Decade of Patient Experience Improvement at a Tertiary Care Urban Hospital.

BACKGROUND AND OBJECTIVE: The purpose of this quality management study was to demonstrate how one hospital made a journey from average patient experience to become a regional leader in the experience of patient care for nationally recognized quality and safety metrics. METHODS: Saint Francis Hospital & Medical Center (SFHMC) located in Hartford, Connecticut, serves a diverse sociodemographic community as part of Trinity Health. "Recommend the Hospital" (RTH) has been the main marker of patient experience at SFHMC and Trinity Health across the United States as part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). From 2010 to 2019, SFHMC implemented unit-based rounding hospital-wide, adopting charge nurse and executive leadership rounding as standard work. The intense support from senior leadership spurred the implementation of these changes across middle management and all frontline workers. The t test was used to determine differences between the mean RTH scores between SFHMC, Connecticut, and the United States. RESULTS: Patient experience at SFHMC was regularly assessed by Press Ganey surveys and HCAHPS, which demonstrated higher scores than averages for the state of Connecticut and the United States between 2010 and 2019 (both Ps < .001). SFHMC was the top performer with an RTH score of 83%, with the state average being 71% and the national average being 72%. In the years following the implementation of a multipronged low-cost strategy, hospital RTH scores rose linearly from the state and national average. SFHMC observed gains in patient safety and quality scores as measured by national benchmarks, including Leapfrog patient safety scores of 7 A's and 1 B over a 4-year period. SFHMC was the only hospital in Connecticut to receive an A grade 4 years in a row. CONCLUSION: A combination of nurse-led, unit-based rounding and executive team rounding with a consistent focus on patient experience resulted in significant improvement in RTH scores for a busy teaching urban hospital, with only a modest investment of resources. There was also improvement in quality and safety outcomes, which together with patient experience of care drove fiscal stability in an increasingly value-based health care environment.

Interprofessional, multitiered daily rounding management in a high-acuity hospital.

PURPOSE: The purpose of this explanatory case study is to explain the implementation of interprofessional, multitiered lean daily management (LDM) and to quantitatively report its impact on hospital safety. DESIGN/METHODOLOGY/APPROACH: This case study explained the framework for LDM implementation and changes in quality metrics associated with the interprofessional, multitiered LDM, implemented at Saint Francis Hospital and Medical Center (SFHMC) at the end of 2018. Concepts from lean, Total Quality Management (TQM) and high reliability science were applied to develop the four tiers and gemba rounding components of LDM. A two-tailed t-test analysis was utilized to determine statistical significance for serious safety events (SSEs) comparing the intervention period (January 2019-December 2019) to the baseline period (calendar years 2017 and 2018). Other quality and efficiency metrics were also tracked. FINDINGS: LDM was associated with decreased SSEs in 2019 compared to 2017 and 2018 (p ≤ 0.01). There were no reportable central line-associated blood stream infection (CLABSI) or catheter-associated urinary tract infection (CAUTI) for first full calendar quarter in the hospital's history. Hospital-acquired pressure injuries were at 0.2 per 1,000 patient days, meeting the annual target of <0.5 per 1,000 patient days. Outcomes for falls with injury, hand hygiene and patient experience also trended toward target. These improvements occurred while also observing a lower observed to expected length of stay (O/E LOS), which is the organizational marker for hospital's efficiency. RESEARCH LIMITATIONS/IMPLICATIONS: LDM may contribute greatly to improve safety outcomes. This observational study was performed in an urban, high-acuity, low cost hospital which may not be representative of other hospitals. Further study is warranted to determine whether this model can be applied more broadly to other settings. PRACTICAL IMPLICATIONS: LDM can be implemented quickly to achieve an improvement in hospital safety and other health-care quality outcomes. This required a redistribution of time for hospital staff but did not require any significant capital or other investment. SOCIAL IMPLICATIONS: As hospital systems move from a volume-based to value-based health-care delivery model, dynamic interventions using LDM can play a pivotal role in helping all patients, particularly in underserved settings where lower cost care is required for sustainability, given limited available resources. ORIGINALITY/VALUE: While many hospital systems promote organizational rounding as a routine quality improvement process, this study shows that a dynamic, intense LDM model can dramatically improve safety within months. This was done in a challenging urban environment for a high-acuity population with limited resources.

Impact of noninvasive prenatal testing in regionally dispersed medical centers in the United States.

OBJECTIVE: Noninvasive prenatal testing using cell-free DNA is a new alternative to screen for common fetal aneuploidies. It is not known what impact regional location may play on noninvasive prenatal testing implementation and downstream invasive prenatal procedure use in the United States. STUDY DESIGN: Six different regionally based centers collected data on noninvasive prenatal testing indication and results between February and November 2012, as well as their invasive prenatal procedure rates before and after offering noninvasive prenatal testing. Statistical analyses were performed using the 2-proportion Z-test. RESULTS: Of 1477 patients who underwent noninvasive prenatal testing; 693 (47%) were from centers in the West; 522 (35.3%) from centers in the East; and 262 (17.7%) from 1 center in the Midwest. Statistically significant differences were observed between West Coast and nonWest Coast sites for gestational age (14.1 weeks; P ≤ .0001). Advanced maternal age (AMA-only) was the most frequent indication in 5 of 6 sites (range, 21.8-62.9%) A total of 98 invasive prenatal procedures performed on 94 (6.4%) patients of which 64 (65.3%) were performed at centers in the West. More invasive procedures were performed following negative noninvasive prenatal testing results (n = 61) than abnormal noninvasive prenatal testing results (n = 30). The overall rate of patients undergoing invasive procedure after an abnormal noninvasive prenatal testing result was 32.6% (30 of 92). All 6 centers reported a decrease in invasive procedure volume after noninvasive prenatal testing introduction. CONCLUSION: This study demonstrates differences in clinical implementation of noninvasive prenatal testing across regionally dispersed centers in the United States, suggesting patient demographics and views toward prenatal testing influence use as well as downstream management.

Efficacy of the genetic sonogram in a stepwise sequential protocol for down syndrome screening.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of the genetic sonogram in Down syndrome screening for women who have received the stepwise sequential test. METHODS: This retrospective cohort study included women with singleton pregnancies who underwent stepwise sequential (first-trimester combined and second-trimester serum) screening and then had a genetic sonogram between March 2005 and January 2010. Stepwise sequential Down syndrome risks were multiplied by either a positive or negative likelihood ratio based on the second-trimester sonographic findings to determine the final Down syndrome risk. A final Down syndrome risk of 1:270 or higher was considered screen positive. RESULTS: A total of 6286 women fulfilled our criteria, including 17 with Down syndrome-affected fetuses. After stepwise sequential testing, the Down syndrome detection rate was 88.2% (15 of 17), and after the genetic sonogram, there was a non-significant reduction in detection to 82.4% (14 of 17; P > .05). For the 6269 unaffected pregnancies, the genetic sonogram converted 58 screen-negative results (1%) to positive and 183 screen-positive results (3.1%) to negative. The net effect was a change in the false-positive rate from 6.2% (390 of 6269) after stepwise sequential screening to 4.2% (266 of 6269) after the genetic sonogram. CONCLUSIONS: The genetic sonogram should be applied cautiously for women who have received prior prenatal screening tests. Women with screen-positive results need to be counseled that a negative sonographic result can be falsely reassuring. Conversely, for women with screen-negative results who have a risk close to the cutoff, a sonographic examination could assist in the decision of whether to accept or reject amniocentesis.

Anaphylactoid syndrome of pregnancy after intracervical dinoprostone for cervical ripening: a report of 3 cases.

BACKGROUND: Three cases of anaphylactoid syndrome of pregnancy developed in association with the use of intracervical dinoprostone for cervical ripening. CASES: All cases occurred at our institution between October 1996 and February 2001. The patients developed respiratory symptoms shortly after placement of 0.25 mg of intracervical dinoprostone gel. Hemodynamic changes, manifested by tetanic uterine contractions and fetal heart rate decelerations, followed. Subsequently all 3 patients developed disseminated intravascular coagulation, characterized by severe hypofibrinogenemia. CONCLUSION: There appears to be an association between intracervical dinoprostone for cervical ripening and anaphylactoid syndrome of pregnancy. Clinicians utilizing this route of dinoprostone administration should be familiar with this rare but potentially life-threatening complication.

Fetal nasal bone length in euploid and aneuploid fetuses between 11 and 20 weeks' gestation: a prospective study.

OBJECTIVE: To develop normative data for nasal bone length between 11 and 20 weeks' gestation and to assess the utility of nasal bone hypoplasia in the detection of fetal aneuploidy in the second trimester. METHODS: Well-dated, nonanomalous fetuses were examined between 11 and 20.9 weeks' gestation. The nasal bone was assessed and measured, and normative data from 11 to 20 weeks' gestation were determined. The nasal bone lengths in fetuses with confirmed aneuploidy were compared with the normative data. RESULTS: The fetal nasal bone length increased linearly with advancing gestational age. Nomograms including the 10th, 50th, and 90th percentiles were created. Nasal bone hypoplasia was seen in 6 of 6 cases of fetal trisomy in the second trimester. CONCLUSIONS: Nasal bone hypoplasia in the early second trimester identifies a cohort of fetuses at high risk for aneuploidy.

A randomized comparison of two regimens of misoprostol for second-trimester pregnancy termination.

OBJECTIVE: The purpose of this study was to compare the efficacy and side effects of two different misoprostol regimens for second-trimester pregnancy termination. STUDY DESIGN: We performed a randomized clinical trial in patients who were at 14 to 23 weeks of gestation and who were admitted for medical termination of pregnancy. All patients received 800 microg of vaginal misoprostol and were assigned randomly to 400 microg of oral misoprostol or 400 microg of vaginal misoprostol every 8 hours. Efficacy and side effects were compared. The mean induction time of the study group was compared with that of an historic control group that had received 400 microg vaginally every 12 hours. RESULTS: Forty-three women were assigned randomly, 22 women to vaginal misoprostol and 21 women to oral misoprostol. Induction time and hospital stay were slightly shorter for the oral group; however, the differences were not significant. Side effects were similar for both groups. CONCLUSION: After an initial 800 microg dose of vaginal misoprostol, a regimen of 400 microg of oral misoprostol every 8 hours is as effective as the same dose of vaginal misoprostol with no additional side effects, which provides a convenient alternative for midtrimester pregnancy termination.

State mandated prenatal human immunodeficiency virus screening at a large community hospital.

PURPOSE: To describe the initial experience of state mandated prenatal HIV screening at a large community hospital. METHODS: HIV screening was provided to all pregnant women as of October 1, 1999. All HIV-positive women identified received aggressive antiretroviral therapy to reduce the likelihood for vertical transmission. Neonates were screened for HIV at zero, six, and 12 months of age. RESULTS: Seven pregnant women (0.3%) and two additional family members tested positive for HIV. All seven infants born to the identified HIV-positive women have tested negative for infection. We estimated that six of nine cases of HIV infection identified would have been missed under a policy of voluntary HIV screening. CONCLUSIONS: Universal screening for HIV in pregnancy is achievable and desirable and provides the best opportunity to minimize the number of new neonatal HIV infections.

Clinical implications of velamentous cord insertion in triplet gestations.

OBJECTIVE: The purpose of this study was to determine the incidence of velamentous cord insertion and to evaluate the association between velamentous cord insertion and small-for-gestational age infants in triplet gestations. STUDY DESIGN: We reviewed our computerized database to identify all cases of velamentous cord insertion in triplet gestations who were delivered at our institution from January 1995 through December 1999. Triplet gestations without velamentous cord insertion who were delivered during this period were used as control subjects. Birth weights and pregnancy outcomes were obtained from medical records. Data were analyzed with descriptive statistics, analysis of variance, and chi(2) with Fisher exact test, where appropriate. RESULTS: Thirty-nine sets of triplets (117 infants) were delivered during the study period. Of these, 11 sets of triplets (28.2%) had a velamentous insertion of at least one umbilical cord. Infants with velamentous cord insertion were more likely to be small-for-gestational age than infants without velamentous cord insertion (33% vs 8%, P =.02). There were no significant differences in the rates of pregnancy complications between the two groups. CONCLUSION: Velamentous cord insertion is found frequently in triplet gestations and is significantly associated with small-for-gestational age in triplet neonates.