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Human factors methods improve efficiency in emergency trauma care
QUALITY, OUTCOMES AND COSTS I The impact of promotional language on patient preference for innovative procedures Peter R Dixon, Robert C Grant, David R Urbach, MD, MS, FRCSC, FACS Toronto General Hospital Toronto, Ontario, Canada
effectiveness, junior-resident perceptions of communication, and senior-resident reporting of incomplete patient-care tasks and lack of patient knowledge on morning rounds were recorded using Likert-scale questionnaires. Statistical analysis included chi-square and Student’s t-test.
INTRODUCTION: While robotic-assisted surgery has become increasingly popular over the past decade, there is limited evidence supporting a benefit beyond less expensive conventional laparoscopic surgery. It is possible that marketing pressure is partly responsible for the widespread adoption of robotic-assisted surgery. In particular, physician-directed and direct-to-consumer advertising and promotion highlights robotic-assisted surgery using terms that emphasize its novelty, which are unrelated to statements about evidence. The impact of language on patient preference for innovative procedures has not been investigated.
RESULTS: We assessed 114 pre-intervention and 140 post-intervention intern-level handoffs. Discussion of PACT content increased significantly, as did the recommended order of discussion. Handoff time increased significantly, as did patient census. Despite increased census, incidence of incomplete tasks and lack of patient knowledge decreased, indicating improved handoff practices (Table). Discrepancy between junior and senior handoffs decreased (p<0.001), and senior residents reported junior residents were better able to handle emergencies (p¼0.03).
METHODS: We surveyed 38 persons at risk of colorectal cancer to elicit their preference of surgical technique for partial colectomy, presented with a hypothetical diagnosis of colon cancer. Each subject made two treatment decisions between robotic-assisted surgery and laparoscopic surgery, with robotic-assisted surgery described as “innovative” and “state-of-the-art” (marketing frame), as well as a second preference elicitation highlighting uncertainty of available evidence (evidence-based frame), in alternating order. RESULTS: 20 participants (52.6%, 95% CI 37.3-67.5) selected robotic-assisted surgery in the marketing frame, as compared with 9 (23.7%, 95% CI 13.0-39.2) in the evidence-based frame. The magnitude of the framing effect was large, with 12 of 20 (60.0%, 95% CI 38.7-78.1) who selected robotic-assisted surgery in the marketing frame selecting laparoscopic surgery in the evidence-based frame. CONCLUSIONS: Words that highlight novelty have an important influence on patient preference for robotic-assisted surgery. Emphasizing uncertainty of risks and benefits can mitigate this effect. PACT project: standardized resident handoff implementation improves handoff quality Nicole M Tapia, MD*, Sara C Fallon, MD, Mary L Brandt, MD, FACS, Jesus A Correa, BA, Bradford G Scott, MD, FACS, James W Suliburk, MD, FACS Baylor College of Medicine, Houston, TX INTRODUCTION: Stricter resident work hours require increased patient care transfers, potentially decreasing quality of care. The purpose of this study is to examine the results of a novel handoff method using the mnemonic PACT (priority, admissions, changes, task review). We hypothesize that implementation of the PACT handoff method will improve quality of patient care transfers. METHODS: We performed a hybrid type II study that assessed the implementation and effectiveness of PACT in two hospitals with high patient census and frequent turnover. Pre-intervention (6/2012-8/15/2012) and post-intervention (8/20/2012-2/2013) handoff practices were compared. To assess implementation, handoffs were directly observed by trained medical students, observing if recommended content and order were discussed. To assess
ª 2013 by the American College of Surgeons Published by Elsevier Inc.
Handoff implementation and outcomes
Handoff time (minutes) Patient census (number of patients) Discussion of priority patients Discussion of admitted patients Discussion of changes during shift Discussion of task review Discussion in PACT order Incidence of incomplete tasks during shift Incidence of unknown patient status during morning rounds
n
prePACT
PACT
253 17 13 22 14
p Value
0.003
246 38 16 52 22 <0.001 253
51%
88%
<0.001
250
82%
95%
0.001
252 254 252
87% 59% 3%
97% 91% 22%
0.002 <0.001 <0.001
157
46%
26%
0.006
170
57%
42%
0.047
CONCLUSIONS: Our institution successfully implemented a standardized handoff method which improved handoff quality. PACT handoffs increased task completion, patient knowledge, and emergency preparedness. Future studies will explore checklist integration to enhance PACT process. Human factors methods improve efficiency in emergency trauma care Alexandra Gangi, MD, Ken Catchpole, PhD, Renaldo Blocker, PhD, Jennifer Blaha, MBA, Daniel Shouhed, MD, Bruce L Gewertz, MD, FACS, Eric J Ley, MD, FACS Cedars-Sinai Medical Center, Los Angeles, CA INTRODUCTION: The time interval between the notification of incoming trauma to patients’ arrival in the emergency department can impact trauma care. The implementation of interventions during the emergency department (ED) phase of care should decrease case duration and the number of deviations from the natural progression of care (flow disruptions, FD). METHODS: Trained observers recorded FD and work system variables using a validated tablet-PC data collection tool at a level I trauma center. Trauma cases were observed and FD were recorded.
S100
ISSN 1072-7515/13/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.07.228
Vol. 217, No. 3S, September 2013
Surgical Forum Abstracts
Based on these observations, four interventions were implemented: trauma bay standardization, patient whiteboards, pre-briefings, and teamwork training. Repeat observations were conducted to measure the impact of the interventions. Cases were stratified based upon time from activation to patient arrival; 0-8 minutes, and >9 minutes. RESULTS: 64 cases from the pre-intervention phase and 108 from the post-intervention phase met criteria. During the pre-intervention phase, more FD and higher FD/min were seen in the >9 minute group. When comparing pre and post intervention phases, the interventions reduced ED case duration in both groups (0-8 min: 66 vs 41.5, p¼0.003; Group 1 (0e8 minutes)
ED duration (min) ED FD rate ED FD rate (FD/min) Group 2 (9 minutes) ED duration (min) ED FD rate ED FD rate (FD/min)
Pre-intervention Post-intervention (mean SD) (mean SD) p Value
66 49.5 7.74 6.1
41.5 27.9 6.51 4.6
0.003 0.17
0.16 0.15
0.18 0.11
0.31
61 40 11.67 8.13
46.3 23.7 5.96 4.03
0.045 <0.0001
0.25 0.17
0.15 0.09
0.001
>9 min: 61 vs 46.3 p¼0.045). There was no significant dfference between FD or FD/min in the 0-8 min group; however, the >9 min group had significant differences in both number of FD (11.7 vs 5.9 p<0.0001) and FD/min (0.25 vs 0.15 p¼0.001). CONCLUSIONS: Using the time before a patient arrives to prepare equipment, gather and share information, and utilize enhanced team skills provides system-level support for improved coordination. These interventions result in faster and more efficient care.
Checklist implementation reduces Advanced Trauma Life Support workflow deviations during trauma resuscitations without pre-arrival notification Deirdre C Kelleher, MD, RP, Jagadeesh Chandra Bose, PhD, Lauren J Waterhouse, BS, Elizabeth A Carter, PhD, MPH, Randall S Burd, MD, PhD, FACS Children’s National Medical Center, Washington, DC INTRODUCTION: Trauma resuscitations without pre-arrival notification are often chaotic, potentially compromising patient care. Checklists may standardize these events and reduce effects of prearrival notification on performance. We hypothesized that trauma resuscitations without pre-arrival notification are performed with more variable adherence to the Advanced Trauma Life Support (ATLS) protocol and that implementation of a checklist would reduce this variability.
S101
METHODS: We analyzed video-review logs of trauma resuscitations from two four-month periods before (n¼222) and after (n¼215) checklist implementation. Individual resuscitations were compared to an optimized workflow model of primary survey tasks and tested for model fitness (range 0 to 1) using process mining. Mean fitness scores and conformance frequency (fitness¼1) were compared (Pearson’s chi-square and Student’s t-test). Multivariate regression analysis controlling for patient and resuscitation characteristics was also performed to determine the effect of checklist implementation. RESULTS: Fifty-five (12.6%) resuscitations lacked pre-arrival notification (pre-implementation, n¼23, post-implementation, n¼32; p¼0.15). Before checklist implementation, resuscitations without notification had lower fitness (0.80 vs 0.90, p<0.001) and conformance (26.1% vs 50.8%, p¼0.03) than those with notification. Following checklist implementation, fitness (0.80 vs 0.91, p¼0.007) and conformance (26.1% vs 59.4%, p¼0.01) improved for resuscitations without notification, with both measurements closer to those of resuscitations with notification (Table 1). Using multivariate analysis, checklist implementation remained associated with higher fitness for resuscitations without pre-arrival notification (B¼0.13, p¼0.006).
Measurement
Notification Yes Fitness, mean (SD) No Yes Conformance, % No Total n ¼ 437
Preimplementation 0.90 (0.13) 0.80 (0.17) 50.8% 26.1%
Postimplementation p Value 0.96 (0.09) <0.001 0.91 (0.13) 0.007 77.6% <0.001 59.4% 0.01
CONCLUSIONS: Trauma resuscitations without pre-arrival notification persist and are associated with a decreased adherence to the ATLS protocol. The addition of a checklist improves protocol adherence and reduces the variability of care between resuscitations with and without notification. Massachusetts health care reform is associated with reduced disparities in the management of acute cholecystitis Andrew P Loehrer, MD, Hugh G Auchincloss, MD, Zirui Song, PhD, Matthew M Hutter, MD, MPH, FACS Massachusetts General Hospital, Boston, MA INTRODUCTION: Immediate cholecystectomy has been shown to be the optimal treatment for acute cholecystitis (AC), yet variation in care persists by insurance status and patient race. The impact of insurance expansion on disparities in surgical care is not known. We evaluated the effect of the 2006 Massachusetts coverage expansion on disparities in the management of AC. METHODS: We used Hospital Cost and Utilization Project State Inpatient Databases to conduct a cohort study comparing Massachusetts with three control states from 2001-2009. All non-elderly
effectiveness, junior-resident perceptions of communication, and senior-resident reporting of incomplete patient-care tasks and lack of patient knowledge on morning rounds were recorded using Likert-scale questionnaires. Statistical analysis included chi-square and Student’s t-test.
INTRODUCTION: While robotic-assisted surgery has become increasingly popular over the past decade, there is limited evidence supporting a benefit beyond less expensive conventional laparoscopic surgery. It is possible that marketing pressure is partly responsible for the widespread adoption of robotic-assisted surgery. In particular, physician-directed and direct-to-consumer advertising and promotion highlights robotic-assisted surgery using terms that emphasize its novelty, which are unrelated to statements about evidence. The impact of language on patient preference for innovative procedures has not been investigated.
RESULTS: We assessed 114 pre-intervention and 140 post-intervention intern-level handoffs. Discussion of PACT content increased significantly, as did the recommended order of discussion. Handoff time increased significantly, as did patient census. Despite increased census, incidence of incomplete tasks and lack of patient knowledge decreased, indicating improved handoff practices (Table). Discrepancy between junior and senior handoffs decreased (p<0.001), and senior residents reported junior residents were better able to handle emergencies (p¼0.03).
METHODS: We surveyed 38 persons at risk of colorectal cancer to elicit their preference of surgical technique for partial colectomy, presented with a hypothetical diagnosis of colon cancer. Each subject made two treatment decisions between robotic-assisted surgery and laparoscopic surgery, with robotic-assisted surgery described as “innovative” and “state-of-the-art” (marketing frame), as well as a second preference elicitation highlighting uncertainty of available evidence (evidence-based frame), in alternating order. RESULTS: 20 participants (52.6%, 95% CI 37.3-67.5) selected robotic-assisted surgery in the marketing frame, as compared with 9 (23.7%, 95% CI 13.0-39.2) in the evidence-based frame. The magnitude of the framing effect was large, with 12 of 20 (60.0%, 95% CI 38.7-78.1) who selected robotic-assisted surgery in the marketing frame selecting laparoscopic surgery in the evidence-based frame. CONCLUSIONS: Words that highlight novelty have an important influence on patient preference for robotic-assisted surgery. Emphasizing uncertainty of risks and benefits can mitigate this effect. PACT project: standardized resident handoff implementation improves handoff quality Nicole M Tapia, MD*, Sara C Fallon, MD, Mary L Brandt, MD, FACS, Jesus A Correa, BA, Bradford G Scott, MD, FACS, James W Suliburk, MD, FACS Baylor College of Medicine, Houston, TX INTRODUCTION: Stricter resident work hours require increased patient care transfers, potentially decreasing quality of care. The purpose of this study is to examine the results of a novel handoff method using the mnemonic PACT (priority, admissions, changes, task review). We hypothesize that implementation of the PACT handoff method will improve quality of patient care transfers. METHODS: We performed a hybrid type II study that assessed the implementation and effectiveness of PACT in two hospitals with high patient census and frequent turnover. Pre-intervention (6/2012-8/15/2012) and post-intervention (8/20/2012-2/2013) handoff practices were compared. To assess implementation, handoffs were directly observed by trained medical students, observing if recommended content and order were discussed. To assess
ª 2013 by the American College of Surgeons Published by Elsevier Inc.
Handoff implementation and outcomes
Handoff time (minutes) Patient census (number of patients) Discussion of priority patients Discussion of admitted patients Discussion of changes during shift Discussion of task review Discussion in PACT order Incidence of incomplete tasks during shift Incidence of unknown patient status during morning rounds
n
prePACT
PACT
253 17 13 22 14
p Value
0.003
246 38 16 52 22 <0.001 253
51%
88%
<0.001
250
82%
95%
0.001
252 254 252
87% 59% 3%
97% 91% 22%
0.002 <0.001 <0.001
157
46%
26%
0.006
170
57%
42%
0.047
CONCLUSIONS: Our institution successfully implemented a standardized handoff method which improved handoff quality. PACT handoffs increased task completion, patient knowledge, and emergency preparedness. Future studies will explore checklist integration to enhance PACT process. Human factors methods improve efficiency in emergency trauma care Alexandra Gangi, MD, Ken Catchpole, PhD, Renaldo Blocker, PhD, Jennifer Blaha, MBA, Daniel Shouhed, MD, Bruce L Gewertz, MD, FACS, Eric J Ley, MD, FACS Cedars-Sinai Medical Center, Los Angeles, CA INTRODUCTION: The time interval between the notification of incoming trauma to patients’ arrival in the emergency department can impact trauma care. The implementation of interventions during the emergency department (ED) phase of care should decrease case duration and the number of deviations from the natural progression of care (flow disruptions, FD). METHODS: Trained observers recorded FD and work system variables using a validated tablet-PC data collection tool at a level I trauma center. Trauma cases were observed and FD were recorded.
S100
ISSN 1072-7515/13/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.07.228
Vol. 217, No. 3S, September 2013
Surgical Forum Abstracts
Based on these observations, four interventions were implemented: trauma bay standardization, patient whiteboards, pre-briefings, and teamwork training. Repeat observations were conducted to measure the impact of the interventions. Cases were stratified based upon time from activation to patient arrival; 0-8 minutes, and >9 minutes. RESULTS: 64 cases from the pre-intervention phase and 108 from the post-intervention phase met criteria. During the pre-intervention phase, more FD and higher FD/min were seen in the >9 minute group. When comparing pre and post intervention phases, the interventions reduced ED case duration in both groups (0-8 min: 66 vs 41.5, p¼0.003; Group 1 (0e8 minutes)
ED duration (min) ED FD rate ED FD rate (FD/min) Group 2 (9 minutes) ED duration (min) ED FD rate ED FD rate (FD/min)
Pre-intervention Post-intervention (mean SD) (mean SD) p Value
66 49.5 7.74 6.1
41.5 27.9 6.51 4.6
0.003 0.17
0.16 0.15
0.18 0.11
0.31
61 40 11.67 8.13
46.3 23.7 5.96 4.03
0.045 <0.0001
0.25 0.17
0.15 0.09
0.001
>9 min: 61 vs 46.3 p¼0.045). There was no significant dfference between FD or FD/min in the 0-8 min group; however, the >9 min group had significant differences in both number of FD (11.7 vs 5.9 p<0.0001) and FD/min (0.25 vs 0.15 p¼0.001). CONCLUSIONS: Using the time before a patient arrives to prepare equipment, gather and share information, and utilize enhanced team skills provides system-level support for improved coordination. These interventions result in faster and more efficient care.
Checklist implementation reduces Advanced Trauma Life Support workflow deviations during trauma resuscitations without pre-arrival notification Deirdre C Kelleher, MD, RP, Jagadeesh Chandra Bose, PhD, Lauren J Waterhouse, BS, Elizabeth A Carter, PhD, MPH, Randall S Burd, MD, PhD, FACS Children’s National Medical Center, Washington, DC INTRODUCTION: Trauma resuscitations without pre-arrival notification are often chaotic, potentially compromising patient care. Checklists may standardize these events and reduce effects of prearrival notification on performance. We hypothesized that trauma resuscitations without pre-arrival notification are performed with more variable adherence to the Advanced Trauma Life Support (ATLS) protocol and that implementation of a checklist would reduce this variability.
S101
METHODS: We analyzed video-review logs of trauma resuscitations from two four-month periods before (n¼222) and after (n¼215) checklist implementation. Individual resuscitations were compared to an optimized workflow model of primary survey tasks and tested for model fitness (range 0 to 1) using process mining. Mean fitness scores and conformance frequency (fitness¼1) were compared (Pearson’s chi-square and Student’s t-test). Multivariate regression analysis controlling for patient and resuscitation characteristics was also performed to determine the effect of checklist implementation. RESULTS: Fifty-five (12.6%) resuscitations lacked pre-arrival notification (pre-implementation, n¼23, post-implementation, n¼32; p¼0.15). Before checklist implementation, resuscitations without notification had lower fitness (0.80 vs 0.90, p<0.001) and conformance (26.1% vs 50.8%, p¼0.03) than those with notification. Following checklist implementation, fitness (0.80 vs 0.91, p¼0.007) and conformance (26.1% vs 59.4%, p¼0.01) improved for resuscitations without notification, with both measurements closer to those of resuscitations with notification (Table 1). Using multivariate analysis, checklist implementation remained associated with higher fitness for resuscitations without pre-arrival notification (B¼0.13, p¼0.006).
Measurement
Notification Yes Fitness, mean (SD) No Yes Conformance, % No Total n ¼ 437
Preimplementation 0.90 (0.13) 0.80 (0.17) 50.8% 26.1%
Postimplementation p Value 0.96 (0.09) <0.001 0.91 (0.13) 0.007 77.6% <0.001 59.4% 0.01
CONCLUSIONS: Trauma resuscitations without pre-arrival notification persist and are associated with a decreased adherence to the ATLS protocol. The addition of a checklist improves protocol adherence and reduces the variability of care between resuscitations with and without notification. Massachusetts health care reform is associated with reduced disparities in the management of acute cholecystitis Andrew P Loehrer, MD, Hugh G Auchincloss, MD, Zirui Song, PhD, Matthew M Hutter, MD, MPH, FACS Massachusetts General Hospital, Boston, MA INTRODUCTION: Immediate cholecystectomy has been shown to be the optimal treatment for acute cholecystitis (AC), yet variation in care persists by insurance status and patient race. The impact of insurance expansion on disparities in surgical care is not known. We evaluated the effect of the 2006 Massachusetts coverage expansion on disparities in the management of AC. METHODS: We used Hospital Cost and Utilization Project State Inpatient Databases to conduct a cohort study comparing Massachusetts with three control states from 2001-2009. All non-elderly