Validity evidence for Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores: consequences of rater number and type using neurology cases

ObjectivesTo develop neurology scenarios for use with the Quality Improvement Knowledge Application Tool Revised (QIKAT-R), gather and evaluate validity evidence, and project the impact of scenario number, rater number and rater type on score reliability.MethodsSix neurological case scenarios were developed. Residents were randomly assigned three scenarios before and after a quality improvement (QI) course in 2015 and 2016. For each scenario, residents crafted an aim statement, selected a measure and proposed a change to address a quality gap. Responses were scored by six faculty raters (two with and four without QI expertise) using the QIKAT-R. Validity evidence from content, response process, internal structure, relations to other variables and consequences was collected. A generalisability (G) study examined sources of score variability, and decision analyses estimated projected reliability for different numbers of raters and scenarios and raters with and without QI expertise.ResultsRaters scored 163 responses from 28 residents. The mean QIKAT-R score was 5.69 (SD 1.06). G-coefficient and Phi-coefficient were 0.65 and 0.60, respectively. Interrater reliability was fair for raters without QI expertise (intraclass correlation = 0.53, 95% CI 0.30 to 0.72) and acceptable for raters with QI expertise (intraclass correlation = 0.66, 95% CI 0.02 to 0.88). Postcourse scores were significantly higher than precourse scores (6.05, SD 1.48 vs 5.22, SD 1.5; p < 0.001). Sufficient reliability for formative assessment (G-coefficient > 0.60) could be achieved by three raters scoring six scenarios or two raters scoring eight scenarios, regardless of rater QI expertise.ConclusionsValidity evidence was sufficient to support the use of the QIKAT-R with multiple scenarios and raters to assess resident QI knowledge application for formative or low-stakes summative purposes. The results provide practical information for educators to guide implementation decisions.

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Documentation of Clinical Reasoning in Admission Notes of Hospitalists: Validation of the CRANAPL Assessment Rubric

Journal of Hospital Medicine ◽

10.12788/jhm.3233 ◽

2019 ◽

Vol 14 (12) ◽

pp. 746-753

Author(s):

Susrutha Kotwal

Keyword(s):

Abdominal Pain ◽

Clinical Reasoning ◽

Interrater Reliability ◽

Community Hospital ◽

Intraclass Correlation ◽

Hospital Medicine ◽

Validity Evidence ◽

Academic Hospitals ◽

The Mean ◽

Study Setting

OBJECTIVE: To establish a metric for evaluating hospitalists’ documentation of clinical reasoning in admission notes. STUDY DESIGN: Retrospective study. SETTING: Admissions from 2014 to 2017 at three hospitals in Maryland. PARTICIPANTS: Hospitalist physicians. MEASUREMENTS: A subset of patients admitted with fever, syncope/dizziness, or abdominal pain were randomly selected. The nine-item Clinical Reasoning in Admission Note Assessment & Plan (CRANAPL) tool was developed to assess the comprehensiveness of clinical reasoning documented in the assessment and plans (A&Ps) of admission notes. Two authors scored all A&Ps by using this tool. A&Ps with global clinical reasoning and global readability/clarity measures were also scored. All data were deidentified prior to scoring. RESULTS: The 285 admission notes that were evaluated were authored by 120 hospitalists. The mean total CRANAPL score given by both raters was 6.4 (SD 2.2). The intraclass correlation measuring interrater reliability for the total CRANAPL score was 0.83 (95% CI, 0.76-0.87). Associations between the CRANAPL total score and global clinical reasoning score and global readability/clarity measures were statistically significant (P < .001). Notes from academic hospitals had higher CRANAPL scores (7.4 [SD 2.0] and 6.6 [SD 2.1]) than those from the community hospital (5.2 [SD 1.9]), P < .001. CONCLUSIONS: This study represents the first step to characterizing clinical reasoning documentation in hospital medicine. With some validity evidence established for the CRANAPL tool, it may be possible to assess the documentation of clinical reasoning by hospitalists.

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Resilience and vulnerability of maternity services in Zimbabwe: a comparative analysis of the effect of Covid-19 and lockdown control measures on maternal and perinatal outcomes, a single-centre cross-sectional study at Mpilo Central Hospital

BMC Pregnancy and Childbirth ◽

10.1186/s12884-021-03884-5 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Clare Shakespeare ◽

Handsome Dube ◽

Sikhangezile Moyo ◽

Solwayo Ngwenya

Keyword(s):

Perinatal Outcomes ◽

Control Measures ◽

Central Hospital ◽

Cross Sectional ◽

Maternity Services ◽

Before And After ◽

The Mean ◽

Significant Change ◽

The Impact ◽

Mpilo Central Hospital

Abstract Background On the 27th of March 2020 the Zimbabwean government declared the Covid-19 pandemic a ‘national disaster’. Travel restrictions and emergency regulations have had significant impacts on maternity services, including resource stock-outs, and closure of antenatal clinics during the lockdown period. Estimates of the indirect impact of Covid-19 on maternal and perinatal mortality was expected it to be considerable, but little data was yet available. This study aimed to examine the impact of Covid-19 and lockdown control measures on non-Covid outcomes in a government tertiary level maternity unit in Bulawayo, Zimbabwe, by comparing maternal and perinatal morbidity and mortality before, and after the lockdown was implemented. Methods This was a retrospective, observational study, using a cross-sectional design to compare routine monthly maternal and perinatal statistics three months before and after Covid-19 emergency measures were implemented at Mpilo Central Hospital. Results Between January-March and April-June 2020, the mean monthly deliveries reduced from 747.3 (SD ± 61.3) in the first quarter of 2020 to 681.0 (SD ± 17.6) during lockdown, but this was not statistically significant, p = 0.20. The Caesarean section rates fell from a mean of 29.8% (SD ± 1.7) versus 28.0% (SD ± 1.7), which was also not statistically significant, p = 0.18. During lockdown, the percentage of women delivering at Mpilo Central Hospital who were booked at the hospital fell from a mean of 41.6% (SD ± 1.1) to 35.8% (SD ± 4.3) which was statistically significant, p = 0.03. There was no significant change, however, in maternal mortality or severe maternal morbidity (such as post-partum haemorrhage (PPH), uterine rupture, and severe preeclampsia/eclampsia), stillbirth rate or special care baby unit admission. There was an increase in the mean total number of early neonatal deaths (ENND) (mean 18.7 (SD ± 2.9) versus 24.0 (SD ± 4.6), but this was not statistically significant, p = 0.32. Conclusions Overall, maternity services at Mpilo showed resilience during the lockdown period, with no significant change in maternal and perinatal adverse outcomes, with the same number of man-hours worked before and during the lockdown Maternal and perinatal outcomes should continue to be monitored to assess the impact of Covid-19 and the lockdown measures as the pandemic in Zimbabwe unfolds. Further studies would be beneficial to explore women’s experiences and understand how bookings and deliveries at local clinics changed during this time.

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Development of a Model for the Acquisition and Assessment of Advanced Laparoscopic Suturing Skills Using an Automated Device

Surgical Innovation ◽

10.1177/1553350618764221 ◽

2018 ◽

Vol 25 (3) ◽

pp. 286-290 ◽

Cited By ~ 2

Author(s):

Elif Bilgic ◽

Madoka Takao ◽

Pepa Kaneva ◽

Satoshi Endo ◽

Toshitatsu Takao ◽

...

Keyword(s):

Laparoscopic Surgery ◽

Interrater Reliability ◽

Intraclass Correlation ◽

Correlation Coefficients ◽

Instructional Video ◽

Validity Evidence ◽

Laparoscopic Suturing ◽

Intraclass Correlation Coefficients ◽

Operative Assessment ◽

Suturing Skills

Background. Needs assessment identified a gap regarding laparoscopic suturing skills targeted in simulation. This study collected validity evidence for an advanced laparoscopic suturing task using an Endo StitchTM device. Methods. Experienced (ES) and novice surgeons (NS) performed continuous suturing after watching an instructional video. Scores were based on time and accuracy, and Global Operative Assessment of Laparoscopic Surgery. Data are shown as medians [25th-75th percentiles] (ES vs NS). Interrater reliability was calculated using intraclass correlation coefficients (confidence interval). Results. Seventeen participants were enrolled. Experienced surgeons had significantly greater task (980 [964-999] vs 666 [391-711], P = .0035) and Global Operative Assessment of Laparoscopic Surgery scores (25 [24-25] vs 14 [12-17], P = .0029). Interrater reliability for time and accuracy were 1.0 and 0.9 (0.74-0.96), respectively. All experienced surgeons agreed that the task was relevant to practice. Conclusion. This study provides validity evidence for the task as a measure of laparoscopic suturing skill using an automated suturing device. It could help trainees acquire the skills they need to better prepare for clinical learning.

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What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

Otolaryngology ◽

10.1177/0194599820969631 ◽

2020 ◽

pp. 019459982096963

Author(s):

Vanessa F. Torrecillas ◽

Kaden Neuberger ◽

Alexander Ramirez ◽

Paul Krakovitz ◽

Jeremy D. Meier

Keyword(s):

Elective Surgery ◽

Lag Time ◽

Cross Sectional Study ◽

Health Claims ◽

Third Party ◽

Prior Authorization ◽

Cross Sectional ◽

Before And After ◽

The Mean ◽

The Impact

Objective Third-party payers advocate for prior authorization (PA) to reduce overutilization of health care resources. The impact of PA in elective surgery is understudied, especially in cases where evidence-based clinical practice guidelines define operative candidacy. The objective of this study is to investigate the impact of PA on the incidence of pediatric tonsillectomy. Study Design Cross-sectional study. Setting Health claims database from a third-party payer. Methods Any pediatric patient who had evaluation for tonsillectomy from 2016 to 2019 was eligible for inclusion. A time series analysis was used to evaluate the change in incidence of tonsillectomy before and after PA. Lag time from consultation to surgery before and after PA was compared with segmented regression. Results A total of 10,047 tonsillectomy claims met inclusion and exclusion criteria. Female patients made up 51% of claims, and the mean age was 7.9 years. Just 1.5% of claims were denied after PA implementation. There was no change in the incidence of tonsillectomy for all plan types ( P = .1). Increased lag time from consultation to surgery was noted immediately after PA implementation by 2.38 days (95% CI, 0.23-4.54; P = .030); otherwise, there was no significant change over time ( P = .98). Conclusion A modest number of tonsillectomy claims were denied approval after implementation of PA. The value of PA for pediatric tonsillectomy is questionable, as it did not result in decreased incidence of tonsillectomy in this cohort.

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Tracheobronchial Foreign Bodies: The Impact of a Postgraduate Educational Program on Diagnosis, Morbidity, and Treatment

PEDIATRICS ◽

10.1542/peds.70.1.96 ◽

1982 ◽

Vol 70 (1) ◽

pp. 96-98

Author(s):

Marc Puterman ◽

Rafael Gorodischer ◽

Alberto Leiberman

Keyword(s):

Educational Program ◽

Foreign Bodies ◽

Final Diagnosis ◽

Physician Performance ◽

Postgraduate Educational ◽

Before And After ◽

History Of ◽

The Mean ◽

Hospital Days ◽

The Impact

Aspirated foreign bodies (FBs) may remain undetected and cause serious complications. As part of a postgraduate educational program, results of a local survey were presented to the local medical staff in order to increase its awareness of this diagnostic possibility. The present study was carried out in order to evaluate the management of children with tracheobronchial FBs during two 2-year periods, before and after teaching sessions held in December 1976. In comparison with the previous two years during the 1977-1978 period, the percentage of cases in which a positive history of aspiration was obtained increased from 47.6% to 84.0%; the mean number of hospitalizations due to tracheobronchial FBs decreased from 1.9 to 1.04 per infant, and the mean number of hospital days required for final diagnosis decreased from 17.6 to 5.3. The postgraduate educational program had a positive effect on physician performance and patient care.

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A Study of Executive Function in Patients with Chronic Kidney Disease before and after a Single Session of Hemodialysis

Journal of Neurosciences in Rural Practice ◽

10.1055/s-0040-1703961 ◽

2020 ◽

Vol 11 (02) ◽

pp. 250-255

Author(s):

Vasantmeghna S. Murthy ◽

Vedant S. Shukla

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Statistical Tests ◽

T Test ◽

Emotional States ◽

Single Session ◽

Dialysis Unit ◽

Before And After ◽

The Mean ◽

The Impact

Abstract Background Executive functions (EFs) are critical to daily life and sensitive to our physiological functioning and emotional states. The number of people living with chronic kidney disease (CKD) on hemodialysis (HD) globally is increasing steadily. We aimed to determine the impact of a single session of HD on EFs in patients with CKD receiving maintenance HD (MHD). Methods This was a quasi-experimental study conducted at the department of psychiatry and dialysis unit of a tertiary hospital. Patients undergoing MHD underwent screening to rule out delirium, using the Confusion Assessment Method prior to EF testing. The tests of EF used were the Trail-Making Test—Part B (TMT-B) and Frontal Assessment Battery (FAB), both of which were administered before and after a session of HD. Statistical tests used were Wilcoxon matched pairs signed ranks test, paired t-test, single sample t-test, and correlation analyses. Results The mean time taken on TMT-B before HD was 195.36 seconds and after HD, 171.1 seconds; difference is significant (p = 0.0001). The mean FAB score was 13.19 before HD and 14.83 after HD; the difference is significant (p < 0.0001). Significant differences were observed on similarities (p = 0.003), lexical fluency (p = 0.02), and go–no go (p = 0.003) subtests of FAB. Mean TMT-B scores before and after HD differed significantly from that of a reference study (reference TMT-B 150.69 seconds), p = 0.0002 and 0.04, respectively. Conclusion We conclude that patients with CKD on MHD, in general, have worse executive cognitive functioning compared with healthy populations. A session of HD results in significant improvement in these functions.

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P139: The impact of a pancreatitis admission algorithm on emergency department length of stay in a tertiary care academic hospital

CJEM ◽

10.1017/cem.2020.343 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S114-S115

Author(s):

A. Albina ◽

F. Kegel ◽

F. Dankoff ◽

G. Clark

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Tertiary Care ◽

Physician Satisfaction ◽

Academic Hospital ◽

Before And After ◽

Potential Applicability ◽

The Mean ◽

Algorithm Implementation ◽

The Impact

Background: Emergency department (ED) overcrowding is associated with a broad spectrum of poor medical outcomes, including medical errors, mortality, higher rates of leaving without being seen, and reduced patient and physician satisfaction. The largest contributor to overcrowding is access block – the inability of admitted patients to access in-patient beds from the ED. One component to addressing access block involves streamlining the decision process to rapidly determine which hospital service will admit the patient. Aim Statement: As of Sep 2011, admission algorithms at our institution were supported and formalised. The pancreatitis algorithm clarified whether general surgery or internal medicine would admit ED patients with pancreatitis. We hypothesize that this prior uncertainty delayed the admission decision and prolonged ED length of stay (LOS) for patients with pancreatitis. Our project evaluates whether implementing a pancreatitis admission algorithm at our institution reduced ED time to disposition (TTD) and LOS. Measures & Design: A retrospective review was conducted in a tertiary care academic hospital in Montreal for all adult ED patients diagnosed with pancreatitis from Apr 2010 to Mar 2014. The data was used to plot separate run charts for ED TTD and LOS. Serial measurements of each outcome were used to monitor change and evaluate for special cause variation. The mean ED LOS and TTD before and after algorithm implementation were also compared using the Student's t test. Evaluation/Results: Over four years, a total of 365 ED patients were diagnosed with pancreatitis and 287 (79%) were admitted. The mean ED LOS for patients with pancreatitis decreased following the implementation of an admission algorithm (1616 vs. 1418 mins, p = 0.05). The mean ED TTD was also reduced (1171 vs. 899 mins, p = 0.0006). A non-random signal of change was suggested by a shift above the median prior to algorithm implementation and one below the median following. Discussion/Impact: This project demonstrates that in a busy tertiary care academic hospital, an admission algorithm helped reduce ED TTD and LOS for patients with pancreatitis. This proves especially valuable when considering the potential applicability of such algorithms to other disease processes, such as gastrointestinal bleeding and congestive heart failure, among others. Future studies demonstrating this external applicability, and the impact of such decision algorithms on physician decision fatigue and within non-academic institutions, proves warranted.

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Exercise right heart catheterisation before and after pulmonary endarterectomy in patients with chronic thromboembolic disease

European Respiratory Journal ◽

10.1183/13993003.00458-2018 ◽

2018 ◽

Vol 52 (3) ◽

pp. 1800458 ◽

Cited By ~ 10

Author(s):

Stefan Guth ◽

Christoph B. Wiedenroth ◽

Andreas Rieth ◽

Manuel J. Richter ◽

Ekkehard Gruenig ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Thromboembolic Disease ◽

Pulmonary Endarterectomy ◽

Right Heart ◽

Heart Catheterisation ◽

Right Heart Catheterisation ◽

Before And After ◽

The Mean ◽

Chronic Thromboembolic Disease ◽

The Impact

Symptomatic patients with chronic thromboembolic disease (CTED) without pulmonary hypertension often show an excessive increase in mean pulmonary arterial pressure (MPAP) during exercise.We report on the impact of pulmonary endarterectomy (PEA) on pulmonary haemodynamics in a prospective series of 32 consecutive CTED patients who underwent PEA. All patients had a comprehensive diagnostic work-up including right heart catheterisation at baseline and 12 months after PEA. Furthermore, in 12 patients exercise right heart catheterisation was performed before and after PEA.After PEA, MPAP was lower at rest (20±3 versus 17±3 mmHg; p=0.008) and during maximal exercise (39±8 versus 31±6 mmHg; p=0.016). The mean total pulmonary resistance (TPR) decreased from 3.6±0.8 Wood Units (WU) pre-operatively to 2.7±0.7 WU 1 year after PEA (p=0.004) and the mean slope of the MPAP/cardiac output (CO) relationship decreased from 3.6±1.0 to 2.3±0.8 WU (p=0.002). Peak oxygen uptake increased from 1.2±0.4 to 1.5±0.3 L·min−1 (p=0.014) and ventilatory equivalents of carbon dioxide decreased from 39±2 to 30±2 (p=0.002). There was a significant improvement in quality of life assessed by the Cambridge Pulmonary Hypertension Outcome Review questionnaire.In CTED patients, PEA resulted in haemodynamic and clinical improvements. The means of TPR and MPAP/CO slopes decreased to <3.0 WU.

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Quality of Life before and after Sleeve Gastrectomy in Lebanese Population

Journal of Obesity ◽

10.1155/2019/1952538 ◽

2019 ◽

Vol 2019 ◽

pp. 1-6

Author(s):

Marwan Alkassis ◽

Fady Gh Haddad ◽

Joseph Gharios ◽

Roger Noun ◽

Ghassan Chakhtoura

Keyword(s):

Quality Of Life ◽

Bariatric Surgery ◽

Weight Loss ◽

Sleeve Gastrectomy ◽

Sexual Pleasure ◽

Life Questionnaire ◽

Before And After ◽

The Mean ◽

The Impact

Introduction. Obesity is increasing worldwide and in Lebanon with a negative impact on the quality of life. The primary objective of this study is to measure the quality of life in obese subjects before and after bariatric surgery, depending on age, sex, and degree of weight loss. A secondary objective is to determine the impact of bariatric surgery on comorbidities associated with obesity. Materials and methods. Patients undergoing laparoscopic sleeve gastrectomy for BMI ≥ 30 kg/m2 between August 2016 and April 2017 were included. Participants completed the Moorehead-Ardelt Quality of Life Questionnaire II (MA II) prior to operation and one year after. Statistical analysis was carried out using SPSS statistics version 20.0. Results. 75 patients participated in the study. The majority were women (75%), and the mean age was 36.3 years. The mean weight loss was 36.57 kg (16–76). Initially, the total MA II score was −0.33 ± 0.93. Postoperatively, it increased to 1.68 ± 0.62 (p≤0.001). All MA II parameters improved after surgery (p≤0.001), but this improvement was independent of age and sex. Improvement in self-esteem, physical activity, work performance, and sexual pleasure was influenced by the degree of weight loss (p≤0.001). All comorbidities associated with obesity regressed significantly after sleeve gastrectomy (p<0.05) with the exception of gastroesophageal reflux and varicose veins of the lower limbs. Conclusion. Sleeve gastrectomy improves quality of life and allows reduction of comorbidities.

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Quality improvement initiative to reduce adverse effects associated with parenteral nutrition overfeeding

Frontline Gastroenterology ◽

10.1136/flgastro-2018-100995 ◽

2018 ◽

Vol 10 (1) ◽

pp. 67-71 ◽

Cited By ~ 1

Author(s):

Andrew J Franck

Keyword(s):

Quality Improvement ◽

Amino Acid ◽

Parenteral Nutrition ◽

Outcome Measures ◽

Liver Dysfunction ◽

Bloodstream Infections ◽

Quality Improvement Initiative ◽

Refeeding Syndrome ◽

The Mean ◽

The Impact

ObjectiveParenteral nutrition (PN) overfeeding is a potential risk factor in the development of infections and other complications including hyperglycaemia, refeeding syndrome and liver dysfunction. This study was conducted to evaluate the impact of a quality improvement initiative to reduce PN overfeeding.DesignRetrospective cohort study of a quality improvement initiative.SettingA health system comprised of two US Department of Veterans Affairs medical centres.PatientsPatients receiving PN.InterventionsMethods to reduce overfeeding included the use of standardised PN products with lower dextrose to amino acid ratios, reduced use of intravenous lipid emulsion (ILE), and use of adjusted body weights or guideline-recommended predictive equations for energy requirements.Main outcome measuresThe primary outcome measures were the doses of kilocalories, amino acids and ILE in each cohort. The proportions of patients developing complications before and after the intervention were evaluated.ResultsThe mean maximum total daily kilocalorie dose was 30.2 kcal/kg/day in the preintervention group (n=86) vs 23.4 kcal/kg/day in the postintervention group (n=62) (p<0.001). More patients in the postintervention group received reduced ILE during the first week of PN therapy compared with the preintervention group (p<0.001). The mean maximum total daily amino acid dose in each group was not significantly different. Significantly fewer cases of central line-associated bloodstream infections, hyperglycaemia and liver dysfunction were observed in the postintervention group.ConclusionsA quality improvement initiative to reduce PN overfeeding was effective in reducing kilocalorie and ILE doses while maintaining similar amino acid doses. Observed complications were reduced following the intervention.

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