<25min average turnover) operative days vs. “slow” (>25min average turnover) days, presence of a non-fellowship trained anesthesiologist (p<0.001), and the presence of an anesthesiology resident (p=0.03) were significantly associated with “fast” days, while the presence of a CRNA was associated with “slow” days (p<0.001). A significantly greater proportion of patients required intubation on “slow” turnover days vs. “fast” days (p=0.13). Only one complication was observed (0.4%). 48 providers were surveyed with a 63% response rate. Reported satisfaction amongst providers was significantly greater on days with at least 10 cases (p=0.047) and on days with turnover times of 25min or less (p<0.001). Pre-operative nursing evaluation/preparation of the patient, inter-provider communication and delays in room cleaning/setup were identified most often as causative factors responsible for delays in turnover. ConclusionsHigh-operative volume operating days are common in pediatric otolaryngology and can be safely performed in an efficient manner. Appropriate scheduling and high-level communication between providers is needed to ensure success on these days. Identified areas of potential inefficiency can be a starting point for work flow optimization practices.

Development of the Connecticut Airway Risk Evaluation (CARE) System to Improve Handoff Communication in Pediatric Patients With Tracheotomy

National attention has focused on the importance of handoffs in medicine. Our practice during airway patient handoffs is to communicate a patient-specific emergency plan for airway reestablishment; patients who are not intubatable by standard means are at higher risk for failure. There is currently no standard classification system describing airway risk in tracheotomized patients. To introduce and assess the interrater reliability of a simple airway risk classification system, the Connecticut Airway Risk Evaluation (CARE) system. We created a novel classification system, the CARE system, based on ease of intubation and the need for ventilation: group 1, easily intubatable; group 2, intubatable with special equipment and/or maneuvers; group 3, not intubatable. A "v" was appended to any group number to indicate the need for mechanical ventilation. We performed a retrospective medical chart review of patients aged 0 to 18 years who were undergoing tracheotomy at our tertiary care pediatric hospital between January 2000 and April 2011. INTERVENTIONS Each patient's medical history, including airway disease and means of intubation, was reviewed by 4 raters. Patient airways were separately rated as CARE groups 1, 2, or 3, each group with or without a v appended, as appropriate, based on the available information. After the patients were assigned to an airway group by each of the 4 raters, the interrater reliability was calculated to determine the ease of use of the rating system. We identified complete data for 155 of 169 patients (92%), resulting in a total of 620 ratings. Based on the patient's ease of intubation, raters categorized tracheotomized patients into group 1 (70%, 432 of 620); group 2 (25%, 157 of 620); or group 3 (5%, 29 of 620), each with a v appended if appropriate. The interrater reliability was κ = 0.95. We propose an airway risk classification system for tracheotomized patients, CARE, that has high interrater reliability and is easy to use and interpret. As medical providers and national organizations place more focus on improvements in interprovider communication, the creation of an airway handoff tool is integral to improving patient safety and airway management strategies following tracheotomy complications.

Physician shortage and the future of medicine.

Dear Sir, I’m a third year college student contemplating postgraduate work in the medical field, either entering Physician Assistant (PA) school or medical school followed possibly by pediatric surgery, but I worry about the future of medicine due to politics and the government's increasing involvement in health care. Initially I was looking into attending PA School, but the projected shortage of physicians in the U.S. may reinforce my plans instead to attend Medical School. I often pause and reflect on the laborious and arduous future that lies ahead of me. In order to learn more about medicine and how physicians function, I have spent numerous hours shadowing physicians and observing surgeons and PAs in the operating room. Not only did I gain a better understanding of how physicians and surgeons function, but I also learned about the government's involvement in the medical field. Already in my own lifetime I have observed the government's intrusion in the medical field culminating with the Affordable Care Act (better known as Obamacare) and its implementation and this worries me.[1,2] I understand physicians are now experiencing lower compensation rates, more administrative duties, and less time nurturing the patient–doctor relationship, which is so important for good health outcomes. All of this makes me nervous for the future of medicine, especially considering the predicted shortage of 90,000 doctors by 2020.[2] I believe that the predicted manpower shortage of physicians is political, in part due to the government's involvement, and the U.S. Congress’ unwillingness to increase Medicare funding and their unwillingness to promote a climate conducive to the expansion of the number of residency spaces needed to provide adequate medical care in the future. There is a growing number of injustices forced upon medicine by the government's increased control and the concomitant gradual loss of physician autonomy. I’m not the only Pre-Med student worried about the future of Medicine. Many medical students are already thinking of going into fields such as vein specialty and plastic surgery, where there is less government involvement. Medicine is a noble profession, and those who practice medicine are able to serve and provide for others. Let us not forget that medicine started as an art before it became a science. The art of medicine was to aid our fellow human beings in sickness and alleviate their suffering, while being reminded men and women are not only physical but also spiritual beings, better ministered with compassion. I hope the venerable art and science of medicine can be saved before the government and politics destroy it. The implications of Medicaid, Medicare, coupled with decreased funding, have caused an increase in the number of patients that physicians see daily in their offices and the emergency room (ER). The result is that medicine has become more and more about increasing patient volume than about individual patient care. Due to increase load and the physician manpower shortage, nurses and PAs have to step in to fill the role of physicians. I also read with great interest the editorial, “The Lost Art of Inter-Provider Communication,” written by Mona Stecker.[3] She drives home many of these issues; inter-provider communication is important to better serve patients and improve efficiency. This becomes even more important as nurses and PAs step into physicians’ shoes in the near future. Sadly, while technology has tremendously advanced and communication has become more efficient, interaction with patients has paradoxically decreased. Tape recordings, computerized notes, and technological advances have displaced face-to-face communication, and the human touch and bedside manners for which physicians have been known in former times. This is an important topic that I will continue to explore as I consider my options prior entering the medical field. It will be interesting and telling to see how the government solves the problem of the predicted shortage of physicians, as well as observing how Nurse Practitioners (NPs) and PAs step up to fill the rank vacated by physicians. Mary-Kate Hunnicutt attends the University of Georgia as a Biology major with a Pre-Med emphasis. She is involved at UGA as a member of the Pre-PA and Pre-Med Club and a member of Phi Sigma Pi, the Honors Fraternity at UGA, as well as an Athletic Relations Committee member of UGA Hero's, an organization helping provide quality life care to children affected by HIV/AIDS.

The lost art of inter-provider communication.

From the days of Neanderthal drawings on cave walls to the sophisticated tools of cell phones, cable phones, and satellite phones, communication among humans has evolved at a dizzying pace. Or has it? Communication among and between healthcare providers in the 21st century may have actually devolved. Computers and smart phones have taken the place of interpersonal communication. While communication among healthcare providers has become more efficient, one can argue that it has become less safe for the patient. Gone are the days of consultants speaking directly to one another about a mutual patient. Now, physicians and mid-level providers read one another's notes either on paper or in a computerized medical record. Gone also are the days of nurses trading information on a patient between shifts. Shift report is either done through tape recordings or, again, via computerized notes. The rationale of decreased interpersonal communication between healthcare providers is “I am too busy.” Yes, we are constantly fighting the clock in our efforts to take care of patients in an environment that is wrought with “crossing Ts and dotting Is” to satisfy increasingly suffocating regulatory demands. Yet, while relying solely on digital communication, we are sacrificing the gain of subtle nuances of patient information that can be of supreme importance in their outcome. Family dynamics, psychosocial situations, or even a vague deviation from a normal exam may not be properly articulated to one another, and this can make a difference in the course of a patient's hospitalization. Perhaps, the quality and quantity of interpersonal communication has suffered because of poorly defined roles and tasks,[4] “turf wars” among hospital departments/units, difficulty in socialization skills between professionals, or competing priorities among hospital staff. The problem of poor communication may be related to all of these factors. Irrespective of the underlying causes of communication breakdown between healthcare professionals, the adverse affect on patient outcome and development of tools to enhance and improve collaboration and communication is well documented in the literature.[1,2] Poor communication among healthcare providers also makes for a stressful workplace and encourages disruptive behavior among clinicians.[3] There is no healthcare professional that is too important or too busy to speak or interact with a colleague, especially when it concerns a patient care issue. Leave egos and personal feelings at the door. Provide unencumbered quality patient care. Let us get back to the fundamentals of patient care and do the best we can for our patients all day, every day.

Association of Self-reported Hospital Discharge Handoffs With 30-Day Readmissions

Poor health care provider communication across health care settings may lead to adverse outcomes. To determine the frequency with which inpatient providers report communicating directly with outpatient providers and whether direct communication was associated with 30-day readmissions. We conducted a single-center prospective study of self-reported communication patterns by discharging health care providers on inpatient medical services from September 2010 to December 2011 at The Johns Hopkins Hospital. A 1000-bed urban, academic center. There were 13 954 hospitalizations in this time period. Of those, 9719 were for initial visits. After additional exclusions, including patients whose outpatient health care provider was the inpatient attending physician, those who had planned or routine admissions, those without outpatient health care providers, those who died in the hospital, and those discharged to other healthcare facilities, we were left with 6635 hospitalizations for analysis. Self-reported communication was captured from a mandatory electronic discharge worksheet field. Thirty-day readmissions, length of stay (LOS), and demographics were obtained from administrative databases. We used multivariable logistic regression models to examine, first, the association between direct communication and patient age, sex, LOS, race, payer, expected 30-day readmission rate based on diagnosis and illness severity, and physician type and, second, the association between 30-day readmission and direct communication, adjusting for patient and physician-level factors. Of 6635 included hospitalizations, successful direct communication occurred in 2438 (36.7%). The most frequently reported reason for lack of direct communication was the health care provider's perception that the discharge summary was adequate. Predictors of direct communication, adjusting for all other variables, included patients cared for by hospitalists without house staff (odds ratio [OR], 1.81 [95% CI, 1.59-2.08]), high expected 30-day readmission rate (OR, 1.18 [95% CI, 1.10-1.28] per 10%), and insurance by Medicare (OR, 1.35 [95% CI, 1.16-1.56]) and private insurance companies (OR, 1.35 [95% CI, 1.18-1.56]) compared with Medicaid. Direct communication with the outpatient health care provider was not associated with readmissions (OR, 1.08 [95% CI, 0.92-1.26]) in adjusted analysis. Self-reported direct communication between inpatient and outpatient providers occurred at a low rate but was not associated with readmissions. This suggests that enhancing interprovider communication at hospital discharge may not, in isolation, prevent readmissions.

Nurses' Perceptions of How Clinical Information System Implementation Affects Workflow and Patient Care

There is a little evidence of the impact of clinical information system implementation on nurses' workflow and patient care to guide institutions across the nation as they implement electronic health records. This study compared changes in nurse's perceptions about patient care processes and workflow before and after a comprehensive clinical information system implementation at a rural referral hospital. The study used the Information Systems Expectations and Experiences survey, which consists of seven scales-provider-patient communication, interprovider communication, interorganizational communication, work-life changes, improved care, support and resources, and patient care processes. Survey responses were examined across three administrations-before and after training and after implementation. The survey responses decreased significantly for eight of the 47 survey items from the first administration to the second and for 37 items from the second administration to the third. Perceptions were more positive in nurses who had previous experience with electronic health records and less positive in nurses with more years of work experience. These findings point to the importance of setting realistic expectations, assessing user perceptions throughout the implementation process, designing training to meet the needs of the end user, and adapting training and implementation processes to support nurses who have concerns.

Effective Communication of Difficult Airway Management to Subsequent Anesthesia Providers

To the Editor: Clinicians frequently have problems obtaining important information about a patient’s previous medical care. In the practice of anesthesia, particularly vital information concerns the management of the patient’s airway, especially if there has been past difficulty. Such information is often unavailable when needed. According to the American Society of Anesthesiologists closed claims project database, difficult tracheal intubation is the second most frequent primary event leading to anesthesia malpractice claims.1 We present a relatively simple method to facilitate interprovider communication of the details of an individual patient’s past airway management. A history of previous difficult tracheal intubation offers clinically suggestive evidence that difficulty may recur and it is the single most important predictor of subsequent difficult laryngoscopy.2,3 The patient, even if aware of previous difficulty, may not be able to communicate this or to recall specific details. Systems to transmit airway information that have been tried include verbal or written reports given to the patient, notes entered in the medical chart, communication with the patient’s surgeon and the primary care physician, and notification bracelets.2 Enrollment in the Medic Alert Emergency Identification Program4 or registration in a local or national database for patients with difficult airways are additional approaches for dissemination of critical information.5 This information may not be available outside of the institution in which it was generated, and bracelets, although pointing to difficult tracheal intubation, cannot transmit the details of airway management. We propose an alternative solution. Our criteria are that the information should be accessible from the patient at all times, that it contains the details of airway management important to subsequent providers, and that it not be dependent on a particular technology. To this end, we have created a wallet-sized card with checkboxes to detail airway management, which is then laminated to provide longevity. The front and back of the card are illustrated in Figure 1. The card was created in PowerPoint 2008 for Mac, version 12.1.1, Microsoft Corp., Seattle, WA.Figure 1.: The front side shows patient’s last name, first name, and date of birth, the hospital address, and the institutional logo. The backside is divided into three sections that contain specific details of the airway difficulty and its management (only devices used in our institution are listed) plus the anesthesia provider’s name, the institutional provider number, and a 24-h contact number for inquiries.Once completed, the card is laminated with a pouch laminator (GBC Heatseal™ H110, ACCO brands, Lincolnshire, IL) for protection. The card is given to the patient or next of kin before discharge from the postanesthesia care unit. At the same time, the patient is formally notified about the difficulty with airway management and instructed to carry the card at all times, e.g., in the wallet. The patients are also specifically instructed to show the card to subsequent anesthesia providers. These cards can be created locally with several different software applications and printing costs are minimal. Laminating devices are inexpensive and we deployed this system at three different sites for less than $400. Until the availability of electronic national health records or “smart” cards with magnetically stored information, the system we describe provides a simple and easily implemented way to transmit vital airway management data between providers. Joerg C. Schaeuble, MD James E. Caldwell, MB ChB Department of Anesthesia and Perioperative Care University of California, San Francisco San Francisco, California [email protected]

Identifying Performance Obstacles among Intensive Care Nurses

In this paper, we compare findings of two studies aimed at identifying performance obstacles among intensive care nurses. The first study is a qualitative study where data was collected from 15 intensive care nurses using individual, semi-structured interviews. The second study is a cross-sectional study conducted among 298 nurses from 17 intensive care units (ICUs) of seven hospitals using a questionnaire survey. Based on the results of these two studies, the most commonly experienced performance obstacles among ICU nurses include inadequate help from others, tools and equipment, ineffective inter-provider communication, materials and supplies, poor physical work environment, and family issues. The results of these two studies have implications regarding efforts aimed at redesigning ICU work organization in order to reduce nursing workload and improve quality of working life and quality and safety of care.

Collecting Workers' Perceptions of Performance Obstacles in Outpatient Surgery

The aim of this study was to gather information from staff of outpatient surgery centers concerning their perception of the patient safety/quality of care issues at their Center and the performance obstacles they face when doing their work. In addition we wished to determine whether performance obstacles research (Brown &amp; Mitchell, 1988; Peters et al, 1985) can be applied to the conceptual framework that serves as the basis for all of our patient safety research (Smith &amp; Carayon, 1989, 1995; Carayon &amp; Smith, 2000). We distributed open-ended surveys to all health care providers in five local outpatient surgery centers. Based on previous work conducted in the area of performance obstacles (Brown &amp; Mitchell, 1988; Peters, et al, 1985) we asked the caregivers to identify instances when they felt their performance was challenged or below par, as well as instances when they were able to perform their job very well. Because the population we surveyed is not familiar with the totality of the work system model as defined by Smith &amp; Carayon (1989, 1995) and Carayon &amp; Smith, (2000), we provided the elements of the work system as examples to the respondents. The resounding themes caregivers listed as significant performance obstacles included inter-provider coordination and communication of care, equipment, work space, scheduling, time pressure and staffing issues.