Physician Notification Research Articles

Electronic physician notification to facilitate the recognition and management of severe aortic stenosis: Rationale, design, and methods of the randomized controlled DETECT AS trial

BackgroundSymptomatic severe aortic stenosis causes substantial morbidity and mortality when left untreated, yet recent data suggest its undertreatment. ObjectiveTo evaluate the efficacy of electronic physician notification to facilitate the guideline-directed management of patients with severe aortic stenosis. HypothesisWe hypothesize that patients with severe aortic stenosis who are in the care of physicians who receive the notification are more likely to undergo aortic valve replacement within 1-year. Methods/DesignThe Electronic Physician Notification to Facilitate the Recognition and Management of Severe Aortic Stenosis (DETECT AS) trial is a randomized controlled trial and quality improvement initiative designed to evaluate the efficacy of electronic provider notification versus usual clinical care in the management of patients with severe aortic stenosis. Providers ordering an echocardiogram with findings potentially indicative of severe aortic stenosis, defined by an aortic valve area ≤1.0 cm2, are randomized in a 1:1 fashion to receive electronic notification (intervention) or usual care. Providers in the notification arm are sent a notification within the electronic health record inbox outlining customized guideline recommendations for the management of patients with severe aortic stenosis based on the 2020 ACC/AHA Clinical Practice Guidelines for Valvular Heart Diseases for the index and all subsequent echocardiograms. Providers in the control arm receive no notification. Randomization continues until 940 patients have been enrolled. SettingMulti-centered, academic health system OutcomesThe primary endpoint is the proportion of patients with severe AS receiving an aortic valve replacement within 1-year of the index echocardiogram. Secondary endpoints include mortality, heart failure hospitalization, transthoracic echocardiogram utilization/surveillance, aortic stenosis billing code diagnosis, and cardiology/Heart Valve Team referral. ConclusionThe DETECT AS trial will provide insight into whether electronic notification of providers on the presence of severe aortic stenosis and associated clinical guideline recommendations will facilitate recognition and guideline-directed management of severe aortic stenosis. Trial RegistrationClinicalTrials.gov, NCT05230225, https://clinicaltrials.gov/ct2/show/NCT05230225

Time to antibiotic administration in patients undergoing HSCT with neutropenic fever.

e19501 Background: Cytotoxic chemotherapy for hematologic malignancies may adversely affect myelopoiesis, resulting in profound neutropenia that predisposes patients to severe infections. Patients undergoing hematopoietic stem cell transplantation (HSCT) are at particularly increased risk. Neutropenia is defined by an absolute neutrophil count (ANC) <500 cells/μL per complete blood count with differential. Neutropenic fever is a critical event with one-time temperature ≥101ºF or ≥100.4ºF sustained over one hour. Current standard-of-care is to initiate broad-spectrum antibacterial therapy within 30-60 minutes of presentation. MetroHealth Medical Center in Cleveland, Ohio launched a new Blood and Marrow Transplant program in 2023 in the state-of-the-art Glick Center. This retrospective study explores time to blood culture draw and initiation of antibiotics in HSCT patients with neutropenic fever. Methods: The MetroHealth HSCT database was used to identify hematologic malignancy patients status-post HSCT treated in the Blood and Marrow Transplant program. Tumor type and staging, chemo history, and infection prophylaxis (PPx) were recorded from chart review. Neutropenic fever episodes were identified by review of vitals history. Time to blood culture draw and antibiotic administration was then calculated from the medication administration record (MAR). Results: N = 11 hematologic malignancy patients status-post HSCT and chemotherapy were identified in the MetroHealth database. 8 presented with multiple myeloma (RISS stage II – IV), 2 with Hodgkin lymphoma, and 1 with mantle cell non-Hodgkin lymphoma. All patients were on Valtrex or acyclovir PPx, 10 on levofloxacin PPx, and 9 on fluconazole PPx. 6 of 11 patients had one documented episode of neutropenic fever each. ANC levels ranged from unidentifiable to 420 cells/μL. Half of the episodes saw blood culture draw within 1 hour and initiation of antibiotics in 60-90 minutes. The other 3 episodes saw culture draw at 2:13, 3:09, and 10:10 hours from fever and antibiotic administration at 12:00, 2:53, and 10:23 hours, respectively. Infectious disease (ID) specialists were consulted in each of the latter 3 cases. Conclusions: No patient at MetroHealth with neutropenic fever has seen appropriate initiation of antimicrobials within 30 to 60 minutes of presentation. Hypotheses for this delay include improper chart documentation, nurse training (delay in physician notification), and provider comfort (antimicrobials deferred to day team, ID consults). The latter is of particular concern given incidents of >10 hour delay to antibiotic initiation. Fortunately, there have not been any severe morbidity or mortality outcomes yet. Next steps are to deploy a quality improvement initiative to increase speed to fever identification, blood culture draw, and empiric antimicrobial delivery.

Abstract WP148: Implementation of a Hospital Wide Process Improves Rapid Administration of In-Hospital Intravenous Thrombolytics and Endovascular Therapy

Background: The recognition of in-hospital strokes (IHS) and their subsequent interventions remain challenging. IHS do not have guideline-based efficiency metrics established. Only 1 in 5 IHS receive treatment within 60 minutes of symptom recognition time (SRT). We aimed to establish a resident physician-nursing collaborative effort to improve IHS time metrics. Methods: We retrospectively compared SRT to bolus time and/or skin puncture time Pre (2010-2016) and Post (2017-2023) implementation of our hospital wide process, which focuses on rapid nursing identification of BEFAST stroke symptoms and notification of the neurology resident physician, who then immediately assesses the patient, validates the last known well time and calls a code stroke if indicated. Chi-square or Fisher’s exact test were used for categorical variables; Wilcoxon’s rank sum test was used for the outcomes of SRT to bolus and SRT to puncture. Result: We identified 196 IHS who received emergent treatment: 58 (30%) in Pre and 138 (70%) in Post Intervention (p=0.05). There was no difference in baseline demographics. SRT to thrombolytic administration significantly improved Post Intervention {49 minutes (IQR: 23-268) vs 82 minutes (IQR: 33-220, p<0.05}; Post Intervention SRT to skin puncture time trended towards improvement {90 minutes (IQR: 33-266) vs 110 minutes (IQR: 52-420), p=0.09}. There were no differences in symptomatic intracerebral hemorrhages between the two groups. Conclusion: The implementation of a hospital wide process that focuses on a neurology resident physician and nursing collaboration greatly improves IHS SRT to thrombolytic administration time with a trend towards improvement in SRT to skin puncture time.

Risk of COVID-19 in different groups of healthcare professionals between February 2020 and June 2021 in Finland: a register-based cohort study

During the Coronavirus Disease 2019 (COVID-19) pandemic, healthcare workers (HCWs) have been a risk group for COVID-19. To assess the cumulative incidence in different groups of HCWs and the risk factors and outcomes of COVID-19 in HCWs between February 2020 and June 2021 in Finland. We linked two national registers, National Infectious Diseases Register (NIDR) and Register of Social Welfare and Healthcare Professionals (Terhikki), using national identity codes. COVID-19 cases were identified from NIDR notifications made by laboratories and physicians, and their healthcare professions from Terhikki. We categorized healthcare professions into seven groups and calculated cumulative incidences using Kaplan-Meier estimate during three periods (1/2/2020-30/6/2020, 1/7/2020-31/12/2020, 1/1/2021-30/6/2021). We identified risk factors in a multivariable model using Cox's regression. We identified 8,009 COVID-19-cases among HCWs, with cumulative incidence of 1.79%; 83% were female, median age was 40.9 years (interquartile range, 31.2-51.6). Most COVID-19-cases occurred in nursing assistants (53%) and nurses (17%), with the highest cumulative incidences 2.07% (95%CI, 2.01-2.13%) and 1.82% (95%CI, 1.73-1.91%), respectively. Risk factors were male sex (hazard ratio (HR) 1.2; 95%CI, 1.1-1.3), foreign native language (HR 2.5; 95%CI, 2.2-2.9) and foreign country of birth (HR 1.2; 95%CI, 1.1-1.4). Physician notification data was available for 6,113/8,009 cases (76.3%); 244/6,113 (4.0%) were hospitalized and 37/6,113 (0.6%) in intensive care. Nurses and nursing assistant, especially men and professionals with foreign background, were at higher risk of COVID-19. This should be specifically addressed during training and implementing infection control measures to protect themselves and patients.

Expediting Treatment of Trauma Patients in the Emergency Department: Rapid Trauma Evaluation (RTE)

BackgroundCriteria for trauma determination evolves. We developed/evaluated a Rapid Trauma Evaluation (RTE) process for a trauma patient subset not meeting preestablished trauma criteria. MethodsRetrospective study (July 2019 - May 2020) for patients either > 65 years with ground level fall within 24 hours or in a motorcycle collision (MCC) arriving by EMS not meeting ACS trauma-criteria. RTE process was immediate evaluation by nurse/EMT, room placement, physician notification, undressing/gowning, vital signs, head-to-toe assessment, upgrade trauma status. Number/type of admissions, discharges, trauma upgrades, LOS obtained via trauma-registry and chart-review. For comparison, historic controls (HC) were used [all patients meeting RTE criteria seen in the ED prior to RTE (Apr- June 2019)]. ResultsThe RTE cohort (n=755) was 77% falls,23% MCCs, median age 82 [IQR 74-88] years; 42% male-Among falls, 3.2% required a modified-upgrade; 0.7% full-upgrade, 55% admitted [29.4% trauma). HC (n=575) was 92.3% falls, 7.7% MCCs, median age 81 (IQR: 67-88) years, 40.5% males-57.4% admitted (22% trauma). RTE MCC median age 42 (IQR:30-49) years, 84.4% male- 21.9% were upgraded [(6 modified-trauma; 1 full-trauma; 43.8% admitted (85.7% trauma)]. HC MCC median age 29 (IQR: 23-41) years, 95.5% male, 54.5% admitted (75% trauma]. No difference on demographics, admissions or discharges between groups (P>0.05) except HC MCC was younger (P<0.005). RTE median LOS was shorter than HC [203 (IQR: 147-278) minutes vs. 286 (IQR: 205-392) minutes, P<0.001]. ConclusionsPatients > 65 years with a ground level fall or in a MCC arriving via EMS not meeting ACS trauma criteria may benefit from RTE.

Arriving Safely: Decreasing Rapid Escalations in Care for Incoming Transported Pediatric Patients.

We created an escalation algorithm utilizing PEWS scores and direct lines of communication between emergency medical technicians and receiving physicians. Audit and feedback increased the adoption of the process. We defined rapid escalations as transfer to a higher level of care within 6 hours of admission. PEWS score completion increased from a mean of 48% to 70%. This result varied by emergency medical technician crew level of care. Eleven percent (n = 114) of PEWS scores required physician notification, 20% (n = 23) of which resulted in interventions en route. There were no differences in rapid escalation rates over time, but it remained low at <2% of all incoming transported patients. Some crew members report improved communication with hospital providers and feel more empowered to speak up when a patient's assessment is not as expected following algorithm implementation. This project improved PEWS score completion and maintained a low rate of rapid escalations of care among incoming transfers.

Utilising low-cost, easy-to-use microscopy techniques for early peritonitis infection screening in peritoneal dialysis patients

Peritoneal dialysis (PD) patients are at high risk for peritonitis, an infection of the peritoneum that affects 13% of PD users annually. Relying on subjective peritonitis symptoms results in delayed treatment, leading to high hospitalisation costs, peritoneal scarring, and premature transition to haemodialysis. We have developed and tested a low-cost, easy-to-use technology that uses microscopy and image analysis to screen for peritonitis across the effluent drain tube. Compared to other technologies, our prototype is made from off-the-shelf, low-cost materials. It can be set up quickly and key stakeholders believe it can improve the overall PD experience. We demonstrate that our prototype classifies infection-indicating and healthy white blood cell levels in clinically collected patient effluent with 94% accuracy. Integration of our technology into PD setups as a screening tool for peritonitis would enable earlier physician notification, allowing for prompt diagnosis and treatment to prevent hospitalisations, reduce scarring, and increase PD longevity. Our findings demonstrate the versatility of microscopy and image analysis for infection screening and are a proof of principle for their future applications in health care.

Standardized Evaluation of Cord Gases in Neonates at Risk for Hypoxic Ischemic Encephalopathy.

Umbilical-cord acidemia may indicate perinatal asphyxia and places a neonate at increased risk for hypoxic ischemic encephalopathy (HIE). Our specific aim was to develop a standardized clinical care pathway, ensuring timely identification and evaluation of neonates with umbilical-cord acidemia at risk for HIE. A standardized clinical care pathway to screen inborn neonates ≥36 weeks with abnormal cord blood gases (a pH of ≤7.0 or base deficit of ≥10) for HIE was implemented in January 2016. Abnormal cord blood gases resulted in a direct notification from the laboratory to an on-call physician. Evaluation included a modified Sarnat examination, postnatal blood gas, and standardized documentation. The percentage of neonates in which physician notification, documented Sarnat examination, and postnatal blood gas occurred was examined for 6 months before and 35 months after implementation. Of 203 neonates with abnormal cord gases in the post-quality improvement (QI) period, physician notification occurred in 92%. In the post-QI period, 94% had a documented Sarnat examination, and 94% had postnatal blood gas, compared with 16% and 11%, respectively, of 87 neonates in the pre-QI period. In the post-QI period, of those evaluated, >96% were documented within 4 hours of birth. In the post-QI period, 15 (7.4%) neonates were cooled; 13 were in the NICU at time of identification, but 2 were identified in the newborn nursery and redirected to the NICU for cooling. A standardized screening pathway in neonates with umbilical-cord acidemia led to timely identification and evaluation of neonates at risk for HIE.

Stakeholder-engaged process for refining the design of a clinical trial in home hospice

BackgroundClinical trials in home hospice settings are important to build the evidence base for practice, but balancing the burden and benefit of clinical trial conduct for clinicians, patients, and family caregivers is challenging. A stakeholder-engaged process can help inform and refine key aspects of home hospice clinical trials. The aim of this study was to describe a stakeholder-engaged process to refine, design, and implement aspects of an educational intervention trial in home hospice, including recommendations for refining intervention content and delivery, recruitment and enrollment strategies, and content and frequency of outcome measurement.MethodsA panel of interprofessional (1 hospice administrator, 3 nurses, 2 physicians, 2 pharmacists) and 2 former family caregiver stakeholders was systematically selected and invited to participate based on expertise, representing 2 geographically distinct hospices who were participating in the clinical trial. Teleconferences followed a predetermined procedural sequence: 1. pre-meeting materials distribution and review; 2. pre-meeting email solicitation of concerns in response to materials; 3. teleconference with structured and guided discussion; and 4. documentation and distribution of minutes for accuracy review and future meeting guidance. Discussion topics were distinct for each panel meeting. Written reflections on the stakeholder engagement process were collected from panel members to further refine our process.ResultsFive initial biweekly teleconferences resulted in recommendations for recruitment strategy, enrollment process, measurement frequency, patient inclusion, and primary care physician notification of the patient’s trial involvement. The panel continues to participate in quarterly teleconferences to review progress and unexpected questions and concerns. Panelist reflections reveal personal and professional benefit from participation.ConclusionsAn interprofessional stakeholder process is feasible and invaluable for developing home hospice intervention studies, contributing to better science, successful trial implementation, and relevant, valid outcomes.Trial registrationClinicaltrials.gov, NCT03972163, Registered June 3, 2019.

Physician Responsiveness to Positive Blood Culture Results at the Minneapolis Veterans Affairs Hospital-Is Anyone Paying Attention?

Patients presenting with suspected infections are typically placed on empiric broad-spectrum antibiotics. With mounting evidence supporting the efficacy of using the narrowest spectrum of antimicrobial therapy to cover the suspected pathogen, current guidelines recommend decreasing the breadth of coverage in response to culture results both in relation to microbe identification and antibiotic sensitivity. A retrospective chart review of electronic health records at the Minneapolis Veterans Affairs Medical Center (VAMC) in Minnesota was performed for 208 positive blood cultures with antibiotic spectrum analysis from July 1, 2015 to June 30, 2016. The time of reporting for pathogen identification and subsequent pathogen susceptibilities were compared to the time at which any alterations to antibiotic coverage were made. The breadth of antibiotic coverage was recorded using a nonlinear spectrum score. The use of this score allowed for the reliable classification of antibiotic adjustments as either deescalation, escalation, or no change. The percentage of cases deescalated was higher in response to physician (house staff or attending physician) notification of pathogen susceptibility information when compared with a response to pathogen identification alone (33.2% vs 22.6%). Empiric antibiotics were not altered within 24 hours in response to pathogen identification in 70.7% of cases and were not altered within 24 hours in response to pathogen sensitivity determination in 58.6% of cases. However, when considering the time frame from when empiric antibiotics were started to 24 hours after notification of susceptibility information, 49.5% of cases were deescalated and 41.5% of cases had no net change in the antibiotic spectrum score. The magnitude of deescalations were notably larger than escalations. The mean (SD) time to deescalation of antibiotic coverage was shorter (P =.049) in response to pathogen identification at 8 (7.4) hours compared with sensitivity information at 10.4 (7) hours, but may not be clinically relevant. Health care providers at the Minneapolis VAMC appear to be using positive blood culture results in a timely fashion consistent with best practices. Because empirically initiated antibiotics typically are broad in spectrum, the magnitude of deescalations were notably larger than escalations. Adherence to these standards may be a reflection of the infectious disease staff oversight of antibiotic administration. Furthermore, the systems outlined in this quality improvement study may be replicated at other VAMCs across the country by either in-house infectious disease staff or through remote monitoring of the electronic health record by other infectious disease experts at a more centralized VAMC. Widespread adoption throughout the Veterans Health Administration may result in improved antibiotic resistance profiles and better clinical outcomes for our nation's veterans.

Bedside Evaluation for Early Sepsis Intervention: Addition of a Sepsis Response Team Leads to Improvement in Sepsis Bundle Compliance.

Sepsis is associated with high morbidity and mortality and high healthcare costs. We hypothesized that a multifaceted quality improvement project would lead to an improvement in compliance with the sepsis "bundles." Patients presenting to the emergency department that met criteria for sepsis at triage triggered notification of an emergency department physician and the sepsis response team in order to facilitate timely completion of the 3-hour bundles. The primary outcome was compliance with the seven sepsis bundle components. Secondary outcomes included all-cause inhospital mortality, hospital length of stay, and time in the emergency department. The study was conducted at a 404-bed tertiary academic medical center over a 2-year period. The study included patients that presented to the emergency department that met criteria for sepsis. The study included 163 patients. Overall compliance with the sepsis bundle was 79% (95% CI, 72-84%). There was significant improvement in comparison with the hospital's historical compliance of 37% (p < 0.001). Compliance with the individual bundle components ranged from 80% to 100%. Sixteen patients died (10%) in the hospital. There was no statistically significant difference between the compliant and noncompliant groups regarding the secondary outcomes of length of stay or inhospital mortality. This study found that implementation of a sepsis response team can improve compliance with completion of sepsis bundles. This indicates that it is feasible to implement a multidisciplinary quality initiative to improve timely treatment of patients with sepsis at an academic center using a resident-driven sepsis response team.

Effect of Physician Notification Regarding Nonadherence to Colorectal Cancer Screening on Early Cancer Detection

This cluster randomized clinical trial compares the effect of physician notification for colorectal cancer screening and cancer detection on patients who were in a patient-specific reminders group in which physicians received a list of nonadherent patients, in a generic reminders group in which physicians received general information about regional screening adherence, or in a usual care group in which physicians received no reminders.

Nurse and Patient Dispute Litigation in Independent Nursing Practice

Although medical dispute and other contentious cases involving patients and nurses have risen significantly in recent years, few studies have examined the litigation issues involved in nurse-patient disputes. This study was designed to explore the background, categories, and degrees of harm to patients and the judgments made by the courts. Qualitative research was used. Cases of criminal, written judgments related to nurse practice negligence and recorded in district courts in Taiwan from 2008 to 2017 were selected. Data were analyzed using content analysis. A total of 41 hospitals and 55 nurses were identified. The largest number of cases involved regional hospitals (36.6%), internal medicine departments (31.7%), general wards (46.3%), night shifts (40.0%), and staff nurses (85.5%). Four categories of independent nurse practice negligence were identified, including observation-evaluation, environmental security, physician notification, and nursing records. Negligent homicide (58.2%) was the most common court judgment and ten nurses (18.2%) were found guilty of the charges brought against them. The results of this study highlight for nurses the content of nurse practice negligence and the related judgments by the courts, which hopefully may guide nurses to avoid practice negligence in the future.

Early Warning System Safeguarding Patient Lives

Disease progression often differs among patients. According to study findings, changes in vital signs, blood oxygen saturation, and consciousness are each related closely to acute deterioration in disease status (Sutherasan et al., 2018). The early warning system (EWS) is a predictive approach to detecting deterioration in disease condition based on the observation of slight variations in patient vital signs and clinical symptoms (Smith et al., 2014). Most patients experience changes in specific physiological variables before experiencing a cardiac arrest. The implementation of a comprehensive EWS facilitates the early identification and prevention of serious adverse events such as unexpected cardiac arrest and death, and may help reduce the risk of other unexpected events as well (Gerry et al., 2017). For medical team members, the use of EWS not only permits the detection of changes in patient condition at an early stage but also allows healthcare workers to respond more proactively and effectively. Moreover, EWS has been shown to improve communication, increase cooperation, and strengthen personal responsibility among healthcare workers (Burns et al., 2018). In summary, implementing EWS allows the prompt initiation of appropriate patient treatment and helps improve patient-care outcomes. While recognizing the importance of incorporating EWS into patient care in clinical and home-based institutions as an important strategy to protecting the lives of patients, appropriate standardized warning systems must be tailored to address different disease characteristics. Changes in patient condition are traditionally addressed through nursing assessment followed by physician notification and response. However, this process may be affected by factors such as assessment accuracy, cultural differences, confidence, and past experiences that may result in decision-making errors (Wood, Chaboyer, & Carr, 2019). The integration of EWS and medical informatics technology is expected to reduce the risks of human-interpretation-related omissions and errors (Downey, Tahir, Randell, Brown, & Jayne, 2017). Although the use of medical informatics technology to enhance EWS remains in its infancy, this will certainly be one of the future trends in patient care. The articles in this issue, in addition to introducing EWS, elucidate the current application of EWS in clinical critical conditions and introduce how informatics technology is being combined in home EWS applications. These articles comprise a rich body of information on EWS that may referenced in clinical nursing care, home care, education, and research.

Utilizing a Physician Notification System in the EPIC Electronic Medical Record to Improve Pediatric Asthma Control: A Quality Improvement Project.

Utilizing a Physician Notification System in the EPIC Electronic Medical Record to Improve Pediatric Asthma Control: A Quality Improvement Project.

Multidisciplinary strategies to treat severe hypoglycemia in hospitalized patients with diabetes mellitus reduce inpatient mortality rate: Experience from an academic community hospital

ObjectiveSevere hypoglycemia (blood glucose < 50 mg/dl) in hospitalized patients with diabetes mellitus is associated with poor outcomes such as increased mortality and readmission rates. We study the effects of system based interventions in managing severe hypoglycemia and its impact on outcomes.Research design and methodsWe performed retrospective review of pre- and post- intervention study to quantify severe hypoglycemia in patients admitted in the general internal medicine wards with primary or secondary diagnosis of diabetes mellitus based on ICD-9 and ICD-10 codes. We implemented multidisciplinary interventions including standardization of treatment, education of in-patient medical teams and physician notification and feedback immediately after severe hypoglycemia. The endpoints were the comparative analysis of incidence of severe hypoglycemia, in-patient mortality rate, 30-day mortality rate, 30-day readmission rate, recovery time from hypoglycemia, time to next glucose measurements, use of standardized treatment and physician notification rate pre-and post-intervention.ResultsThe incidence of severe hypoglycemia per patient with diabetes was reduced from 9.6% (233/2416) to 5.6% (202/3607) (p<0.001) post-intervention. The in-patient mortality rate in patients with severe hypoglycemia reduced from 4.1% to 0% (p = 0.019), 30-day mortality rate reduced from 9.8% to 3.8% (p = 0.058) post-intervention. 30-day readmission rate was comparable between pre-intervention (31.7%) and post-intervention (29%) (p = 0.60). In comparison, the mortality and readmission rates of all diabetic patients did not reduce during the same observation periods. Recovery time reduced from 116 (83–161) to 75 (57–102) min (p<0.01), time to next glucose measurement reduced from 39.5 (34–48) to 32 (28–35) min (p<0.01), use of standardized treatment improved from 22.7% (53/233) to 72.2% (146/202) (p<0.001) and physician notification rate increased from 29.2 (68/233) to 84.7% (171/202) post-intervention.ConclusionsOur study shows that multidisciplinary strategies improves the process of early detection and management of severe hypoglycemia and reduce incidence and in-patient mortality rate.

NICU to Home Discharge Communication: a Quality Improvement Project

Background: Approximately 1 in 10 babies is born prematurely each year in the United States. Many graduates of the NICU will require chronic care management after discharge, with needs for frequent primary care visits, multispecialty care, complex pharmaceutical and dietary regimens, and community- based early intervention services particularly if they are extremely preterm or had rough NICU course. Our NICU discharge process did not include routine notification of primary care physicians (PCP). We undertook a longitudinal QI project aimed at initiating a two way communication with the receiving physician in …

Cross-Cover Documentation: Multicenter Development of Assessment Tool for Quality Improvement

Construct: We aimed to develop an assessment tool to measure the quality of electronic health record inpatient documentation of cross-cover events. Background: Cross-cover events occur in hospitalized patients when the primary team is absent. Documentation is critical for safe transitions of care. The quality of documentation for cross-cover events remains unknown, and no standardized tool exists for assessment. Approach: We created an assessment tool for cross-cover note quality with content validation based on input from 15 experts. We measured interrater reliability of the tool and scored cross-cover note quality for hospitalized patients with overnight rapid response team activation on internal medicine services at 2 academic hospitals for 1 year. Patients with a code blue or a clinically insignificant event were excluded. The presence of a note, writer identity (resident or faculty), time from rapid response to documentation, note content (subjective and objective information, diagnosis, and plan), and patient outcomes were compared. Results: The instrument included 8 items to determine quality of cross-cover documentation: reason for physician notification, note written within 6 hours, subjective and objective patient information, diagnosis, treatment, level of care, and whether the attending physician was notified. The mean Cohen's kappa coefficient demonstrated good interrater agreement at 0.76. The instrument was scored in 222 patients with cross-cover notes. Notes documented by faculty scored higher in quality than residents (89% vs. 74% of 8 items present, p < .001). Cross-cover notes often lacked subjective information, diagnosis, and notification of attending, which was present in 60%, 62%, and 7% of notes, respectively. Conclusions: This study presents reliability evidence for an 8-item assessment tool to measure quality of documentation of cross-cover events and indicates improvement is needed for cross-cover education and safe transitions of care in acutely decompensating medical patients.

Abstract WP504: Utilizing a Nurse Driven Hand off Tool to Improve Neuro Interventional Post Procedural Documentation

Introduction: In preparation for Comprehensive Stroke Certification (CSC) survey, auditing of pre-, intra-, and post-procedural documentation of neuro-interventional (NIR) angiograms was performed. Auditing identified post-procedural documentation was not consistent with physician orders or clinical practice guidelines (CPG) designated by the Joint Commission. Nursing developed a post-procedure tool to improve nurse to nurse hand-off and documentation compliance. Methods: A post-procedure tool was developed for nurse hand-off when transferring patients from NIR to Critical Care. The one-page tool contained the type of procedure performed, post procedure orders, time of sheath removal, type of required documentation (vital signs, neurological and neurovascular exams), and time-frame grid when documentation was due. Also included was criteria for issues requiring physician notification and management of groin hematoma flow chart. Results: Initial audits revealed virtually no post assessments were documented 100% correctly per order. After implementation and during time of CSC survey, auditing revealed an improvement to only 31%, but demonstrated a significant improvement from having substantial assessments missing to only 1-2 items. The CSC designation was granted with a requirement for improvement (RFI) to improve documentation. Additional focused auditing identified at-risk time frames, and specific assessments and staff locations to target further education. Editing of the tool was made with suggestions from nursing. Jan-Jun 2017 auditing demonstrated &gt;80% compliance in all three assessment requirements with June having 91% neuro assessments documented, and 100% with neurovascular and vital signs documented appropriately for the required six hours of focused assessments. Nurses feel the tool has improved communication and provides a better hand-off between NIR and Critical Care. Conclusions: Compliance with orders and CPG required documentation, as well as improved nurse to nurse hand-off can be achieved utilizing a comprehensive tool identifying the type of assessment and designated time assessments are required.

Data Transmission Delay in Medtronic Reveal LINQ&amp;lt;sup&amp;gt;TM&amp;lt;/sup&amp;gt; Implantable Cardiac Monitor: Clinical Experience in 520 Patients

Background: The Implantable Cardiac Monitor (ICM) is an invaluable tool for detecting cardiac arrhythmias by providing physicians. Critical to the success of ICMs depends on how quickly and accurately the data can be transmitted to a physician’s office after an arrhythmic event. Then, the clinical event can be analyzed and the treatment will be provided accordingly. However, no reports have been published as to how efficiently the ICM data is transmitted. Methods: There is a retrospective review of 520 patients who received a Medtronic Reveal LINQTM between 2/01/2015 and 6/01/2017. The time from the arrhythmic event to the time of physician notification was calculated and reason for delay was noted. Results: One hundred and twenty patients out of 520 patients (23%) had arrhythmic events transmitted over a mean follow up of 14 ± 4 months. The mean time between cardiac events and physician notification was 15 ± 8 days. Sixty-three percent (63%) of data transmission delay (defined as >24 hours) was due to the MyCareLinkTM Monitor not being in proximity to the patient. Connection failure between the monitor and the network accounted for 34% of data transmission delay. Conclusion: Significant delay in data transmission from Medtronic Reveal LINQTM cardiac monitor occurs frequently impacting patient care. Newer generations of the implantable cardiac monitors utilize Bluetooth technology, enabling immediate transfer of data from ICM to a patient’s cellular phone and subsequently to their physician’s office. This technology could potentially improve efficiency and reliability eliminating the issues of proximity and connectivity.