Lost in Translation: A Standardized, Interdepartmental Approach to Improve the Safety of Inpatient Transitions of Care

AIM: During the 2016-2017 academic year physician perception of favorability regarding inpatient interunit handoffs will meet the national HSOPS benchmark without negatively impacting patient bed flow. All ACGME training programs at Thomas Jefferson University Hospital will expose their new trainees to standardized handoff training during orientation in June 2017 as well as adapt a framework for monitoring trainee compliance and proficiency.https://jdc.jefferson.edu/patientsafetyposters/1028/thumbnail.jp

Understanding Differences in Medical Versus Surgical Patients Alerted by the Modified Early Warning Score (MEWS) at Jefferson Hospital

An Early Warning Score (EWS) is a risk-management tool to identify patients experiencing clinical deterioration early, therefore allowing timely treatment to occur. Although EWS scores are recommended for all in-patients, more data is available for patients under general medical services compared to surgical services. This study aims to understand differences between medical versus surgical in-patients who receive a red alert from the Modified Early Warning Score (MEWS) at Jefferson hospital. Patients who received a red MEWS alert during admission and discharged between June 2017 to March 2018 (N=812) were categorized as medical or surgical patients. Patient characteristics were compared using an independent samples t-test (age, alert count) or chi-square test (sex, race, admission source, insurance). Patient outcomes were compared using a binary logistic regression (in-hospital mortality, RRT, sepsis diagnosis, ICU transfer, intubation, discharge to hospice) or a Cox regression model (length of stay), controlling for age, sex, and race. Compared to medical patients, surgical patients were younger by 2.7 years (p=0.026) and more likely to have a Commercial and/or Medicare category of insurance (OR=1.568, p=0.005). Surgical patients were more likely to have ICU transfer (OR=1.487, p=0.013) and intubation post-alert (OR=2.470, p=0.006), while less likely to be discharged early (HR=0.675,

To Fib or Not to Fib: Misdiagnosis of Atrial Fibrillation on Telemetry Case Presentation and Root Cause Analysis

Case presentation, current practices of telemetry management, root cause analysis, goals for improvement, proposed intervention and next steps

Easy Identification of Missed DVT Prophylaxis-A Chance for Intervention

Goal: To minimize the number of missed or refused medications for inpatients so that adverse patient events such as PE or DVT are prevented SMART AIM: Within 3 months of initiating an EMR based electronic identification system for refused and missed medications, we will decrease the rate at which DVT prophylaxis was ordered however not eventually administered by 50%.https://jdc.jefferson.edu/patientsafetyposters/1014/thumbnail.jp

The TJUH Hospital Medicine COVID19 Emergency Taskforce: A guiding light during the surge of spring 2020

What’s the Problem? In mid March 2020 a highly infectious and deadly disease appeared in Philadelphia that no American physician had ever treated before. The challenge of disseminating reliable and relevant information about a novel and dangerous pathogen across practice areas cannot be understated. Usual practices for communication and leadership are not designed to manage this kind of challenge

At the Leading Edge of Change: Creation of the Housestaff Quality and Safety Leadership Council

Background: The ACGME Clinical Learning Environment Review (CLER) is driving a national re-evaluation of the engagement and alignment of housestaff in institutional Quality and Safety. In 2008, the concept of a housestaff quality and safety committee was born, as a means of driving practice change Our CLER data suggested that we need a similar councilhttps://jdc.jefferson.edu/patientsafetyposters/1004/thumbnail.jp

Process design for optimizing text-based communication between physicians and nurses

Background and Aim Communication between physicians and nurses is a cornerstone of high-quality inpatient care. HIPAA-compliant text-based methods offer an alternative to the pager for communication between nurses and physicians. While messaging is popular in the personal setting, text-based professional communication in hospitals may increase the number of messages without improving coordination between care providers. (1) In addition, urgent messages that are more appropriately calls could be missed by the physician, leading to a delay in action. Other institutions use triage systems to communicate a question or clinical change by the urgency of expected physician response, which have attempted to mitigate this issue. (2) We aimed to improve bidirectional communication between housestaff and nursing with a communication process developed jointly by both parties using QI methods such as stakeholder analysis and a structured Work-Out session to brainstorm solutions