Planning the Episode: Home Care Admission Nurse Decision-Making Regarding the Patient Visit Pattern.

During home health care (HHC) admissions, nurses provide input into decisions regarding the skilled nursing visit frequency and episode duration. This important clinical decision can impact patient outcomes including hospitalization. Episode duration has recently gained greater importance due to the Centers for Medicare and Medicaid Services (CMS) decrease in reimbursable episode length from 60 to 30 days. We examined admissions nurses' visit pattern decision-making and whether it is influenced by documentation available before and during the first home visit, agency standards, other disciplines being scheduled, and electronic health record (EHR) use. This observational mixed-methods study included admission document analysis, structured interviews, and a think-aloud protocol with 18 nurses from 3 diverse HHC agencies (6 at each) admitting 2 patients each (36 patients). Findings show that prior to entering the home, nurses had an information deficit; they either did not predict the patient's visit frequency and episode duration or stated them based on experience with similar patients. Following patient interaction in the home, nurses were able to make this decision. Completion of documentation using the EHR did not appear to influence visit pattern decisions. Patient condition and insurance restrictions were influential on both frequency and duration. Given the information deficit at admission, and the delay in visit pattern decision making, we offer health information technology recommendations on electronic communication of structured information, and EHR documentation and decision support.

Identification of temporal condition patterns associated with pediatric obesity incidence using sequence mining and big data.

BACKGROUND: Electronic health records (EHRs) are potentially important components in addressing pediatric obesity in clinical settings and at the population level. This work aims to identify temporal condition patterns surrounding obesity incidence in a large pediatric population that may inform clinical care and childhood obesity policy and prevention efforts. METHODS: EHR data from healthcare visits with an initial record of obesity incidence (index visit) from 2009 through 2016 at the Children's Hospital of Philadelphia, and visits immediately before (pre-index) and after (post-index), were compared with a matched control population of patients with a healthy weight to characterize the prevalence of common diagnoses and condition trajectories. The study population consisted of 49,694 patients with pediatric obesity and their corresponding matched controls. The SPADE algorithm was used to identify common temporal condition patterns in the case population. McNemar's test was used to assess the statistical significance of pattern prevalence differences between the case and control populations. RESULTS: SPADE identified 163 condition patterns that were present in at least 1% of cases; 80 were significantly more common among cases and 45 were significantly more common among controls (p < 0.05). Asthma and allergic rhinitis were strongly associated with childhood obesity incidence, particularly during the pre-index and index visits. Seven conditions were commonly diagnosed for cases exclusively during pre-index visits, including ear, nose, and throat disorders and gastroenteritis. CONCLUSIONS: The novel application of SPADE on a large retrospective dataset revealed temporally dependent condition associations with obesity incidence. Allergic rhinitis and asthma had a particularly high prevalence during pre-index visits. These conditions, along with those exclusively observed during pre-index visits, may represent signals of future obesity. While causation cannot be inferred from these associations, the temporal condition patterns identified here represent hypotheses that can be investigated to determine causal relationships in future obesity research.

Impact of Home Care Admission Nurses' Goals on Electronic Health Record Documentation Strategies at the Point of Care.

Home care nurses have multiple goals at the patient admission visit. Electronic health records support some of these goals, including high-quality documentation, but nurses may not complete the electronic documentation at the point of care. To characterize admission nurses' practices at the point of care and lay the foundation for design recommendations, this study investigates admission nurses' documentation strategies with respect to entering electronic data and how nursing goals affect them. We conducted 10 observations of home care agency admissions with five admission nurses in rural Pennsylvania. We collected screenshots and recorded the admission process. We asked the nurses questions outside the point of care. We coded the nurses' strategies at the data-entry screen level. Using thematic analysis, we investigated the influence of nursing goals on documentation strategies. Subject matter experts reviewed our findings. Several goals affect nurses' documentation strategies: ensure data accuracy, reduce time in the patient's home, and prevent infection. Home care admission nurses distribute the electronic documentation temporally due to their goals. Nurses developed memory aids to support completion of the documentation after leaving the patients' homes. Design and training should support the distributed manner in which home care nurses document patient encounters.

Beyond the VAD: Human Factors Engineering for Mechanically Assisted Circulation in the 21st Century.

Thousands of ventricular assist devices (VADs) currently provide circulatory support to patients worldwide, and dozens of heart pump designs for adults and pediatric patients are under various stages of development in preparation for translation to clinical use. The successful bench-to-bedside development of a VAD involves a structured evaluation of possible system states, including human interaction with the device and auxiliary component usage in the hospital or home environment. In this study, we review the literature and present the current landscape of preclinical design and assessment, decision support tools and procedures, and patient-centered therapy. Gaps of knowledge are identified. The study findings support the need for more attention to user-centered design approaches for medical devices, such as mechanical circulatory assist systems, that specifically involve detailed qualitative and quantitative assessments of human-device interaction to mitigate risk and failure.

Implementing a Family-Centered Rounds Intervention Using Novel Mentor-Trios.

BACKGROUND AND OBJECTIVES: Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites. METHODS: Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents. RESULTS: We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged. CONCLUSIONS: Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.

Perioperative Environment Safety Culture: A Scoping Review Addressing Safety Culture, Climate, Enacting Behaviors, and Enabling Factors.

While there is an increasing interest in patient safety and in transforming safety culture in the perioperative environment, it is not clear what methods are being used to understand, assess, and influence safety culture and climate. This article seeks to uncover what instruments and measures are used to assess safety culture and investigates how these measures are applied in baseline assessments and interventions in the perioperative environment to enhance/support safety culture. Study investigators are encouraged to collect and analyze data about engaging in behaviors that prevent, respond to, or resolve safety issues, and related factors that support understanding their effects.

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

BACKGROUND: Resident duty hour restrictions have resulted in more frequent patient care handoffs, increasing the need for improved quality of residents' sign-out process. OBJECTIVE: To characterize resident sign-out process and identify effective strategies for quality improvement. DESIGN: Mixed methods analysis of resident sign-out, including a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement. PARTICIPANTS: Internal medicine residents (n = 89). INTERVENTIONS: An appreciative inquiry process identified five exemplar residents and their peers' effective sign-out strategies. MAIN MEASURES: Surveys were analyzed and observations of sign-out sessions were characterized for duration and content. Common effective strategies were identified from the five exemplar residents using an appreciative inquiry approach. KEY RESULTS: The survey identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were frequently accurate. The duration of observed sign-outs averaged 134 ±73 s per patient for the day shift (6 p.m.) sign-out compared with 59 ± 41 s for the subsequent night shift (8 p.m.) sign-out for the same patients (p = 0.0002). Active problems (89% vs 98%, p = 0.013), treatment plans (52% vs 73%, p = 0.004), and laboratory test results (56% vs 80%, p = 0.002) were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out (mean vote 11 ± 1.6 vs 1.7 ± 2.3) identified strategies for sign-out: (1) discussing acutely ill patients first, (2) minimizing discussion on straightforward patients, (3) limiting plans to active issues, (4) using a systematic approach, and (5) limiting error-prone chart duplication. CONCLUSIONS: Resident views toward sign-out are diverse, and accuracy of written records may be limited. Consecutive sign-outs are associated with degradation of information. An appreciative-inquiry approach capitalizing on exemplar residents was effective at creating standards for sign-out.

Chronic wounds in persons living with dementia: An integrative review.

BACKGROUND: Persons living with dementia (PLWD) are at risk for chronic wounds; however, they are rarely included in research. OBJECTIVES: To inform practice and research directions, the aim of this integrative review was to identify and synthesise previous knowledge about the characteristics of chronic wounds in PLWD, in terms of chronic wound types, prevalence, setting and interventions. DESIGN: A literature search was conducted for publications in English using PubMed, Web of Science and CINAHL. The minimum information required for inclusion was how many PLWD enrolled in the study had wounds. METHODS: This integrative review followed the Whittemore and Knafl methodology. Data extraction and synthesis were guided by a directed content analysis, with a coding structure based on an initial review of the literature. RESULTS: Thirty-six articles met the inclusion criteria. The majority were missing characteristics of PLWD including severity of dementia and race/ethnicity/nationality, and none mentioned skin tone. Most focused on pressure injuries in the nursing home and acute care setting. Few included information on interventions. Only one discussed challenges of wound care for a PLWD exhibiting aggression. CONCLUSION: There is a gap in the literature regarding PLWD and chronic wounds other than pressure injuries that are common in older adults (e.g. diabetic foot ulcers, venous leg ulcers). Research is warranted among those PLWD who live alone and those who receive wound care from family caregivers to understand experiences. Knowledge can inform the development of future novel interventions for wound healing. Future research is needed regarding chronic wounds in those who exhibit behavioural and psychological symptoms of dementia. RELEVANCE TO CLINICAL PRACTICE: Nurses that care for chronic wounds in PLWD can contribute their knowledge to include information in guidelines on best care practices and contribute their perspective to research teams for future research.

Systematic Approach for Comparing Team-based Care Processes.

Team-based care process modeling techniques have focused on understanding and designing solutions for a single site. Less is known about tailoring an effective team-based care process from one site to another, which is necessary for multi-site implementation efforts. We propose an approach for analyzing and comparing a team-based care process performed at two sites to inform redesign opportunities. Our approach includes abstracting the goals and strategies of each process by identifying whether sociotechnical system element differences exist. Element differences may exist for the phase, tasks, roles, information, and technology and tools. Differences in system elements may still support process goals and strategies and, thus, be irrelevant for redesign opportunities. We demonstrate the utility of the approach using an operating room to intensive care unit handoff protocol. This approach should be useful for researchers and practitioners that are tailoring and implementing a successful team-based care process at more than one site.

Intervention, individual, and contextual determinants to high adherence to structured family-centered rounds: a national multi-site mixed methods study.

BACKGROUND: Effective communication in transitions between healthcare team members is associated with improved patient safety and experience through a clinically meaningful reduction in serious safety events. Family-centered rounds (FCR) can serve a critical role in interprofessional and patient-family communication. Despite widespread support, FCRs are not utilized consistently in many institutions. Structured FCR approaches may prove beneficial in increasing FCR use but should address organizational challenges. The purpose of this study was to identify intervention, individual, and contextual determinants of high adherence to common elements of structured FCR in pediatric inpatient units during the implementation phase of a large multi-site study implementing a structured FCR approach. METHODS: We performed an explanatory sequential mixed methods study from September 2019 to October 2020 to evaluate the variation in structured FCR adherence across 21 pediatric inpatient units. We analyzed 24 key informant interviews of supervising physician faculty, physician learners, nurses, site administrators, and project leaders at 3 sites using a qualitative content analysis paradigm to investigate site variation in FCR use. We classified implementation determinants based on the Consolidated Framework for Implementation Research. RESULTS: Provisional measurements of adherence demonstrated considerable variation in structured FCR use across sites at a median time of 5 months into the implementation. Consistent findings across all three sites included generally positive clinician beliefs regarding the use of FCR and structured rounding approaches, benefits to learner self-efficacy, and potential efficiency gains derived through greater rounds standardization, as well as persistent challenges with nurse engagement and interaction on rounds and coordination and use of resources for families with limited English proficiency. CONCLUSIONS: Studies during implementation to identify determinants to high adherence can provide generalizable knowledge regarding implementation determinants that may be difficult to predict prior to implementation, guide adaptation during the implementation, and inform sustainment strategies.

Association of Patient and Family Reports of Hospital Safety Climate With Language Proficiency in the US.

Importance: Patients with language barriers have a higher risk of experiencing hospital safety events. This study hypothesized that language barriers would be associated with poorer perceptions of hospital safety climate relating to communication openness. Objective: To examine disparities in reported hospital safety climate by language proficiency in a cohort of hospitalized children and their families. Design, Setting, and Participants: This cohort study conducted from April 29, 2019, through March 1, 2020, included pediatric patients and parents or caregivers of hospitalized children at general and subspecialty units at 21 US hospitals. Randomly selected Arabic-, Chinese-, English-, and Spanish-speaking hospitalized patients and families were approached before hospital discharge and were included in the analysis if they provided both language proficiency and health literacy data. Participants self-rated language proficiency via surveys. Limited English proficiency was defined as an answer of anything other than "very well" to the question "how well do you speak English?" Main Outcomes and Measures: Primary outcomes were top-box (top most; eg, strongly agree) 5-point Likert scale ratings for 3 Children's Hospital Safety Climate Questionnaire communication openness items: (1) freely speaking up if you see something that may negatively affect care (top-box response: strongly agree), (2) questioning decisions or actions of health care providers (top-box response: strongly agree), and (3) being afraid to ask questions when something does not seem right (top-box response: strongly disagree [reverse-coded item]). Covariates included health literacy and sociodemographic characteristics. Logistic regression was used with generalized estimating equations to control for clustering by site to model associations between openness items and language proficiency, adjusting for health literacy and sociodemographic characteristics. Results: Of 813 patients, parents, and caregivers who were approached to participate in the study, 608 completed surveys (74.8% response rate). A total of 87.7% (533 of 608) of participants (434 [82.0%] female individuals) completed language proficiency and health literacy items and were included in the analyses; of these, 14.1% (75) had limited English proficiency. Participants with limited English proficiency had lower odds of freely speaking up if they see something that may negatively affect care (adjusted odds ratio [aOR], 0.26; 95% CI, 0.15-0.43), questioning decisions or actions of health care providers (aOR, 0.19; 95% CI, 0.09-0.41), and being unafraid to ask questions when something does not seem right (aOR, 0.44; 95% CI, 0.27-0.71). Individuals with limited health literacy (aOR, 0.66; 95% CI, 0.48-0.91) and a lower level of educational attainment (aOR, 0.59; 95% CI, 0.36-0.95) were also less likely to question decisions or actions. Conclusions and Relevance: This cohort study found that limited English proficiency was associated with lower odds of speaking up, questioning decisions or actions of providers, and being unafraid to ask questions when something does not seem right. This disparity may contribute to higher hospital safety risk for patients with limited English proficiency. Dedicated efforts to improve communication with patients and families with limited English proficiency are necessary to improve hospital safety and reduce disparities.

Family, nurse, and physician beliefs on family-centered rounds: A 21-site study.

BACKGROUND: Variation exists in family-centered rounds (FCR). OBJECTIVE: We sought to understand patient/family and clinician FCR beliefs/attitudes and practices to support implementation efforts. DESIGNS, SETTINGS AND PARTICIPANTS: Patients/families and clinicians at 21 geographically diverse US community/academic pediatric teaching hospitals participated in a prospective cohort dissemination and implementation study. INTERVENTION: We inquired about rounding beliefs/attitudes, practices, and demographics using a 26-question survey coproduced with family/nurse/attending-physician collaborators, informed by prior research and the Consolidated Framework for Implementation Research. MAIN OUTCOME AND MEASURES: Out of 2578 individuals, 1647 (64%) responded to the survey; of these, 1313 respondents participated in FCR and were included in analyses (616 patients/families, 243 nurses, 285 resident physicians, and 169 attending physicians). Beliefs/attitudes regarding the importance of FCR elements varied by role, with resident physicians rating the importance of several FCR elements lower than others. For example, on adjusted multivariable analysis, attending physicians (odds ratio [OR] 3.0, 95% confidence interval [95% CI] 1.2-7.8) and nurses (OR 3.1, 95% CI 1.3-7.4) were much more likely than resident physicians to report family participation on rounds as very/extremely important. Clinician support for key FCR elements was higher than self-reported practice (e.g., 88% believed family participation was important on rounds; 68% reported it often/always occurred). In practice, key elements of FCR were reported to often/always occur only 23%-70% of the time. RESULT: Support for nurse and family participation in FCR is high among clinicians but varies by role. Physicians, particularly resident physicians, endorse several FCR elements as less important than nurses and patients/families. The gap between attitudes and practice and between clinician types suggests that attitudinal, structural, and cultural barriers impede FCR.

Implementing Family-Centered Rounds in Hospital Pediatric Settings: A Scoping Review.

CONTEXT: The American Academy of Pediatrics and Institute for Patient and Family-Centered Care issued a joint policy statement in 2012 recommending family and nurse participation in rounds as a standard practice. OBJECTIVE: To synthesize available evidence on the state of the implementation of family-centered rounds (FCRs), including identified barriers to stakeholder acceptance and participation in FCRs in pediatric inpatient settings and implementation strategies to increase adherence and related outcomes. DATA SOURCES: PubMed and Medline and the Cochrane Database of Systematic Reviews. STUDY SELECTION: Observational and experimental studies from January 2009 to July 2020. DATA EXTRACTON: Two reviewers independently screened each study to determine eligibility and extract data. Initial evidence quality was evaluated on the basis of study design. RESULTS: A total of 53 studies were included in the final synthesis. FCRs are increasingly accepted by stakeholders, although participation lags. Structural barriers to nurse and family attendance persist. Limited high-quality evidence exists regarding the effectiveness of FCRs and related implementation strategies in improving patient outcomes. The lack of a clear, consistent definition of the elements that combine for a successful FCR encounter remains a significant barrier to measuring its effect. CONCLUSIONS: Standardized research methods for improving the quality and comparability of FCR studies are needed to enhance the existing guidelines for FCR use. Structural changes in care delivery may be required to ensure the rounding process remains amenable to the needs of patients and their families.

Getting to Complete and Accurate Medication Lists During the Transition to Home Health Care.

OBJECTIVES: Characterize the work that home health care (HHC) admission nurses complete as part of the medication reconciliation tasks, explore the impact of shared electronic medication data (interoperability) from the referral source on medication reconciliation, and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies. DESIGN: Observational field study. SETTINGS AND PARTICIPANTS: Three diverse Pennsylvania HHC agencies; each used different electronic health record systems with different interoperability characteristics. Six nurses per site admitted 2 patients each (36 patients total). METHODS: Researchers observed the admission process in the patient home and at the HHC agency. The nurses' tasks related to medication reconciliation were characterized by (1) number and change types (ie, medications dropped or added; changes to dose, frequency/administration time, or tablet types) made to the referrer medication list during and after the home visit, and (2) reasons that the nurse called the health provider (doctor, pharmacy) to resolve medication-related issues. Differences between interoperable and non-interoperable observations were explored. RESULTS: Polypharmacy (on average, study patients were taking more than 12 medications) and high-risk medications (on average, more than 8 per patient) were pervasive. For 91% of patients, the number of medications decreased between pre- and post-reconciliation medication lists; 41% of the medications required changes. Nurses using interoperable systems needed to make fewer changes than nurses using non-interoperable systems. In two-thirds of observations, the nurse called a provider. CONCLUSIONS AND IMPLICATIONS: Changes to the referrer medication list and calls to providers highlighted the nurses' effort to complete the medication reconciliation. Interoperability appeared to reduce the number of changes required, but did not eliminate changes or calls to providers. We highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.

There's a Problem With the Problem List: Incongruence of Patient Problem Information Across the Home Care Admission.

OBJECTIVES: Illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer. DESIGN: Observational field study. SETTING AND PARTICIPANTS: Three diverse HHC agencies using different commercial point-of-care electronic health records (EHRs). Six nurses per agency each admitted 2 patients (36 total). METHODS: Researchers observed the admission process and photographed documents and EHR screens across 3 phases: referral, assessment, and plan of care (POC). To create a standardized data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created 180 problem pattern cases (5 problem patterns per patient). RESULTS: Each pattern of problem information being present or absent was observed. In 52 cases (28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all 3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared on the POC. Within the EHRs, there were no rationale fields to clarify including Problems or not and no problem status fields to identify active, resolved, or potential ones. CONCLUSIONS AND IMPLICATIONS: Diagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the POC. Because of the EHR structure, clinicians could not identify inactive problem or problem priority. Documentation or mapping of a structured problem list using a standardized interprofessional terminology such as the Omaha System coupled with identification of rationale could support the documentation of problem status and priority and reduce information loss.

A Cross University-Led COVID-19 Rapid-Response Effort: Design, Build, and Distribute Drexel AJFlex Face Shields.

The purpose of this article is to demonstrate how a new cross-community leadership team came together, collaborated, coordinated across academic units with external community partners, and executed a joint mission to address the unmet clinical need for medical face shields during these unprecedented times. Key aspects of this success include the ability to forge and leverage new opportunities, overcome challenges, adapt to changing constraints, and serve the significant need across the Philadelphia region and healthcare systems. We teamed to design-build durable face shields (AJFlex Shields). This was accomplished by high-volume manufacturing via injection molding and by 3-D printing the key headband component that supports the protective shield. Partnering with industry collaborators and civic-minded community allies proved to be essential to bolster production and deliver approximately 33,000 face shields to more than 100 organizations in the region. Our interdisciplinary team of engineers, clinicians, product designers, manufacturers, distributors, and dedicated volunteers is committed to continuing the design-build effort and providing Drexel AJFlex Shields to our communities.

Handoffs and transitions in critical care-understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial.

BACKGROUND: The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings. METHODS: The Handoffs and Transitions in Critical Care-Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU). DISCUSSION: The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04571749 . Date of registration: October 1, 2020.

Improving pairwise sequence alignment accuracy using near-optimal protein sequence alignments.

BACKGROUND: While the pairwise alignments produced by sequence similarity searches are a powerful tool for identifying homologous proteins - proteins that share a common ancestor and a similar structure; pairwise sequence alignments often fail to represent accurately the structural alignments inferred from three-dimensional coordinates. Since sequence alignment algorithms produce optimal alignments, the best structural alignments must reflect suboptimal sequence alignment scores. Thus, we have examined a range of suboptimal sequence alignments and a range of scoring parameters to understand better which sequence alignments are likely to be more structurally accurate. RESULTS: We compared near-optimal protein sequence alignments produced by the Zuker algorithm and a set of probabilistic alignments produced by the probA program with structural alignments produced by four different structure alignment algorithms. There is significant overlap between the solution spaces of structural alignments and both the near-optimal sequence alignments produced by commonly used scoring parameters for sequences that share significant sequence similarity (E-values < 10-5) and the ensemble of probA alignments. We constructed a logistic regression model incorporating three input variables derived from sets of near-optimal alignments: robustness, edge frequency, and maximum bits-per-position. A ROC analysis shows that this model more accurately classifies amino acid pairs (edges in the alignment path graph) according to the likelihood of appearance in structural alignments than the robustness score alone. We investigated various trimming protocols for removing incorrect edges from the optimal sequence alignment; the most effective protocol is to remove matches from the semi-global optimal alignment that are outside the boundaries of the local alignment, although trimming according to the model-generated probabilities achieves a similar level of improvement. The model can also be used to generate novel alignments by using the probabilities in lieu of a scoring matrix. These alignments are typically better than the optimal sequence alignment, and include novel correct structural edges. We find that the probA alignments sample a larger variety of alignments than the Zuker set, which more frequently results in alignments that are closer to the structural alignments, but that using the probA alignments as input to the regression model does not increase performance. CONCLUSIONS: The pool of suboptimal pairwise protein sequence alignments substantially overlaps structure-based alignments for pairs with statistically significant similarity, and a regression model based on information contained in this alignment pool improves the accuracy of pairwise alignments with respect to structure-based alignments.

Temporal condition pattern mining in large, sparse electronic health record data: A case study in characterizing pediatric asthma.

OBJECTIVE: This study introduces a temporal condition pattern mining methodology to address the sparse nature of coded condition concept utilization in electronic health record data. As a validation study, we applied this method to reveal condition patterns surrounding an initial diagnosis of pediatric asthma. MATERIALS AND METHODS: The SPADE (Sequential PAttern Discovery using Equivalence classes) algorithm was used to identify common temporal condition patterns surrounding the initial diagnosis of pediatric asthma in a study population of 71 824 patients from the Children's Hospital of Philadelphia. SPADE was applied to a dataset with diagnoses coded using International Classification of Diseases (ICD) concepts and separately to a dataset with the ICD codes mapped to their corresponding expanded diagnostic clusters (EDCs). Common temporal condition patterns surrounding the initial diagnosis of pediatric asthma ascertained by SPADE from both the ICD and EDC datasets were compared. RESULTS: SPADE identified 36 unique diagnoses in the mapped EDC dataset, whereas only 19 were recognized in the ICD dataset. Temporal trends in condition diagnoses ascertained from the EDC data were not discoverable in the ICD dataset. DISCUSSION: Mining frequent temporal condition patterns from large electronic health record datasets may reveal previously unknown associations between diagnoses that could inform future research into causation or other relationships. Mapping sparsely coded medical concepts into homogenous groups was essential to discovering potentially useful information from our dataset. CONCLUSIONS: We expect that the presented methodology is applicable to the study of diagnostic trajectories for other clinical conditions and can be extended to study temporal patterns of other coded medical concepts such as medications and procedures.