Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study.

BACKGROUND: Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system. METHODS: Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers. RESULTS: A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56-79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40-2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58-80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47-7.78]; stroke centers (77.4%-90.0%); nonstroke centers [59.3%-72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, -9.68 [95% CI, -17.17 to -2.20]; stroke centers [41-35 minutes]; nonstroke centers [55-52 minutes]). No differences were observed in clinical effectiveness outcomes. CONCLUSIONS: A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.

Alerting Wisely: Reducing Inappropriate Blood Chemistry Panel Orders Using a Clinical Decision Support Tool.

The Choosing Wisely (CW) initiative provides recommendations for healthcare providers, aimed at reducing unnecessary or inappropriate tests and procedures. A clinical decision support (CDS) alert in the electronic health record was developed to reflect organizational CW guidelines regarding blood chemistry panel ordering in the primary care setting. An interrupted time series design was used to analyze the weekly proportion of inappropriate blood chemistry panel orders prior to and after implementation of the CDS alert in treatment and control groups. Implementation of the CDS alert significantly decreased the average weekly proportion of inappropriate blood chemistry panels from 28.64% to 15.69% in the treatment group (p < .001). Apart from other efforts implemented simultaneously to reduce inappropriate lab ordering, the CDS alert produced a significant reduction in inappropriate lab ordering. We conclude that CDS alerts can be an effective strategy for healthcare organizations seeking to more closely adhere to CW guidelines.

"Pharming out" support: a promising approach to integrating clinical pharmacists into established primary care medical home practices.

Objective Embedding clinical pharmacists into ambulatory care settings needs to be assessed in the context of established medical home models. Methods A retrospective, observational study examined the effectiveness of the Intermountain Healthcare Collaborative Pharmacist Support Services (CPSS) program from 2012-2015 among adult patients diagnosed with diabetes mellitus (DM) and/or high blood pressure (HBP). Patients who attended this program were considered the intervention (CPSS) cohort. These patients were matched using propensity scores with a reference group (no-CPSS cohort) to determine the effect of achieving disease management goals and time to achievement. Results A total of 17,684 patients had an in-person office visit with their provider and 359 received CPSS (the matched no-CPSS cohort included 999 patients). CPSS patients were 93% more likely to achieve a blood pressure goal < 140/90 mmHg, 57% more likely to achieve HbA1c values < 8%, and 87% more likely to achieve both disease management goals compared with the reference group. Time to goal achievement demonstrated increasing separation between the study cohorts across the entire study period ( P < .001), and specifically, at 180 days post-intervention (HBP: 48% vs 27% P < .001 and DM: 39% vs 30%, P < .05). Conclusions CPSS participation is associated with significant improvement in achievement of disease management goals, time to achievement, and increased ambulatory encounters compared with the matched no-CPSS cohort.

The stability of time estimation in older adults.

The ability to correctly estimate time is important for many daily activities, such as cooking and driving. This study investigated the stability time estimation in healthy older adults and compared them to healthy younger adults. Participants were tested and retested across the duration of 1 year. Using a prospective paradigm, verbal estimates were provided for intervals of 10, 25, 45, and 60 seconds. Although the older adults demonstrated a greater magnitude of error in their time estimates than younger adults, their time estimates remained stable across the 1-year duration. This suggests that instability in time estimates across two time points is unlikely to account for the discrepant task findings in the aging and verbal time estimation literature.

State-level strategies for reducing prescription drug overdose deaths: Utah's prescription safety program.

INTRODUCTION: The Utah Department of Health created a program to decrease deaths and other harm from prescription pain medication. Program goals included educating the public, providers, and patients on prescription safety and creating guidelines for providers on prescribing opioids. PROGRAM INTERVENTIONS: The department's Prescription Pain Medication Program was organized in collaboration with many state agencies as well as public and private organizations. The program developed a statewide media campaign, running messages using the slogan "Use Only As Directed" from May 2008 to May 2009. The program facilitated the publication and distribution of opioid prescribing guidelines. PROGRAM OUTCOMES: Collaboration among stakeholders to develop educational materials furthered use of the materials. The program distributed more than 2,800 copies of the prescribing guidelines and more than 120,000 copies of print materials, including bookmarks, patient information cards, and posters. STATEWIDE DATA: In 2008, unintentional overdose deaths from prescription opioids dropped 14.0% compared with the number of deaths in 2007. In 2009, the number of deaths remained stable from 2008. The campaign funding ended in May 2009. State agencies have continued collaborating and have pooled money to renew the media campaign in 2011. Evaluation of the impact of the prescribing guidelines is ongoing. CONCLUSIONS: The state-funded educational campaign may have contributed to a reduction in overdose deaths. Collaboration among state agencies and a sustained educational effort are important aspects of a successful prevention campaign.

Recovery of time estimation following moderate to severe traumatic brain injury.

OBJECTIVE: Accurate time estimation abilities are thought to play an important role in efficient performance of many daily activities. This study investigated the role of episodic memory in the recovery of time estimation abilities following moderate to severe traumatic brain injury (TBI). METHOD: Using a prospective verbal time estimation paradigm, TBI participants were tested in the early phase of recovery from TBI and then again approximately one year later. Verbal time estimations were made for filled intervals both within (i.e., 10 s, 25 s) and beyond (i.e., 45 s 60 s) the time frame of working memory. RESULTS: At baseline, when compared to controls, the TBI group significantly underestimated time durations at the 25 s, 45 s and 60 s intervals, indicating that the TBI group perceived less time as having passed than actually had passed. At follow-up, despite the presence of continued episodic memory impairment and little recovery in episodic memory performance, the TBI group exhibited estimates of time passage that were similar to controls. CONCLUSION: The pattern of data was interpreted at suggesting that episodic memory performance did not play a noteworthy role in the recovery of temporal perception in TBI participants.

Assessment of memory self-awareness following traumatic brain injury.

OBJECTIVE: To examine memory self-awareness abilities in individuals with moderate-to-severe traumatic brain injury (TBI) using both 'online assessment' and 'offline assessment' methodologies. DESIGN AND METHODS: Participants were 23 individuals with TBI and 23 controls matched on age, education and sex. Online assessment of memory was assessed by comparing the predicted amount of information participants expected that they would remember following trial 1, trial 5 and a 20-minute delay with actual memory performance on list-learning and visuospatial memory tests. Offline assessment of memory involved contrasting self-ratings provided by TBI participants about their everyday memory functioning with ratings from knowledgeable informants and with performance on objective memory tests. RESULTS: Individuals with TBI displayed poorer recall for newly learned information than control participants, but no significant group differences emerged in the online assessment of memory self-awareness. The offline assessment comparisons similarly demonstrated that the individuals with TBI exhibited accurate awareness for their everyday memory performances. CONCLUSIONS: These findings suggest intact memory self-awareness following moderate-to-severe TBI during the early stages of recovery (2-10 months post-injury).

Mild cognitive impairment and feeling-of-knowing in episodic memory.

This study examined both retrospective and prospective memory self-monitoring abilities in 33 individuals with amnestic mild cognitive impairment (MCI) and 33 healthy older adult controls. Participants learned 36 critical cue-target word pairs. Following a distractor task, participants were asked to recall each target word that corresponded to a given cue word. Confidence ratings were provided for recalled words. For nonrecalled words, feeling-of-knowing judgments about the likelihood of recognizing the target word on a subsequent recognition test were provided. We found that despite poorer episodic memory performance, the MCI individuals demonstrated accurate retrospective self-monitoring of recalled episodic material. In contrast, the MCI participants were less accurate than controls prospectively self-monitoring their memory for newly learned information. These findings suggest that memory self-monitoring is not a unitary construct and that amnestic MCI participants have difficulty with prospective memory self-monitoring abilities.

Predictions of episodic memory following moderate to severe traumatic brain injury during inpatient rehabilitation.

We examined memory self-awareness and memory self-monitoring abilities during inpatient rehabilitation in participants with moderate to severe traumatic brain injury (TBI). A total of 29 participants with moderate to severe TBI and 29 controls matched on age, gender, and education completed a performance prediction paradigm. To assess memory self-awareness, participants predicted the amount of information they would remember before completing list-learning tasks and visual-spatial memory tasks. Memory self-monitoring was assessed by participants' ability to increase accuracy of their predictions after experience with the tests. Although the TBI participants performed more poorly than controls on both episodic memory tasks, no significant group differences emerged in memory self-awareness or memory self-monitoring. The TBI participants predicted that their memory performances would be poorer than that of controls, accurately adjusted their predictions in accordance with the demands of the tasks, and successfully modified their predictions following experience with the tasks. The results indicate that moderate to severe TBI individuals in the early stages of recovery can competently assess the demands of externally driven metamemorial situations and utilize experience with task to accurately update their knowledge of memory abilities.

A policy and environmental response to overweight in childhood: the impact of Gold Medal Schools.

BACKGROUND: The prevalence of overweight among US children and adolescents has increased substantially since 1980. As a result, overweight in childhood and adolescence has become a substantial health problem that requires effective health promotion programs and interventions. CONTEXT: Coinciding with the 2002 Winter Olympic Games in Salt Lake City, the Utah Department of Health (UDOH) developed a pilot program called Gold Medal Schools (GMS) to promote healthy lifestyles among school-aged children. METHODS: The GMS program was designed to help schools develop policies and create healthy school environments to meet specific criteria at 5 levels: bronze, silver, gold, platinum, and platinum focus. Participating schools, mentored by the UDOH, earn incentives to create a healthy school environment. CONSEQUENCES: A total of 316 schools and approximately 166,600 students in 37 Utah school districts have participated in the GMS program. As a result, 1,029 medals have been awarded, 2,205 policies have been developed, and 2,121 environmental changes have been reported since program inception (2001-2002 school year). INTERPRETATION: Because of their participation in the GMS program, schools have developed and implemented a wide range of school-based policies and environmental changes. To improve the program, we recommend enhanced efforts in impact and outcome evaluation and increased participation in vigorous-intensity physical activity during the school day.

Feeling of knowing in episodic memory following moderate to severe closed-head injury.

The ability to accurately monitor one's memory is a metacognitive process that is important in everyday life. The authors examined episodic memory feeling-of-knowing (FOK) ratings in 21 moderate to severe closed-head injury (CHI) participants (more than 1 year postinjury) and 21 controls. Participants studied 36 critical cue-target word pairs. Following a brief delay, they were asked to recall the target that corresponded to a given cue. Confidence ratings were made for recalled words, and FOK judgments were made for nonrecalled words in terms of the likelihood of recognizing the target word on a subsequent recognition test. CHI participants demonstrated less accurate recall but accurate ability to judge their recall performance (retrospective memory monitoring). They also demonstrated intact FOK judgments when providing binary judgments but demonstrated difficulties making finer discriminations on an ordinal scale (prospective memory monitoring). These findings suggest that memory monitoring is not a unitary construct. It is proposed that CHI participants may display intact memory monitoring when predictions are based on familiarity assessment but not when continued probing for additional episodic information is required.

Attention dysfunction and parent reporting in children with brain tumors.

BACKGROUND: The IQ declines observed in children treated for brain tumor emerge as "late effects" and are conceptualized as secondary to changes in underlying mental processes, such as attention. Early identification of the underlying changes might help minimize the long-term adverse outcomes. We evaluated the validity of a time-efficient, standardized parent-report measure in identifying attention dysfunction in childhood brain tumor survivors. PROCEDURE: Seventy survivors between ages 6 and 16 who met eligibility criteria and who had completed a standard neuropsychological evaluation were classified into an attention dysfunction group and a non-attention dysfunction group, based on their performance on objective measures of attention. Analysis of covariance was used to evaluate group differences on the widely used, parent report Child Behavioral Checklist (CBCL). RESULTS: Survivors in the attention dysfunction group were reported by their parents as having significantly more attention problems relative to the group without attention dysfunction on objective testing. Furthermore, survivors categorized as having attention dysfunction based on their neuropsychological test scores were reported on the CBCL by their parents as having significantly more social problems compared to the non-attention dysfunction group. CONCLUSIONS: Standardized parent reporting of attention problems shows promise as a screening tool to detect attention dysfunction among survivors of childhood brain tumors. Findings include a strong association of decreased social functioning with attention dysfunction in brain tumor survivors. Furthermore, exploratory data suggest that the behavioral presentation of attention dysfunction in this group may be different from other clinical groups.