Improving the assessment and documentation of patient mobility using a quality improvement framework.

OBJECTIVE: To implement a system for assessing and documenting patient mobility in an inpatient geriatric unit using a quality improvement framework. METHODS: Whiteboards incorporating the Johns Hopkins Highest Level of Mobility scale were placed on each door of the unit. Staff were trained to assess and document patient mobility, and documentation compliance was measured. Nurses were surveyed to assess perceived burden of the system. Fall rates were calculated and analyzed for change from baseline. RESULTS: Median daily documentation rates reached 79% by the end of the project. Surveys indicated a low perceived burden of the system. Fall rates did not increase when compared to the previous year baseline (p = 0.80) and the analogous time frames during the previous two years (p = 0.84). CONCLUSION: A quality improvement framework may be used to improve mobility assessment and documentation in a geriatric unit without increasing patient falls or nursing burden.

Creating a Quality Improvement Course for Undergraduate Medical Education: Practice What You Teach.

PROBLEM: More than half of U.S. medical schools have implemented curricula addressing quality improvement (QI); however, the evidence on which pedagogical methods are most effective is limited. APPROACH: As of January 2015, students at Vanderbilt University School of Medicine are required to take a QI course consisting of three 1-month-long (4 hours per week) blocks during their third or fourth year, in which student-identified faculty sponsors are paired with highly trained QI professionals from Vanderbilt University Medical Center. The three blocks of the course include didactic instruction using Institute for Healthcare Improvement Open School modules, readings, weekly assignments, and experiential learning activities (i.e., students develop and implement a QI project with two Plan-Do-Study-Act cycles using a systematic approach that employs the principles of improvement science, which they present as a poster on the last day of the third block). OUTCOMES: From January 2015 to January 2017, 132 students completed all three blocks, resulting in 110 completed QI projects. On evaluations (distributed after each completed block), a majority of students rated the clinical relevance of the blocks highly (191/273; 70%), agreed the blocks contributed to their development as physicians (192/273; 70%), and reported the blocks motivated them to continue to learn more about QI (168/273; 62%). NEXT STEPS: The authors have applied QI methods to improve the course and will aim to assess the sustainability of the course by tracking clinical outcomes related to the projects and students' ongoing involvement in QI after graduation.

The Listening and Spoken Language Data Repository: Design and Project Overview.

Purpose: The purpose of the Listening and Spoken Language Data Repository (LSL-DR) was to address a critical need for a systemwide outcome data-monitoring program for the development of listening and spoken language skills in highly specialized educational programs for children with hearing loss highlighted in Goal 3b of the 2007 Joint Committee on Infant Hearing position statement supplement. Method: The LSL-DR is a multicenter, international data repository for recording and tracking the demographics and longitudinal outcomes achieved by children who have hearing loss who are enrolled in private, specialized programs focused on supporting listening and spoken language development. Since 2010, annual speech-language-hearing outcomes have been prospectively obtained by qualified clinicians and teachers across 48 programs in 4 countries. Results: The LSL-DR has been successfully implemented, bringing together the data collection efforts of these programs to create a large and diverse data repository of 5,748 children with hearing loss. Conclusion: Due to the size and diversity of the population, the range of assessments entered, and the demographic information collected, the LSL-DR will provide an unparalleled opportunity to examine the factors that influence the development of listening in spoken language in this population.

Impact of revised triage to improve throughput in an ED with limited traditional fast track population.

BACKGROUND: Emergency department (ED) crowding is associated with patient safety concerns, increased patients left without being seen (LWBS), low patient satisfaction, and lost ED revenue. The objective was to measure the impact of a revised triage process on ED throughput. METHODS: This study took place at an urban, university-affiliated, adult ED with an annual census of 70,000 and admission rate of 34%. The revised triage approach included: identifying eligible patients at triage based on complaint, comorbidities, and illness acuity; and reallocating a nurse practitioner (NP) into our triage area. We trialed the intervention from 1100-2300 on weekdays from January 13-26, 2016. Adult patients who were not likely to require intensive evaluations were eligible. Primary outcomes were throughput measures including: time to provider, ED length of stay (LOS), and LWBS. Pre- and post-intervention metrics were compared using the Mann-Whitney U test, given the non-normal distribution of the metrics. RESULTS: The NP evaluated 120 patients of which 101 (84%) were discharged, 3 (2.5%) admitted, and 16 (13%) required more intense evaluation. Time to provider decreased from a median (IQR) of 42 (16, 114) to 27 (12.4, 81.5) minutes (p<0.01) and ED LOS from 290 (194.8, 405.6) to 257 (171.2, 363.4) minutes (p<0.01) for all patients not admitted and not requiring a consult. LWBS decreased from a pre-trial 4.6% to 2.2% (p<0.01). CONCLUSION: The revised triage intervention was associated with improvements in several ED throughput metrics and a reduction in LWBS.

The Monetary Cost of Sexual Assault to Privately Insured US Women in 2013.

OBJECTIVES: To determine whether privately insured female rape victims were billed for charges associated with a specific rape in the United States. METHODS: We examined 2013 de-identified patient data from Truven Analytics Health MarketScan database for an assault that occurred by using International Classification of Diseases, Ninth Revision, code E960.1. RESULTS: Analysis of insurance providers' payment patterns for 1355 incident events to female victims aged between 16 and 61 years revealed that victims remit, on average, 14% or $948 of the rape cost, whereas insurance providers pay 86% or $5789 of the total cost. CONCLUSIONS: Hospital billing procedures for privately insured victims of rape across the United States are not separate from billing procedures for privately insured nonrape patients. This standardized procedure leads hospitals to bill victims directly for services not paid under the victims' insurance policy. Public Health Implications. The Violence Against Women Act (passed in 1994, reauthorized in 2000, 2005, and 2013) must be amended to mandate that all costs incurred because of rape are not passed on to the victim.

Cochlear implant programming.

Cochlear implants have become a viable treatment option for individuals who present with severe to profound hearing loss. While there are several parameters that affect the successful use of this technology, quality programming of the cochlear implant system is crucial. This review chapter focuses on general device programming techniques, programming techniques specific to children, objective programming techniques, a brief overview of programming parameters of the currently commercially available multichannel systems, and managing patient complaints and device failures. The chapter also provides what the authors believe the future may hold for new programming techniques.

Auditory processing following sequential bilateral cochlear implantation: a pediatric case study using event-related potentials.

BACKGROUND: Past studies using event-related potentials (ERPs) elicited to single syllable stimuli in unilateral and bilateral cochlear implant users have suggested reorganization of the auditory cortex within the first 6-8 mo postimplantation (Sharma et al, 2002a, 2002b, 2006; Bauer et al, 2006). Better behavioral performance with bilateral implants is expected when bilateral cochlear implantation is performed simultaneously or when a second implant is provided after a short interval of auditory deprivation at a younger age (Murphy and O'Donoghue, 2007; Wolfe et al, 2007; Steffens et al, 2008). PURPOSE: The purpose of this case study was to examine changes in various levels of auditory processing using single syllable and word-level stimuli in a child who received bilateral cochlear implants sequentially. RESEARCH DESIGN: Brain responses were recorded at pre-activation and 2, 4, and 6 mo postactivation of a second cochlear implant using passive paradigms involving two types of auditory perception (speech and word level). Auditory stimuli were presented at 75 dB SPL(A) through a speaker above the participant's head with the cochlear implant(s) at typical user settings. Cortical responses were recorded from 128 electrodes. STUDY SAMPLE: The participant was a 6-yr-old female with the diagnosis of bilateral profound sensorineural hearing loss. She received her first cochlear implant in her right ear (2 yr, 4 mo of age), underwent revision surgery (3 yr, 6 mo of age), and later received a bilateral cochlear implant (6 yr, 8 mo of age). DATA COLLECTION AND ANALYSIS: For the purposes of the case study, the waveforms were visually examined for morphology and amplitude or latency differences between conditions. The ERPs of the cochlear implant user were compared to those from a group of five children with normal hearing. CONCLUSIONS: The results suggest that sequential bilateral cochlear implantation contributes to improved auditory processing beyond the benefits of the single implant even in users with an extended period of deafness in the later-implanted ear.

Cochlear implant candidacy in the United States: prevalence in children 12 months to 6 years of age.

OBJECTIVE: Pediatric cochlear implantation has been demonstrated to be effective for children as well as cost effective for society. One of Healthy People 2010 goals is to increase the number of people who are deaf or significantly hard of hearing to begin to use a cochlear implant system. NIDCDs Healthy Hearing Progress Reports from 1999 reported that only 2 out of every 1000 adults who are deaf or hard of hearing received a cochlear implant. There were two main objectives for this study: (1) to estimate the number of children between the ages of 12 months and 6 years of age with severe to profound bilateral hearing loss who could benefit from a cochlear implant and (2) to determine if the number of children projected to be candidates received this medical care. METHODS: Using the 2000 US Census Data from children 12 months to 6 years, the number of children with severe to profound bilateral hearing loss was calculated. Children who would be considered "neurologically devastated" and the children with absent eighth nerves were excluded from the calculations. RESULTS: Based on the total population of slightly over 231 million, 15,219 children presented with severe to profound hearing loss. Taking into account some exclusions, 12,816 children would be considered cochlear implant candidates. Based on the number of children who were implanted in 2000, approximately 55% of the projected number of candidates received a cochlear implant. CONCLUSION: Even though the estimates do not reflect a direct measure of actual candidates in the targeted age groups, the population who could benefit from this technology is still being significantly underserved in the United States. With a continued shortage of qualified personnel to serve these children, insufficient reimbursement rates, and disparities in implantation rates based on ethnicity and socioeconomic status, the question remains can we truly meet the needs of these children?

The Effect of Examiner's Race on the Performance of African American Children on the SCAN.

PURPOSE: With African American children, processingdependent central auditory nervous system (CANS) tests, such as the Screening Test for Auditory Processing Disorders (SCAN) (Keith, 1986), may be less culturally biased than traditional knowledge-dependent standardized language measures. Keith found that African American children received lower scores on the SCAN than did Anglo American children. The primary purpose of this study was to determine whether middle-class African American children might improve their SCAN performance when tested by an African American versus an Anglo American examiner. METHOD: The SCAN was administered twice to 47 African American children, ages 5-10 years. Half of the participants were tested by an African American examiner first and then by an Anglo American examiner, with the order of testing counterbalanced for the remaining half of the participants. Data were also analyzed by grade level. RESULTS: A 2 (examiner race) x 3 (grade level) analysis of variance did not reveal a significant effect for examiner race, but did show a main effect for grade level on certain SCAN subtests; however, effect size results revealed that the magnitude of differences between mean scores on the Competing Words subtest and the composite score were large enough to be potentially significant. Results also indicated a significant learning effect. CLINICAL IMPLICATIONS: Although examiner race did not appear to influence SCAN performance for this group of children, the possibility of a race effect needs further investigation with a larger sample, as does the clinical utility of the SCAN as a processing-dependent measure. The significant learning effect also suggests potential problems with the test-retest reliability of the SCAN.