Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

BACKGROUND: The first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals. METHODS: We conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression. RESULTS: A total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions. CONCLUSION: A multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.

Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation.

BACKGROUND: The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1. METHODS: MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient. DISCUSSION: A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

Measuring the true success of laparoscopic pyeloplasty.

BACKGROUND AND PURPOSE: Laparoscopic pyeloplasty (LP) is a highly successful minimally invasive management option for ureteropelvic junction obstruction (UPJO) with success rates equaling or surpassing open repair. Definitions of success have varied greatly among reports of series in the literature. We propose that true success or failure be strictly defined by resolution of obstruction on objective physiologic testing (diuretic renography or Whitaker testing) and accordingly present our results. PATIENTS AND METHODS: We prospectively gathered data on all LP from December 2001 to November 2006. Ninety-two patients have matured to follow-up testing (> 3 months). Primary uncomplicated procedures were completed in 62/92 (67%) while secondary and/or complex repairs were performed in 30/92 (33%). Rigorous follow-up with physiologic testing was performed postoperatively. Patients with equivocal diuretic renal scans were evaluated with Whitaker pressure-flow studies. The subjective symptom score was assessed for our first 47 patients using a visual analog scale (VAS). Treatment in patients who lacked objective evidence of resolution of UPJO was considered a failure. RESULTS: The mean age of the cohort was 39 years (range 18-69 yrs). Average operating room time was 250 minutes (range 138-488 min), and estimated blood loss was 63 mL (range 10-500 mL). Average hospital length of stay was 1.2 days (range 1-6 d). Crossing vessels were identified in 47/92 (51%) patients. Overall mean follow-up was 13 months (range 2-54 months). There were no intraoperative complications and three perioperative complications. Overall, 85/92 (92%) patients were found to have resolution of UPJO on postoperative physiologic testing. The primary uncomplicated cohort success rate was 98%, while that for the secondary or complex repair cohort was 80%. The mean overall VAS pain score was 84%. CONCLUSION: Objective physiologic testing should be used as the measurement of true success after LP. A uniform definition of success will allow improved comparison of results with literature series and comparison with alternative management modalities.

Relationship of biochemical outcome to percentage of positive biopsies in men with clinically localized prostate cancer treated with permanent interstitial brachytherapy.

OBJECTIVES: Recent studies have demonstrated that the percentage of positive prostate needle biopsies (PPBs) is an independent predictor of biochemical failure (BF) after radical prostatectomy and external beam radiotherapy. Few studies have confirmed this phenomenon in patients treated with permanent interstitial brachytherapy. We conducted an analysis to determine the clinical utility of the PPBs in predicting BF after permanent interstitial brachytherapy for patients with clinically localized prostate cancer. METHODS: The clinical and pathologic data from 245 hormone-naive patients with clinical Stage T1c-T2cNxM0 prostate cancer who had undergone permanent prostate brachytherapy from 1992 to 2002 at our institution were retrospectively evaluated. The PPBs, preimplant prostate-specific antigen, and biopsy Gleason score were evaluated as predictors of BF after brachytherapy. The risk of BF was calculated using logistic regression models. The time to BF was assessed using Cox proportional hazard models and Kaplan-Meier estimates. RESULTS: The median PPBs in our study cohort was 27%. The risk of BF was 10.9% for those with a PPBs less than the median versus 26.2% for those with a PPBs greater than the median. A PPBs greater than the median was an independent predictor of BF on multivariate analysis (relative risk 2.3, 95% confidence interval 1.21 to 4.39, P = 0.011). In the time-to-failure models, the PPBs, prostate-specific antigen level, and Gleason score were significantly associated with BF. CONCLUSIONS: Our data suggest that the PPBs is significantly associated with BF in patients undergoing permanent interstitial brachytherapy. The PPBs, along with the pretreatment prostate-specific antigen level and Gleason biopsy score, is a useful preoperative parameter in predicting for BF and the time to failure for patients treated with interstitial brachytherapy.

Communication between the ureter and an aortic aneurysm sac after an abdominal aortic aneurysm repair.

Fistulae between the vasculature and the ureter are rare. We describe a communication between the ureter and the sac of an aortic aneurysm following abdominal aortic aneurysm repair.

Salvage laparoscopic pyeloplasty in the worst case scenario: after both failed open repair and endoscopic salvage.

BACKGROUND AND PURPOSE: Historically, open pyeloplasty has been the gold-standard treatment for primary ureteropelvic junction (UPJ) obstruction, with success rates >90%. Over the past decade, laparoscopic pyeloplasty has emerged as a highly successful alternative for primary UPJ and secondary obstruction. For patients failing open pyeloplasty, endoscopic procedures such as antegrade and retrograde endopyelotomy have been used as salvage therapies with success rates as high as 87.5%. Persistent obstruction after an initial open pyeloplasty and a subsequent unsuccessful salvage endoscopic procedure presents a difficult scenario, often necessitating complex and challenging repairs. We reviewed our experience with salvage laparoscopic pyeloplasty as a reconstructive option for this difficult group of patients. PATIENTS AND METHODS: Between January 2002 and April 2005, 66 laparoscopic pyeloplasties were performed. Four patients, who had persistent obstruction after both open pyeloplasty and subsequent salvage endoscopic procedures, were the subject of this analysis. Operative time, length of stay (LOS), pain score resolution, and physiologic success rates were evaluated. Success was defined as resolution of obstruction on physiologic testing (renal scan). RESULTS: The mean operative time was 310 minutes and the mean LOS 1.2 days. Three patients experienced resolution of obstruction by nuclear scan. The remaining patient, who has persistent obstruction but stable function on nuclear scan and resolution of pain, has refused evaluation with Whitaker testing. All patients have experienced at least 50% reduction of pain. Utilizing our strict physiologic criteria for success, including a diuretic T(1/2) of <10 minutes, a success rate of 75% was obtained. CONCLUSION: Our series of laparoscopic reconstructions of the UPJ in patients failing both an initial open pyeloplasty and subsequent salvage endoscopic procedures is the largest in the literature at present. As in open surgery, the ability to respond to intraoperative findings with techniques such as flap repair and renal mobilization are essential. Although time consuming, these repairs can be successful and maintain the advantages of laparoscopy.

Metastatic ocular melanoma to the kidney 20 years after initial diagnosis.

Metastatic tumors are the most common malignancies of the kidney. We report a rare case of isolated metastatic ocular melanoma to the kidney occurring 20 years after diagnosis. A 71-year-old man presented with gross hematuria. He had undergone left enucleation 20 years previously for ocular melanoma and had not required adjuvant therapy. A right upper pole mass was identified on computed tomography and was excised laparoscopically. Pathologic examination revealed metastatic melanoma. Metastatic melanoma to the kidney is rare. A high index of suspicion must be maintained in any patient with a renal mass and a history of a nonrenal malignancy.

Laparoscopic partial nephrectomy: use of the TissueLink hemostatic dissection device.

Hemostasis remains the major challenge in laparoscopic partial nephrectomy (LPN). The TissueLink Floating Ball (TissueLink Medical, Inc., Dover, NH), a high-density monopolar saline-cooled radiofrequency device, is an effective coagulation and dissection device to aid in LPN. Our porcine laboratory model and human clinical experience have shown the device capable of deep renal parenchymal hemostasis without the need for hilar vascular occlusion. We review the excisional technique and initial clinical results, as well as device function, setup, and clinical literature. We find the TissueLink capable of avoiding warm ischemia for excision of selected endophytic masses and, in combination with other techniques, a valuable adjunct for even deeper lesions.