Nurse-Doctor Co-Teaching: A Pilot Study of the Design, Development, and Implementation of Structured Interprofessional Co-Teaching Sessions

INTRODUCTION

High levels of interprofessional collaboration are beneficial for patients and healthcare providers. Co-teaching may be one method for creating a collaborative environment. This pilot study designed, developed, and implemented Nurse-Doctor Co-Teaching on an inpatient medicine service.

METHODS

Ten Nurse-Doctor Co-Teaching pairs designed 30-minute, structured co-teaching sessions with learning objectives, evidence-based content, interactive teaching strategies and a Take-Away of key content with the help of a coaching team. Each session was presented by a nurse and senior doctor to nurse and resident learners. Our assessment blueprint included: 1. Anonymous surveys assessing the overall rating of each session and 2. Pre- and post-anonymous surveys assessing measures of interprofessional collaboration and communication between nurses and residents before and after the series of ten co-teaching sessions.

RESULTS

Data from ten post-session surveys included 121 of 156 participants (77.6%). Attendance at each session ranged from 13-19 participants with 8-17 participants completing a survey per session for an average of 12.1 surveys analyzed. All Nurse-Doctor Co-Teaching sessions scored in the excellent range between 1.00 and 1.43 on a Likert scale (1 is excellent and 5 is poor). In response to the question "What did you like best?", interactive teaching strategies was the most frequent spontaneous answer. A significant correlation between the number of interactive teaching strategies and enjoyability of the session (p-value=0.01) was observed. Measures of interprofessional collaboration and communication did not change significantly in the pre-intervention compared to post-intervention period.

CONCLUSION

We created a unique model of interprofessional co-teaching on an inpatient service. The overall excellent ratings of our interactive sessions indicate that Nurse-Doctor Co-Teaching is a valued form of learning. Our structured format is adaptable to various medical settings and could be expanded to include additional allied health professionals. We plan further studies to assess if Nurse-Doctor Co-Teaching improves measures of interprofessional collaboration.

Is Asking Questions on Rounds a Teachable Skill? A Randomized Controlled Trial to Increase Attendings' Asking Questions

BACKGROUND

Morning bedside rounds remain an essential part of Internal Medicine residency education, but rounds vary widely in terms of educational value and learner engagement.

OBJECTIVE

To evaluate the efficacy of an intervention to increase the number and variety of questions asked by attendings at the bedside and assess its impact.

DESIGN

We conducted a randomized, controlled trial to evaluate the efficacy of our intervention.

PARTICIPANTS

Hospitalist attendings on the general medicine service were invited to participate. Twelve hospitalists were randomized to the experimental group and ten hospitalists to the control group.

INTERVENTION

A one-hour interactive session which teaches and models the method of asking questions using a non-medical case, followed by practice using role plays with medical cases.

MAIN MEASURES

Our primary outcome was the number of questions asked by attendings during rounds. We used audio-video recordings of rounds evaluated by blinded reviewers to quantify the number of questions asked, and we also recorded the type of question and the person asked. We assessed whether learners found rounds worthwhile using anonymous surveys of residents, patients, and nurses.

KEY RESULTS

Blinded analysis of the audio-video recordings demonstrated significantly more questions asked by attendings in the experimental group compared to the control group (mean number of questions 23.5 versus 10.8, p< 0.001) with significantly more questions asked of the residents (p<0.003). Residents rated morning bedside rounds with the experimental attendings as significantly more worthwhile compared to rounds with the control group attendings (p=0.009).

CONCLUSION

Our study findings highlight the benefits of a one-hour intervention to teach faculty a method of asking questions during bedside rounds. This educational strategy had the positive outcome of including significantly more resident voices at the bedside. Residents who rounded with attendings in the experimental group were more likely to "strongly agree" that bedside rounds were "worthwhile".

The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial

BACKGROUND

Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up.

KEY RESULTS

Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03).

CONCLUSIONS

Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern.

CLINICAL TRIALS IDENTIFIER

NCT01153451.

Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services

BACKGROUND

Dispersion of inpatient care teams across different medical units impedes effective team communication, potentially leading to adverse events (AEs).

OBJECTIVE

To regionalize 3 inpatient general medical teams to nursing units and examine the association with communication and preventable AEs.

DESIGN

Pre-post cohort analysis.

SETTING

A 700-bed academic medical center.

PATIENTS

General medicine patients on any of the participating nursing units before and after implementation of regionalized care.

INTERVENTION

Regionalizing 3 general medical physician teams to 3 corresponding nursing units.

MEASUREMENTS

Concordance of patient care plan between nurse and intern, and adjusted odds of preventable AEs.

RESULTS

Of the 414 included nurse and intern paired surveys, there were no significant differences pre- versus postregionalization in total mean concordance scores (0.65 vs 0.67, P = 0.26), but there was significant improvement in agreement on expected discharge date (0.56 vs 0.68, P = 0.003), knowledge of the other provider's name (0.56 vs 0.86,P < 0.001), and daily care plan discussions (0.73 vs 0.88, P < 0.001). Of the 392 reviewed patient medical records, there was no significant difference in the adjusted odds of preventable AEs pre- versus postregionalization (adjusted odds ratio: 1.37, 95% confidence interval: 0.69, 2.69).

CONCLUSIONS

We found that regionalization of care teams improved recognition of care team members, discussion of daily care plan, and agreement on estimated discharge date, but did not significantly improve nurse and physician concordance of the care plan or reduce the odds of preventable AEs. Our findings suggest that regionalization alone may be insufficient to effectively promote communication and lead to patient safety improvements. Journal of Hospital Medicine 2016;11:620-627. © 2016 Society of Hospital Medicine.

An initiative to improve the management of clinically significant test results in a large health care network

BACKGROUND

The failure of providers to communicate and follow up clinically significant test results (CSTR) is an important threat to patient safety. The Massachusetts Coalition for the Prevention of Medical Errors has endorsed the creation of systems to ensure that results can be received and acknowledged.

METHODS

In 2008 a task force was convened that represented clinicians, laboratories, radiology, patient safety, risk management, and information systems in a large health care network with the goals of providing recommendations and a road map for improvement in the management of CSTR and of implementing this improvement plan during the sub-force sequent five years. In drafting its charter, the task broadened the scope from "critical" results to "clinically significant" ones; clinically significant was defined as any result that requires further clinical action to avoid morbidity or mortality, regardless of the urgency of that action.

RESULTS

The task force recommended four key areas for improvement--(1) standardization of policies and definitions, (2) robust identification of the patient's care team, (3) enhanced results management/tracking systems, and (4) centralized quality reporting and metrics. The task force faced many challenges in implementing these recommendations, including disagreements on definitions of CSTR and on who should have responsibility for CSTR, changes to established work flows, limitations of resources and of existing information systems, and definition of metrics.

CONCLUSIONS

This large-scale effort to improve the communication and follow-up of CSTR in a health care network continues with ongoing work to address implementation challenges, refine policies, prepare for a new clinical information system platform, and identify new ways to measure the extent of this important safety problem.

Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial

BACKGROUND AND OBJECTIVE

Physician awareness of the results of tests pending at discharge (TPADs) is poor. We developed an automated system that notifies responsible physicians of TPAD results via secure, network email. We sought to evaluate the impact of this system on self-reported awareness of TPAD results by responsible physicians, a necessary intermediary step to improve management of TPAD results.

METHODS

We conducted a cluster-randomized controlled trial at a major hospital affiliated with an integrated healthcare delivery network in Boston, Massachusetts. Adult patients with TPADs who were discharged from inpatient general medicine and cardiology services were assigned to the intervention or usual care arm if their inpatient attending physician and primary care physician (PCP) were both randomized to the same study arm. Patients of physicians randomized to discordant study arms were excluded. We surveyed these physicians 72 h after all TPAD results were finalized. The primary outcome was awareness of TPAD results by attending physicians. Secondary outcomes included awareness of TPAD results by PCPs, awareness of actionable TPAD results, and provider satisfaction.

RESULTS

We analyzed data on 441 patients. We sent 441 surveys to attending physicians and 353 surveys to PCPs and received 275 and 152 responses from 83 different attending physicians and 112 different PCPs, respectively (attending physician survey response rate of 63%). Intervention attending physicians and PCPs were significantly more aware of TPAD results (76% vs 38%, adjusted/clustered OR 6.30 (95% CI 3.02 to 13.16), p<0.001; 57% vs 33%, adjusted/clustered OR 3.08 (95% CI 1.43 to 6.66), p=0.004, respectively). Intervention attending physicians tended to be more aware of actionable TPAD results (59% vs 29%, adjusted/clustered OR 4.25 (0.65, 27.85), p=0.13). One hundred and eighteen (85%) and 43 (63%) intervention attending physician and PCP survey respondents, respectively, were satisfied with this intervention.

CONCLUSIONS

Automated email notification represents a promising strategy for managing TPAD results, potentially mitigating an unresolved patient safety concern.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT01153451).

Body size and sexual size dimorphism in primates: influence of climate and net primary productivity

Understanding the evolution of body size and sexual size dimorphism has been a longstanding goal in evolutionary biology. Previous work has shown that environmental stress can constrain male-biased sexual size dimorphism at the population level, but we know little about how this might translate to geographical patterns of body size and sexual size dimorphism at the species level. Environmental constraints due to a highly seasonal, resource-poor and/or variable environment have often been cited to explain the unusual lack of sexual size dimorphism among Madagascar's diverse and numerous primate taxa; however, empirical tests of this hypothesis are lacking. Using a phylogenetic approach and a geographical information system platform, we explored the role of seasonality, interannual variability and annual measures of temperature and rainfall, and net primary productivity on patterns of body size and sexual size dimorphism across 130 species of primates. Phylogenetically controlled comparisons showed no support for a role of environmental constraints in moderating sexual size dimorphism at the interspecific level, despite significant associations of environmental variables with body mass. Results suggest that the focus of discussions that have dominated in the last two decades regarding the role of environmental constraints in driving patterns of monomorphism of Madagascar's lemurs should be reconsidered; however, the conundrum remains.

Does phylogeny matter? Assessing the impact of phylogenetic information in ecological meta-analysis

Meta-analysis is increasingly used in ecology and evolutionary biology. Yet, in these fields this technique has an important limitation: phylogenetic non-independence exists among taxa, violating the statistical assumptions underlying traditional meta-analytic models. Recently, meta-analytical techniques incorporating phylogenetic information have been developed to address this issue. However, no syntheses have evaluated how often including phylogenetic information changes meta-analytic results. To address this gap, we built phylogenies for and re-analysed 30 published meta-analyses, comparing results for traditional vs. phylogenetic approaches and assessing which characteristics of phylogenies best explained changes in meta-analytic results and relative model fit. Accounting for phylogeny significantly changed estimates of the overall pooled effect size in 47% of datasets for fixed-effects analyses and 7% of datasets for random-effects analyses. Accounting for phylogeny also changed whether those effect sizes were significantly different from zero in 23 and 40% of our datasets (for fixed- and random-effects models, respectively). Across datasets, decreases in pooled effect size magnitudes after incorporating phylogenetic information were associated with larger phylogenies and those with stronger phylogenetic signal. We conclude that incorporating phylogenetic information in ecological meta-analyses is important, and we provide practical recommendations for doing so.

Design and implementation of an automated email notification system for results of tests pending at discharge

Physicians are often unaware of the results of tests pending at discharge (TPADs). The authors designed and implemented an automated system to notify the responsible inpatient physician of the finalized results of TPADs using secure, network email. The system coordinates a series of electronic events triggered by the discharge time stamp and sends an email to the identified discharging attending physician once finalized results are available. A carbon copy is sent to the primary care physicians in order to facilitate communication and the subsequent transfer of responsibility. Logic was incorporated to suppress selected tests and to limit notification volume. The system was activated for patients with TPADs discharged by randomly selected inpatient-attending physicians during a 6-month pilot. They received approximately 1.6 email notifications per discharged patient with TPADs. Eighty-four per cent of inpatient-attending physicians receiving automated email notifications stated that they were satisfied with the system in a brief survey (59% survey response rate). Automated email notification is a useful strategy for managing results of TPADs.

Lessons learned from implementation of a computerized application for pending tests at hospital discharge

BACKGROUND

Patients are often discharged from the hospital before test results are finalized. Awareness of these results is poor and therefore an important patient safety concern. Few computerized systems have been deployed at care transitions to address this problem. We describe an attempt to implement a computerized application to help inpatient physicians manage these test results.

METHODS

We modified an ambulatory electronic medical record (EMR)-based results management application to track pending tests at hospital discharge (Hospitalist Results Manager, HRM). We trained inpatient physicians at 2 academic medical centers to track these tests using this application. We surveyed inpatient physicians regarding usage of and satisfaction with the application, barriers to use, and the characteristics of an ideal system to track pending tests at discharge.

RESULTS

Of 29 survey respondents, 14 (48%) reported never using HRM, and 13 (45%) used it 1 to 2 times per week. A total of 23 (79%) reported barriers prohibiting use, including being inundated with clinically "irrelevant" results, not having sufficient time, and a lack of integration of post-discharge test result management into usual workflow. Twenty-one (72%) wanted to receive notification of abnormal and clinician-designated pending test results. Twenty-seven physicians (93%) agreed that an ideally designed computerized application would be valuable for managing pending tests at discharge.

CONCLUSIONS

Although inpatient physicians would highly value a computerized application to manage pending tests at discharge, the characteristics of an ideal system are unclear and there are important barriers prohibiting adoption and optimal usage of such systems. We outline suggestions for future electronic systems to manage pending tests at discharge.

Hospital readmissions: physician awareness and communication practices

BACKGROUND

Patients requiring early hospital readmission may be readmitted to different physicians, potentially without the knowledge of the prior caregivers. This lost opportunity to share information about readmitted patients may be detrimental to quality of care and resident education.

OBJECTIVE

To measure physician awareness of and communication about readmissions.

DESIGN

Cross-sectional study.

SETTING

Two academic medical centers.

PARTICIPANTS

A total of 432 patients discharged from the general medicine services and readmitted within 14 days.

MEASUREMENTS

We identified patients discharged from the general medicine services and readmitted within 14 days, excluding patients readmitted to the same physician(s) and planned readmissions. We surveyed discharging and readmitting physicians 48 h after the time of readmission.

RESULTS

Discharging physician teams were aware of 48.5% (95% CI 41.5%-55.5%) of patient readmissions. Communication between teams occurred on 43.7% (95% CI 37.1%-50.3%). Higher medical complexity was associated with an increased likelihood of physician communication (adjusted OR 1.12, 95% CI 1.06-1.19). When communication occurred, readmitting physicians received information about the discharging team's overall assessment (61.9%, 95% CI 51.9%-71.9%), psychosocial issues (52.6%, 95% CI 42.4%-62.8%), pending tests (34.0%, 95% CI 24.2%-43.8%), and discharge medications (30.9%, 95% CI 21.5%-40.3%). When communication did not occur, most physicians (60.8%, 95% CI 56.7%-64.9%) responded it would have been desirable to communicate.

CONCLUSIONS

Physicians are frequently unaware of patient readmissions and often do not communicate when readmissions occur. This communication is often desired and frequently results in the exchange of important patient information. Further work is needed to design systems to address this potential discontinuity of care.

Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes

BACKGROUND

Accreditation Council on Graduate Medical Education (ACGME) duty hour restrictions have led to the widespread implementation of non-house staff services in academic medical centers, yet little is known about the quality and efficiency of patient care on such services.

OBJECTIVE

To evaluate the quality and efficiency of patient care on a physician assistant/hospitalist service compared with that of traditional house staff services.

DESIGN

Retrospective cohort study.

SETTING

Inpatient general medicine service of a 747-bed academic medical center.

PATIENTS

A total of 5194 consecutive patients admitted to the general medical service from July 2005 to June 2006, including 992 patients on the physician assistant/hospitalist service and 4202 patients on a traditional house staff service.

INTERVENTION

A geographically localized service staffed with physician assistants and supervised by hospitalists.

MEASUREMENTS

Length of stay (LOS), cost of care, inpatient mortality, intensive care unit (ICU) transfers, readmissions, and patient satisfaction.

RESULTS

Patients admitted to the study service were younger, had lower comorbidity scores, and were more likely to be admitted at night. After adjustment for these and other factors, and for clustering by attending physician, total cost of care was marginally lower on the study service (adjusted costs 3.9% lower; 95% confidence interval [CI] -7.5% to -0.3%), but LOS was not significantly different (adjusted LOS 5.0% higher; 95% CI, -0.4% to +10%) as compared with house staff services. No difference was seen in inpatient mortality, ICU transfers, readmissions, or patient satisfaction.

CONCLUSIONS

For general medicine inpatients admitted to an academic medical center, a service staffed by hospitalists and physician assistants can provide a safe alternative to house staff services, with comparable efficiency.

Non-housestaff medicine services in academic centers: models and challenges

Non-housestaff medicine services are growing rapidly in academic medical centers (AMCs), partly driven by efforts to comply with resident duty hour restrictions. Hospitalists have emerged as a solution to providing these services given their commitment to delivering efficient and high-quality care and the field's rapid growth. However, limited evidence is available on designing these services, including the similarities and differences of existing ones. We describe non-housestaff medicine services at 5 AMCs in order to share our experiences and outline important considerations in service development. We discuss common challenges in building and sustaining these models along with local institutional factors that affect decision making. Keys to success include ensuring an equitable system for scheduling and staffing, fostering opportunities for scholarly activities and academic promotion (defining the "academic hospitalist"), and providing compensation that supports recruitment and retention of hospitalists. With further work hour restrictions expected in the future and increased requests for surgical comanagement, the relationship between AMCs and hospitalists will continue to evolve. To succeed in developing hospitalist faculty who follow long careers in hospital medicine, academic leadership must carefully plan for and evaluate the methods of providing these clinical services while expanding on our academic mission.

Does this patient with a pericardial effusion have cardiac tamponade?

CONTEXT

Cardiac tamponade is a state of hemodynamic compromise resulting from cardiac compression by fluid trapped in the pericardial space. The clinical examination may assist in the decision to perform pericardiocentesis in patients with cardiac tamponade diagnosed by echocardiography.

OBJECTIVE

To systematically review the accuracy of the history, physical examination, and basic diagnostic tests for the diagnosis of cardiac tamponade.

DATA SOURCES

MEDLINE search of English-language articles published between 1966 and 2006, reference lists of these articles, and reference lists of relevant textbooks.

STUDY SELECTION

We included articles that compared aspects of the clinical examination to a reference standard for the diagnosis of cardiac tamponade. We excluded studies with fewer than 15 patients. Of 787 studies identified by our search strategy, 8 were included in our final analysis.

DATA EXTRACTION

Two authors independently reviewed articles for study results and quality. A third reviewer resolved disagreements.

DATA SYNTHESIS

All studies evaluated patients with known tamponade or those referred for pericardiocentesis with known effusion. Five features occur in the majority of patients with tamponade: dyspnea (sensitivity range, 87%-89%), tachycardia (pooled sensitivity, 77%; 95% confidence interval [CI], 69%-85%), pulsus paradoxus (pooled sensitivity, 82%; 95% CI, 72%-92%), elevated jugular venous pressure (pooled sensitivity, 76%; 95% CI, 62%-90%), and cardiomegaly on chest radiograph (pooled sensitivity, 89%; 95% CI, 73%-100%). Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers the likelihood (likelihood ratio, 0.03; 95% CI, 0.01-0.24).

CONCLUSIONS

Among patients with cardiac tamponade, a minority will not have dyspnea, tachycardia, elevated jugular venous pressure, or cardiomegaly on chest radiograph. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. Diagnostic certainty of the presence of tamponade requires additional testing.

Role of pharmacist counseling in preventing adverse drug events after hospitalization

BACKGROUND

Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs.

METHODS

We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs.

RESULTS

Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization.

CONCLUSIONS

Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.

Patient safety concerns arising from test results that return after hospital discharge

BACKGROUND

Failure to relay information about test results pending when patients are discharged from the hospital may pose an important patient-safety problem. Few data are available on the epidemiology of test results pending at discharge or on physician awareness of these results.

OBJECTIVE

To determine the prevalence, characteristics, and physician awareness of potentially actionable laboratory and radiologic test results returning after hospital discharge.

DESIGN

Cross-sectional study.

SETTING

Two tertiary care academic hospitals.

PATIENTS

2644 consecutive patients discharged from hospitalist services from February to June 2004.

MEASUREMENTS

The main outcomes were the prevalence and characteristics of potentially actionable test results returning after hospital discharge, awareness of these results by inpatient and primary care physicians, and satisfaction of inpatient physicians with current systems for follow-up on test results. The authors prospectively collected data on test results pending at the time of discharge and, as results returned after discharge, surveyed hospitalists, junior residents, and primary care physicians about those results that were potentially actionable according to a physician-reviewer.

RESULTS

A total of 1095 patients (41%) had 2033 test results return after discharge. Of these results, 191 (9.4% [95% CI, 8.0% to 11.0%]) were potentially actionable. Surveys were sent regarding 155 results, and 105 responses were returned. Of the 105 results in the surveys with responses, physicians had been unaware of 65 (61.6% [CI, 51.3% to 70.9%]); of these 65, they agreed with physician-reviewers that 24 (37.1% [CI, 25.7% to 50.2%]) were actionable and 8 (12.6% [CI, 6.4% to 23.3%]) required urgent action. Inpatient physicians were dissatisfied with their systems for following up on test results returning after discharge.

LIMITATIONS

The authors were unable to determine whether physicians' lack of awareness of test results returning after discharge was associated with adverse outcomes.

CONCLUSIONS

Many patients are discharged from hospitals with test results still pending, and physicians are often unaware of potentially actionable test results returning after discharge. Further work is needed to design better follow-up systems for test results returning after hospital discharge.

Developing nursing knowledge: practice issues raised from four philosophical perspectives

Analysis and comparison of emerging perspectives in nursing on some of the key issues of practice theory can create an enhanced vision of the discipline. Four philosophy-of-science perspectives--realism, relativism, interpretivism, and humanism--are catalysts for fruitful insights about practice. However, together they generate more questions than they answer, both from each perspective and from the intersection of the assumptions of the four philosophies about the nature of knowledge. The nature of knowledge for practice emerges from examining how the philosophical basis and the derived practice theories address such issues as the phenomena of the discipline, environment, teleology, and nursing theoretical frameworks. This is the time for good debate and collaborative knowledge-building among scholars of various persuasions within a milieu of ethos, pathos, and logic.