From the 2023 HVPA National Conference
Holly Zurich PA-C, Lead APP Performance Improvement Surgical Services (Yale New Haven Health System), Linda Fan Assistant Professor of Obstetrics, Gynecology; Chair GYN operations committee; Chair gynecologic quality and safety (Yale School of Medicine), Rohit Sangal MD, MBA, FACEP; Associate Medical Director Dept of Emergency Medicine (Yale New Haven Hospital) Bertie Geng PGY4, Obstetrics and Gynecology
Although many gynecology and gynecologic oncology patients are able to be safely discharged, there are delayed surgical complications that can present following discharge, including infection, bleeding, and bowel injury. The delayed recognition of bowel injury can lead to higher morbidity outcomes for patients. Strategies to mitigate this risk and increase vigilance in the care of these patients within the 30-day post-operative period have not been well-described. The electronic medical record (EMR) and mobile technology are resources which can be leveraged to combat the role of cognitive bias resulting in care delays in a tertiary-care academic medical center.
The project smart aim was to reduce the occurrence of delayed recognition of bowel injury for gynecologic and gynecologic oncology patients who have undergone surgery at a tertiary-care academic medical center, and then re-present for care within the institution to zero between August to December 2022.
In June 2022, an electronic flag was added in the electronic medical record (EMR) for the ED, gynecology, and gynecologic oncology staff with a simultaneous automated push notification to gynecology housestaff when a gynecologic surgery patient re-presents to the emergency room within 30-days of surgery. The goal of this pilot study is to assess if this automated electronic alert system decreases the time from presentation to evaluation by a gynecology or gynecologic oncology provider and identification of post-operative complications.
In the time period of August 1, 2022-Dec 31, 2022 the 30-day, re-presentation intervention fired for 124 recent gynecologic surgery patients re-presenting to the emergency room within 30-days of surgery. Of the 124 patients, 43 patients were readmitted for medical and/or surgical management. There were no patients with delayed recognition of surgical complications including delayed bowel injury.
Significant improvement from ED room to first GYN surgery resident chart opening at any point among patients who had a GYN consult note sign/shared during the encounter (55.71 min pre-intervention and 11.03 min post-intervention). Among all the post-intervention ED representation patients not admitted to gynecologic surgery we demonstrated an increase (p=0.001) in GYN first chart access compared to pre intervention (35% pre-intervention vs. 64% post-intervention). This trend demonstrated that GYN housestaff are reviewing the medical record. This is consistent with the desired state of shared responsibility for these 30-day ED re-presentation of postoperative gynecologic surgical patients.
The pilot was associated with overall heightened staff awareness and a reduction cognitive bias of recent GYN Surgery status in patients re-presenting to ED within 30-Days of Surgery. Ongoing work in below areas is needed:
Feasible of sustaining the smart aim
Design considerations needed to avoid unnecessary workflow disruptions
Ongoing feedback from frontline staff needs to be obtained
Scale considerations to other surgical specialties
Ongoing Data collection for organizational learning and to develop pro-active interventions to predict and prevent complications