Nurse and Physician Perceptions and Decision Making During Interdisciplinary Communication: Factors That Influence Communication Channel Selection.

Errors in decision making and communication play a key role in poor patient outcomes. Safe patient care requires effective decision making during interdisciplinary communication through communication channels. Research on factors that influence nurse and physician decision making during interdisciplinary communication is limited. Understanding influences on nurse and physician decision making during communication channel selection is needed to support effective communication and improved patient outcomes. The purpose of the study was to explore nurse and physician perceptions of and decision-making processes for selecting interruptive or noninterruptive interdisciplinary communication channels in medical-surgical and intermediate acute care settings. Twenty-six participants (10 RNs, 10 resident physicians, and six attending physicians) participated in semistructured interviews in two acute care metropolitan hospitals for this qualitative descriptive study. The Practice Primed Decision Model guided interview question development and early data analysis. Findings include a core category, Development of Trust in the Communication Process, supported by three main themes: (1) Understanding of Patient Status Drives Communication Decision Making; (2) Previous Interdisciplinary Communication Experience Guides Channel Selection; and (3) Perceived Usefulness Influences Communication Channel Selection. Findings from this study provide support for future design and research of communication channels within the EHR and clinical decision support systems.

Wind from the black-hole accretion disk driving a molecular outflow in an active galaxy.

Powerful winds driven by active galactic nuclei are often thought to affect the evolution of both supermassive black holes and their host galaxies, quenching star formation and explaining the close relationship between black holes and galaxies. Recent observations of large-scale molecular outflows in ultraluminous infrared galaxies support this quasar-feedback idea, because they directly trace the gas from which stars form. Theoretical models suggest that these outflows originate as energy-conserving flows driven by fast accretion-disk winds. Proposed connections between large-scale molecular outflows and accretion-disk activity in ultraluminous galaxies were incomplete because no accretion-disk wind had been detected. Conversely, studies of powerful accretion-disk winds have until now focused only on X-ray observations of local Seyfert galaxies and a few higher-redshift quasars. Here we report observations of a powerful accretion-disk wind with a mildly relativistic velocity (a quarter that of light) in the X-ray spectrum of IRAS F11119+3257, a nearby (redshift 0.189) optically classified type 1 ultraluminous infrared galaxy hosting a powerful molecular outflow. The active galactic nucleus is responsible for about 80 per cent of the emission, with a quasar-like luminosity of 1.5 × 10(46) ergs per second. The energetics of these two types of wide-angle outflows is consistent with the energy-conserving mechanism that is the basis of the quasar feedback in active galactic nuclei that lack powerful radio jets (such jets are an alternative way to drive molecular outflows).

Efficiency Metrics at an Academic Freestanding Ambulatory Surgery Center: Analysis of the Impact on Scheduled End-Times.

BACKGROUND: Understanding the impact of key metrics on operating room (OR) efficiency is important to optimize utilization and reduce costs, particularly in freestanding ambulatory surgery centers. The aim of this study was to assess the association between commonly used efficiency metrics and scheduled end-time accuracy. METHODS: Data from patients who underwent surgery from May 2018 to June 2019 at an academic freestanding ambulatory surgery center was extracted from the medical record. Unique operating room days (ORDs) were analyzed to determine (1) duration of first case delays, (2) turnover times (TOT), and (3) scheduled case duration accuracies. Spearman's correlation coefficients and mixed-effects multivariable linear regression were used to assess the association of each metric with scheduled end-time accuracy. RESULTS: There were 1378 cases performed over 300 unique ORDs. There were 86 (28.7%) ORDs with a first case delay, mean (standard deviation [SD]) 11.2 minutes (15.1 minutes), range of 2-101 minutes; the overall mean (SD) TOT was 28.1 minutes (19.9 minutes), range of 6-83 minutes; there were 640 (46.4%) TOT >20 minutes; the overall mean (SD) case duration accuracy was -6.6 minutes (30.3 minutes), range of -114 to 176; and there were 389 (28.2%) case duration accuracies ≥30 minutes. The mean (SD) scheduled end-time accuracy was 6.9 minutes (68.3 minutes), range of -173 to 229 minutes; 48 (15.9%) ORDs ended ≥1 hour before scheduled end-time and 56 (18.6%) ORDs ended ≥1 hour after scheduled end-time. The total case duration accuracy was strongly correlated with the scheduled end-time accuracy (r = 0.87, 95% confidence interval [CI], 0.84-0.89, P < .0001), while the total first case delay minutes (r = 0.12, 95% CI, 0.01-0.21, P = .04) and total turnover time (r = -0.16, 95% CI, 0.21-0.05, P = .005) were less relevant. Case duration accuracy had the highest association with the dependent variable (0.95 minutes changed in the difference between actual and schedule end time per minute increase in case duration accuracy, 95% CI, 0.90-0.99, P < .0001), compared to turnover time (estimate = 0.87, 95% CI, 0.75-0.99, P < .0001) and first case delay time (estimate = 0.83, 95% CI, 0.56-1.11, P < .0001). CONCLUSIONS: Standard efficiency metrics are similarly associated with scheduled end-time accuracy, and addressing problems in each is requisite to having an efficient ambulatory surgery center. Pursuing methods to narrow the gap between scheduled and actual case duration may result in a more productive enterprise.

Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm.

The telehealth revolution in response to COVID-19 has increased essential health care access during an unprecedented public health crisis. However, virtual patient care can also limit the patient-provider relationship, quality of examination, efficiency of health care delivery, and overall quality of care. As we witness the most rapidly adopted medical trend in modern history, clinicians are beginning to comprehend the many possibilities of telehealth, but its limitations also need to be understood. As outcomes are studied and federal regulations reconsidered, it is important to be precise in the virtual patient encounter approach. Herein, we offer some simple guidelines that could assist health care providers and clinic schedulers in determining the appropriateness of a telehealth visit by considering visit types, patient characteristics, and chief complaint or disease states.

Landscape scale heterogeneity in the East Turkana ecosystem during the Okote Member (1.56-1.38 Ma).

Placing the biological adaptations of Pleistocene hominins within a well-resolved ecological framework has been a longstanding goal of paleoanthropology. This effort, however, has been challenging due to the discontinuous nature of paleoecological data spanning many important periods in hominin evolution. Sediments from the Upper Burgi (1.98-1.87 Ma), KBS (1.87-1.56 Ma) and Okote (1.56-1.38 Ma) members of the Koobi Fora Formation at East Turkana in northern Kenya document an important time interval in the evolutionary history of the hominin genera Homo and Paranthropus. Although much attention has been paid to Upper Burgi and KBS member deposits, far less is known regarding the East Turkana paleoecosystem during Okote Member times. This study pairs spatially-resolved faunal abundance data with stable isotope geochemistry from mammalian enamel to investigate landscape-scale ecosystem variability during Okote Member times. We find that during this period 1) taxa within the East Turkana large mammal community were distributed heterogeneously across space, 2) the abundance of C3 and C4 vegetation varied between East Turkana subregions, and 3) the Karari subregion, an area with abundant evidence of hominin stone tool manufacture, had significantly more C3 vegetation than regions closer to the central axis of the Turkana Basin (i.e., Ileret and Koobi Fora). These findings indicate that the East Turkana paleoecosystem during the Okote Member was highly variable across space and provided a complex adaptive landscape for Pleistocene hominins.

Disseminated Streptococcus pneumoniae infection involving a ventricular assist device.

We describe the first reported case, to our knowledge, of disseminated pneumococcal infection involving a left ventricular assist device (LVAD). The management of this infection was extremely challenging, requiring multiple surgical debridements, LVAD removal, and prolonged courses of antibiotics. The Streptococcus pneumoniae isolate was found to be serotype 19F, which is included in both the pneumococcal polysaccharide and conjugate vaccines. This report highlights the importance of routine screening for up-to-date vaccination in patients who undergo LVAD implantation.

Safety of intravenous metoprolol use in unmonitored wards: a single-centre observational study.

BACKGROUND AND AIM: This study aims to examine and quantify the risks associated with the use of intravenous metoprolol on unmonitored wards. METHOD: This study was a retrospective single-centre observational study from 1 January 2009 to 31 December 2013. The study hospital was a 415-bed, private hospital in Melbourne, Victoria. The study population was all patients who received intravenous metoprolol on an unmonitored ward. The primary outcome measure was the rate of serious adverse events (SAE), defined as a complication of intravenous metoprolol resulting in transfer to a critical-care environment, a medical emergency team call or death. RESULTS: Six hundred and nine patients received a total of 8260 doses of intravenous metoprolol. Seven cases were identified with a SAE deemed possibly related to beta-blocker use and there was one death. All SAE were hypotension, giving an overall rate of hypotension of 7/609 or 1.1% (95% confidence interval (CI), 0.5 to 2.4%) with a rate per dose delivered of 0.8/1000 doses (95% CI 0.3 to 1.7). The death occurred in a 94-year-old woman with abdominal sepsis. After case file review, consensus opinion deemed this to be unrelated to intravenous metoprolol. CONCLUSION: The use of intravenous metoprolol on unmonitored wards appears to be safe. The complication rate was low, suggesting that this may be a sensible approach to the management of in-hospital populations at risk of beta-blocker withdrawal.

Estimation of inbreeding and effective population size of full-blood Wagyu cattle registered with the American Wagyu Cattle Association.

The objective of this research was to examine the population structure of full-blood (100%) Wagyu cattle registered in the United States with the American Wagyu Association, with the aim of estimating and comparing the levels of inbreeding from both pedigree and genotypic data. A total of 4132 full-blood Wagyu cattle pedigrees were assessed and used to compute the inbreeding coefficients (FIT and FST ) and the effective population size (Ne ) from pedigree data for the period 1994 to 2011. In addition to pedigree analysis, 47 full-blood Wagyu cattle representing eight prominent sire lines in the American Wagyu cattle population were genotyped using the Illumina BovineSNP50 BeadChip. Genotypic data were then used to estimate genomic inbreeding coefficients (FROH ) by calculating runs of homozygosity. The mean inbreeding coefficient based on the pedigree data was estimated at 4.80%. The effective population size averaged 17 between the years 1994 and 2011 with an increase of 42.9 in 2000 and a drop of 1.8 in 2011. Examination of the runs of homozygosity revealed that the 47 Wagyu cattle from the eight prominent sire lines had a mean genomic inbreeding coefficient (FROH ) estimated at 9.08% compared to a mean inbreeding coefficient based on pedigree data of 4.8%. These data suggest that the mean genotype inbreeding coefficient of full-blood Wagyu cattle exceeds the inbreeding coefficient identified by pedigree. Inbreeding has increased slowly at a rate of 0.03% per year over the past 17 years. Wagyu breeders should continue to utilize many sires from divergent lines and consider outcrossing to other breeds to enhance genetic diversity and minimize the adverse effects of inbreeding in Wagyu.

Call me Ishmael: addressing the white whale of team communication in the operating room with labelled surgical caps at an academic medical centre.

INTRODUCTION: Effective communication in the operating room (OR) is crucial. Addressing a colleague by their name is respectful, humanising, entrusting and associated with improved clinical outcomes. We aimed to enhance team communication in the perioperative environment by offering personalised surgical caps labelled with name and provider role to all OR team members at a large academic medical centre. MATERIALS AND METHODS: This was a quasi-experimental, uncontrolled, before-and-after quality improvement study. A survey regarding perceptions of team communication, knowledge of names and roles, communication barriers, and culture was administered before and after cap delivery. Survey results were measured on a 5-point Likert Scale; descriptive statistics and mean scores were compared. All cause National Surgical Quality Improvement Project (NSQIP) morbidity and mortality outcomes for surgical specialties were examined. RESULTS: 1420 caps were delivered across the institution. Mean survey scores increased for knowing the names and roles of providers around the OR, feeling that people know my name and feeling comfortable communicating without barriers across disciplines. The mean score for team communication around the OR is excellent was unchanged. The highest score both before and after was knowing the name of an interdisciplinary team member is important for patient care. A total of 383 and 212 providers participated in the study before and after cap delivery, respectively. Participants agreed or strongly agreed that labelled surgical caps made it easier to talk to colleagues (64.9%) while improving communication (66.0%), team culture (60.5%) and patient care (56.8%). No significant differences were noted in NSQIP outcomes. CONCLUSIONS: Personalised labelled surgical caps are a simple, inexpensive tool that demonstrates promise in improving perioperative team communication. Creating highly reliable surgical teams with optimal communication channels requires a multifaceted approach with engaged leadership, empowered front-line providers and an institutional commitment to continuous process improvement.

Variation among arthropod taxa in the amino acid content of exoskeleton and digestible tissue.

Arthropod consumption provides amino acids to invertebrates and vertebrates alike, but not all amino acids in arthropods may be digestible as some are bound in the exoskeleton. Consumers may not be able to digest exoskeleton in significant amounts or avoid it entirely (e.g., extraoral digestion). Hence, measures that do not separate digestible amino acids from those in exoskeleton may not accurately represent the amino acids available to consumers. Additionally, arthropods are taxonomically diverse, and it remains unclear if taxonomic differences also reflect differences in amino acid availability. Thus, we tested: (1) if there were consistent differences in the content and balance of amino acids between the digestible tissue and exoskeleton of arthropods and (2) if arthropod Orders differ in amino acid content and balance. We measured the amino acid content (mg/100 mg dry mass) and balance (mg/100 mg protein) of whole bodies and exoskeleton of a variety of arthropods using acid hydrolysis. Overall, there was higher amino acid content in digestible tissue. There were also significant differences in the amino acid balance of proteins in digestible tissue and exoskeleton. Amino acid content and balance also varied among Orders; digestible tissues of Hemiptera contained more of some essential amino acids than other Orders. These results demonstrate that arthropod taxa vary in amino acid content, which could have implications for prey choice by insectivores. In addition, exoskeleton and digestible tissue content differ in arthropods, which means that whole body amino acid content of an arthropod is not necessarily a predictor of amino acid intake of a predator that feeds on that arthropod.

Surgery and Anesthesia Preoperative "Virtual Huddle": A Pilot Trial to Enhance Communication across the Drape.

OBJECTIVES: Effective communication between surgeons and anesthesiologists is critical for high-quality, safe, and efficient perioperative patient care. Despite widespread implementation of surgical safety checklists and time-outs, ineffective team communication remains a leading cause of patient safety events in the operating room. To promote effective communication, we conducted a pilot trial of a "virtual huddle" between anesthesiologists and surgeons. METHODS: Attending anesthesiologists and surgeons at an academic medical center were recruited by email to participate in this feasibility trial. An electronic health record-based smartphone application was utilized to create secure group chats among trial participants the day before a surgery. Text notifications connected a surgeon/anesthesiologist pair in order to introduce colleagues, facilitate a preoperative virtual huddle, and enable open-ended, text message-based communication. A 5-point Likert scale-based survey with a free-text component was used to evaluate the utility of the virtual huddle and usability of the electronic platform. RESULTS: A total of 51 unique virtual huddles occurred between 16 surgeons and 12 anesthesiologists over 99 operations. All postintervention survey questions received a positive rating (range: 3.50/5.00-4.53/5.00) and the virtual huddle was considered to be easy to use (4.47/5.00), improve attending-to-attending communication (4.29/5.00), and improve patient care (4.22/5.00). There were no statistically significant differences in the ratings between surgery and anesthesia. In thematic analysis of qualitative survey results, Participants indicated the intervention was particularly useful in interdisciplinary relationship-building and reducing room turnover. The huddle was less useful for simple, routine cases or when participation was one sided. CONCLUSION: A preoperative virtual huddle may be a simple and effective intervention to improve communication and teamwork in the operating room. Further study and consideration of broader implementation is warranted.

Anesthesia providers' perspectives on abortion provision: deductive findings from a qualitative study.

INTRODUCTION: A clinician's willingness to provide abortion care is complex. Anesthesia providers' experiences in providing anesthesia for abortion are not well studied. We aimed to explore anesthesia providers' perspectives on abortion provision. METHODS: We conducted semi-structured, qualitative interviews with currently practising anesthesia providers in the southeastern United States. Participants were recruited from scientific meetings of two regional anesthesiology organizations and via snowball sampling. A semi-structured interview guide included domains of standardized second trimester abortion cases and personal abortion attitudes. Data were coded and analyzed iteratively using both inductive and deductive approaches with MAXQDA software. Deductive results are presented. RESULTS: Fifteen participants completed interviews from February 2018 to February 2019, at which point thematic saturation occurred. Participants represented a range of provider type, years of experience, workplace setting, and prior abortion experience. Participants demonstrated varied personal abortion attitudes, with greater acceptability of maternal or fetal health indications than social or financial indications for abortion. Most participants were willing to provide anesthesia for abortion in specific clinical scenarios. CONCLUSIONS: Southeastern United States anesthesia providers hold a spectrum of personal views on abortion and are willing to provide anesthesia for second trimester abortion in specific clinical scenarios. Findings may inform future research or professional development activities, which are important efforts toward improving multidisciplinary abortion care.

Bringing student health and Well-Being onto a health system EHR: the benefits of integration in the COVID-19 era.

ObjectiveTo detail the implementation, benefits and challenges of onboarding campus-based health services onto a health system's electronic health record.ParticipantsUC San Diego Student Health and Well-Being offers medical services to over 39,000 students. UC San Diego Health is an academic medical center.Methods20 workstreams and 9 electronic modules, systems, or interfaces were converted to new electronic systems.Results36,023 student-patient medical records were created. EHR-integration increased security while creating visibility to 19,700 shared patient visits and records from 236 health systems across the country over 6 months. Benefits for the COVID-19 response included access to screening tools, decision support, telehealth, patient alerting system, reporting and analytics, COVID-19 dashboard, and increased testing capabilities.ConclusionIntegration of an interoperable EHR between neighboring campus-based health services and an affiliated academic medical center can streamline case management, improve quality and safety, and increase access to valuable health resources in times of need. Pertinent examples during the COVID-19 pandemic included uninterrupted and safe provision of clinical services through access to existing telehealth platforms and increased testing capacity.

A Novel Fellowship in Perioperative Administration, Quality and Informatics: A Pilot Experience for Training Surgical Leaders.

Value-based, outcome-oriented care supported with innovative technology is the future of surgery. We established a novel fellowship in Perioperative Administration, Quality, and Informatics. The aim is to equip future surgeon scholars with the requisite knowledge base and skillset to serve as institutional leaders capable of transforming surgical healthcare delivery. The model was designed as a project-based, "operations-focused" education with supplemental didactics and mentored by surgical leaders and institutional executives. We describe our initial experience, successes, and challenges such that a similar model may be replicated elsewhere.

The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy.

BACKGROUND: Early experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease. METHODS: A Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n = 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year. RESULTS: The model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year. CONCLUSION: The current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.

Questionnaire measures of self-directed ageing stereotype in older adults: a systematic review of measurement properties.

The population is ageing, but while average life expectancy continues to increase, healthy life expectancy has not necessarily matched this and negative ageing stereotypes remain prevalent. Self-directed ageing stereotypes are hypothesised to play an important role in older adults' health and well-being; however, a wide variety of terms and measures are used to explore this construct meaning there is a lack of clarity within the literature. A review was conducted to identify tools used to measure self-directed ageing stereotype in older adults and evaluate their quality. Searches identified 109 papers incorporating 40 different measures. Most common were the Philadelphia Geriatric Centre Morale Scale Attitude Towards Own Ageing (ATOA) subscale, Ageing Perceptions Questionnaire (APQ) and Attitudes to Ageing Questionnaire. Despite being most frequently used, the ATOA was developed to measure morale in older adults rather than self-directed ageing stereotypes. Over 25 terms were used to describe the concept, and it is suggested that for consistency the term "self-directed ageing stereotype" be adopted universally. Across measures, poor reporting of psychometric properties made it difficult to assess scale quality and more research is needed to fully assess measures before conclusions can be drawn as to the best tool; however, the Brief-APQ appears to hold most promise. Future research must address this issue before interventions to reduce negative self-directed ageing stereotypes can be developed and fully evaluated.

Functional status as a marker of need for hospital admission following outpatient hernia repair.

INTRODUCTION: The careful selection of patients for hernia repair in ambulatory surgery centres is critical to prevent unanticipated inpatient admissions. The aim of this study was to evaluate risk factors associated with inpatient admission. METHODS: A multivariable logistic regression was performed utilising the ACS NSQIP database from 2007 to 2016. The primary outcome was same-day hospital discharge. The primary exposure variable was preoperative functional status. Additional covariates included sex, obesity, age, smoking status, steroid use, dyspnoea, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, hypertension, bleeding disorder, dialysis-dependence and American Society of Anesthesiologists classification score. RESULTS: A total of 194,822 patients underwent hernia repair in the outpatient setting; 8705 (4.5%) required hospital admission. The variables with the most significantly increased odds for hospital admission were partially dependent and totally dependent preoperative functional status. CONCLUSION: A non-independent baseline functional status is the strongest predictor of need for admission following outpatient hernia repair.

The Clinical Information Systems Response to the COVID-19 Pandemic.

OBJECTIVE: The year 2020 was predominated by the coronavirus disease 2019 (COVID-19) pandemic. The objective of this article is to review the areas in which clinical information systems (CIS) can be and have been utilized to support and enhance the response of healthcare systems to pandemics, focusing on COVID-19. METHODS: PubMed/MEDLINE, Google Scholar, the tables of contents of major informatics journals, and the bibliographies of articles were searched for studies pertaining to CIS, pandemics, and COVID-19 through October 2020. The most informative and detailed studies were highlighted, while many others were referenced. RESULTS: CIS were heavily relied upon by health systems and governmental agencies worldwide in response to COVID-19. Technology-based screening tools were developed to assist rapid case identification and appropriate triaging. Clinical care was supported by utilizing the electronic health record (EHR) to onboard frontline providers to new protocols, offer clinical decision support, and improve systems for diagnostic testing. Telehealth became the most rapidly adopted medical trend in recent history and an essential strategy for allowing safe and effective access to medical care. Artificial intelligence and machine learning algorithms were developed to enhance screening, diagnostic imaging, and predictive analytics - though evidence of improved outcomes remains limited. Geographic information systems and big data enabled real-time dashboards vital for epidemic monitoring, hospital preparedness strategies, and health policy decision making. Digital contact tracing systems were implemented to assist a labor-intensive task with the aim of curbing transmission. Large scale data sharing, effective health information exchange, and interoperability of EHRs remain challenges for the informatics community with immense clinical and academic potential. CIS must be used in combination with engaged stakeholders and operational change management in order to meaningfully improve patient outcomes. CONCLUSION: Managing a pandemic requires widespread, timely, and effective distribution of reliable information. In the past year, CIS and informaticists made prominent and influential contributions in the global response to the COVID-19 pandemic.