Randomized Controlled Comparative Effectiveness Trial of Risk Model-Guided Clinical Decision Support for Suicide Screening

Suicide prevention requires risk identification, appropriate intervention, and follow-up. Traditional risk identification relies on patient self-reporting, support network reporting, or face-to-face screening with validated instruments or history and physical exam. In the last decade, statistical risk models have been studied and more recently deployed to augment clinical judgment. Models have generally been found to be low precision or problematic at scale due to low incidence. Few have been tested in clinical practice, and none have been tested in clinical trials to our knowledge.

Methods

We report the results of a pragmatic randomized controlled trial (RCT) in three outpatient adult Neurology clinic settings. This two-arm trial compared the effectiveness of Interruptive and Non-Interruptive Clinical Decision Support (CDS) to prompt further screening of suicidal ideation for those predicted to be high risk using a real-time, validated statistical risk model of suicide attempt risk, with the decision to screen as the primary end point. Secondary outcomes included rates of suicidal ideation and attempts in both arms. Manual chart review of every trial encounter was used to determine if suicide risk assessment was subsequently documented.

Results

From August 16, 2022, through February 16, 2023, our study randomized 596 patient encounters across 561 patients for providers to receive either Interruptive or Non-Interruptive CDS in a 1:1 ratio. Adjusting for provider cluster effects, Interruptive CDS led to significantly higher numbers of decisions to screen (42%=121/289 encounters) compared to Non-Interruptive CDS (4%=12/307) (odds ratio=17.7, p-value <0.001). Secondarily, no documented episodes of suicidal ideation or attempts occurred in either arm. While the proportion of documented assessments among those noting the decision to screen was higher for providers in the Non-Interruptive arm (92%=11/12) than in the Interruptive arm (52%=63/121), the interruptive CDS was associated with more frequent documentation of suicide risk assessment (63/289 encounters compared to 11/307, p-value<0.001).

Conclusions

In this pragmatic RCT of real-time predictive CDS to guide suicide risk assessment, Interruptive CDS led to higher numbers of decisions to screen and documented suicide risk assessments. Well-powered large-scale trials randomizing this type of CDS compared to standard of care are indicated to measure effectiveness in reducing suicidal self-harm. ClinicalTrials.gov Identifier: NCT05312437.

Inpatient nurses' preferences and decisions with risk information visualization

OBJECTIVE

We examined the influence of 4 different risk information formats on inpatient nurses' preferences and decisions with an acute clinical deterioration decision-support system.

MATERIALS AND METHODS

We conducted a comparative usability evaluation in which participants provided responses to multiple user interface options in a simulated setting. We collected qualitative data using think aloud methods. We collected quantitative data by asking participants which action they would perform after each time point in 3 different patient scenarios.

RESULTS

More participants (n = 6) preferred the probability format over relative risk ratios (n = 2), absolute differences (n = 2), and number of persons out of 100 (n = 0). Participants liked average lines, having a trend graph to supplement the risk estimate, and consistent colors between trend graphs and possible actions. Participants did not like too much text information or the presence of confidence intervals. From a decision-making perspective, use of the probability format was associated with greater concordance in actions taken by participants compared to the other 3 risk information formats.

DISCUSSION

By focusing on nurses' preferences and decisions with several risk information display formats and collecting both qualitative and quantitative data, we have provided meaningful insights for the design of clinical decision-support systems containing complex quantitative information.

CONCLUSION

This study adds to our knowledge of presenting risk information to nurses within clinical decision-support systems. We encourage those developing risk-based systems for inpatient nurses to consider expressing risk in a probability format and include a graph (with average line) to display the patient's recent trends.

Using intervention mapping to design and implement a multicomponent intervention to improve antibiotic and NSAID prescribing

Successfully changing prescribing behavior to reduce inappropriate antibiotic and nonsteroidal anti-inflammatory drug (NSAID) prescriptions often requires combining components into a multicomponent intervention. However, multicomponent interventions often fail because of development and implementation complexity. To increase the likelihood of successfully changing prescribing behavior, we applied a systematic process to design and implement a multicomponent intervention. We used Intervention Mapping to create a roadmap for a multicomponent intervention in unscheduled outpatient care settings in the Veterans Health Administration. Intervention Mapping is a systematic process consisting of six steps that we grouped into three phases: (i) understand behavioral determinants and barriers to implementation, (ii) develop the intervention, and (iii) define evaluation plan and implementation strategies. A targeted literature review, combined with 25 prescriber and 25 stakeholder interviews, helped identify key behavioral determinants to inappropriate prescribing (e.g. perceived social pressure from patients to prescribe). We targeted three desired prescriber behaviors: (i) review guideline-concordant prescribing and patient outcomes, (ii) manage diagnostic and treatment uncertainty, and (iii) educate patients and caregivers. The intervention consisted of components for academic detailing, prescribing feedback, and alternative prescription order sets. Implementation strategies consisted of preparing clinical champions, conducting readiness assessments, and incentivizing use of the intervention. We chose a mixed-method study design with a commonly used evaluation framework to assess effectiveness and implementation outcomes in a subsequent trial. This study furthers knowledge about causes of inappropriate antibiotic and NSAID prescribing and demonstrates how theoretical, empirical, and practical information can be systematically applied to develop a multicomponent intervention to help address these causes.

Evaluation of inpatient medication guidance from an artificial intelligence chatbot

PURPOSE

To analyze the clinical completeness, correctness, usefulness, and safety of chatbot and medication database responses to everyday inpatient medication-use questions.

METHODS

We evaluated the responses from an artificial intelligence chatbot, a medication database, and clinical pharmacists to 200 real-world medication-use questions. Answer quality was rated by a blinded group of pharmacists, providers, and nurses. Chatbot and medication database responses were deemed "acceptable" if the mean reviewer rating was within 3 points of the mean rating for pharmacists' answers. We used descriptive statistics for reviewer ratings and Kendall's coefficient to evaluate interrater agreement.

RESULTS

The medication database generated responses to 194 (97%) questions, with 88% considered acceptable for clinical correctness, 76% considered acceptable for completeness, 83% considered acceptable for safety, and 81% considered acceptable for usefulness compared to pharmacists' answers. The chatbot responded to only 160 (80%) questions, with 85% considered acceptable for clinical correctness, 65% considered acceptable for completeness, 71% considered acceptable for safety, and 68% considered acceptable for usefulness.

CONCLUSION

Traditional search methods using a drug database provide more clinically correct, complete, safe, and useful answers than a chatbot. When the chatbot generated a response, the clinical correctness was similar to that of a drug database; however, it was not rated as favorably for clinical completeness, safety, or usefulness. Our results highlight the need for ongoing training and continued improvements to artificial intelligence chatbots for them to be incorporated reliably into the clinical workflow. With continued improvement in chatbot functionality, chatbots could be a useful pharmacist adjunct, providing healthcare providers with quick and reliable answers to medication-use questions.

Adapting Cognitive Task Analysis Methods for Use in a Large Sample Simulation Study of High-Risk Healthcare Events

Cognitive task analysis (CTA) methods are traditionally used to conduct small-sample, in-depth studies. In this case study, CTA methods were adapted for a large multi-site study in which 102 anesthesiologists worked through four different high-fidelity simulated high-consequence incidents. Cognitive interviews were used to elicit decision processes following each simulated incident. In this paper, we highlight three practical challenges that arose: (1) standardizing the interview techniques for use across a large, distributed team of diverse backgrounds; (2) developing effective training; and (3) developing a strategy to analyze the resulting large amount of qualitative data. We reflect on how we addressed these challenges by increasing standardization, developing focused training, overcoming social norms that hindered interview effectiveness, and conducting a staged analysis. We share findings from a preliminary analysis that provides early validation of the strategy employed. Analysis of a subset of 64 interview transcripts using a decompositional analysis approach suggests that interviewers successfully elicited descriptions of decision processes that varied due to the different challenges presented by the four simulated incidents. A holistic analysis of the same 64 transcripts revealed individual differences in how anesthesiologists interpreted and managed the same case.

Medication Safety Amid Technological Change: Usability Evaluation to Inform Inpatient Nurses' Electronic Health Record System Transition

BACKGROUND

Electronic health record (EHR) system transitions are challenging for healthcare organizations. High-volume, safety-critical tasks like barcode medication administration (BCMA) should be evaluated, yet standards for ensuring safety during transition have not been established.

OBJECTIVE

Identify risks in common and problem-prone medication tasks to inform safe transition between BCMA systems and establish benchmarks for future system changes.

DESIGN

Staff nurses completed simulation-based usability testing in the legacy system (R1) and new system pre- (R2) and post-go-live (R3). Tasks included (1) Hold/Administer, (2) IV Fluids, (3) PRN Pain, (4) Insulin, (5) Downtime/PRN, and (6) Messaging. Audiovisual recordings of task performance were systematically analyzed for time, navigation, and errors. The System Usability Scale measured perceived usability and satisfaction. Post-simulation interviews captured nurses' qualitative comments and perceptions of the systems.

PARTICIPANTS

Fifteen staff nurses completed 2-3-h simulation sessions. Eleven completed both R1 and R2, and seven completed all three rounds. Clinical experience ranged from novice (< 1 year) to experienced (> 10 years). Practice settings included adult and pediatric patient populations in ICU, stepdown, and acute care departments.

MAIN MEASURES

Task completion rates/times, safety and non-safety-related use errors (interaction difficulties), and user satisfaction.

KEY RESULTS

Overall success rates remained relatively stable in all tasks except two: IV Fluids task success increased substantially (R1: 17%, R2: 54%, R3: 100%) and Downtime/PRN task success decreased (R1: 92%, R2: 64%, R3: 22%). Among the seven nurses who completed all rounds, overall safety-related errors decreased 53% from R1 to R3 and 50% from R2 to R3, and average task times for successfully completed tasks decreased 22% from R1 to R3 and 38% from R2 to R3.

CONCLUSIONS

Usability testing is a reasonable approach to compare different BCMA tasks to anticipate transition problems and establish benchmarks with which to monitor and evaluate system changes going forward.

Empowering patients to address diabetes care gaps: formative usability testing of a novel patient portal intervention

Objective

The aim of this study was to design and assess the formative usability of a novel patient portal intervention designed to empower patients with diabetes to initiate orders for diabetes-related monitoring and preventive services.

Materials and Methods

We used a user-centered Design Sprint methodology to create our intervention prototype and assess its usability with 3 rounds of iterative testing. Participants (5/round) were presented with the prototype and asked to perform common, standardized tasks using think-aloud procedures. A facilitator rated task performance using a scale: (1) completed with ease, (2) completed with difficulty, and (3) failed. Participants completed the System Usability Scale (SUS) scored 0-worst to 100-best. All testing occurred remotely via Zoom.

Results

We identified 3 main categories of usability issues: distrust about the automated system, content concerns, and layout difficulties. Changes included improving clarity about the ordering process and simplifying language; however, design constraints inherent to the electronic health record system limited our ability to respond to all usability issues (eg, could not modify fixed elements in layout). Percent of tasks completed with ease across each round were 67%, 60%, and 80%, respectively. Average SUS scores were 87, 74, and 93, respectively. Across rounds, participants found the intervention valuable and appreciated the concept of patient-initiated ordering.

Conclusions

Through iterative user-centered design and testing, we improved the usability of the patient portal intervention. A tool that empowers patients to initiate orders for disease-specific services as part of their existing patient portal account has potential to enhance the completion of recommended health services and improve clinical outcomes.

Decision-Making During High-Risk Events: A Systematic Literature Review

Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.

Human-Centered Design to Address Biases in Artificial Intelligence

The potential of artificial intelligence (AI) to reduce health care disparities and inequities is recognized, but it can also exacerbate these issues if not implemented in an equitable manner. This perspective identifies potential biases in each stage of the AI life cycle, including data collection, annotation, machine learning model development, evaluation, deployment, operationalization, monitoring, and feedback integration. To mitigate these biases, we suggest involving a diverse group of stakeholders, using human-centered AI principles. Human-centered AI can help ensure that AI systems are designed and used in a way that benefits patients and society, which can reduce health disparities and inequities. By recognizing and addressing biases at each stage of the AI life cycle, AI can achieve its potential in health care.

Understanding Patient and Clinician Reported Nonroutine Events in Ambulatory Surgery

OBJECTIVE

Nonroutine events (NREs, i.e., deviations from optimal care) can identify care process deficiencies and safety risks. Nonroutine events reported by clinicians have been shown to identify systems failures, but this methodology fails to capture the patient perspective. The objective of this prospective observational study is to understand the incidence and nature of patient- and clinician-reported NREs in ambulatory surgery.

METHODS

We interviewed patients about NREs that occurred during their perioperative care using a structured interview tool before discharge and in a 7-day follow-up call. Concurrently, we interviewed the clinicians caring for these patients immediately postoperatively to collect NREs. We trained 2 experienced clinicians and 2 patients to assess and code each reported NRE for type, theme, severity, and likelihood of reoccurrence (i.e., likelihood that the same event would occur for another patient).

RESULTS

One hundred one of 145 ambulatory surgery cases (70%) contained at least one NRE. Overall, 214 NREs were reported-88 by patients and 126 by clinicians. Cases containing clinician-reported NREs were associated with increased patient body mass index ( P = 0.023) and lower postcase patient ratings of being treated with respect ( P = 0.032). Cases containing patient-reported NREs were associated with longer case duration ( P = 0.040), higher postcase clinician frustration ratings ( P < 0.001), higher ratings of patient stress ( P = 0.019), and lower patient ratings of their quality of life ( P = 0.010), of the quality of clinician teamwork ( P = 0.010), being treated with respect ( P = 0.003), and being listened to carefully ( P = 0.012). Trained patient raters evaluated NRE severity significantly higher than did clinician raters ( P < 0.001), while clinicians rated recurrence likelihood significantly higher than patients for both clinician ( P = 0.032) and patient-reported NREs ( P = 0.001).

CONCLUSIONS

Both patients and clinicians readily report events during clinical care that they believe deviate from optimal care expectations. These 2 primary stakeholders in safe, high-quality surgical care have different experiences and perspectives regarding NREs. The combination of patient- and clinician-reported NREs seems to be a promising patient-centered method of identifying healthcare system deficiencies and opportunities for improvement.

Preventing clinical deterioration in cancer outpatients: Human centered design of a predictive model and response system

e13567

Background: Patients (pts) with cancer in the outpatient setting are at a high-risk for adverse events, such as unplanned hospitalizations and ER visits. A recent study found that up to 30% of hospital admissions were preventable. Identifying pts at risk of avoidable clinical deterioration remains a challenge, as clinicians may not be aware of pts’ experiences at home. The growing use of health IT presents an opportunity to identify and respond to clinical deterioration in patients before an adverse event occurs. In this study, we describe a human-centered design (HCD) process used to develop a clinical deterioration risk prediction system to improve the detection of and response to deterioration in cancer outpatients. Methods: Predictive model: We enrolled eligible cancer pts and collected data from each one including: FitBit, geolocation, EHR, and weekly patient-reported outcome measures (PROMs). Pts and their family caregivers could also report non-routine events (NREs), defined as any deviation from expected optimal care. We also captured unplanned treatment events (UTEs), a clinically meaningful change in the pt’s treatment course or care pathway. We developed a predictive model that generates a pt’s 7-day risk of clinical deterioration. Response system: We are developing a risk communication system (RCS) to communicate predicted risk scores to clinical teams. Using a HCD process, we first conducted 36 observations across 100 patient encounters to understand the environment of use. Next, we conducted 18 clinician interviews to define user needs. We have conducted 7 multi-disciplinary design sessions to iteratively develop prototypes of the RCS. We are currently conducting formative usability testing to assess the prototype and gather clinician feedback. Results: Predictive model: We have enrolled 36 cancer outpatients (24 head & neck, 9 gastrointestinal, and 3 lung). Pts completed a total of 219 weekly PROM surveys, reported 107 NREs and experienced 18 UTEs (e.g., infection). So far, models using EHR and PROM data are the most sensitive and precise (AUC: 0.983; 0.999). More patient data are required to develop higher quality stable models. Response system: We identified key design elements to include in the RCS, such as the caregiver’s phone number and the pt’s weight over time. Preliminary findings demonstrate high usability of the prototype RCS. Oncologists identified opportunities for the system to better support team communication and coordination, and to improve the identification and response to clinical deterioration in cancer outpatients. Conclusions: We have developed and tested a clinical deterioration risk prediction system for cancer outpatients. Future studies will implement the response system and evaluate its impact on clinical care.

[Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]

The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.

Optical analysis of glutamate spread in the neuropil

Fast synaptic communication uses diffusible transmitters whose spread is limited by uptake mechanisms. However, on the submicron-scale, the distance between two synapses, the extent of glutamate spread has so far remained difficult to measure. Here, we show that quantal glutamate release from individual hippocampal synapses activates extracellular iGluSnFr molecules at a distance of >1.5 μm. 2P-glutamate uncaging near spines further showed that alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)-Rs and N-methyl-D-aspartate (NMDA)-Rs respond to distant uncaging spots at approximately 800 and 2000 nm, respectively, when releasing the amount of glutamate contained in approximately five synaptic vesicles. The uncaging-induced remote activation of AMPA-Rs was facilitated by blocking glutamate transporters but only modestly decreased by elevating the recording temperature. When mimicking release from neighboring synapses by three simultaneous uncaging spots in the microenvironment of a spine, AMPA-R-mediated responses increased supra-additively. Interfering with extracellular glutamate diffusion through a glutamate scavenger system weakly reduced field synaptic responses but not the quantal amplitude. Together, our data suggest that the neuropil is more permissive to short-range spread of transmitter than suggested by theory, that multivesicular release could regularly coactivate nearest neighbor synapses and that on this scale glutamate buffering by transporters primarily limits the spread of transmitter and allows for cooperative glutamate signaling in extracellular microdomains.

Vaginal injuries after consensual sexual intercourse - a survey among office-based gynecologists in Hamburg, Germany

Studies on the occurrence of injuries following consensual sexual intercourse (CSI) among patients treated by office-based gynecologists are lacking. This survey aimed to assess the presence and medical relevance of vaginal injuries after CSI in gynecological office-based practice, associated risk factors, and their significance for forensic medical assessment practice. All office-based gynecologists in Hamburg, Germany (n = 316), were asked to fill in a one-page questionnaire via a fax survey. The questionnaire covered various aspects such as having observed CSI-related injuries, injury severity, risk factors, and concomitant factors (bleeding, need for surgical care, hospitalization). Response rate was 43.2% (n = 115). Overall, 83.5% of office-based gynecologists reported having observed vaginal injuries after CSI at least once and 59.1% repeatedly. Regarding maximum injury severity, 52.1% observed mucosal erosions, 32.3% mucosa penetrating injuries, and 14.6% injuries penetrating the vagina. Having observed bleeding was reported by 56.3%, 28.1% had to perform surgical suture care, and hospital admission was initiated by 20.8%. Menopause (37.5%), use of objects (19.8%), alcohol, and/or drug use (16.7%) were reported as the most frequently observed associated risk factors. Vaginal injuries after CSI have been observed by the majority of office-based gynecologists in Hamburg involving a wide spectrum of severity, including the necessity of surgical care and hospital admission. Complementing published work in clinical and emergency medicine, these findings are highly relevant to the forensic evaluation of injuries in an allegation of sexual assault, as the severity of a vaginal injury in this setting does not necessarily support a conclusion on the issue of consent.

[Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]

The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.

Arterial stiffness in acute COVID-19 and potential associations with clinical outcome

BACKGROUND

Coronavirus disease 2019 (COVID-19) interferes with the vascular endothelium. It is not known whether COVID-19 additionally affects arterial stiffness.

METHODS

This case-control study compared brachial-ankle pulse wave (baPWV) and carotid-femoral pulse wave velocities (cfPWV) of acutely ill patients with and without COVID-19.

RESULTS

Twenty-two COVID-19 patients (50% females, 77 [67-84] years) were compared with 22 age- and sex-matched controls. In COVID-19 patients, baPWV (19.9 [18.4-21.0] vs. 16.0 [14.2-20.4], P = 0.02) and cfPWV (14.3 [13.4-16.0] vs. 11.0 [9.5-14.6], P = 0.01) were higher than in the controls. In multiple regression analysis, COVID-19 was independently associated with higher cfPWV (β = 3.164, P = 0.004) and baPWV (β = 3.532, P = 0.003). PWV values were higher in nonsurvivors. In survivors, PWV correlated with length of hospital stay.

CONCLUSION

COVID-19 appears to be related to an enhanced PWV reflecting an increase in arterial stiffness. Higher PWV might be related to an increased length of hospital stay and mortality.

Using Fitbit data to predict clinical deterioration and unplanned treatment events in cancer outpatients

e13560

Background: A common cause of preventable harm is the failure to detect and appropriately respond to clinical deterioration. Timely intervention is needed, particularly in cancer patients, to mitigate the effects of adverse events, disease progression, and medical error. This problem requires effective clinical surveillance, early recognition, timely notification of the appropriate clinician, and effective intervention. Methods: Applying a user-centered systems engineering design approach, we designed and implemented a surveillance-and-response system to improve the detection and response to clinical deterioration in cancer outpatients. The surveillance system predicts 7-day risk of UTEs, defined as clinically meaningful changes in the patient’s treatment course or cancer care pathway (e.g., any unplanned/unexpected: clinic or ER visit, hospital admission, or major treatment change and/or delays, and/or death). Data inputs consist of: 1) patient activity and health data collected by a Fitbit monitor; 2) geolocation data to measure activity outside the home (i.e., locations preselected at study onset); 3) clinical data from the hospital’s electronic health record; and 4) patient-reported outcomes measures (i.e., PROMs; the NCCN Distress Thermometer, the Comprehensive OpeN-Ended Survey or CONES, Global Health Score, items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS)). Herein, we measured the effectiveness of Fitbit data alone to UTEs in a pilot sample of patients. Dimension reduction of Fitbit variables was first carried out by using Pearson correlation analysis to eliminate redundant variables. As UTEs are rare events, they were oversampled using the Synthetic Minority Oversampling Technique (SMOTE) to balance the dataset. A random forest classification model was trained to predict 7-day UTE risk. Model accuracy was determined by calculating the mean of Stratified 5-Fold Cross-Validation with 10 repeats. Results: Fitbit data was collected over a 6-8-week period from 14 head and neck cancer patients receiving surgical resection, outpatient chemotherapy, and/or radiotherapy. We identified six UTEs in 5 patients. A random forest classification model was developed from 10 variables derived from 7 Fitbit measures. The following variables were averaged or summed daily: average heart rate (HR), resting HR, below 50% or zone 1 of maximum HR, zone 2 and zone 3 HR combined (i.e., 70-100% of max HR), total daily calories, steps, and sleep in minutes. We achieved a model accuracy of 94% (ROC AUC: 0.984, Precision-Recall AUC: 0.985). Conclusions: Activity and health data collected by a commercial activity monitor demonstrated effectiveness in predicting patient UTEs when an oversampling procedure was used to adjust for class imbalance (i.e., low UTE rate). Future studies are recommended to verify and validate this result in a larger patient sample.

A Time and Motion Analysis of Nursing Workload and Electronic Health Record Use in the Emergency Department

INTRODUCTION

The use of an electronic health record may create unanticipated consequences for emergency care delivery. We sought to describe emergency department nursing task distribution and the use of the electronic health record.

METHODS

This was a prospective observational study of nurses in the emergency department using a time-and-motion methodology. Three trained research assistants conducted 1:1 observations between March and September 2019. Nurse tasks were classified into 6 established categories: electronic health record, direct/indirect patient care, communication, personal time, and other. Nurses' perceived workload was assessed using the National Aeronautics and Space Administration (NASA) Task Load Index.

RESULTS

Twenty-three observations were conducted over 46 hours. Overall, nurses spent 27% of their time on electronic health record tasks, 25% on direct patient care, 17% on personal time, 15% on indirect patient care, and 6% on communication. During morning (7 am-12 pm) and afternoon shifts (12 pm-3 pm), the use of the health record was the most commonly performed task, whereas indirect patient care was the task most performed during evening shifts (3 pm-12 pm). Using the National Aeronautics and Space Administration (NASA) Task Load Index, nurses reported an increase in mental demand and effort during afternoon shifts compared with morning shifts.

DISCUSSION

We observed that emergency nurses spent more time using the electronic health record as compared to other tasks. Increased usability of the electronic health record, particularly during high occupancy periods, may be a target for improvement.

User-Centered Design in Pediatric Acute Care Settings Antimicrobial Stewardship

BACKGROUND

Antibiotic prescribing in ambulatory care centers is increasing. Previous research suggests that 20 to 50% of antibiotic prescriptions are either unnecessary or inappropriate. Unnecessary antibiotic consumption can harm patients by increasing antibiotic resistance and drug-associated toxicities, and the reasons for such use are multifactorial. Antimicrobial Stewardship Programs (ASP) were developed to guide better use of antibiotics. A core element of ASP is to provide feedback to clinical providers. To create clinically meaningful feedback, user-center design (UCD) is a robust approach to include end-users in the design process to improve systems.

OBJECTIVE

The study aimed to take a UCD approach to developing antibiotic prescribing feedback through input from clinicians in two ambulatory care settings.

METHODS

We conducted two group prototyping sessions with pediatric clinicians who practice in the emergency department and urgent care settings at a tertiary care children's hospital. Participants received background on the problem of antibiotic prescribing and then were interviewed about their information needs, perceived value, and desired incentives for a prescribing feedback system. Sessions concluded with their response and recommendations to sample sections of an antibiotic feedback report including orienting material, report detail, targeted education, and resources.

RESULTS

A UCD approach was found to be highly valuable in the development of a feedback mechanism that is viewed as desirable by clinicians. Clinicians preferred interpreting the data themselves with aids such as diagrams and charts over the researcher concluded statements about the clinician's behavior. Specific feedback that clinicians considered redundant were removed from the model if preexisting alerts were established.

CONCLUSION

Integrating a UCD approach in developing ASP feedback identified desirable report characteristics that substantially modified preliminary wireframes for feedback. Future research will evaluate the clinical effectiveness of our feedback reports in outpatient settings.

Ultrasound-versus visual-guided transversus abdominis plane block prior to transabdominal preperitoneal ingunial hernia repair. A retrospective cohort study

BACKGROUND

The transversus abdominis plane block is a regional anesthesia technique. Recently, its impact on early chronic pain and the cumulative need of analgesic medication following inguinal hernia repair is being monitored. In terms of effectiveness and patient safety, it remains unclear whether the approach should be conducted preoperatively through ultrasound guidance, or through intraoperative visual guidance.The study at hand aims to provide more evidence on this topic.

METHODS

A monocentric retrospective matched pair analysis was performed. The intraoperative visual guided and ultrasound guided -transversus abdominis plane block prior to inguinal hernia repair in transabdominal preperitoneal technique were consecutively compared in regard to analgesic effectiveness and complication rate. The data of individuals who were operated on from June 2007 to February 2019 were analyzed. The matching criteria were ASA-Score, Gender, Age ( ±6 years), and hernia size (<1,5 cm, 1,5-3 cm, >1,5 cm).

RESULTS

A total of 116 patients were enrolled. Both groups were homogenous in terms of age, gender contribution, body mass index, ASA-Score, hernia type, and size. The pain score at the postoperative anesthesia care unit was lower in the ultrasound-guided-transversus abdominis plane group without being statistically significant (VAS-Score: 0.67 vs.0.84). Patients of the ultrasound-guided-transversus abdominis plane group received significantly less metamizole on the day of operation (1.29 g (0.96) vs. 1.68 g (0.70), p = 0.015).

CONCLUSION

Due to our findings, we assume that the ultrasound-guided-transversus abdominis plane -Block may reduce postoperative pain and analgesic consumption more effectively than the visual-guided-transversus abdominis plane lock. Further prospective clinical trials are mandatory.

Vaginal laceration leading to air embolism during consensual sexual intercourse

Vaginal injuries with clinical complications apart from local bleeding following sexual intercourse are thought to be rare events that have recently fostered a discussion on the topic. We report a case of a vaginal laceration resulting in death caused by air embolism in a non-pregnant woman during consensual sexual intercourse with digital and penile penetration. Hysterectomy and a preexisting vaginal injury were additional risk factors present in this case. Besides case history and autopsy findings, histological examination of the vaginal lesion and postmortem computer tomography (PMCT) helped in diagnosing the cause of death and underlying pathophysiological mechanisms.

Health Management in the Home: A Qualitative Study of Pregnant Women and Their Caregivers

With growth in consumer health technologies, patients and caregivers have become increasingly involved in their health and medical care. Such health-related engagement often occurs at home. Pregnancy is a common condition and, for many women, their first exposure to health management practices. This study examined how pregnant women and caregivers managed health in their homes. Participants completed sociodemographic surveys and semi-structured interviews about living situation, information needs, and technology use. Using an iterative, inductive coding approach, we identified themes about health management, including the physical home, help at home, community, the virtual home, and biggest concerns. Most expectant mothers encountered everyday problems with mobility and household management. Pregnant women desired more assistance from caregivers, who often did not know how to help. Caregivers who provided help took on new roles. Many expectant families did not trust advice found online. Over half of expectant families had biggest concerns that involved the home.

The transversus abdominis plane block may reduce early postoperative pain after laparoscopic ventral hernia repair a matched pair analysis

Purpose

Patients suffering from a ventral hernia can be treated by laparoscopic ventral hernia repair (VHR) with the intraperitoneal onlay mesh (IPOM) technique. To reduce early postoperative pain and the analgesic cumulative need for medication (CNM), the transversus abdominis plane (TAP) block has recently been investigated and implemented in hernia surgery. We aimed to investigate its impact when conducting a VHR in IPOM technique.

Methods

A single center retrospective observational matched pair analysis has been conducted from March to April 2020. The data of patients who underwent VHR in IPOM technique with prior TAP block administration were enrolled. The matching was performed using the variables age ( ±5 years), gender, type of surgery, BMI and ASA stage.

Results

52 patients were enrolled. Among the individuals of the TAP block group, (18 males, 8 females) the average age was 52.4 (15.9). The average BMI was 29.0 (3.95) kg/m². 14 patients suffered from an umbilical, 9 from an incisional, and three from an epigastric hernia. Except for COX-2-inhibitors, (TAP group: 41.9 mg (31.0), Control group 9.23 (22.1), p < 0.001) the analgesic CNM of both groups did not statistically differ from each other. The literature review yielded four relevant publications (n = 100). The authors stated a positive impact of the TAP block on early postoperative pain and analgesic medication consumption.

Conclusion

The TAP block prior to laparoscopic ventral hernia repair may reduce early postoperative pain and analgesic medication consumption in selected patients. More randomized clinical trials are needed to confirm these findings.

•

The transversus abdominis plane block may reduce early postoperative pain after laparoscopic ventral hernia repair.

•

Four relevant publication (n = 100) has been yielded on that topic.

•

Review findings are contradictorily.

Correction to: The transversus abdominis plane block reduces the cumulative need of analgesic medication following inguinal hernia repair in TAPP technique: a retrospective single center analysis among 838 patients

The updated table has been copied below.

The transversus abdominis plane block reduces the cumulative need of analgesic medication following inguinal hernia repair in TAPP technique: a retrospective single center analysis among 838 patients

PURPOSE

Laparoscopic inguinal hernia repair (IHR) may lead to early postoperative pain. Therefore, opioid and non-opioid analgesic agents are often administered in the post-anesthesia care unit (PACU). To reduce the postoperative cumulative need of analgesic medication, as well as to accelerate the physical recovery time, the transversus abdominis plane (TAP) block has recently been studied. The TAP block is a regional anesthesia technique. Even though there is evidence about the efficacy of the block used in procedure such as an open inguinal hernia repair, the evidence regarding its use for the TAPP (transabdominal preperitoneal) technique remains low. We aim to provide more sufficient evidence regarding this topic.

METHODS

A monocentric retrospective observational study investigating the effect of the TAP block prior to primary IHR in TAPP technique was conducted. The data of 838 patients who were operated on using this technique from June 2007 to February 2019 were observed. 72 patients were excluded because of insufficient information regarding their analgesic medication protocol. The patients' data were taken from their files.

RESULTS

The patients in the TAP block group (n = 364) did not differ statistically significantly compared to the control group (n = 402) in terms of gender, BMI and age. Individuals of the TAP block group experienced less postoperative pain in the PACU (p < 0.001) and received less analgesic medication (morphine, oxycodone, piritramide, acetaminophen; p < 0.001).

CONCLUSION

We assume that the TAP block is a sufficient approach to reduce postoperative pain and analgesic medication administration for IHR in TAPP technique.

Improving the Effectiveness of Health Information Technology: The Case for Situational Analytics

Health information technology has contributed to improvements in quality and safety in clinical settings. However, the implementation of new technologies in health care has also been associated with the introduction of new sociotechnical hazards, produced through a range of complex interactions that vary with social, physical, temporal, and technological context. Other industries have been confronted with this problem and have developed advanced analytics to examine context-specific activities of workers and related outcomes. The skills and data exist in health care to develop similar insights through situational analytics, defined as the application of analytic methods to characterize human activity in situations and identify patterns in activity and outcomes that are influenced by contextual factors. This article describes the approach of situational analytics and potentially useful data sources, including trace data from electronic health record activity, reports from users, qualitative field data, and locational data. Key implementation requirements are discussed, including the need for collaboration among qualitative researchers and data scientists, organizational and federal level infrastructure requirements, and the need to implement a parallel research program in ethics to understand how the data are being used by organizations and policy makers.

Decision-Centered Design of Patient Information Visualizations to Support Chronic Pain Care

BACKGROUND

For complex patients with chronic conditions, electronic health records (EHRs) contain large amounts of relevant historical patient data. To use this information effectively, clinicians may benefit from visual information displays that organize and help them make sense of information on past and current treatments, outcomes, and new treatment options. Unfortunately, few clinical decision support tools are designed to support clinical sensemaking.

OBJECTIVE

The objective of this study was to describe a decision-centered design process, and resultant interactive patient information displays, to support key clinical decision requirements in chronic noncancer pain care.

METHODS

To identify key clinical decision requirements, we conducted critical decision method interviews with 10 adult primary care clinicians. Next, to identify key information needs and decision support design seeds, we conducted a half-day multidisciplinary design workshop. Finally, we designed an interactive prototype to support the key clinical decision requirements and information needs uncovered during the previous research activities.

RESULTS

The resulting Chronic Pain Treatment Tracker prototype summarizes the current treatment plan, past treatment history, potential future treatments, and treatment options to be cautious about. Clinicians can access additional details about each treatment, current or past, through modal views. Additional decision support for potential future treatments and treatments to be cautious about is also provided through modal views.

CONCLUSION

This study designed the Chronic Pain Treatment Tracker, a novel approach to decision support that presents clinicians with the information they need in a structure that promotes quick uptake, understanding, and action.

A technology-based patient and family engagement consult service for the pediatric hospital setting

Objective

The Vanderbilt Children's Hospital launched an innovative Technology-Based Patient and Family Engagement Consult Service in 2014. This paper describes our initial experience with this service, characterizes health-related needs of families of hospitalized children, and details the technologies recommended to promote engagement and meet needs.

Materials and Methods

We retrospectively reviewed consult service documentation for patient characteristics, health-related needs, and consultation team recommendations. Needs were categorized using a consumer health needs taxonomy. Recommendations were classified by technology type.

Results

Twenty-two consultations were conducted with families of patients ranging in age from newborn to 15 years, most with new diagnoses or chronic illnesses. The consultation team identified 99 health-related needs (4.5 per consultation) and made 166 recommendations (7.5 per consultation, 1.7 per need). Need categories included 38 informational needs, 26 medical needs, 23 logistical needs, and 12 social needs. The most common recommendations were websites (50, 30%) and mobile applications (30, 18%). The most frequent recommendations by need category were websites for informational needs (39, 50%), mobile applications for medical needs (15, 40%), patient portals for logistical needs (12, 44%), and disease-specific support groups for social needs (19, 56%).

Discussion

Families of hospitalized pediatric patients have a variety of health-related needs, many of which could be addressed by technology recommendations from an engagement consult service.

Conclusion

This service is the first of its kind, offering a potentially generalizable and scalable approach to assessing health-related needs, meeting them with technologies, and promoting patient and family engagement in the inpatient setting.

Information Needs and Requirements for Decision Support in Primary Care: An Analysis of Chronic Pain Care

Decision support system designs often do not align with the information environments in which clinicians work. These work environments may increase Clinicians' cognitive workload and harm their decision making. The objective of this study was to identify information needs and decision support requirements for assessing, diagnosing, and treating chronic noncancer pain in primary care. We conducted a qualitative study involving 30 interviews with 10 primary care clinicians and a subsequent multidisciplinary systems design workshop. Our analysis identified four key decision requirements, eight clinical information needs, and four decision support design seeds. Our findings indicate that clinicians caring for chronic pain need decision support that aggregates many disparate information elements and helps them navigate and contextualize that information. By attending to the needs identified in this study, decision support designers may improve Clinicians' efficiency, reduce mental workload, and positively affect patient care quality and outcomes.

Human performance measures for the evaluation of process control human-system interfaces in high-fidelity simulations

We reviewed the available literature on measuring human performance to evaluate human-system interfaces (HSIs), focused on high-fidelity simulations of industrial process control systems, to identify best practices and future directions for research and operations. We searched the available literature and then conducted in-depth review, structured coding, and analysis of 49 articles, which described 42 studies. Human performance measures were classified across six dimensions: task performance, workload, situation awareness, teamwork/collaboration, plant performance, and other cognitive performance indicators. Many studies measured performance in more than one dimension, but few studies addressed more than three dimensions. Only a few measures demonstrated acceptable levels of reliability, validity, and sensitivity in the reviewed studies in this research domain. More research is required to assess the measurement qualities of the commonly used measures. The results can provide guidance to direct future research and practice for human performance measurement in process control HSI design and deployment.

UNDERSTANDING HOW PRIMARY CARE CLINICIANS MAKE SENSE OF CHRONIC PAIN

Chronic pain leads to reduced quality of life for patients, and strains health systems worldwide. In the U.S. and some other countries, the complexities of caring for chronic pain are exacerbated by individual and public health risks associated with commonly used opioid analgesics. To help understand and improve pain care, this article uses the data-frame theory of sensemaking to explore how primary care clinicians in the U.S. manage their patients with chronic noncancer pain. We conducted Critical Decision Method interviews with 10 primary care clinicians about 30 individual patients with chronic pain. In these interviews, we identified several patient, social/environmental, and clinician factors that influence the frames clinicians use to assess their patients and determine a pain management plan. Findings suggest significant ambiguity and uncertainty in clinical pain management decision making. Therefore, interventions to improve pain care might focus on supporting sensemaking in the context of clinical evidence rather than attempting to provide clinicians with decontextualized and/or algorithm-based decision rules. Interventions might focus on delivering convenient and easily interpreted patient and social/environmental information in the context of clinical practice guidelines.

[Ankle cartilage repair : Therapeutic options, results and technical aspects]

BACKGROUND

Therapeutic strategies for cartilage repair of the talus are varied. With the use of biologic scaffolds and biologic agents new cell-based therapies have become the focus of attention.

OBJECTIVES

Ankle cartilage repair techniques are presented and assessed by current data. In addition, technical notes for each technique are given.

MATERIAL AND METHODS

Currently, the following established ankle cartilage repair procedures exist: microfracturing, AMIC (autologous matrix-induced chondrogenesis), OCT (osteochondral transplantation, mosaicplasty), allograft transplantation.

DISCUSSION

The success of each repair technique is dependent on the proper indication, addressing of co-morbidities like axis deviation or ligament instabilities, the experience of the surgeon and the appropriate rehabilitation. Mid- and long-term results are often good or excellent. Best results are seen in isolated cartilage defects without co-morbidities in patients younger than 40 years of age and non-smokers with normal BMI and early intervention. New cell-based therapies utilize scaffolds and biologic agents. They offer promising perspectives, although current data is inconsistent.

Supporting Caregivers in Pregnancy: A Qualitative Study of Their Activities and Roles

Background:

The significant role of lay caregivers has been explored in chronic and acute illnesses. In pregnancy, caregivers’ (eg, the baby’s father, friends, and family) roles in promoting the health of the mother and baby are not well understood.

Objective:

We characterize the activities and roles of pregnancy caregivers and offer opportunities for engaging this important group.

Method:

We conducted interviews with 29 pregnancy caregivers. Interview transcripts were analyzed inductively, resulting in a coding scheme of actions and roles that pregnancy caregivers perform.

Results:

The most common actions and roles included searching for information (97%), accompanying patients to medical appointments (69%), and being a source of emotional support (76%). Identified actions and roles fit a patient work framework, including work types identified by Corbin and Strauss: illness, everyday life, biographical, articulation, and invisible.

Conclusion:

The patient work framework can be employed to describe the activities and roles of pregnancy caregivers. We have contributed new insights into the experiences of pregnancy caregivers and recommendations for educational and technological interventions.

Common Consumer Health-Related Needs in the Pediatric Hospital Setting: Lessons from an Engagement Consultation Service

BACKGROUND

Informed and engaged parents may influence outcomes for childhood illness. Understanding the needs of the caregivers of pediatric patients is a critical first step in promoting engagement in their child's care. In 2014, we developed an Engagement Consultation Service at the Monroe Carell Jr. Children's Hospital at Vanderbilt. This service determines the health-related needs of the caregivers of hospitalized children and makes educational or technology recommendations to meet those needs and support engagement.

OBJECTIVES

This report describes the most common health-related needs identified in the caregivers of hospitalized pediatric patients and details the recommended interventions to meet those needs.

METHODS

The most commonly reported consumer health-related needs from our 3-year experience with the Engagement Consultation Service were extracted from consultations notes. Each need was classified by semantic type using a taxonomy of consumer health needs. Typical recommendations for each need and their administration were detailed.

RESULTS

The most frequently recognized needs involved communicating with health care providers after discharge, using medical devices, distinguishing between benign and concerning symptoms, knowing what questions to ask providers and remembering them, finding trustworthy sources of information online, understanding disease prognosis, and getting emotional support. A variety of apps, Web sites, printed materials, and online groups were recommended.

CONCLUSION

The parents of hospitalized patients share several common health-related needs that can be addressed with educational and technology interventions. An inpatient Engagement Consultation Service provides a generalizable framework for identifying health-related needs and delivers tools to meet those needs and promote engagement during and after hospitalizations.

Use of the Multidimensional Health Locus of Control to Predict Information-Seeking Behaviors and Health-Related Needs in Pregnant Women and Caregivers

Pregnancy produces important health-related needs, and expectant families have turned to technologies to meet them. The ability to predict needs and technology preferences might aid in connecting families with resources. This study examined the relationships among Multidimensional Health Locus of Control (MHLC) scores, information-seeking behaviors, and health-related needs in 71 pregnant women and 29 caregivers. Internal MHLC scores were positively correlated with information-seeking behaviors, including website and patient portal use. Higher Chance scores were associated with decreased portal or pregnancy website use (p=0.002), with the exception of FitPregnancy.com (p=0.02). MHLC scores were not significantly correlated with number of health-related needs or whether needs were met. Individuals with needs about disease management had higher Powerful Others scores (p=0.01); those with questions about tests had lower Powerful Others scores (p=0.008). MHLC scores might be used to identify individuals less likely to seek information and to predict need types.

Training and Assessing Critical Airway, Breathing, and Hemorrhage Control Procedures for Trauma Care: Live Tissue Versus Synthetic Models

INTRODUCTION

Optimal teaching and assessment methods and models for emergency airway, breathing, and hemorrhage interventions are not currently known. The University of Minnesota Combat Casualty Training consortium (UMN CCTC) was formed to explore the strengths and weaknesses of synthetic training models (STMs) versus live tissue (LT) models. In this study, we compare the effectiveness of best in class STMs versus an anesthetized caprine (goat) model for training and assessing seven procedures: junctional hemorrhage control, tourniquet (TQ) placement, chest seal, needle thoracostomy (NCD), nasopharyngeal airway (NPA), tube thoracostomy, and cricothyrotomy (Cric).

METHODS

Army combat medics were randomized to one of four groups: 1) LT trained-LT tested (LT-LT), 2) LT trained-STM tested (LT-STM), 3) STM trained-LT tested (STM-LT), and 4) STM trained-STM tested (STM-STM). Participants trained in small groups for 3 to 4 hours and were evaluated individually. LT-LT was the "control" to which other groups were compared, as this is the current military predeployment standard. The mean procedural scores (PSs) were compared using a pairwise t-test with a Dunnett's correction. Logistic regression was used to compare critical fails (CFs) and skipped tasks.

RESULTS

There were 559 subjects included. Junctional hemorrhage control revealed no difference in CFs, but LT-tested subjects (LT-LT and STM-LT) skipped this task more than STM-tested subjects (LT-STM and STM-STM; p < 0.05), and STM-STM had higher PSs than LT-LT (p < 0.001). For TQ, both STM-tested groups (LT-STM and STM-STM) had more CFs than LT-LT (p < 0.001) and LT-STM had lower PSs than LT-LT (p < 0.05). No differences were seen for chest seal. For NCD, LT-STM had more CFs than LT-LT (p = 0.001) and lower PSs (p = 0.001). There was no difference in CFs for NPA, but all groups had worse PSs versus LT-LT (p < 0.05). For Cric, we were underpowered; STM-LT trended toward more CFs (p = 0.08), and STM-STM had higher PSs than LT-LT (p < 0.01). Tube thoracostomy revealed that STM-LT had higher CFs than LT-LT (p < 0.05), but LT-STM had lower PSs (p < 0.05). An interaction effect (making the subjects who trained and tested on different models more likely to CF) was only found for TQ, chest seal, and Cric; however, of these three procedures, only TQ demonstrated any significant difference in CF rates.

CONCLUSION

Training on STM or LT did not demonstrate a difference in subsequent performance for five of seven procedures (junctional hemorrhage, TQ, chest seal, NPA, and NCD). Until STMs are developed with improved anthropomorphic and tissue fidelity, there may still be a role for LT for training tube thoracostomy and potentially Cric. For assessment, our STM appears more challenging for TQ and potentially for NCD than LT. For junctional hemorrhage, the increased "skips" with LT may be explained by the differences in anatomic fidelity. While these results begin to uncover the effects of training and assessing these procedures on various models, further study is needed to ascertain how well performance on an STM or LT model translates to the human model.

Simulation for Assessment of Milestones in Emergency Medicine Residents

OBJECTIVES

All residency programs in the United States are required to report their residents' progress on the milestones to the Accreditation Council for Graduate Medical Education (ACGME) biannually. Since the development and institution of this competency-based assessment framework, residency programs have been attempting to ascertain the best ways to assess resident performance on these metrics. Simulation was recommended by the ACGME as one method of assessment for many of the milestone subcompetencies. We developed three simulation scenarios with scenario-specific milestone-based assessment tools. We aimed to gather validity evidence for this tool.

METHODS

We conducted a prospective observational study to investigate the validity evidence for three mannequin-based simulation scenarios for assessing individual residents on emergency medicine (EM) milestones. The subcompetencies (i.e., patient care [PC]1, PC2, PC3) included were identified via a modified Delphi technique using a group of experienced EM simulationists. The scenario-specific checklist (CL) items were designed based on the individual milestone items within each EM subcompetency chosen for assessment and reviewed by experienced EM simulationists. Two independent live raters who were EM faculty at the respective study sites scored each scenario following brief rater training. The inter-rater reliability (IRR) of the assessment tool was determined by measuring intraclass correlation coefficient (ICC) for the sum of the CL items as well as the global rating scales (GRSs) for each scenario. Comparing GRS and CL scores between various postgraduate year (PGY) levels was performed with analysis of variance.

RESULTS

Eight subcompetencies were chosen to assess with three simulation cases, using 118 subjects. Evidence of test content, internal structure, response process, and relations with other variables were found. The ICCs for the sum of the CL items and the GRSs were >0.8 for all cases, with one exception (clinical management GRS = 0.74 in sepsis case). The sum of CL items and GRSs (p < 0.05) discriminated between PGY levels on all cases. However, when the specific CL items were mapped back to milestones in various proficiency levels, the milestones in the higher proficiency levels (level 3 [L3] and 4 [L4]) did not often discriminate between various PGY levels. L3 milestone items discriminated between PGY levels on five of 12 occasions they were assessed, and L4 items discriminated only two of 12 times they were assessed.

CONCLUSION

Three simulation cases with scenario-specific assessment tools allowed evaluation of EM residents on proficiency L1 to L4 within eight of the EM milestone subcompetencies. Evidence of test content, internal structure, response process, and relations with other variables were found. Good to excellent IRR and the ability to discriminate between various PGY levels was found for both the sum of CL items and the GRSs. However, there was a lack of a positive relationship between advancing PGY level and the completion of higher-level milestone items (L3 and L4).

Design of nanostructured hybrid materials: twin polymerization of urethane-based twin prepolymers

Organic–inorganic hybrid materials with urethane functionalities were obtained by simultaneous twin polymerization of twin prepolymers in combination with the ideal twin monomer 2,2′-spirobi[4H-1,3,2-benzodioxasiline]. The twin prepolymers consist of a urethane-based prepolymer with reactive terminal groups which can react during the twin polymerization process. Nanostructured hybrid materials with integrated dialkylsiloxane crosslinked urethane structures, phenolic resin and SiO₂ are obtained in a one pot process. The effects of the polymerization temperature as well as those of various catalysts and reagent ratios on the polymerization behavior were investigated. The molecular structures of the obtained materials were determined by ¹³C- and ²⁹Si-{¹H}-CP-MAS NMR spectroscopies. HAADF-STEM-measurements were performed to prove the distribution of silicon in the hybrid material.

Organic–inorganic hybrid materials with urethane functionalities were obtained by simultaneous twin polymerization of twin prepolymers in combination with the twin monomer 2,2′-spirobi[4H-1,3,2-benzodioxasiline].

Validation of an Assessment Tool for Field Endotracheal Intubation

OBJECTIVES

Endotracheal intubation (ETI) is an important skill for all emergency providers; our ability to train and assess our learners is integral to providing optimal patient care. The primary aim of this study was to assess the inter-rater reliability (IRR) and discriminant validity of a novel field ETI assessment tool using a checklist-derived performance score (PS) and critical failure (CF) rate.

METHODS

Forty-three participants (18 paramedic students, 11 paramedics, and 14 emergency physicians [EPs]) performed ETI during a simulated trauma scenario on a pseudo-ventilated cadaver. Each participant was assessed by two experienced raters. IRR was calculated using the intraclass correlation coefficient. Regarding discriminant validity, a Kruskal-Wallis test was used to analyze PSs and a χ² test was used for CFs. Mean global rating scale (GRS) scores were compared using an analysis of variance.

RESULTS

The ETI assessment tool had excellent IRR, with an intraclass correlation coefficient of 0.94. There was a significant difference in PSs, CFs, and GRSs (p < 0.05) between cohorts.

CONCLUSION

The novel field ETI assessment tool has excellent reliability among trained raters and discriminates between experienced ETI providers (EPs) and less experienced ETI performers using PSs, CFs, and GRSs on a fresh cadaveric model.

Facilitators of high-quality teaching in medical school: findings from a nation-wide survey among clinical teachers

BACKGROUND

Clinical teachers in medical schools are faced with the challenging task of delivering high-quality patient care, producing high-impact research and contributing to undergraduate medical education all at the same time. Little is known on the gap between an 'ideal' environment supporting clinical teachers to provide high quality teaching for their students and the reality of clinical teaching during worktime in the clinical environment. Most quantitative research published so far was done in a wide range of medical educators and did not consider individual academic qualifications. In this study, we wanted to survey clinical teachers in particular and assess the potential impact of individual academic qualification on their perceptions.

METHODS

Based on qualitative data of focus group discussions, we developed a questionnaire which was piloted among 189 clinical teachers. The final web-based questionnaire was completed by clinical teachers at nine German medical schools.

RESULTS

A total of 833 clinical teachers (569 junior physicians, 264 assistant professors) participated in the online survey. According to participants, the most important indicator of high quality teaching was "sustained student learning outcome" followed by "stimulation of interest in the subject matter". Lack of time was the main factor impeding effective teaching (78%). Among the factors facilitating high-quality teaching, protected preparation time during working hours (48%) and more recognition of high-quality teaching within medical schools (21%) were perceived as most helpful. Three out of four teachers (76%) were interested in faculty development programmes directed at teaching skills, but 60% stated they had no time to engage in such activities. With regard to evaluation, teachers preferred individual feedback (75%) over global ratings (21%). Differences between assistant professors and junior physicians were found in that the latter group perceived their teaching conditions as more difficult.

CONCLUSIONS

Lack of time is a major barrier against planning and delivering good clinical teaching in medical schools. According to our findings, the situation at German medical schools is particularly challenging for junior physicians. Creating an institutional culture in which teaching is regarded as highly as patient care and research is a prerequisite for overcoming the barriers identified in this study.

Discovery of novel drug sensitivities in T-PLL by high-throughput ex vivo drug testing and mutation profiling

T-cell prolymphocytic leukemia (T-PLL) is a rare and aggressive neoplasm of mature T-cells with an urgent need for rationally designed therapies to address its notoriously chemo-refractory behavior. The median survival of T-PLL patients is <2 years and clinical trials are difficult to execute. Here we systematically explored the diversity of drug responses in T-PLL patient samples using an ex vivo drug sensitivity and resistance testing platform and correlated the findings with somatic mutations and gene expression profiles. Intriguingly, all T-PLL samples were sensitive to the cyclin-dependent kinase inhibitor SNS-032, which overcame stromal-cell-mediated protection and elicited robust p53-activation and apoptosis. Across all patients, the most effective classes of compounds were histone deacetylase, phosphoinositide-3 kinase/AKT/mammalian target of rapamycin, heat-shock protein 90 and BH3-family protein inhibitors as well as p53 activators, indicating previously unexplored, novel targeted approaches for treating T-PLL. Although Janus-activated kinase-signal transducer and activator of transcription factor (JAK-STAT) pathway mutations were common in T-PLL (71% of patients), JAK-STAT inhibitor responses were not directly linked to those or other T-PLL-specific lesions. Overall, we found that genetic markers do not readily translate into novel effective therapeutic vulnerabilities. In conclusion, novel classes of compounds with high efficacy in T-PLL were discovered with the comprehensive ex vivo drug screening platform warranting further studies of synergisms and clinical testing.

CLUSTERING AND PRIORITIZING PATIENT SAFETY ISSUES DURING EHR IMPLEMENTATION AND UPGRADES IN HOSPITAL SETTINGS

Our aim was to elicit, label, and prioritize clusters of de-identified patient safety issues experienced during the implementation and upgrade installations of Electronic Health Records (EHRs) in hospitals. Conference participants included clinical personnel (physicians, nurses, pharmacists), human factors experts, patient safety experts, information technology experts from vendors and hospitals, academic experts, graduate students, and other attendees. De-identified reports of patient safety issues were shared via share4safety@gmail.com by conference and non-conference attendees before and during a 90-minute session featured at the Human Factors in Healthcare International Symposium on March 8, 2017. One submitted example of a reported patient safety issue was provided to the group. During the session, each attendee shared with a partner five concerns and identified their top concern. Subsequently, each two-person group shared with the larger group these issues, which were written by a facilitator onto sticky paper and placed on the walls. The issues were grouped using pre-defined categories and new categories were identified. Next, each participant voted for the highest priority cluster and/or individual patient safety issue using stickers. This paper reports the results of the interactive session, including the labeled and prioritized clusters and illustrative examples for each cluster. These clusters may inform reporting systems and quality improvement initiatives with health information technology where choices made during implementation and upgrades as well as design flaws with EHR technology both contribute and interact to produce potential patient safety issues.