Radiology and the Dialysis Patient: Collaboration and Quality of Care

This article will discuss the value of collaboration between nephrology and interventional radiology in the care of the dialysis patient.     

Using Patient Care Quality Measures to Assess Educational Outcomes

Objectives To report the results of a project designed to develop and implement a prototype methodology for identifying candidate patient care quality measures for potential use in assessing the outcomes and effectiveness of graduate medical education in emergency medicine. Methods A workgroup composed of experts in emergency medicine residency education and patient care quality measurement was convened. Workgroup members performed a modified Delphi process that included iterative review of potential measures; individual expert rating of the measures on four dimensions, including measures quality of care and educational effectiveness; development of consensus on measures to be retained; external stakeholder rating of measures followed by a final workgroup review; and a post hoc stratification of measures. The workgroup completed a structured exercise to examine the linkage of patient care process and outcome measures to educational effectiveness. Results The workgroup selected 62 measures for inclusion in its final set, including 43 measures for 21 clinical conditions, eight medication measures, seven measures for procedures, and four measures for department efficiency. Twenty‐six measures met the more stringent criteria applied post hoc to further stratify and prioritize measures for development. Nineteen of these measures received high ratings from 75% of the workgroup and external stakeholder raters on importance for care in the ED, measures quality of care, and measures educational effectiveness; the majority of the raters considered these indicators feasible to measure. The workgroup utilized a simple framework for exploring the relationship of residency program educational activities, competencies from the six Accreditation Council for Graduate Medical Education general competency domains, patient care quality measures, and external factors that could intervene to affect care quality. Conclusions Numerous patient care quality measures have potential for use in assessing the educational effectiveness and performance of graduate medical education programs in emergency medicine. The measures identified in this report can be used as a starter set for further development, implementation, and study. Implementation of the measures, especially for high‐stakes use, will require resolution of significant measurement issues.     

Using Electronic Communication Safely in Health Care Settings

Nurses are increasingly using mobile and other devices, such as cell phones, smartphones, tablets, bar‐coding scanners, monitoring equipment and bedside computers, to communicate with members of the health care team and with patients. Communication accomplished with such devices includes direct verbal communication, text‐messaging, emailing, obtaining patient care information and accessing medical records for order entry and for documenting nursing care. Problems that could occur with such communication methods include distraction, errors, de‐personalized care, violation of confidentiality and transmission of nosocomial pathogens. Policies are needed to prevent inappropriate use of technological devices in patient care and to promote patient safety and quality care with their use.     

Determining Goal Concordant Care in the Intensive Care Unit Using Electronic Health Records

BackgroundGoal concordant care (GCC) is the alignment of care to patient values and preferences. GCC is a major outcome of communication with patients and families in serious/critical illness. Using the electronic health record (EHR) to study the provision of GCC would be pragmatic and cost-effective for research and quality improvement efforts.Research questionDo EHRs contain information to identify GCC?MethodsThis is a feasibility retrospective chart review performed by two independent reviewers. An existing framework containing four questions for identifying GCC was adopted. Two clinicians reviewed multi-disciplinary notes and extracted pertinent information. The primary outcomes were whether the four key questions for determining goal concordance could be answered using information in the EHR. The secondary outcome was the type of goals identified. Cohen's kappa was used to measure agreement between two reviewers.ResultsPatient care was considered goal concordant in 35 (85%) of 41 patients in a random sample comprising of 36 survivors and five who died in hospital. Inter-rater agreement on identifying data to determine GCC was excellent (Kappa 0.70). Patient goals were identified in 80% of charts reviewed. Note sources informative of patient preferences, included social work (39%), hospital progress notes (29%), palliative care (20%), and physical/occupational therapy (15%). “Returning home” and “getting better/ stronger” were among the most common patient goals captured in EHR.ConclusionThe EHR can be used to understand patient goals, but the information is scattered across the multi-disciplinary notes. Improving EHR and external validation will facilitate ascertainment of goal concordance as an important outcome measure.     

Improving PACU Throughput Using an Electronic Dashboard: A Quality Improvement Initiative

PurposePatients boarding in a 14-bed postanesthesia care unit (PACU) impacted throughput in a large university hospital in West Virginia. The PACU and operating room (OR) boarder rate in 2019 was 12% (n = 1241) and 5% (n = 503), respectively. The purpose of this initiative was to improve PACU throughput by developing an efficient and evidence-based handoff communication process between the PACU and the medical-surgical floors.DesignThe design of the project was evidence-based quality improvement.MethodsAn interprofessional team created a nursing patient dashboard in the electronic medical record to be used during handoff communication between the PACU and medical-surgical floor nurses. The dashboard displayed real-time vital signs, patient history, medications, and laboratory results. When the patient met Aldrete score requirements for transfer, PACU nurses notified the floor that the patient was ready for transfer. After allowing 20 minutes for the floor nurse to view the dashboard, the PACU nurse and floor nurse spoke on the phone to discuss any outstanding questions. PACU and OR boarder rates were obtained from the electronic medical record 12 months before and after implementing the nursing patient dashboard. User feedback was gathered via plan-do-study-act cycles, posters, and interviews.FindingsThe electronic dashboard was a successful strategy to improve handoff communication between the PACU and receiving units. The dashboard was accepted by the staff with 70% (n = 24) of the comments being positive. A significant decrease in the number of PACU (χ2(1, n = 20,608) =122.63, P < .00001) and OR boarding (χ2 (1, n = 20,283) =14.55, P = .000136) of patients was found in the C-year compared to 2019. For patients who were boarded in the PACU, no significant difference in PACU delay duration was found (t(11) =1.49, P = .149) with the mean in 2019 of 166.96 (SD = 68.38) and the C-Year mean 132.84 (SD = 39.74). For patients who boarded in the OR, there was a significant difference (t(11) =15.590162, P <.00001) between groups for average duration of boarding with the mean in 2019 of 19.06 minutes (SD = 3.72) compared to 1.62 (SD = 1.1) in C-year. However, in July 2020 the PACU intermittently opened 2 flexible beds when the PACU was full, suggesting that OR boarding was not a reliable measure, but PACU boarding remained an accurate measure.ConclusionsThe findings of this evidence-based quality improvement project demonstrated the usefulness of an electronic dashboard tool combined with verbal report to improve patient throughput by decreasing the number of patients boarding in the PACU.     

Diabetes Quality of Care and Outpatient Utilization Associated With Electronic Patient-Provider Messaging: A Cross-Sectional Analysis

OBJECTIVE

To test the hypothesis that electronic patient-provider messaging is associated with high care quality for diabetes and lower outpatient utilization.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional analysis of electronic patient-provider messaging over a 15-month period between 1 January 2004 and 31 March 2005. The study was set at Group Health Cooperative—a consumer-governed, nonprofit health care system that operates in Washington and Idaho. Participants included all patients aged ≥18 years with a diagnosis of diabetes. In addition to usual care, all patients had the option to use electronic messaging to communicate with their care providers. The primary outcome measures were diabetes-related quality-of-care indicators (A1C, blood pressure, and LDL cholesterol) and outpatient visits (primary care, specialty care, and emergency).

RESULTS

Nineteen percent of patients with diabetes used electronic messaging to communicate with their care providers during the study period (n = 2,924) (overall study cohort: 15,427 subjects). In multivariate models, frequent use of electronic messaging was associated with A1C <7% (relative risk [RR] 1.36 [95% CI 1.16–1.58]). Contrary to our hypothesis, frequent use of electronic messaging was also associated with a higher rate of outpatient visits (1.39 [1.26–1.53]).

CONCLUSIONS

Frequent use of electronic secure messaging is associated with better glycemic control and increased outpatient utilization. Electronic patient-provider communication may represent one strategy to meet the health care needs of this unique population. More research is necessary to assess the effect of electronic messaging on care quality and utilization.Online patient-provider communication has the potential to fill unmet needs of patients with chronic conditions. The Institute of Medicine has suggested a shift in care toward “continuous healing relationships” supported by access to care outside in-person office visits such as over the Internet and by telephone (1). Although electronic mail has been slow to diffuse into clinical settings, its use is increasing in response to the Institute of Medicine report and strong consumer demand (2). Despite the promise of electronic patient-provider communication to improve care, there is a paucity of prior research in the area and, consequently, little is understood about the relationship between electronic communication and care quality. Specifically, it is unclear whether electronic communication is used as a complement to or a substitute for traditional outpatient utilization.To explore these questions, we have conducted a cross-sectional analysis of electronic patient-provider messaging at a large health care delivery system. Our analysis focused on diabetes care as a result of the need for frequent communication and care coordination in this condition (3). We hypothesized that electronic messaging would be associated with improved care quality and lower utilization of in-person services (4,5). Although causation cannot directly be inferred from cross-sectional data, demonstration of an association between electronic messaging and care quality or altered patterns of utilization would suggest that electronic messaging may interact with care processes in important ways and provide justification for further study.     

Collaboration Between Nurses and Professional Caregivers to Provide Medical Care in Japan

In Japan, as more people require medical care, the importance of effective collaboration between nurses and professional caregivers, both in the home setting and in nursing home facilities, is increasing. The purpose of this study was to identify differences in the way professional caregivers in Japan view medical care administration in the home and in nursing home facilities. Responses to a questionnaire given to in-home and nursing home caregivers demonstrated that many professional caregivers, especially nursing home caregivers, desired collaboration with nurses to enable them to provide safe medical care. An educational system for professional caregivers in Japan is needed.     

Using Electronic Health Care Records for Drug Safety Signal Detection: A Comparative Evaluation of Statistical Methods

BACKGROUND:: Drug safety monitoring relies primarily on spontaneous reporting, but electronic health care record databases offer a possible alternative for the detection of adverse drug reactions (ADRs). OBJECTIVES:: To evaluate the relative performance of different statistical methods for detecting drug-adverse event associations in electronic health care record data representing potential ADRs. RESEARCH DESIGN:: Data from 7 databases across 3 countries in Europe comprising over 20 million subjects were used to compute the relative risk estimates for drug-event pairs using 10 different methods, including those developed for spontaneous reporting systems, cohort methods such as the longitudinal gamma poisson shrinker, and case-based methods such as case-control. The newly developed method "longitudinal evaluation of observational profiles of adverse events related to drugs" (LEOPARD) was used to remove associations likely caused by protopathic bias. Data from the different databases were combined by pooling of data, and by meta-analysis for random effects. A reference standard of known ADRs and negative controls was created to evaluate the performance of the method. MEASURES:: The area under the curve of the receiver operator characteristic curve was calculated for each method, both with and without LEOPARD filtering. RESULTS:: The highest area under the curve (0.83) was achieved by the combination of either longitudinal gamma poisson shrinker or case-control with LEOPARD filtering, but the performance between methods differed little. LEOPARD increased the overall performance, but flagged several known ADRs as caused by protopathic bias. CONCLUSIONS:: Combinations of methods demonstrate good performance in distinguishing known ADRs from negative controls, and we assume that these could also be used to detect new drug safety signals.