Walk Rounds Research Articles

Novel Method of Edge-Removing Walk for Graph Representation in User Identity Linkage

Random-walk-based graph representation methods have been widely applied in User Identity Linkage (UIL) tasks, which links overlapping users between two different social networks. It can help us to obtain more comprehensive portraits of criminals, which is helpful for improving cyberspace governance. Yet, random walk generates a large number of repeating sequences, causing unnecessary computation and storage overhead. This paper proposes a novel method called Edge-Removing Walk (ERW) that can replace random walk in random-walk-based models. It removes edges once they are walked in a walk round to capture the l−hop features without repetition, and it walks the whole graph for several rounds to capture the different kinds of paths starting from a specific node. Experiments proved that ERW can exponentially improve the efficiency for random-walk-based UIL models, even maintaining better performance. We finally generalize ERW into a general User Identity Linkage framework called ERW-UIL and verify its performance.

Cutting the fat: Utilizing LEAN methodology to improve rounding efficiency of surgical residents

BackgroundLEAN was developed by Toyota to provide a systematic way to eliminate waste and standardize processes. We sought to introduce LEAN methodology to surgical residents with the goal of increasing rounding efficiency. MethodsA Kaizen event was used as a rounding efficiency improvement strategy. A multidisciplinary healthcare team participated in the event; first to identify the current state of rounds, second to create the ideal state. Value-stream maps were created and improved efficiency was seen by increased ratio of productive time to lead time. ResultsTwo interventions were prioritized. The first introduced table rounds before walk rounds and the second changed the sign-out tool from Baton to Microsoft Word with file encryption. The ratio of productive time to lead time during morning rounds was higher after implementing these interventions (3.73 vs. 2.03). ConclusionsThis Kaizen event introduced surgical trainees to LEAN and resulted in improved efficiency of morning rounds.

Changes in Safety and Teamwork Climate After Adding Structured Observations to Patient Safety WalkRounds.

Patient safety is essential for the reliable delivery of health care. One way to positively influence patient safety is to improve the safety and teamwork climate of a clinical area. Research shows that patient safety WalkRounds (WRs) are an appropriate and common method to improve safety culture. The aim of this study was to combine WRs with observations of specific patient safety dimensions and to measure the safety and teamwork climate. In this observational study, WRs took place in eight work settings across a 770-bed university hospital in Switzerland. During rounds, health care workers (HCWs) were observed in relation to defined patient safety dimensions. In addition, HCWs were surveyed using safety and teamwork climate scales before the initial WRs and six to nine months later, and implementation of planned improvement actions following the WRs was evaluated. During WRs, 810 activities of HCWs were observed, of which 85.4% met the requirements for safe care. Safety and teamwork climate did not change significantly after nine months. A total of 36 action plan items were planned to address safety deficits that surfaced during WRs, but only 40.7% of the action items had been implemented after nine months. WRs with structured in-person observations identified safe care practices and deficits in patient safety. Improvement action plans to address safety deficits were not fully implemented nine months later, and there were no significant changes in the safety and teamwork climate at that time.

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature.

IntroductionOn psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.MethodIn Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.ResultsThe prevalence of aggressive behaviour on psychiatric wards varied (8–76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.ConclusionDespite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

Safety walk-round education to develop risk prediction skills of novice health professional students

Introduction: Students in the early years of medical school should learn clinical site risk assessment skills. However, the effect of this training on clinically inexperienced students is not clear, and it is difficult for students to predict risks from a wide range of perspectives. This study aims to develop and implement three patterns of safety walk rounds (SWR) in a class of students with no clinical experience. Methods: Three types of SWR were conducted: (A) 37 students observed a familiar classroom and predicted safety risks; (B) 39 students created a profile of a fictitious student in advance and then used Type A parameters; (C) 100 students participated. First, Type A was conducted as a practice. Next, students observed a hospital and predicted risks. All participants in Types A to C had no clinical experience. We classified all risks into perception, comprehension, and action. Results: For each safety walk-round, there were two types of risk prediction. In Type A, risks such as perception and comprehension were more than 80%. In Types B and C, action risks were 60%. Students had little experience in observing facilities and none at finding safety risks. Conclusion: Each method had a different risk prediction tendency. Combining the methods could enable students to acquire comprehensive skills in assessing hidden environmental patient safety risks.

Institutional Practices of a Private Hospital in Saudi Arabia: An Initiative to Improve the Hospital’s Safety Culture

Introduction: Study findings pertain to a private healthcare facility in the Eastern Region of Saudi Arabia, which highlighted its healthcare organization’s implementation of hospital-wide approach aimed at promoting culture change to enhance patient safety. Patient safety is a vital component of quality health care. Health care organizations continually strive for improvement, leading to a growing recognition of the importance of establishing a safe culture, most especially within the Kingdom of Saudi. Materials and Methods: The hospital's culture of safety was investigated using a descriptive research design. The study further discusses how the hospital was able to improve the safety culture within the confines of their organization by instituting several programs which forms as the framework of the hospital’s commitment to safety. The study covers all the healthcare professional of the hospital (clinical and non-clinical) to provide their perception on the topic. Results: This study yielded more than sixty percent (60%) response rate for three consecutive years which strongly supports the findings of the study. The institution’s safety culture has dramatically improved from 2017’s result of 46.4%, 58.6% (2018) and 74.4% in 2019 after engaging an organizational intervention which includes; leadership patient safety walk rounds, good catch campaign, improvement projects, adoption of lean management, continuous organization learning and development, quality accreditation and an intensified leadership support. A number of dimensions contributed to the highest perception of patient safety, including teamwork within and across units, organizational learning and continuous quality improvement, management support for patient safety, and an increase in the perception of overall patient safety culture by staff. Conclusion: The result suggested that the commitment of all healthcare professionals within the organization and an active engagement of managers and executives will absolutely result to positive change in the institution’s culture of safety.

Evaluating the effects of a high-tech call system on patient-staff communication.

Evaluating the effects of a high-tech call system on patient-staff communication.

Outdoor walking rounds: combining resident education and wellness.

It is challenging to achieve quality teaching on a busy resident service. Teams must balance the competing drivers of patient care, clinical efficiency, patient satisfaction and resident learning. Our novel outdoor walking rounds improve both the quality of resident instruction and their physician wellness without negatively affecting patient care. Our team meets outside for attending rounds on the sidewalks or hiking trails near our hospital. The residents present their clinical plans as we walk. We are able to achieve more in-depth clinical discussions and teaching than with traditional rounds conducted inside. Residents were surveyed to compare their experiences with traditional rounds. Twenty-seven residents were surveyed over 5years (29.6% were first-year residents, 33.3% were second-year residents and 37.0% were third-year residents): 81% of residents indicated that walking rounds improved the time dedicated to teaching; 100% of residents believed that the quality of teaching had improved; 70% of residents indicated that walking rounds improved their sense of physician wellness; and 59% of residents identified that walking rounds were as efficient, or more efficient, than traditional rounds. Striving to provide in-depth resident clinical teaching without negatively affecting the quality and efficiency of patient care is a tall order. Outdoor walking rounds are a teaching method that combines dedicated non-distracted time for resident teaching with exercise. Our study indicates that this teaching method improves the quantity and quality of dedicated teaching time, improves resident physician wellness and does so in an innovative way that maintains efficient patient care.

COVID-19 Response in the Global Epicenter: Converting a New York City Level 1 Orthopedic Trauma Service into a Hybrid Orthopedic and Medicine COVID-19 Management Team.

The SARS-COV-2 (COVID-19) pandemic has placed unprecedented challenges on the health care system in the United States with New York City at its epicenter. By the end of the 8 week (4/23/2020) since the virus's emergence in New York City, there have been 142,432 confirmed COVID-19 cases and 10,977 deaths attributed to complications from COVID-19-related illnesses. Secondary to policies enacted by the New York State government to limit spread of the virus, Orthopedic Surgery departments at hospitals around the area have witnessed an abrupt change in clinical demands. At a local level one trauma hospital in Queens, New York, Orthopedic Surgery elective cases have been cancelled, trauma consult volume has experienced a sharp decline, and both residents and attendings have been repurposed to meet the new clinical demands of this medical crisis. Our own orthopedic surgery service has adopted care for patients normally admitted to an internal medicine service in a novel Ortho-Medical COVID-19 management team. We prepared this primer to make our experience with caring for COVID-19 patents available as a reference for other surgical subspecialty services preparing to adjust the clinical focus of their hospital teams during this or future pandemics. LEVEL OF EVIDENCE:: Level V.

MASLENITSA ("BUTTER WEEK") IN THE FOLK CALENDAR OF THE BESERMEN: TEMPORAL, SPATIAL AND NUTRITIONAL PARAMETERS

The article deals with food, time and space parameters of the Beserman Maslenitsa ("butter week, crepe week") rite Machencha / Machincha in the folk calendar and their transformation in the modern rite. The time parameters of the holiday were limited by the week of the Maslenitsa, the last week before the Great Lent, which regulated the beginning and end of the ceremony, some types of works, forms of entertainment and meals. Spatial parameters of the ritual, as well as the movement (sledging) had a producing character, aimed at obtaining a good harvest (flax), and are associated with women's crafts. During the Maslenitsa days, the objects of the landscape - mountain, street, village center - were the places of festive sledgings, festivities and meetings. Maslenitsa rituals reflected the social changes of some residents and honours of members of the village community, family, social and age groups in their new status - newlyweds, young women, girls and boys of marriageable age. Meals, visits to relatives and festive walk rounds of the village's youth were part of the celebration. The main dish of the festival were small flatcakes named taban' made of yeast dough. Modern Maslenitsa as a public event refers to the holiday «Farewell of the Russian winter», with changes of the spatial, temporal and nutritional parameters of the traditional rite. The article is based on field materials and observation of the modern rite.

Outcomes of a Resident-Led Early Hospital Discharge Intervention.

Early morning patient discharge from the hospital is increasingly being recognized as a key dimension of quality of care. At our institution, there is a significantly lower early discharge rate on the teaching hospitalist teams in comparison with the non-teaching teams. To implement a resident-driven intervention in the teaching medical services to increase overall discharge order rate before 11 am (DOB-11) and assess the effect of this intervention on hospital length of stay (LOS), 30-day readmission rates (RR), and resident perception. Interrupted time series as well as controlled before-after designs. All inpatients discharged from general medicine units. We implemented an educational didactic in conjunction with resident-attending daily walk rounds followed by resident-led multidisciplinary discharge huddles to identify next-day discharges. The primary outcome was DOB-11 rates 18months pre- and 12months post-intervention. LOS and RR. Additionally, we assessed residents' perception of the early discharge protocol. The DOB-11 rate increased from 12 to 29% (p < 0.001), LOS increased by 1.47days (P < 0.001), and RR increased by 0.32% (P = 0.84), respectively, on the teaching teams. Compared with the non-teaching (control) teams, the teaching teams registered a greater increase in DOB-11 rate (by 17%, p < 0.001; ratio of adjusted ORs 2.16; 95% CI, 1.65, 2.85; p value < 0.001), small increase in LOS (by 0.74day, p = 0.39; ratio of adjusted post-/pre-intervention ratio [teaching] and post-/pre- intervention ratio [non-teaching] = 1.05, 95% CI, 0.97, 1.14, p = 0.23), and relative increase in RR (by 3.98%, p = 0.07, and ratio of ORs = 1.35, 95% CI, 1.03, 1.8), p = 0.03). Approximately 55% (16/29) of the residents agreed that the early discharge initiative helped in understanding the importance of prioritizing patients for early discharge. Additionally, 55% (20/36) of the residents "agreed" that the early discharge initiative compromised their learning during teaching rounds. Our study demonstrates that DOB-11 is an achievable goal, not only for non-teaching teams but also for resident-run teaching teams.

1119. Implementation of Pediatric Antimicrobial Stewardship Rounds in a Children’s Hospital

BackgroundAntimicrobial stewardship programs (ASP) are required in all acute care hospitals per The Joint Commission. ASP must adhere to the recommendations laid out by the Centers for Disease Control and Prevention, but how each ASP chooses to implement these recommendations is left to the individual program. In January 2018, we began formal antimicrobial stewardship (AMS) walking rounds, led by infectious diseases trained physician and pharmacist, in our 99-bed pediatric hospital.MethodsIn January 2018, we started twice-weekly AMS rounds on the pediatric hospitalist service. A custom-made “Antimicrobial Stewardship Patient List” was designed in our electronic medical record (EMR) to generate a list of all patients receiving antibiotics. The ASP team (comprised of an infectious diseases pharmacist and a pediatric infectious diseases physician) reviewed EMR charts to determine antibiotic prescribing appropriateness and design recommended interventions. Any recommendations and teaching points were then discussed with the hospitalist team in person. After piloting the hospitalist service, AMS rounds were extended to include the general surgery patients and finally the intensive care unit. Data on number of charts reviewed, proposed interventions, and acceptance rates were collected throughout the process. Descriptive statistics were used to assess the intervention data.ResultsIn the first year of the program, 427 patient charts were reviewed with 186 identified interventions. In total, 156 (84.3%) of the interventions were accepted and implemented by the primary team. The most common types of interventions were the duration of therapy (29%), antibiotic discontinuation (16.7%), intravenous to oral conversion (11.3%), de-escalation (10.2%), and infectious diseases consult (5.9%).ConclusionPediatric AMS rounds led to the successful implementation of the majority of recommended interventions. Future goals of the program include calculating days of therapy per 1000 patient-days to assess antibiotic consumption before and after AMS rounds and to expand into other services to further promote appropriate antibiotic use in hospitalized pediatric patients.Disclosures All authors: No reported disclosures.

Safety Walk Rounds - Clinical unit visits with a focus on patient safety

Safety Walk Rounds - Clinical unit visits with a focus on patient safety Abstract. Background: Safety Walk Rounds are a promising strategy to promote the safety culture and optimising patient safety. The purpose of this study was to explore patient safety attributes in various clinical areas including recommendations for improvement and leadership support. Methods: Safety Walk Rounds were conducted by the chief patient safety officer based on a structured questions format to open patient safety dialogues with clinicians at the ward level. Field notes were utilized for thematic analyses and topic categorization. Results: A total of 187 clinicians (64 % nursing staff, 19 % physicians, 17 % other health care professionals) participated on the Safety Walk Rounds. The discussion findings are presented in five categories: Events & circumstances (potentially) harmful for patients; safety culture; need for local action, as well as the need for leadership support to provide safe care. Conclusion and outlook: Safety Walk Rounds across the hospitals' clinical areas delivered insight into patient safety issues and safety culture with its caregiver's engagement to provide safe care as well as action points for future improvement including leadership support.

Teaching methods used by internal medicine residents on rounds: what works?

BackgroundThe specific teaching methods used by internal medicine residents on walk rounds are unknown.Objectives1) To characterize in real time the specific teaching methods used by internal medicine residents on rounds and 2) to identify attributes of successful resident teaching on rounds.Materials and methodsWe conducted a prospective mixed-methods study on inpatient medical services at a single academic medical center from September 2016 to January 2017. Participants were internal medicine residents (postgraduate year [PGY]-1, PGY-2, and PGY-3) and attending physicians. Teachers were PGY-2 and PGY-3 residents, and learners were PGY-1 residents. Residents’ teaching on rounds was observed and characterized according to resident demographics, specific teaching methods, and length of time. Participants completed a survey with Likert scale and free-text questions.Results and conclusionAmong 136 surveys across 28 separate teaching encounters, we noted that PGY-3 residents’ teaching was rated significantly better than PGY-2 residents’ teaching. Teaching lasting >1 minute was rated significantly better than teaching lasting <1 minute. Free-text responses emphasized the value of immediate clinical relevance, citing published evidence, conciseness, clarity, and pertinence to the patient. Our findings may help guide internal medicine residents aiming to teach better on rounds and inform further research into specific resident teaching methods.

Detailed Findings From the CLER National Report of Findings 2018.

Detailed Findings From the CLER National Report of Findings 2018.

The Methodology for the CLER National Report of Findings 2018.

The Methodology for the CLER National Report of Findings 2018.

The Overview of the CLER Program: CLER National Report of Findings 2018.

Since its inception in 2012, the Clinical Learning Environment Review (CLER) Program has had at its core a commitment to formative assessment and feedback regarding graduate medical education (GME) engagement in 6 important, cross-cutting areas of focus—patient safety; health care quality; care transitions; supervision; fatigue management, mitigation, and duty hours; and professionalism. CLER's formative approach recognizes that, although there are shared elements, each hospital, medical center, and ambulatory care site that serves as a clinical learning environment (CLE) for resident and fellow physicians has a unique set of internal and external factors that influence the development and implementation of that CLE's strategic goals aimed at improving patient care.As in the CLER National Report of Findings 2016, the CLER Program continues to refer to CLEs as living and breathing entities—the embodiment of all of the individuals within these settings that influence and imprint upon these early learners. The CLER Program relies on the power of the information it provides to stimulate conversations and motivate CLEs to build upon their strengths and internally address opportunities for improvement.The CLER Program's primary link to accreditation is that every Sponsoring Institution (SI) must periodically complete a site visit. The 2016 National Report provided information on the CLER Program's background and structure.1In the second set of visits to SIs with 3 or more core residency programs, the structure of the site visit remained essentially unchanged. The site visitors met with GME and executive leadership and the CLE's leaders in patient safety and health care quality; held group interview sessions with residents and fellows, faculty physicians, and program directors; and had numerous conversations with various members of the clinical care team while on walking rounds within the CLE.For the second set of visits, the CLER Site Visitors used Protocol 2.0, which was similar but not identical to the version used in the first set of visits (ie, Protocol 1.0). Whereas the majority of the questions remained constant, Protocol 2.0 included new questions to explore important topics in greater depth. In addition, it included several other changes to enhance the quality of the information gathered as part of the CLER Program's commitment to a model of continual improvement:In Protocol 2.0, the CLER Evaluation Committee continued to provide oversight of and guidance for all aspects of program development. The committee is composed of members with expertise in patient safety and health care quality improvement, as well as GME and executive leadership of hospitals and medical centers (eg, chief medical officer, chief nursing officer). The committee also includes postgraduate physician representation and public members.For Protocol 2.0, the committee reviewed and provided guidance on the changes described in the previous section. They also reviewed the data resulting from the site visits and brought an external voice in response to the findings—presented here as overarching themes and challenges and opportunities. Their views and commentary on the significance of the overarching themes and the challenges and opportunities are reflected in the discussion sections of this report.This report includes data from the second set of visits to 287 participating sites of SIs accredited by the Accreditation Council for Graduate Medical Education with 3 or more core residency programs. Similar to the first report of findings, this report presents several different perspectives, including overarching themes, highlights of the challenges and opportunities in each of the 6 CLER Focus Areas, and detailed findings, as well as a new section that examines changes since the last set of CLER visits. The CLER Program will present the findings from the initial visits to SIs with 2 or fewer core residency programs in a separate report scheduled for release in 2019.

Effects of patient safety auditing in hospital care: results of a mixed-method evaluation (part 1).

ObjectiveTo evaluate the effectiveness of internal auditing in hospital care focussed on improving patient safety.Design, Setting and ParticipantsA before-and-after mixed-method evaluation study was carried out in eight departments of a university medical center in the Netherlands.Intervention(s)Internal auditing and feedback focussed on improving patient safety.Main Outcome Measure(s)The effect of internal auditing was assessed 15 months after the audit, using linear mixed models, on the patient, professional, team and departmental levels. The measurement methods were patient record review on adverse events (AEs), surveys regarding patient experiences, safety culture and team climate, analysis of administrative hospital data (standardized mortality rate, SMR) and safety walk rounds (SWRs) to observe frontline care processes on safety.ResultsThe AE rate decreased from 36.1% to 31.3% and the preventable AE rate from 5.5% to 3.6%; however, the differences before and after auditing were not statistically significant. The patient-reported experience measures regarding patient safety improved slightly over time (P < 0.001). The SMR, patient safety culture and team climate remained unchanged after the internal audit. The SWRs showed that medication safety and information security were improved (P < 0.05).ConclusionsInternal auditing was associated with improved patient experiences and observed safety on wards. No effects were found on adverse outcomes, safety culture and team climate 15 months after the internal audit.

Asking a Variety of Questions on Walk Rounds: a Pilot Study.

Morning walk rounds have lost some of their engagement while remaining a useful and valued practice. We created a pilot study to evaluate the impact on rounds of learning to asking a variety of different questions. One-hour intervention sessions were voluntarily offered to members of the Department of Medicine and taught by an expert in the question, listen, and respond method. Participants included attendings and residents in Internal Medicine on medical teams. Questionnaires were collected on six pre-intervention and six post-intervention days. Nine months later, an anonymous online survey was sent to participants asking about their use of a wider variety of questions. Two hundred eight physicians (residents 175 (45.5%), attending physicians 25 (27.7%)) filled out pre-intervention surveys. One hundred eighty-one physicians (residents 155 (40.3%), attending physicians 18 (20%)) filled out post-intervention surveys. When survey responses from the attendings and residents on the medical teams were combined, post-intervention rounds were perceived as more worthwhile (1.99 pre-intervention and 1.55 post-intervention, [95% confidence interval 1.831-2.143]) (p < 0.001) and more engaging (1.68 pre-intervention and 1.30 post-intervention, [95% confidence interval 1.407-1.688]) (p < 0.001).Non-medical teams' survey responses did not change. Patient census data indicated no significant difference in the hospital's census on the pre- and post-intervention dates. Spontaneous suggestions for improving rounds came largely from the residents and included teaching points, clinical pearls, patient focus, more interactive, increased dedicated time for teaching, inclusive/multidisciplinary, questions, and evidence-based teaching. Of the participants who answered the online survey 9months later, 75% (6/8) reported that they "actually asked a wider variety of types of questions." This pilot study indicates that the 1-h intervention of learning to ask a variety of different questions is associated with rounds that are rated as more worthwhile and engaging by the medical teams.

Improving Patient Safety Culture: A Report of a Multifaceted Intervention.

The aim of the study was to improve the safety culture at a Veterans Administration hospital using evidence-based approaches. We implemented a patient safety summit with follow-up actions. We measured safety climate before and after the summit using the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety Culture with modifications and the Safety Attitudes Questionnaire (SAQ). The summit brought hospital leaders together to discuss patient safety topics and relate them to our hospital. At the summit's end, hospital workgroups collectively submitted Safety Culture Action forms, indicating their intended actions to improve safety culture. We analyzed all survey results using the χ2 test. We shared lessons learned. The hospital leadership started safety walk rounds. There were 107 hospital employees at the summit. Attendees submitted 53 Safety Culture Action forms. We received 232 AHRQ survey responses in 2014 and 116 in 2016, for response rates of approximately 11% and 8.9%, respectively. We received 140 SAQ responses (11%) from 1244 employees in 2016 and 242 responses (18%) from 1342 employees in 2017. The AHRQ survey results indicated that perception of teamwork within hospital units improved. The SAQ results indicated that employees' comfort with reporting errors and expressing disagreement with physicians improved, and employees' perceptions of leadership's safety efforts and the levels of staffing worsened. Although some aspects of safety culture improved after the summit and follow-up interventions, others did not. Future interventions should be targeted toward individual microsystems or units and measure safety climate perceptions for intervention recipients exclusively.