How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis

Background Despite substantial implications for healthcare provider practice and patient outcomes, gender has yet to be systematically explored with regard to interprofessional operating room (OR) teamwork. We aimed to explore and describe how gender and additional social identity factors shape experiences and perceptions of teamwork in the OR. Methods This study was a qualitative secondary analysis of semi-structured interviews with OR team members conducted between November 2018 and July 2019. Participants were recruited across hospitals in Ontario, Canada. We conducted both purposive and snowball sampling until data saturation was reached. Transcripts were analyzed thematically by two independent research team members, moving from open to axial coding. Results Sixty-six interviews of OR healthcare professionals were completed: anesthesia (n=17), nursing (n=19), perfusion (n=2), and surgery (n=26). Traditional gender roles, norms, and stereotypes were perceived and experienced by both women and men, but with different consequences. Both women and men participants described challenges that women face in the OR, such as being perceived negatively for displaying leadership behaviours. Participants also reported that interactions and behaviours vary depending on the team gender composition, and that other social identities, such as age and race, often interact with gender. Nevertheless, participants indicated a belief that the influence of gender in the OR may be modified. Conclusions The highly gendered reality of the OR creates an environment conducive to breakdowns in communuication and patient safety risks in addition to diminishing team morale, psychological safety, and provider well-being. Consequently, until teamwork interventions adequately account for gender, they are unlikely to be optimally effective or sustainable.

615. A Year with COVID19 – Experience from the Front Line in a Large Infectious Disease (ID) Clinical Practice

Background ID Care (IDC) is a large, 43 physician, 74 provider, practice that treats patients in 16 acute care hospitals (ACH) and 120 skilled nursing facilities (SNF) in NJ. March 4, 2021 was the first day a patient with COVID19 seen by IDC. Over the subsequent year IDC evaluated, treated, and tested over 23,000 persons for COVID19. Patients were seen in 2 distinct times - wave 1 (W1) March 5-August 31 and wave 2 (W2) September 1 to March 4. We compare the experience of these 2 waves and report on the year of COVID19 at IDC. Methods The administrative data base for IDC was queried for demographic, visit and testing information. A survey of providers was performed to capture incidence of COVID19 and vaccination rates. Daily census logs were used to create epi curves. Comparisons between waves were performed using student T Test or X2. Results Table 1 provides the comparisons between waves. More patients were seen in W2, however, the number of visits per patient was less, consistent with a shorter length of stay. Fewer patients were seen in SNF in W2 compared to W1. The age and sex distribution between the waves were the same. A total of 8741 molecular tests were performed. Test positivity peaked the week of December 31 at 6.99% and dropped to 0% by May 1 consistent with vaccination and the NJ epidemic curve. During the year of COVID19, 6/74 (8%) clinicians were infected with SARSCoV2. All recovered. Infections in providers were not clearly work-related exposures. 73/74 clinicians were vaccinated. Table 1. Demographics For the Year in COVID19 at ID Care Figure 1. Test Positivity Rate for ID Care Conclusion The year of COVID19 occurred in 2 distinct waves. W1 was short and intense. The age and gender distributions were the same between the waves. Even though wave 2 was numerically greater, the cases in SNF were statistically less than the first wave likely from improved IP practice initiated in W1. The numbers of visits per patient, a surrogate for LOS, was statistically less in W2. The decline in test positivity paralleled deployment of vaccination. Despite an intensity of exposure of 158 patients/provider or 1198 visits/provider to SARSCoV2 infected persons only 8% of the clinician staff were infected. ID clinical practice can use electronic databases to help describe regional outbreaks of transmissible disease giving additional perspective across the care continuum. A more usable standard tool would enhance this capacity. Disclosures Ronald G. Nahass, MD, Abbvie (Grant/Research Support, Speaker's Bureau)Alkermes (Grant/Research Support)Gilead (Grant/Research Support, Speaker's Bureau)Merck (Grant/Research Support, Speaker's Bureau)

Is a ‘guideline-compliant’ primary cesarean delivery associated with a modified risk for maternal and neonatal morbidity?: a clinical evaluation of the 2014 ACOG/SMFM obstetric care consensus statement

Background It is currently unknown whether primary CDs performed in compliance with the 2014 ACOG/SMFM Obstetric Care Consensus Statement guidelines (“guideline-compliant”) are associated with a modified risk of maternal and neonatal morbidity, when compared to primary CDs performed outside the guidelines (“guideline-noncompliant”). Our primary objective was to determine if a guideline-compliant primary CD is associated with a modified risk for maternal or neonatal morbidity, when compared to guideline-noncompliant primary CD. Methods A retrospective cohort study of all primary CDs at one tertiary referral center in the calendar year following publication of the Consensus Statement. Logistic regression was performed to calculate the risk of adverse maternal and neonatal outcomes for guideline-compliant primary CDs, when compared to guideline-noncompliant and guideline-not addressed, and when adjusted for maternal age, BMI, hypertension, gestational age at delivery, insurance carrier, and provider practice. Results Eight hundred twenty-seven primary CDs were included during the study period, of which 34.8, 26.0, and 39.2% were guideline compliant, guideline-noncompliant, and guideline-not addressed. No statistically significant differences in the frequency of adverse maternal outcomes across these three groups were observed with the exception of maternal ICU admission, which was significantly associated with a guideline-not addressed primary CD (p = 0.0002). No statistical difference in rates of NICU admissions, 5 min APGAR < 5, or umbilical artery cord pH < 7 were observed between guideline-compliant and guideline-noncompliant primary CDs. Conclusion Women undergoing guideline-compliant primary CDs were not significantly more likely to experience a maternal or neonatal morbidity when compared to guideline-noncompliant primary CDs.

A National Survey of Social Workers Focusing on Attitudes, Knowledge, and Practice Behaviors for Educating Patients About Advance Directives: Implication During COVID19

Social workers have a critical role on medical teams for facilitating effective conversations about advance care planning (ACP) in palliative and end-of-life care. Engaging patients in such conversations may be influenced by clinicians’ attitudes. During the COVID19 pandemic, the need to examine barriers to serious illness care across healthcare settings and areas of specialty practice became abundantly clear. This study examines: (1) social workers’ attitudes about ACP and (2) factors that influence the completion of advance directives (ADs). Using a cross-sectional study design, we surveyed 142 social workers on their knowledge, attitudes, and behaviors related to ADs. Using exploratory factor analyses, we identified 2 provider practice attitudes factors, 3 perceived barriers factors, and 2 perceived importance of AD factors. We then used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for each of the factors in association with the frequency social workers reported educating patients about ADs. While various positive and negative attitudes and barriers toward educating patients are important factors to consider, social workers’ perceptions of the importance of engaging patients in ACP education was the most important factor that influenced their behaviors. The odds of always/often (vs. sometimes/rarely/never) educating patients about ADs in their practice were greater for those social workers who reported they see the importance of AD decision-making (OR = 3.21, 95%CI = 1.83-5.62) and confirming goals-of-care (OR = 1.76, 95%CI = 1.03-3.01). Social worker’s ACP knowledge and skills for educating patients are important in initiating conversations prior to a health crisis, especially important for developing a comprehensive care plan.

Reducing Intubation Time in Adult Cardiothoracic Surgery Patients With a Fast-track Extubation Protocol

Background Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the operation, the patient’s baseline physiological condition, workflow processes, and provider practice patterns. Local Problem Progression to extubation lacked consistency and coordination across the team. The purpose of the project was to engage interprofessional stakeholders to reduce intubation times after cardiac surgery by implementing fast-track extubation and redesigned care processes. Methods This staged implementation study used the Define, Measure, Analyze, Improve, and Control approach to quality improvement. Barriers to extubation were identified and reduced through care redesign. A protocol-driven approach to extubation was also developed for the cardiothoracic intensive care unit. The team was engaged with clear goals and given progress updates. Results In the preimplementation cohort, early extubation was achieved in 48 of 101 patients (47.5%) who were designated for early extubation on admission to the cardiothoracic intensive care unit. Following implementation of a fast-track extubation protocol and improved care processes, 153 of 211 patients (72.5%) were extubated within 6 hours after cardiac surgery. Reintubation rate, length of stay, and 30-day mortality did not differ between cohorts. Conclusions The number of early extubations following cardiac surgery was successfully increased. Faster progression to extubation did not increase risk of reintubation or other adverse events. Using a framework that integrated personal, social, and environmental influences helped increase the impact of this project.

Assessing the Quality of SK&A’s Office-Based Physician Database for Identifying Oncologists

Health services research increasingly uses commercial databases that capture provider practice characteristics. Little is known about how these data sets compare along other dimensions with publicly available data. We assess the quality of one of the most commonly used commercial databases, SK&A’s office-based physician database, for capturing oncologists who bill the Medicare fee-for-service program. Using 2017 data, we find that nearly 74% of the oncologists in Medicare claims can be found in the SK&A data. Weighted by patients, service volume, or spending, match rates increase to 77%, 96%, and 92%, respectively. Matched oncologists have a high concordance (above 95%) on subspecialty as well as contact information other than street address. Oncologists who appear only in Medicare tend to have low service volumes and spending relative to those who are matched while over half of oncologists who appear only in SK&A have a pediatric subspecialty.

Interprofessional primary care during COVID-19: a survey of the provider perspective

Background Interprofessional primary care (IPC) teams provide comprehensive and coordinated care and are ideally equipped to support those populations most at risk of adverse health outcomes during the COVID-19 pandemic, including older adults, and patients with chronic physical and mental health conditions. There has been little focus on the experiences of healthcare teams and no studies have examined IPC practice during the early phase of the COVID-19 pandemic. The objective of the study was to describe the state of interprofessional health provider practice within IPC teams during the COVID-19 pandemic. Methods Observational cross-sectional design. A web-based survey was deployed to IPC providers working in team-based primary care clinics in the province of Ontario, Canada. The survey included 26 close-ended and six open-ended questions. Close-ended questions were analyzed using descriptive statistics. Content analysis was used to analyze the open-ended questions. Results 445 surveys were included in the final analysis. Service delivery shifted from in-person care (77% pre-COVID-19) to telephone (76.5% during the COVID-19 pandemic). Less than half of the respondents (40%) reported receiving any training for virtual delivery. Wait times to access team members were reported to have decreased. There has also been a shift in what IPC providers report as the most commonly seen conditions, with increases in visits related to mental health concerns, acute infections (including COVID-19), social isolation, and resource navigation. Respondents also reported a reduction in healthcare provision for multiple chronic conditions including diabetes, cardiovascular disease, and chronic pain. Conclusions IPC teams are rapidly shifting their practice to supporting their patients during the pandemic. A surge in mental health issues has been seen and is expected to continue to increase in response to COVID-19. Understanding early experiences can help plan for future pandemic waves.