Publications by authors named "Bradford D Winters"

38 Publications

Safety Culture as a Patient Safety Practice for Alarm Fatigue.

JAMA 2021 Sep;326(12):1207-1208

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1001/jama.2021.8316DOI Listing
September 2021

SWIFT: A Deep Learning Approach to Prediction of Hypoxemic Events in Critically-Ill Patients Using SpO Waveform Prediction.

medRxiv 2021 Mar 5. Epub 2021 Mar 5.

Hypoxemia is a significant driver of mortality and poor clinical outcomes in conditions such as brain injury and cardiac arrest in critically ill patients, including COVID-19 patients. Given the host of negative clinical outcomes attributed to hypoxemia, identifying patients likely to experience hypoxemia would offer valuable opportunities for early and thus more effective intervention. We present SWIFT (SpO W aveform I CU F orecasting T echnique), a deep learning model that predicts blood oxygen saturation (SpO ) waveforms 5 and 30 minutes in the future using only prior SpO values as inputs. When tested on novel data, SWIFT predicts more than 80% and 60% of hypoxemic events in critically ill and COVID-19 patients, respectively. SWIFT also predicts SpO waveforms with average MSE below .0007. SWIFT provides information on both occurrence and magnitude of potential hypoxemic events 30 minutes in advance, allowing it to be used to inform clinical interventions, patient triaging, and optimal resource allocation. SWIFT may be used in clinical decision support systems to inform the management of critically ill patients during the COVID-19 pandemic and beyond.
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http://dx.doi.org/10.1101/2021.02.25.21252234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941630PMC
March 2021

Management of Coronavirus Disease 2019 Intubation Teams.

A A Pract 2020 Jun;14(8):e01263

From the Emory University, Atlanta, Georgia.

Some patients infected with the Coronavirus Disease 2019 (COVID-19) require endotracheal intubation, an aerosol-generating procedure that is believed to result in viral transmission to personnel performing the procedure. Additionally, donning and doffing personal protective equipment can be time consuming. In particular, doffing requires strict protocol adherence to avoid exposure. We describe the Emory Healthcare intubation team approach during the COVID-19 pandemic. This structure resulted in only 1 team member testing positive for COVID-19 despite 253 patient intubations over a 6-week period with 153 anesthesia providers on service.
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http://dx.doi.org/10.1213/XAA.0000000000001263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323820PMC
June 2020

A comparison of two structured taxonomic strategies in capturing adverse events in U.S. hospitals.

Health Serv Res 2019 06 25;54(3):613-622. Epub 2018 Nov 25.

Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Objective: To compare the Agency for Healthcare Research and Quality's Quality and Safety Review System (QSRS) and the proposed triadic structure for the 11th version of the International Classification of Disease (ICD-11) in their ability to capture adverse events in U.S. hospitals.

Data Sources/study Setting: One thousand patient admissions between 2014 and 2016 from three general, acute care hospitals located in Maryland and Washington D.C.

Study Design: The admissions chosen for the study were a random sample from all three hospitals.

Data Collection/extraction Methods: All 1000 admissions were abstracted through QSRS by one set of Certified Coding Specialists and a different set of coders assigned the draft ICD-11 codes. Previously assigned ICD-10-CM codes for 230 of the admissions were also used.

Principal Findings: We found less than 20 percent agreement between QSRS and ICD-11 in identifying the same adverse event. The likelihood of a mismatch between QSRS and ICD-11 was almost twice that of a match. The findings were similar to the agreement found between QSRS and ICD-10-CM in identifying the same adverse event. When coders were provided with a list of potential adverse events, the sensitivity and negative predictive value of ICD-11 improved.

Conclusions: While ICD-11 may offer an efficient way of identifying adverse events, our analysis found that in its draft form, it has a limited ability to capture the same types of events as QSRS. Coders may require additional training on identifying adverse events in the chart if ICD-11 is going to prove its maximum benefit.
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http://dx.doi.org/10.1111/1475-6773.13090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6505417PMC
June 2019

Using Continuous Vital Sign Monitoring to Detect Early Deterioration in Adult Postoperative Inpatients.

J Nurs Care Qual 2019 Apr/Jun;34(2):107-113

Johns Hopkins Hospital, Baltimore, Maryland (Drs Verrillo and Winters); Office of Integrated Healthcare Delivery, Johns Hopkins Health System, Baltimore, Maryland (Dr Cvach); and The Johns Hopkins University School of Nursing, Baltimore, Maryland (Dr Hudson).

Background: Episodic vital sign collection (eVSC), as single data points, gives an incomplete picture of adult patients' postoperative physiologic status.

Local Problem: Late detection of patient deterioration resulted in poor patient outcomes on a postsurgical unit.

Methods: Baseline demographic and outcome data were collected through retrospective chart review of all patients admitted to the surgical unit for 12 weeks prior to this quality improvement project. Data on the same outcomes were collected during the 12-week project.

Intervention: This project compared outcomes between the current standard of eVSC and the proposed standard of continuous vital sign monitoring (cVSM).

Results: Using cVSM demonstrated a statistically significant 27% decrease in the complication rate, and a clinically significant decrease in transfers to an intensive care unit and failure-to-rescue (FTR) events rate.

Conclusions: cVSM demonstrated detection of early signs of patient deterioration to prevent FTR.
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http://dx.doi.org/10.1097/NCQ.0000000000000350DOI Listing
March 2019

Review: Continuous Monitoring to Detect Failure to Rescue in Adult Postoperative Inpatients.

Biomed Instrum Technol 2018 Jul/Aug;52(4):281-287

Failure to rescue, or the unexpected death of a patient due to a preventable complication, is a nationally documented problem with numerous and multifaceted contributing factors. These factors include the frequency and method of collecting vital sign data, response to abnormal vital signs, and delays in the escalation of care for general ward patients who are showing signs of clinical deterioration. Patients' clinical deterioration can be complicated by concurrent secondary factors, including opioid abuse/dependence, being uninsured, or having sleep-disordered breathing. Using the Johns Hopkins Nursing Evidence-Based Practice Model, this integrative review synthesizes 43 research and nonresearch sources of evidence. Published between 2001 and 2017, these sources of evidence focus on failure to rescue, the multifaceted contributing factors to failure to rescue, and how continuous vital sign monitoring could ameliorate failure to rescue and its causes. Recommendations from the sources of evidence have been divided into system, structural, or technological categories.
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http://dx.doi.org/10.2345/0899-8205-52.4.281DOI Listing
October 2018

Effective approaches to control non-actionable alarms and alarm fatigue.

J Electrocardiol 2018 Nov - Dec;51(6S):S49-S51. Epub 2018 Jul 17.

Department of Anesthesiology and Critical Care Medicine, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University School of Medicine, 9127 Zayed 1800 Orleans Street, Baltimore, MD 21287, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.jelectrocard.2018.07.007DOI Listing
October 2019

Intensivist Presence at Code Events Is Associated with High Survival and Increased Documentation Rates.

Crit Care Clin 2018 Apr 13;34(2):259-266. Epub 2018 Feb 13.

Johns Hopkins University, School of Medicine, Johns Hopkins Medicine, Armstrong Institute for Quality and Patient Safety, 1800 Orleans Street, Baltimore, MD 21287, USA.

To better support the highest function of the Johns Hopkins Hospital adult code and rapid response teams, a team leadership role was created for a faculty intensivist, with the intention to integrate improve processes of care delivery, documentation, and decision-making. This article examines process and outcomes associated with the introduction of this role. It demonstrates that an intensivist has the potential to improve patient care while offsetting costs through improved billing capture.
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http://dx.doi.org/10.1016/j.ccc.2017.12.009DOI Listing
April 2018

Technological Distractions (Part 2): A Summary of Approaches to Manage Clinical Alarms With Intent to Reduce Alarm Fatigue.

Crit Care Med 2018 01;46(1):130-137

1Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD.2Department of Integrated Healthcare Delivery, Johns Hopkins Health System, Baltimore, MD.3Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.4Departments of Physiological Nursing and Neurological Surgery, UC Berkeley/UCSF Joint Bio-Engineering Graduate Programe, Berkeley, CA.5Department of Clinical Engineering, Clinical Engineering Professional Services, University of Virginia Health System, Charlottesville, VA.6Department of Anesthesia and Critical Care Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.7Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.8Department of Nephrology, Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, Nottingham, United Kingdom.9Department of Physiological Nursing, University of California, San Francisco, San Francisco, CA.10Critical Care Division, Department of Critical Care, Grady Health Systems, Atlanta, GA.11Department of Pharmacy and Therapeutics, Critical Care Medicine, Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA.

Objective: Alarm fatigue is a widely recognized safety and quality problem where exposure to high rates of clinical alarms results in desensitization leading to dismissal of or slowed response to alarms. Nonactionable alarms are thought to be especially problematic. Despite these concerns, the number of clinical alarm signals has been increasing as an everincreasing number of medical technologies are added to the clinical care environment.

Data Sources: PubMed, SCOPUS, Embase, and CINAHL.

Study Selection: We performed a systematic review of the literature focused on clinical alarms. We asked a primary key question; "what interventions have been attempted and resulted in the success of reducing alarm fatigue?" and 3-secondary key questions; "what are the negative effects on patients/families; what are the balancing outcomes (unintended consequences of interventions); and what human factor approaches apply to making an effective alarm?"

Data Extraction: Articles relevant to the Key Questions were selected through an iterative review process and relevant data was extracted using a standardized tool.

Data Synthesis: We found 62 articles that had relevant and usable data for at least one key question. We found that no study used/developed a clear definition of "alarm fatigue." For our primary key question 1, the relevant studies focused on three main areas: quality improvement/bundled activities; intervention comparisons; and analysis of algorithm-based false and total alarm suppression. All sought to reduce the number of total alarms and/or false alarms to improve the positive predictive value. Most studies were successful to varying degrees. None measured alarm fatigue directly.

Conclusions: There is no agreed upon valid metric(s) for alarm fatigue, and the current methods are mostly indirect. Assuming that reducing the number of alarms and/or improving positive predictive value can reduce alarm fatigue, there are promising avenues to address patient safety and quality problem. Further investment is warranted not only in interventions that may reduce alarm fatigue but also in defining how to best measure it.
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http://dx.doi.org/10.1097/CCM.0000000000002803DOI Listing
January 2018

Technologic Distractions (Part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics.

Crit Care Med 2017 Sep;45(9):1481-1488

1Department of Pharmacy, Critical Care Medicine, Biomedical Informatics and Clinical Translational Science Institute, University of Pittsburgh, Pittsburgh, PA. 2Department of Pharmacy, UPMC, Pittsburgh, PA. 3Department of Anesthesia and Critical Care Section of Pulmonary and Critical Care Medicine, The University of Chicago, Chicago, IL. 4Department of Medicine, The University of Chicago, Chicago, IL. 5Division of General Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA. 6Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, United Kingdom. 7Critical Care Division, Grady Health Systems, Atlanta, GA. 8Division of General Pediatrics, Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA. 9Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 10John Hopkins Health System, Baltimore, MD. 11Department of Physiological Nursing, University of California, San Francisco, CA. 12Clinical Engineering Professional Services, University of Virginia Health System, Charlottesville, VA. 13Department of Anesthesiology, Critical Care Medicine, Surgery and Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD.

Objective: To provide ICU clinicians with evidence-based guidance on tested interventions that reduce or prevent alert fatigue within clinical decision support systems.

Design: Systematic review of PubMed, Embase, SCOPUS, and CINAHL for relevant literature from 1966 to February 2017.

Patients: Focus on critically ill patients and included evaluations in other patient care settings, as well.

Interventions: Identified interventions designed to reduce or prevent alert fatigue within clinical decision support systems.

Measurements And Main Results: Study selection was based on one primary key question to identify effective interventions that attempted to reduce alert fatigue and three secondary key questions that covered the negative effects of alert fatigue, potential unintended consequences of efforts to reduce alert fatigue, and ideal alert quantity. Data were abstracted by two reviewers independently using a standardized abstraction tool. Surveys, meeting abstracts, "gray" literature, studies not available in English, and studies with non-original data were excluded. For the primary key question, articles were excluded if they did not provide a comparator as key question 1 was designed as a problem, intervention, comparison, and outcome question. We anticipated that reduction in alert fatigue, including the concept of desensitization may not be directly measured and thus considered interventions that reduced alert quantity as a surrogate marker for alert fatigue. Twenty-six articles met the inclusion criteria.

Conclusion: Approaches for managing alert fatigue in the ICU are provided as a result of reviewing tested interventions that reduced alert quantity with the anticipated effect of reducing fatigue. Suggested alert management strategies include prioritizing alerts, developing sophisticated alerts, customizing commercially available alerts, and including end user opinion in alert selection. Alert fatigue itself is studied less frequently, as an outcome, and there is a need for more precise evaluation. Standardized metrics for alert fatigue is needed to advance the field. Suggestions for standardized metrics are provided in this document.
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http://dx.doi.org/10.1097/CCM.0000000000002580DOI Listing
September 2017

Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events.

Crit Care Med 2017 Jul;45(7):1208-1215

1Armstrong Institute, Johns Hopkins School of Medicine, Baltimore, MD.2Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.3The Hospital and Healthsystem Association of Pennsylvania, Harrisburg, PA.4Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD.5Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.6Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, MA.7Department of Medicine, Brigham and Women's Hospital, Boston, MA.8Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Objectives: Ventilator-associated events are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the National Institute of Health and Agency for Healthcare Research and Quality funded a two-state collaborative to reduce ventilator-associated events. We describe the collaborative's impact on ventilator-associated event rates in 56 ICUs.

Design: Longitudinal quasi-experimental study.

Setting: Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015.

Interventions: We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork, and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multidisciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a Web-based portal.

Measurements And Results: ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively.

Conclusions: A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in ventilator-associated event, infection-related ventilator-associated complication, and probable ventilator-associated pneumonia. Our study is the largest to date affirming that best practices can prevent ventilator-associated events.
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http://dx.doi.org/10.1097/CCM.0000000000002463DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5474162PMC
July 2017

Anesthesiologists and Disaster Medicine: A Needs Assessment for Education and Training and Reported Willingness to Respond.

Anesth Analg 2017 05;124(5):1662-1669

From the *Division of Cardiac Anesthesiology, Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; †Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; ‡Independent Contractor at Natasha Shallow MD SC, Brookfield, Wisconsin; §Department of Anesthesiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; ‖Johns Hopkins Bloomberg School of Public Health Biostatistics Center, Baltimore, Maryland; ¶Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington Medical Center, Seattle, Washington; and #Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.

Background: Anesthesiologists provide comprehensive health care across the emergency department, operating room, and intensive care unit. To date, anesthesiologists' perspectives regarding disaster medicine and public health preparedness have not been described.

Methods: Anesthesiologists' thoughts and attitudes were assessed via a Web-based survey at 3 major academic institutions. Frequencies, percentages, and odds ratios (ORs) were used to assess self-reported perceptions of knowledge and skills, as well as attitudes and beliefs regarding education and training, employee development, professional obligation, safety, psychological readiness, efficacy, personal preparedness, and willingness to respond (WTR). Three representative disaster scenarios (natural disaster [ND], radiological event [RE], and pandemic influenza [PI]) were investigated. Results are reported as percent or OR (95% confidence interval).

Results: Participants included 175 anesthesiology attendings (attendings) and 95 anesthesiology residents (residents) representing a 47% and 51% response rate, respectively. A minority of attendings indicated that their hospital provides adequate pre-event preparation and training (31% [23-38] ND, 14% [9-21] RE, and 40% [31-49] PI). Few residents felt that their residency program provided them with adequate preparation and training (22% [14-33] ND, 16% [8-27] RE, and 17% [9-29] PI). Greater than 85% of attendings (89% [84-94] ND, 88% [81-92] RE, and 87% [80-92] PI) and 70% of residents (81% [71-89] ND, 71% [58-81] RE, and 82% [70-90] PI) believe that their hospital or residency program, respectively, should provide them with preparation and training. Approximately one-half of attendings and residents are confident that they would be safe at work during response to a ND or PI (55% [47-64] and 58% [49-67] of attendings; 59% [48-70] and 48% [35-61] of residents, respectively), whereas approximately one-third responded the same regarding a RE (31% [24-40] of attendings and 28% [18-41] of residents). Fewer than 40% of attendings (34% [26-43]) and residents (38% [27-51]) designated who would take care of their family obligations in the event they were called into work during a disaster. Regardless of severity, 79% (71-85) of attendings and 73% (62-82) of residents indicated WTR to a ND, whereas 81% (73-87) of attendings and 70% (58-81) of residents indicated WTR to PI. Fewer were willing to respond to a RE (63% [55-71] of attendings and 52% [39-64] of residents). In adjusted logistic regression analyses, those anesthesiologists who reported knowing one's role in response to a ND (OR, 15.8 [4.5-55.3]) or feeling psychologically prepared to respond to a ND (OR, 6.9 [2.5-19.0]) were found to be more willing to respond. Similar results were found for RE and PI constructs. Both attendings and residents were willing to respond in whatever capacity needed, not specifically to provide anesthesia.

Conclusions: Few anesthesiologists reported receiving sufficient education and training in disaster medicine and public health preparedness. Providing education and training and enhancing related employee services may further bolster WTR and help to build a more capable and effective medical workforce for disaster response.
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http://dx.doi.org/10.1213/ANE.0000000000002002DOI Listing
May 2017

PPV and the PSIs/HAC Measures.

Med Care 2017 01;55(1):87-88

The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1097/MLR.0000000000000681DOI Listing
January 2017

Validity of the Agency for Health Care Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: A Systematic Review and Meta-Analysis.

Med Care 2016 Dec;54(12):1105-1111

*Johns Hopkins School of Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD Departments of †Health Policy and Management, Johns Hopkins School of Medicine ‡Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine §Johns Hopkins University Bloomberg School of Public Health ∥Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD.

Background: The Agency for Health Care Research and Quality Patient Safety Indicators (PSIs) and Centers for Medicare and Medicaid Services Hospital-acquired Conditions (HACs) are increasingly being used for pay-for-performance and public reporting despite concerns over their validity. Given the potential for these measures to misinform patients, misclassify hospitals, and misapply financial and reputational harm to hospitals, these need to be rigorously evaluated. We performed a systematic review and meta-analysis to assess PSI and HAC measure validity.

Methods: We searched MEDLINE and the gray literature from January 1, 1990 through January 14, 2015 for studies that addressed the validity of the HAC measures and PSIs. Secondary outcomes included the effects of present on admission (POA) modifiers, and the most common reasons for discrepancies. We developed pooled results for measures evaluated by ≥3 studies. We propose a threshold of 80% for positive predictive value or sensitivity for pay-for-performance and public reporting suitability.

Results: Only 5 measures, Iatrogenic Pneumothorax (PSI 6/HAC 17), Central Line-associated Bloodstream Infections (PSI 7), Postoperative hemorrhage/hematoma (PSI 9), Postoperative deep vein thrombosis/pulmonary embolus (PSI 12), and Accidental Puncture/Laceration (PSI 15), had sufficient data for pooled meta-analysis. Only PSI 15 (Accidental Puncture and Laceration) met our proposed threshold for validity (positive predictive value only) but this result was weakened by considerable heterogeneity. Coding errors were the most common reasons for discrepancies between medical record review and administrative databases. POA modifiers may improve the validity of some measures.

Conclusion: This systematic review finds that there is limited validity for the PSI and HAC measures when measured against the reference standard of a medical chart review. Their use, as they currently exist, for public reporting and pay-for-performance, should be publicly reevaluated in light of these findings.
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http://dx.doi.org/10.1097/MLR.0000000000000550DOI Listing
December 2016

Evaluation of Noninvasive Hemoglobin Monitoring in Surgical Critical Care Patients.

Crit Care Med 2016 Jun;44(6):e344-52

1Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, MD. 2Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, MD.

Objective: To assess the clinical utility of noninvasive hemoglobin monitoring based on pulse cooximetry in the ICU setting.

Design And Setting: A total of 358 surgical patients from a large urban, academic hospital had the noninvasive hemoglobin monitoring pulse cooximeter placed at admission to the ICU. Core and stat laboratory hemoglobin measurements were taken at the discretion of the clinicians, who were blinded to noninvasive hemoglobin monitoring values.

Measurement And Main Results: There was a poor correlation between the 2,465 time-matched noninvasive hemoglobin monitoring and laboratory hemoglobin measurements (r = 0.29). Bland-Altman analysis showed a positive bias of 1.0 g/dL and limits of agreement of -2.5 to 4.6 g/dL. Accuracy was best at laboratory values of 10.5-14.5 g/dL and least at laboratory values of 6.5-8 g/dL. At hemoglobin values that would ordinarily identify a patient as requiring a transfusion (< 8 g/dL), noninvasive hemoglobin monitoring consistently overestimated the patient's true hemoglobin. When sequential laboratory values declined below 8 g/dL (n = 102) and 7 g/dL (n = 13), the sensitivity and specificity of noninvasive hemoglobin monitoring at identifying these events were 27% and 7%, respectively. At a threshold of 8 g/dL, continuous noninvasive hemoglobin monitoring values reached the threshold before the labs in 45 of 102 instances (44%) and at 7 g/dL, noninvasive hemoglobin monitoring did so in three of 13 instances (23%). Noninvasive hemoglobin monitoring minus laboratory hemoglobin differences showed an intraclass correlation coefficient of 0.47 within individual patients. Longer length of stay and higher All Patient Refined Diagnostic-Related Groups severity of illness were associated with poor noninvasive hemoglobin monitoring accuracy.

Conclusions: Although noninvasive hemoglobin monitoring technology holds promise, it is not yet an acceptable substitute for laboratory hemoglobin measurements. Noninvasive hemoglobin monitoring performs most poorly in the lower hemoglobin ranges that include commonly used transfusion trigger thresholds and is not consistent within individual patients. Further refinement of the signal acquisition and analysis algorithms and clinical reevaluation are needed.
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http://dx.doi.org/10.1097/CCM.0000000000001634DOI Listing
June 2016

Hospital Characteristics and the Agency for Healthcare Research and Quality Inpatient Quality Indicators: A Systematic Review.

J Healthc Qual 2016 Sep-Oct;38(5):304-13

Background: The Agency for Healthcare Research and Quality Inpatient Quality Indicators (IQIs) include inpatient mortality for selected procedures and medical conditions. They have assumed an increasingly prominent role in hospital comparisons. Healthcare delivery and policy-related decisions need to be driven by reliable research that shows associations between hospital characteristics and quality of inpatient care delivered.

Objectives: To systematically review the literature on associations between hospital characteristics and IQIs.

Methods: We systematically searched PubMed and gray literature (2000-2012) for studies relevant to 14 hospital characteristics and 17 IQIs. We extracted data for study characteristics, IQIs analyzed, and hospital characteristics (e.g., teaching status, bed size, patient volume, rural vs. urban location, and nurse staffing).

Results: We included 16 studies, which showed few significant associations. Four hospital characteristics (higher hospital volume, higher nurse staffing, urban vs. rural status, and higher hospital financial resources) had statistically significant associations with lower mortality and selected IQIs in approximately half of the studies. For example, there were no associations between nurse staffing and four IQIs; however, approximately 50% of studies showed a statistically significant relationship between nurse staffing and lower mortality for six IQIs. For two hospital characteristics-higher bed size and disproportionate share percentage-all statistically significant associations had higher mortality. Five hospital characteristics (teaching status, system affiliation, ownership, minority-serving hospitals, and electronic health record status) had some studies with significantly positive and some with significantly negative associations, and many studies with no association.

Conclusions: We found few associations between hospital characteristics and mortality IQIs. Differences in study methodology, coding across hospitals, and hospital case-mix adjustment may partly explain these results. Ongoing research will evaluate potential mechanisms for the identified associations.
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http://dx.doi.org/10.1097/JHQ.0000000000000015DOI Listing
April 2018

The prevalence of long QT interval in post-operative intensive care unit patients.

J Clin Monit Comput 2016 Aug 14;30(4):437-43. Epub 2015 Jul 14.

Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

The severity of patient illnesses and medication complexity in post-operative critically ill patients increase the risk for a prolonged QT interval. We determined the prevalence of prolonged QTc in surgical intensive care unit (SICU) patients. We performed a prospective cross-sectional study over a 15-month period at a major academic center. SICU pre-admission and admission EKGs, patient demographics, and laboratory values were analyzed. QTc was evaluated as both a continuous and dichotomous outcome (prolonged QTc > 440 ms). 281 patients were included in the study: 92 % (n = 257) post-operative and 8 % (n = 24) non-operative. On pre-admission EKGs, 32 % of the post-operative group and 42 % of the non-operative group had prolonged QTc (p = 0.25); on post-admission EKGs, 67 % of the post-operative group but only 33 % of the non-operative group had prolonged QTc (p < 0.01). The average change in QTc in the post-operative group was +30.7 ms, as compared to +2 ms in the non-operative group (p < 0.01). On multivariable adjustment for long QTc as a dichotomous outcome, pre-admission prolonged QTc (OR 3.93, CI 1.93-8.00) and having had an operative procedure (OR 4.04, CI 1.67-9.83) were associated with developing prolonged QTc. For QTc as a continuous outcome, intra-operative beta-blocker use was associated with a statistically-significant decrease in QTc duration. None of the patients developed a lethal arrhythmia in the ICU. Prolonged QTc is common among post-operative SICU patients (67 %), however lethal arrhythmias are uncommon. The operative experience increases the risk for long QTc.
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http://dx.doi.org/10.1007/s10877-015-9736-1DOI Listing
August 2016

Integration of a difficult airway response team into a hospital emergency response system.

Anesthesiol Clin 2015 Jun;33(2):369-79

Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287-0910, USA. Electronic address:

Hospital-wide emergency response teams have been an area of development for several decades. Highly specialized to address emergent needs, they mimic the cardiac-pulmonary arrest teams established at hospitals nationwide, such as heart attack, brain attack, medical emergency, rapid response, and difficult airway response teams (DART). The DART at Johns Hopkins Hospital is a collaboration of the Anesthesiology and Critical Care Medicine, Otolaryngology-Head and Neck Surgery, General Surgery, and Emergency Medicine departments. This successful model may be used by other hospitals to establish improved and comprehensive care of the difficult airway patient.
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http://dx.doi.org/10.1016/j.anclin.2015.02.008DOI Listing
June 2015

Diagnostic errors in the pediatric and neonatal ICU: a systematic review.

Pediatr Crit Care Med 2015 Jan;16(1):29-36

1Division of Pediatric Critical Care, Department of Pediatrics, University of Maryland, Baltimore, MD. 2Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 3Welsh Library for the School of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 4Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 5Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.

Objective: Diagnostic errors lead to preventable hospital morbidity and mortality. ICU patients may be at particularly high risk for misdiagnosis. Little is known about misdiagnosis in pediatrics, including PICU and neonatal ICU. We sought to assess diagnostic errors in PICU and neonatal ICU settings by systematic review.

Data Sources: We searched PubMed, Embase, CINAHL, and Cochrane.

Study Selection: We identified observational studies reporting autopsy-confirmed diagnostic errors in PICU or neonatal ICU using standard Goldman criteria.

Data Extraction: We abstracted patient characteristics, diagnostic error description, rates and error classes using standard Goldman criteria for autopsy misdiagnoses and calculated descriptive statistics.

Data Synthesis: We screened 329 citations, examined 79 full-text articles, and included 13 studies (seven PICU; six neonatal ICU). The PICU studies examined a total of 1,063 deaths and 498 autopsies. Neonatal ICU studies examined a total of 2,124 neonatal deaths and 1,259 autopsies. Major diagnostic errors were found in 19.6% of autopsied PICU and neonatal ICU deaths (class I, 4.5%; class II, 15.1%). Class I (potentially lethal) misdiagnoses in the PICU (43% infections, 37% vascular) and neonatal ICU (62% infections, 21% congenital/metabolic) differed slightly. Although missed infections were most common in both settings, missed vascular events were more common in the PICU and missed congenital conditions in the neonatal ICU.

Conclusion: Diagnostic errors in PICU/neonatal ICU populations are most commonly due to infection. Further research is needed to better quantify pediatric intensive care-related misdiagnosis and to define potential strategies to reduce their frequency or mitigate misdiagnosis-related harm.
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http://dx.doi.org/10.1097/PCC.0000000000000274DOI Listing
January 2015

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

Infect Control Hosp Epidemiol 2014 Jan 26;35(1):56-62. Epub 2013 Nov 26.

Johns Hopkins Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections.

Methods: We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented.

Results: A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16-18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50-0.65) at 16-18 months after implementation.

Conclusion: Coincident with the implementation of the national "On the CUSP: Stop BSI" program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.
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http://dx.doi.org/10.1086/674384DOI Listing
January 2014

Rapid response systems: should we still question their implementation?

J Hosp Med 2013 May 22;8(5):278-81. Epub 2013 Apr 22.

Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, and Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD 21287, USA.

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http://dx.doi.org/10.1002/jhm.2050DOI Listing
May 2013

Rapid-response systems as a patient safety strategy: a systematic review.

Ann Intern Med 2013 Mar;158(5 Pt 2):417-25

Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.

Rapid-response systems (RRSs) are a popular intervention in U.S. hospitals and are supported by accreditors and quality improvement organizations. The purpose of this review is to evaluate the effectiveness and implementation of these systems in acute care settings. A literature search was performed between 1 January 2000 through 30 October 2012 using PubMed, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies published in any language evaluating outcome changes that occurred after implementing an RRS and differences between groups using and not using an RRS (effectiveness) or describing methods used by RRSs (implementation) were reviewed. A single reviewer (checked by a second reviewer) abstracted data and rated study quality and strength of evidence. Moderate-strength evidence from a high-quality meta-analysis of 18 studies and 26 lower-quality before-and-after studies published after that meta-analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest outside of the intensive care unit and reduced mortality. Eighteen studies examining facilitators of and barriers to implementation suggested that the rate of use of RRSs could be improved.
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http://dx.doi.org/10.7326/0003-4819-158-5-201303051-00009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695999PMC
March 2013

Decreasing central-line-associated bloodstream infections in Connecticut intensive care units.

J Healthc Qual 2013 Sep-Oct;35(5):78-87. Epub 2013 Jan 24.

Connecticut Hospital Association in Wallingford, Connecticut, USA.

Central-line-associated bloodstream infections (CLABSIs) are a significant cause of preventable harm. A collaborative project involving a multifaceted intervention was used in the Michigan Keystone Project and associated with significant reductions in these infections. This intervention included the Comprehensive Unit-based Safety Program, a multifaceted approach to CLABSI prevention, and the monitoring and reporting of infections. The purpose of this study was to determine whether the multifaceted intervention from the Michigan Keystone program could be implemented in Connecticut and to evaluate the impact on CLABSI rates in intensive care units (ICUs). The primary outcome was the NHSN-defined rate of CLABSI. Seventeen ICUs, representing 14 hospitals and 104,695 catheter days were analyzed. The study period included up to four quarters (12 months) of baseline data and seven quarters (21 months) of postintervention data. The overall mean (median) CLABSI rate decreased from 1.8 (1.8) infections per 1,000 catheter days at baseline to 1.1 (0) at seven quarters postimplementation of the intervention. This study demonstrated that the multifaceted intervention used in the Keystone program could be successfully implemented in another state and was associated with a reduction in CLABSI rates in Connecticut. Moreover, even though the statewide baseline CLABSI rate in Connecticut was low, rates were reduced even further and well below national benchmarks.
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http://dx.doi.org/10.1111/j.1945-1474.2012.00210.xDOI Listing
June 2014

A novel approach to implementation of quality and safety programmes in anaesthesiology.

Best Pract Res Clin Anaesthesiol 2011 Dec;25(4):557-67

Department of Anesthesiology, Critical Care and Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA.

Far too many patients suffer preventable harm from medical errors that add to needless suffering and cost of care. Underdeveloped residency training programmes in patient safety are a major contributor to preventable harm. Consequently, the Institute of Medicine has called for health professionals to reform their educational programmes to advance health-care safety and quality. Additionally, the Accreditation Council for Graduate Medical Education (ACGME) now requires education in 'systems-based practice' and 'practice-based learning and improvement' as core competencies of residency training programmes. The specific aim of this article is to describe the implementation of a novel programme designed to enhance residency education, meet ACGME core competencies and improve quality and safety education in one residency programme at an academic medical institution.
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http://dx.doi.org/10.1016/j.bpa.2011.08.002DOI Listing
December 2011

Eradicating central line-associated bloodstream infections statewide: the Hawaii experience.

Am J Med Qual 2012 Mar-Apr;27(2):124-9. Epub 2011 Sep 14.

Hawaii Medical Services Association, Honolulu, HI, USA.

The authors' goal was to determine if a national intensive care unit (ICU) collaborative to reduce central line-associated bloodstream infections (CLABSIs) would succeed in Hawaii. The intervention period (July 2009 to December 2010) included a comprehensive unit-based safety program; a multifaceted approach to CLABSI prevention; and monitoring of infections. The primary outcome was CLABSI rate. A total of 20 ICUs, representing 16 hospitals and 61 665 catheter days, were analyzed. Median hospital bed size was 159 (interquartile range [IQR] = 71-212) and median ICU bed size was 10 (IQR = 8-12). Median unit catheter days per month were 112 (IQR = 52-197). The overall mean CLABSI rate decreased from 1.5 infections per 1000 catheter days at baseline (January to June 2009) to 0.6 at 16 to 18 months postintervention (October to December 2010). The median rate was zero CLABSIs per 1000 catheter days at baseline and remained zero throughout the study period. Hawaii demonstrated that the national program can be successfully spread, providing further evidence that most CLABSIs are preventable.
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http://dx.doi.org/10.1177/1062860611414299DOI Listing
July 2012

Commentary: Reducing diagnostic errors: another role for checklists?

Acad Med 2011 Mar;86(3):279-81

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Diagnostic errors are a widespread problem, although the true magnitude is unknown because they cannot currently be measured validly. These errors have received relatively little attention despite alarming estimates of associated harm and death. One promising intervention to reduce preventable harm is the checklist. This intervention has proven successful in aviation, in which situations are linear and deterministic (one alarm goes off and a checklist guides the flight crew to evaluate the cause). In health care, problems are multifactorial and complex. A checklist has been used to reduce central-line-associated bloodstream infections in intensive care units. Nevertheless, this checklist was incorporated in a culture-based safety program that engaged and changed behaviors and used robust measurement of infections to evaluate progress. In this issue, Ely and colleagues describe how three checklists could reduce the cognitive biases and mental shortcuts that underlie diagnostic errors, but point out that these tools still need to be tested. To be effective, they must reduce diagnostic errors (efficacy) and be routinely used in practice (effectiveness). Such tools must intuitively support how the human brain works, and under time pressures, clinicians rarely think in conditional probabilities when making decisions. To move forward, it is necessary to accurately measure diagnostic errors (which could come from mapping out the diagnostic process as the medication process has done and measuring errors at each step) and pilot test interventions such as these checklists to determine whether they work.
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http://dx.doi.org/10.1097/ACM.0b013e3182082692DOI Listing
March 2011

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

Crit Care Med 2010 Aug;38(8 Suppl):S292-8

Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA.

Healthcare-associated infections are common, costly, and often lethal. Although there is growing pressure to reduce these infections, one project thus far has unprecedented collaboration among many groups at every level of health care. After this project produced a 66% reduction in central catheter-associated bloodstream infections and a median central catheter-associated bloodstream infection rate of zero across >100 intensive care units in Michigan, the Agency for Healthcare Research and Quality awarded a grant to spread this project to ten additional states. A program, called On the CUSP: Stop BSI, was formulated from the Michigan project, and additional funding from the Agency for Healthcare Research and Quality and private philanthropy has positioned the program for implementation state by state across the United States. Furthermore, the program is being implemented throughout Spain and England and is undergoing pilot testing in several hospitals in Peru. The model in this program balances the tension between being scientifically rigorous and feasible. The three main components of the model include translating evidence into practice at the bedside to prevent central catheter-associated bloodstream infections, improving culture and teamwork, and having a data collection system to monitor central catheter-associated bloodstream infections and other variables. If successful, this program will be the first national quality improvement program in the United States with quantifiable and measurable goals.
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http://dx.doi.org/10.1097/CCM.0b013e3181e6a165DOI Listing
August 2010

Long-term mortality and quality of life in sepsis: a systematic review.

Crit Care Med 2010 May;38(5):1276-83

Departments of Anesthesiology and Critical Care Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Long-term outcomes from sepsis are poorly understood, and sepsis in patients may have different long-term effects on mortality and quality of life. Long-term outcome studies of other critical illnesses such as acute lung injury have demonstrated incremental health effects that persist after hospital discharge. Whether patients with sepsis have similar long-term mortality and quality-of-life effects is unclear.

Objective: We performed a systematic review of studies reporting long-term mortality and quality-of-life data (>3 months) in patients with sepsis, severe sepsis, and septic shock using defined search criteria.

Design: Systematic review of the literature.

Interventions: None.

Main Results: Patients with sepsis showed ongoing mortality up to 2 yrs and beyond after the standard 28-day inhospital mortality end point. Patients with sepsis also had decrements in quality-of-life measures after hospital discharge. Results were consistent across varying severity of illness and different patient populations in different countries, including large and small studies. In addition, these results were consistent within observational and randomized, controlled trials. Study quality was limited by inadequate control groups and poor adjustment for confounding variables.

Conclusions: Patients with sepsis have ongoing mortality beyond short-term end points, and survivors consistently demonstrate impaired quality of life. The use of 28-day mortality as an end point for clinical studies may lead to inaccurate inferences. Both observational and interventional future studies should include longer-term end points to better-understand the natural history of sepsis and the effect of interventions on patient morbidities.
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http://dx.doi.org/10.1097/CCM.0b013e3181d8cc1dDOI Listing
May 2010

Clinical review: checklists - translating evidence into practice.

Crit Care 2009 31;13(6):210. Epub 2009 Dec 31.

Departments of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD 21287, USA.

Checklists are common tools used in many industries. Unfortunately, their adoption in the field of medicine has been limited to equipment operations or part of specific algorithms. Yet they have tremendous potential to improve patient outcomes by democratizing knowledge and helping ensure that all patients receive evidence-based best practices and safe high-quality care. Checklist adoption has been slowed by a variety of factors, including provider resistance, delays in knowledge dissemination and integration, limited methodology to guide development and maintenance, and lack of effective technical strategies to make them available and easy to use. In this article, we explore some of the principles and possible strategies to further develop and encourage the implementation of checklists into medical practice. We describe different types of checklists using examples and explore the benefits they offer to improve care. We suggest methods to create checklists and offer suggestions for how we might apply them, using some examples from our own experience, and finally, offer some possible directions for future research.
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http://dx.doi.org/10.1186/cc7792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811937PMC
April 2010
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