Bracing for the Storm: One Health Care System's Planning for the COVID-19 Surge.

PROBLEM: University of Washington Medicine (UW Medicine), an academic health system in Washington State, was at the epicenter of the first outbreak of the COVID-19 pandemic in the United States. The extent of emergency activation needed to adequately respond to this global pandemic was not immediately known, as the evolving situation differed significantly from any past disaster response preparations in that there was potential for exponential growth of infection, unproven mitigation strategies, serious risk to health care workers, and inadequate supply chains for critical equipment. APPROACH: The rapid transition of the UW Medicine system to account for projected COVID-19 and usual patient care, while balancing patient and staff safety and conservation of resources, represents an example of an adaptive disaster response. KEY INSIGHTS: Although our organization's ability to meet the needs of the public was uncertain, we planned and implemented changes to space, supply management, and staffing plans to meet the influx of patients across our clinical entities. The surge management plan called for specific actions to be implemented based on the level of activity. This article describes the approach taken by UW Medicine as we braced for the storm.

One Academic Health System's Early (and Ongoing) Experience Responding to COVID-19: Recommendations From the Initial Epicenter of the Pandemic in the United States.

On January 19, 2020, the first case of a patient with coronavirus disease 2019 (COVID-19) in the United States was reported in Washington State. On February 29, 2020, a patient infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) passed away in a hospital in Seattle-King County, the first reported COVID-19-related death in the United States. That same day, a skilled nursing and rehabilitation facility in the county reported that several of its residents tested positive for SARS-CoV-2 and that many staff had symptoms compatible with COVID-19.The University of Washington Medicine health system (UW Medicine), which is based in Seattle-King County and provides quaternary care for the region, was one of several health care organizations called upon to address this growing crisis. What ensued was a series of swiftly enacted decisions and activities at UW Medicine, in partnership with local, state, and national public health agencies, to respond to the COVID-19 pandemic. Tapping into the multipronged mission areas of academic medicine, UW Medicine worked to support the community, innovate in science and clinical practice; lead policy and practice guideline development; and adopt changes as the crisis unfolded. In doing so, health system leaders had to balance their commitments to students, residents and fellows, researchers, faculty, staff, and hospital and health center entities, while ensuring that patients continued to receive cutting-edge, high-quality, safe care. In this Invited Commentary, the authors highlight the work and challenges UW Medicine has faced in responding to the global COVID-19 pandemic.

A Cross-Sectional Analysis of Publication Types in Quality Improvement Journals.

Despite widespread engagement in quality improvement activities, little is known about the designs of studies currently published in quality improvement journals. This study's goal is to establish the prevalence of the types of research conducted in articles published in journals dedicated to quality improvement. A cross-sectional analysis was performed of 145 research articles published in 11 quality improvement journals in 2011. The majority of study designs were considered pre-experimental (95%), with a small percentage of quasi-experimental and experimental designs. Of the studies that reported the results of an intervention (n = 60), the most common research designs were pre-post studies (33%) and case studies (25%). There were few randomized controlled trials or quasi-experimental study designs (12% of intervention studies). These results suggest that there are opportunities for increased use of quasi-experimental study designs.

Pocket change: a simple educational intervention increases hospitalist documentation of comorbidities and improves hospital quality performance measures.

BACKGROUND: Complete documentation of patient comorbidities in the medical record is important for clinical care, hospital reimbursement, and quality performance measures. We designed a pocket card reminder and brief educational intervention aimed at hospitalists with the goal of improving documentation of 6 common comorbidities present on admission: coagulation abnormalities, metastatic cancer, anemia, fluid and electrolyte abnormalities, malnutrition, and obesity. METHODS: Two internal medicine inpatient teams led by 10 hospitalist physicians at an academic medical center received the educational intervention and pocket card reminder (n = 520 admissions). Two internal medicine teams led by nonhospitalist physicians served as a control group (n = 590 admissions). Levels of documentation of 6 common comorbidities, expected length of stay, and expected mortality were measured at baseline and during the 9-month study period. RESULTS: The intervention was associated with increased documentation of anemia, fluid and electrolyte abnormalities, malnutrition, and obesity in the intervention group, both compared to baseline and compared to the control group during the study period. The expected length of stay increased in the intervention group during the study period. CONCLUSIONS: A simple educational intervention and pocket card reminder were associated with improved documentation and hospital quality measures at an academic medical center.

A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-line-associated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections.

To achieve sustainable reductions in healthcare-associated infections (HAIs), the University of Washington Medical Center (UWMC) deployed a collaborative, systems-level initiative. With the sponsorship of senior leadership, multidisciplinary teams were established to address healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA), central-line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and respiratory virus infections. The goal of the initiative was to eliminate these four HAIs among medical center inpatients by 2012. In the first 24 months of the project, the number of healthcare-associated MRSA cases decreased 58%; CLABSI cases decreased 54%. Staff and provider compliance with infection prevention measures improved and remained strong, for example, 96% compliance with hand hygiene, 98% compliance with the recommended influenza vaccination program, and 100% compliance with the VAP bundle. Achieving these results required an array of coordinated, systems-level interventions. Critical project success factors were believed to include creating organizational alignment by declaring eliminating HAIs as an organizational breakthrough goal, having the organization's executive leadership highly engaged in the project, coordination by an experienced and effective project leader and manager, collaboration by multidisciplinary project teams, and promoting transparency of results across the organization.

A case-based approach to outpatient evaluation and management service coding.

Understanding Center for Medicare and Medicaid Services (CMS) documentation and coding rules is challenging for most physicians. To accurately bill for clinical services, physicians must learn a system that may initially seem daunting, but is in fact governed by a small number of straightforward rules. The Evaluation and Management (E/M) guidelines for all service codes specify 3 components: history, examination, and medical decision-making, each with a defined set of elements or characteristics. Service coding is based on the level of care supported by the number of history and examination elements and the complexity of decision-making. This article will clarify the guidelines for outpatient clinical services and suggest a practical method of selecting appropriate E/M codes. Because physicians must often choose between billing codes 99213 and 99214 for a visit by an established patient, it will particularly focus on the minimum documentation needed to bill a 99214 code.

BRIEF REPORT: Patient-physician agreement as a predictor of outcomes in patients with back pain.

OBJECTIVE: To determine whether a patient-physician agreement instrument predicts important health outcomes. DESIGN: Three hundred eighty patients with back pain were enrolled in a comparison of rapid magnetic resonance imaging with standard x-rays. One month later, patients rated agreement with their physician in the following areas: diagnosis, diagnostic plan, and treatment plan. Outcomes included patient satisfaction with care at 1 and 12 months and functional and health status at 12 months. SETTING: Urban academic and community primary care and specialty clinics. MEASUREMENTS AND MAIN RESULTS: Higher agreement at 1 month (using a composite sum of scores on the 3 agreement questions) was correlated in univariate analysis with higher patient satisfaction at 1 month (R=.637, P<.001). In multivariate analysis, controlling for 1-month satisfaction and other potential confounders, higher agreement independently predicted better 12-month patient satisfaction (beta=0.188, P=.003), mental health (beta=1.080, P<.001), social function (beta=1.124, P=.001), and vitality (beta=1.190, P<.001). CONCLUSION: Agreement between physicians and patients regarding diagnosis, diagnostic plan, and treatment plan is associated with higher patient satisfaction and better health status outcomes in patients with back pain. Additional research is required to clarify the relationship between physician communication skills, agreement, and patient outcomes.

Systematic review of antidepressants in the treatment of chronic low back pain.

BACKGROUND: Three previous reviews have reached conflicting conclusions regarding the efficacy of antidepressants for patients with back pain. OBJECTIVES: To systematically review the efficacy of antidepressants for the treatment of patients with back pain and to determine whether there is evidence that outcomes vary between classes of antidepressants. MATERIALS AND METHODS: Best evidence synthesis of randomized, placebo-controlled trials of oral antidepressive agents in patients with back pain. Studies were identified by searching MEDLINE, PsycINFO, and the Cochrane Controlled Trials Registry. Two independent reviewers performed data extraction and assessed included studies with a 22-point methodologic quality assessment scale. Effect sizes were calculated if sufficient data were available. RESULTS: Twenty-two trials of antidepressants for the treatment of back pain were identified, of which seven studies of chronic low back pain met inclusion criteria. Among studies using antidepressants that inhibit norepinephrine reuptake (tricyclic or tetracyclic antidepressants), four of five found significant improvement in at least one relevant outcome measure. Assessment of these agents' impact on functional measures produced mixed results. No benefit in pain relief or functional status was found in three studies of antidepressants that do not inhibit norepinephrine reuptake. CONCLUSIONS: Based on a small number of studies, tricyclic and tetracyclic antidepressants appear to produce moderate symptom reductions for patients with chronic low back pain. This benefit appears to be independent of depression status. SSRIs do not appear to be beneficial for patients with chronic low back pain. There is conflicting evidence whether antidepressants improve functional status of patients with chronic low back pain.

Predictors of perioperative complications in head and neck patients.

BACKGROUND: Patients with significant medical problems requiring major otolaryngology procedures are at high risk for both medical and surgical complications. OBJECTIVE: To identify risk factors associated with perioperative complications in medically compromised patients undergoing major otolaryngology procedures. METHODS: Ninety-three consecutive patients with significant comorbid medical illnesses (eg, diabetes, hypertension) undergoing major head and neck surgical procedures were referred to a medical consultation center for preoperative assessment and medical management. Patient and surgical characteristics as well as perioperative complications were identified and recorded. Univariate and multivariate analyses were performed to determine which characteristics were associated with complications. RESULTS: Thirty-two patients (34%) had postoperative complications. Twenty-six patients (28%) had serious medical complications, and 18 (19%) had surgical complications. No deaths occurred in the study population. On univariate analysis, the factors associated with all complications included history of hepatitis, flap reconstruction, oncologic surgery, preoperative radiation therapy, preoperative gastrostomy placement, intraoperative transfusion, anesthesia time (> or =8 hours), and those with greater intraoperative fluid replacement and estimated blood losses. Only anesthesia time (> or =8 hours) remained independently significant on multivariate analysis. A history of hepatitis and prolonged anesthesia time were the only independent predictors of medical complications. The only independent predictor of surgical complications was the volume of intraoperative fluid administered. CONCLUSIONS: Prolonged anesthesia times of 8 hours or more, a history of hepatitis, and large-volume intraoperative fluid resuscitations predicted adverse outcomes. Special care must be taken in counseling these patients preoperatively and in caring for them during their operative and postoperative course.