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IntroductionPhysician communication is critical to patient care. However, integration of sound communication practice with clinical workflows has proven difficult. In this quality improvement initiative, medical students used the rapid improvement model to test interventions that could enhance patients' perception of listening by physicians as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems survey.MethodsLiterature review and process analysis yielded 42 potential interventions, of which 24 were feasible for implementation. Small-scale testing established the 4 most promising interventions; pilot testing was subsequently undertaken on the entire Medicine service. Patient and physician feedback guided further refinement. The final intervention used a structured reminder embedded in the electronic health record to direct physicians to begin interviews by eliciting patient concerns.ResultsPatient concerns elicited after implementation included pain symptoms (28%), disease or treatment course (16%), and discharge planning (10%). In the Hospital Consumer Assessment of Healthcare Providers and Systems survey, physician listening scores rose from a 2014 average of 73.6% to 77% in 2015.DiscussionAmong 24 tested interventions, an open-ended question was most feasible and had the greatest perceived impact by hospitalists and patients. A structured reminder embedded in required electronic medical record documentation facilitated the behavioral change without being overly burdensome to physicians and established a mechanism to enact change in practice.ConclusionMedical students used established improvement methods to promote patient-centered care and align patient and physician agendas, providing a strategy to improve hospitalized patients' perceptions of physician listening.

Purpose: To compare maternal and neonatal outcomes following the development of a multidisciplinary care team for the management of pregnancies complicated by placenta accreta spectrum (PAS) in a rural state. Methods: This is a retrospective cohort study evaluating pregnancies managed before PAS team care management formation (2010–2015) and after (2016–2020) in a university medical center. Maternal and neonatal outcomes were analyzed. Patients were grouped by delivery date to either before or after dedicated PAS team formation. Maternal and neonatal outcomes were analyzed. Frequencies and percentages were reported for categorical measures while means and standard deviations were computed for continuous measures. Wilcoxon rank-sum test was used for continuous variables while Chi-square or Fisher’s exact was used for categorical measures. Findings: There were 82 patients with PAS managed at our institution (29 in Pre-PAS team group and 53 in Post-PAS team group). The number of units of packed red blood cells (PRBCS) transfused intraoperatively was significantly higher in the Pre-PAS care team group (6.52 vs. 3.26, p = .0057). The total number of units PRBCS transfused (9.93 vs. 3.51, p = .0014) and total number of cryoprecipitate transfused (0.77 vs. 0.08, p = .0225) during the entire hospital stay were increased in the Pre-PAS team group. Median neonatal 1 min and 5 min APGAR scores were lower in the Pre-PAS care team group (2 vs 6 at 1 min, p = .0035; 6 vs. 7at 5 min, p = .0301). Conclusions: Management of PAS by a dedicated, multidisciplinary team results in less blood transfusion requirements and improved maternal and neonatal outcomes. [ABSTRACT FROM AUTHOR]

Objective: In 2012, two Kaiser Permanente Northern California (KPNC) hospitals began offering outpatient cervical ripening with oral misoprostol under a study protocol. We evaluated inpatient time from admission to delivery and adverse maternal and neonatal outcomes associated with outpatient use of misoprostol for cervical ripening among low-risk women with term pregnancies., Study Design: We conducted a retrospective cohort study comparing three groups: women who received misoprostol (1) outpatient, under a study protocol; (2) inpatient, at the study sites; and (3) inpatient, at all KPNC hospitals. Data were obtained from between 2012 and 2017. The primary outcome was time from inpatient admission to delivery. Secondarily, we evaluated maternal and neonatal outcomes, including the duration and maximum rate of oxytocin administered, rate of cesarean delivery, incidence of chorioamnionitis and blood transfusion, Apgar scores, and neonatal intensive care unit admissions. Demographic and clinical characteristics and outcomes of the outpatient group were compared with both inpatient misoprostol groups using the appropriate statistical test. Variables included in the regression analysis were either statistically significant in the bivariate analyses or have been reported in the literature to be potential confounders: maternal age at admission, race/ethnicity, body mass index, cervical dilation at initial misoprostol, and parity., Results: We analyzed data from 10,253 patients: (1) 345 outpatients, under a study protocol; (2) 1,374 inpatients, at the study sites; and (3) 9,908 inpatients, at all the Kaiser hospitals. Women in the outpatient group were more likely to be white than both inpatient groups (63.3 vs. 56.3% at study sites and 47.1% in all hospitals, p =  0.002 and <0.001, respectively); other demographics were clinically comparable. Most women undergoing labor induction were nulliparous; however, a greater proportion in the outpatient group were nulliparous compared with inpatient groups (70.8 vs. 61.8% and 64.3%, p  = 0.002 and 0.01). On inpatient admission for delivery, women who received outpatient misoprostol were more likely to have a cervical dilation of ≥3 cm (39.8 vs. 12.5% at study sites and 9.7% at all KPNC hospitals, p  < 0.001 for both). The outpatient group had a shorter mean time between admission and delivery (23.6 vs. 29.4 at study sites and 29.8 hours at all KPNC, p  < 0.001 for both). The adjusted estimated mean difference between the outpatient and inpatient group at all the Kaiser hospitals in time from admission to delivery was -6.48 hours ( p  < 0.001), and the adjusted estimated mean difference in cervical dilation on admission was +1.02 cm ( p  < 0.001). There was no difference in cesarean delivery rates between groups. The rate of chorioamnionitis in the outpatient group was higher compared with inpatients at all hospitals (17.7 vs. 10.6%, p <  0 . 001), but similar when compared with the inpatients at the study sites (17.7 vs. 15.4%, p  = 0.29)., Conclusion: Outpatient use of misoprostol for cervical ripening under the study protocol was associated with reduced inpatient time from admission to delivery compared with inpatient misoprostol. Although there was a higher rate of chorioamnionitis among outpatients under the study protocol compared with inpatients at all hospitals, there was no difference when compared with inpatients at the study sites. There was no difference in rates of cesarean delivery or maternal or neonatal complications with outpatient misoprostol., Key Points: · Outpatient misoprostol patients had 6.46 fewer hours from admission to delivery compared with inpatients at all hospitals.. · There was no difference in the rate of cesareans between the outpatient versus inpatient misoprostol groups.. · Other maternal and neonatal complications were low and comparable among outpatients and inpatients who received misoprostol; this study was not large enough to assess rare safety outcomes.., Competing Interests: None declared., (Thieme. All rights reserved.)