Impact of Teamwork and Communication Training Interventions on Safety Culture and Patient Safety in Emergency Departments: A Systematic Review.

OBJECTIVES: This study aimed to narratively summarize the literature reporting on the effect of teamwork and communication training interventions on culture and patient safety in emergency department (ED) settings. METHODS: We searched PubMed, EMBASE, Psych Info CINAHL, Cochrane, Science Citation Inc, the Web of Science, and Educational Resources Information Centre for peer-reviewed journal articles published from January 1, 1988, to June 8, 2018, that assessed teamwork and communication interventions focusing on how they influence patient safety in the ED. One additional search update was performed in July 2019. RESULTS: Sixteen studies were included from 8700 screened publications. The studies' design, interventions, and evaluation methods varied widely. The most impactful ED training interventions were End-of-Course Critique, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), and crisis resource management (CRM)-based training. Crisis resource management and TeamSTEPPS CRM-based training curriculum were used in most of the studies. Multiple tools, including the Kirkpatrick evaluation model, the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture, the TeamSTEPPS Teamwork Attitudes Questionnaire, the Safety Attitudes Questionnaire, and the Communication and Teamwork Skills Assessment, were used to assess the impact of such interventions. Improvements in one of the domains of safety culture and related domains were found in all studies. Four empirical studies established improvements in patient health outcomes that occurred after simulation CRM training (Kirkpatrick 4), but there was no effect on mortality. CONCLUSIONS: Overall, teamwork and communication training interventions improve the safety culture in ED settings and may positively affect patient outcome. The implementation of safety culture programs may be considered to reduce incidence of medical errors and adverse events.

A systematic review of adenosine triphosphate as a surrogate for bacterial contamination of duodenoscopes used for endoscopic retrograde cholangiopancreatography.

BACKGROUND: Bacterial culture is the accepted standard to measure the adequacy of high-level disinfection (HLD) of duodenoscopes. Adenosine triphosphate (ATP) bioluminescence assays have been suggested as an alternative method of evaluating the quality of reprocessing. We systematically reviewed published research describing the correlation between ATP and bacterial cultures. METHODS: The primary outcome was the correlation or concordance between concomitantly sampled ATP and bacterial contamination obtained from the instrument channel and/or elevator mechanism of the duodenoscope. A secondary outcome included the reduction in ATP measurements between paired samples before and after stages of duodenoscope reprocessing. RESULTS: Ten studies were included in the analysis. Four studies reported the relationship between concomitantly sampled ATP and cultures. Three studies reported receiver operating characteristic curves (1 study additionally reported a Wilcoxon rank sum test), and 1 study reported Spearman correlation coefficients and paired dichotomous measurements of ATP and bacterial contamination. All analyses suggested a poor relationship between the 2 measures. Studies measuring ATP before and after manual cleaning and before and after HLD reported a reduction in ATP after the reprocessing stage. CONCLUSION: Current research does not support the direct substitution of ATP for bacterial culture surveillance of duodenoscopes. Serial ATP measurement may be a useful tool to evaluate the adequacy of manual cleaning and for training of endoscopic reprocessing staff.

Efficacy of Treatments for Opioid-Induced Constipation: Systematic Review and Meta-analysis.

BACKGROUND & AIMS: Opioid-induced constipation (OIC) is a common problem in patients on chronic opioid therapy for cancer-related and non-cancer-related pain. Approved treatments for OIC are methylnaltrexone, naloxone, naloxegol, alvimopan, naldemedine, and lubiprostone. Since a meta-analysis performed in 2014, 2 new agents have been approved by the Food and Drug Administration for treatment of OIC (naloxegol and naldemedine). METHODS: We conducted a search of the medical literature following the protocol outlined in the Cochrane Handbook for systematic review. We searched MEDLINE, EMBASE, EMBASE Classic, Web of Science, and the Cochrane Central Register of Controlled Trials until March 2017 to identify randomized controlled trials of peripheral µ-opioid-receptor antagonists (methylnaltrexone, naloxone, naloxegol, alvimopan, axelopran, or naldemedine), lubiprostone, or prucalopride. Response to therapy was extracted in a dichotomous assessment as an overall response to therapy. The effect of pharmacologic therapies was pooled and reported as a relative risk (RR) of failure to respond to the treatment drug, with 95% CIs. RESULTS: We included 27 placebo-controlled trials in our meta-analysis (23 trials evaluated µ-opioid-receptor antagonists, 3 trials evaluated lubiprostone, and 1 trial evaluated prucalopride). In these trials, 5390 patients received a drug and 3491 received a placebo. Overall, µ-opioid-receptor antagonists, lubiprostone, and prucalopride were superior to placebo for the treatment of OIC, with a RR of failure to respond to therapy of 0.70 (95% CI, 0.64-0.75) and an overall number needed to treat of 5 (95% CI, 4-7). When restricted to only Food and Drug Administration-approved medications for OIC, the RR of failure to respond to therapy was 0.69 (95% CI, 0.62-0.77), with a number needed to treat of 5 (95% CI, 4-7). Sensitivity analyses and meta-regression performed to account for heterogeneity showed that treatment was more likely to be effective in study populations taking higher doses of opiates at baseline or refractory to laxatives. Study duration and prespecified primary outcome did not affect the RR of failure. Participants who received µ-opioid-receptor antagonists were significantly more likely to have diarrhea, abdominal pain, nausea, or vomiting than patients who received placebo. CONCLUSIONS: In a systematic review and meta-analysis, we found µ-opioid-receptor antagonists to be safe and effective for the treatment of OIC. Prescription-strength laxatives (prucalopride, lubiprostone) are slightly better than placebo in reducing OIC.

Characteristics of knowledge content in a curated online evidence library.

Objective: To describe types of recommendations represented in a curated online evidence library, report on the quality of evidence-based recommendations pertaining to diagnostic imaging exams, and assess underlying knowledge representation. Materials and Methods: The evidence library is populated with clinical decision rules, professional society guidelines, and locally developed best practice guidelines. Individual recommendations were graded based on a standard methodology and compared using chi-square test. Strength of evidence ranged from grade 1 (systematic review) through grade 5 (recommendations based on expert opinion). Finally, variations in the underlying representation of these recommendations were identified. Results: The library contains 546 individual imaging-related recommendations. Only 15% (16/106) of recommendations from clinical decision rules were grade 5 vs 83% (526/636) from professional society practice guidelines and local best practice guidelines that cited grade 5 studies (P < .0001). Minor head trauma, pulmonary embolism, and appendicitis were topic areas supported by the highest quality of evidence. Three main variations in underlying representations of recommendations were "single-decision," "branching," and "score-based." Discussion: Most recommendations were grade 5, largely because studies to test and validate many recommendations were absent. Recommendation types vary in amount and complexity and, accordingly, the structure and syntax of statements they generate. However, they can be represented in single-decision, branching, and score-based representations. Conclusion: In a curated evidence library with graded imaging-based recommendations, evidence quality varied widely, with decision rules providing the highest-quality recommendations. The library may be helpful in highlighting evidence gaps, comparing recommendations from varied sources on similar clinical topics, and prioritizing imaging recommendations to inform clinical decision support implementation.

Assessing Strength of Evidence of Appropriate Use Criteria for Diagnostic Imaging Examinations.

OBJECTIVE: For health information technology tools to fully inform evidence-based decisions, recommendations must be reliably assessed for quality and strength of evidence. We aimed to create an annotation framework for grading recommendations regarding appropriate use of diagnostic imaging examinations. METHODS: The annotation framework was created by an expert panel (clinicians in three medical specialties, medical librarians, and biomedical scientists) who developed a process for achieving consensus in assessing recommendations, and evaluated by measuring agreement in grading the strength of evidence for 120 empirically selected recommendations using the Oxford Levels of Evidence. RESULTS: Eighty-two percent of recommendations were assigned to Level 5 (expert opinion). Inter-annotator agreement was 0.70 on initial grading (κ = 0.35, 95% CI, 0.23-0.48). After systematic discussion utilizing the annotation framework, agreement increased significantly to 0.97 (κ = 0.88, 95% CI, 0.77-0.99). CONCLUSIONS: A novel annotation framework was effective for grading the strength of evidence supporting appropriate use criteria for diagnostic imaging exams.

Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches.

IMPORTANCE: Optimal approaches to teaching bedside procedures are unknown. OBJECTIVE: To identify effective instructional approaches in procedural training. DATA SOURCES: We searched PubMed, EMBASE, Web of Science and Cochrane Library through December 2014. STUDY SELECTION: We included research articles that addressed procedural training among physicians or physician trainees for 12 bedside procedures. Two independent reviewers screened 9312 citations and identified 344 articles for full-text review. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data from full-text articles. MAIN OUTCOMES AND MEASURES: We included measurements as classified by translational science outcomes T1 (testing settings), T2 (patient care practices) and T3 (patient/public health outcomes). Due to incomplete reporting, we post hoc classified study outcomes as 'negative' or 'positive' based on statistical significance. We performed meta-analyses of outcomes on the subset of studies sharing similar outcomes. RESULTS: We found 161 eligible studies (44 randomised controlled trials (RCTs), 34 non-RCTs and 83 uncontrolled trials). Simulation was the most frequently published educational mode (78%). Our post hoc classification showed that studies involving simulation, competency-based approaches and RCTs had higher frequencies of T2/T3 outcomes. Meta-analyses showed that simulation (risk ratio (RR) 1.54 vs 0.55 for studies with vs without simulation, p=0.013) and competency-based approaches (RR 3.17 vs 0.89, p<0.001) were effective forms of training. CONCLUSIONS AND RELEVANCE: This systematic review of bedside procedural skills demonstrates that the current literature is heterogeneous and of varying quality and rigour. Evidence is strongest for the use of simulation and competency-based paradigms in teaching procedures, and these approaches should be the mainstay of programmes that train physicians to perform procedures. Further research should clarify differences among instructional methods (eg, forms of hands-on training) rather than among educational modes (eg, lecture vs simulation).

The landscape of inappropriate laboratory testing: a 15-year meta-analysis.

BACKGROUND: Laboratory testing is the single highest-volume medical activity and drives clinical decision-making across medicine. However, the overall landscape of inappropriate testing, which is thought to be dominated by repeat testing, is unclear. Systematic differences in initial vs. repeat testing, measurement criteria, and other factors would suggest new priorities for improving laboratory testing. METHODS: A multi-database systematic review was performed on published studies from 1997-2012 using strict inclusion and exclusion criteria. Over- vs. underutilization, initial vs. repeat testing, low- vs. high-volume testing, subjective vs. objective appropriateness criteria, and restrictive vs. permissive appropriateness criteria, among other factors, were assessed. RESULTS: Overall mean rates of over- and underutilization were 20.6% (95% CI 16.2-24.9%) and 44.8% (95% CI 33.8-55.8%). Overutilization during initial testing (43.9%; 95% CI 35.4-52.5%) was six times higher than during repeat testing (7.4%; 95% CI 2.5-12.3%; P for stratum difference <0.001). Overutilization of low-volume tests (32.2%; 95% CI 25.0-39.4%) was three times that of high-volume tests (10.2%; 95% CI 2.6-17.7%; P<0.001). Overutilization measured according to restrictive criteria (44.2%; 95% CI 36.8-51.6%) was three times higher than for permissive criteria (12.0%; 95% CI 8.0-16.0%; P<0.001). Overutilization measured using subjective criteria (29.0%; 95% CI 21.9-36.1%) was nearly twice as high as for objective criteria (16.1%; 95% CI 11.0-21.2%; P = 0.004). Together, these factors explained over half (54%) of the overall variability in overutilization. There were no statistically significant differences between studies from the United States vs. elsewhere (P = 0.38) or among chemistry, hematology, microbiology, and molecular tests (P = 0.05-0.65) and no robust statistically significant trends over time. CONCLUSIONS: The landscape of overutilization varies systematically by clinical setting (initial vs. repeat), test volume, and measurement criteria. Underutilization is also widespread, but understudied. Expanding the current focus on reducing repeat testing to include ordering the right test during initial evaluation may lead to fewer errors and better care.

Pain and temporomandibular disorders: a pharmaco-gender dilemma.

Gender is the biggest risk factor in the development of temporomandibular disorders (TMD) and orofacial pain. Gender differences in pain thresholds, temporal summation, pain expectations, and somatic awareness exist in patients with chronic TMD or orofacial pain. There are gender differences in pharmacokenetics and pharmacodynamics of medications used to treat pain. A better understanding of the mechanisms that contribute to the increased incidence and persistence of chronic pain in females is needed. Future research will elucidate the sex effects on factors that protect against developing pain or prevent debilitating pain. Gender-based treatments for TMD and orofacial pain treatment will evolve from the translational research stimulated by this knowledge.

50 years of publication in the field of medical education.

BACKGROUND: The advent of new medical education (ME) journals makes evident the growth of the field of ME. However, the nature and context of growth is undefined. AIM: To analyze the evolution of publication in ME. METHODS: MEDLINE retrieval using medical subject headings was used to analyze patterns of ME publications from 1960-2010: changes in number of ME publications; number of journals publishing ME articles; co-topics occurring frequently in ME articles; differences among journals' publication of co-topics. RESULTS: Annual publication of ME articles increased from 279 in 1960 to 3760 in 2010. 81,531 articles were published in 4208 different journals. 104 journals published ME articles in 1960, 855 in 2010. Despite an increase in journals in all fields, ME journals now account for a larger proportion of all journals indexed in MEDLINE than in 1960. One-quarter of all ME articles were indexed as internship/residency; 16% as graduate ME; 15% as undergraduate ME; and 14% as continuing ME. The five journals that published the most ME articles distinguished themselves by publishing some topics with greater or less frequency. CONCLUSIONS: The increase in the number of ME publications and in the number of journals publishing ME articles suggests a supportive environment for a growing field; but variation in journals' foci has implications for readers, editors and authors.

A systematic review of the prevalence of herb usage among racial/ethnic minorities in the United States.

Clinical studies display a wide range of herb use prevalence among racial/ethnic minorities in the United States. We searched databases indexing the literature including CINAHL, EMBASE, Global Health, CAB Abstracts, and Medline. We included studies that reported herbal medicine prevalence among ethnic minorities, African American, Hispanic, or Asian adults living in the United States. Data from 108 included studies found the prevalence of herb use by African Americans was 17 % (range 1-46 %); for Hispanics, 30 % (4-100 %); and for Asians, 30 % (2-73 %). Smaller studies were associated with higher reported herb use (p = 0.03). There was a significant difference (p = 0.01) between regional and national studies with regional studies reporting higher use. While herb usage surveys in racial/ethnic minorities show great variability, indications suggest high prevalence. More research is needed to understand herb use among ethnic/racial minorities, reasons for use, and barriers to disclosure of use to clinicians.

Therapeutic intervention for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): a systematic review and meta-analysis.

BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has been treated with several different interventions with limited success. This meta-analysis aims to review all trials reporting on therapeutic intervention for CP/CPPS using the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI). METHODS: We searched Medline, PubMed, the Cochrane Pain, Palliative & Supportive Care Trials, the Cochrane Register of Controlled Trials, CINAHL, ClinicalTrials.gov, and the NIDDK website between 1947 and December 31, 2011 without language or study type restrictions. All RCTs for CP/CPPS lasting at least 6 weeks, with a minimum of 10 participants per arm, and using the NIH-CPSI score, the criterion standard for CP/CPPS, as an outcome measure were included. Data was extracted from each study by two independent reviewers. Gillbraith and I-squared plots were used for heterogeneity testing and Eggers and Peters methods for publication bias. Quality was assessed using a component approach and meta-regression was used to analyze sources of heterogeneity. RESULTS: Mepartricin, percutaneous tibial nerve stimulation (PTNS), and triple therapy comprised of doxazosin + ibuprofen + thiocolchicoside (DIT) resulted in clinically and statistically significant reduction in NIH-CPSI total score. The same agents and aerobic exercise resulted in clinically and statistically significant NIH-CPSI pain domain score reduction. Acupuncture, DIT, and PTNS were found to produce statistically and clinically significant reductions in the NIH-CPSI voiding domain. A statistically significant placebo effect was found for all outcomes and time analysis showed that efficacy of all treatments increased over time. Alpha-blockers, antibiotics, and combinations of the two failed to show statistically or clinically significant NIH-CPSI reductions. CONCLUSION: Results from this meta-analysis reflect our current inability to effectively manage CP/CPPS. Clinicians and researchers must consider placebo effect and treatment efficacy over time and design studies creatively so we can more fully elucidate the etiology and role of therapeutic intervention in CP/CPPS.

Tropical American plants in the treatment of infectious diseases.

The increasingly diverse U.S. immigrant populations and the growing use of medicinal herbs create a need for health care professionals to expand their knowledge in this area. This is a review of tropical plants, Annona Muricata, Artemisia absinthium, Cinchona officinalis, Illicium verum, Momordica charantia, Opuntia streptacantha, Schinus terebinthifolius, and Tabebuia avellanedae (impetiginosa), commonly used by Latino and Haitian populations for the treatment of infectious disease. All the eight plants discussed here have one or more of the following: antibacterial, antiviral, antifungal, or antiparasitic properties. All of these plants are primarily known and used in the tropical region, but they are also readily available for purchase in the United States, specifically in the ethnic markets. This review discusses their traditional uses, chemical constituents, proven scientific evidence, and toxicities.

Hospital library foreign language labs: the experiences of two hospital libraries.

Increasingly, hospital-based physicians, residents, and medical students are welcoming into their care foreign-born patients, who do not speak English. Most hospitals today have an Interpretive Services Department, but many of the physicians, residents, and medical students want to become more proficient in the most frequently spoken foreign languages in their respective locales. To help recruit and retain a diverse workforce, some hospitals sponsor English programs for staff. The Treadwell Library at Massachusetts General Hospital in Boston, Massachusetts, and the Grady Branch Library at Grady Memorial Hospital in Atlanta, Georgia, have developed a special collection and hospital library-based language laboratories in order to meet this need.

Views of pediatric health care providers on the use of herbs and dietary supplements in children.

Herbs and dietary supplements (HDS) are widely used by adults for treating illnesses and/or preserving good health, and many parents use HDS for their children as well. Previous reports suggest parents will not divulge HDS use to health care providers for fear of their skepticism or disapproval. Yet the views of pediatric health care providers on HDS use in children are not well known. This study investigated the attitudes and practices of pediatric nurses and physicians regarding HDS use in children, in order to identify those characteristics associated with a high degree of confidence in initiating a dialogue on the topic of HDS with families in their practice. A written survey on attitudes and practices toward HDS was developed, piloted, revised, and then administered to a convenience sample of practitioners attending a regional postgraduate course in general pediatrics. Only 42% of 204 pediatric health care providers sampled felt confident in initiating discussions about the therapeutic use of herbs and dietary supplements with families in their practice. Confidence in discussing HDS with families correlated with both personal use of an HDS (OR 3.22; p=0.033) and length of time in practice less than 10 years (OR 8.26; p=0.007). Less than 18% felt that HDS were safe for children under 6 months of age; and only 35% felt they were safe for use in children < 24 months old. Only 7% felt that parents should be allowed to give their hospitalized child an herb or dietary supplement they had brought with them from home, although this increased to 35% if the herb or dietary supplement had been prescribed by a physician. Ninety-two percent of practitioners thought that HDS should be more closely regulated by the FDA. Only a minority of pediatric community practitioners felt confident in discussing HDS with families of children in their practice. Those who had been in practice for a shorter time and who had used HDS themselves were more likely to report confidence in initiating such discussions. The provision of more postgraduate educational opportunities to learn about herbs and dietary supplements may alleviate some practitioners' concerns about their own competency in discussing HDS with families in their practice.

Herbal medicine course within pharmacy curriculum.

Due to the growing use of herbs and dietary supplements by consumers, pharmacists now need a basic knowledge of this topic for their professional practices. To meet this need, an elective course on herbs and dietary supplements is being taught at the Massachusetts College of Pharmacy and Health Science. The objective of the course is to teach students basic phytopharmacology, counseling skills on herbal medicine, evidence- based resources, manufacturing practices, and dietary regulations. A review of over 50 herbs touches on clinical use, efficacy, safety, and drug interactions. This paper reviews the course curriculum, resources and exercises used throughout the course.

HolisticKids.org--evolution of information resources in pediatric complementary and alternative medicine projects: from monographs to Web learning.

Use of complementary and alternative medicine (CAM) is growing in the United States. Children are a part of this trend, with adolescent self-care exceeding adult use. As a result, the necessity of educating pediatricians on CAM practices has become clear. This paper describes the Pediatric Integrative Medicine Education (PIME) project with a focus on the creation of HolisticKids.org, a Website designed to educate pediatric residents. HolisticKids.org also addresses the needs and interests of medical students, fellows, faculty, and community-based care providers who work with children and CAM. An outstanding aspect of this effort is its interdisciplinary nature, involving physicians, pharmacists, dieticians, nurses, medical librarians, and Web specialists. Collaboration is mirrored on an institutional level, where the participating institutions include Children's Hospital Boston, Harvard Medical School, Boston Medical Center, the Massachusetts College of Pharmacy and Health Sciences, and Dana Farber Cancer Institute. Now in the third year of development, this Web-based education project demonstrates how integrative medical education can contribute to pediatric care for diverse families and complement cultural competency efforts. Ongoing efforts focus on adding content, developing evaluation techniques, and disseminating this resource to the health sciences community.

Herbs and other dietary supplements: healthcare professionals' knowledge, attitudes, and practices.

CONTEXT: Herbs and other dietary supplements (H/DS) are frequently used by the public. They have significant health implications, yet little is known about health professionals' knowledge, attitudes, or clinical practices related to H/DS. DESIGN: Cross-sectional survey of clinicians prior to participation in an Internet-based educational program on herbs and dietary supplements. PARTICIPANTS: The 537 participants included 111 physicians (MD), 30 advanced practice nurses (RN), 46 pharmacists (PharmD), and 350 dietitians (RD). In addition to demographic information, participants were asked about their knowledge, attitudes, and practices related to H/DS. RESULTS: Most participants were involved in direct patient care (85%), in practice or on faculty (84%), and from outside our local institutions (76%); 66% reported receiving professional education about H/DS in the past year. There were statistically significant differences between professional groups, with RDs scoring better than others, but even their average scores were less than 60% of possible. The average score on knowledge questions was 10/20; the average confidence score was 4 out of 10 possible, and the average communication score was 1.4 out of 4 possible. Most respondents knew the most common clinical uses of echinacea and St. John's wort, and felt confident that they knew more than their colleagues about H/DS. Key deficits were in knowledge about adverse effects, confidence in reporting side effects, routinely communicating with patients about H/DS, and recording H/DS information in the medical record. CONCLUSIONS: Despite significant interest and previous training in H/DS, these clinicians had substantial room for improvement in knowledge, attitudes, and clinical practices about H/DS. Educational interventions and institutional policies are needed to improve the quality of patient care regarding H/DS, and such interventions should be rigorously evaluated to ensure that continuous improvements occur.