1
|
Hasegawa S, Harris CM, Gupta V, Pappas M, Vaughn VM, Perencevich EN, Dukes KC, Goto M. Clinicians' interpretation of thresholds in hospital antibiograms for gram-negative rod infections: A survey and contingent valuation study of hospitalists. J Hosp Med 2024; 19:297-301. [PMID: 38353153 DOI: 10.1002/jhm.13303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/23/2024] [Accepted: 01/31/2024] [Indexed: 04/04/2024]
Abstract
Clinical guidelines suggest that hospital antibiograms are a key component when deciding empiric therapy, but little is known about how often clinicians use antibiograms and how they influence clinicians' empiric therapy decisions. We surveyed hospitalists at seven healthcare systems in the United States on their reported practices related to antibiograms and their hypothetical prescribing for four clinical scenarios associated with gram-negative rod pathogens. Each was given a randomly assigned antibiogram susceptibility percentage, and we used contingent valuation analysis to assess whether the antibiogram susceptibility percentage was associated with prescribing practices. Of the 193 survey responders, only 52 (26.9%) respondents reported using antibiograms more than monthly. Across all four clinical scenarios, there was no evidence that antibiogram susceptibility levels influenced antibiotic prescribing practices. With limited utilization and no evidence that they influenced practice, antibiograms may have a limited role in hospitalist care delivery for common gram-negative rod infections.
Collapse
Affiliation(s)
- Shinya Hasegawa
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Che M Harris
- Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Vineet Gupta
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Matthew Pappas
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Valerie M Vaughn
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Kimberly C Dukes
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Michihiko Goto
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
2
|
O’Brien WJ, Schweizer ML, Strymish J, Beck BF, Au V, Chan JA, Brown M, Itani KMF, Dukes KC, Walhof JF, Gupta K. Propensity Score-Weighted Analysis of Postoperative Infection in Patients With and Without Preoperative Urine Culture. JAMA Netw Open 2024; 7:e240900. [PMID: 38436958 PMCID: PMC10912952 DOI: 10.1001/jamanetworkopen.2024.0900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/11/2024] [Indexed: 03/05/2024] Open
Abstract
Importance Although recent guidelines recommend against performance of preoperative urine culture before nongenitourinary surgery, many clinicians still order preoperative urine cultures and prescribe antibiotics for treatment of asymptomatic bacteriuria in an effort to reduce infection risk. Objective To assess the association between preoperative urine culture testing and postoperative urinary tract infection (UTI) or surgical site infection (SSI), independent of baseline patient characteristics or type of surgery. Design, Setting, and Participants This cohort study analyzed surgical procedures performed from January 1, 2017, to December 31, 2019, at any of 112 US Department of Veterans Affairs (VA) medical centers. The cohort comprised VA enrollees who underwent major elective noncardiac, nonurological operations. Machine learning and inverse probability of treatment weighting (IPTW) were used to balance the characteristics between those who did and did not undergo a urine culture. Data analyses were performed between January 2023 and January 2024. Exposures Performance of urine culture within 30 days prior to surgery. Main Outcomes and Measures The 2 main outcomes were UTI and SSI occurring within 30 days after surgery. Weighted logistic regression was used to estimate odds ratios (ORs) for postoperative infection based on treatment status. Results A total of 250 389 VA enrollees who underwent 288 858 surgical procedures were included, with 88.9% (256 753) of surgical procedures received by males and 48.9% (141 340) received by patients 65 years or older. Baseline characteristics were well balanced among treatment groups after applying IPTW weights. Preoperative urine culture was performed for 10.5% of surgical procedures (30 384 of 288 858). The IPTW analysis found that preoperative urine culture was not associated with SSI (adjusted OR [AOR], 0.99; 95% CI, 0.90-1.10) or postoperative UTI (AOR, 1.18; 95% CI, 0.98-1.40). In analyses limited to orthopedic surgery and neurosurgery as a proxy for prosthetic implants, the adjusted risks for UTI and SSI were also not associated with preoperative urine culture performance. Conclusions and Relevance This cohort study found no association between performance of a preoperative urine culture and lower risk of postoperative UTI or SSI. The results support the deimplementation of urine cultures and associated antibiotic treatment prior to surgery, even when using prosthetic implants.
Collapse
Affiliation(s)
- William J. O’Brien
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Marin L. Schweizer
- William S. Middleton VA Hospital, Madison, Wisconsin
- Department of Medicine, University of Wisconsin-Madison, Madison
| | | | - Brice F. Beck
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Vanessa Au
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Jeffrey A. Chan
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Madisen Brown
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Kamal M. F. Itani
- VA Boston Health Care System Department of Surgery, Boston University and Harvard Medical School, Boston, Massachusetts
| | - Kimberly C. Dukes
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
- Carver College of Medicine, The University of Iowa, Iowa City
| | - Julia Friberg Walhof
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Kalpana Gupta
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
- VA Boston Department of Medicine, Boston, Massachusetts
| |
Collapse
|
3
|
Elliott K, Dukes KC, Barlow PB, Kossioni A, Marchini L. Ageism scale for dental students (ASDS): A focus group review of content validity. Spec Care Dentist 2024. [PMID: 38217073 DOI: 10.1111/scd.12960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/14/2024]
Abstract
PURPOSE/AIM Improve content validity of the Ageism Scale for Dental Students (ASDS) and identify barriers to using the scale. METHODS Thematic analysis of transcripts of three purposively sampled focus groups of 1) geriatric dentistry specialists, 2) older adult dental patients, and 3) dental students. RESULTS Twenty-five participants engaged in focus groups. No new concepts to define ageism were identified. Experts found the scale acceptable and appropriate, yet they raised specific potential revisions to scale questions. Commonly reported themes already addressed by ASDS included the importance of tailoring decision-making to patient preference and not making assumptions about older adults' capacity or preferences for dental care. Barriers to identifying ageism or using the scale included experiential differences in interpreting scale items, cultural differences in attitudes towards older adults, and potential overlap with social determinants of health. Secondary findings include recommendations for older-adult focused training for dental students to provide positive, concrete guidance on caring for older adults. CONCLUSION There are opportunities to refine the Ageism Scale for Dental Students and to allow tailoring of the scale for specific national or cultural contexts.
Collapse
Affiliation(s)
| | - Kimberly C Dukes
- University of Wisconsin-Madison Law School, Iowa City, USA
- Iowa City Veterans Affairs Health Care System (ICVAHCS), Iowa City, USA
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Patrick B Barlow
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Anastassia Kossioni
- School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonardo Marchini
- College of Dentistry and Dental Clinics, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
4
|
Dukes KC, Reisinger HS, Schweizer M, Ward MA, Chapin L, Ryken TC, Perl TM, Herwaldt LA. Examining barriers to implementing a surgical-site infection bundle. Infect Control Hosp Epidemiol 2024; 45:13-20. [PMID: 37493031 PMCID: PMC10782202 DOI: 10.1017/ice.2023.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Surgical-site infections (SSIs) can be catastrophic. Bundles of evidence-based practices can reduce SSIs but can be difficult to implement and sustain. OBJECTIVE We sought to understand the implementation of SSI prevention bundles in 6 US hospitals. DESIGN Qualitative study. METHODS We conducted in-depth semistructured interviews with personnel involved in bundle implementation and conducted a thematic analysis of the transcripts. SETTING The study was conducted in 6 US hospitals: 2 academic tertiary-care hospitals, 3 academic-affiliated community hospitals, 1 unaffiliated community hospital. PARTICIPANTS In total, 30 hospital personnel participated. Participants included surgeons, laboratory directors, clinical personnel, and infection preventionists. RESULTS Bundle complexity impeded implementation. Other barriers varied across services, even within the same hospital. Multiple strategies were needed, and successful strategies in one service did not always apply in other areas. However, early and sustained interprofessional collaboration facilitated implementation. CONCLUSIONS The evidence-based SSI bundle is complicated and can be difficult to implement. One implementation process probably will not work for all settings. Multiple strategies were needed to overcome contextual and implementation barriers that varied by setting and implementation climate. Appropriate adaptations for specific settings and populations may improve bundle adoption, fidelity, acceptability, and sustainability.
Collapse
Affiliation(s)
- Kimberly C. Dukes
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans’ Affairs (VA) Health Care System (ICVAHCS), Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
- College of Public Health, University of Iowa, Iowa City, Iowa
| | - Heather Schacht Reisinger
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans’ Affairs (VA) Health Care System (ICVAHCS), Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
| | - Marin Schweizer
- Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Melissa A. Ward
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | | | - Timothy C. Ryken
- MercyOne Northeast Iowa Neurosurgery, Iowa City, Iowa
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Trish M. Perl
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Loreen A. Herwaldt
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
- College of Public Health, University of Iowa, Iowa City, Iowa
- University of Iowa Hospitals and Clinics (UIHC), Iowa City, Iowa
| |
Collapse
|
5
|
Chan PS, McNally B, Al-Araji R, Kennedy K, Kennedy M, Del Rios M, Sperling J, Sasson C, Breathett K, Dukes KC, Girotra S. Survey of resuscitation practices at emergency medical service agencies in the U.S. Resusc Plus 2023; 16:100483. [PMID: 37854286 PMCID: PMC10580039 DOI: 10.1016/j.resplu.2023.100483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
Background Survival for out-of-hospital cardiac arrest (OHCA) varies across emergency medical service (EMS) agencies. Yet, little is known about resuscitation response and quality improvement activities at EMS agencies. We describe herein a novel survey to EMS agencies in a U.S. registry for OHCA. Methods Using data from the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 577 EMS agencies with ≥10 OHCA cases annually between 2015 and 2019 that remained active in CARES. We administered a survey to EMS directors regarding agency characteristics, cardiac arrest response, relationships with first responders and dispatchers, quality improvement activities and perceived barriers in the community. Results Of eligible EMS agencies, 470 (81.5%) completed the survey. The high completion rate was likely due to frequent personalized emails and phone calls, liaising with CARES state coordinators to encourage survey response, and multiple periodic drawings of an automated external defibrillator during the survey period for participating EMS agencies. The survey examined rates of resuscitation training modalities; use of resuscitation equipment and devices in the field; frequency of simulation; non-EMS stakeholder response to OHCA (dispatchers, fire, police); quality improvement; and community factors affecting bystander response to OHCA. Conclusions In this study design paper on the RED-CASO survey, we provide summary data on EMS agency characteristics in the U.S. Upon linkage to CARES patient-level data, this survey will provide critical insights into 'best practices' at EMS agencies with the highest OHCA survival rates as well as provide insights into current disparities in outcomes.
Collapse
Affiliation(s)
- Paul S. Chan
- Saint Luke’s Mid America Heart Institute, United States
| | - Bryan McNally
- Emory University Rollins School of Public Health, United States
- Department of Emergency Medicine, Emory University School of Medicine, United States
| | - Rabab Al-Araji
- Emory University Rollins School of Public Health, United States
| | - Kevin Kennedy
- Saint Luke’s Mid America Heart Institute, United States
| | - Marci Kennedy
- Saint Luke’s Mid America Heart Institute, United States
| | - Marina Del Rios
- University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Jessica Sperling
- Social Science Research Institute, Duke University, Durham, NC, United States
| | - Comilla Sasson
- University of Colorado School of Medicine and School of Public Health, Aurora, CO, United States
- The American Heart Association, Dallas, TX, United States
| | - Khadijah Breathett
- Krannert Cardiovascular Research Center, Indiana University, United States
| | - Kimberly C. Dukes
- University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Saket Girotra
- University of Texas-Southwestern Medical Center, Dallas, TX, United States
| | - CARES Surveillance Group
- Saint Luke’s Mid America Heart Institute, United States
- Emory University Rollins School of Public Health, United States
- Department of Emergency Medicine, Emory University School of Medicine, United States
- University of Iowa Carver College of Medicine, Iowa City, IA, United States
- Social Science Research Institute, Duke University, Durham, NC, United States
- University of Colorado School of Medicine and School of Public Health, Aurora, CO, United States
- The American Heart Association, Dallas, TX, United States
- Krannert Cardiovascular Research Center, Indiana University, United States
- University of Texas-Southwestern Medical Center, Dallas, TX, United States
| |
Collapse
|
6
|
Uzendu AI, Spertus JA, Nallamothu BK, Girotra S, Jones PG, McNally BF, Del Rios M, Sasson C, Breathett K, Sperling J, Dukes KC, Chan PS. Cardiac Arrest Survival at Emergency Medical Service Agencies in Catchment Areas With Primarily Black and Hispanic Populations. JAMA Intern Med 2023; 183:1136-1143. [PMID: 37669067 PMCID: PMC10481323 DOI: 10.1001/jamainternmed.2023.4303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 07/12/2023] [Indexed: 09/06/2023]
Abstract
Importance Black and Hispanic patients are less likely to survive an out-of-hospital cardiac arrest (OHCA) than White patients. Given the central importance of emergency medical service (EMS) agencies in prehospital care, a better understanding of OHCA survival at EMS agencies that work in Black and Hispanic communities and White communities is needed to address OHCA disparities. Objective To examine whether EMS agencies serving catchment areas with primarily Black and Hispanic populations (Black and Hispanic catchment areas) have different rates of OHCA survival than agencies serving catchment areas with primarily White populations (White catchment areas). Design, Setting, and Participants A cohort study including adults with nontraumatic OHCA from January 1, 2015, to December 31, 2019, in the Cardiac Arrest Registry to Enhance Survival was conducted. Data analysis was conducted from August 17, 2022, to July 7, 2023. Exposure Emergency medical service agencies, categorized as working in catchment areas where the combination of Black and Hispanic residents made up more than 50% of the population or where White residents made up more than 50% of the population. Main Outcomes and Measures The unit of analysis was the EMS agency. The primary outcome was agency-level risk-standardized survival rates (RSSRs) to hospital admission for OHCA at each EMS agency, which were calculated using hierarchical logistic regression and compared between agencies serving Black and Hispanic and White catchment areas. Whether differences in OHCA survival were explained by EMS and first responder measures was evaluated with additional adjustment for these factors. Results Among 764 EMS agencies representing 258 342 OHCAs, 82 EMS agencies (10.7%) had a Black and Hispanic catchment area. Overall median age of the patients was 63.0 (IQR, 52.0-75.0) years, 36.1% were women, and 63.9% were men. Overall, the mean (SD) RSSR was 27.5% (3.6%), with lower survival at EMS agencies with Black and Hispanic catchment areas (25.8% [3.6%]) compared with agencies with White catchment areas (27.7% [3.5%]; P < .001). Among the 82 EMS agencies with Black and Hispanic catchment areas, a disproportionately higher number (32 [39.0%]) was in the lowest survival quartile, whereas a lower number (12 [14.6%]) was in the highest survival quartile. Additional adjustment for EMS response times, EMS termination of resuscitation rates, and first responder rates of initiating cardiopulmonary resuscitation or applying an automated external defibrillator before EMS arrival did not meaningfully attenuate differences in RSSRs between agencies with Black and Hispanic compared with White catchment areas (mean [SD] RSSRs after adjustment, 25.9% [3.3%] vs 27.7% [3.1%]; P < .001). Conclusions and Relevance Risk-standardized survival rates for OHCA were 1.9% lower at EMS agencies working in Black and Hispanic catchment areas than in White catchment areas. This difference was not explained by EMS response times, rates of EMS termination of resuscitation, or first responder rates of initiating cardiopulmonary resuscitation or applying an automated external defibrillator. These findings suggest there is a need for further assessment of these discrepancies.
Collapse
Affiliation(s)
- Anezi I. Uzendu
- Saint Luke’s Hospital Mid America Heart Institute, Kansas City, Missouri
- Department of Medicine, University of Missouri–Kansas City, Kansas City
| | - John A. Spertus
- Saint Luke’s Hospital Mid America Heart Institute, Kansas City, Missouri
- Department of Medicine, University of Missouri–Kansas City, Kansas City
| | - Brahmajee K. Nallamothu
- Michigan Integrated Center for Health Analytics and Medical Prediction, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Saket Girotra
- University of Texas–Southwestern Medical Center, Dallas
| | - Philip G. Jones
- Saint Luke’s Hospital Mid America Heart Institute, Kansas City, Missouri
| | - Bryan F. McNally
- Emory University School of Medicine, Rollins School of Public Health, Atlanta, Georgia
| | - Marina Del Rios
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Comilla Sasson
- Department of Psychiatry, University of Colorado School of Medicine, Aurora
- Department of Community and Behavioral Health, Colorado School of Public Health, Aurora
- American Heart Association, Dallas, Texas
| | - Khadijah Breathett
- Division of Cardiology, Krannert Cardiovascular Research Center, Indiana University, Indianapolis
| | - Jessica Sperling
- Social Science Research Institute, Duke University, Durham, North Carolina
- Clinical and Translational Science Institute, Durham, North Carolina
| | - Kimberly C. Dukes
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City
- University of Iowa College of Public Health, Iowa City
| | - Paul S. Chan
- Saint Luke’s Hospital Mid America Heart Institute, Kansas City, Missouri
- Department of Medicine, University of Missouri–Kansas City, Kansas City
| |
Collapse
|
7
|
Dukes KC, Girotra S. How Should We Talk With Families After a Sudden Cardiac Death? Circ Cardiovasc Qual Outcomes 2023; 16:e009841. [PMID: 37013815 PMCID: PMC10776025 DOI: 10.1161/circoutcomes.123.009841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Affiliation(s)
- Kimberly C Dukes
- Department of Internal Medicine, Carver College of Medicine, University of Iowa (K.D.)
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System (K.D.)
- Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City IA (K.D.)
| | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX (S.G.)
| |
Collapse
|
8
|
Cifra CL, Tigges CR, Miller SL, Curl N, Monson CD, Dukes KC, Reisinger HS, Pennathur PR, Sittig DF, Singh H. Reporting Outcomes of Pediatric Intensive Care Unit Patients to Referring Physicians via an Electronic Health Record-Based Feedback System. Appl Clin Inform 2022; 13:495-503. [PMID: 35545126 PMCID: PMC9095343 DOI: 10.1055/s-0042-1748147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Many critically ill children are initially evaluated in front-line settings by clinicians with variable pediatric training before they are transferred to a pediatric intensive care unit (PICU). Because clinicians learn from past performance, communicating outcomes of patients back to front-line clinicians who provide pediatric emergency care could be valuable; however, referring clinicians do not consistently receive this important feedback. OBJECTIVES Our aim was to determine the feasibility, usability, and clinical relevance of a semiautomated electronic health record (EHR)-supported system developed at a single institution to deliver timely and relevant PICU patient outcome feedback to referring emergency department (ED) physicians. METHODS Guided by the Health Information Technology Safety Framework, we iteratively designed, implemented, and evaluated a semiautomated electronic feedback system leveraging the EHR in one institution. After conducting interviews and focus groups with stakeholders to understand the PICU-ED health care work system, we designed the EHR-supported feedback system by translating stakeholder, organizational, and usability objectives into feedback process and report requirements. Over 6 months, we completed three cycles of implementation and evaluation, wherein we analyzed EHR access logs, reviewed feedback reports sent, performed usability testing, and conducted physician interviews to determine the system's feasibility, usability, and clinical relevance. RESULTS The EHR-supported feedback process is feasible with timely delivery and receipt of feedback reports. Usability testing revealed excellent Systems Usability Scale scores. According to physicians, the process was well-integrated into their clinical workflows and conferred minimal additional workload. Physicians also indicated that delivering and receiving consistent feedback was relevant to their clinical practice. CONCLUSION An EHR-supported system to deliver timely and relevant PICU patient outcome feedback to referring ED physicians was feasible, usable, and important to physicians. Future work is needed to evaluate impact on clinical practice and patient outcomes and to investigate applicability to other clinical settings involved in similar care transitions.
Collapse
Affiliation(s)
- Christina L Cifra
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Cody R Tigges
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Sarah L Miller
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Nathaniel Curl
- Emergency Medicine, UnityPoint Health-Trinity Medical Center, Rock Island, Illinois, United States
| | - Christopher D Monson
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Kimberly C Dukes
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, United States.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Heather S Reisinger
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, United States.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States.,Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa, United States
| | - Priyadarshini R Pennathur
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States.,Department of Industrial and Systems Engineering, College of Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Dean F Sittig
- School of Biomedical Informatics, Center for Healthcare Quality and Safety, University of Texas Health Science Center, Houston, Texas, United States
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, United States
| |
Collapse
|
9
|
Abstract
OBJECTIVES Multidisciplinary PICU teams must effectively share information while caring for critically ill children. Clinical documentation helps clinicians develop a shared understanding of the patient's diagnosis, which informs decision-making. However, diagnosis-related documentation in the PICU is understudied, thus limiting insights into how pediatric intensivists convey their diagnostic reasoning. Our objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission. DESIGN Retrospective mixed methods study describing diagnosis documentation in electronic health records. SETTING Academic tertiary referral PICU. PATIENTS Children 0-17 years old admitted nonelectively to a single PICU over 1 year. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred PICU admission notes for 96 unique patients were reviewed. In 87% of notes, both attending physicians and residents or advanced practice providers documented a primary diagnosis; in 13%, primary diagnoses were documented by residents or advanced practice providers alone. Most diagnoses (72%) were written as narrative free text, 11% were documented as problem lists/billing codes, and 17% used both formats. At least one rationale was documented to justify the primary diagnosis in 91% of notes. Diagnostic uncertainty was present in 52% of notes, most commonly suggested by clinicians' use of words indicating uncertainty (65%) and documentation of differential diagnoses (60%). Clinicians' integration and interpretation of information varied in terms of: 1) organization of diagnosis narratives, 2) use of contextual details to clarify the diagnosis, and 3) expression of diagnostic uncertainty. CONCLUSIONS In this descriptive study, most PICU admission notes documented a rationale for the primary diagnosis and expressed diagnostic uncertainty. Clinicians varied widely in how they organized diagnostic information, used contextual details to clarify the diagnosis, and expressed uncertainty. Future work is needed to determine how diagnosis narratives affect clinical decision-making, patient care, and outcomes.
Collapse
Affiliation(s)
| | - Sonali Ramesh
- Department of Pediatrics, BronxCare Health System, New York, New York
| | - Kimberly C. Dukes
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Loreen A. Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Heather Schacht Reisinger
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
| | - Christina L. Cifra
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| |
Collapse
|
10
|
Hockett Sherlock S, Goedken CC, Balkenende EC, Dukes KC, Perencevich EN, Reisinger HS, Forrest GN, Pfeiffer CD, West KA, Schweizer M. Strategies for the implementation of a nasal decolonization intervention to prevent surgical site infections within the Veterans Health Administration. Front Health Serv 2022; 2:920830. [PMID: 36925849 PMCID: PMC10012655 DOI: 10.3389/frhs.2022.920830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022]
Abstract
As part of a multicenter evidence-based intervention for surgical site infection prevention, a qualitative study was conducted with infection control teams and surgical staff members at three Department of Veterans Affairs Healthcare Systems in the USA. This study aimed to identify strategies used by nurses and other facility champions for the implementation of a nasal decolonization intervention. Site visit observations and field notes provided contextual information. Interview data were analyzed with inductive and deductive content analysis. Interview data was mapped to the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies. These strategies were then considered in the context of power and relationships as factors that influence implementation. We found that implementation of this evidence-based surgical site infection prevention intervention was successful when nurse champions drove the day-to-day implementation. Nurse champions sustained implementation strategies through all phases of implementation. Findings also suggest that nurse champions leveraged the influence of their role as champion along with their understanding of social networks and relationships to help achieve implementation success. Nurse champions consciously used multiple overlapping and iterative implementation strategies, adapting and tailoring strategies to stakeholders and settings. Commonly used implementation categories included: "train and educate stakeholders," "use evaluative and iterative strategies," "adapt and tailor to context," and "develop stakeholder interrelationships." Future research should examine the social networks for evidence-based interventions by asking specifically about relationships and power dynamics within healthcare organizations. Implementation of evidence-based interventions should consider if the tasks expected of a nurse champion fit the level of influence or power held by the champion. Trial registration ClinicalTrials.gov, identifier: NCT02216227.
Collapse
Affiliation(s)
- Stacey Hockett Sherlock
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Cassie Cunningham Goedken
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States
| | - Erin C Balkenende
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Kimberly C Dukes
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Heather Schacht Reisinger
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States.,Institute for Clinical and Translational Science, The University of Iowa, Iowa City, IA, United States
| | - Graeme N Forrest
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Christopher D Pfeiffer
- Department of Hospital and Specialty Medicine, VA Portland Health Care System, Portland, OR, United States.,Department of Medicine, Oregon Health & Sciences University, Portland, OR, United States
| | - Katelyn A West
- VA Portland Healthcare System, Portland, OR, United States
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| |
Collapse
|
11
|
Culp KR, Corwin C, Dukes KC, Sinnwell E. FDA Full Approval for COVID-19 Vaccine Increases the Call for Mandates. Workplace Health Saf 2021; 69:492-493. [PMID: 34668445 DOI: 10.1177/21650799211051649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
12
|
Culp K, Dukes KC, Cowin C, Sinnwell E. Emergency Use Authorization of COVID-19 Vaccine: Implications for Worker Communities. Workplace Health Saf 2021; 69:152-153. [PMID: 33787400 DOI: 10.1177/2165079921998657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Claudia Cowin
- University of Iowa Carver College of Medicine.,University of Iowa Hospitals & Clinics
| | | |
Collapse
|
13
|
Cifra CL, Dukes KC, Ayres BS, Calomino KA, Herwaldt LA, Singh H, Reisinger HS. Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: A pilot ethnography. J Crit Care 2020; 63:246-249. [PMID: 32980235 DOI: 10.1016/j.jcrc.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/27/2020] [Accepted: 09/12/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The effect of communication between referring and accepting clinicians during patient transitions to the pediatric intensive care unit (PICU) on diagnostic quality is largely unknown. This pilot study aims to determine the feasibility of using focused ethnography to understand the relationship between referral communication and the diagnostic process for critically ill children. MATERIALS AND METHODS We conducted focused ethnography in an academic tertiary referral PICU by directly observing the referral and admission of 3 non-electively admitted children 0-17 years old. We also conducted 21 semi-structured interviews of their parents and admitting PICU staff (intensivists, fellows/residents, medical students, nurses, and respiratory therapists) and reviewed their medical records post-discharge. RESULTS Performing focused ethnography in a busy PICU is feasible. We identified three areas for additional exploration: (1) how information transfer affects the PICU diagnostic process; (2) how uncertainty in patient assessment affects the decision to transfer to the PICU; and (3) how the PICU team's expectations are influenced by referral communication. CONCLUSIONS Focused ethnography in the PICU is feasible to investigate relationships between clinician referral communication and the diagnostic process for critically ill children.
Collapse
Affiliation(s)
- Christina L Cifra
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, 200 Hawkins Dr 8600-M JCP, Iowa City, IA 52242, USA.
| | - Kimberly C Dukes
- Institute for Clinical and Translational Science, University of Iowa 200 Hawkins Dr, Iowa City, IA 52242, USA; Iowa City Veterans Affairs Health Care System, 601 US-6 W Suite 42-1 VAMC, Iowa City, IA 52246, USA.
| | - Brennan S Ayres
- Department of Industrial and Systems Engineering, University of Iowa College of Engineering 3100 Seamans Center for the Engineering Arts and Sciences, Iowa City, IA 52242, USA; Touro College of Osteopathic Medicine (present address), 230 W 125(th) St, New York, NY 10027, USA
| | - Kelsey A Calomino
- University of Iowa College of Nursing, 50 Newton Rd, Iowa City, IA 52242, USA.
| | - Loreen A Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine 200 Hawkins Dr, Iowa City, IA 52242, USA; Department of Epidemiology, University of Iowa College of Public Health 145 N Riverside Dr, Iowa City, IA 52242, USA.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey eterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd, Houston, TX 77030, USA.
| | - Heather Schacht Reisinger
- Institute for Clinical and Translational Science, University of Iowa 200 Hawkins Dr, Iowa City, IA 52242, USA; Department of Internal Medicine, University of Iowa Carver College of Medicine 200 Hawkins Dr, Iowa City, IA 52242, USA; Iowa City Veterans Affairs Health Care System, 601 US-6 W Suite 42-1 VAMC, Iowa City, IA 52246, USA.
| |
Collapse
|