Implementation of Home-Based Telerehabilitation of Patients With Stroke in the United States: Protocol for a Realist Review

BACKGROUND

Stroke is a common cause of mortality and morbidity. Insufficient and untimely rehabilitation has been associated with inadequate recovery. Telerehabilitation provides an opportunity for timely and accessible services for individuals with stroke, especially in remote areas. Telerehabilitation is defined as a health care team's use of a communication mode (eg, videoconferencing) to remotely provide rehabilitation services. Telerehabilitation is as effective as facility-based rehabilitation; however, it is infrequently used due to implementation barriers.

OBJECTIVE

The aim of the study is to explore the interaction between the implementation strategies, context, and outcomes of telerehabilitation of patients with stroke.

METHODS

This review will follow four steps: (1) defining the review scope, (2) literature search and quality appraisal, (3) data extraction and evidence synthesis, and (4) narrative development. PubMed via MEDLINE, the PEDro database, and CINAHL will be queried till June 2023 and supplemented with citation tracking and a gray literature search. The relevance and rigor of papers will be appraised using the TAPUPAS (Transparency, Accuracy, Purposivity, Utility, Propriety, Accessibility, and Specificity) and Weight of Evidence frameworks. The reviewers will extract and synthesize data iteratively and develop explanatory links between contexts, mechanisms, and outcomes. The results will be reported according to the Realist Synthesis publication standards set by Wong and colleagues in 2013.

RESULTS

The literature search and screening will be completed in July 2023. Data extraction and analysis will be completed in August 2023, and findings will be synthesized and reported in October 2023.

CONCLUSIONS

This will be the first realist synthesis, uncovering the causal mechanisms to explain how, why, and to what extent implementation strategies impact telerehabilitation adoption and implementation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47009.

Low prevalence of clinical decision support to calculate caloric and fluid intake for infants in the neonatal intensive care unit

BACKGROUND

Clinical decision support (CDS) improves nutrition delivery for infants in the neonatal intensive care unit (NICU), however, the prevalence of CDS to support nutrition is unknown.

METHODS

Online surveys, with telephone and email validation of responses, were administered to NICU clinicians in the Children's Hospital Neonatal Consortium (CHNC). We determined and compared the availability of CDS to calculate calories and fluid received in the prior 24 h, stratified by enteral and parenteral intake, using McNemar's test.

RESULTS

Clinicians at all 34 CHNC hospitals responded with 98 of 108 (91%) surveys completed. NICUs have considerably less CDS to calculate enteral calories received than enteral fluid received (32% vs. 82%, p < 0.001) and less CDS to calculate parenteral calories received than parenteral fluid received (29% vs. 82%, p < 0.001).

DISCUSSION

Most CHNC NICUs are unable to reliably and consistently monitor caloric intake delivered to critically ill infants at risk for growth failure.

Energy and Protein Intake During the Transition from Parenteral to Enteral Nutrition in Infants of Very Low Birth Weight

OBJECTIVE

To evaluate the association between nutrition delivery practices and energy and protein intake during the transition from parenteral to enteral nutrition in infants of very low birth weight (VLBW).

STUDY DESIGN

This was a retrospective analysis of 115 infants who were VLBW from a regional neonatal intensive care unit. Changes in energy and protein intake were estimated during transition phase 1 (0% enteral); phase 2 (>0, ≤33.3% enteral); phase 3 (>33.3, ≤66.7% enteral); phase 4 (>66.7, <100% enteral); and phase 5 (100% enteral). Associations between energy and protein intake were determined for each phase for parenteral nutrition, intravenous lipids, central line, feeding fortification, fluid restriction, and excess non-nutritive fluid intake.

RESULTS

In phases 2 and 3, infants receiving feeding fortification received less protein than infants who were unfortified (-1.1 and -0.3 g/kg/d, respectively; P < .001). However, this negative association was not observed after adjusting for relevant nutrition delivery practices. Despite greater enteral protein intake during phases 2 and 3 (0.3 and 0.8 g/kg/d, respectively; P < .001), infants with early fortification received less parenteral protein than infants who were unfortified (-1.4 and -1.1 g/kg/d, respectively; P < .001). Similar patterns were observed for energy intake. Protein intake declined during phases 3 and 4.

CONCLUSIONS

Infants paradoxically received less protein and energy on days with early fortification, suggesting that clinicians may lack easily accessible data to detect the association between nutrition delivery practices and overall nutrition in infants who are VLBW.

Redesigning Transplant Organ Labeling to Prevent Patient Harm and Organ Loss

BACKGROUND

In 2012, the Health Resources and Services Administration and the United Network for Organ Sharing launched the "Electronic Tracking and Transportation" (ETT) project, in response to "labeling and packaging issues" being a frequently reported safety incident. This article describes an improvement project conducted as part of this United Network for Organ Sharing project.

METHODS

An interdisciplinary team conducted a Process Failure Modes and Effects Analysis, laboratory simulations of organ labeling during procurement, and a heuristic evaluation of a label software application to inform the design of TransNet, a system that uses barcode technology at the point of organ recovery. A total of 42 clinicians and staff from 10 organ procurement organizations and 2 transplant centers in the United States participated. Processes Addressed: Key features of the redesigned labeling system include independent, double entry of label information into the software application, a machine-readable barcode on each organ's label, and a handheld printer for at "point of use" label printing.

OUTCOMES

The new labeling system, TransNet, has become mandatory since June 2017. A survey conducted on early adopters (N = 11), after 1 year of use, indicates the process is safer and more efficient.

IMPLICATIONS FOR PRACTICE

The findings from this study suggest that the application of quality planning methods, common in other industries, when redesigning a health-care process, are valuable and revelatory and should be adopted more extensively. Future evaluation of TransNet effectiveness to reduce safety incidents is critical.

Immediate and long-term effects of a team-based quality improvement training programme

Background

Although many studies of quality improvement (QI) education programmes report improvement in learners’ knowledge and confidence, the impact on learners’ future engagement in QI activities is largely unknown and few studies report project measures beyond completion of the programme.

Method

We developed the Academy for Quality and Safety Improvement (AQSI) to prepare individuals, across multiple departments and professions, to lead QI. The 7-month programme consisted of class work and team-based project work. We assessed participants’ knowledge using a multiple choice test and an adapted Quality Improvement Knowledge Assessment Test (QIKAT) before and after the programme. We evaluated participants’ postprogramme QI activity and project status using surveys at 6 and 18 months.

Results

Over 5 years, 172 individuals and 32 teams participated. Participants had higher multiple choice test (71.9±12.7 vs 79.4±13.2; p<0.001) and adapted QIKAT scores (55.7±16.3 vs 61.8±14.7; p<0.001) after the programme. The majority of participants at 6 months indicated that they had applied knowledge and skills learnt to improve quality in their clinical area (129/148; 87.2%) and to implement QI interventions (92/148; 62.2%). At 18 months, nearly half (48/101; 47.5%) had led other QI projects and many (41/101; 40.6%) had provided QI mentorship to others. Overall, 14 (43.8%) teams had positive postintervention results at AQSI completion and 20 (62.5%) had positive results at some point (ie, completion, 6 months or 18 months after AQSI).

Conclusions

A team-based QI training programme resulted in a high degree of participants’ involvement in QI activities beyond completion of the programme. A majority of team projects showed improvement in project measures, often occurring after completion of the programme.

Predictors of responses to immune checkpoint blockade in advanced melanoma

Immune checkpoint blockers (ICB) have become pivotal therapies in the clinical armamentarium against metastatic melanoma (MMel). Given the frequency of immune related adverse events and increasing use of ICB, predictors of response to CTLA-4 and/or PD-1 blockade represent unmet clinical needs. Using a systems biology-based approach to an assessment of 779 paired blood and tumor markers in 37 stage III MMel patients, we analyzed association between blood immune parameters and the functional immune reactivity of tumor-infiltrating cells after ex vivo exposure to ICB. Based on this assay, we retrospectively observed, in eight cohorts enrolling 190 MMel patients treated with ipilimumab, that PD-L1 expression on peripheral T cells was prognostic on overall and progression-free survival. Moreover, detectable CD137 on circulating CD8⁺ T cells was associated with the disease-free status of resected stage III MMel patients after adjuvant ipilimumab + nivolumab (but not nivolumab alone). These biomarkers should be validated in prospective trials in MMel.The clinical management of metastatic melanoma requires predictors of the response to checkpoint blockade. Here, the authors use immunological assays to identify potential prognostic/predictive biomarkers in circulating blood cells and in tumor-infiltrating lymphocytes from patients with resected stage III melanoma.

Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population

OBJECTIVE

Efforts to improve patient safety are challenged by the lack of universally agreed upon terms. The International Classification for Patient Safety (ICPS) was developed by the World Health Organization for this purpose. This study aimed to test the applicability of the ICPS to a surgical population.

DESIGN

A web-based safety debriefing was sent to clinicians involved in surgical care of abdominal organ transplant patients. A multidisciplinary team of patient safety experts, surgeons and researchers used the data to develop a system of classification based on the ICPS. Disagreements were reconciled via consensus, and a codebook was developed for future use by researchers.

RESULTS

A total of 320 debriefing responses were used for the initial review and codebook development. In total, the 320 debriefing responses contained 227 patient safety incidents (range: 0-7 per debriefing) and 156 contributing factors/hazards (0-5 per response). The most common severity classification was 'reportable circumstance,' followed by 'near miss.' The most common incident types were 'resources/organizational management,' followed by 'medical device/equipment.' Several aspects of surgical care were encompassed by more than one classification, including operating room scheduling, delays in care, trainee-related incidents, interruptions and handoffs.

CONCLUSIONS

This study demonstrates that a framework for patient safety can be applied to facilitate the organization and analysis of surgical safety data. Several unique aspects of surgical care require consideration, and by using a standardized framework for describing concepts, research findings can be compared and disseminated across surgical specialties. The codebook is intended for use as a framework for other specialties and institutions.

Targeting histone deacetylase 6 mediates a dual anti-melanoma effect: Enhanced antitumor immunity and impaired cell proliferation

The median survival for metastatic melanoma is in the realm of 8-16 months and there are few therapies that offer significant improvement in overall survival. One of the recent advances in cancer treatment focuses on epigenetic modifiers to alter the survivability and immunogenicity of cancer cells. Our group and others have previously demonstrated that pan-HDAC inhibitors induce apoptosis, cell cycle arrest and changes in the immunogenicity of melanoma cells. Here we interrogated specific HDACs which may be responsible for this effect. We found that both genetic abrogation and pharmacologic inhibition of HDAC6 decreases in vitro proliferation and induces G1 arrest of melanoma cell lines without inducing apoptosis. Moreover, targeting this molecule led to an important upregulation in the expression of tumor associated antigens and MHC class I, suggesting a potential improvement in the immunogenicity of these cells. Of note, this anti-melanoma activity was operative regardless of mutational status of the cells. These effects translated into a pronounced delay of in vivo melanoma tumor growth which was, at least in part, dependent on intact immunity as evidenced by the restoration of tumor growth after CD4+ and CD8+ depletion. Given our findings, we provide the initial rationale for the further development of selective HDAC6 inhibitors as potential therapeutic anti-melanoma agents.

A rater training protocol to assess team performance

INTRODUCTION

Simulation-based methodologies are increasingly used to assess teamwork and communication skills and provide team training. Formative feedback regarding team performance is an essential component. While effective use of simulation for assessment or training requires accurate rating of team performance, examples of rater-training programs in health care are scarce. We describe our rater training program and report interrater reliability during phases of training and independent rating.

METHODS

We selected an assessment tool shown to yield valid and reliable results and developed a rater training protocol with an accompanying rater training handbook. The rater training program was modeled after previously described high-stakes assessments in the setting of 3 facilitated training sessions. Adjacent agreement was used to measure interrater reliability between raters.

RESULTS

Nine raters with a background in health care and/or patient safety evaluated team performance of 42 in-situ simulations using post-hoc video review. Adjacent agreement increased from the second training session (83.6%) to the third training session (85.6%) when evaluating the same video segments. Adjacent agreement for the rating of overall team performance was 78.3%, which was added for the third training session. Adjacent agreement was 97% 4 weeks posttraining and 90.6% at the end of independent rating of all simulation videos.

DISCUSSION

Rater training is an important element in team performance assessment, and providing examples of rater training programs is essential. Articulating key rating anchors promotes adequate interrater reliability. In addition, using adjacent agreement as a measure allows differentiation between high- and low-performing teams on video review.

Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system

BACKGROUND

Rates of medical errors and adverse events remain high for patients who undergo kidney transplantation; they are particularly vulnerable because of the complexity of their disease and the kidney transplantation procedure. Although institutional incident-reporting systems are used in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems.

METHODS

Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011, and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported.

RESULTS

A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared with incident reports, more attending physicians completed the debriefings (32.0 vs 3.5%).

DISCUSSION

The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants.

Educating future physicians to track health care quality: feasibility and perceived impact of a health care quality report card for medical students

PURPOSE

Quality improvement (QI) requires measurement, but medical schools rarely provide opportunities for students to measure their patient outcomes. The authors tested the feasibility and perceived impact of a quality metric report card as part of an Education-Centered Medical Home longitudinal curriculum.

METHOD

Student teams were embedded into faculty practices and assigned a panel of patients to follow longitudinally. Students performed retrospective chart reviews and reported deidentified data on 30 nationally endorsed QI metrics for their assigned patients. Scorecards were created for each clinic team. Students completed pre/post surveys on self-perceived QI skills.

RESULTS

A total of 405 of their patients' charts were abstracted by 149 students (76% response rate; mean 2.7 charts/student). Median abstraction time was 21.8 (range: 13.1-37.1) minutes. Abstracted data confirmed that the students had successfully recruited a "high-risk" patient panel. Initial performance on abstracted quality measures ranged from 100% adherence on the use of beta-blockers in postmyocardial infarction patients to 24% on documentation of dilated diabetic eye exams. After the chart abstraction assignment, grand rounds, and background readings, student self-assessment of their perceived QI skills significantly increased for all metrics, though it remained low.

CONCLUSIONS

Creation of an actionable health care quality report card as part of an ambulatory longitudinal experience is feasible, and it improves student perception of QI skills. Future research will aim to use statistical process control methods to track health care quality prospectively as our students use their scorecards to drive clinic-level improvement efforts.

The patient centered medical home as curricular model: perceived impact of the "education-centered medical home"

BACKGROUND

The patient-centered medical home (PCMH) model aims to provide patient-centered care, lower costs, and improve health outcomes. Medical students have not been meaningfully integrated in this model.

AIM

To test the feasibility of a longitudinal clerkship based on PCMH principles and anchored by PCMH educational objectives.

SETTING

Two community-based family medicine clinics, one academic internal medicine clinic, and one pediatric clinic affiliated with an urban medical school.

PARTICIPANTS

56 medical student volunteers.

PROGRAM DESCRIPTION

We embedded student teams in existing faculty practices and recruited a high-risk patient panel for each team. Clinical education occurred through a traditional clinic preceptor model and was augmented by 3rd and 4th year students directly observing 1st and 2nd year students. Didactic content included monthly Grand Rounds conferences.

PROGRAM EVALUATION

Students attended 699 clinics, recruited 273 continuity patients, and participated in 9 Grand Rounds conferences. Student confidence with PCMH principles increased and attitudes regarding continuity were highly positive. "Continuity," "early clinical exposure," and "peer teaching" were the most powerful themes expressed by students. Faculty response to the pilot was highly positive.

DISCUSSION

An Education-Centered Medical Home (ECMH) is feasible and is highly rated by students and faculty. Expansion of this model is underway.

NUTORC-a transdisciplinary health services and outcomes research team in transplantation

The field of solid organ transplantation has historically concentrated research efforts on basic science and translational studies. However, there has been increasing interest in health services and outcomes research. The aim was to build an effective and sustainable, inter- and transdisciplinary health services and outcomes research team (NUTORC), that leveraged institutional strengths in social science, engineering, and management disciplines, coupled with an international recognized transplant program. In 2008, leading methodological experts across the university were identified and intramural funding was obtained for the NUTORC initiative. Inter- and transdisciplinary collaborative teams were created across departments and schools within the university. Within 3 years, NUTORC became fiscally sustainable, yielding more than tenfold return of the initial investment. Academic productivity included funding for 39 grants, publication of 60 manuscripts, and 166 national presentations. Sustainable educational opportunities for students were created. Inter- and transdisciplinary health services and outcomes research in transplant can be innovative and sustainable.

Assessing Chronic Illness Care Education (ACIC-E): a tool for tracking educational re-design for improving chronic care education

BACKGROUND

Recent Breakthrough Series Collaboratives have focused on improving chronic illness care, but few have included academic practices, and none have specifically targeted residency education in parallel with improving clinical care. Tools are available for assessing progress with clinical improvements, but no similar instruments have been developed for monitoring educational improvements for chronic care education.

AIM

To design a survey to assist teaching practices with identifying curricular gaps in chronic care education and monitor efforts to address those gaps.

METHODS

During a national academic chronic care collaborative, we used an iterative method to develop and pilot test a survey instrument modeled after the Assessing Chronic Illness Care (ACIC). We implemented this instrument, the ACIC-Education, in a second collaborative and assessed the relationship of survey results with reported educational measures.

PARTICIPANTS

A combined 57 self-selected teams from 37 teaching hospitals enrolled in one of two collaboratives.

ANALYSIS

We used descriptive statistics to report mean ACIC-E scores and educational measurement results, and Pearson's test for correlation between the final ACIC-E score and reported educational measures.

RESULTS

A total of 29 teams from the national collaborative and 15 teams from the second collaborative in California completed the final ACIC-E. The instrument measured progress on all sub-scales of the Chronic Care Model. Fourteen California teams (70%) reported using two to six education measures (mean 4.3). The relationship between the final survey results and the number of educational measures reported was weak (R(2) = 0.06, p = 0.376), but improved when a single outlier was removed (R(2) = 0.37, p = 0.022).

CONCLUSIONS

The ACIC-E instrument proved feasible to complete. Participating teams, on average, recorded modest improvement in all areas measured by the instrument over the duration of the collaboratives. The relationship between the final ACIC-E score and the number of educational measures was weak. Further research on its utility and validity is required.

A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices

BACKGROUND

There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care.

OBJECTIVE

To improve training for residents who provide chronic illness care in teaching practice settings.

DESIGN

US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure <or=130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked.

PARTICIPANTS

Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives.

INTERVENTIONS

Teaching-practice teams-faculty, residents and staff-participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly.

RESULTS

Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives.

CONCLUSIONS

These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.

Developing measures of educational change for academic health care teams implementing the chronic care model in teaching practices

BACKGROUND

The Chronic Care Model (CCM) is a multidimensional framework designed to improve care for patients with chronic health conditions. The model strives for productive interactions between informed, activated patients and proactive practice teams, resulting in better clinical outcomes and greater satisfaction. While measures for improving care may be clear, measures of residents' competency to provide chronic care do not exist. This report describes the process used to develop educational measures and results from CCM settings that used them to monitor curricular innovations.

SUBJECTS

Twenty-six academic health care teams participating in the national and California Academic Chronic Care Collaboratives.

METHOD

Using successive discussion groups and surveys, participants engaged in an iterative process to identify desirable and feasible educational measures for curricula that addressed educational objectives linked to the CCM. The measures were designed to facilitate residency programs' abilities to address new accreditation requirements and tested with teams actively engaged in redesigning educational programs.

ANALYSIS

Field notes from each discussion and lists from work groups were synthesized using the CCM framework. Descriptive statistics were used to report survey results and measurement performance.

RESULTS

Work groups generated educational objectives and 17 associated measurements. Seventeen (65%) teams provided feasibility and desirability ratings for the 17 measures. Two process measures were selected for use by all teams. Teams reported variable success using the measures. Several teams reported use of additional measures, suggesting more extensive curricular change.

CONCLUSION

Using an iterative process in collaboration with program participants, we successfully defined a set of feasible and desirable education measures for academic health care teams using the CCM. These were used variably to measure the results of curricular changes, while simultaneously addressing requirements for residency accreditation.

Joy and challenges in improving chronic illness care: capturing daily experiences of academic primary care teams

BACKGROUND

Two chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education.

OBJECTIVE

We developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member's experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork.

DESIGN

The ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members' daily work and subsequent outcomes.

PARTICIPANTS

Forty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff.

APPROACH

Each team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative).

KEY RESULTS

At the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or "Joy in Work". In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments-"lack of professional satisfaction" and awareness of "system failures".

CONCLUSIONS

The ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.

Puccinia jaceae var. solstitialis teliospore priming on yellow starthistle

Following the introduction of Puccinia jaceae var. solstitialis to California for biological control of yellow starthistle (Centaurea solstitialis, Asteraceae), teliospores, pycnia, and multiple urediniospore generations have been observed in the field. Because urediniospores have a relatively short life span in the field, functioning teliospores are expected to be necessary for the permanent establishment of P. jaceae var. solstitialis in California. To determine if conditions in California were conducive to this, teliospore emergence and priming were evaluated in the field. A factorial experiment in the laboratory with five incubation times and three incubation temperatures was used to determine teliospore priming requirements. Teliospore production coincided with plant senescence in August and September at two sites in 2 years; fewer teliospores were produced in 2006, suggesting inconsistent teliospore production may limit population growth and contribute to local extinctions in some areas. When teliospores were primed in the field, germination was low through the fall and abruptly peaked in January during both years. In the laboratory, teliospore germination increased as incubation time increased from 2 to 6 weeks and temperatures decreased from 12 to 4 degrees C. A degree-hour model derived from laboratory data accurately predicts when teliospores are primed for germination in the field. Based on the results obtained in this study, it is apparent that teliospore germination can occur over a range of priming conditions. However, lower temperatures and longer incubation periods are superior in breaking teliospore dormancy.

Gaps in pediatric clinician communication and opportunities for improvement

Teamwork and good communication are central to the provision of high-quality care. A standardized focus-group protocol was used. Analysis assessed emergent themes of patient safety-related effective and problematic clinician communication. Sixty-three focus groups were conducted with clinicians from five Chicago Pediatric Patient Safety Consortium hospitals. Effective and problematic clinician-to-clinician communication themes were described in all focus groups and at each participating hospital. Problematic communication contexts included the communication process for orders, consultations, acuity assessment, management of surgical and medical patients, and the discharge process. Organizational policies and systems leading to patient safety risk included a lack of clear responsibilities and expectations for clinicians and for clinical communication, as well as a lack of a clear chain of responsibility for communication when hierarchical communication barriers affected safe patient care. Results of this investigation highlighted gaps in pediatric clinician communication and opportunities for improvement.

Ambulatory care adverse events and preventable adverse events leading to a hospital admission

BACKGROUND

Most healthcare in the US is delivered in the ambulatory care setting, but the epidemiology of errors and adverse events in ambulatory care is understudied.

METHODS

Using the population-based data from the Colorado and Utah Medical Practices Study, we identified adverse events that occurred in an ambulatory care setting and led to hospital admission. Proportions with 95% CIs are reported.

RESULTS

We reviewed 14,700-hospital discharge records and found 587 adverse events of which 70 were ambulatory care adverse events (AAEs) and 31 were ambulatory care preventable adverse events (APAEs). When weighted to the general population, there were 2608 AAEs and 1296 (44.3%) APAEs in Colorado and Utah, USA, in 1992. APAEs occurred most commonly in physicians' offices (43.1%, range 46.8-27.8), the emergency department (32.3%, 46.1-18.5) and at home (13.1%, 23.1-3.1). APAEs in day surgery were less common (7.1%, 13.6-0.6) but caused the greatest harm to patients. The types of APAEs were broadly distributed among missed or delayed diagnoses (36%, 50.2-21.8), surgery (24.1%, 36.7-11.5), non-surgical procedures (14.6%, 25.0-4.2), medication (13.1%, 23.1-3.1) and therapeutic events (12.3%, 22.0-2.6). Overall, 10% of the APAEs resulted in serious permanent injury or death. The proportion of APAEs that resulted in death was 31.8% for general internal medicine, 22.5% for family practice and 16.7% for emergency medicine.

CONCLUSION

An estimated 75,000 hospitalisations per year are due to preventable adverse events that occur in outpatient settings in the US, resulting in 4839 serious permanent injuries and 2587 deaths.

Anatomy of a patient safety event: a pediatric patient safety taxonomy

BACKGROUND

Idiosyncratic terminology and frameworks in the study of patient safety have been tolerated but are increasingly problematic. Agreement on standard language and frameworks is needed for optimal improvement and dissemination of knowledge about patient safety.

METHODS

Patient safety events were assessed using critical incident analysis, a method used to classify risks that has been more recently applied to medicine. Clinician interviews and clinician reports to a web based reporting system were used for analysis of hospital based and ambulatory care events, respectively. Events were classified independently by three investigators.

RESULTS

A pediatric patient safety taxonomy, relevant to both hospital based and ambulatory pediatric care, was developed from the analysis of 122 hospital based and 144 ambulatory care events. It is composed of four main categories: (1) problem type; (2) domain of medicine; (3) contributing factors in the patient (child-specific), environment (latent conditions) and care providers (human factors); and (4) outcome or result of the event and level of harm. A classification of preventive mechanisms was also developed. Inter-rater reliability of classifications ranged from 72% to 86% for sub-categories of the taxonomy.

CONCLUSIONS

This patient safety taxonomy reflects the nature of events that occur in both pediatric hospital based and ambulatory care settings. It is flexible in its construction, permits analysis to begin at any point, and depicts the relationships and interactions of elements of an event.

Patient safety problems in adolescent medical care

PURPOSE

This study estimates the annual incidence and describes the nature, types, and contributing factors involved in patient safety problems in adolescent medical care.

METHODS

This study uses data from the population-based Colorado and Utah Medical Practice Study to describe the incidence of hospital-based adverse events and preventable adverse events in adolescents and "critical incidence analysis" data reported by pediatric clinicians to elucidate the nature, types, and contributing factors in adolescent patient safety problems.

RESULTS

The incidence of adverse events in adolescents in the Colorado and Utah Medical Practice Study was 2.74 (CI 95% = 2.62-2.86), significantly higher than all other age groups of children. The incidence of preventable adverse events in adolescents was 0.95 (CI 95% = 0.65-1.25), significantly higher than that of children 1-12 years old, but not significantly different than infants. Diagnostic events were most common, followed by medication events. Services associated with the highest frequency of events were pharmacy and Family Practice. In the critical incident analysis, adolescent-specific factors contributed to 54.8% of the described patient safety problems. Discomfort with adolescents, a factor not described for other age groups of children, contributed to 17% of the adolescent patient safety problems.

CONCLUSIONS

Adolescents experience relatively high rates of patient safety problems compared with other age groups of children. Adolescents represent a defined population with a patient safety risk profile that differs from adults and younger children. The substantial contribution of adolescent-specific factors suggests that patient safety improvements, to be effective, should address adolescent-specific risks.

First Report of Musk Thistle Rust (Puccinia carduorum) in California and Nevada

Musk thistle, Carduus nutans L., is an introduced weed of pastures, rangelands, and natural areas in much of North America. Puccinia carduorum Jacky, an autoecious rust fungus from Turkey, has been evaluated for biological control of musk thistle since 1978, including a field study near Blacksburg, VA, from 1987 to 1990. After release of the fungus in Virginia, rusted musk thistle was found in eight eastern states by 1992, in Missouri by 1994 (1), and in Oklahoma by 1997 (2). A rust disease was discovered on musk thistle near Mt. Shasta, CA, on 22 September 1998, and near Mogul, NV, on 12 August 1999. The pathogen was identified as P. carduorum on the basis of pathogenicity on musk thistle and urediniospore morphology (ovate spores, 21 μm diameter, three germ pores equatorial in location, and echinulations over the upper two-thirds to three-quarters of urediniospores). Ribosomal RNA internal transcribed spacer DNA sequences (ITS1 and ITS2) were identical to those from the isolate obtained after the field release in Virginia, verifying that the California isolate is P. carduorum. The initial California infestation was observed on a few plants late in the season, and by September 2000, nearly 100% of plants were infected. The occurrence of P. carduorum in California is apparently the result of natural, unaided spread of the fungus on musk thistle from the East Coast of the United States. References: (1) A. B. A. M. Baudoin and W. L. Bruckart. Plant Dis. 80:1193, 1996. (2) L. J. Littlefield et al. Plant Dis. 82:832, 1998.

Experimental enhancement of drug uptake using short-term flow occlusion: a comparison of balloon and tourniquet techniques

Three groups of dogs, four per group, were used to examine the safety of short-term arterial flow occlusion and potential benefits of balloon and/or tourniquet occlusion-infusion techniques. In part 1, local plasma gases and pH were monitored during a 1-hr period of vascular occlusion. Tourniquet occlusion was found to significantly (p = 0.01) lower pO2. In part 2, local muscle and venous blood samples were obtained during and after a 30-min intraarterial infusion of floxuridine (FUDR). A tourniquet was added to try to eliminate collateral circulation. Local FUDR concentration was increased by 1.3 times in muscle and 19.6 times (p less than 0.01) in ipsilateral femoral vein serum when a tourniquet was added to arterial balloon occlusion-infusion. In addition, the combination of the two occlusion techniques produced a 4.1-fold reduction (p less than 0.05) in systemic venous FUDR levels during infusion when compared to balloon occlusion.