The Association of Standardized Documentation of Serious Illness Conversations With Healthcare Utilization in Hospitalized Patients: A Propensity Score Matched Cohort Analysis

Background: Serious Illness Conversations (SICs) conducted during hospitalization can lead to meaningful patient participation in the decision-making process affecting medical management. The aim of this study is to determine if standardized documentation of a SIC within an institutionally approved EHR module during hospitalization is associated with palliative care consultation, change in code status, hospice enrollment prior to discharge, and 90-day readmissions. Methods: We conducted retrospective analyses of hospital encounters of general medicine patients at a community teaching hospital affiliated with an academic medical center from October 2018 to August 2019. Encounters with standardized documentation of a SIC were identified and matched by propensity score to control encounters without a SIC in a ratio of 1:3. We used multivariable, paired logistic regression and Cox proportional-hazards modeling to assess key outcomes. Results: Of 6853 encounters (5143 patients), 59 (.86%) encounters (59 patients) had standardized documentation of a SIC, and 58 (.85%) were matched to 167 control encounters (167 patients). Encounters with standardized documentation of a SIC had greater odds of palliative care consultation (odds ratio [OR] 60.10, 95% confidence interval [CI] 12.45-290.08, P < .01), a documented code status change (OR 8.04, 95% CI 1.54-42.05, P = .01), and discharge with hospice services (OR 35.07, 95% CI 5.80-212.08, P < .01) compared to matched controls. There was no significant association with 90-day readmissions (adjusted hazard ratio [HR] .88, standard error [SE] .37, P = .73). Conclusions: Standardized documentation of a SIC during hospitalization is associated with palliative care consultation, change in code status, and hospice enrollment.

A Mixed Methods Analysis of Standardized Documentation of Serious Illness Conversations Within an Electronic Health Record Module During Hospitalization

BACKGROUND

Analysis of documented Serious Illness Conversations (SICs) in the inpatient setting can help clinicians align management to address patient and caregiver needs.

METHODS

We conducted a mixed methods analysis of the first instance of standardized documentation of a SIC within a structured module among hospitalized general medicine patients from 2018 to 2019. Percentage of documentations that included a description of patient or family understanding of the patient's medical condition and use of radio buttons to answer the "prognostic information shared," "hopes," and "worries" modules are reported. Using grounded theory approach, physicians analyzed free text entries to: "What is important to the patient/family?" and "Recommendations or next steps planned."

RESULTS

Out of 5142 patients, 59 patients had a documented SIC. Patient or family understanding of the medical condition(s) was reported in 56 (95%). For "prognostic information shared," the most frequently selected radio buttons were: 49 (83%) incurable disease and 28 (48%) prognosis of weeks to months while those for "hopes" were: 52 (88%) be comfortable and 27 (46%) be at home and for "worries" were: 49 (83%) other physical suffering and 36 (61%) pain. Themes generated from entries to "What's important to patient/family?" included being with loved ones; comfort; mentally and physically present; and reliable care while those for "Recommendations" were coordinating support services; symptom management; and support and communication.

CONCLUSIONS

SIC content indicated concern about pain and reliable care suggesting the complex, intensive nature of caring for seriously ill patients and the need to consider SICs earlier in the life course of patients.

Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care

Importance

Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients.

Objective

To determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalized adults transferred to an intensive care unit (ICU) or who died.

Design, Setting, and Participants

Retrospective cohort study conducted at 29 academic medical centers in the US in a random sample of adults hospitalized with general medical conditions and who were transferred to an ICU, died, or both from January 1 to December 31, 2019. Each record was reviewed by 2 trained clinicians to determine whether a diagnostic error occurred (ie, missed or delayed diagnosis), identify diagnostic process faults, and classify harms. Multivariable models estimated association between process faults and diagnostic error. Opportunity for diagnostic error reduction associated with each fault was estimated using the adjusted proportion attributable fraction (aPAF). Data analysis was performed from April through September 2023.

Main Outcomes and Measures

Whether or not a diagnostic error took place, the frequency of underlying causes of errors, and harms associated with those errors.

Results

Of 2428 patient records at 29 hospitals that underwent review (mean [SD] patient age, 63.9 [17.0] years; 1107 [45.6%] female and 1321 male individuals [54.4%]), 550 patients (23.0%; 95% CI, 20.9%-25.3%) had experienced a diagnostic error. Errors were judged to have contributed to temporary harm, permanent harm, or death in 436 patients (17.8%; 95% CI, 15.9%-19.8%); among the 1863 patients who died, diagnostic error was judged to have contributed to death in 121 (6.6%; 95% CI, 5.3%-8.2%). In multivariable models examining process faults associated with any diagnostic error, patient assessment problems (aPAF, 21.4%; 95% CI, 16.4%-26.4%) and problems with test ordering and interpretation (aPAF, 19.9%; 95% CI, 14.7%-25.1%) had the highest opportunity to reduce diagnostic errors; similar ranking was seen in multivariable models examining harmful diagnostic errors.

Conclusions and Relevance

In this cohort study, diagnostic errors in hospitalized adults who died or were transferred to the ICU were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.

Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: A multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients

BACKGROUND

Few hospitals have built surveillance for diagnostic errors into usual care or used comparative quantitative and qualitative data to understand their diagnostic processes and implement interventions designed to reduce these errors.

OBJECTIVES

To build surveillance for diagnostic errors into usual care, benchmark diagnostic performance across sites, pilot test interventions, and evaluate the program's impact on diagnostic error rates.

METHODS AND ANALYSIS

Achieving diagnostic excellence through prevention and teamwork (ADEPT) is a multicenter, real-world quality and safety program utilizing interrupted time-series techniques to evaluate outcomes. Study subjects will be a randomly sampled population of medical patients hospitalized at 16 US hospitals who died, were transferred to intensive care, or had a rapid response during the hospitalization. Surveillance for diagnostic errors will occur on 10 events per month per site using a previously established two-person adjudication process. Concurrent reviews of patients who had a qualifying event in the previous week will allow for surveys of clinicians to better understand contributors to diagnostic error, or conversely, examples of diagnostic excellence, which cannot be gleaned from medical record review alone. With guidance from national experts in quality and safety, sites will report and benchmark diagnostic error rates, share lessons regarding underlying causes, and design, implement, and pilot test interventions using both Safety I and Safety II approaches aimed at patients, providers, and health systems. Safety II approaches will focus on cases where diagnostic error did not occur, applying theories of how people and systems are able to succeed under varying conditions. The primary outcome will be the number of diagnostic errors per patient, using segmented multivariable regression to evaluate change in y-intercept and change in slope after initiation of the program.

ETHICS AND DISSEMINATION

The study has been approved by the University of California, San Francisco Institutional Review Board (IRB), which is serving as the single IRB. Intervention toolkits and study findings will be disseminated through partners including Vizient, The Joint Commission, and Press-Ganey, and through national meetings, scientific journals, and publications aimed at the general public.

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study

BACKGROUND

The second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results.

METHODS

This study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2-5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of system-level interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates.

RESULTS

Among 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75-0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient).

CONCLUSION AND RELEVANCE

Patient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions.

Assessing Equitable Recruitment in a Digital Health Trial for Asthma

OBJECTIVE

This study aimed to assess a multipronged strategy using primarily digital methods to equitably recruit asthma patients into a clinical trial of a digital health intervention.

METHODS

We approached eligible patients using at least one of eight recruitment strategies. We recorded approach dates and the strategy that led to completion of a web-based eligibility questionnaire that was reported during the verbal consent phone call. Study team members conducted monthly sessions using a structured guide to identify recruitment barriers and facilitators. The proportion of participants who reported being recruited by a portal or nonportal strategy was measured as our outcomes. We used Fisher's exact test to compare outcomes by equity variable, and multivariable logistic regression to control for each covariate and adjust effect size estimates. Using grounded theory, we coded and extracted themes regarding recruitment barriers and facilitators.

RESULTS

The majority (84.4%) of patients who met study inclusion criteria were patient portal enrollees. Of 6,366 eligible patients who were approached, 627 completed the eligibility questionnaire and were less frequently Hispanic, less frequently Spanish-speaking, and more frequently patient portal enrollees. Of 445 patients who consented to participate, 241 (54.2%) reported completing the eligibility questionnaire after being contacted by a patient portal message. In adjusted analysis, only race (odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.28-0.77, p = 0.003) and college education (OR: 0.60, 95% CI: 0.39-0.91, p = 0.016) remained significant. Key recruitment barriers included technology issues (e.g., lack of email access) and facilitators included bilingual study staff, Spanish-language recruitment materials, targeted phone calls, and clinician-initiated "1-click" referrals.

CONCLUSION

A primarily digital strategy to recruit patients into a digital health trial is unlikely to achieve equitable participation, even in a population overrepresented by patient portal enrollees. Nondigital recruitment methods that address racial and educational disparities and less active portal enrollees are necessary to ensure equity in clinical trial enrollment.

Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach

Objective

To describe a user-centered approach to develop, pilot test, and refine requirements for 3 electronic health record (EHR)-integrated interventions that target key diagnostic process failures in hospitalized patients.

Materials and Methods

Three interventions were prioritized for development: a Diagnostic Safety Column (DSC) within an EHR-integrated dashboard to identify at-risk patients; a Diagnostic Time-Out (DTO) for clinicians to reassess the working diagnosis; and a Patient Diagnosis Questionnaire (PDQ) to gather patient concerns about the diagnostic process. Initial requirements were refined from analysis of test cases with elevated risk predicted by DSC logic compared to risk perceived by a clinician working group; DTO testing sessions with clinicians; PDQ responses from patients; and focus groups with clinicians and patient advisors using storyboarding to model the integrated interventions. Mixed methods analysis of participant responses was used to identify final requirements and potential implementation barriers.

Results

Final requirements from analysis of 10 test cases predicted by the DSC, 18 clinician DTO participants, and 39 PDQ responses included the following: DSC configurable parameters (variables, weights) to adjust baseline risk estimates in real-time based on new clinical data collected during hospitalization; more concise DTO wording and flexibility for clinicians to conduct the DTO with or without the patient present; and integration of PDQ responses into the DSC to ensure closed-looped communication with clinicians. Analysis of focus groups confirmed that tight integration of the interventions with the EHR would be necessary to prompt clinicians to reconsider the working diagnosis in cases with elevated diagnostic error (DE) risk or uncertainty. Potential implementation barriers included alert fatigue and distrust of the risk algorithm (DSC); time constraints, redundancies, and concerns about disclosing uncertainty to patients (DTO); and patient disagreement with the care team's diagnosis (PDQ).

Discussion

A user-centered approach led to evolution of requirements for 3 interventions targeting key diagnostic process failures in hospitalized patients at risk for DE.

Conclusions

We identify challenges and offer lessons from our user-centered design process.

Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19

BACKGROUND

The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs).

OBJECTIVE

To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19.

DESIGN

Retrospective cohort.

SETTING

Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN).

TARGET POPULATION

Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020.

MEASUREMENTS

We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs.

RESULTS

Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error.

LIMITATIONS

Results are limited by available documentation and do not capture communication between providers and patients.

CONCLUSION

Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

Early Expected Discharge Date Accuracy During Hospitalization: A Multivariable Analysis

INTRODUCTION

Accurate estimation of an expected discharge date (EDD) early during hospitalization impacts clinical operations and discharge planning.

METHODS

We conducted a retrospective study of patients discharged from six general medicine units at an academic medical center in Boston, MA from January 2017 to June 2018. We retrieved all EDD entries and patient, encounter, unit, and provider data from the electronic health record (EHR), and public weather data. We excluded patients who expired, discharged against medical advice, or lacked an EDD within the first 24 h of hospitalization. We used generalized estimating equations in a multivariable logistic regression analysis to model early EDD accuracy (an accurate EDD entered within 24 h of admission), adjusting for all covariates and clustering by patient. We similarly constructed a secondary multivariable model using covariates present upon admission alone.

RESULTS

Of 3917 eligible hospitalizations, 890 (22.7%) had at least one accurate early EDD entry. Factors significantly positively associated (OR > 1) with an accurate early EDD included clinician-entered EDD, admit day and discharge day during the work week, and teaching clinical units. Factors significantly negatively associated (OR < 1) with an accurate early EDD included Elixhauser Comorbidity Index ≥ 11 and length of stay of two or more days. C-statistics for the primary and secondary multivariable models were 0.75 and 0.60, respectively.

CONCLUSIONS

EDDs entered within the first 24 h of admission were often inaccurate. While several variables from the EHR were associated with accurate early EDD entries, few would be useful for prospective prediction.

Providers' and Patients' Perspectives on Diagnostic Errors in the Acute Care Setting

BACKGROUND

Diagnostic errors (DEs) have been studied extensively in ambulatory care, but less work has been done in the acute care setting. In this study, the authors examined health care providers' and patients' perspectives about the classification of DEs, the main causes and scope of DEs in acute care, the main gaps in current systems, and the need for innovative solutions.

METHODS

A qualitative mixed methods study was conducted, including semistructured interviews with health care providers and focus groups with patient advisors. Using grounded theory approach, thematic categories were derived from the interviews and focus groups.

RESULTS

The research team conducted interviews with 17 providers and two focus groups with seven patient advisors. Both providers and patient advisors struggled to define and describe DEs in acute care settings. Although participants agreed that DEs pose a significant risk to patient safety, their perception of the frequency of DEs was mixed. Most participants identified communication failures, lack of comfort with diagnostic uncertainty, incorrect clinical evaluation, and cognitive load as key causes of DEs. Most respondents believed that non-information technology (IT) tools and processes (for example, communication improvement strategies) could significantly reduce DEs.

CONCLUSION

The study findings represent an important supplement to our understanding of DEs in acute care settings and the advancement of a culture of patient safety in the context of patient-centered care and patient engagement. Health care organizations should consider the key factors identified in this study when trying to create a culture that engages clinicians and patients in reducing DEs.

A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts

OBJECTIVES

To test a structured electronic health record (EHR) case review process to identify diagnostic errors (DE) and diagnostic process failures (DPFs) in acute care.

METHODS

We adapted validated tools (Safer Dx, Diagnostic Error Evaluation Research [DEER] Taxonomy) to assess the diagnostic process during the hospital encounter and categorized 13 postulated e-triggers. We created two test cohorts of all preventable cases (n=28) and an equal number of randomly sampled non-preventable cases (n=28) from 365 adult general medicine patients who expired and underwent our institution's mortality case review process. After excluding patients with a length of stay of more than one month, each case was reviewed by two blinded clinicians trained in our process and by an expert panel. Inter-rater reliability was assessed. We compared the frequency of DE contributing to death in both cohorts, as well as mean DPFs and e-triggers for DE positive and negative cases within each cohort.

RESULTS

Twenty-seven (96.4%) preventable and 24 (85.7%) non-preventable cases underwent our review process. Inter-rater reliability was moderate between individual reviewers (Cohen's kappa 0.41) and substantial with the expert panel (Cohen's kappa 0.74). The frequency of DE contributing to death was significantly higher for the preventable compared to the non-preventable cohort (56% vs. 17%, OR 6.25 [1.68, 23.27], p<0.01). Mean DPFs and e-triggers were significantly and non-significantly higher for DE positive compared to DE negative cases in each cohort, respectively.

CONCLUSIONS

We observed substantial agreement among final consensus and expert panel reviews using our structured EHR case review process. DEs contributing to death associated with DPFs were identified in institutionally designated preventable and non-preventable cases. While e-triggers may be useful for discriminating DE positive from DE negative cases, larger studies are required for validation. Our approach has potential to augment institutional mortality case review processes with respect to DE surveillance.

Who Gets (and Who Should Get) a Serious Illness Conversation in the Hospital? An Analysis of Readmission Risk Score in an Electronic Health Record

Serious Illness Conversations (SICs) explore patients' prognostic awareness, hopes, and worries, and can help establish priorities for their care during and after hospitalization. While identifying patients who benefit from an SIC remains a challenge, this task may be facilitated by use of validated prediction scores available in most commercial electronic health records (EHRs), such as Epic's Readmission Risk Score (RRS). We identified the RRS on admission for all hospital encounters from October 2018 to August 2019 and measured the area under the receiver operating characteristic (AUROC) curve to determine whether RRS could accurately discriminate post discharge 6-month mortality. For encounters with standardized SIC documentation matched in a 1:3 ratio to controls by sex and age (±5 years), we constructed a multivariable, paired logistic regression model and measured the odds of SIC documentation per every 10% absolute increase in RRS. RRS was predictive of 6-month mortality with acceptable discrimination (AUROC .71) and was significantly associated with SIC documentation (adjusted OR 1.42, 95% CI 1.24-1.63). An RRS >28% used to identify patients with post discharge 6-month mortality had a high specificity (89.0%) and negative predictive value (NPV) (97.0%), but low sensitivity (25.2%) and positive predictive value (PPV) (7.9%). RRS may serve as a practical EHR-based screen to exclude patients not requiring an SIC, thereby leaving a smaller cohort to be further evaluated for SIC needs using other validated tools and clinical assessment.

Development and Testing of an Electronic Health Record‐Integrated Patient‐Reported Outcome Application and Intervention to Improve Efficiency of Rheumatoid Arthritis Care

Objective

Many patients with rheumatoid arthritis (RA) have difficulty finding clinicians to treat them because of workforce shortages. We developed an app to address this problem by improving care efficiency. The app collects patient‐reported outcomes (PROs) and can be used to inform visit timing, potentially reducing the volume of low‐value visits. We describe the development process, intervention design, and planned study for testing the app.

Methods

We employed user‐centered design, interviewing patients and clinicians, to develop the app. To improve visit efficiency, symptom tracking logic alerts clinicians to PRO trends: worsening PROs generate alerts suggesting an earlier visit, and stable or improving PROs generate notifications that scheduled visits could be delayed. An interrupted time‐series analysis with a nonrandomized control population will allow assessment of the impact of the app on visit frequency.

Results

Patient interviews identified several of the following needs for effective app and intervention design: the importance of a simple user interface facilitating rapid answering of PROs, the availability of condensed summary information with links to more in‐depth answers to common questions regarding RA, and the need for clinicians to discuss the PRO data during visits with patients. Clinician interviews identified the following user needs: PRO data must be easy to view and use during the clinical workflow, and there should be reduced interval visits when PROs are trending worse. Some clinicians believed visits could be delayed for patients with stable PROs, whereas others raised concerns.

Conclusion

PRO apps may improve care efficiency in rheumatology. Formal evaluation of an integrated PRO RA app is forthcoming.

Comparison of a Voluntary Safety Reporting System to a Global Trigger Tool for Identifying Adverse Events in an Oncology Population

OBJECTIVE

There is a lack of research on adverse event (AE) detection in oncology patients, despite the propensity for iatrogenic harm. Two common methods include voluntary safety reporting (VSR) and chart review tools, such as the Institute for Healthcare Improvement's Global Trigger Tool (GTT). Our objective was to compare frequency and type of AEs detected by a modified GTT compared with VSR for identifying AEs in oncology patients in a larger clinical trial.

METHODS

Patients across 6 oncology units (from July 1, 2013, through May 29, 2015) were randomly selected. Retrospective chart reviews were conducted by a team of nurses and physicians to identify AEs using the GTT. The VSR system was queried by the department of quality and safety of the hospital. Adverse event frequencies, type, and harm code for both methods were compared.

RESULTS

The modified GTT detected 0.90 AEs per patient (79 AEs in 88 patients; 95% [0.71-1.12] AEs per patient) that were predominantly medication AEs (53/79); more than half of the AEs caused harm to the patients (41/79, 52%), but only one quarter were preventable (21/79; 27%). The VSR detected 0.24 AEs per patient (21 AEs in 88 patients; 95% [0.15-0.37] AEs per patient), a large plurality of which were medication/intravenous related (8/21); more than half did not cause harm (70%). Only 2% of the AEs (2/100) were detected by both methods.

CONCLUSIONS

Neither the modified GTT nor the VSR system alone is sufficient for detecting AEs in oncology patient populations. Further studies exploring methods such as automated AE detection from electronic health records and leveraging patient-reported AEs are needed.

User-centered design of a scalable, electronic health record-integrated remote symptom monitoring intervention for patients with asthma and providers in primary care

OBJECTIVE

To determine user and electronic health records (EHR) integration requirements for a scalable remote symptom monitoring intervention for asthma patients and their providers.

METHODS

Guided by the Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, we conducted a user-centered design process involving English- and Spanish-speaking patients and providers affiliated with an academic medical center. We conducted a secondary analysis of interview transcripts from our prior study, new design sessions with patients and primary care providers (PCPs), and a survey of PCPs. We determined EHR integration requirements as part of the asthma app design and development process.

RESULTS

Analysis of 26 transcripts (21 patients, 5 providers) from the prior study, 21 new design sessions (15 patients, 6 providers), and survey responses from 55 PCPs (71% of 78) identified requirements. Patient-facing requirements included: 1- or 5-item symptom questionnaires each week, depending on asthma control; option to request a callback; ability to enter notes, triggers, and peak flows; and tips pushed via the app prior to a clinic visit. PCP-facing requirements included a clinician-facing dashboard accessible from the EHR and an EHR inbox message preceding the visit. PCP preferences diverged regarding graphical presentations of patient-reported outcomes (PROs). Nurse-facing requirements included callback requests sent as an EHR inbox message. Requirements were consistent for English- and Spanish-speaking patients. EHR integration required use of custom application programming interfaces (APIs).

CONCLUSION

Using the NASSS framework to guide our user-centered design process, we identified patient and provider requirements for scaling an EHR-integrated remote symptom monitoring intervention in primary care. These requirements met the needs of patients and providers. Additional standards for PRO displays and EHR inbox APIs are needed to facilitate spread.

nalyzing diagnostic errors in the acute setting: a process-driven approach

OBJECTIVES

We describe an approach for analyzing failures in diagnostic processes in a small, enriched cohort of general medicine patients who expired during hospitalization and experienced medical error. Our objective was to delineate a systematic strategy for identifying frequent and significant failures in the diagnostic process to inform strategies for preventing adverse events due to diagnostic error.

METHODS

Two clinicians independently reviewed detailed records of purposively sampled cases identified from established institutional case review forums and assessed the likelihood of diagnostic error using the Safer Dx instrument. Each reviewer used the modified Diagnostic Error Evaluation and Research (DEER) taxonomy, revised for acute care (41 possible failure points across six process dimensions), to characterize the frequency of failure points (FPs) and significant FPs in the diagnostic process.

RESULTS

Of 166 cases with medical error, 16 were sampled: 13 (81.3%) had one or more diagnostic error(s), and a total of 113 FPs and 30 significant FPs were identified. A majority of significant FPs (63.3%) occurred in "Diagnostic Information and Patient Follow-up" and "Patient and Provider Encounter and Initial Assessment" process dimensions. Fourteen (87.5%) cases had a significant FP in at least one of these dimensions.

CONCLUSIONS

Failures in the diagnostic process occurred across multiple dimensions in our purposively sampled cohort. A systematic analytic approach incorporating the modified DEER taxonomy, revised for acute care, offered critical insights into key failures in the diagnostic process that could serve as potential targets for preventative interventions.

Evaluation of electronic health record-integrated digital health tools to engage hospitalized patients in discharge preparation

OBJECTIVE

To evaluate the effect of electronic health record (EHR)-integrated digital health tools comprised of a checklist and video on transitions-of-care outcomes for patients preparing for discharge.

MATERIALS AND METHODS

English-speaking, general medicine patients (>18 years) hospitalized at least 24 hours at an academic medical center in Boston, MA were enrolled before and after implementation. A structured checklist and video were administered on a mobile device via a patient portal or web-based survey at least 24 hours prior to anticipated discharge. Checklist responses were available for clinicians to review in real time via an EHR-integrated safety dashboard. The primary outcome was patient activation at discharge assessed by patient activation (PAM)-13. Secondary outcomes included postdischarge patient activation, hospital operational metrics, healthcare resource utilization assessed by 30-day follow-up calls and administrative data and change in patient activation from discharge to 30 days postdischarge.

RESULTS

Of 673 patients approached, 484 (71.9%) enrolled. The proportion of activated patients (PAM level 3 or 4) at discharge was nonsignificantly higher for the 234 postimplementation compared with the 245 preimplementation participants (59.8% vs 56.7%, adjusted OR 1.23 [0.38, 3.96], P = .73). Postimplementation participants reported 3.75 (3.02) concerns via the checklist. Mean length of stay was significantly higher for postimplementation compared with preimplementation participants (10.13 vs 6.21, P < .01). While there was no effect on postdischarge outcomes, there was a nonsignificant decrease in change in patient activation within participants from pre- to postimplementation (adjusted difference-in-difference of -16.1% (9.6), P = .09).

CONCLUSIONS

EHR-integrated digital health tools to prepare patients for discharge did not significantly increase patient activation and was associated with a longer length of stay. While issues uncovered by the checklist may have encouraged patients to inquire about their discharge preparedness, other factors associated with patient activation and length of stay may explain our observations. We offer insights for using PAM-13 in context of real-world health-IT implementations.

TRIAL REGISTRATION

NIH US National Library of Medicine, NCT03116074, clinicaltrials.gov.

Toward an asthma patient-reported outcome measure for use in digital remote monitoring

OBJECTIVE

To develop and test a patient-reported outcome measure (PROM) for suitability in digital remote asthma symptom monitoring to identify uncontrolled asthma.

METHODS

We modified a 5-item PROM that does not require a license, the asthma control measure (ACM), from a one-month to one-week lookback period, and evaluated it using the 5-item asthma control questionnaire (ACQ-5). We recruited subjects with asthma through MTurk, an online platform.

RESULTS

In a sample of 498 subjects, the ACM identified uncontrolled asthma with sensitivity 0.99 and specificity 0.65. The two measures correlated with r = 0.81.

CONCLUSION

The ACM modified to a weekly lookback period can differentiate patients with well-controlled asthma from those with uncontrolled asthma. This PROM does not require a license and can be used in digital remote monitoring interventions.

The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial

BACKGROUND

Transitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission.

OBJECTIVES

To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events.

DESIGN, SETTING, AND PARTICIPANTS

Two-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO).

INTERVENTIONS

Multicomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient "discharge advocate" and a primary care "responsible outpatient clinician," postdischarge phone calls, and postdischarge primary care visit.

MAIN OUTCOMES AND MEASURES

The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission.

RESULTS

Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates.

CONCLUSION

A multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.

Assessing the cognitive and work load of an inpatient safety dashboard in the context of opioid management

For health information technology to realize its potential to improve flow, care, and patient safety, applications should be intuitive to use and burden neutral for frontline clinicians. We assessed the impact of a patient safety dashboard on clinician cognitive and work load within a simulated information-seeking task for safe inpatient opioid medication management. Compared to use of an electronic health record for the same task, the dashboard was associated with significantly reduced time on task, mouse clicks, and mouse movement (each p < 0.001), with no significant increases in cognitive load nor task inaccuracy. Cognitive burden was higher for users with less experience, possibly partly attributable to usability issues identified during this study. Findings underscore the importance of assessing the usability, cognitive, and work load analysis during the design and implementation of health information technology applications.

Interactive Digital Health Tools to Engage Patients and Caregivers in Discharge Preparation: Implementation Study

BACKGROUND

Poor discharge preparation during hospitalization may lead to adverse events after discharge. Checklists and videos that systematically engage patients in preparing for discharge have the potential to improve safety, especially when integrated into clinician workflow via the electronic health record (EHR).

OBJECTIVE

This study aims to evaluate the implementation of a suite of digital health tools integrated with the EHR to engage hospitalized patients, caregivers, and their care team in preparing for discharge.

METHODS

We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify pertinent research questions related to implementation. We iteratively refined patient and clinician-facing intervention components using a participatory process involving end users and institutional stakeholders. The intervention was implemented at a large academic medical center from December 2017 to July 2018. Patients who agreed to participate were coached to watch a discharge video, complete a checklist assessing discharge readiness, and request postdischarge text messaging with a physician 24 to 48 hours before their expected discharge date, which was displayed via a patient portal and bedside display. Clinicians could view concerns reported by patients based on their checklist responses in real time via a safety dashboard integrated with the EHR and choose to open a secure messaging thread with the patient for up to 7 days after discharge. We used mixed methods to evaluate our implementation experience.

RESULTS

Of 752 patient admissions, 510 (67.8%) patients or caregivers participated: 416 (55.3%) watched the video and completed the checklist, and 94 (12.5%) completed the checklist alone. On average, 4.24 concerns were reported per each of the 510 checklist submissions, most commonly about medications (664/2164, 30.7%) and follow-up (656/2164, 30.3%). Of the 510 completed checklists, a member of the care team accessed the safety dashboard to view 210 (41.2%) patient-reported concerns. For 422 patient admissions where postdischarge messaging was available, 141 (33.4%) patients requested this service; of these, a physician initiated secure messaging for 3 (2.1%) discharges. Most patient survey participants perceived that the intervention promoted self-management and communication with their care team. Patient interview participants endorsed gaps in communication with their care team and thought that the video and checklist would be useful closer toward discharge. Clinicians participating in focus groups perceived the value for patients but suggested that low awareness and variable workflow regarding the intervention, lack of technical optimization, and inconsistent clinician leadership limited the use of clinician-facing components.

CONCLUSIONS

A suite of EHR-integrated digital health tools to engage patients, caregivers, and clinicians in discharge preparation during hospitalization was feasible, acceptable, and valuable; however, important challenges were identified during implementation. We offer strategies to address implementation barriers and promote adoption of these tools.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03116074; https://clinicaltrials.gov/ct2/show/NCT03116074.

Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center

OBJECTIVE

The objective of this paper is to share challenges, recommendations, and lessons learned regarding the development and implementation of a Patient Safety Learning Laboratory (PSLL) project, an innovative and complex intervention comprised of a suite of Health Information Technology (HIT) tools integrated with a newly implemented Electronic Health Record (EHR) vendor system in the acute care setting at a large academic center.

MATERIALS AND METHODS

The PSLL Administrative Core engaged stakeholders and study personnel throughout all phases of the project: problem analysis, design, development, implementation, and evaluation. Implementation challenges and recommendations were derived from direct observations and the collective experience of PSLL study personnel.

RESULTS

The PSLL intervention was implemented on 12 inpatient units during the 18-month study period, potentially impacting 12,628 patient admissions. Challenges to implementation included stakeholder engagement, project scope/complexity, technology/governance, and team structure. Recommendations to address each of these challenges were generated, some enacted during the trial, others as lessons learned for future iterative refinements of the intervention and its implementation.

CONCLUSION

Designing, implementing, and evaluating a suite of tools integrated within a vendor EHR to improve patient safety has a variety of challenges. Keys to success include continuous stakeholder engagement, involvement of systems and human factors engineers within a multidisciplinary team, an iterative approach to user-centered design, and a willingness to think outside of current workflows and processes to change health system culture around adverse event prevention.

Use, Perceived Usability, and Barriers to Implementation of a Patient Safety Dashboard Integrated within a Vendor EHR

BACKGROUND

Preventable adverse events continue to be a threat to hospitalized patients. Clinical decision support in the form of dashboards may improve compliance with evidence-based safety practices. However, limited research describes providers' experiences with dashboards integrated into vendor electronic health record (EHR) systems.

OBJECTIVE

This study was aimed to describe providers' use and perceived usability of the Patient Safety Dashboard and discuss barriers and facilitators to implementation.

METHODS

The Patient Safety Dashboard was implemented in a cluster-randomized stepped wedge trial on 12 units in neurology, oncology, and general medicine services over an 18-month period. Use of the Dashboard was tracked during the implementation period and analyzed in-depth for two 1-week periods to gather a detailed representation of use. Providers' perceptions of tool usability were measured using the Health Information Technology Usability Evaluation Scale (rated 1-5). Research assistants conducted field observations throughout the duration of the study to describe use and provide insight into tool adoption.

RESULTS

The Dashboard was used 70% of days the tool was available, with use varying by role, service, and time of day. On general medicine units, nurses logged in throughout the day, with many logins occurring during morning rounds, when not rounding with the care team. Prescribers logged in typically before and after morning rounds. On neurology units, physician assistants accounted for most logins, accessing the Dashboard during daily brief interdisciplinary rounding sessions. Use on oncology units was rare. Satisfaction with the tool was highest for perceived ease of use, with attendings giving the highest rating (4.23). The overall lowest rating was for quality of work life, with nurses rating the tool lowest (2.88).

CONCLUSION

This mixed methods analysis provides insight into the use and usability of a dashboard tool integrated within a vendor EHR and can guide future improvements and more successful implementation of these types of tools.

A Clinically Integrated mHealth App and Practice Model for Collecting Patient-Reported Outcomes between Visits for Asthma Patients: Implementation and Feasibility

OBJECTIVE

Mobile health (mHealth) apps may prove to be useful tools for supporting chronic disease management. We assessed the feasibility of implementing a clinically integrated mHealth app and practice model to facilitate between-visit asthma symptom monitoring as per guidelines and with the help of patient-reported outcomes (PRO).

METHODS

We implemented the intervention at two pulmonary clinics and conducted a mixed-methods analysis of app usage data and semi-structured interview of patients and clinician participants over a 25-week study period.

RESULTS

Five physicians, 1 physician's assistant, 1 nurse, and 26 patients participated. Twenty-four patients (92%) were still participating in the intervention at the end of the 25-week study period. On average, each patient participant completed 21 of 25 questionnaires (84% completion rate). Weekly completion rates were higher for participants who were female (88 vs. 73%, p = 0.02) and obtained a bachelor's degree level or higher (94 vs. 74%, p = 0.04). On average, of all questionnaires, including both completed and not completed (25 weekly questionnaires times 26 patient participants), 25% had results severe enough to qualify for a callback from a nurse; however, patients declined this option in roughly half of the cases in which they were offered the option. We identified 6 key themes from an analysis of 21 patients and 5 clinician interviews. From the patient's perspective, these include more awareness of asthma, more connected with provider, and app simplicity. From the clinician's perspective, these include minimal additional work required, facilitating triage, and informing conversations during visits.

CONCLUSION

Implementation of a clinically integrated mHealth app and practice model can achieve high patient retention and adherence to guideline-recommended asthma symptom monitoring, while minimally burdening clinicians. The intervention has the potential for scaling to primary care and reducing utilization of urgent and emergency care.

Acute Care Patient Portal Intervention: Portal Use and Patient Activation

Background

Patient-facing health information technology (HIT) tools, such as patient portals, are recognized as a potential mechanism to facilitate patient engagement and patient-centered care, yet the use of these tools remains limited in the hospital setting. Although research in this area is growing, it is unclear how the use of acute care patient portals might affect outcomes, such as patient activation.

Objective

The aim of this study was to describe the use of an acute care patient portal and investigate its association with patient and care partner activation in the hospital setting.

Methods

We implemented an acute care patient portal on 6 acute care units over an 18-month period. We investigated the characteristics of the users (patients and their care partners) of the patient portal, as well as their use of the portal. This included the number of visits to each page, the number of days used, the length of the user’s access period, and the average percent of days used during the access period. Patient and care partner activation was assessed using the short form of the patient activation measure (PAM-13) and the caregiver patient activation measure (CG-PAM). Comparisons of the activation scores were performed using propensity weighting and robust weighted linear regression.

Results

Of the 2974 randomly sampled patients, 59.01% (1755/2974) agreed to use the acute care patient portal. Acute care patient portal enrollees were younger, less sick, less likely to have Medicare as their insurer, and more likely to use the Partners Healthcare enterprise ambulatory patient portal (Patient Gateway). The most used features of the acute care patient portal were the laboratory test results, care team information, and medication list. Most users accessed the portal between 1 to 4 days during their hospitalization, and the average number of days used (logged in at least once per day) was 1.8 days. On average, users accessed the portal 42.69% of the hospital days during which it was available. There was significant association with patient activation on the neurology service (P<.001) and medicine service (P=.01), after the introduction of HIT tools and the acute care patient portal, but not on the oncology service.

Conclusions

Portal users most often accessed the portal to view their clinical information, though portal usage was limited to only the first few days of enrollment. We found an association between the use of the portal and HIT tools with improved levels of patient activation. These tools may help facilitate patient engagement and improve outcomes when fully utilized by patients and care partners. Future study should leverage usage metrics to describe portal use and assess the impact of HIT tools on specific outcome measures in the hospital setting.

Systems engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the hospital

We established a Patient Safety Learning Laboratory comprising 2 core and 3 individual project teams to introduce a suite of digital health tools integrated with our electronic health record to identify, assess, and mitigate threats to patient safety in real time. One of the core teams employed systems engineering (SE) and human factors (HF) methods to analyze problems, design and develop improvements to intervention components, support implementation, and evaluate the system of systems as an integrated whole. Of the 29 participants, 19 and 16 participated in surveys and focus groups, respectively, about their perception of SE and HF. We identified 7 themes regarding use of the 12 SE and HF methods over the 4-year project. Qualitative methods (interviews, focus, groups, observations, usability testing) were most frequently used, typically by individual project teams, and generated the most insight. Quantitative methods (failure mode and effects analysis, simulation modeling) typically were used by the SE and HF core team but generated variable insight. A decentralized project structure led to challenges using these SE and HF methods at the project and systems level. We offer recommendations and insights for using SE and HF to support digital health patient safety initiatives.

Potential of an Electronic Health Record-Integrated Patient Portal for Improving Care Plan Concordance during Acute Care

BACKGROUND

Care plan concordance among patients and clinicians during hospitalization is suboptimal.

OBJECTIVE

This article determines whether an electronic health record (EHR)-integrated patient portal was associated with increased understanding of the care plan, including the key recovery goal, among patients and clinicians in acute care setting.

METHODS

The intervention included (1) a patient portal configured to solicit a single patient-designated recovery goal and display the care plan from the EHR for participating patients; and (2) an electronic care plan for all unit-based nurses that displays patient-inputted information, accessible to all clinicians via the EHR. Patients admitted to an oncology unit, including their nurses and physicians, were enrolled before and after implementation. Main outcomes included mean concordance scores for the overall care plan and individual care plan elements.

RESULTS

Of 457 and 283 eligible patients approached during pre- and postintervention periods, 55 and 46 participated in interviews, respectively, including their clinicians. Of 46 postintervention patients, 27 (58.7%) enrolled in the patient portal. The intention-to-treat analysis demonstrated a nonsignificant increase in the mean concordance score for the overall care plan (62.0-67.1, adjusted p = 0.13), and significant increases in mean concordance scores for the recovery goal (30.3-57.7, adjusted p < 0.01) and main reason for hospitalization (58.6-79.2, adjusted p < 0.01). The on-treatment analysis of patient portal enrollees demonstrated significant increases in mean concordance scores for the overall care plan (61.9-70.0, adjusted p < 0.01), the recovery goal (30.4-66.8, adjusted p < 0.01), and main reason for hospitalization (58.3-81.7, adjusted p < 0.01), comparable to the intention-to-treat analysis.

CONCLUSION

Implementation of an EHR-integrated patient portal was associated with increased concordance for key care plan components. Future efforts should be directed at improving concordance for other care plan components and conducting larger, randomized studies to evaluate the impact on key outcomes during transitions of care.

CLINICAL TRIALS IDENTIFIER

NCT02258594.

An informatics research agenda to support patient and family empowerment and engagement in care and recovery during and after hospitalization

As part of an interdisciplinary acute care patient portal task force with members from 10 academic medical centers and professional organizations, we held a national workshop with 71 attendees representing over 30 health systems, professional organizations, and technology companies. Our consensus approach identified 7 key sociotechnical and evaluation research focus areas related to the consumption and capture of information from patients, care partners (eg, family, friends), and clinicians through portals in the acute and post-acute care settings. The 7 research areas were: (1) standards, (2) privacy and security, (3) user-centered design, (4) implementation, (5) data and content, (6) clinical decision support, and (7) measurement. Patient portals are not yet in routine use in the acute and post-acute setting, and research focused on the identified domains should increase the likelihood that they will deliver benefit, especially as there are differences between needs in acute and post-acute care compared to the ambulatory setting.

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study

OBJECTIVE

To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds.

DESIGN

Prospective, multicenter before and after intervention study.

SETTING

Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017.

PARTICIPANTS

All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents.

INTERVENTION

Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds ("family centered rounds"), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement.

MAIN OUTCOME MEASURES

Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting.

RESULTS

The overall rate of medical errors (per 1000 patient days) was unchanged (41.2 (95% confidence interval 31.2 to 54.5) pre-intervention v 35.8 (26.9 to 47.7) post-intervention, P=0.21), but harmful errors (preventable adverse events) decreased by 37.9% (20.7 (15.3 to 28.1) v 12.9 (8.9 to 18.6), P=0.01) post-intervention. Non-preventable adverse events also decreased (12.6 (8.9 to 17.9) v 5.2 (3.1 to 8.8), P=0.003). Top box (eg, "excellent") ratings for six of 25 components of family reported experience improved; none worsened. Family centered rounds occurred more frequently (72.2% (53.5% to 85.4%) v 82.8% (64.9% to 92.6%), P=0.02). Family engagement 55.6% (32.9% to 76.2%) v 66.7% (43.0% to 84.1%), P=0.04) and nurse engagement (20.4% (7.0% to 46.6%) v 35.5% (17.0% to 59.6%), P=0.03) on rounds improved. Families expressing concerns at the start of rounds (18.2% (5.6% to 45.3%) v 37.7% (17.6% to 63.3%), P=0.03) and reading back plans (4.7% (0.7% to 25.2%) v 26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly.

CONCLUSIONS

Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02320175.

Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review

Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD. We also excluded letters, editorials, commentaries, abstracts, case reports, and case series. Of the 9,592 abstracts retrieved, eight met the inclusion criteria and reported the successful communication of TPAD. A team member abstracted predetermined data elements from each study, and a senior scientist reviewed the abstraction. Two experienced reviewers independently appraised the quality of each study using published Laboratory Medicine Best Practices (LMBP™) A-6 scoring criteria. We assessed the body of evidence using the A-6 methodology, and the evidence suggested that electronic tools or one-on-one education increased documentation of pending tests in discharge summaries. We also found that automated notifications improved awareness of TPAD. The interventions were supported by suggestive evidence; this type of evidence is below the level of evidence required for LMBP™ recommendations. We encourage additional research into the impact of these interventions on key processes and health outcomes.

Semiautomated System for Nonurgent, Clinically Significant Pathology Results

BACKGROUND

Failure of timely test result follow-up has consequences including delayed diagnosis and treatment, added costs, and potential patient harm. Closed-loop communication is key to ensure clinically significant test results (CSTRs) are acknowledged and acted upon appropriately. A previous implementation of the Alert Notification of Critical Results (ANCR) system to facilitate closed-loop communication of imaging CSTRs yielded improved communication of critical radiology results and enhanced adherence to institutional CSTR policies.

OBJECTIVE

This article extends the ANCR application to pathology and evaluates its impact on closed-loop communication of new malignancies, a common and important type of pathology CSTR.

MATERIALS AND METHODS

This Institutional Review Board-approved study was performed at a 150-bed community, academically affiliated hospital. ANCR was adapted for pathology CSTRs. Natural language processing was used on 30,774 pathology reports 13 months pre- and 13 months postintervention, identifying 5,595 reports with malignancies. Electronic health records were reviewed for documented acknowledgment for a random sample of reports. Percent of reports with documented acknowledgment within 15 days assessed institutional policy adherence. Time to acknowledgment was compared pre- versus postintervention and postintervention with and without ANCR alerts. Pathologists were surveyed regarding ANCR use and satisfaction.

RESULTS

Acknowledgment within 15 days was documented for 98 of 107 (91.6%) pre- and 89 of 103 (86.4%) postintervention reports (p = 0.2294). Median time to acknowledgment was 7 days (interquartile range [IQR], 3, 11) preintervention and 6 days (IQR, 2, 10) postintervention (p = 0.5083). Postintervention, median time to acknowledgment was 2 days (IQR, 1, 6) for reports with ANCR alerts versus 6 days (IQR, 2.75, 9) for reports without alerts (p = 0.0351). ANCR alerts were sent on 15 of 103 (15%) postintervention reports. All pathologists reported that the ANCR system positively impacted their workflow; 75% (three-fourths) felt that the ANCR system improved efficiency of communicating CSTRs.

CONCLUSION

ANCR expansion to facilitate closed-loop communication of pathology CSTRs was favorably perceived and associated with significant improved time to documented acknowledgment for new malignancies. The rate of adherence to institutional policy did not improve.

A Case of Disseminated Histoplasmosis in a Patient with Rheumatoid Arthritis on Abatacept

Biologic agents are effective treatments for rheumatoid arthritis but are associated with important risks, including severe infections. Tumor Necrosis Factor (TNF) α inhibitors are known to increase the risk of systemic fungal infections such as disseminated histoplasmosis. Abatacept is a biologic agent with a mechanism different from that of TNFα inhibitors: It suppresses cellular immunity by competing for the costimulatory signal on antigen-presenting cells. The risk of disseminated histoplasmosis for patients on abatacept is not known. We report a case of abatacept-associated disseminated histoplasmosis and review the known infectious complications of abatacept. While the safety of resuming biologic agents following treatment for disseminated histoplasmosis is also not known, abatacept is recommended over TNFα inhibitors for rheumatoid arthritis patients with a prior serious infection. We discuss the evidence supporting this recommendation and discuss alternative treatments for rheumatoid arthritis patients with a history of a serious infection.

Acute care patient portals: a qualitative study of stakeholder perspectives on current practices

Objective

To describe current practices and stakeholder perspectives of patient portals in the acute care setting. We aimed to: (1) identify key features, (2) recognize challenges, (3) understand current practices for design, configuration, and use, and (4) propose new directions for investigation and innovation.

Materials and Methods

Mixed methods including surveys, interviews, focus groups, and site visits with stakeholders at leading academic medical centers. Thematic analyses to inform development of an explanatory model and recommendations.

Results

Site surveys were administered to 5 institutions. Thirty interviews/focus groups were conducted at 4 site visits that included a total of 84 participants. Ten themes regarding content and functionality, engagement and culture, and access and security were identified, from which an explanatory model of current practices was developed. Key features included clinical data, messaging, glossary, patient education, patient personalization and family engagement tools, and tiered displays. Four actionable recommendations were identified by group consensus.

Discussion

Design, development, and implementation of acute care patient portals should consider: (1) providing a single integrated experience across care settings, (2) humanizing the patient-clinician relationship via personalization tools, (3) providing equitable access, and (4) creating a clear organizational mission and strategy to achieve outcomes of interest.

Conclusion

Portals should provide a single integrated experience across the inpatient and ambulatory settings. Core functionality includes tools that facilitate communication, personalize the patient, and deliver education to advance safe, coordinated, and dignified patient-centered care. Our findings can be used to inform a "road map" for future work related to acute care patient portals.

A web-based and mobile patient-centered ''microblog'' messaging platform to improve care team communication in acute care

Communication in acute care settings is fragmented and occurs asynchronously via a variety of electronic modalities. Providers are often not on the same page with regard to the plan of care. We designed and developed a secure, patient-centered "microblog" messaging platform that identifies care team members by synchronizing with the electronic health record, and directs providers to a single forum where they can communicate about the plan of care. The system was used for 35% of patients admitted to a medical intensive care unit over a 6-month period. Major themes in messages included care coordination (49%), clinical summarization (29%), and care team collaboration (27%). Message transparency and persistence were seen as useful features by 83% and 62% of respondents, respectively. Availability of alternative messaging tools and variable use by non-unit providers were seen as main barriers to adoption by 83% and 62% of respondents, respectively. This approach has much potential to improve communication across settings once barriers are addressed.

Opportunities and Challenges for Improving the Patient Experience in the Acute and Postacute Care Setting Using Patient Portals: The Patient's Perspective

Efforts to improve the patient experience are increasingly focusing on engaging patients and their "care partners" by using patient portals. The Acute Care Patient Portal Task Force was supported by the Gordon and Betty Moore Foundation to convene a national meeting of an interdisciplinary group of stakeholders, including patient advocates, to consider how the acute and postacute care patient experience can be improved by using patient-facing technologies. We identified key opportunities and challenges for enhancing cognitive support, promoting respect while maintaining boundaries, and facilitating patient and family empowerment through the lens of the patient. Institutions, clinicians, and vendors would benefit tremendously by considering these 3 patient-centered themes when partnering with patients and family advisors to implement and realize the full potential of patient portals to enhance the acute and postacute care experience.

Peritoneal encapsulation - an unexpected cause of acute intestinal obstruction

Peritoneal encapsulation (PE) is a rare congenital anomaly that is formed due to an accessory peritoneal layer encapsulating the small bowel. Kinking of bowel within the accessory peritoneal layer or adhesions between the bowel loops and the peritoneal layer causes symptoms ranging from colicky abdominal pain to rarely intestinal obstruction. Cleland was the first person to have reported this condition as early as 1868 and since then only around 30 cases have been reported. Here, we present a case of acute intestinal obstruction in a 22-year-old woman. Imaging showed dilated bowel loops confined to the centre of the peritoneal cavity. Intraoperatively it was seen to be a case of peritoneal encapsulation. The small intestine was freed and accessory layer excised. This report is to demonstrate this rare congenital anomaly.

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance

Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.

Objective

To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.

Design, Setting, and Participants

We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.

Main Outcomes and Measures

Error and AE rates.

Results

Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.

Conclusions and Relevance

Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

How often are hospitalized patients and providers on the same page with regard to the patient's primary recovery goal for hospitalization?

BACKGROUND

To deliver high-quality, patient-centered care during hospitalization, healthcare providers must correctly identify the patient's primary recovery goal.

OBJECTIVE

To determine the degree of concordance between patients and key hospital providers.

DESIGN

A validated questionnaire administered to a random sample of hospitalized patients alongside their nurse and physician provider. Goals included: "be cured," "live longer," "improve/maintain health," "be comfortable," "accomplish a particular life goal," or "other."

SETTING

Major academic hospital in Boston, Massachusetts.

PARTICIPANTS

Adult patients admitted for more than 48 hours from November 2013 to May 2014 were eligible. When a patient was incapacitated, a legal proxy was interviewed. The nurse and physician provider were then interviewed within 24 hours.

MEASUREMENTS

Frequencies of responses for each recovery goal and the rate of concordance among the patient, nurse, and physician provider were measured. The frequency of responses across groups were compared using adjusted χ(2) analyses. Inter-rater agreement was measured using 2-way Kappa tests.

RESULTS

All 3 participants were interviewed in 109 of the 181 (60.2%) patients approached (or with proxy available). Significant differences in selected goals were observed across respondent groups (P < 0.001). Patients frequently chose "be cured" (46.8%). Nurses and physician providers frequently selected "improve or maintain health" (38.5% and 46.8%, respectively). All 3 participants selected the same goal in 22 cases (20.2%). Inter-rater agreement was poor to slight for all pairs (kappa 0.09 [-0.03-0.19], 0.19 [0.08-0.30], and 0.20 [0.08-0.32] for patient-physician, patient-nurse, and nurse-physician, respectively).

CONCLUSIONS

We observed poor to slight concordance among hospitalized patients and key medical team members with regard to the patient's primary recovery goal. Journal of Hospital Medicine 2016;11:615-619. © 2016 Society of Hospital Medicine.

Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial

BACKGROUND

Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal.

OBJECTIVE

The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge.

DESIGN

Randomized, controlled trial with concealed allocation and blinded outcome assessors

SETTING

Two tertiary care academic medical centers

PARTICIPANTS

Adults hospitalized with a diagnosis of ACS and/or ADHF.

INTERVENTION

Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge

MAIN MEASURES

The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) are reported.

KEY RESULTS

A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women's Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR = 1.04, 95% CI 0.78-1.39). There was an interaction of treatment effect by site (p = 0.04 for interaction); VUH aHR = 0.77, 95% CI 0.51-1.15; BWH aHR = 1.44 (95% CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95% CI 0.17-1.00). There was no difference in treatment effect by patient cognition.

CONCLUSION

A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.

Care team identification in the electronic health record: A critical first step for patient-centered communication

Patient-centered communication is essential to coordinate care and safely progress patients from admission through discharge. Hospitals struggle with improving the complex and increasingly electronic conversation patterns among care team members, patients, and caregivers to achieve effective patient-centered communication across settings. Accurate and reliable identification of all care team members is a precursor to effective patient-centered communication and ideally should be facilitated by the electronic health record. However, the process of identifying care team members is challenging, and team lists in the electronic health record are typically neither accurate nor reliable. Based on the literature and on experience from 2 initiatives at our institution, we outline strategies to improve care team identification in the electronic health record and discuss potential implications for patient-centered communication. Journal of Hospital Medicine 2016;11:381-385. © 2016 Society of Hospital Medicine.

Does integrating nonurgent, clinically significant radiology alerts within the electronic health record impact closed-loop communication and follow-up?

OBJECTIVE

To assess whether integrating critical result management software--Alert Notification of Critical Results (ANCR)--with an electronic health record (EHR)-based results management application impacts closed-loop communication and follow-up of nonurgent, clinically significant radiology results by primary care providers (PCPs).

MATERIALS AND METHODS

This institutional review board-approved study was conducted at a large academic medical center. Postintervention, PCPs could acknowledge nonurgent, clinically significant ANCR-generated alerts ("alerts") within ANCR or the EHR. Primary outcome was the proportion of alerts acknowledged via EHR over a 24-month postintervention. Chart abstractions for a random sample of alerts 12 months preintervention and 24 months postintervention were reviewed, and the follow-up rate of actionable alerts (eg, performing follow-up imaging, administering antibiotics) was estimated. Pre- and postintervention rates were compared using the Fisher exact test. Postintervention follow-up rate was compared for EHR-acknowledged alerts vs ANCR.

RESULTS

Five thousand nine hundred and thirty-one alerts were acknowledged by 171 PCPs, with 100% acknowledgement (consistent with expected ANCR functionality). PCPs acknowledged 16% (688 of 4428) of postintervention alerts in the EHR, with the remaining in ANCR. Follow-up was documented for 85 of 90 (94%; 95% CI, 88%-98%) preintervention and 79 of 84 (94%; 95% CI, 87%-97%) postintervention alerts (P > .99). Postintervention, 11 of 14 (79%; 95% CI, 52%-92%) alerts were acknowledged via EHR and 68 of 70 (97%; 95% CI, 90%-99%) in ANCR had follow-up (P = .03).

CONCLUSIONS

Integrating ANCR and EHR provides an additional workflow for acknowledging nonurgent, clinically significant results without significant change in rates of closed-loop communication or follow-up of alerts.

A web-based, patient-centered toolkit to engage patients and caregivers in the acute care setting: a preliminary evaluation

We implemented a web-based, patient-centered toolkit that engages patients/caregivers in the hospital plan of care by facilitating education and patient-provider communication. Of the 585 eligible patients approached on medical intensive care and oncology units, 239 were enrolled (119 patients, 120 caregivers). The most common reason for not approaching the patient was our inability to identify a health care proxy when a patient was incapacitated. Significantly more caregivers were enrolled in medical intensive care units compared with oncology units (75% vs 32%; P < .01). Of the 239 patient/caregivers, 158 (66%) and 97 (41%) inputted a daily and overall goal, respectively. Use of educational content was highest for medications and test results and infrequent for problems. The most common clinical theme identified in 291 messages sent by 158 patients/caregivers was health concerns, needs, preferences, or questions (19%, 55 of 291). The average system usability scores and satisfaction ratings of a sample of surveyed enrollees were favorable. From analysis of feedback, we identified barriers to adoption and outlined strategies to promote use.

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record

Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory patient safety concern. Tools within electronic health records (EHRs) may facilitate test result acknowledgment, but their utility with regard to nonurgent CSTRs is unclear. We measured use of an acknowledgment tool by 146 primary care physicians (PCPs) at 13 network-affiliated practices that use the same EHR. We then surveyed PCPs to assess use of, satisfaction with, and desired enhancements to the acknowledgment tool. The rate of acknowledgment of non-urgent CSTRs by PCPs was 78%. Of 73 survey respondents, 72 reported taking one or more actions after reviewing a CSTR; fewer (40-75%) reported that using the acknowledgment tool was helpful for a specific purpose. Forty-six (64%) were satisfied with the tool. Both satisfied and nonsatisfied PCPs reported that enhancements linking acknowledgment to routine actions would be useful. EHR vendors should consider enhancements to acknowledgment functionality to ensure follow-up of nonurgent CSTRs.

Changes in medical errors after implementation of a handoff program

BACKGROUND

Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking.

METHODS

We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events.

RESULTS

In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time.

CONCLUSIONS

Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

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).

An optimal painless treatment for early hemorrhoids; our experience in Government Medical College and Hospital

OBJECTIVE

To evaluate the efficacy of Infrared Coagulation Therapy (IRC) for hemorrhoids. IRC is a painless, safe and successful procedure.

PLACE AND DURATION OF STUDY

Department of Surgery, Government Medical College and Hospital, Sector-32, Chandigarh, India, from August 2006 to October 2008. The choice of procedure depends on the patient's symptoms, the extent of the hemorrhoidal disease, and the experience of the surgeon along with the availability of the techniques/instruments.

MATERIALS AND METHODS

This is a prospective study done from August 2006 to October 2008. Total number of 155 patients was included in the study. Infrared Coagulation Therapy (IRC) was performed through a special designed proctoscope. Patients excluded were with coagulopathy disorders, fissure in ano, and anal ulcers. Results - It is an outpatient Department (OPD), non-surgical, ambulatory, painless and bloodless procedure, without any hospital stay. Early recovery and minimal recurrence of hemorrhoids were noted without any morbidity or mortality. We have studied 155 patients, treated with IRC on OPD basis. Surgery was required in few patients in whom IRC failed or was contraindicated. Out of the total 155 patients, 127 came for follow up. After the 1st sitting of IRC therapy: out of 127; 43 patients got a total relief, mass shrinkage was of > 75% in 57 cases and < 50% in 14 cases. Twenty-eight cases did not come for follow-up. In the 2nd sitting, out of 84/127; 58 patients got a total relief, >75% relief in 15 cases and >50 % relief in 11 patients. In the 3rd sitting out of 26/84 cases: 13 cases got a total relief and 13 cases refused to take the third sitting; however, in 7 cases the hemorrhoidal mass shrank up to 50% after the two sittings. These 14 were operated as there was no relief from bleeding after giving two sittings of IRC. Our opinion is that, in the above 14 cases, the patient might have not followed the instructions properly for dietary habits.

CONCLUSION

IRC is a safe, simple and effective procedure for early hemorrhoids without any complications. IRC is nowadays the world's leading office treatment for hemorrhoids. IRC is a better option than the surgical treatment as it is easy, well tolerated, and remarkably complication-free. In our study, we have not used any course of antibiotics. In the management of early hemorrhoids, IRC should be considered as a simple trouble-free and painless option.

Primary tuberculosis of the breast presented as multiple discharge sinuses

Breast tuberculosis is a rare form of tuberculosis (TB). It is mainly classified as primary and secondary forms. Primary form is rare. We are reporting a case of primary TB breast with history of breast lump and multiple sinuses. TB was diagnosed on FNAC. Patient was put on anti-tubercular drugs.