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Background The coronavirus disease 2019 (COVID-19) pandemic presented the world with a sudden need for additional medical professionals. Senior medical students were identified as potential workers and many worldwide graduated early to serve as Junior Physicians in hospitals. The authors sought to identify factors that informed the decision to work, describe experiences in this capacity, and elucidate benefits for trainees. Methods The investigators conducted a mixed-methods observational cohort study of early medical graduates eligible to work as Junior Physicians at two New York medical centers in April/May 2020 during an initial surge in COVID-19 hospitalizations. Graduates were surveyed, and a sample of Junior Physicians participated in a focus group. Survey responses of those who worked were compared to those who did not. Focus group responses were transcribed, coded, and thematically analyzed. Results Fifty-nine graduates completed the study methods and 39 worked as Junior Physicians. Primary reasons for working included duty to help (39 [100%]), financial incentive (32 [82%]), desire to learn about pandemic response (25 [64%]), and educational incentive (24 [62%]). All had direct contact with COVID-19 patients, believed working was beneficial to their medical training, and were glad they worked. None contracted a symptomatic infection while working. Compared with non-Junior Physicians, Junior Physicians reported increased comfort levels in completing medical intern-level actions like transitions of care functions, such as writing transfer notes (P P = 0.01), and providing verbal sign out (P = 0.05), and they reported more comfort in managing COVID-19 patients. Sixteen themes emerged from the focus group and were placed into four categories: development of skills, patient care, safety, and wellness. Conclusions Senior medical students chose to work as Junior Physicians for both personal and educational reasons. Experiences were beneficial to trainees and can inform future innovations in medical education.

Objetivo: Identificar o processo de implementação e o uso diário da lista de verificação de segurança cirúrgica, segundo relato de enfermeiros queatuavam no centro cirúrgico de hospitais. Método: Estudo descritivo-exploratório, com amostra de 77 enfermeiros. A coleta de dados ocorreu duranteseis meses, no ano de 2016, por meio da aplicação de instrumento elaborado e submetido à validação de face e conteúdo. Na análise dos dados, adotou-sea estatística descritiva. Resultados: A realização de programa educacional foi essencial no processo de implementação da lista de verificação de segurançacirúrgica. O circulante era o responsável pela checagem diária da ferramenta na sala cirúrgica. A maioria dos enfermeiros relatou adesão parcial no uso dochecklist pela equipe cirúrgica; houve diferença de adesão entre as etapas de checagem (entrada, pausa e saída) e entre as categorias profissionais. Conclusão:O conhecimento produzido oferece subsídios para a implementação da ferramenta e o uso de estratégias que podem auxiliar no cotidiano da prática clínica.

Introduction Standardized rounding and sign-out reports can improve provider efficiency and satisfaction. The purpose of this quality improvement project was to evaluate implementing an electronic medical record-integrated neonatal intensive care unit-specific rounding report and sign-out report on provider efficiency and satisfaction. Method A pre- and post–quality improvement project was implemented to evaluate the effectiveness of standardized electronic rounding and sign-out reports on a 48-bed level-4 neonatal intensive care unit staffed daily by two neonatologists and four advanced practice providers. Results The electronic rounding and sign-out reports were implemented on 745 patient encounters. The process of using the electronic rounding report was found to be faster than the paper prerounding report. Completing the standardized sign-out report was faster than the previous method used. Discussion Improving efficiency is essential for optimizing patient care and improving provider satisfaction. Electronic rounding and standardized sign-out reports can improve efficiency and provider satisfaction.

Introduction The introduction of a new generation of core needle biopsies (CNBs) for endoscopic procedures has prompted reconsideration of the role of cytopathologists in the handling of small biopsies. The American Society of Cytopathology (ASC) has therefore conducted a survey with the intention of elucidating current practices regarding the handling of small CNBs. Materials and methods The membership of the ASC was invited by email to participate in an online survey over a 2-month period. The survey consisted of 20 multiple choice questions with 2-8 possible responses per question. Results Of 2651 members contacted by e-mail, 282 (10.6%) responded to the survey questions, including 196 pathologists (69.5%) and 86 cytotechnologists (30.5%). Of these, 265 respondents were from the US/Canada (94.0%), with 156 from academic institutions (58.9%) and 109 from non-academic practices (41.1%); 17 were from other countries (6.0%). In 18.8% of all practices, cytopathologists sign out >90% of small CNBs from endoscopic and radiologically guided procedures; in 36.5% of practices >90% are signed out by surgical pathologists; the remainder have such cases divided more evenly between cytopathologists and surgical pathologists. Responses show that 78.0% of all respondents are interested in signing out more small biopsies in the future, and 80.5% desire increased small biopsy-related resources from the ASC. Conclusions The survey responses indicate that practices currently vary widely across institutions. Most indicated an interest in greater incorporation of small biopsies into the practice of cytopathology.

OBJECTIVES A surgical safety checklist has been a globally implemented and mandated adoption in several countries. However, its use is not mandatory in Thailand. This study aimed to evaluate the perceptions of surgical personnel on surgical complications and safety and to examine the satisfaction and barriers of surgical safety checklist implementation. METHODS A survey study was performed between November 2013 and February 2015 in 61 Thai hospitals. A questionnaire capturing demographics, perceptions related to surgical complications and safety, and the satisfaction and barriers of surgical safety checklist implementation was distributed to surgical personnel. RESULTS A total of 2024 surgical personnel were recruited. Nearly all of them reported experience or knowledge of an adverse surgical event (99.6%). Most thought that it could be preventable (98.2%) and quality care improvement could help reduce the occurrence of adverse events (97.7%). Overall, respondents reported a high level of satisfaction with the checklist (mean [SD] = 3.79 [0.71]). The three areas of highest satisfaction were benefit to the patient (mean [SD] = 4.11 [0.69]), benefit to the organization (mean [SD] = 4.05 [0.68]), and reduction in adverse events (mean [SD] = 4.02 [0.69]). Overall, the barrier for implementation of the checklist was rated as moderate (mean [SD] = 2.52 [0.99]). However, the means of barriers in each period, sign in, time out, and sign out, were rated as low (means [SD] = 2.41 [1.07], 2.50 [1.03], and 2.34 [1.01], respectively). CONCLUSIONS The data document that the satisfaction with the checklist are fairly high. However, some barriers were identified. Efforts to increase understanding through more rigorous policy enforcement and strategic support may lead to improving the checklist implementation.

Anastomising hemangioma is a rare benign neoplasm originally described in urogenital organs [1]. Even if it is seldom encountered in routine diagnostic sign out, it is important for pathologist...

A surgical safety checklist is a communication tool for patient safety that is used by the surgical team in the operating room, including the sign in, time out, and sign out process. The time out process aims to prevent patient error, location, and surgical procedures. Therefore, compliance is required in conducting time out. The level of knowledge of nurses about time out is very important because it affects the behavior of nurses in doing time out. This study purposed to determine the correlation between the nurse knowledge level about time out and compliance in doing time out at the Bali Med Hospital, Denpasar. The design used was a descriptive correlation with the cross-sectional approach. The relationship test used the Spearman Rho test. This study involved 31 nurses as a sample with a total sampling technique. The results of research on nurse compliance were mostly 70.9% adherent category and the results for the knowledge level of nurses were mostly 77.4% with a good level. Based on the statistical test with ? = 5%, it was obtained p = 0.000 (p

A systematic review of published English-language articles on handoffs is conducted (1987 to June 4, 2008). Forty-six articles describing 24 handoff mnemonics are identified by trained reviewers. The majority (82.6%) have been published in the last 3 years (2006-2008), and SBAR (Situation, Background, Assessment, Recommendation) is the most frequently cited mnemonic (69.6%). Of 7 handoff research articles, only 4 study mnemonics. All 4 of these studies have relatively small sample sizes (10-100) and lack validated instruments. Only 1 study has obtained IRB approval. Scientifically rigorous research studies are needed to assess the effectiveness of handoff mnemonics. These should be published in the peer-reviewed literature using the Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines.

Objective The primary aim of the study was to evaluate whether the WhatsApp application can be used for obtaining a quick second opinion on histopathological and cytological diagnosis and also for discussing difficult cases in pathology practice. Material and method A WhatsApp group named "FESPATH" was created with total of 17 pathologists (the authors of this manuscript as group administrators and 15 general pathologists from 7 different cities in Morocco, working in 12 different institutions as members). The group was used to discuss difficult routine sign out cases, to obtain a second opinion. Pathology-related academic files, books and links were also shared. At the end of 20 months, members were asked to complete a feedback questionnaire. Results Over a 20-month period, 86 cases were discussed with 515 posted pictures. 78 cases were related to histopathology, and 8 cases to cytopathology. Twenty-one links regarding educational materials and books were also shared. A total of 14 participants out of 17 were active participants, and the majority of them found the discussions very useful for overcoming challenging cases. Conclusion Sharing microphotographs of histopathological or cytological cases via WhatsApp is a very easy and fast method to obtain a second opinion in pathology practice and also to discuss difficult cases.

Three similar clinical incidences over a three-month period highlighted an issue with the readiness and availability of neonatal resuscitation personnel and equipment at the time of caesarean section (CS). This identified a potential risk to the wellbeing of the mother and baby that had to be addressed. A joint venture was undertaken with the maternity and theatre directorates. A maternity-specific checklist in use in the UK maternity services was sourced, adapted and implemented. No further incidents have been reported since with resulting overall enhanced safety of pregnant women and newborn babies in the unit.

Introduction: Handoff miscommunications are a leading cause of medical errors. A structured handoff is an effective communication tool. We introduced the I-PASS Handoff Bundle for resident sign-out in the inpatient setting. We aimed to reduce preventable adverse events and unexpected floor calls while also improving residents’ confidence and preparedness to care for patients overnight. Methods: We conducted an observational study at a single-site family medicine residency between April 2019 and March 2020. Residents received trainings in the I-PASS standardized handoff through didactic lectures and on-the-job sessions in September and November 2019. We evaluated the effectiveness of the I-PASS Handoff Bundle by comparing pre- and postimplementation data including number of medical errors and unexpected floor calls, along with residents’ reported levels of preparedness and confidence to care for patients overnight. Results: Prior to the I-PASS intervention, more than half of resident surveys included at least one unexpected floor call whereas postintervention about one-third of resident surveys included unexpected floor calls (P

Background With the rise of the COVID-19 pandemic, medical systems and providers have been forced to undertake substantial changes to staffing structure, hospital policy, and surgical indications to remain able to care for patients and protect the providers. Here, we present a survey of orthopaedic trauma fellowship directors to assess when and what changes these individual units have made in order to cope with this global pandemic. Methods The survey was distributed via email to all 62 programs listed in the Orthopaedic Trauma Association web site. Results Twenty four responses were received. The majority of programs implemented changes between March 1st and 14th, with nearly all splitting teams into individual units, incorporating virtual sign out, and reducing the number of available, i.e. exposed, staff, fellows, and residents at any particular time. Conclusions These changes have been implemented in order to proactively maintain the functionality of these vital teams to patient care with no definite end point to this pandemic in sight. We hope this study provides other trauma centers and orthopaedic practices insight into possible precautions that can be taken in response to the COVID-19 pandemic.

BACKGROUND Resident duty-hour restrictions have led to more sign-out transitions, increasing the potential for preventable harm. An unfavorable environment is expected to exacerbate sign-out risks to patient safety. OBJECTIVE The aim of the study was to evaluate the impact of noise, interruptions, long sign-outs, and sign-outs exceeding allotted time on sign-out quality. METHODS Eight trained observers evaluated 620 evening patient sign-outs between interns for 40 weeknights between February and April 2015 at a large internal medicine training program. Quality of sign-out was measured three ways: information quality, scores from the Handoff CEX Tool, and peer evaluations. RESULTS Noise had no impact on information quality. Interruptions negatively affected information quality (-0.10 < r < -0.15, P < 0.001) and Handoff CEX quality scores (-0.11 < r < -0.26, P < 0.001). Long sign-outs taking more than 1 hour negatively affected sign-out quality (-0.09 < r < -0.23, P < 0.05). Sign-outs exceeding allotted time negatively impacted peer evaluations (-0.11 < r < -0.22, P < 0.001). CONCLUSIONS Interruptions, long sign-outs, and sign-outs exceeding allotted time were related to lower sign-out quality. Improving the environment to reduce interruptions and training interns to manage their time during sign-outs may improve sign-out quality.

Subspecialty sign-out is increasingly common in academic medical centers as well as some community practices. Reducing interobserver variability in anatomic pathology is desirable so that clinicians can select the appropriate therapy. Many departments that elect subspecialty sign-out do so with the assumption that it will improve diagnostic accuracy and interobserver variability-but does it? The literature is mixed.

Background Unplanned returns to the operating room (OR) may be necessary at times to salvage a compromised free flap. The aim of this study was to assess the influence of attending surgeon continuity on free flap outcomes following a return to the OR. Methods We retrospectively reviewed patients who underwent free flap reconstruction and experienced an unplanned return to the OR within 30 days from 2002 to 2017. Logistic regression modeling was used to determine factors that predict unplanned returns to the OR. Results Of the 1,177 patients were identified, 267 (22.5%) had an unplanned return to the OR. Of these, 69 (5.9%) patients experienced total flap loss. Overall, 216 take-back procedures were performed by the primary surgeons (80.2%), while 50 were performed by covering surgeons (18.8%). Flap loss occurred more frequently during a weekend procedure (p = 0.013). Additionally, when the take-back procedure was performed within 5 days of the original surgery by the primary as opposed to a covering surgeon, patients experienced lower estimated blood loss (75 vs. 150 cc, p = 0.04). Overall, there was a significantly lower incidence of flap loss when the take-back procedure was performed by the primary, as opposed to the covering, surgeon (20 vs. 47%, p = 0.0001). Conclusion Higher rates of flap loss occur when a covering surgeon performs a take-back procedure in comparison to the primary surgeon. It is important to ensure the availability of the primary surgeon in the first few postoperative days following free flap reconstruction. When transfer of care is necessary, photographic or video documentation of the microvascular anastomosis may be helpful in addition to a verbal sign out.

Hospitalized medical patients undergoing transition of care by house staff teams at the end of a ward rotation are associated with an increased risk of mortality, yet best practices surrounding this transition are lacking. To assess the impact of a warm handoff protocol for end-of-rotation care transitions. A large, university-based internal medicine residency using three different training sites. PGY-2 and PGY-3 internal medicine residents. Implementation of a warm handoff protocol whereby the incoming and outgoing residents meet at the hospital to sign out in-person and jointly round at the bedside on sicker patients using a checklist. An eight-question survey completed by 60 of 99 eligible residents demonstrated that 85% of residents perceived warm handoffs to be safer for patients (p

Poor sign-out or handover of care may lead to preventable patient harm. Critically ill patients in intensive care units (ICU) are complex and prone to rapid clinical deterioration. If clinical deterioration occurs, timeliness of appropriate interventions is essential to prevent or reduce adverse outcomes. Therefore sign-outs need to efficiently transmit key information and provide anticipatory guidance. Interventions to improve resident-to-resident ICU sign-outs have not been well described. We conducted a controlled trial to test the effectiveness of a standardised ICU sign-out process to the usual ICU sign-out.Prospective controlled trial.A 26-bed medical intensive care unit (MICU) in an urban tertiary academic medical centre.Residents rotating through the MICU.ICU-specific written sign-out template.Residents completed postcall surveys assessing satisfaction with verbal and written sign-outs and incidence of non-routine events. Our main outcome of interest was the occurrence of non-routine events.Compared with the intervention group, on significantly more nights, night float residents in the control group encountered patients who were sicker than sign-out would have suggested (15.94% vs 43.75%; p0.0001). On significantly fewer nights, night float residents in the intervention group indicated that either something happened to patients that was unexpected (18.84% vs 36.51%; p=0.023) or they were insufficiently prepared for (4.35% vs 35.94%; p0.0001). Similarly, on fewer nights, residents in the intervention group indicated that they had to perform interventions that were unplanned or unanticipated (15.9% vs 37.7%; p=0.005).A structured sign-out process compared with usual sign-out significantly reduced the occurrence of non-routine events in an academic MICU.

BACKGROUND Computer-assisted communication is shown to prevent critical omissions ("errors") in the handoff process. OBJECTIVE The aim of the study was to study this effect and related provider satisfaction, using a standardized software. METHODS Fourteen internal medicine house officers staffed 6 days and 1 cross-covering teams were randomized to either the intervention group or control, employing usual handoff, so that handoff information was exchanged only between same-group subjects (daily, for 28 days). RESULTS In the intervention group, fewer omissions (among those studied) occurred intravenous access (17 versus 422, P < 0.001), code status (1 versus 158, P < 0.001), diet/nothing per mouth (28 versus 477, P < 0.001), and deep venous thrombosis prophylaxis (17 versus 284, P < 0.001); duration to compose handoff was similar; and physicians perceived less workload adjusted for patient census and provider characteristics (P = 0.004) as well as better handoff quality (P < 0.001) and clarity (P < 0.001). CONCLUSIONS The intervention was associated with fewer errors and superior provider satisfaction.

A community hospital implemented a bar code medication verification (BMV) system to improve tracking of medications and support safe medication administration. In addition to the software for BMV, hospital administrators purchased laptop computers stationed atop wheeled carts, or workstations on wheels, and medication bar code scanners. Medication errors were made, the same medication errors the BMV system was supposed to correct. Medications were kept in a med room that housed a dispensing machine. Nurses had to enter their username and personal identification number, choose the patient, choose the medication, remove it, and sign out. Although against policy, nurses routinely did this with controlled medications because in the paper system if a nurse forgot to sign off the medicine, someone could sign and cosign it so the record was kept properly. BMV programs are sophisticated, complex systems that are supposed to increase the safety of patients and decrease errors in medication administration.

Operating room (OR) to intensive care unit (ICU) handoffs are complex and known to be associated with adverse events and patient harm. The authors hypothesized that handoff quality diminishes during nights/weekends and that bedside handoff practices are similar between ICUs of the same health system. Bedside OR-to-ICU handoffs were directly observed in 2 surgical ICUs with different patient volumes. Handoff quality measures were compared within the ICUs on weekdays versus nights/weekends as well as between the high- and moderate-volume ICUs. In the high-volume ICU, transmitter delivery scores were significantly better during off hours, while other measures were not different. High-volume ICU scores were consistently better than those in the moderate-volume ICU. Bedside handoff practices are not worse during off hours and may be better in ICUs used to a higher patient volume. Specific handoff protocols merit evaluation and training to ensure consistent practices in different ICU models and at different times.

Background and aims The World Health Organisation (WHO) surgical checklist acts as a safety check before surgery. The three components are: sign in, surgical pause and sign out. This study aims to assess and improve the surgical pause at a tertiary paediatric surgical unit. Methods and results Theatre nurses used as a standardised tool to record how the pause was carried out. All other theatre staff were blinded. Presentation of these data at departmental meetings allowed creation of a checklist poster which was placed in every theatre. Data collection was repeated five months later. Data on 114 operations were initially collected. Fifty-one per cent of operations completed all four steps to guideline. Introduction step met guideline in 61% of operations, identity and procedure in 90%, checklist in 98% and concerns in 71%. Following intervention, data were collected from 39 operations; 77% of operations completed all four steps to guideline. Introduction step met guideline in 87% of operations, identity and procedure in 100%, checklist in 100% and concerns in 90%. Conclusions This study shows that by engaging with theatre staff to create an acceptable checklist poster, better standard of patient safety in the operating theatre can be achieved.

Background Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations. Study design A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times. Results Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p Conclusions In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.

Background The AAP recommends ACE screening, but effective implementation and support for patients with high ACE scores is challenging. Many providers are hesitant to screen without intervention support. The second-year resident class worked sequentially to implement ACE screening and use the momentum from screening to pilot an integrated wellness program. Aim Statement 1. Screen for ACE in >80% of patients at annual preventative care visits by December 2019 2. Determine resources needed by patients with high ACE scores 3. Implement an integrated wellness program for patients with high ACE scores. Interventions Interventions addressed barriers for our primary drivers: medical assistants (MA), providers, and families. A MA champion taught best screening strategies and communicated updates. Providers received educational sessions and progress updates via email and monthly meetings. EHR was modified to simplify documentation. Intake forms were streamlined to combat form fatigue. Residents created a QI sign out to update the next resident team and share successes. The wellness nurse developed a menu of services including information about toxic stress and a strength's-based wellness assessment. Integrative techniques were provided to improve resilience, develop strengths, and connect patients to mental health services. Measures Monthly ACE screening rates were determined by measuring the number of screens compared to preventative care visits. Patients with a score of 3 with symptoms or 4-10 were referred to a wellness team. Secondary measures were ACE team referrals, wellness assessments, counseling sessions, integrative interventions, and resources provided. Results ACE screening improved from 2 to 89% in 18 months. During the first 5 months of the wellness program, there were 161 referrals, 80 full wellness assessments, 136 integrative appointments, and 92 in-office counseling sessions. Community resources (food, housing) were provided 617 times, and 2230 pieces of written education were distributed by the wellness team. Conclusions and Next Steps Interventions have shown a sustained increase in ACE screening rates. After establishing the wellness program, there was a marked increase in the number of screens, referrals and wellness appointments. The addition of dedicated staff allowed for better care coordination and resource distribution. Next steps are to decrease no show rates for wellness appointments and to monitor resilience scores and patient surveys for ongoing improvements to the program.

Failure of communication of critical information during handoffs is one of the leading causes of medical errors, resulting in serious, yet preventable, adverse events in hospitals across the United States. Recent studies have shown that a majority of these errors occur during patient handoffs, with notable communication gaps in interdisciplinary handoffs. We suggest some features that would improve the handoff usability and effectiveness for interdisciplinary medical and nursing teams while potentially improving patient safety.

Death and complication due to surgeries or surgical actions is a global health problem. The WHO estimates that at least half a million deaths that are caused by surgeries can be prevented. On 2008, the WHO released a campaign about safe surgery and the surgical safety checklist to improve the quality of our surgery cases and decrease the number of complication and deaths caused by surgeries. Hospital accreditation is used to improve the quality of hospital management, including in reducing numbers of death and complication due to surgeries. This is a quantitative descriptive approach study. The study population used were all surgical safety checklist. Sample number of 75 surgical safety checklist, 15 surgical safety checklist each from June 2017, August 2017, January 2018, June 2018, and January 2019. Data analysis shown by statistic table and percentage. There was a change of number in completing compliance of the surgical safety checklist before and after hospital accreditation. It showed that nearing hospital accreditation, the compliance rate was almost 100% on all the items. This continued a month after, but some of the items had a lower rate of compliance further after the hospital accreditation. The number of completing compliance of the surgical safety checklist nearing hospital accreditation is higher than after hospital accreditation. The sign in item have the highest rate of completing compliance whereas the sign out item had the lowest number of compliance.

Background: A patient “handoff,” or the “sign-out” process, is an episode during which the responsibility of a patient transitions from one health-care provider to another. These are important events that affect patient safety, particularly because a significant proportion of adverse events have been associated with a relative lack of physician communication. The objective of this investigation was to survey podiatric surgical residency programs with respect to patient care handoff and sign-out practices. Methods: A survey was initially developed and subsequently administered to the chief residents of 40 Council on Podiatric Medical Education–approved podiatric surgical residency programs attempting to elucidate patient care handoff protocols and procedures and on-call practices. Results: Although it was most common for patient care handoffs to occur in person (60.0%), programs also reported that handoffs regularly occurred by telephone (52.5%) and with no direct personal communication whatsoever other than the electronic passing of information (50.0%). In fact, 27.5% of programs reported that their most common means of patient care handoff was without direct resident communication and was instead purely electronic. We observed that few residents reported receiving formal education or assessment/feedback (17.5%) regarding their handoff proficiency, and only 5.0% of programs reported that attending physicians regularly took part in the handoff/sign-out process. Although most programs felt that their sign-out practices were safe and effective, 67.5% also believed that their process could be improved. Conclusions: These results provide unique information on a potentially underappreciated aspect of podiatric medical education and might point to some common deficiencies regarding the development of interprofessional communication within our profession during residency training.

This chapter examines transference and countertransference experiences in various clinical scenarios involving requests for discharge against medical advice (AMA). It highlights those psychiatric disorders more highly associated with AMA discharges. Transference and countertransference toward patients, including those without psychiatric diagnoses, can impact how the primary team makes decisions regarding the patient’s request to sign out. It is always worthwhile to ask, “What about my feelings towards the patient might influence my willingness or lack of willingness to agree with the patient’s request?” Patients with psychiatric diagnoses are more likely to request discharge AMA, especially those patients with substance use disorders. Consultation-liaison psychiatrists are particularly equipped to assess patients with active psychiatric disorders who are requesting discharge AMA or patients who are requesting discharge and whose capacity to do so is unclear. They are a resource for the physician to guide the process to allow a patient to leave or to not allow a patient to leave.

A surgical safety checklist consists of three parts; sign-in, time-out, and sign-out. It has been observed that the sign-out process is the least frequently completed part. We redesigned the sign-out process as a web-based application embedded on a desktop and on a tablet. Both web-based platforms were tested along with the current process on a computer. We recorded time, performance, workload, usability, satisfaction and preference measures for these three approaches in operating rooms. The time to complete the sign-out process was the longest using the WebApp on the desktop and the shortest using the current system. The WebApp on both electronic devices resulted in fewer items being skipped than the current system. The web-based app on the desktop resulted in fewer items not being discussed than the current system. Frustration was rated as lower with the WebApp on the desktop than with the current system. The WebApp on the desktop was rated higher than the current system for situation awareness, detecting errors, understanding the benefits of the sign-out process, and ability to view information all at once. The WebApp on both electronic devices was rated higher than the current system for maintaining records and foraccessibility from all locations.

To date, gender differences and decisional capacity have not been studied. Altogether, decisional capacity assessments were required twice as often for male than for female patients. While female patients more commonly had endocrine disorders, male patients more commonly had neurological disorders, which contributed to decisional capacity impairment. Psychiatrically, mood disorders were more common in women and substance use disorders in men. Regarding decisional capacity tasks, men more frequently requested to sign out against medical advice. Overall, the ability to make appropriate health care decisions did not vary between genders. Although more decisional capacity assessments were requested for male patients, the degree to which decisional capacity existed did not vary between genders. Male patients more often displayed substance use and neurological disorders and more frequently requested to sign out against medical advice. Cognitive disorders caused more impairment for men than for women.

Digital microscopy combines the benefits of traditional optical microscopy and the advantages of computer sciences. Using digital whole slides in all areas of pathology is increasingly popular. Telepathology or long distance diagnosis is one such area. In our study we have evaluated digital slide based histopathology diagnosis in an international setting, between Sweden and Hungary. Routine cases from the Sundsvall County Hospital (Landstinget Vasternorrland) were collected. Glass slides were scanned using Pannoramic 250 Flash II. (3DHISTECH Ltd., Budapest, Hungary). During the first round of evaluation the glass slides were shipped to Hungary for primary diagnosis. Two pathologists from Hungary, reading glass slides and one pathologist from Sweden reading digital slides signed out 500 cases. Pathologists from Hungary reached the hospital information system with a secure connection. During the second round the pathologists in Hungary reevaluated 200 from the 500 cases using digital slides after three months washout period. Diagnostic accuracy was calculated and diagnostic errors was graded according to clinicopathological consequences. In 182/200 (91%) cases digital and optical diagnoses were in full agreement. Out of the remaining 18 cases, 1 (0.5%) critical error was identified. In this case the error had therapeutic and prognostic consequence and no uncertainty either because of case complexity or poor image quality was recorded by the pathologist. We think language and communication issues as well as differences in minimal data sets of pathological reports and in guidelines used in Sweden and in Hungary are factors potentially limiting the widespread use of digital slides in a teleconsultation service provided to Sweden from Hungary. We found the quality of digital slides in our study setting acceptable to reach correct primary diagnosis in routine, unselected, random cases of a small-to-medium sized pathology department in Sweden.

This article shows the evolving history of the Banff classification for allograft biopsies and gives helpful clues on properly diagnosing each classification. In today’s pathology practice, a general pathologist who does not regularly sign out many transplant kidney cases may be unsure of the details that the nephrologist may need to know for proper patient treatment. This article also discusses the latest Banff classification and the differential diagnoses one may encounter when diagnosing an allograft biopsy.

Objective Cytotechnologist (CT) screening workload has been decreasing due to the falling number of Papanicolaou tests. This continuing trend has prompted exploration of ways to best employ the CT skillset. One potential way of more effective use is by having two CTs double screen non-gynaecological (NGC) cases to assess whether this improves screening quality and concordance with pathologists. Another is evaluating the CT's performance on low-complexity negative NGC cases for a potential independent CT sign-out without pathologist review. Methods In total, 1119 NGC cases were reviewed; 577 screened by two CTs and 542 screened by one CT. All cases were signed out by a pathologist and all CT interpretations were compared to the pathologist final diagnoses. The disagreements were classified based on degree of discrepancy. The extra workload by adding the second screener was assessed. Results The agreement rate between the CT's screening interpretation and pathologist's interpretation did not improve by adding a second CT compared to a single screener (91.5% vs 92.9%, respectively). CT to pathologist concordance was very high on low complexity NGC cases (voided urine, fluid, sputum) whether screened and interpreted as negative by one CT (97.3%) or two CTs (99.3%). Conclusion Double screening of NGC cases by two cytotechnologists prior to pathologist sign-out does not improve screening quality and is not cost-effective. The high concordance between the CTs and pathologists in this limited group of low complexity negative cases suggests that such cases could be signed out independently by cytotechnologists.

Context.— Pathologists' computer-assisted diagnosis (pCAD) is a proposed framework for alleviating challenges through the automation of their routine sign-out work. Currently, hypothetical pCAD is based on a triad of advanced image analysis, deep integration with heterogeneous information systems, and a concrete understanding of traditional pathology workflow. Prototyping is an established method for designing complex new computer systems such as pCAD. Objective.— To describe, in detail, a prototype of pCAD for the sign-out of a breast cancer specimen. Design.— Deidentified glass slides and data from breast cancer specimens were used. Slides were digitized into whole-slide images with an Aperio ScanScope XT, and screen captures were created by using vendor-provided software. The advanced workflow prototype was constructed by using PowerPoint software. Results.— We modeled an interactive, computer-assisted workflow: pCAD previews whole-slide images in the context of integrated, disparate data and predefined diagnostic tasks and subtasks. Relevant regions of interest (ROIs) would be automatically identified and triaged by the computer. A pathologist's sign-out work would consist of an interactive review of important ROIs, driven by required diagnostic tasks. The interactive session would generate a pathology report automatically. Conclusions.— Using animations and real ROIs, the pCAD prototype demonstrates the hypothetical sign-out in a stepwise fashion, illustrating various interactions and explaining how steps can be automated. The file is publicly available and should be widely compatible. This mock-up is intended to spur discussion and to help usher in the next era of digitization for pathologists by providing desperately needed and long-awaited automation.

Many pathology departments are introducing subspecialty sign-out in surgical pathology. In 2014, the University of Vermont Medical Center transitioned from general sign-out to partial subspecialty sign-out to include gastrointestinal and breast/cervix subspecialty benches; other specimens remained on general benches. Our experiences with the transition are described, including attending pathologist, trainee, support staff, and clinician satisfaction. A survey was e-mailed to all University of Vermont Medical Center anatomic pathology attendings, pathology trainees, pathologist assistants and grossing technicians, and clinicians who send surgical pathology specimens, immediately before and 1 year after transitioning to partial subspecialty sign-out. Quality assurance metrics were obtained for the 18 months prior to and following the transition. Gastrointestinal and breast/cervix attendings were more satisfied with partial subspecialty sign-out compared to those on the general benches. Overall, trainees were more satisfied with general sign-out because of the rotation schedule but preferred partial subspecialty sign-out due to improved teaching and more focused learning while on subspecialty benches. Clinicians remained very satisfied with our department and our reports; no differences were observed. Turnaround time was unchanged. After switching to partial subspecialty sign-out, there were significantly fewer discrepancies following multidisciplinary conference review for gastrointestinal and breast/cervix cases but remained the same for general cases. Fewer formal internal consults were performed after transitioning to partial subspecialty sign-out across all areas, but more notable for gastrointestinal and breast/cervix cases. Our data show improved quality assurance metrics and trainee education in a subspecialty sign-out setting compared to general sign-out setting.

Luke C Kohan,1,* Vijaiganesh Nagarajan,1,* Michael A Millard,2 Michael J Loguidice,2 Nancy M Fauber,1 Ellen C Keeley1 1Division of Cardiology, 2Department of Medicine, University of Virginia, Charlottesville, VA, USA * These authors contributed equally to this work Objectives: To assess if a change in our cardiology fellowship program impacted our ST elevation myocardial infarction (STEMI) program. Background: Fellows covering the cardiac care unit were spending excessive hours in the hospital while on call, resulting in increased duty hours violations. A night float fellow system was started on July 1, 2012, allowing the cardiac care unit fellow to sign out to a night float fellow at 5:30 pm. The night float fellow remained in-house until the morning. Methods: We performed a retrospective study assessing symptom onset to arrival, arterial access to first device, and door-to-balloon (D2B) times, in consecutive STEMI patients presenting to our emergency department before and after initiation of the night float fellow system. Results: From 2009 to 2013, 208 STEMI patients presented to our emergency department and underwent primary percutaneous coronary intervention. There was no difference in symptom onset to arrival (150±102 minutes vs 154±122 minutes, p=0.758), arterial access to first device (12±8 minutes vs 11±7 minutes, p=0.230), or D2B times (50±32 minutes vs 52±34 minutes, p=0.681) during regular working hours. However, there was a significant decrease in D2B times seen during off-hours (72±33 minutes vs 49±15 minutes, p=0.007). There was no difference in in-hospital mortality (11% vs 8%, p=0.484) or need for intra-aortic balloon pump placement (7% vs 8%, p=0.793). Conclusion: In academic medical centers, in-house cardiology fellow coverage during off-hours may expedite care of STEMI patients. Keywords: door-to-balloon time, 24/7 in-house call, cardiology fellow