Faculty Bibliography

BACKGROUND: Failure to rescue (FTR), the rate of death in patients suffering 1 of 6 in-hospital complications, is an Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator calculated from administrative data. OBJECTIVE: : We sought to assess the accuracy of the AHRQ FTR algorithm. METHODS: We undertook a retrospective chart review of 60 denominator cases of FTR identified by the algorithm at each of 40 University HealthSystem Consortium institutions. The primary outcome was the overall accuracy of the algorithm compared with chart review. We also assessed accuracy by complication type, patient characteristics, institution, service assignment, and mortality. RESULTS: Of 2354 cases, 1193 (50.7%) were accurately identified by the algorithm as having had at least one of the FTR-qualifying complications during hospitalization. Of the 3073 complications identified in these patients, 1497 (48.7%) were correctly flagged by the algorithm, 907 (29.5%) were present on admission, 419 (13.6%) were not confirmed by chart review, and 250 (8.1%) met a predefined complication-specific criterion for exclusion. The case accuracy rate varied significantly by institution (mean, 50.7%; range, 18.3-100%; P < 0.001), service assignment (surgical service, 62.9% vs. nonsurgical service, 42.9%; P < 0.001), and mortality (alive, 43.9% vs. dead, 67.5%; P < 0.001) but was not affected by patients' age, gender, race, or insurance status. CONCLUSIONS: As currently calculated from administrative data, the FTR algorithm misidentifies half of the cases on average, is least accurate for nonsurgical cases, and is widely variable across institutions. This indicator may be useful internally to flag possible cases of quality failure but has limitations for external institutional comparisons. Improvements in coding quality and consistency across institutions are needed.

BACKGROUND: Work hour regulations for house staff were intended in part to improve resident clinical and educational performance. OBJECTIVE: To characterize the effect of work hour regulation on internal medicine resident inpatient clinical experience and didactic education. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Chief residents at all accredited U.S. internal medicine residency programs outside New York. MEASUREMENTS AND MAIN RESULTS: The response rate was 62% (202/324). Most programs (72%) reported no change in average patient load per intern after work hour regulation. Many programs (48%) redistributed house staff admissions through the call cycle. The number of admissions per intern on long call (the day interns have the most admitting responsibility) decreased in 31% of programs, and the number of admissions on other days increased in 21% of programs. Residents on outpatient rotations were given new ward responsibilities in 36% of programs. Third-year resident ward and float time increased in 34% of programs, while third-year elective time decreased in 22% of programs. The mean weekly hours allotted to educational activities did not change significantly (12.7 vs 12.4, P = .12), but 56% of programs reported a decrease in intern attendance at educational activities. CONCLUSIONS: In response to work hour regulation, many internal medicine programs redistributed rather than reduced residents' inpatient clinical experience. Hours allotted to educational activities did not change; however, most programs saw a decrease in intern attendance at conferences, and many reduced third-year elective time.

BACKGROUND: Transfer of responsibility for patient care between physicians is a key process in the care of hospitalized patients. Systems of transfer management and transfer frequency may affect clinical outcomes. METHODS: To characterize the systems by which patient information is transferred ("signed out") between resident physicians in internal medicine residency programs and to determine the impact of recently enacted resident work-hour regulations on the frequency of transfers, we mailed a self-administered survey to chief residents at 324 accredited US internal medicine residency programs outside of New York State. The main outcome measures were sign-out practices, skills training, and transfer frequency. RESULTS: Surveys were returned from 202 programs (62%). Transfer systems varied among and within institutions: 55% did not consistently require both a written and an oral sign-out at transfers of care, 34% left sign-out to interns alone, and 59% had no means of informing nurses that a transfer had taken place. In addition, 60% of the programs did not provide any lectures or workshops on sign-out skills. After work-hour regulations were instituted, transfers of care for a hypothetical patient increased by a mean of 11% (from 7.0 to 7.8 transfers; P<.001) during a Monday-Friday hospitalization. A member of the primary team was in the hospital for 47% of the hospitalization. CONCLUSION: Although transfers of care are increasingly frequent, few internal medicine residency programs have comprehensive transfer of care systems in place, and most do not provide formal training in sign-out skills to all residents.

Noninvasive techniques, such as the signal averaged ECG, have been used to assess risk of ventricular tachyarrhythmias (VT). However, these methods produce false positive and negative results. The purpose of this study was to develop body surface map algorithms which would enhance prediction of susceptibility to VT. Fifty-three patients referred for programmed electrical stimulation were enrolled in this study. All patients underwent signal averaged ECG, body surface map, programmed electrical stimulation. Group I patients had no sustained inducible VT and group II patients had either inducible sustained VT at electrophysiology study or previously documented spontaneous, sustained VT. For body surface map analysis, the difference between extrema on isoarea maps was calculated and defined as the gradient range. An abnormal body surface map was defined as a QRST gradient range < or = 109 mv.ms. The mean QRST gradient range in group II was significantly < that in group I (P < 0.05). By logistic regression analysis, the presence of coronary artery disease, a QRST gradient range < or = 109 mv.ms, an EF < 40% and a signal averaged ECG QRS duration > 114 ms predicted VT. The sensitivity, specificity, positive and negative predictive values for predicting VT susceptibility of an algorithm which combines the signal averaged ECG QRS duration and the QRST gradients were 0.93, 0.76, 0.79, and 0.91, respectively, while those for the signal averaged ECG alone were 0.52, 0.69, 0.63, and 0.59 for VT susceptibility. A combined body surface map-signal averaged ECG algorithm was more sensitive in detecting susceptibility to VT than the signal averaged ECG alone.

The purpose of this study was to develop a simple computer-guided approach to localizing ventricular tachycardias during ventricular mapping. Six patients with sustained monomorphic ventricular tachycardia were connected to a 32-lead computer body surface mapping system. Isoarea maps of induced ventricular tachycardia were recorded. Then a pacing probe was placed in either the right or left ventricle, and maps were generated from a variety of sites. Differences between ventricular tachycardia and pace map maxima X, Y coordinates were utilized to guide catheter manipulation and localization. In 6 of 6 patients (100%) this method appeared to provide a systematic approach to ventricular tachycardia localization. Computer-generated correlations as well as the X, Y coordinates of the QRS isoarea maxima were used to determine proximity to the ventricular tachycardia foci and direct catheter manipulation. In the next three patients this method was applied prospectively to help guide catheter manipulation during ventricular tachycardia (two right ventricular outflow tract tachycardias, and one left ventricular tachycardia). After a mean of 4.0 +/- 1.7 radiofrequency applications, ventricular tachycardia was no longer inducible, and at 7 +/- 0 months follow-up there have been no arrhythmia recurrences. We conclude that online computerized body surface mapping can assist in localizing ventricular tachycardia. Differences in maxima during pace maps and in-situ ventricular tachycardias can help with catheter manipulation as well as with more precise identification of focal tachycardias. This technique appears to hold the promise of a simple computer-guided method that may facilitate radiofrequency catheter ablation.

A simple algorithm that combines QT dispersion with the signal-averaged electrocardiogram QRS duration provides an extremely sensitive method for predicting spontaneous or inducible ventricular tachyarrhythmias. This new algorithm may prove useful in determining which patients are at risk for ventricular tachyarrhythmia