- Email: [email protected]
Electronic Discharge Summaries for Surgical Patients: Evaluating Risks and Benefits
290
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
(p<0.05). There was no difference in the false positive rates (blinded surgeon¼5% and radiologist¼6%, original radiologists¼5%, p<0.05). Conclusions: Radiologists were less likely to call a scan positive. Surgeon recognition of subtle anatomic asymmetry increases the sensitivity of technetium-99m-sestamibi imaging and the successful completion of MIP. 35.10. Electronic Discharge Summaries for Surgical Patients: Evaluating Risks and Benefits. C. E. Reinke,1,2 C. Baillie,4 A. Norris,4 S. L. Schmidt,3 J. Myers2,4; 1Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; 2Center for Health Improvement and Patient Safety, Dept. of Medicine, Perelman School of Medicine, Philadelphia, PA; 3Department of Clinical Effectiveness and Quality Improvement, Hospital of the University of Penn, Philadelphia, PA; 4Department of Medicine, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA Introduction: As electronic discharge summaries (EDS) become more prevalent, analysis of summary quality after implementation remains important. Current literature evaluating EDS quality has mixed results, and no prior studies have studied surgical discharges
or evaluated the use of copy and paste. We sought to assess the quality of surgical discharge summaries after implementation of an EDS and the impact of copy and paste on quality. Methods: We conducted a retrospective study of a sample of discharge summaries from surgical admissions in an urban university teaching hospital before and after the implementation of an EDS program. All patients discharged from the hospital with a discharge summary authored by a surgical intern were potential study subjects, and a random sample of 200 summaries (100 before and 100 after EDS implementation) was chosen for grading. Summaries were evaluated on several items including time to summary completion, summary length, and quality which was measured on a 13-item scoring tool. Electronic summaries were also evaluated for use of obvious copy and paste and its relationship to the quality and readability of summaries. Interrater reliability was analyzed with Crohnbach’s alpha. Results were analyzed using the chi-squre test, students t-test, Fisher’s exact test, and ranksum test as appropriate. Results: After exclusion of 5 patients who died, 195 discharge summaries were evaluated. Discharge summaries before and after EDS implementation were similar in admission type, length of stay, and discharge destination of the patients. Compared with dictated summaries, there was a significant decrease in time to completion and length of electronic discharge summaries. Electronic discharge summaries
TABLE FROM ABSTRACT 35.10
Hospital Course and Discharge Summary Characteristics Number of discharges Admission type - Elective - Emergent Length of stay (days) - Mean (+/- SD) Discharge destination - Home - Facility Time to completion (days) - Median (range) Length of summary (words) - Median (range) Obvious cut & paste - Yes - No Quality aspect Dates of admission and discharge Principle diagnosis Condition at discharge Follow-up provider - Name - Number - Time frame Follow-up instructions Pending results Discharge medication list History of present illness Significant findings Procedures Pathology Readability Ability to communicate Total Score
Dictated
Electronic
p-value*
96
99
54 (57%) 41 (43%)
44 (45%) 53 (55%)
0.11
6.6 (+/ 4.1)
6.1 (+/ 6.3)
0.56
84 (89%) 10 (11%)
83 (85%) 15 (15%)
0.337
6 (0-49)
0 (0-45)
<0.0001
216 (22-970)
124 (0-1081)
0.0003y
– 95
8 89
–
Dictated (mean score) 2 1.95 1.34
Electronic (mean score) 1.98 1.91 1.42
Possible points 2 2 2
p-value* 0.32 0.26 0.43
1.92 0.35 1.90 1.15 0.06 1.34 1.79 1.51 1.93 0.37 2.17 2.06 72%
1.84 1.86 1.98 1.65 0.63 1.83 1.68 1.42 1.89 0.39 1.93 1.88 75%
2 2 2 2 2 2 3 2 2 2 3 3 100
0.25 <0.0001y 0.09 0.0001y 0.004y <0.0001y 0.38 0.27 0.45 0.90 0.03y 0.21 0.11
y
*p-value tests compares total for dictated vs. total for electronic for each characteristic (Fisher’s exact for admission type; t-test for length of stay; ranksum for time to completion and length of summary and each quality aspect; Chi-square for discharge destination) y indicates values significant at the alpha <0.05 level.
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS were equal in overall quality, with improvements in provision of follow-up phone number, follow-up instructions, pending results, and a complete discharge medication list. All other specific quality aspects, such as discharge diagnosis, history of present illness, and significant findings had equivalent scores, with the exception of readability. Obvious use of copy and paste was identified in 8% of discharge summaries, and resulted in decreased readability (score 2.0 vs 1.4, p¼0.02). Conclusions: The implementation of electronic discharge summaries for patients discharged from surgical services improved the timeliness of summary completion without sacrificing quality. Excessive copy and paste can reduce the readability of discharge summaries and strategies to discourage this practice should be employed.
EDUCATION 2: THE SURGICAL RESIDENT 36.1. Sometimes You Can’t Make it on Your Own: The Impact of a Professionalism Curriculum on the Behaviors, Attitudes, and Values of an Academic Plastic Surgery Practice. C. S. Hultman, M. O. Meyers, P. Rowland, E. G. Halvorson, A. A. Meyer; University of North Carolina at Chapel Hill, Chapel Hill, NC Introduction: Professionalism is now recognized as a core competency for graduate medical education and maintenance of certification. However, few models exist in plastic surgery that define, teach, and assess professionalism as a competency. the purpose of this project was to evaluate the effectiveness of a professionalism program in an academic plastic surgery practice. Methods: We created and conducted a 6-week, 12-hour course for health care professionals in plastic surgery (faculty, residents, nurses, medical students). Teaching methods included didactic lectures, journal club, small group discussions, and book review (Forgive and Remember, by Charles Bosk). Topics included 1) Professionalism in Our Culture, 2) Leadership Styles, 3) Modeling Professional Behavior, 4) Leading Your Team, 5) Managing Oneself, and 6) Leading While You Work. Using Kirkpatrick methodology to assess perception of the course (Level 1 data), learning of the material (Level 2 data), effect on behavior (Level 3 data), and impact on the organization (Level 4 data), we compiled participant questionnaires, scores from pre- and post-tests, and such metrics as incidence of sentinel events (defined as infractions requiring involvement by senior administrators), number of patient complaints reported to Patient Relations, and patient satisfaction (Press-Gainey surveys), for the 6 months before and after the course. Results: 30 health care professionals participated in a 6-week course, designed to improve professionalism in plastic surgery. Level 1 data: Although only 54.4% of respondents felt that the course was a ‘‘good use of my time,’’ 72.7% agreed that the course ‘‘will help me become a better professional’’ and 81.8% ‘‘would recommend the course to others.’’ Level 2 data: Posttest scores increased from 48% to 70% (p<0.05), and the ability to recall all 6 competencies increased from 22% to 73% (p<0.01). Level 3 data: the number of sentinel events in our division decreased from 12 to 3. After the course, one resident was placed on probation and resigned, and two other employees left the division after being counseled on issues of professionalism. Interestingly, these participants did very well on the post-test but were not considered to be ‘‘team players.’’ Level 4 data: Patient complaints decreased from 14 to 8, and patient satisfaction increased from 85.5% to 90.5%. Conclusions: A focused curriculum in professionalism may improve the knowledge of participants and overall behavior of the group, but may not affect individual attitudes. Nevertheless, efforts toward assessing, teaching, and influencing professionalism in plastic surgery are very valuable and should be pursued by educators, to help satisfy GME/MOC requirements and to improve the performance of the organization.
291
36.2. Perceived Barriers to Professional Advancement in Academic Surgery: A Structured Analysis of Gender-Based Differences. T. Hauschild,1 W. B. Elder,1 L. A. Neumayer,1 K. J. Brasel,2 M. Crandall,3 A. Cochran1; 1University of Utah, Salt Lake City, UT; 2Medical College of Wisconsin, Milwaukee, WI; 3Northwestern University, Chicago, IL Introduction: Women represent roughly 50% of U.S. medical students and one-third of U.S. surgery residents. Within academic surgery departments, however, women are disproportionately underrepresented, particularly at the more senior levels; 2010 data showed that 16% of Associate Professors and 8% of Professors of Surgery are women. We hypothesized that female academic surgeons perceive different barriers to professional advancement relative to their male colleagues. Methods: A modified version of the Career Barriers Inventory was administered to senior surgical residents (R) and early career surgical faculty (F) at a diverse cohort of 8 academic medical centers via an online survey tool. Likert scales were used to measure respondents’ agreement with each survey item. Fisher’s exact test was used to identify significant differences based upon gender. IRB exemption was obtained. Results: Respondents included 85 R (44 female, 41 male; 74% response rate) and 69 F (26 female, 43 male; 37% response rate). Women responding to this survey anticipated or perceived active discrimination in the form of being treated differently (41% R, 77% of F) and experiencing negative comments about their sex (23% R, 58% F) in academic surgical practice, findings that were notably different from their male counterparts (different treatment: 17.5% R, p¼0.001, 14% F, p<0.001; negative comments: 7.5% R, p¼0.001, 7% F, p<0.001). Non-conscious bias or implicit resistance to women holding academic surgical jobs manifested in the form of negative attitudes; 23% of female residents and no male residents strongly agreed or agreed that negative attitudes based upon sex as a barrier to career aspirations (p¼0.009) as did 50% of female faculty and 2% of male faculty (p<0.001). the presence of overt and implicit bias results in a sense that sex is a barrier to women surgeon’s career development in academic surgery (Table 1). No differences were observed between male and female respondents with regard to career preparation or structural barriers to advancement. Conclusions: Women in academic surgery experience a number of difficulties that are perceived by them to be different from their male counterparts. Women who participated in this study report feeling excluded from the male culture in Departments of Surgery, which are more maledominated than any other medical school department. This study may help to guide plans that will ultimately transform the culture of Departments of Surgery, such as the creation of professional development programs, education of those in leadership regarding the specific barriers women face in their careers in academic surgery, and deliberate recruiting of women into academic positions.
TABLE 1 My Gender Is Currently a Barrier to My Career Aspirations Strongly Agree
Agree
Residents (n)* Male (41) 0 0 Female (44) 1 (2.3%) 5 (11.4%) Faculty (n)** Male (43) 0 1 (2.3%) Female (26) 2 (7.7%) 8 (30.8%) Reported numbers are n (%). *p¼0.031 **p<0.001.
Neutral
Disagree
Strongly Disagree
5 (12.2%) 18 (43.9%) 18 (43.9%) 7 (15.9%) 22 (50%) 9 (20.4%) 3 (7.0%) 24 (55.8%) 15 (34.9%) 7 (26.9%) 7 (26.9%) 2 (7.7%)
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
(p<0.05). There was no difference in the false positive rates (blinded surgeon¼5% and radiologist¼6%, original radiologists¼5%, p<0.05). Conclusions: Radiologists were less likely to call a scan positive. Surgeon recognition of subtle anatomic asymmetry increases the sensitivity of technetium-99m-sestamibi imaging and the successful completion of MIP. 35.10. Electronic Discharge Summaries for Surgical Patients: Evaluating Risks and Benefits. C. E. Reinke,1,2 C. Baillie,4 A. Norris,4 S. L. Schmidt,3 J. Myers2,4; 1Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; 2Center for Health Improvement and Patient Safety, Dept. of Medicine, Perelman School of Medicine, Philadelphia, PA; 3Department of Clinical Effectiveness and Quality Improvement, Hospital of the University of Penn, Philadelphia, PA; 4Department of Medicine, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA Introduction: As electronic discharge summaries (EDS) become more prevalent, analysis of summary quality after implementation remains important. Current literature evaluating EDS quality has mixed results, and no prior studies have studied surgical discharges
or evaluated the use of copy and paste. We sought to assess the quality of surgical discharge summaries after implementation of an EDS and the impact of copy and paste on quality. Methods: We conducted a retrospective study of a sample of discharge summaries from surgical admissions in an urban university teaching hospital before and after the implementation of an EDS program. All patients discharged from the hospital with a discharge summary authored by a surgical intern were potential study subjects, and a random sample of 200 summaries (100 before and 100 after EDS implementation) was chosen for grading. Summaries were evaluated on several items including time to summary completion, summary length, and quality which was measured on a 13-item scoring tool. Electronic summaries were also evaluated for use of obvious copy and paste and its relationship to the quality and readability of summaries. Interrater reliability was analyzed with Crohnbach’s alpha. Results were analyzed using the chi-squre test, students t-test, Fisher’s exact test, and ranksum test as appropriate. Results: After exclusion of 5 patients who died, 195 discharge summaries were evaluated. Discharge summaries before and after EDS implementation were similar in admission type, length of stay, and discharge destination of the patients. Compared with dictated summaries, there was a significant decrease in time to completion and length of electronic discharge summaries. Electronic discharge summaries
TABLE FROM ABSTRACT 35.10
Hospital Course and Discharge Summary Characteristics Number of discharges Admission type - Elective - Emergent Length of stay (days) - Mean (+/- SD) Discharge destination - Home - Facility Time to completion (days) - Median (range) Length of summary (words) - Median (range) Obvious cut & paste - Yes - No Quality aspect Dates of admission and discharge Principle diagnosis Condition at discharge Follow-up provider - Name - Number - Time frame Follow-up instructions Pending results Discharge medication list History of present illness Significant findings Procedures Pathology Readability Ability to communicate Total Score
Dictated
Electronic
p-value*
96
99
54 (57%) 41 (43%)
44 (45%) 53 (55%)
0.11
6.6 (+/ 4.1)
6.1 (+/ 6.3)
0.56
84 (89%) 10 (11%)
83 (85%) 15 (15%)
0.337
6 (0-49)
0 (0-45)
<0.0001
216 (22-970)
124 (0-1081)
0.0003y
– 95
8 89
–
Dictated (mean score) 2 1.95 1.34
Electronic (mean score) 1.98 1.91 1.42
Possible points 2 2 2
p-value* 0.32 0.26 0.43
1.92 0.35 1.90 1.15 0.06 1.34 1.79 1.51 1.93 0.37 2.17 2.06 72%
1.84 1.86 1.98 1.65 0.63 1.83 1.68 1.42 1.89 0.39 1.93 1.88 75%
2 2 2 2 2 2 3 2 2 2 3 3 100
0.25 <0.0001y 0.09 0.0001y 0.004y <0.0001y 0.38 0.27 0.45 0.90 0.03y 0.21 0.11
y
*p-value tests compares total for dictated vs. total for electronic for each characteristic (Fisher’s exact for admission type; t-test for length of stay; ranksum for time to completion and length of summary and each quality aspect; Chi-square for discharge destination) y indicates values significant at the alpha <0.05 level.
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS were equal in overall quality, with improvements in provision of follow-up phone number, follow-up instructions, pending results, and a complete discharge medication list. All other specific quality aspects, such as discharge diagnosis, history of present illness, and significant findings had equivalent scores, with the exception of readability. Obvious use of copy and paste was identified in 8% of discharge summaries, and resulted in decreased readability (score 2.0 vs 1.4, p¼0.02). Conclusions: The implementation of electronic discharge summaries for patients discharged from surgical services improved the timeliness of summary completion without sacrificing quality. Excessive copy and paste can reduce the readability of discharge summaries and strategies to discourage this practice should be employed.
EDUCATION 2: THE SURGICAL RESIDENT 36.1. Sometimes You Can’t Make it on Your Own: The Impact of a Professionalism Curriculum on the Behaviors, Attitudes, and Values of an Academic Plastic Surgery Practice. C. S. Hultman, M. O. Meyers, P. Rowland, E. G. Halvorson, A. A. Meyer; University of North Carolina at Chapel Hill, Chapel Hill, NC Introduction: Professionalism is now recognized as a core competency for graduate medical education and maintenance of certification. However, few models exist in plastic surgery that define, teach, and assess professionalism as a competency. the purpose of this project was to evaluate the effectiveness of a professionalism program in an academic plastic surgery practice. Methods: We created and conducted a 6-week, 12-hour course for health care professionals in plastic surgery (faculty, residents, nurses, medical students). Teaching methods included didactic lectures, journal club, small group discussions, and book review (Forgive and Remember, by Charles Bosk). Topics included 1) Professionalism in Our Culture, 2) Leadership Styles, 3) Modeling Professional Behavior, 4) Leading Your Team, 5) Managing Oneself, and 6) Leading While You Work. Using Kirkpatrick methodology to assess perception of the course (Level 1 data), learning of the material (Level 2 data), effect on behavior (Level 3 data), and impact on the organization (Level 4 data), we compiled participant questionnaires, scores from pre- and post-tests, and such metrics as incidence of sentinel events (defined as infractions requiring involvement by senior administrators), number of patient complaints reported to Patient Relations, and patient satisfaction (Press-Gainey surveys), for the 6 months before and after the course. Results: 30 health care professionals participated in a 6-week course, designed to improve professionalism in plastic surgery. Level 1 data: Although only 54.4% of respondents felt that the course was a ‘‘good use of my time,’’ 72.7% agreed that the course ‘‘will help me become a better professional’’ and 81.8% ‘‘would recommend the course to others.’’ Level 2 data: Posttest scores increased from 48% to 70% (p<0.05), and the ability to recall all 6 competencies increased from 22% to 73% (p<0.01). Level 3 data: the number of sentinel events in our division decreased from 12 to 3. After the course, one resident was placed on probation and resigned, and two other employees left the division after being counseled on issues of professionalism. Interestingly, these participants did very well on the post-test but were not considered to be ‘‘team players.’’ Level 4 data: Patient complaints decreased from 14 to 8, and patient satisfaction increased from 85.5% to 90.5%. Conclusions: A focused curriculum in professionalism may improve the knowledge of participants and overall behavior of the group, but may not affect individual attitudes. Nevertheless, efforts toward assessing, teaching, and influencing professionalism in plastic surgery are very valuable and should be pursued by educators, to help satisfy GME/MOC requirements and to improve the performance of the organization.
291
36.2. Perceived Barriers to Professional Advancement in Academic Surgery: A Structured Analysis of Gender-Based Differences. T. Hauschild,1 W. B. Elder,1 L. A. Neumayer,1 K. J. Brasel,2 M. Crandall,3 A. Cochran1; 1University of Utah, Salt Lake City, UT; 2Medical College of Wisconsin, Milwaukee, WI; 3Northwestern University, Chicago, IL Introduction: Women represent roughly 50% of U.S. medical students and one-third of U.S. surgery residents. Within academic surgery departments, however, women are disproportionately underrepresented, particularly at the more senior levels; 2010 data showed that 16% of Associate Professors and 8% of Professors of Surgery are women. We hypothesized that female academic surgeons perceive different barriers to professional advancement relative to their male colleagues. Methods: A modified version of the Career Barriers Inventory was administered to senior surgical residents (R) and early career surgical faculty (F) at a diverse cohort of 8 academic medical centers via an online survey tool. Likert scales were used to measure respondents’ agreement with each survey item. Fisher’s exact test was used to identify significant differences based upon gender. IRB exemption was obtained. Results: Respondents included 85 R (44 female, 41 male; 74% response rate) and 69 F (26 female, 43 male; 37% response rate). Women responding to this survey anticipated or perceived active discrimination in the form of being treated differently (41% R, 77% of F) and experiencing negative comments about their sex (23% R, 58% F) in academic surgical practice, findings that were notably different from their male counterparts (different treatment: 17.5% R, p¼0.001, 14% F, p<0.001; negative comments: 7.5% R, p¼0.001, 7% F, p<0.001). Non-conscious bias or implicit resistance to women holding academic surgical jobs manifested in the form of negative attitudes; 23% of female residents and no male residents strongly agreed or agreed that negative attitudes based upon sex as a barrier to career aspirations (p¼0.009) as did 50% of female faculty and 2% of male faculty (p<0.001). the presence of overt and implicit bias results in a sense that sex is a barrier to women surgeon’s career development in academic surgery (Table 1). No differences were observed between male and female respondents with regard to career preparation or structural barriers to advancement. Conclusions: Women in academic surgery experience a number of difficulties that are perceived by them to be different from their male counterparts. Women who participated in this study report feeling excluded from the male culture in Departments of Surgery, which are more maledominated than any other medical school department. This study may help to guide plans that will ultimately transform the culture of Departments of Surgery, such as the creation of professional development programs, education of those in leadership regarding the specific barriers women face in their careers in academic surgery, and deliberate recruiting of women into academic positions.
TABLE 1 My Gender Is Currently a Barrier to My Career Aspirations Strongly Agree
Agree
Residents (n)* Male (41) 0 0 Female (44) 1 (2.3%) 5 (11.4%) Faculty (n)** Male (43) 0 1 (2.3%) Female (26) 2 (7.7%) 8 (30.8%) Reported numbers are n (%). *p¼0.031 **p<0.001.
Neutral
Disagree
Strongly Disagree
5 (12.2%) 18 (43.9%) 18 (43.9%) 7 (15.9%) 22 (50%) 9 (20.4%) 3 (7.0%) 24 (55.8%) 15 (34.9%) 7 (26.9%) 7 (26.9%) 2 (7.7%)