Large Academic Medical Institution Research Articles

Corticosteroid Exposure in the Treatment of Severe COPD Exacerbations

Background: Recent literature and guidelines support treatment of severe acute exacerbation of COPD (AECOPD) with prednisone 40 mg (or equivalent) for 5 days. Objective: The purpose of this study was to determine whether systemic corticosteroids were being prescribed at the appropriate dose and duration in the treatment of severe AECOPD at a large academic medical institution. Methods: This was a single-center, retrospective, observational study conducted to evaluate corticosteroid prescribing patterns for adults admitted for severe AECOPD from March to May 2019 at a large academic medical institution. Appropriate therapy was defined as: prednisone 40 mg (or equivalent) for 5 days. The primary outcome was to determine the frequency of appropriate dose and duration. The secondary outcomes were to identify the frequency of appropriate dose or duration, compare the prevalence of adverse effects, such as new/worsening hyperglycemia or hypertension, and compare 30- and 90-day readmission rates. Results: Of the 190 patients included, 16 (8.4%) had an appropriate duration and 8 (4.2%) an appropriate dose. Only 4 patients (2.1%) had both appropriate corticosteroid dose and duration. New/worsening hyperglycemia occurred in 96 (50.5%), and hypertension developed in 13 (6.8%). Thirty-day readmission occurred in 46 (24.2%) and 90-day readmission in 78 (41.1%). These were more likely in those without appropriate dose and duration. Conclusion: Systemic corticosteroids for the treatment of severe AECOPD are not prescribed in accordance with evidence-based recommendations at this institution. This might result in a greater incidence of adverse effects and readmissions.

Secondary Traumatic Stress in Ob-Gyn: A Mixed Methods Analysis Assessing Physician Impact and Needs

This study aims to evaluate the incidence of secondary traumatic stress in Obstetrics and Gynecology physicians including symptoms, impact, and programmatic needs for support. This study used a mixed-methods approach comprised of an anonymous online survey and individual interviews/focus groups. IBM SPSS 24.0 generated statistical analysis: descriptive statistics, Fisher's exact test to compare nominal survey data and across groups, phi correlations (ϕ) and interitem reliability (Cronbach alpha). Constant comparative qualitative analysis determined cross-cutting themes. Research was approved by institutional IRB. This study was conducted at the Medical College of Wisconsin, Milwaukee, Wisconsin, a large academic medical institution. Participants were recruited from the Department of Obstetrics & Gynecology via email. Faculty, fellows, and residents participated in an anonymous online survey and were invited to complete individual interviews or focus groups. The online survey was distributed to 67 clinical faculty, residents, and fellows with a total of 27 individuals completing the reliable (alpha = 0.71) anonymous survey (40% response rate). Ten faculty participated in individual interviews or focus groups. Respondents to the quantitative survey identified involvement in adverse medical events (95%) and symptoms of traumatic stress (75%). Anxiety (81%), guilt (62%), and disrupted sleep (58%) were most frequently reported symptoms (mean number of symptoms = (3.4(±2.1)). Individuals reporting anxiety were more likely to seek support from colleagues (ϕ = 0.5, p < 0.006); those reporting guilt would go to friends (ϕ = 0.5, p < 0.007). Disrupted sleep more commonly led to seeking mental health services (ϕ = 0.5, p < 0.007). Desire for support varied. Those reporting anxiety were interested in peer-to-peer responders (ϕ = 0.6, p < 0.001); those reporting guilt would use debriefing sessions (ϕ = 0.4, p < 0.023). Qualitative data from individual interviews and focus groups yielded descriptions of physical and cognitive symptoms associated with second victim experiences included responsibility, guilt/shame, self-doubt, anxiety/rumination and sleep disturbance. Identified resources for coping: just culture, collegial support, peer-to-peer responders, and structured case conferences for emotional debriefing. Obstetrics and Gynecology providers are likely to experience symptoms of secondary traumatic stress following adverse patient events similar to other medical specialties. Comprehensive programs to address emotional well-being of physicians are important to promote collegiality and reduce symptoms of secondary traumatic stress. Safety and transparency with opportunities for group processing are identified as essentials for positive institutional culture, as well as peer support programs.

Abstract 2023: Advancing diversity of the current cancer research workforce: Employing a new pathway to improve recruitment of minorities from underserved populations

Abstract Introduction: To address the paucity of workforce diversity in cancer research and the slow recruitment of underrepresented minority (URM) populations in clinical trials, we developed an education program - Student-centered Pipeline to Advance Research in Cancer Careers (SPARCC), to prepare URMs as clinical research professionals (CRPs). Procedures: To target cultural/racial incongruence between patient and physician/researcher requires increased diversity in the clinical cancer workforce. SPARCC is a five-year NCI R25 program to recruit URM undergraduate students to become CRPs and/or seek advanced degrees in cancer research. CRP jobs are readily available with several avenues for professional growth. These positions also provide excellent interim employment and financial resources for those exploring advanced science careers. Over eight weeks, the first cohort of SPARCC Scholars participated in 84 workshop learning experiences, ten different practicum rotations and a culminating research project. Mixed methods evaluated the components of SPARCC. Collected data informed programmatic modifications for subsequent cohorts. Summary: Within 16 weeks of announcement, 39 completed applications were received, 62% (24/39) identified as URM and 77% (30/39) were females. Most were pursuing biomedical science majors (30/39) with interest to seek careers in healthcare (34/39). The first cohort of ten scholars began in June 2019. Scholars globally evaluated each workshop on average of 9.1(10=excellent), Of the 433 workshop evaluations scholars completed, 92% (400/433) of sessions were rated ‘outstanding' or ‘very good' in “advancing understanding of the topic area, a chief request included more interactive elements, especially if sessions were solely lecture-based. Upon completion of the practicum rotations, scholars were evaluated by preceptors on average of 9.2(10 = excellent). Participants identified the benefit of learning from various professionals and specialties they did not know existed. Other programmatic modifications include: increased time between workshop sessions to allow for deeper comprehension of content, inclusion of a financial literacy session, and increased protected time to conduct and formalize research projects. All scholars identified a strong sense of belonging at the large academic medical institution, which is frequently cited as a barrier for URM. Upon SPARCC's conclusion, all scholars reported interest in seeking careers in research and/or medicine. Of the 10 graduates, 2 are applying to medical school, 2 obtained employment as CRPs immediately after SPARCC and both are planning to pursue advanced research degrees, 5 are currently completing their final year of under-grad, and 1 is currently working in a research laboratory. Conclusion: Participation in SPARCC provided access to a professional network for 2 URM participants to quickly attain permanent employment in clinical trials research and be prepared for advanced education applications. Citation Format: Kristina Kaljo, Robert Treat, Janet S. Rader. Advancing diversity of the current cancer research workforce: Employing a new pathway to improve recruitment of minorities from underserved populations [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2023.

Restructuring the inpatient advanced pharmacy practice experience to reduce the risk of contracting coronavirus disease 2019: Lessons from Saudi Arabia.

IntroductionOn March 11, 2020, the World Health Organization announced the rapidly spreading epidemic of the coronavirus disease 2019 (COVID‐19) pandemic. Almost all countries started to take proactive precautionary measures to reduce the risk of contracting the virus. The education sector, including pharmacy education, has been drastically impacted by this pandemic. During the outbreak, many hospitals instructed the health profession's schools to restrict or prevent the presence of their students and interns in their hospitals in an effort to limit the spread of the virus.ObjectivesConstraining the presence of interns in the affiliated hospital has impacted the integrity of delivering the learning outcomes of each clinical rotation. In this paper, we present the experience of four faculty preceptors in restructuring the advanced pharmacy practice experience in different clinical settings, including critical care, infectious diseases, cardiology, and internal medicine, in order to reduce the risk of contracting COVID‐19 at a large academic medical institution in Saudi Arabia.ConclusionWe believe that this experience could provide guidance and insights for other pharmacy schools dealing with this issue during this global pandemic.

Development of a National Caregiver Health Survey for Hematopoietic Stem Cell Transplant: Qualitative Study of Cognitive Interviews and Verbal Probing.

BackgroundRoadmap 1.0 is a mobile health app that was previously developed for caregivers of patients who have undergone hematopoietic stem cell transplantation (HSCT). Formative research targeted toward its end users (caregivers) can help inform app design and development, allowing additional components to be incorporated into the app, which can then be tested in a future randomized controlled trial.ObjectiveThis study aimed to create a methodologically rigorous national survey that would help inform the development of Roadmap 2.0.MethodsWe conducted a prospective, qualitative research study that took place between November 18, 2018, and February 7, 2019, in a blood and marrow transplant unit within a large academic medical institution in the midwestern part of the United States. Cognitive interviews, including think-aloud and verbal probing techniques, were conducted in 10 adult caregivers (≥18 years) of patients who had undergone HSCT.ResultsMost participants were female (9/10, 90%), white (9/10, 90%), married (9/10, 90%), employed at least part time (6/10, 60%), caregivers of adult patients (7/10, 70%), and had some college education (9/10, 90%) and an annual household income of $60,000 or higher (6/10, 60%). All but one interview was audio-recorded, with permission. Overall, participants were engaged in the cognitive interview process of the draft survey, which included 7 topics. The interviews highlighted areas wherein survey items could be further refined, such as offering more response choices (eg, “NA”) or clarifying the type of transplant (eg, autologous or allogeneic) or context of transplant care (eg, pre-HSCT, during HSCT, post-HSCT, inpatient, and outpatient). Apart from these findings, the items in demographics, caregiving experiences, technology, positive activities, and mood were generally interpreted as intended. On the basis of the transcript data and field notes by the interviewer, items within self-efficacy (Caregiver Self-Efficacy Scale) and coping (Brief Coping Orientation to Problems Experienced inventory) questionnaires generated more confusion among interviewer and participants, reflecting difficulties in interpreting the meaning of some survey items.ConclusionsThis study incorporated the four cognitive aspects of survey methodology that describe the question-answering process—(1) comprehension, (2) information retrieval, (3) judgment and decision making, and (4) responding—by using the think-aloud and probing techniques in cognitive interviews. We conclude that this methodologically rigorous process informed revisions and improved our final questionnaire design.International Registered Report Identifier (IRRID)RR2-10.2196/resprot.49188

Prevalence and predictors of inappropriate apixaban dosing in patients with non-valvular atrial fibrillation at a large tertiary academic medical institution

The aim of this study was to assess apixaban prescribing practices for stroke prevention in patients with non-valvular atrial fibrillation (NVAF), and to examine the factors contributing to dosing inappropriateness at a large academic medical institution in Saudi Arabia. A retrospective cohort analysis of all adult patients with NVAF receiving apixaban for stroke prevention was conducted for the period from June 2015 to May 2019. Of the 1271 patients included in the analysis, inappropriate apixaban dosing was present in 223 (17.50%) patients and absent in 1048 (82.50%) patients. Among those who received an inappropriate apixaban dosage, 103 (46.19%) and 120 (53.81%) received an over- or under-dosed apixaban regimen, respectively. Increasing age, lower body mass index, a history of minor bleeding, concomitant antiplatelet therapy with either clopidogrel + aspirin or aspirin only, reduced renal function, and elevated CHA2DS2-VASc score were significantly associated with increasing the risk of receiving an inappropriate apixaban dosage. In patients with NVAF receiving apixaban for stroke prevention in this real-world analysis, > 80% were prescribed an appropriate dosage of apixaban. Proactive procedures, such as integrating an electronic dosing algorithm, educating healthcare providers, and involving clinical pharmacists in medication review, may help ensure the use of appropriate apixaban dosages.

Conversion to Chlorhexidine Gluconate for Perioperative Vaginal Preparation: An Evidence-Based Process Improvement Project.

Surgical site infections (SSIs) occur during the postoperative period and involve the operative site. To lower the occurrence of SSIs in their patient population, the gynecology SSI prevention committee at a large academic medical institution initiated a process improvement project examining vaginal antiseptic skin prep solutions. Some studies indicate that chlorhexidine gluconate (CHG) is superior to povidone-iodine in the reduction of microbial skin counts and SSIs. After reviewing the available literature, the committee members determined there was an opportunity to make an evidence-based practice change and realize significant cost savings by converting povidone-iodine prepping kits to CHG prepping kits for vaginal procedures. The committee members worked with perioperative and facility leaders to revise the vaginal preparation policy, provide staff member education, and convert to CHG prepping kits. Facility leaders supported this cost-saving conversion for all perioperative units, and the project led to a successful, large-scale, evidence-based process improvement.

Effectiveness and tolerability of neoadjuvant pertuzumab-containing regimens for HER2-positive localized breast cancer.

Based on improvement in pathologic complete response (pCR) in the NeoSphere and TRYPHAENA studies, the FDA approved neoadjuvant pertuzumab for HER2+ localized breast cancer. These studies demonstrated high pCR rates with THP (docetaxel + HP), FEC (5-fluorouracil, epirubicin, and cyclophosphamide)-THP, and TCHP (docetaxel, carboplatin + HP). However, in the United States, doxorubicin/cyclophosphamide (AC) is favored over FEC despite no data comparing neoadjuvant AC-THP with AC-TH or TCHP. Here we report outcomes for patients with localized HER2+ breast cancer treated with pertuzumab-containing neoadjuvant regimens and AC-TH. We reviewed clinicopathological characteristics of patients with HER2+ breast cancer (Stage I-III) treated with either a neoadjuvant pertuzumab-containing regimen or dose-dense (dd) AC-TH, from 2011 to 2016at a large academic medical institution and two affiliated community sites. pCR was defined as ypT0/is ypN0. Fisher's exact test and logistic regression analysis were used for statistical analysis. In this study (N = 121), pCR was numerically higher with pertuzumab-based regimens, including ddAC-THP (60%), TCHP (63%), THP (55%), as compared with ddAC-TH (46%). THP resulted in significantly less cycle delays due to toxicity compared to the other regimens (p = 0.02). THP also resulted in the least dose reductions, lowest rate of hospitalization, and lowest rate of treatment discontinuation. Pertuzumab-based regimens, including THP, resulted in higher pCR rates as compared to ddAC-TH, with the THP regimen associated with the best tolerability among patients with localized HER2+ breast cancer. Given the various neoadjuvant regimens, additional studies are needed to determine optimal treatment sequencing and escalation/de-escalation strategies to personalize neoadjuvant regimens for localized HER2+ breast cancer.

Examining the Impact of Using the SIMPL Application on Feedback in Surgical Education

The System for Improving and Measuring Procedural Learning (SIMPL) smartphone application allows physicians to provide dictated feedback to surgical residents. The impact of this novel feedback medium on the quality of feedback is unknown. Our objective was to compare the delivery and quality of best-case operative performance feedback given via SIMPL to feedback given in-person. We collected operative performance feedback given both in-person and via SIMPL from surgeons to residents over 6 weeks. Feedback transcripts were coded using Verbal Response Modes speech acts taxonomy to compare the delivery of feedback. We evaluated quality of feedback using a validated resident survey and third-party assessment form. University of Wisconsin School of Medicine and Public Health, a large academic medical institution. Four surgical attendings and 9 general surgery residents. Nineteen SIMPL and 18 in-person feedback encounters were evaluated. Feedback via SIMPL was more directive (containing thoughts, perceptions, evaluations of resident behavior, or advice) and contained more presumptuous utterances (in which the physician reflected on and assessed resident performance or offered suggestions for improvement) than in-person feedback (p = 0.01). The resident survey showed no significant difference between the quality of feedback given via SIMPL and in-person (p = 0.07). The mean score was 47.74 (SD = 3.00) for SIMPL feedback and 45.33 (SD = 4.77) for in-person feedback, with a total possible score of 50. Third-party assessment showed no significant difference between the quality of feedback given via SIMPL and in-person (p = 0.486). The mean score was 23.40 (SD = 3.75) for SIMPL feedback and 22.25 (SD = 5.94) for in-person feedback, with a total possible score of 30. Although feedback given via SIMPL was more direct and based on the attendings' perspectives, the quality of the feedback did not differ significantly. Use of the dictation feature of SIMPL to deliver resident operative performance feedback is a reasonable alternative to in-person feedback.

Patient and provider perspectives on the development of personalized medicine: a mixed-methods approach.

While genetic testing gains adoption in specialty services such as oncology, neurology, and cardiology, use of genetic and genomic testing has yet to be adopted as widely in primary care. The purpose of this study is to identify and compare patient and primary care provider (PCP) expectations of genetics services in primary care. Patient and PCP perspectives were assessed through a mixed-method approach combining an online survey and semi-structured interviews in a primary care department of a large academic medical institution. A convenience sample of 100 adult primary care patients and 26 PCPs was gathered. The survey and interview questions focused on perceptions of genetic testing, experience with genetic testing, and expectations of genetic services in primary care. Patients felt that their PCP was knowledgeable about genetic testing and expected their PCP to be the first to recognize a need for genetic testing based on family history. Nonetheless, patients reported that PCPs rarely used family history information to discuss genetic risks or order testing. In contrast, PCPs felt uncertain about the clinical utility and scientific value of genetic testing. PCPs were concerned that genetic testing could cause anxiety, frustration, discrimination, and reduced insurability, and that there was unequal access to testing. PCPs described themselves as being "gatekeepers" to genetic testing but did not feel confident or have the desire to become experts in genetic testing. However, PCPs were open to increasing their working knowledge of genetic testing. Within this academic medical center, there is a gap between what patients expect and what primary care providers feel they are adequately prepared to provide in terms of genetic testing services.

Advancing health care quality and safety through action learning

PurposeThe purpose of this study is to demonstrate how action learning can be practically applied to quality and safety challenges at a large academic medical health system and become fundamentally integrated with an institution’s broader approach to quality and safety.Design/methodology/approachThe authors describe how the fundamental principles of action learning have been applied to advancing quality and safety in health care at a large academic medical institution. The authors provide an academic contextualization of action learning in health care and then transition to how this concept can be practically applied to quality and safety by providing detailing examples at the unit, cross-functional and executive levels.FindingsThe authors describe three unique approaches to applying action learning in the comprehensive unit-based safety program, clinical communities and the quality management infrastructure. These examples, individually, provide discrete ways to integrate action learning in the advancement of quality and safety. However, more importantly when combined, they represent how action learning can form the basis of a learning health system around quality and safety.Originality/valueThis study represents the broadest description of action learning applied to the quality and safety literature in health care and provides detailed examples of its use in a real-world context.

Relapsing polychondritis in Singapore: a case series and review of literature.

This study aimed to describe the clinical presentation, treatment and outcome of patients with relapsing polychondritis (RP) who were seen at a large tertiary-care academic medical institution in Singapore. The medical records of all patients diagnosed with RP at the Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, between 2005 and 2013 were reviewed. The diagnosis of RP was made using the modified McAdam criteria. Ten patients were diagnosed with RP during the study period. Among these patients, five fulfilled the modified McAdam criteria and five were probable cases of RP. The most common clinical presentations were auricular chondritis (n = 9), episcleritis or scleritis (n = 5), and large airway involvement (n = 3). All of the patients received prednisolone. Five patients developed haematological disorders. Patients with both RP and haematological disorders had a longer duration of RP symptoms prior to diagnosis, compared to patients with RP who did not develop haematological disorders (average duration of symptoms 14.7 months vs. 4.2 months). The high frequency of patients with haematological malignancies in this series was unexpected. Myelodysplastic syndrome has been reported, but other haematological malignancies are rarely associated with RP. As the association between haematological malignancies and RP is currently unclear, the threshold for haematological/lymphoproliferative screening should be lowered in patients with RP.

Construct Validation of a Cost-Effective Vessel Ligation Benchtop Simulator

Many benchtop surgical simulators assess laparoscopic proficiency, yet few address core open surgical skills. The purpose of this study is to describe a cost-effective benchtop vessel ligation simulator and provide construct validation. A prospective comparison of blinded proficiency assessments among participants performing a benchtop vessel ligation simulation task. Evaluations were performed using Objective Structured Assessments of Technical Skills. This study took place at the University of Virginia, School of Medicine: a large academic medical institution. The participants included fourth-year medical students participating in a focused surgical elective course (n = 16), postgraduate year 2 to 3 surgery residents (n = 6), and surgical faculty (n = 5). The total fixed costs of the vessel ligation simulator was $30. Flexible costs of operation were less than $0.20 per attempt. The median task-specific checklist scores among the medical students, residents, and faculty were 4.83, 7.33, and 7.67, respectively. Median global rating scores across the 3 groups were 2.29, 4.43, and 4.76, respectively. Significant proficiency differences were noted between the students and the residents/faculty for both the metrics (p < 0.001). A cost-effective benchtop simulator can effectively measure proficiency with basic open surgical techniques such as vessel ligation. Among the junior surgical trainees, this tool can identify learning gaps and improve operative skills in a preclinical setting.

The use of barbed suture for bladder and bowel repair.

To describe the laparoscopic repair of bladder and bowel injuries using barbed suture and review postoperative outcomes. Retrospective medical chart review (Canadian Task Force classification II-3). Large academic medical institution. Thirty-three women who underwent laparoscopic repair of the bladder and/or bowel wall using barbed suture between January 2009 and July 2013. Not applicable. The patients underwent a total of 9 cystotomies (27.3%), 7 enterotomies (21.2%), 4 bladder seromuscular injuries (12.1%), 12 bowel seromuscular injuries (36.4%), and 1 bladder and bowel seromuscular injury (3.0%). Of the 33 injuries, 17 (51.5%) were intentional in the setting of bladder or bowel endometriosis nodule excision, whereas the other 16 (48.5%) were accidental and occurred at the time of lysis of adhesions. Thirteen of 14 bladder injuries (92.9%) were at the dome, and 1 injury (7.1%) was at the trigone. Fifteen of 20 bowel injuries (75%) were rectal, 3 (15%) were on the colon, and 2 (10%) were on the small intestine. Cystotomies ranged in length from 1 to 5 cm, and enterotomies ranged from 1.5 to 6 cm. All bladder and bowel seromuscular injuries were repaired using a single layer of barbed suture. Twelve full-thickness bladder or bowel wall defects (75%) were repaired using 2 layers of barbed suture, and 4 defects (25%) were repaired using a layer of barbed suture and a layer of a running or interrupted smooth delayed absorbable suture. Duration of follow-up ranged from 1 month to 15 months. There were no major complications. Only 1 patient who had undergone a large enterotomy repair developed constipation secondary to a mild rectal stricture diagnosed 3 months postoperatively. Symptoms of constipation since resolved spontaneously in that patient. Barbed suture provides adequate tension-free bladder and bowel repair. No major complications have been encountered; therefore, the use of barbed suture for the repair of bladder or bowel defects seems feasible and safe.

Laparoscopic Excision of Ovarian Remnants: Retrospective Cohort Study with Long-term Follow-up

Study Objective To review the clinical presentation, surgical and pathologic findings, and long-term outcomes after excision of ovarian remnants using a predominantly laparoscopic approach. Design Retrospective medical record review and long-term follow-up via telephone interview (Canadian Task Force classification II-3). Setting Large academic medical institution. Patients Thirty women who underwent excision of pathologically confirmed ovarian remnants by a single surgeon between 2001 and 2009. Intervention Excision of ovarian remnants, 29 at laparoscopy and 1 at laparotomy. Measurements and Main Results Of the 30 patients, 29 had pain and 1 had a persistent adnexal mass. Of the 29 patients who underwent preoperative ultrasonography, 26 (89.6%) had an adnexal mass on the side of previous salpingo-oophorectomy. Masses ranged in size from 0.8 to 7.4 cm in greatest diameter and most commonly contained debris-filled cysts. Intraoperatively, 29 excisions (96.7%) required retroperitoneal dissection, 27 (90.0%) required enterolysis, 28 (93.3%) required ureterolysis, and 20 (66.7%) required ligation of the uterine artery at its origin. All pathology reports confirmed ovarian tissue, often associated with endometriosis, corpus luteal cysts, and simple cysts. Four bowel injuries and 2 bladder injuries were laparoscopically repaired by the primary surgeon. Three patients required bowel resections by a general surgeon. Records from postoperative visits were available for 28 patients, of whom 17 (60.7%) reported resolution of pain, 9 (32.1%) reported improvement, and 2 (7.1%) reported persistent pain. Of the 18 women who returned written consent for the telephone interview, 11 (61.1%) reported resolution of pain, 5 (27.8%) reported improvement, and 2 (11.1%) reported persistent pain. Conclusion While laparoscopic excision of ovarian remnants is feasible, the procedure almost always requires a retroperitoneal dissection and is associated with high risk of complications. Careful surgical planning and preparation are essential.

Major Incident Hospital: Development of a Permanent Facility for Management of Incident Casualties.

Preparation is essential to cope with the challenge of providing optimal care when there is a sudden, unexpected surge of casualties due to a disaster or major incident. By definition, the requirements of such cases exceed the standard care facilities of hospitals in qualitative or quantitative respects and interfere with the care of regular patients. To meet the growing demands to be prepared for disasters, a permanent facility to provide structured, prepared relief in such situations was developed. A permanent but reserved Major Incident Hospital (MIH) has been developed through cooperation between a large academic medical institution, a trauma center, a military hospital, and the National Poison Information Centre (NVIC). The infrastructure, organization, support systems, training and systematic working methods of the MIH are designed to create order in a chaotic, unexpected situation and to optimize care and logistics in any possible scenario. Focus points are: patient flow and triage, registration, communication, evaluation and training. Research and the literature are used to identify characteristic pitfalls due to the chaos associated with and the unexpected nature of disasters, and to adapt our organization. At the MIH, the exceptional has become the core business, and preparation for disaster and large-scale emergency care is a daily occupation. An Emergency Response Protocol enables admittance to the normally dormant hospital of up to 100 (in exceptional cases even 300) patients after a start-up time of only 15 min. The Patient Barcode Registration System (PBR) with EAN codes guarantees quick and adequate registration of patient data in order to facilitate good medical coordination and follow-up during a major incident. The fact that the hospital is strictly reserved for this type of care guarantees availability and minimizes impact on normal care. When it is not being used during a major incident, there is time to address training and research. Collaboration with the NVIC and infrastructural adjustments enable us to not only care for patients with physical trauma, but also to provide centralized care of patients under quarantine conditions for, say, MRSA, SARS, smallpox, chemical or biological hazards. Triage plays an important role in medical disaster management and is therefore key to organization and infrastructure. Caps facilitate role distribution and recognizibility. The PBR resulted in more accurate registration and real-time availability of patient and group information. Infrastructure and a plan is not enough; training, research and evaluation are necessary to continuously work on disaster preparedness. The MIH in Utrecht (Netherlands) is a globally unique facility that can provide immediate emergency care for multiple casualties under exceptional circumstances. Resulting from the cooperation between a large academic medical institution, a trauma center, a military hospital and the NVIC, the MIH offers not only a good and complete infrastructure but also the expertise required to provide large-scale emergency care during disasters and major incidents.

Implementation of Bar Coded Wristbands in a Large Academic Medical Center

In numerous settings bar code enabled systems have been shown to be able to improve process and reduce the errors that occur with manual data entry. We have implemented a bar coded patient wristband for all emergency department (ED) and inpatients at a large academic medical institution. Examining glucometry error rates and nursing surveys we find that the bar coded wristbands reduced patient identification errors and were well accepted by clinical staff. Bar coded patient wristbands are an important part of a hospital's infrastructure and the content and format of the wristbands deserves close consideration.