Closed‐loop communication (CLC) is a fundamental aspect of effective communication, critical in the cardiac catheterization laboratory (cath lab) where physician orders are verbal. Complete CLC is ...typically a hospital and national mandate. Deficiencies in CLC have been shown to impair quality of care. Single center observational study, CLC for physician verbal orders in the cath lab were assessed by direct observation during a 5‐year quality improvement effort. Performance feedback and educational efforts were used over this time frame to improve CLC, and the effects of each intervention assessed. Responses to verbal orders were characterized as complete (all important parameters of the order repeated, the mandated response), partial, acknowledgment only, or no response. During the first observational period of 101 cases, complete CLC occurred in 195 of 515 (38%) medication orders and 136 of 235 (50%) equipment orders. Complete CLC improved over time with various educational efforts, (p < 0.001) but in the final observation period of 117 cases, complete CLC occurred in just 259 of 328 (79%) medication orders and 439 of 581 (76%) equipment orders. Incomplete CLC was associated with medication and equipment errors. CLC of physician verbal orders was used suboptimally in this medical team setting. Baseline data indicate that physicians and staff have normalized weak, unreliable communication methods. Such lapses were associated with errors in order implementation. A subsequent 5‐year quality improvement program resulted in improvement but a sizable minority of unacceptable responses. This represents an opportunity to improve patient safety in cath labs.
To assess the impact of an aggressive protocol to decrease the time from hospital arrival to onset of reperfusion therapy ("door to balloon DTB time") on the incidence of false-positive (FP) ...diagnosis of ST-segment elevation myocardial infarction (STEMI) and in-hospital mortality.
The study population included 1031 consecutive patients with presumed STEMI and confirmed ST-segment elevation who underwent emergent catheterization between July 1, 2008, and December 1, 2012, On July 1, 2009, we instituted an aggressive protocol to reduce DTB time. A quality improvement (QI) initiative was introduced on January 1, 2011, to maintain short DTB while improving outcomes. Outcomes were compared before and after the initiation of the DTB time protocol and similarly before and after the QI initiative. Outcomes were DTB time, the incidence of FP-STEMI, and in-hospital mortality. A review of the emergency catheterization database for the 10-year period from January 1, 2001, through December 31, 2010, was performed for historical comparison.
Of the 1031 consecutive patients with presumed STEMI who were assessed, 170 were considered to have FP-STEMI. The median DTB time decreased significantly from 76 to 61 minutes with the aggressive DTB time protocol (P=.001), accompanied by an increase of FP-STEMI (7.7% vs 16.5%; P=.02). Although a nonsignificant reduction of in-hospital mortality occurred in patients with true-positive STEMI (P=.60), a significant increase in in-hospital mortality was seen in patients with FP-STEMI (P=.03). After the QI initiative, a shorter DTB time (59 minutes) was maintained while decreasing FP-STEMI in-hospital mortality.
Aggressive measures to reduce DTB time were associated with an increased incidence of FP-STEMI and FP-STEMI in-hospital mortality. Efforts to reduce DTB time should be monitored systematically to avoid unnecessary procedures that may delay other appropriate therapies in critically ill patients.
Objectives
To assess closed‐loop communications (readback), a fundamental aspect of effective communication, among cardiovascular teams and assess improvement efforts.
Background
Effective ...communication within teams is essential to assure safety and optimal outcomes. Readback of verbal physician orders is a hospital and national requirement.
Methods
Single‐center observational study, where the readback responses to physician verbal orders in the catheterization laboratory were characterized over three distinct time intervals from 2015 to 2017. Performance feedback and focused education on the value of readbacks was provided to the teams in two waves, with subsequent remeasurement. Responses to verbal orders were characterized as complete (all important parameters of the order repeated for verification), partial, acknowledgement only, or no response. Changes in readback performance after quality interventions were assessed.
Results
During the first‐observational period of 101 cases, complete readback occurred in 195 of 515 (38%) medication orders and 136 of 235 (58%) equipment orders. After initial quality improvement efforts, 102 cases were observed. In these, 298 of 480 (62%) medication orders had complete readback, and 210 of 420 (50%) equipment orders had complete readback. After additional quality improvement efforts, 168 cases were observed. In these, 506 of 723 (70%) medication orders had complete readback, and 630 of 1,061 (59%) equipment orders had complete readback. Overall, medication order readback improved over time (correlation = 0.26 −0.30, −0.21; p < 0.001), but equipment order readback did not (correlation = 0.02 −0.07, 0.03; p = 0.44).
Conclusions
Closed‐loop communication of physician verbal orders was used infrequently in this medical team setting and proved difficult to fully improve. This is an important safety gap.
Cath derived values were based on simultaneous pressure wire recording of left ventricular pressure and fluid filled pressure catheter recording of aortic pressure measured > 5 cm above the valve.
Using pressure wire for aortic stenosis assessment with dobutamine challenge may offer a safe and higher quality technique to assess the severity of AS in LF/LG and NF/LG AS with reduced Ejection ...Fraction (EF).
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