Tobacco screening multicomponent quality improvement network program: beyond education.

OBJECTIVES: Due to the addictive nature of the disease and interrelated societal influences on the behavior of tobacco use, repeated interventions are often required before people successfully stop using tobacco. Our objective was to implement a multicomponent clinical intervention initiative enabling health care providers to effectively screen for tobacco use. We also sought to describe changes in emergency medicine providers' documentation of cessation advice to tobacco users. METHODS: The intervention was conducted at three emergency departments (EDs) and four clinics at a community-based teaching hospital and health network. Health care providers with the opportunity to identify and counsel tobacco-using patients in ambulatory health care settings were the study population. The authors initiated a quality improvement initiative for tobacco screening that employed a multicomponent strategy to facilitate systemic changes that support 100% tobacco use identification, documentation, and counseling. Baseline, posteducation, and post-wrap-around documented screening rates were compared within each site across the intervention. Cumulative ED baseline, posteducation, and post-wrap-around rates of provider advice to tobacco users were compared across the intervention. Percentage of possible available gain was calculated in consideration of a 100% ceiling effect. Statistical analysis was performed using SPSS and MetStat. Descriptive statistics and Pearson's chi-square cell frequency were used to analyze and compare sites. Fisher's exact test was used to compare those tests with a chi-square cell frequency of five or less. The statistical tests used for pre-/postintervention percentage comparisons by site had power between 80% and 90%, detecting differences of 10% and 20% or more at a 0.05 level of significance. RESULTS: Significant increases in posteducation screening rates for all ED sites complemented significant increases in ED post-wrap-around intervention screening rates. Significant increases in ED provider documented cessation advice were also noted. CONCLUSIONS: This initiative successfully changed tobacco screening behavior of health care providers at all sites. It was particularly successful in the ED, typically an environment less likely to be conducive to preventive health interventions.

Testing the use of symptom-based terrorism triage algorithms with hospital-based providers.

INTRODUCTION: A set of symptom-based, all-hazards, decision-making algorithms was designed to aid the first-contact provider during early patient presentations after a terrorist incident. OBJECTIVE: The primary objective was to assess the usability of these algorithms. A secondary objective was to assess the psychometric properties of the testing scenarios. METHODS: This was a written, usability assessment of the algorithms employing a convenience sample of hospital-based, healthcare providers who had not taken any specific training in the use of the algorithms. A series of 26 paragraph-length, moderately difficult scenarios was created to reflect possible agents, means of attack, and types of patients. Each of the 26 scenarios requires that one make a triage choice on the "attack" algorithm (the trunk algorithm), then proceed to one of four other branch algorithms (dirty resuscitation, chemical agents, biological agents, bomb/blast/radiation dispersal device) to make a final triage choice. Conditional scores based on getting both the attack and final card correct were calculated for each algorithm. RESULTS: Nineteen attending physicians, 50 emergency medicine residents, and 41 nurses took the assessment. The total score was 45% correct for all participants. The score on the attack algorithm was 66% correct. Dirty resuscitation, biological, chemical, and bomb/blast scores were 46%, 54%, 46%, and 51% respectively. The probability of guessing the correct answer on the attack algorithm was 1/7 or 14%. The conditional probability of guessing both the attack algorithm and the final card correct ranged from 4.7% for the biological, chemical, and bomb/blast algorithms to 2.4% for the dirty resuscitation algorithm. Item discrimination, item difficulty, and Cronbach's alpha were acceptable for the overall test. Certain individual items had item difficulty levels suggesting they were too difficult and should be replaced in future versions of the test. CONCLUSIONS: Performance on the test suggests that participants did substantially better than would have been expected by chance alone. Future efforts will revise the algorithms with the goal of simplification. Revision of the testing instrument and testing algorithm use after instruction also are needed.

Do hybrid simulator-generated metrics correlate with content-valid outcome measures?

BACKGROUND: Hybrid simulators provide objective metrics for laparoscopic task performance. This study aimed to evaluate the correlation between hybrid simulator-generated metrics and content-valid outcome measures. METHODS: Residents underwent training with a previously validated 5-task simulation model (5-TSM). The resident tasks included vessel clipping and dividing, lesion excision, loop appendectomy, mesh placement with tacks, and suture perforation with intracorporeal knot tying. After training, the residents were tested using the open module of a hybrid simulator (ProMIS) with previously validated passing scores. Content validity was defined as the extent to which outcome measures departed from clinical reality. Content-valid outcome measures (accuracy error, knot slippage, leak, operating time, tissue damage) were evaluated by two blinded raters. The hybrid simulator-generated metrics were path length and smoothness of movements. Values are given as means (standard deviation is not shown). RESULTS: Over 23 months, 20 residents underwent training with 5-TSM. Respectively, for tasks 1 to 5, the path length was 3,895, 3,472, 4,620, 2,408, and 9,089 mm; the smoothness (jerk) was 346, 455, 549, 264, and 910 cm/sec3; the accuracy error was 0.45, 2.20, 0.55, 0.87, and 0.20 mm; and the knot slippage was 5%. There were no leaks. The operating time, respectively, was 54, 61, 135, 43, and 130 s, and the tissue damage was 0, 0.28, 0, 0.8, and 0 mm. The interrater reliability was more than 0.80 for all the outcome measures except accuracy error (k=0.52). There was correlation between path length and operating time (Spearman rho, 0.537-0.709; p<0.05) for all the tasks. There was no correlation between path length and accuracy error, knot slippage, leak, and tissue damage. No correlation was found between smoothness and any of the outcome measures for any of the tasks except operating time (Spearman rho, 0.762-0.958; p<0.05). CONCLUSIONS: Although an expected strong correlation was observed between hybrid simulator-generated metrics and operating time, this study showed no correlation between simulator-generated metrics and other content-valid outcome measures.

Nonpunitive medication error reporting: 3-year findings from one hospital's Primum Non Nocere initiative.

OBJECTIVE: To identify underlying practices and attitudes on medication error occurrences and reporting practices. BACKGROUND: In response to a hospital-wide quality improvement initiative, a task force was formed to facilitate a nonpunitive culture toward reporting medication errors. To identify underlying practices and attitudes on medication errors and medication error reporting, a baseline survey was conducted. Based on findings, an initiative that included modifications to clinical and administrative processes was developed and implemented. METHODS: A pre/post initiative questionnaire to measure staff practices and attitudes on medication error reporting was developed and administered. Findings from the presurvey were used to craft the Nonpunitive Patient Safety Policy and its implementation plan. Pre-post comparative analysis was performed following a baseline-postimplementation design. RESULTS: Conceptually, a medication error is qualified by its outcome severity. Medication errors with more serious outcomes are more likely to be reported than those with less serious ones. Staff perception that medication error reporting carries the risks of disciplinary action was identified as a primary barrier to the likelihood of reporting. CONCLUSION: Evaluation of the initiative suggests that a multicomponent approach facilitates positive movement in the direction of a nonpunitive culture toward reporting medication errors.

Electronic residency application service scores: do they correlate with the rank order list for the match?

OBJECTIVE: To investigate the relationship between ERAS-based preinterview scores, residency program postinterview scores and candidate rank order for the match. STUDY DESIGN: Two hundred sixty-three candidates' preinterview and postinterview scores and rank order were evaluated. The rank order was stratified as 1-4, 5-8, 9-12, > 13 and unranked. Spearman's p statistical analysis was used. RESULTS: There was a moderate relationship, r2 = 0.543, between preinterview and postinterview scores for all applicants. There was a significant inverse correlation between preinterview score and rank order, r2 = -0.763, and for the postinterview and rank order, r2 = -0.768. However, there were no significant relationships between factors significant for the top 4 ranked candidates. CONCLUSION: Preinterview and postinterview scores significantly correlated with each other and with the rank order list except for top-ranked candidates. Other factors may influence the rank order list.

Episiotomy rates in private vs. resident service deliveries: a comparison.

OBJECTIVE: To compare the use of episiotomy by private practitioners vs. resident staff and to determine if number of years in practice influences episiotomy use. STUDY DESIGN: A retrospective chart review of vaginal deliveries at 35 weeks or greater between January 2001 and June 2001. The number of years in practice by each private physician was documented. Independent sample t tests and chi2 tests were used to analyze data. RESULTS: In 995 deliveries, episiotomies were performed in 6% of low-risk resident deliveries vs. 26% of low-risk private deliveries (p<0.001). Physicians in practice > or = 15 years performed episiotomies in 32% of low-risk births. Physicians in practice <15 years performed episiotomies in 22% of low-risk births (p = 0.027). CONCLUSION: Deliveries performed by private practitioners are associated with a higher rate of episiotomy than those by resident staff. The number of episiotomies appears to increase by number of years in practice.

Does the presence of a funnel increase the risk of adverse perinatal outcome in a patient with a short cervix?

OBJECTIVE: This study was undertaken to determine whether the presence of a dilated internal os (funneling or beaking) alters the outcome of patients with a short cervix documented by transvaginal ultrasound in the second trimester. STUDY DESIGN: Between January 1998 and May 2004, all singleton pregnancies with a short cervix (< or =2.5 cm) and no funnel between 16 and 24 weeks' gestational age were identified by query and review of the Lehigh Valley Perinatal Ultrasound Database. These no funnel patients were compared with patients with a short cervix and funnel matched in accordance with cervical length and risk factors. Multiple variables of perinatal outcome were identified and compared between the Funnel and No Funnel groups. Correlations between cervical measurements and gestational age at birth were analyzed. RESULTS: Of the 279 patients with a short cervix identified, 82 were singleton with a T-shaped cervix and no funnel and 82 patients matched with a typical Y-shaped funnel. There was no difference between groups with respect to maternal demographics, previous preterm birth (28.1% No Funnel group vs 36.5% Funnel group, P = .3), prior cervical surgery (24.3% vs 22.0 %, P = .8), gestational age at entry (20.5 +/- 2.1 vs 21.1 +/- 2.4 weeks, P = .1), and cervical length (1.9 +/- 0.4 vs 1.8 +/- 0.5 cm , P = .1). The No Funnel group had significantly less readmissions for preterm labor (43.2% vs 67.1 %, P = .004), chorioamnionitis (2.4% vs 23.2 %, P = .0002), abruption (1.2% vs 13.4 %, P = .007), preterm rupture of membranes (6.1% vs 23.4%, P = .002), and cerclage placement (23.2% vs 43 %, P = .008). The neonates in the no funnel group delivered later (36.2% +/- 4.6 vs 33.8 +/- 5.4 weeks , P = .003), and had less morbidity and mortality (17.1% vs 37.8 %, P = .02) compared with the Funnel group. The width and depth of the funnel did not correlate with perinatal outcome. Cervical length ( R(2) = 0.07, P = .02) and cervical funneling as a categorical variable ( r = 0.3, P = .0002) did correlate with earlier delivery. CONCLUSION: The disruption of the internal os, as documented by funneling, is a significant risk factor for adverse perinatal outcome (ie, preterm labor, chorioamnionitis, abruption, rupture of the membranes, and serious neonatal morbidity and mortality). Cervical funneling is best measured as a categorical variable (present or absent).

The effects of mindfulness-based stress reduction on nurse stress and burnout, Part II: A quantitative and qualitative study.

This article is the second in a series reporting on research exploring the effects of Mindfulness-based Stress Reduction on nurses and describes the quantitative data. The third article describes qualitative data. Treatment group participants reduced scores on 2 of 3 subscales of the Maslach Burnout Inventory significantly more than wait-list controls; within-group comparisons for both groups pretreatment and posttreatment revealed similar findings. Changes were maintained as long as 3-month posttreatment. Implications of these findings are discussed.

Impact of immediate reconstruction on the local recurrence of breast cancer after mastectomy.

The incidence of local recurrence of breast cancer in women who underwent mastectomy with or without reconstruction was examined. All female mastectomy patients were followed-up in a 10-year retrospective review. Groups consisted of patients who had mastectomy, mastectomy with immediate reconstruction, or delayed reconstruction. Reconstruction was performed using prostheses, latissimus dorsi musculocutaneous flaps with or without implants, or transverse rectus abdominis musculocutaneous flaps. Charts were reviewed for local breast cancer recurrence. Statistical analysis was performed using Pearson's chi-square and analysis of variance. Of the 1,444 mastectomies performed from 1988 to 1997, 1,262 breasts (87%) were not reconstructed, 182 (13%) were reconstructed, 158 (87%) were immediately reconstructed, and 24 (13%) were reconstructed later. There were no recurrences in the delayed reconstruction group, two recurrences (1.3%) in the immediate reconstruction group, and nine recurrences (0.7%) in the mastectomy without reconstruction group (p=0.746). Analyses of an additional time period from 1992 to 2000 yielded similar results. There is little relationship between local recurrence of breast cancer after mastectomy and reconstruction.

Does cerclage location influence perinatal outcome?

OBJECTIVE: The study was undertaken to measure cerclage location within the cervix and to determine whether placement closer to the internal os is related to perinatal outcome. STUDY DESIGN: We analyzed data collected during a randomized trial of cervical cerclage versus no cerclage that was conducted at Lehigh Valley Hospital between May 1998 and June 2001 in women with ultrasound findings of short cervix less than 25 mm or funneling between 16 and 24 weeks' gestation. Women who were randomly assigned to the cerclage arm had cervical measurements performed before cerclage, including dilation of the internal os, depth of membrane prolapse into the endocervical canal, cervical length below any funnel (distal length), and total cervical length (including any funnel). Measurements obtained after cerclage placement included the distance from external os to cerclage (A), and a repeat of the same four measurements. The distance from the external os to the cerclage (A) was divided by the total cervical length (B) and a cerclage to cervical length ratio (A/B) was calculated. The relationship between these measurements and gestational age at birth was assessed by linear regression analysis. RESULTS: Of 150 patients enrolled, 74 received a McDonald cerclage suture. Mean distal cervical length was 1.9+/-0.9 cm before and 2.9+/-1.0 cm after cerclage (P=.001). The mean distance between the cerclage and external os (A) was 1.8+/-0.6 cm; the total cervical length after cerclage (B) was 3.6+/-0.9 cm. The mean cerclage to cervical length ratio (A/B) was 0.5+/-0.1. Linear regression analysis did not demonstrate a correlation between either the cerclage to external os measurement (A) or the cervical length ratio (A/B) and gestational age at birth (R(2)=0.0006 and 0.008, P=.8 and.6, respectively). CONCLUSION: The length of the cervix below the level of cerclage is not related to duration of pregnancy in women treated with cerclage because of ultrasound evidence of cervical effacement.