Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study.

BACKGROUND: Efforts to increase physician engagement in quality and safety are most often approached from an organisational or administrative perspective. Given hospital-based physicians' strong professional identification, physician-led strategies may offer a novel strategic approach to enhancing physician engagement. It remains unclear what role medical leadership can play in leading programmes to enhance physician engagement. In this study, we explore physicians' experience of participating in a Medical Safety Huddle initiative and how participation influences engagement with organisational quality and safety efforts. METHODS: We conducted a qualitative study of the Medical Safety Huddle initiative implemented across six sites. The initiative consisted of short, physician focused and led, weekly meetings aimed at reviewing, anticipating and addressing patient safety issues. We conducted 29 semistructured interviews with leaders and participants. We applied an interpretive thematic analysis to the data using self-determination theory as an analytic lens. RESULTS: The results of the thematic analysis are organised in two themes, (1) relatedness and meaningfulness, and (2) progress and autonomy, representing two forms of intrinsic motivation for engagement that we found were leveraged through participation in the initiative. First, participation enabled a sense of community and a 'safe space' in which professionally relevant safety issues are discussed. Second, participation in the initiative created a growing sense of ability to have input in one's work environment. However, limited collaboration with other professional groups around patient safety and the ability to consistently address reported concerns highlights the need for leadership and organisational support for physician engagement. CONCLUSION: The Medical Safety Huddle initiative supports physician engagement in quality and safety through intrinsic motivation. However, the huddles' implementation must align with the organisation's multipronged patient safety agenda to support multidisciplinary collaborative quality and safety efforts and leaders must ensure mechanisms to consistently address reported safety concerns for sustained physician engagement.

Protocol for a stepped wedge cluster randomized quality improvement project to evaluate the impact of medical safety huddles on patient safety.

Introduction: Physician engagement is crucial for furthering patient safety and quality improvement within healthcare organizations. Medical Safety Huddles, which are physician-specific huddles, is a novel way to engage physicians with patient safety and may reduce adverse events experienced by patients. We plan to conduct a multi-center quality improvement (QI) initiative to implement and evaluate Medical Safety Huddles. The primary objective is to determine the impact of the huddles on adverse events experienced by patients. Secondary objectives include assessing the impact of the huddles on patient safety culture and physician engagement, and a process evaluation to assess the fidelity of implementation. Methods: This stepped wedge cluster randomized study will be conducted at four academic inpatient hospitals over 19 months. Each site will adapt Medical Safety Huddles to its own practice context to best engage physicians. We will review randomly selected patient charts for adverse events. Generalized linear mixed effects regression will be used to estimate the overall intervention effect on adverse events. Process measures such as physician attendance rates and number of safety issues raised per huddle will be tracked to monitor implementation adherence. Conclusion: Medical Safety Huddles may help healthcare organizations and medical leaders to better engage physicians with patient safety. The project results will assess the fidelity of implementation and determine the impact of Medical Safety Huddles on patient safety.

Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE).

OBJECTIVES: To assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients admitted to hospital with covid-19. DESIGN: Multicentre pragmatic randomised clinical trial. SETTING: 15 hospitals in Canada and the United States from May 2020 until May 2021. PARTICIPANTS: Eligible patients had a laboratory confirmed or a clinically highly suspected diagnosis of covid-19, needed supplemental oxygen (up to 50% fraction of inspired oxygen), and were able to independently lie prone with verbal instruction. Of the 570 patients who were assessed for eligibility, 257 were randomised and 248 were included in the analysis. INTERVENTION: Patients were randomised 1:1 to prone positioning (that is, instructing a patient to lie on their stomach while they are in bed) or standard of care (that is, no instruction to adopt prone position). MAIN OUTCOME MEASURES: The primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as needing at least 60% fraction of inspired oxygen for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to fraction of inspired oxygen. RESULTS: The trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomisation was 1 day, the median age of patients was 56 (interquartile range 45-65) years, 89 (36%) patients were female, and 222 (90%) were receiving oxygen via nasal prongs at the time of randomisation. The median time spent prone in the first 72 hours was 6 (1.5-12.8) hours in total for the prone arm compared with 0 (0-2) hours in the control arm. The risk of the primary outcome was similar between the prone group (18 (14%) events) and the standard care group (17 (14%) events) (odds ratio 0.92, 95% confidence interval 0.44 to 1.92). The change in the ratio of oxygen saturation to fraction of inspired oxygen after 72 hours was similar for patients randomised to prone positioning and standard of care. CONCLUSION: Among non-critically ill patients with hypoxaemia who were admitted to hospital with covid-19, a multifaceted intervention to increase prone positioning did not improve outcomes. However, wide confidence intervals preclude definitively ruling out benefit or harm. Adherence to prone positioning was poor, despite multiple efforts to increase it. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning. STUDY REGISTRATION: ClinicalTrials.gov NCT04383613.

Understanding the Influence of the Junior Attending Role on Transition to Practice: A Qualitative Study.

BACKGROUND: The Junior Attending (JA) role is an educational model, commonly implemented in the final years of training, wherein a very senior resident assumes the responsibilities of an attending physician under supervision. However, there is heterogeneity in the model's structure, and data are lacking on how it facilitates transition to independent practice. OBJECTIVE: The authors sought to determine the value of the JA role and factors that enabled a successful experience. METHODS: The authors performed a collective case study informed by a constructivist grounded theory analytical approach. Twenty semi-structured interviews from 2017 to 2020 were conducted across 2 cases: (1) Most Responsible Physician JA role (general internal medicine), and (2) Consultant JA role (infectious diseases and rheumatology). Participants included recent graduates who experienced the JA role, supervising attendings, and resident and faculty physicians who had not experienced or supervised the role. RESULTS: Experiencing the JA role builds resident confidence and may support the transition to independent practice, mainly in non-medical expert domains, as well as comfort in dealing with clinical uncertainty. The relationship between the supervising attending and the JA is an essential success factor, with more productive experiences reported when there is an establishment of clear goals and role definition that preserves the autonomy of the JA and legitimizes the JA's status as a team leader. CONCLUSIONS: The JA model offers promise in supporting the transition to independent practice when key success factors are present.

Do Not Waste a Crisis: Physician Engagement during the COVID-19 Pandemic.

Physician engagement is an important factor in improving care quality and patient safety, but engaging physicians is not easy. Winston Churchill's famous assertion about never wasting a crisis has defined the approach taken by many leaders during the COVID-19 pandemic. This paper describes three case studies of successful physician engagement across the continuum of acute care, chronic care and primary care settings during the pandemic. These examples offer insights on physician engagement within unique settings by leveraging intrinsic motivators and Spurgeon's model of medical engagement.

Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study.

BACKGROUND: Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes. METHODS: Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program. RESULTS: From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey. INTERPRETATION: Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents' overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.

Junior Rounds: an educational initiative to improve role transitions for junior residents.

OBJECTIVE: At our institution, Morning Report focuses mostly on diagnostic reasoning. This makes it a challenge for first-year residents to learn to manage common on-call emergencies, such as hyperkalemia. We sought to improve their preparedness for the transitions they would encounter: from medical student to physician at the beginning of the academic year, and from junior resident to senior resident toward the end. In response to feedback, we developed the Junior Rounds curriculum: a weekly session focused on the approach to commonly encountered on-call emergencies and internal medicine referrals. Anonymous surveys were sent to trainees, and iterative analysis of monthly feedback led to changes to Junior Rounds. RESULTS: Junior Rounds was implemented from August 2015 to June 2016. Thirty-nine of 92 possible respondents (44%) completed surveys in that period. Most respondents agreed that Junior Rounds met their educational needs, was presented at an appropriate level, and was more important to their learning than other available educational activities. Our experience demonstrates that dedicated time for level-specific learning aimed to support the transitions of junior residents can be successfully achieved. Iterative adjustment to these rounds based on feedback allowed for evolution of the curriculum to meet the changing priorities of junior learners.

Assessing Risk and Preventing 30-Day Readmissions in Decompensated Heart Failure: Opportunity to Intervene?

Heart failure (HF) patients are at high risk of hospital readmission, which contributes to substantial health care costs. There is great interest in strategies to reduce rehospitalization for HF. However, many readmissions occur within 30 days of initial hospital discharge, presenting a challenge for interventions to be instituted in a short time frame. Potential strategies to reduce readmissions for HF can be classified into three different forms. First, patients who are at high risk of readmission can be identified even before their initial index hospital discharge. Second, ambulatory remote monitoring strategies may be instituted to identify early warning signs before acute decompensation of HF occurs. Finally, strategies may be employed in the emergency department to identify low-risk patients who may not need hospital readmission. If symptoms improve with initial therapy, low-risk patients could be referred to specialized, rapid outpatient follow-up care where investigations and therapy can occur in an outpatient setting.

Widespread receptivity to neuropeptide PDF throughout the neuronal circadian clock network of Drosophila revealed by real-time cyclic AMP imaging.

The neuropeptide PDF is released by sixteen clock neurons in Drosophila and helps maintain circadian activity rhythms by coordinating a network of approximately 150 neuronal clocks. Whether PDF acts directly on elements of this neural network remains unknown. We address this question by adapting Epac1-camps, a genetically encoded cAMP FRET sensor, for use in the living brain. We find that a subset of the PDF-expressing neurons respond to PDF with long-lasting cAMP increases and confirm that such responses require the PDF receptor. In contrast, an unrelated Drosophila neuropeptide, DH31, stimulates large cAMP increases in all PDF-expressing clock neurons. Thus, the network of approximately 150 clock neurons displays widespread, though not uniform, PDF receptivity. This work introduces a sensitive means of measuring cAMP changes in a living brain with subcellular resolution. Specifically, it experimentally confirms the longstanding hypothesis that PDF is a direct modulator of most neurons in the Drosophila clock network.