A. Gurses | Johns Hopkins University (original) (raw)
Papers by A. Gurses
American Journal of Medical Quality, 2012
Health care has primarily used retrospective review approaches to identify and mitigate hazards, ... more Health care has primarily used retrospective review approaches to identify and mitigate hazards, with little evidence of measurable and sustained improvements in patient safety. Conversely, the nuclear power industry has used a prospective peer-to-peer (P2P) assessment process grounded in open information exchange and cooperative organizational learning to realize substantial and sustainable improvements in safety. In comparing approaches, it is evident that health care’s sluggish progress stems from weaknesses in hazard identification and mitigation and in organizational learning. This article proposes creating and implementing a structured prospective P2P assessment model in health care, similar to that used in the nuclear power industry, to accelerate improvements in patient safety.
Home health care services quarterly, Jan 23, 2015
Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for... more Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for experiencing suboptimal transitions. Using the human factors approach of shadowing and contextual inquiry, we studied the workflow for transitioning older adults from the hospital to SHHC. We created a representative diagram of the hospital to SHHC transition workflow, we examined potential workflow variations, we categorized workflow challenges, and we identified artifacts developed to manage variations and challenges. We identified three overarching challenges to optimal care transitions-information access, coordination, and communication/teamwork. Future investigations could test whether redesigning the transition from hospital to SHHC, based on our findings, improves workflow and care quality.
This study synthesizes information contained in 27 mnemonics to identify what information should ... more This study synthesizes information contained in 27 mnemonics to identify what information should be communicated during a handoff. Clustering and content analysis resulted in 12 primary information clusters that should be communicated. Given the large amount of information identified, it would be beneficial to use a structured handoff communication tool developed using a participatory approach. In addition, we recommend local standardization of information communicated during handoffs with variation across settings.
Interactive CardioVascular and Thoracic Surgery, 2013
Objectives: Mediastinal lymph node metastasis is still the most important prognostic factor for l... more Objectives: Mediastinal lymph node metastasis is still the most important prognostic factor for lung carcinoma without distant metastasis. Nevertheless, mediastinal lymph nodes are heterogeneous groups. We investigated the prognostic effect of lymph node metastasis in completely resected left upper lobe carcinoma. Methods: Between 1998 and 2010, 181 patients with proven left lung carcinoma who underwent complete resection were retrospectively analysed. The patients were divided into five groups acccording to N status: N0 (n = 68, 37.5%), N1-single (n = 49, 27.1%), N1-multiple (n = 15, 8.3%), N2-5,6+ (only metastasized to #5 and/or #6, n = 36, 19.9%), N2-7+ (only metastasized to #7, n = 13, 7.2%). Results: The overall 5-year and 10-year survival rates were 55.1% and 35.2%, respectively. The 5-year survivals were 76.1% for N0, 54.3% for N1 (60.1% for N1-single, 36.6% for N1-multiple), 20.7% for N2 (24.3% for N2-5,6+). N2 was the worst prognostic factor when compared with N0/1 (P < 0.0001). Patients with N0 had a significantly better survival than those patients with N1 (P = 0.006). N1-single patients were found to have statistically significantly better survival rates when compared to both N1-multiple and N2-5,6+ (P = 0.02, P = 0.008, respectively). Patients having involvement of subcarinal lymph nodes had a significantly poorer prognosis than those patients with metastases only to aortopulmonary lymph nodes (stations 5 and/or 6) (P = 0.02). Conclusions: Metastasis to mediastinal lymph nodes in completely resected left upper lobe NSCLC has a worse prognostic effect on survival. Patients with N0 and N-single were found to have better prognostic rates in comparison with N1-multiple and N2-5,6+. The presence of aortopulmonary lymph nodes has a worse effect on survival.
The Thoracic and Cardiovascular Surgeon, 2007
Generally, the operative procedures for the diagnosis or treatment of mediastinal, intrathoracic ... more Generally, the operative procedures for the diagnosis or treatment of mediastinal, intrathoracic and/or chest wall lesions requiring rib resection are performed under general anesthesia. Although evidence suggests that thoracoscopy can be performed under local anesthesia, no report has indicated that some major thoracic procedures can be accomplished without general anesthesia. In our study, we advocate that certain surgical procedures could be performed under local anesthesia with a performance similar to that of general anesthesia. Thirty patients underwent thoracic procedures with local anesthesia and sedation for diagnosis and treatment. Seventeen of the patients were men, and the mean age of the patients was 49.6 years (range 16 to 71 years). There were 13 diagnostic procedures, and 17 procedures were for treatment purposes. The operative procedures performed using only local anesthesia were mini-thoracotomy (n = 9), mediastinotomy (n = 4), revision of a full-thickness posterolateral thoracic incision (n = 7), resection of the chondroma (n = 4), Eloesser flap (n = 1), metastasectomy of the chest wall (n = 3), empyectomy (n = 1), and video-assisted thoracoscopy (n = 2). Severity of pain was evaluated by VAS. There were no oral or intravenous analgesic requirements in the early postoperative period. No complications attributable to the procedure were observed. Thoracic surgical procedures for diagnosis and treatment performed under local anesthesia are simple, effective, economical and comfortable for the patient.
The Thoracic and Cardiovascular Surgeon, 2009
This study aims to investigate the treatment modalities and factors influencing survival in surgi... more This study aims to investigate the treatment modalities and factors influencing survival in surgically treated superior sulcus tumors. Sixty-five cases of surgically treated non-small cell carcinoma of the lung occurring as superior sulcus tumors between 1994 and 2007 were retrospectively reviewed. Twenty-five patients underwent induction radiotherapy (RT), 10 had induction chemoradiotherapy (CT/RT). In thirty patients surgery was performed directly. The mortality rate was 6.2 %. Pathological stage was T3 in 55, T4 in 10, N0 in 52, and N1 in 5 and N2 in 8 patients. Overall 5- and 10-year survival rates were 31 % and 28 %, respectively. Complete resection rate was 90 % for patients who received induction CT/RT and 80 % for patients who either received induction RT alone or patients in whom surgery was performed directly. In patients who received neoadjuvant therapy with complete tumor resection, the median survival time was 33 months (28 months for patients who received induction RT alone and 36 months for patients who received induction CT/RT), and the 5-year survival rate was 41 %. Median survival time and 5-year survival rate of patients treated by direct surgery with complete resection was 24 months and 37 %, respectively ( P = 0.87). Five-year survival and 10-year survival rates were significantly higher after complete resection than after incomplete resection (38 % and 34 % vs. 0 %, P = 0.0001). In multivariate analysis, only N2 disease ( P = 0.04) and incomplete resection ( P = 0.03) were found to be poor prognostic factors. The presence of N2 disease and incomplete resection are the two most important factors affecting survival. Induction CT/RT may increase the ability to achieve complete surgical resection.
Journal for Healthcare Quality, 2012
European Journal of Cardio-Thoracic Surgery, 2002
American Journal of Medical Quality, 2012
Health care has primarily used retrospective review approaches to identify and mitigate hazards, ... more Health care has primarily used retrospective review approaches to identify and mitigate hazards, with little evidence of measurable and sustained improvements in patient safety. Conversely, the nuclear power industry has used a prospective peer-to-peer (P2P) assessment process grounded in open information exchange and cooperative organizational learning to realize substantial and sustainable improvements in safety. In comparing approaches, it is evident that health care&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s sluggish progress stems from weaknesses in hazard identification and mitigation and in organizational learning. This article proposes creating and implementing a structured prospective P2P assessment model in health care, similar to that used in the nuclear power industry, to accelerate improvements in patient safety.
Issues with workflow integration have contributed to slow rates of EHR adoption in ambulatory out... more Issues with workflow integration have contributed to slow rates of EHR adoption in ambulatory outpatient care settings. In response to workflow integration challenges with EHRs, clinicians often develop workarounds to complete clinical tasks in ways other than were intended by system designers. Based on the insights generated during collegial discussions with physician Subject Matter Experts (SMEs) and three interdisciplinary team meetings with clinical and human factors experts, we created process map visualizations. A wide range of opportunities to improve workflow through enhanced functionality with the EHR were identified. Targeted recommendations for EHR developers and ambulatory (outpatient) care centers are proposed to increase efficiency, allow for better eye contact between the physician and patient, improve physician's information workflow, and reduce alert fatigue. These recommendations provide a first step in moving from a billing-centered perspective to a clinician-centered perspective.
American Journal of Medical Quality, 2012
Health care has primarily used retrospective review approaches to identify and mitigate hazards, ... more Health care has primarily used retrospective review approaches to identify and mitigate hazards, with little evidence of measurable and sustained improvements in patient safety. Conversely, the nuclear power industry has used a prospective peer-to-peer (P2P) assessment process grounded in open information exchange and cooperative organizational learning to realize substantial and sustainable improvements in safety. In comparing approaches, it is evident that health care’s sluggish progress stems from weaknesses in hazard identification and mitigation and in organizational learning. This article proposes creating and implementing a structured prospective P2P assessment model in health care, similar to that used in the nuclear power industry, to accelerate improvements in patient safety.
Home health care services quarterly, Jan 23, 2015
Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for... more Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for experiencing suboptimal transitions. Using the human factors approach of shadowing and contextual inquiry, we studied the workflow for transitioning older adults from the hospital to SHHC. We created a representative diagram of the hospital to SHHC transition workflow, we examined potential workflow variations, we categorized workflow challenges, and we identified artifacts developed to manage variations and challenges. We identified three overarching challenges to optimal care transitions-information access, coordination, and communication/teamwork. Future investigations could test whether redesigning the transition from hospital to SHHC, based on our findings, improves workflow and care quality.
This study synthesizes information contained in 27 mnemonics to identify what information should ... more This study synthesizes information contained in 27 mnemonics to identify what information should be communicated during a handoff. Clustering and content analysis resulted in 12 primary information clusters that should be communicated. Given the large amount of information identified, it would be beneficial to use a structured handoff communication tool developed using a participatory approach. In addition, we recommend local standardization of information communicated during handoffs with variation across settings.
Interactive CardioVascular and Thoracic Surgery, 2013
Objectives: Mediastinal lymph node metastasis is still the most important prognostic factor for l... more Objectives: Mediastinal lymph node metastasis is still the most important prognostic factor for lung carcinoma without distant metastasis. Nevertheless, mediastinal lymph nodes are heterogeneous groups. We investigated the prognostic effect of lymph node metastasis in completely resected left upper lobe carcinoma. Methods: Between 1998 and 2010, 181 patients with proven left lung carcinoma who underwent complete resection were retrospectively analysed. The patients were divided into five groups acccording to N status: N0 (n = 68, 37.5%), N1-single (n = 49, 27.1%), N1-multiple (n = 15, 8.3%), N2-5,6+ (only metastasized to #5 and/or #6, n = 36, 19.9%), N2-7+ (only metastasized to #7, n = 13, 7.2%). Results: The overall 5-year and 10-year survival rates were 55.1% and 35.2%, respectively. The 5-year survivals were 76.1% for N0, 54.3% for N1 (60.1% for N1-single, 36.6% for N1-multiple), 20.7% for N2 (24.3% for N2-5,6+). N2 was the worst prognostic factor when compared with N0/1 (P < 0.0001). Patients with N0 had a significantly better survival than those patients with N1 (P = 0.006). N1-single patients were found to have statistically significantly better survival rates when compared to both N1-multiple and N2-5,6+ (P = 0.02, P = 0.008, respectively). Patients having involvement of subcarinal lymph nodes had a significantly poorer prognosis than those patients with metastases only to aortopulmonary lymph nodes (stations 5 and/or 6) (P = 0.02). Conclusions: Metastasis to mediastinal lymph nodes in completely resected left upper lobe NSCLC has a worse prognostic effect on survival. Patients with N0 and N-single were found to have better prognostic rates in comparison with N1-multiple and N2-5,6+. The presence of aortopulmonary lymph nodes has a worse effect on survival.
The Thoracic and Cardiovascular Surgeon, 2007
Generally, the operative procedures for the diagnosis or treatment of mediastinal, intrathoracic ... more Generally, the operative procedures for the diagnosis or treatment of mediastinal, intrathoracic and/or chest wall lesions requiring rib resection are performed under general anesthesia. Although evidence suggests that thoracoscopy can be performed under local anesthesia, no report has indicated that some major thoracic procedures can be accomplished without general anesthesia. In our study, we advocate that certain surgical procedures could be performed under local anesthesia with a performance similar to that of general anesthesia. Thirty patients underwent thoracic procedures with local anesthesia and sedation for diagnosis and treatment. Seventeen of the patients were men, and the mean age of the patients was 49.6 years (range 16 to 71 years). There were 13 diagnostic procedures, and 17 procedures were for treatment purposes. The operative procedures performed using only local anesthesia were mini-thoracotomy (n = 9), mediastinotomy (n = 4), revision of a full-thickness posterolateral thoracic incision (n = 7), resection of the chondroma (n = 4), Eloesser flap (n = 1), metastasectomy of the chest wall (n = 3), empyectomy (n = 1), and video-assisted thoracoscopy (n = 2). Severity of pain was evaluated by VAS. There were no oral or intravenous analgesic requirements in the early postoperative period. No complications attributable to the procedure were observed. Thoracic surgical procedures for diagnosis and treatment performed under local anesthesia are simple, effective, economical and comfortable for the patient.
The Thoracic and Cardiovascular Surgeon, 2009
This study aims to investigate the treatment modalities and factors influencing survival in surgi... more This study aims to investigate the treatment modalities and factors influencing survival in surgically treated superior sulcus tumors. Sixty-five cases of surgically treated non-small cell carcinoma of the lung occurring as superior sulcus tumors between 1994 and 2007 were retrospectively reviewed. Twenty-five patients underwent induction radiotherapy (RT), 10 had induction chemoradiotherapy (CT/RT). In thirty patients surgery was performed directly. The mortality rate was 6.2 %. Pathological stage was T3 in 55, T4 in 10, N0 in 52, and N1 in 5 and N2 in 8 patients. Overall 5- and 10-year survival rates were 31 % and 28 %, respectively. Complete resection rate was 90 % for patients who received induction CT/RT and 80 % for patients who either received induction RT alone or patients in whom surgery was performed directly. In patients who received neoadjuvant therapy with complete tumor resection, the median survival time was 33 months (28 months for patients who received induction RT alone and 36 months for patients who received induction CT/RT), and the 5-year survival rate was 41 %. Median survival time and 5-year survival rate of patients treated by direct surgery with complete resection was 24 months and 37 %, respectively ( P = 0.87). Five-year survival and 10-year survival rates were significantly higher after complete resection than after incomplete resection (38 % and 34 % vs. 0 %, P = 0.0001). In multivariate analysis, only N2 disease ( P = 0.04) and incomplete resection ( P = 0.03) were found to be poor prognostic factors. The presence of N2 disease and incomplete resection are the two most important factors affecting survival. Induction CT/RT may increase the ability to achieve complete surgical resection.
Journal for Healthcare Quality, 2012
European Journal of Cardio-Thoracic Surgery, 2002
American Journal of Medical Quality, 2012
Health care has primarily used retrospective review approaches to identify and mitigate hazards, ... more Health care has primarily used retrospective review approaches to identify and mitigate hazards, with little evidence of measurable and sustained improvements in patient safety. Conversely, the nuclear power industry has used a prospective peer-to-peer (P2P) assessment process grounded in open information exchange and cooperative organizational learning to realize substantial and sustainable improvements in safety. In comparing approaches, it is evident that health care&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s sluggish progress stems from weaknesses in hazard identification and mitigation and in organizational learning. This article proposes creating and implementing a structured prospective P2P assessment model in health care, similar to that used in the nuclear power industry, to accelerate improvements in patient safety.
Issues with workflow integration have contributed to slow rates of EHR adoption in ambulatory out... more Issues with workflow integration have contributed to slow rates of EHR adoption in ambulatory outpatient care settings. In response to workflow integration challenges with EHRs, clinicians often develop workarounds to complete clinical tasks in ways other than were intended by system designers. Based on the insights generated during collegial discussions with physician Subject Matter Experts (SMEs) and three interdisciplinary team meetings with clinical and human factors experts, we created process map visualizations. A wide range of opportunities to improve workflow through enhanced functionality with the EHR were identified. Targeted recommendations for EHR developers and ambulatory (outpatient) care centers are proposed to increase efficiency, allow for better eye contact between the physician and patient, improve physician's information workflow, and reduce alert fatigue. These recommendations provide a first step in moving from a billing-centered perspective to a clinician-centered perspective.