Routinization of HIV Testing in an Inpatient Setting: A Systematic Process for Organizational Change.

In 2006, the U.S. Centers for Disease Control and Prevention released revised recommendations for routinization of HIV testing in healthcare settings. Health professionals have been challenged to incorporate these guidelines. In March 2013, a routine HIV testing initiative was launched at a large urban academic medical center in a high prevalence region. The goal was to routinize HIV testing by achieving a 75% offer and 75% acceptance rate and promoting linkage to care in the inpatient setting. A systematic six-step organizational change process included stakeholder buy-in, identification of an interdisciplinary leadership team, infrastructure development, staff education, implementation, and continuous quality improvement. Success was measured by monitoring the percentage of offered and accepted HIV tests from March to December 2013. The targeted offer rate was exceeded consistently once nurses became part of the consent process (September 2013). Fifteen persons were newly diagnosed with HIV. Seventy-eight persons were identified as previously diagnosed with HIV, but not engaged in care. Through this process, patients who may have remained undiagnosed or out-of-care were identified and linked to care. The authors propose that this process can be replicated in other settings. Increasing identification and treatment will improve the individual patient's health and reduce community disease burden.

Anonymous group peer review in surgery morbidity and mortality conference.

BACKGROUND: Surgical peer review might be characterized by assessment heterogeneity. METHODS: We performed a prospective, anonymous, peer review of surgeon and system performance during a morbidity and mortality conference. RESULTS: Twenty-two cases were reviewed by a mean of 48.9 respondents each, including attendings, fellows, and residents. A mean of 50% (standard deviation, 23%) of respondents identified some quality issue in each case, reflecting high heterogeneity. The mean percentage in identifying a system issue was 27%, and in identifying a physician issue was 37%. When identifying a physician issue, physician care was judged as appropriate by 72%, as controversial by 26%, or as inappropriate by 2%. Residents were more likely than attendings to identify system issues (odds ratio, 2.23) and physician issues (odds ratio, 3.58), but attendings were more likely to rate care controversial or inappropriate (odds ratio, 2.53). CONCLUSIONS: Surgical peer reviews, even after group discussion, display substantial heterogeneity. Review methods should account for this heterogeneity.

Effectiveness of a clinical decision support system to identify heparin induced thrombocytopenia.

BACKGROUND: Subtle decreases in platelet count may impede timely recognition of heparin-induced thrombocytopenia (HIT), placing the patient at increased risk of thrombotic events. OBJECTIVE: A clinical decision support system (CDSS) was developed to alert physicians using computerized provider order entry when a patient with an active order for heparin experienced platelet count decreases consistent with HIT. METHODS: Comparisons for timeliness of HIT identification and treatment were evaluated for the year preceding and year following implementation of the CDSS in patients with laboratory confirmation of HIT. RESULTS: During the intervention time period, the CDSS alert occurred 41,922 times identifying 2,036 patients who had 2,338 inpatient admissions. The CDSS had no significant impact on time from fall in platelet count to HIT laboratory testing (control 2.3 days vs intervention 3.0 days P = 0.30) and therapy (control 19.3 days vs intervention 15.0 days P = 0.45), and appeared to delay discontinuation of heparin products (control 1.3 days vs. intervention 2.9 days P = 0.04). However, discontinuation of heparin following shorter exposure duration and after smaller decrease in platelet count occurred during the intervention period. The HIT CDSS sensitivity and specificity were each 87% with a negative predictive value of 99.9% and positive predictive value of 2.3%. CONCLUSIONS: Implementation of a CDSS did not appear to improve the ability to detect and respond to potential HIT, but resulted in increased laboratory testing and changes in clinician reactions to decreasing platelet counts that deserve further study.

Hypoglycemia in hospitalized patients treated with antihyperglycemic agents.

OBJECTIVE: To determine the incidence and manifestations of hypoglycemia in hospitalized patients receiving antihyperglycemic therapy. RESEARCH DESIGN AND METHODS: The study was a 3-month prospective review of consecutive medical records of all adult, nonpregnant hospitalized patients at a 675-bed university hospital who experienced at least 1 blood glucose (BG)

Enhancing patient safety during feeding-tube insertion: a review of more than 2,000 insertions.

BACKGROUND: An intervention to reduce complications from insertion of small-bore nasogastric feeding tubes was performed. METHODS: This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding-tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre- and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology-guided insertion, and implementation of explicit policies and procedures. RESULTS: Of all small-bore nasogastric feeding-tube placements, 1.3%-2.4% resulted in 50 documented cases of feeding-tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly attributed to the feeding-tube malposition. Only 2 of the 13 complications and none of the misplacements had been recorded in the risk management database; most cases were identified from the search of radiology reports. In the 15-month postintervention period, no complications were identified. The control chart showed that after the intervention, there was a significant increase in the "number between" tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project. CONCLUSIONS: Unassisted feeding tube insertion carries significant risk in vulnerable patients, which can be mitigated. Voluntary reporting appears inadequate to capture complications from feeding tube insertion.