Opportunities For Practice Improvement Research Articles

Anesthesia Providers' Knowledge of Medication Interference with Hormonal Contraception: A Multisite Survey.

Sugammadex, aprepitant, and fosaprepitant are increasingly used perioperatively. These medications may interfere with the effectiveness of hormonal contraception. This study assessed anesthesia providers' use of sugammadex and aprepitant, their knowledge of interactions with hormonal birth control, and patient counseling practices to identify possible knowledge gaps or opportunities for practice improvement. In January 2023, an electronic survey was distributed to all anesthesia providers at Mayo Clinic sites (Mayo Clinic Rochester, Mayo Clinic Arizona, Mayo Clinic Florida, and Mayo Clinic Health System hospitals). The survey included 32 questions assessing providers' use of sugammadex and aprepitant, their knowledge of the medications' interactions with hormonal contraceptives (HC), their perceptions regarding education of these interactions during training, and their perioperative patient counseling practices. The collected data were analyzed using descriptive statistics. A total of 337 of 1092 (31%) providers completed the survey. While almost all respondents (324; 96%) knew that sugammadex may interfere with oral contraceptive effectiveness, only 158 (47%) knew about aprepitant's potential contraceptive interference. Only 176 providers (52%) knew the recommended duration for alternative contraceptive methods after use after sugammadex, and 119 providers (35%) knew the recommended duration after aprepitant exposure. Most respondents considered the interference of these perioperative drugs with HCs to be clinically relevant (sugammadex, 217, 64%; aprepitant, 191, 58%). Despite the common belief that the decision between these medications and alternatives should be shared between provider and patient, most providers reported rarely engaging in such shared decision-making (SDM) in practice. Most providers recognized the need for preoperative discussions on sugammadex (280, 83%) and aprepitant (257, 76%), yet 184 providers (73%) never or rarely discussed contraception use before surgery for aprepitant, and 135 (36%) never or rarely did so for sugammadex. Lastly, many providers believed that the interference between sugammadex, aprepitant, and HC was poorly taught during training. The results of this study highlight the need for increased education and awareness among anesthesia providers regarding drug interactions with HCs during the perioperative period. To facilitate SDM, it is imperative that providers discuss alternative medications and the potential need for additional contraception methods after drug administration and communicate the risks with patients preoperatively to enable informed and SDM. The patient's preferences should be accounted for, especially if they are unwilling or unable to use an alternative contraceptive for 7 to 30 days, thereby avoiding the complexities and burdens of altering birth control methods.

The Impact of Using Electronic Consents on Documentation of Language-Concordant Surgical Consent for Patients with Limited English Proficiency

Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP). The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022. A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (p < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent. The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.

Be a Champion! An Approach to Medical Emergency Response In Situ Simulations in the Outpatient Setting.

Results from a needs assessment conducted by nursing professional development practitioners across several clinics in the Midwest showed current educational methods to prepare for medical emergencies were insufficient. A champion model was used to complete in situ medical emergency response simulations. This proved to be an effective method for staff preparation when resources were limited and identified opportunities for practice improvement.

Improving Handoffs After Osteoporotic Fractures

Osteoporotic fractures among long-term care residents have substantial economic and human costs. After a fracture, many older adults do not receive an osteoporosis diagnosis or evidence-based treatment, which leads to increased risk of recurrent fractures. Optimal processes are well defined for transitioning medical care after a hip or vertebral fracture for osteoporosis evaluation, but the handoff process from the specialist back to a primary care practitioner (PCP) or to a rehabilitative setting is not well defined. Our interdisciplinary quality improvement team developed and evaluated a program for transitioning care from a hospital-based fracture liaison clinic (FLC) to PCPs caring for older adults across the care continuum. To understand the current process of postfracture care transitions, we analyzed the postfracture patient experience. We surveyed PCPs to assess barriers to osteoporosis treatment, and retrospectively conducted a baseline analysis of 87 patients who had sustained an osteoporotic fracture in 2020. This preliminary work showed several opportunities for practice improvement and helped us develop a practical multicomponent intervention aimed at improving care transitions from the FLC to PCPs. The intervention (June-September 2021) comprised a standardized documentation template in the electronic health record (EHR) for FLC clinicians, a structured handoff process, and an engagement tool for patients outlining the roles and responsibilities of each care team member. We compared care transition measures before and after intervention. EHR documentation of an osteoporosis diagnosis increased from 56% (49 of 87 patients) before intervention to 92% (48 of 52) after intervention (P < .001). Additionally, increases were observed in documentation of treatment recommendations, associated risk factors, and PCP discussions with patients regarding osteoporosis and related treatment. This practical, commonsense intervention established clear roles for each care team member. The intervention addressed systemwide barriers in facilitating a safe transition from a subspecialty care team to PCPs providing care to older adults with osteoporosis.

Prevalence of antibiotic use for dogs and cats in United States veterinary teaching hospitals, August 2020.

Awareness of prescribing practices helps identify opportunities to improve antibiotic use (AU). To estimate AU prevalence in dogs and cats in U.S. veterinary teaching hospitals (VTHs) and identify antibiotic drugs commonly prescribed, indications for use, and evidence of bacterial infection. Medical record data were collected from dogs and cats examined at 14 VTHs. Data were collected from VTH medical records of dogs and cats examined by primary care, urgent care, emergency and critical care, internal medicine, and surgery services on a single day during August 13-September 3, 2020. Data included signalment; clinical service; inpatient or outpatient status; clinical conditions; diagnostic tests; evidence of bacterial infection; intended reason for AU; name and route of antibiotics prescribed. Of 883 dogs and cats, 322 (36.5%) were prescribed at least 1 antibiotic. Among 285 antibiotics administered systemically intended for treatment of infection, 10.9% were prescribed without evidence of infection. The most common class of antibiotics presribed for systemic administration was potentiated penicillin for dogs (115/346, 33.3%) and cats (27/80, 33.8%). For dogs and cats, first-generation cephalosporins (93/346, 26.9% and 11/80, 13.8%, respectively) and fluoroquinolones (51/346, 14.7% and 19/80, 23.8%, respectively) was second or third most-prescribed. Common AU indications included skin, respiratory, and urinary conditions, and perioperative use. Collaborative data collection provides a sustainable methodology to generate national AU prevalence estimates and bring attention to areas requiring additional research and detailed data collection. These efforts can also identify practice improvement opportunities in settings where future veterinarians are trained.

Evaluating the impact of hemodynamic support measures on head and neck free tissue transfer outcomes: A population-based analysis

ObjectivesThis study sought to analyze the effects of perioperative blood transfusions and vasopressors on 30-day surgical complications and 1-year mortality after reconstructive surgery in head and neck free tissue transfer (FTT) and to identify predictors of administration of perioperative blood transfusions or vasopressors. Materials and MethodsTriNetX (TriNetX LLC, Cambridge, USA), an international population-level electronic health record database, was queried to identify subjects that underwent FTT requiring perioperative (intraoperative to postoperative day 7) vasopressors or blood transfusions. Primary dependent variables were 30-day surgical complications and 1-year mortality. Propensity score matching was used to control for population differences, and covariate analysis was used to identify preoperative comorbidities associated with perioperative vasopressor or transfusion requirements. Results7,631 patients met inclusion criteria. Preoperative malnutrition was associated with increased odds of perioperative transfusion (p = 0.002) and vasopressor requirement (p < 0.001). Perioperative blood transfusion (n = 941) was associated with increased odds of any surgical complication (p = 0.041) within 30 days postoperatively and specifically increased odds of wound dehiscence (p = 0.008) and FTT failure (p = 0.002), respectively. Perioperative vasopressor was (n = 197) was not associated with 30-day surgical complications. Vasopressor requirement was associated with increased hazards-ratio of mortality at 1-year (p = 0.0031). ConclusionPerioperative blood transfusion in FTT is associated with increased odds for surgical complications. Judicious use as a hemodynamic support measure should be considered. Perioperative vasopressor use was associated with an increased risk of one-year mortality. Malnutrition is a modifiable risk factor for perioperative transfusion and vasopressor requirement. These data warrant further investigation to assess causation and potential opportunity for practice improvement.

Trends in Surgical Recurrence Among Pediatric Crohn's Disease Patients Using Administrative Claims Data.

Despite the growing armamentarium of medical therapies for Crohn's disease (CD), well over half of patients with CD will require surgical intervention. We estimated the surgical recurrence risk and characterized postoperative treatment and colonoscopy use in pediatric CD patients using a large, geographically diverse administrative claims database. We analyzed postresection pediatric (≤18 years) CD patients identified in the 2007-2018 IQVIA Legacy PharMetrics administrative claims database using diagnosis and procedural codes. We estimated the surgical recurrence risk over time, characterized postoperative treatments, and reported the frequency of colonoscopy 6-15 months postoperatively. Among 434 pediatric CD patients who underwent intestinal resection (median age 16 years, 46% female), risk of surgical recurrence was 3.5%, 4.6%, and 5.3% at 1, 3, and 5 years, respectively. Patients were most commonly prescribed an immune modulator (33%), anti-tumor necrosis factor agent (32%), or antibiotic (27%) postoperatively. Among 281 patients with ≥15 months of follow-up, 24% underwent colonoscopy 6-15 months postoperatively. Surgical recurrence risk increases over time and the low colonoscopy rates and treatment variation postoperatively represent an opportunity for practice improvement.

One Year of Clinic-Wide Cherenkov Imaging for Discovery of Quality Improvement Opportunities in Radiation Therapy

PurposeCherenkov imaging is clinically available as a radiation therapy treatment verification tool. The aim of this work was to discover the benefits of always-on Cherenkov imaging as a novel incident detection and quality improvement system through review of all imaging at our center. Methods and MaterialsMulticamera Cherenkov imaging systems were permanently installed in 3 treatment bunkers, imaging continuously over a year. Images were acquired as part of normal treatment procedures and reviewed for potential treatment delivery anomalies. ResultsIn total, 622 unique patients were evaluated for this study. We identified 9 patients with treatment anomalies occurring over their course of treatment, which were only detected with Cherenkov imaging. Categorizing each event indicated issues arising in simulation, planning, pretreatment review, and treatment delivery, and none of the incidents were detected before this review by conventional measures. The incidents identified in this study included dose to unintended areas in planning, dose to unintended areas due to positioning at treatment, and nonideal bolus placement during setup. ConclusionsCherenkov imaging was shown to provide a unique method of detecting radiation therapy incidents that would have otherwise gone undetected. Although none of the events detected in this study reached the threshold of reporting, they identified opportunities for practice improvement and demonstrated added value of Cherenkov imaging in quality assurance programs.

Tier-based antimicrobial stewardship metrics for genitourinary-related antibiotic use in Veterans’ Affairs outpatient settings

Background: Tracking antibiotic use is a core element of antimicrobial stewardship. We developed a set of metrics based on electronic health record data to support an outpatient stewardship initiative to improve management of urinary tract infections (UTIs) in Veterans’ Affairs (VA) emergency departments (EDs) and primary care clinics. Because UTI diagnostic codes only capture a portion of genitourinary (GU)-related antibiotic use, a tier-based approach was used to evaluate practices. Methods: Metrics were developed to target practices related to antibiotic prescribing and diagnostic testing (Table 1). GU conditions were divided into 3 categories: tier 1, conditions for which antibiotics are usually or always indicated; tier 2, conditions for which antibiotics are sometimes indicated; and tier 3, conditions for which antibiotics are rarely or never indicated (eg, benign prostatic hypertrophy with symptoms). Patients with visits related to urological procedures, nontarget providers, and concomitant non-GU infections were excluded. Descriptive analyses included calculation of the correlation matrix for the 7 metrics and the construction of box plots to display interfacility variability. Results: Metrics were calculated quarterly for 18 VA medical centers, including affiliated clinics, in a western VA network, from July 2018 to June 2020 (Table 1). Tier 3 GU conditions accounted for 1,276 of 11,840 (11%) of GU-related antibiotic use. Metrics 1 and 6b were strongly correlated with each other and were also positively correlated with metrics 2 and 5 (coefficients &gt; 0.5) (Fig. 1). Substantial interfacility variation was observed (Fig. 2). Conclusions: Stewardship metrics for suspected or documented UTIs can identify opportunities for practice improvement. Broadly capturing GU conditions in addition to UTIs may enhance utility for performance feedback. Antibiotic prescribing for tier 3 GU conditions is analogous to unnecessary antibiotic use for acute, uncomplicated bronchitis and upper respiratory tract infections.Funding: NoneDisclosures: None

Evaluating quality of care at the end of life and setting best practice performance standards: a population-based observational study using linked routinely\xa0collected administrative databases

BackgroundA high percentage of people dying at home, and a low percentage of people being admitted to hospital and dying there are regarded as indicators of appropriate care at the end of life. However, performance standards for these quality indicators are often lacking, which makes it difficult to state whether an indicator score falls between the ranges of good or poor quality care. The aim of this study was to assess quality indicators concerning place of death and hospital care utilization in people with diseases relevant for palliative care, and to establish best practice performance standards based on indicator scores in 31 regions in the Netherlands.MethodsA retrospective nationwide population-based observational study was conducted, using routinely collected administrative data concerning persons who died in 2017 in the Netherlands with underlying causes relevant for palliative care (N = 109,707). Data from four registries were linked for analysis. Scores on eight quality indicators concerning place of death and hospital care utilization were calculated, and compared across 31 healthcare insurance regions to establish relative benchmarks.ResultsOn average, 36.4% of the study population died at home (range between regions 30.5%-42.6%) and 20.4% in hospital (range 16.6%-25.5%). Roughly half of the population who received hospital care at any time in the last year of life were found to (also) receive hospital care in the last month of life. In the last month, 32.0% of the study population were admitted to hospital (range 29.4-36.4%), 5.3% to an Intensive Care Unit (range 3.2-6.9%) and 23.9% visited an Emergency Department (range 21.0-27.4%). In the same time period, less than 1% of the study population was resuscitated in hospital or received tube or intravenous feeding in hospital.ConclusionsThe variation between regions points towards opportunities for practice improvement. The best practice performance standards as set in this study serve as ambitious but attainable targets for those regions that currently do not meet the standards. Policymakers, healthcare providers and researchers can use the suggested performance standards to further analyze causes of variance between regions and develop and test interventions that can improve practice.

Procedural Sedation by Non-Anesthesiologists: A Review of Malpractice Litigation

Introduction Medical professionals other than anesthesiologists at times administer sedation for procedures. The aim of this study is to identify the adverse events, and their root causes, resulting in medical malpractice litigation in the United States related to procedural sedation administration by non-anesthesiologists. Methods Cases containing the phrase “conscious sedation” were identified using Anylaw, an online national legal database. Cases were excluded if the primary allegation was not malpractice related to conscious sedation or the listing was a duplicate. Results Of the 92 cases identified, 25 remained after application of exclusion criteria. The procedure type most commonly involved was dental (56%), followed by gastrointestinal (28%). The remaining procedure types were urology, electrophysiology, otolaryngology, and magnetic resonance imaging (MRI). Discussion By reviewing malpractice case narratives and outcomes, this study offers insight and opportunities for practice improvement among non-anesthesiologists providing conscious sedation for procedures.

A100 A PROVINCIAL APPROACH TO ASSESSING ENDOSCOPY PATIENT EXPERIENCE ENHANCES SITE PARTICIPATION AND CANADA-GLOBAL RATING SCALE COMPLIANCE

BackgroundThe Canada-Global Rating Scale (C-GRS) is a web-based, patient centered endoscopy quality improvement tool. It assesses the quality of services a unit provides in two dimensions: clinical quality and patient experience. Endoscopy units submit results to the Canadian Association of Gastroenterology twice a year. In Alberta, units receive an A, B, C or D grade for each of the 12 C-GRS Items and a C-GRS score.The C-GRS promotes that patient feedback is sought annually. Patient feedback is important because it informs practice improvement opportunities. However, survey creation, distribution, analysis and reporting can be time consuming and costly for an endoscopy unit and is a potential barrier to participation.AimsThe purpose of this quality improvement project is to demonstrate how a provincial infrastructure, which includes coordination, management and reporting of an endoscopy patient satisfaction survey, can enhance provincial endoscopy unit survey participation and facilitate C-GRS compliance.MethodsThe Digestive Health Strategic Clinical Network (DHSCN), the Alberta Colorectal Cancer Screening Program and Primary Data Support (PDS) collaborated on the Provincial Endoscopy Patient Experience Survey (PEPES) in 2019. An existing paper survey was adapted to meet the needs of the 50 endoscopy units in AB with the addition of an electronic version. Education about the PEPES process was provided via a webinar and site visits. Each unit was responsible for distribution of the surveys to their patients. PDS coordinated the paper survey process and the DHSCN managed the electronic survey submissions. Paper survey results were merged with electronic PEPES data. A summary report was provided to units and shared with each AHS Zone Endoscopy Executive Leadership Team.ResultsProvincially coordinated implementation of the PEPES fosters compliance with C-GRS criteria. Participating endoscopy units were able to achieve at minimum 9 C-GRS descriptors and improve their C-GRS score in the following 7 of the 12 C-GRS Items: consent, comfort, equality, booking, privacy, aftercare and feedback.Initial enrollment in the PEPES increased with the onset of provincial coordination (Figure 1). However, subsequent participation was negatively impacted by COVID-19 as many endoscopy units in AB were required to decrease their capacity and redeploy staff.ConclusionsA provincially coordinated approach to the management of an endoscopy patient experience survey is an effective way to enhance site participation and improve C-GRS scores. Units can focus on actioning survey results, rather than the burden of survey administration. Future work includes comparison of results across sites allowing for potential provincial equity issues to be addressed. Funding AgenciesNone

CAR Peer Learning Guide.

Peer learning is a quality initiative used to identify potential areas of practice improvement, both on a patient level and on a systemic level. Opportunities for peer learning include review of prior imaging studies, evaluation of cases from multidisciplinary case conferences, and review of radiology trainees' call cases. Peer learning is non-punitive and focuses on promoting life-long learning. It seeks to identify and disseminate learning opportunities and areas for systems improvement compared to traditional peer review. Learning opportunities arise from peer learning through both individual communication of cases reviewed for routine work, as well as through anonymous presentation of aggregate cases in an educational format. In conjunction with other tools such as root cause analysis, peer learning can be used to guide future practice improvement opportunities. This guide provides definitions of terms and a synthetic evidence review regarding peer review and peer learning, as well as medicolegal and jurisdictional considerations. Important aspects of what makes an effective peer learning program and best practices for implementing such a program are presented. The guide is intended to be a living document that will be updated regularly as new data emerges and peer learning continues to evolve in radiology practices.

Unique factors to the implementation of a disaster preparedness plan at Georgetown Public Hospital in Guyana.

Disaster planning in developing countries is largely ineffective despite these countries being more likely to suffer from catastrophic events. This article aims to identify strengths, educational needs, practice improvement opportunities, and local factors that may contribute to the development/implementation of a disaster preparedness plan at Georgetown Public Hospital in Guyana.

Physician\u2013patient communication in decision-making about Caesarean sections in eight district hospitals in Bangladesh: a mixed-method study

BackgroundCaesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician–patient communication leading to informed-consent for the operation.MethodsWe conducted a mixed-method study using structured observations with the Option Grid Collaborative’s OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥ 80 births every month; and for physicians, was that they had performed CSs. Women aged ≥ 18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS were selected for the in-depth interviews. Quantitative data from observations were analysed using descriptive statistics. Following transcription and translation, a preliminary coding framework was devised for the qualitative data analysis. We combined both inductive and deductive approaches in our thematic analysis.ResultsIn total, 306 labour situations were observed, and interviews were conducted with 16 physicians and 32 women who delivered by CS (16 emergency CS; 16 elective CS). In 92.5% of observations of physician–patient communication in the context of labour situations, the OPTION5 mean scores were low (5–25 out of 100) for presenting options, patient partnership, describing pros/cons, eliciting patient preferences and integrating patient preferences. Interviews found that non-clinical factors prime both physicians and patients in favour of CS prior to the clinical encounter in which the decision to perform a CS is documented. These interactions were both minimal in content and limited in purpose, with consent being an artefact of a process involving little communication.ConclusionsInsufficient communication between physicians and patients is one of many factors driving increasing rates of caesarean section in Bangladesh. While this single clinical encounter provides an opportunity for practice improvement, interventions are unlikley to impact rates of CS without simultaneoulsy addressing physician, patient and health system contextual factors too.

Computed tomography technologist notes in PACS to radiologists: what are they telling us and how does it increase value?

In the clinical workflow of radiology services, a critical connection exists between technologists and radiologists, yet there is often limited communication between this key link in the chain of patient imaging. Our aim was to quantify and detail the communication between CT technologists and radiologists in our tertiary oncology practice. Using the note function in our EMR, as standard operating procedure, CT technologists are instructed to place pertinent notes for the radiologist relevant to any portion of the patient encounter. Note categories pertain to quality and/or safety: patient limitations (e.g., patient unable to raise arm), protocol confirmation (e.g., rectal contrast given), critical finding communication, scan range considerations, IV issues, reduction in eGFR, oral contrast issues, allergy information, general feedback, equipment malfunction, and radiologist approval information. The percentage of notes within each category were recorded upon review of contiguous abdominal CT scans in July 2018 with the primary outcome measure of overall note volume compared to baseline in July 2016 after which time technologists were educated on the importance of notes and were requested to increase use of this tool. Notes were regularly reviewed to identify practice improvement opportunities. Compared to baseline 2years earlier (8860 CT scans, 812 technologist notes), there was a 32% increase in technologist note volume (10,948 CT scans, 1330 technologist notes), representing an increase of notes from 9.2% of exams to 12.1% of exams (p < .001) and there were 14 related practice improvements. After communicating the importance of CT technologist notes and requesting increased notation frequency, technologist note volume significantly increased and 14 specific case examples of related practice improvement demonstrate the electronic medical record note function to be a robust tool in the management of patient imaging.

Earn CME While Completing MOCA Minute Questions – A Free ASA Member Benefit!

Article| February 2021 Earn CME While Completing MOCA Minute Questions – A Free ASA Member Benefit! David P. Martin, MD, PhD, FASA David P. Martin, MD, PhD, FASA Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor February 2021, Vol. 85, 6–7. https://doi.org/10.1097/01.ASM.0000733788.67999.91 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation David P. Martin; Earn CME While Completing MOCA Minute Questions – A Free ASA Member Benefit!. ASA Monitor 2021; 85:6–7 doi: https://doi.org/10.1097/01.ASM.0000733788.67999.91 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: education, medical, continuing If you're like most ASA members, you're dedicated to lifelong learning and you push to stay on top of changes and innovations in your specialty. That's why ASA works hard to help members build their skills and fulfill MOCA requirements by offering CME programs, practice improvement opportunities, and simulation activities. And now, ABA Diplomates who are ASA members can earn free CME credits with their MOCA Minute participation. What is MOCA Minute? ABA's MOCA Minute is designed to help Diplomates assess their medical knowledge and retention through the span of their 10-year MOCA cycle. It was created as a more effective, meaningful, and convenient approach to continuous assessment than the high-stakes exam, elevating the importance of ongoing and on-the-go learning. So-named because participating Diplomates are given one minute to answer personalized multiple-choice questions, based on their specialty certificates and practice profile. Diplomates access their MOCA Minute questions from their ABA... You do not currently have access to this content.

The Ethical and Political Contours of Institutional Promotion in eSports: From Precariat Models to Sustainable Practices

This study evaluated five early cases in which esport developer Riot Games made rulings regarding activities and infractions by members of various institutions related to its product, League of Legends. The findings of this study support future theoretical exploration of other esports in seeking a fuller understanding of issues related to consent, power differentials, and roles and behaviors expected of the institutional activities of players and teams in competition. Increased investigation of these—and other—issues from an ethical standpoint could lead to a framework that not only would facilitate future study but also bring opportunities for improvements in practices in concert with necessary policy changes.

Medical Malpractice in Interventional Cardiology: Identifying Patterns and Areas for Improvement

Introduction: The feared possibility of involvement in a medical malpractice lawsuit ultimately becomes reality for many physicians in high-risk specialties including cardiology. In a survey of cardiologists and fellows, 15.9% of those from the United States and 13.5% from China stated they were influenced by the fear of malpractice litigation in at least half of all cases they managed daily. A study of 40,916 physicians covered by a large nationwide professional liability insurer from 1991 to 2005 found that the percentage of cardiologists facing a malpractice claim each year is between 7.5%-10%, above the average across all physicians. This study analyzes interventional cardiology malpractice claims by specific procedure and allegation types. Methods: Seventy-nine cardiology malpractice claims involving procedures were identified in a major nationwide legal database (over 200,000 cases) called VerdictSearch. An exemption was obtained from the Yale University Institutional Review Board. Baseline patient characteristics, reasons for lawsuit, and case outcomes were recorded. Statistical analysis included percentage distributions and Fisher’s exact test. Results: A defendant verdict was reached in 64.6% of cases; plaintiƒ verdict, 21.5% (with average payout $5,212,719.79); and settlement, 13.9%. Death was the injury in 48.1% of cases and did not influence the likelihood of a plaintiƒ verdict. Of the 53.2% of cases involving cardiac catheterization, angioplasty, or stenting, periprocedural injury was alleged in 83.3%, lack of informed consent in 7.1%, failure to perform the correct procedure in a timely manner or at all in 14.3%, and performance of an unnecessary procedure in 7.1% (Figure 1). The most common injury type was arterial (non-coronary), including injury to the catheterization site, followed by coronary artery dissection or tamponade (Figure 2). Electrophysiology procedures were the next most common category, and receiving a defendant verdict was significantly less likely for these cases than any other type. A cardiothoracic or vascular surgeon was named as a co-defendant in 25.3% of cases. In 12.6% of cases, cardiologist failure to obtain timely surgical consultation or ensure backup surgeon availability during procedure performance was alleged. Discussion: Comprehensively reviewing interventional cardiology malpractice claims can elucidate common contributory factors to adverse outcomes and practice improvement opportunities. This study ’ s results suggest, for instance, that securing appropriate cardiothoracic surgical backup prior to a catheterization, angioplasty, or stent procedure would significantly decrease the number of lawsuits. Diligence in the informed consent process should also be prioritized, as this area generated allegations in 7.1% of cases. Though VerdictSearch is a large, nationwide legal database, its content is limited to those attorneys, courts, and states who choose to report cases. However, any selection biases may be bidirectional and ultimately cancel each other out, since the attorney on the prevailing side of every case theoretically has equal incentive to report it to a public database so the verdict can be used as a marketing tool for that attorney. By uniquely stratifying cardiology malpractice claims within a large nationwide database by specific procedure types and allegations, this study points to factors that commonly contribute to adverse patient outcomes and enables cardiologists to reflect upon opportunities for clinical practice improvement.

Profile of Fluid Exposure and Recognition of Fluid Overload in Critically Ill Children.

Fluid overload is common in the PICU and has been associated with increased morbidity and mortality. It remains unclear whether fluid overload is a surrogate marker for severity of illness and need for increased support, an iatrogenic modifiable risk factor, or a sign of oliguria. The proportions of various fluid intake contributing to fluid overload and its recognition have not been adequately examined. We aimed to: 1) describe the types and amounts of fluid exposure in the PICU and 2) identify the clinicians' recognition of fluid overload. Noncardiac PICU in a quaternary care hospital. Pediatric patients admitted for more than 24 hours. Prospective observational study over 28 days. Data were collected on the amount and type of fluid exposure-resuscitative boluses, blood products, enteral intake, parenteral nutrition (total parenteral nutrition), or modifiable fluids (IV fluids and medications) indexed to the patients' admission body surface area on days 1 and 3. Charts of patients admitted for 3 days who developed 15% fluid overload were reviewed to assess clinicians' recognition of fluid overload. One hundred two patients were included. Day 1 median fluid exposure was 2,318 mL/m (1,831-3,037 mL/m; 1,646 mL/m [1,296-2,086 mL/m] modifiable fluids). Forty-seven patients (46%) received fluid boluses, and 16 (16%) received blood products. Day 3 median fluid exposure was 2,233 mL/m (1,904-2,556 mL/m; 750 mL/m [375-1,816 mL/m] modifiable fluids). Of the 54 patients, one patient (1.9%) received a fluid bolus and two (3.7%) received blood products. In our cohort, 47 of 54 (87%) had fluid exposure greater than 1,600 mL/m on day 3. Fluid overload was not recognized by the clinicians in 30% of the patients who developed more than 15% fluid overload. Although resuscitation fluids contributed more to fluid exposure on day 1 compared with day 3, fluid exposure frequently exceeded maintenance requirements on day 3. Fluid overload was not always recognized by PICU practitioners. Further studies to correlate modifiable fluid exposure to fluid overload and explore modifiable practice improvement opportunities are needed.