Exploring Distress Caused by Blame for a Negative Patient Outcome.

OBJECTIVE: The aim of this study was to explore blame-related distress (B-RD). BACKGROUND: No research exists describing the incidence and characteristics of consequences of blame. METHODS: Survey research was used to explore the incidence, characteristics, and consequences of the distress caused by blame in the workplace. RESULTS: B-RD is prevalent among intensive care and oncology staff. Participants reported an organizational impact to B-RD in terms of staff morale, turnover, and employee health. Management, physicians, and peers were the most frequently cited source of blame. CONCLUSIONS: A proposed model is described to relate blame to other similar constructs.

Comparing nurse practitioners/physician assistants and physicians in diagnosing pediatric abdominal pain for ESI level 3 patients seen in the emergency department.

BACKGROUND: Accuracy of emergency department (ED) diagnosis affects care management including tests, discharges, and readmissions. PURPOSE: This retrospective study compared nurse practitioners/physician assistants (NPs/PAs) with physicians (MDs/DOs) on accuracy of diagnosing Emergency Severity Index (ESI) level 3 pediatric abdominal pain (AP) in the ED. Abdominal pain unrelated to trauma is a common ED pediatric visit. METHODOLOGY: Data acquired from four hospital sites of a multistate emergency group examined patients younger than 18 years who were initially admitted for AP ESI level 3. RESULTS: The accuracy of AP ESI level 3 diagnoses was 94.9%, 90.9%, and 96.5% by physicians, NPs/PAs, and a collaboration of NP/PA/physician, respectively (χ2 = 13.187, p < .001). Accuracy of AP ESI level 3 diagnoses was greater with general admissions, intensive care unit admissions, transfers, or left against medical advice (100%) than with those who were discharged (χ2 = 11.058, p = .001). Abdominal pain complaints were segmented into five areas (i.e., AP, back pain, chest pain, epigastric pain, and pelvic pain). Irrespective of provider, those with a final diagnosis of AP or epigastric pain were correctly triaged and those with a final diagnosis of chest or back pain were incorrectly triaged as AP ESI level 3. CONCLUSIONS: When comparing providers in this subset (n = 43), there was no significant difference in the accuracy of assigning AP ESI level 3 (χ2 = 0.467, p = .495). IMPLICATIONS: Only cases with a final diagnosis of pelvic/genitourinary pain saw disparity in the accuracy (27 correct, 16 incorrect, χ2 = 1,681.80, p < .001).

A bedside ultrasound sign of cardiac disease: the left atrium-to-aorta diastolic diameter ratio.

PURPOSE: This study evaluated a simple ultrasound method to detect left atrial (LA) enlargement by comparing the diameters of the LA and aortic root. PROCEDURES: The LA and aortic diameters, the LA volume index (LAVI), and significant echo findings were analyzed in 101 consecutive echocardiograms. Mean LAVI and the prevalence of an abnormal echo were compared between groups in which the ratio of the LA diameter to aortic diameter in diastole was >1 vs < or = 1. FINDINGS: Left atrial-to-aortic diameter ratio increased with LAVI (r = 0.64, P < .001). Left atrial-to-aortic diameter ratio >1 vs < or = 1 was noted in 45% vs 55% of patients and had a mean (+ or - SD) LAVI = 39 + or - 12 vs 27 + or - 7 mL/m(2) (P < .001) and a 78% vs 43% prevalence of an abnormal echo (P < .001). CONCLUSION: The left atrium-to-aorta diastolic diameter ratio can detect LA enlargement and may be useful as a quick bedside technique to screen for cardiac disease.

Effect of morbidity and mortality peer review on nurse accountability and ventilator-associated pneumonia rates.

OBJECTIVE: This program was designed to evaluate the effect of morbidity and mortality peer review conferences (MMPRCs) for ventilator-associated pneumonia (VAP) on nurse accountability and compliance with evidence-based VAP prevention practices. BACKGROUND: Ventilator-associated pneumonia is associated with longer average length of stay (ALOS), greater cost, and increased morbidity and mortality. Traditionally, passive or punitive methods have been used to reduce undesirable outcomes. The MMPRC is not a conventional nursing intervention. METHODS: Each MMPRC included case history, relevant hospital course, diagnostic comorbidities, and compliance with VAP prevention strategies. The preventability of each VAP was determined by RN peers. Ventilator days, VAP bundle compliance, VAP incidence, ICU ALOS, cost, and satisfaction data were collected. RESULTS: Nurse accountability improved significantly (chi(2)= 24.041, P < .001), and VAP incidence was reduced. Data demonstrated satisfaction with the MMPRC. Number of ventilator days and ALOS did not change significantly, although VAP bundle compliance improved from 90.1% to 95.2%. CONCLUSIONS: The nonpunitive MMPRC process was cost-effective and should be considered for other nurse-sensitive indicators to increase nurse accountability and improve outcomes.

Value of a cardiovascular limited ultrasound examination using a hand-carried ultrasound device on clinical management in an outpatient medical clinic.

Limited ultrasound imaging studies using hand-carried ultrasound devices at the point of care have individually shown feasibility in the detection of carotid atheroma, left ventricular systolic dysfunction, left atrial enlargement, and abdominal aortic aneurysm. To evaluate the utility of a specific cardiovascular limited ultrasound examination (CLUE) designed to detect all 4 entities in patients seen in an outpatient medical clinic. One hundred ninety-six patients underwent coronary heart disease risk stratification by National Cholesterol Education Program guidelines and CLUE with a hand-carried ultrasound device with cardiac and vascular transducers. CLUE included brief imaging of the carotid arteries, the heart, and the intra-abdominal aorta. The prevalence of abnormal CLUE results and their effect on clinical management were tabulated and stratified by coronary heart disease risk class. Patient age (mean +/- SD) was 56 +/- 14 years (range 22 to 95), and 32.1% were at low risk, 30.6% at intermediate risk, and 37.2% at high risk. Of the 196 CLUEs, abnormalities were present in 37.2% (32.7% had carotid atheroma, 3.1% had systolic dysfunction, 6.1% had left atrial enlargement, and 1.0% had abdominal aortic aneurysm) and were related to age, increasing coronary heart disease risk, and male gender. Overall, CLUE resulted in new management recommendations in 20% of patients, primarily in coronary heart disease risk prevention. In patients at intermediate risk or aged 60 to 69 years, CLUE resulted in new recommendations in 39% and 37%, respectively. In conclusion, when applied to a clinic population, brief cardiovascular ultrasound exams frequently demonstrate unsuspected findings that can change management.

Workplace Blame and Related Concepts: An Analysis of Three Case Studies.

Blame has been thought to affect quality by decreasing error reporting. Very little is known about the incidence, characteristics, or consequences of the distress caused by being blamed. Blame-related distress (B-RD) may be related to moral distress, but may also be a factor in burnout, compassion fatigue, lateral violence, and second-victim syndrome. The purpose of this article is to explore these related concepts through a literature review applied to three index critical care clinician cases.

The magnitude and nature of unfunded published cardiovascular research.

OBJECTIVES: The aim of this study was to determine the extent, type (e.g., staff, equipment), and sources of funding for published cardiovascular research. BACKGROUND: Important cardiovascular research is often performed without direct financial support. The degree to which medical research is conducted on an unfunded basis remains uncertain. METHODS: We sent an electronic survey (Survey Monkey) to 938 corresponding authors who published papers in the Journal of the American College of Cardiology from 2007 through 2009. The data sought included the authors' characteristics (e.g., age, institution, type of research), funding, sources of funding, and types of support for their research. RESULTS: The response rate was 41% (388 of 938). The percentage of authors who were fully funded was 26%, 44.1% were partially funded, and those without any direct funding amounted to 30%. Most funding came from government (41.8%) and industry (35.1%), whereas institutional, foundation, association, philanthropy, and other grants contributed the remaining 23.1%. Funded authors received supplies (43.6%), staff (41.5%), and salary (39.7%) to a greater extent than equipment (27.3%) or administrative (24.7%) support. Significantly fewer authors 40 years of age or younger (24.3%) were partially funded relative to authors older than 40 years of age (≥ 47%) (p = 0.001). Significantly fewer authors from a community hospital (0%), from Europe (16.7%), or conducting interventional (7.3%) or heart rhythm (11.5%) studies were fully funded (all p < 0.05). Although only a trend, clinical investigators were more likely to be unfunded (35.7%) relative to basic/basic and clinical investigators (19.1%) (p = 0.001). Those significantly more likely to be fully funded were authors from the United States (35.3%) relative to non-American authors (≤ 28.6%) (p = 0.006). In addition, authors received more funding working in a government or VA hospital (45.9%) than nongovernment hospitals (≤ 27.1%) (p = 0.001). The authors who were 50 years of age or older, from the United States, had PhD degrees, doing basic as well as clinical research, or studying genetics/genomics had significantly more sources of funding and types of support (all p < 0.05). CONCLUSIONS: Considerable published cardiovascular research is currently being conducted without direct financial support. This is particularly true for young clinical investigators. The inability to accommodate this investigation in the medical enterprise might substantially diminish the amount of new knowledge coming forth.

Feasibility of remote real-time guidance of a cardiac examination performed by novices using a pocket-sized ultrasound device.

Background. The potential of pocket-sized ultrasound devices (PUDs) to improve global healthcare delivery is limited by the lack of a suitable imaging protocol and trained users. Therefore, we investigated the feasibility of performing a brief, evidence-based cardiac limited ultrasound exam (CLUE) through wireless guidance of novice users. Methods. Three trainees applied PUDs on 27 subjects while directed by an off-site cardiologist to obtain a CLUE to screen for LV systolic dysfunction (LVSD), LA enlargement (LAE), ultrasound lung comets (ULC+), and elevated CVP (eCVP). Real-time remote audiovisual guidance and interpretation by the cardiologist were performed using the iPhone 4/iPod (FaceTime, Apple, Inc.) attached to the PUD and transmitted data wirelessly. Accuracy and technical quality of transmitted images were compared to on-site, gold-standard echo thresholds. Results. Novice versus sonographer imaging yielded technically adequate views in 122/135 (90%) versus 130/135 (96%) (P < 0.05). CLUE's combined SN, SP, and ACC were 0.67, 0.96, and 0.90. Technical adequacy (%) and accuracy for each abnormality (n) were LVSD (85%, 0.93, n = 5), LAE (89%, 0.74, n = 16), ULC+ (100%, 0.94, n = 5), and eCVP (78%, 0.91, n = 1). Conclusion. A novice can perform the CLUE using PUD when wirelessly guided by an expert. This method could facilitate PUD use for off-site bedside medical decision making and triaging of patients.

Teaching cost-conscious medicine: impact of a simple educational intervention on appropriate abdominal imaging at a community-based teaching hospital.

BACKGROUND: Rising costs pose a major threat to US health care. Residency programs are being asked to teach residents how to provide cost-conscious medical care. METHODS: An educational intervention incorporating the American College of Radiology appropriateness criteria with lectures on cost-consciousness and on the actual hospital charges for abdominal imaging was implemented for residents at Scripps Mercy Hospital in San Diego, CA. We hypothesized that residents would order fewer abdominal imaging examinations for patients with complaints of abdominal pain after the intervention. We analyzed the type and number of abdominal imaging studies completed for patients admitted to the inpatient teaching service with primary abdominal complaints for 18 months before (738 patients) and 12 months following the intervention (632 patients). RESULTS: There was a significant reduction in mean abdominal computed tomography (CT) scans per patient (1.7-1.4 studies per patient, P < .001) and total abdominal radiology studies per patient (3.1-2.7 studies per patient, P  =  .02) following the intervention. The avoidance of charges solely due to the reduction in abdominal CT scans following the intervention was $129 per patient or $81,528 in total. CONCLUSIONS: A simple educational intervention appeared to change the radiologic test-ordering behavior of internal medicine residents. Widespread adoption of similar interventions by residency programs could result in significant savings for the health care system.

Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination.

BACKGROUND: Despite the future potential of using ultrasound stethoscopes to augment the bedside cardiac physical, few data exist on a general cardiovascular imaging protocol that can be taught to physicians on a perpetual basis as a curriculum in graduate medical education. METHODS: During the past decade, we developed and integrated a cardiovascular limited ultrasound training program within the confines of an internal medicine residency. The evidence-based rationale for the exam, the teaching methods, and curriculum are delineated, and subsequent observations regarding program requirements, proficiency, and academic outcomes are explored. Analysis of variance and linear regression assessed for relationships between academic scores, chief resident selection, and gender to proficiency in ultrasound. RESULTS: A brief, 5-minute cardiovascular limited ultrasound exam (CLUE) was taught using both didactic and bedside methods, and practiced primarily within the cardiology consult, outpatient clinic, and intensive care rotations. Program costs were minimized by employing readily available institutional resources. After a 2-year lead-in training phase, the subsequent 4 years of senior resident performance (n = 41 residents) showed an 81% pass rate in CLUE competency. Resident ultrasound performance did not relate to academic scores (r = 0.05, P = 0.75), chief resident selection, nor gender. Observations regarding resident pitfalls in CLUE practice and increased participation in extracurricular research are described. CONCLUSIONS: We report our initial experience in developing and implementing a training program for bedside cardiovascular ultrasound examination that employed evidence-based techniques, set proficiency goals, and assessed resident performance. It may be feasible to teach future internist-hospitalists the technique of bedside ultrasound during residency.