Effects of Unit Census and Patient Acuity Levels on Discussions During Patient Rounds

OBJECTIVES

PICU teams adapt the duration of patient rounding discussions to accommodate varying contextual factors, such as unit census and patient acuity. Although studies establish that shorter discussions can lead to the omission of critical patient information, little is known about how teams adapt their rounding discussions about essential patient topics (i.e., introduction/history, acute clinical status, care plans) in response to changing contexts. To fill this gap, we examined how census and patient acuity impact time spent discussing essential topics during individual patient encounters.

DESIGN

Observational study.

SETTING

PICU at a university-affiliated children's hospital, Toronto, ON, Canada.

SUBJECTS

Interprofessional morning rounding teams.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We observed 165 individual patient encounters during morning rounds over 10 weeks. Regardless of census or patient acuity, the duration of patient introductions/history did not change. When census was high versus low, acute clinical status discussions significantly decreased for both low acuity patients (00 min:50 s high census; 01 min:39 s low census; -49.5% change) and high acuity patients (01 min:10 s high census; 02 min:02 s low census; -42.6% change). Durations of care plan discussions significantly reduced as a function of census (01 min:19 s high census; 02 min:52 s low census; -54.7% change) for low but not high acuity patients.

CONCLUSIONS

Under high census and patient acuity levels, rounding teams disproportionately shorten time spent discussing essential patient topics. Of note, while teams preserved time to plan the care for acute patients, they cut care plan discussions of low acuity patients. This study provides needed detail regarding how rounding teams adapt their discussions of essential topics and establishes a foundation for consideration of varying contextual factors in the design of rounding guidelines. As ICUs are challenged with increasing census and patient acuity levels, it is critical that we turn our attention to these contextual aspects and understand how these adaptations impact clinical outcomes to address them.

Cognitive biases in surgery: systematic review

BACKGROUND

Although numerous studies have established cognitive biases as contributors to surgical adverse events, their prevalence and impact in surgery are unknown. This review aimed to describe types of cognitive bias in surgery, their impact on surgical performance and patient outcomes, their source, and the mitigation strategies used to reduce their effect.

METHODS

A literature search was conducted on 9 April and 6 December 2021 using MEDLINE, Embase, PsycINFO, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Included studies investigated how cognitive biases affect surgery and the mitigation strategies used to combat their impact. The National Institutes of Health tools were used to assess study quality. Inductive thematic analysis was used to identify themes of cognitive bias impact on surgical performance.

RESULTS

Thirty-nine studies were included, comprising 6514 surgeons and over 200 000 patients. Thirty-one types of cognitive bias were identified, with overconfidence, anchoring, and confirmation bias the most common. Cognitive biases differentially influenced six themes of surgical performance. For example, overconfidence bias associated with inaccurate perceptions of ability, whereas anchoring bias associated with inaccurate risk-benefit estimations and not considering alternative options. Anchoring and confirmation biases associated with actual patient harm, such as never events. No studies investigated cognitive bias source or mitigation strategies.

CONCLUSION

Cognitive biases have a negative impact on surgical performance and patient outcomes across all points of surgical care. This review highlights the scarcity of research investigating the sources that give rise to cognitive biases in surgery and the mitigation strategies that target these factors.

Electroencephalography can provide advance warning of technical errors during laparoscopic surgery

BACKGROUND

Intraoperative adverse events lead to patient injury and death, and are increasing. Early warning systems (EWSs) have been used to detect patient deterioration and save lives. However, few studies have used EWSs to monitor surgical performance and caution about imminent technical errors. Previous (non-surgical) research has investigated neural activity to predict future motor errors using electroencephalography (EEG). The present proof-of-concept cohort study investigates whether EEG could predict technical errors in surgery.

METHODS

In a large academic hospital, three surgical fellows performed 12 elective laparoscopic general surgeries. Audiovisual data of the operating room and the surgeon's neural activity were recorded. Technical errors and epochs of good surgical performance were coded into events. Neural activity was observed 40 s prior and 10 s after errors and good events to determine how far in advance errors were detected. A hierarchical regression model was used to account for possible clustering within surgeons. This prospective, proof-of-concept, cohort study was conducted from July to November 2021, with a pilot period from February to March 2020 used to optimize the technique of data capture and included participants who were blinded from study hypotheses.

RESULTS

Forty-five technical errors, mainly due to too little force or distance (n = 39), and 27 good surgical events were coded during grasping and dissection. Neural activity representing error monitoring (p = .008) and motor uncertainty (p = .034) was detected 17 s prior to errors, but not prior to good surgical performance.

CONCLUSIONS

These results show that distinct neural signatures are predictive of technical error in laparoscopic surgery. If replicated with low false-alarm rates, an EEG-based EWS of technical errors could be used to improve individualized surgical training by flagging imminent unsafe actions-before errors occur and cause patient harm.

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review

BACKGROUND

Despite being implemented for over a decade, literature describing how the surgical safety checklist (SSC) is completed by operating room (OR) teams and how this relates to its effectiveness is scarce. This systematic review aimed to: (1) quantify how many studies reported SSC completion versus described how the SSC was completed; (2) evaluate the impact of the SSC on provider outcomes (Communication, case Understanding, Safety Culture, CUSC), patient outcomes (complications, mortality rates) and moderators of these relationships.

METHODS

A systematic literature search was conducted using Medline, CINAHL, Embase, PsycINFO, PubMed, Scopus and Web of Science on 10 January 2020. We included providers who treat human patients and completed any type of SSC in any OR or simulation centre. Statistical directional findings were extracted for provider and patient outcomes and key factors (eg, attentiveness) were used to determine moderating effects.

RESULTS

300 studies were included in the analysis comprising over 7 302 674 operations and 2 480 748 providers and patients. Thirty-eight per cent of studies provided at least some description of how the SSC was completed. Of the studies that described SSC completion, a clearer positive relationship was observed concerning the SSC's influence on provider outcomes (CUSC) compared with patient outcomes (complications and mortality), as well as related moderators.

CONCLUSION

There is a scarcity of research that examines how the SSC is completed and how this influences safety outcomes. Examining how a checklist is completed is critical for understanding why the checklist is successful in some instances and not others.

The Effect of Information Formats and Incidental Affect on Prior and Posterior Probability Judgments

Background. Interpreting medical test results involves judging probabilities, including making Bayesian inferences such as judging the positive and negative predictive values. Although prior work has shown that experience formats (e.g., slide shows of representative patient cases) produce more accurate Bayesian inferences than description formats (e.g., verbal statistical summaries), there are disadvantages of using the experience format for real-world medical decision making that may be solved by presenting relevant information in a 2 × 2 table format. Furthermore, medical decisions are often made in stressful contexts, yet little is known about the influence of acute stress on the accuracy of Bayesian inferences. This study aimed to a) replicate the description-experience format effect on probabilistic judgments; b) examine judgment accuracy across description, experience, and a new 2 × 2 table format; and c) assess the effect of acute stress on probability judgments. Method. The study employed a 2 (stress condition) × 3 (format) factorial between-subjects design. Participants (N = 165) completed a Bayesian inference task in which information about a medical screening test was presented in 1 of 3 formats (description, experience, 2 × 2 table), following a laboratory stress induction or a no-stress control condition. Results. Overall, the 2 × 2 table format produced the most accurate probability judgments, including Bayesian inferences, compared with the description and experience formats. Stress had no effect on judgment accuracy. Discussion. Given its accuracy and practicality, a 2 × 2 table may be better suited than description or experience formats for communicating probabilistic information in medical contexts.

Retracted: The Effect of Bilingualism on Older Adults' Inhibitory Control: A Meta-Analysis

BACKGROUND AND OBJECTIVES

The effect bilingualism has on older adults' inhibitory control has been extensively investigated, yet there is continued controversy regarding whether older adult bilinguals show superior inhibitory control compared with monolinguals. The objective of the current meta-analysis was to examine the reliability and magnitude of the bilingualism effect on older adults' inhibitory control as measured by the Simon and Stroop tasks. In addition, we examined whether individual characteristics moderate the bilingual advantage in inhibition, including age (young-old vs old-old), age of second language acquisition, immigrant status, language proficiency, and frequency of language use.

RESEARCH DESIGN AND METHODS

A total of 22 samples for the Simon task and 14 samples for the Stroop task were derived from 28 published and unpublished articles (32 independent samples, with 4 of these samples using more than 1 task) and were analyzed in 2 separate meta-analyses.

RESULTS

Analyses revealed a reliable effect of bilingualism on older adults' performance on the Simon (g = 0.60) and Stroop (g = 0.27) tasks. Interestingly, individual characteristics did not moderate the association between bilingualism and older adults' inhibitory control.

DISCUSSION AND IMPLICATIONS

The results suggest there is a bilingual advantage in inhibitory control for older bilinguals compared with older monolinguals, regardless of the individual characteristics previously thought to moderate this effect. Based on these findings, bilingualism may protect inhibitory control from normal cognitive decline with age.

Aiding Risk Information learning through Simulated Experience (ARISE): A Comparison of the Communication of Screening Test Information in Explicit and Simulated Experience Formats

OBJECTIVE

To determine whether the use of Aiding Risk Information learning through Simulated Experience (ARISE) to communicate conditional probabilities about maternal serum screening results for Down syndrome promotes more accurate positive predictive value (PPV) estimates and conceptual understanding of screening, compared with explicitly providing individuals with this information via numerical summary or icon array.

METHOD

In experiment 1, 582 participants completed an online study in which they were asked to estimate the PPV and rate their attitudes toward a screening test when information was presented in either a description (required calculation of the PPV), explicit (PPV was provided and had to be identified), or an ARISE format (PPV was inferred through experience-based learning). In experiment 2, 316 participants estimated the PPV and rated their attitudes toward screening based on information presented in either an icon array (identify the icons that represent the PPV) or ARISE format.

RESULTS

In experiment 1, ARISE elicited the most accurate PPV estimates compared with the description and explicit formats, and both the explicit and ARISE formats led to more unfavorable attitudes toward screening. In experiment 2, both the icon array and ARISE resulted in similar PPV estimates; however, ARISE led to more negative attitudes toward screening.

CONCLUSIONS

These findings suggest that ARISE may be superior to other formats in the communication of PPV information for screening tests. However, differences in the complexity of the formats vary and require further investigation.

Acute stress and altruism in younger and older adults

Recent studies of aging and decision making suggests that altruism increases with age. It is unclear, however, whether this pattern holds when choices are made under stress, as is often the case in real-world scenarios. The current study used an intertemporal choice task in which younger and older adults received a financial endowment before making a series of consequential intertemporal decisions involving gains, losses and charitable donations. Preceding the choice task, participants were exposed to a laboratory stressor. Physiological stress reactivity was a predictor of altruistic decision making in younger adults, such that individuals with higher stress reactivity made more generous choices. Older adults showed higher altruism than younger adults overall, with altruism unrelated to stress reactivity in older adults. These findings are consistent with an age-related change in the mechanisms underlying altruistic behavior.

Acute pediatric rhabdomyolysis

Rhabdomyolysis is a relatively common condition that may occur intermittently in chronic and inflammatory myopathy, muscular dystrophy, and metabolic myopathy. Rhabdomyolysis can also present acutely in otherwise healthy individuals. The list of etiologies for acute muscle cell lysis is enormous, with new causes described yearly. Series on acute pediatric rhabdomyolysis have not yet been published. This article describes a retrospective review of children admitted to the authors' institution during an 8-year period in whom rhabdomyolysis was recognized as a complication during their hospital stay. Patients with intermittent or relapsing rhabdomyolysis were excluded. Nineteen children were identified. Trauma (five cases), nonketotic hyperosmolar coma (two cases), viral myositis (two cases), dystonia (two cases), and malignant hyperthermia-related conditions (two cases) were the most common causes of rhabdomyolysis. Acute renal failure was the most frequent complication, occurring in 42% of cases. The mean age of renal failure patients was 13.9 years, compared to 8 years for non-renal failure children. Careful assessment of the initial urinalysis would have suggested a diagnosis of rhabdomyolysis in 9 of 16 patients tested.

Anomalous origin of the left coronary artery in tetralogy of Fallot associated with abnormal mitral valve pathology

The association of anomalous left coronary artery with congenital heart disease is a rare occurrence. Seven cases of anomalous left coronary artery associated with tetralogy of Fallot have been reported in the literature. We report a unique case with severe mitral valve abnormality that precluded standard surgical repair.

Alterations in the Ha-ras-1 and the p53 pathway genes in the progression of N-methyl-N-nitrosourea-induced rat mammary tumors

Well-differentiated mammary carcinomas carrying mutated Ha-ras-1 oncogenes arise frequently in pubescent rats exposed to the direct-acting methylating agent N-methyl-N-nitrosourea (MNU). When these tumors are serially transplanted, they acquire more aggressive phenotypes. To determine the genetic alterations underlying local invasion, hormone independence, and metastasis, we studied alterations in the Ha-ras-1, p53, and mdm2 genes in successive generations of tumors passaged in intact or ovariectomized rats. Although previous studies have shown that selective amplification of the mutant Ha-ras-1 allele correlates strongly with the acquisition of hormone independence, we found that the acquisition of an invasive phenotype did not depend on mutational activation or amplification of Ha-ras-1. Mutations in the p53 gene were rare. Of a total of 120 primary, locally invasive, hormone-independent, and metastatic tumors tested for mutations in exons 4-9 of the p53 gene, only one mutation was detected in the later passages of an invasive tumor line. No gross gene alteration or amplification was seen in mdm2, a negative regulator of p53 transcription. Thus, the p53 gene is an infrequent mutational target, and amplification of the mdm2 gene does not appear to play a role in initiation or progression of rat mammary tumorigenesis.

Protocol: isolated systolic hypertension in the elderly

Isolated systolic hypertension is common in the elderly population and has only recently been recognized as a pathophysiologic process. In the past it was considered to be part of the normal aging process. Assessment of isolated systolic hypertension is covered, including the differentiation between isolated systolic hypertension, essential hypertension and secondary hypertension. Non-pharmacologic therapy, the treatment of first choice, and pharmacologic therapy are discussed, including treatment considerations related to the aging process. Also included are patient education guidelines and indications for physician referral. Isolated systolic hypertension is an important clinical entity in the growing elderly population and can be appropriately diagnosed and managed by the nurse practitioner in primary care.

Role of irradiation in the management of superior vena cava syndrome

The records of 125 patients treated for superior vena cava syndrome secondary to malignant disease were reviewed retrospectively. The mean age of patients was 55 years. Bronchogenic carcinoma was the cause of the syndrome in 79% of cases, malignant lymphoma 18%, and other tumors 6%. Approximately 80% of the patients obtained good to excellent symptomatic relief. High initial dose radiation therapy (300-400 cGy daily for three fractions) yielded good symptomatic relief in less than 2 weeks in 70% of patients; conventional dose radiation therapy (200 cGy daily, five weekly fractions) yielded the same response in 56% of patients (p = 0.09). Lymphoma patients displayed a 1 year survival of 41%, small cell carcinoma 24%, and other types of bronchogenic carcinoma 17%. Combination of radiation and chemotherapy did not improve response rate, degree of symptomatic relief or long-term survival. Patients exhibiting symptomatic relief within 30 days had a significantly better survival rate than those who did not (p = 0.002). Thirteen percent of patients showed a recurrence of superior vena cava syndrome. There was no correlation between tumor regression and symptomatic relief. Side effects of therapy were minimal; dysphagia was the most common complaint (26% of patients).