Capturing the emotional and social experiences of COVID-19 through journal entries: A qualitative study of COVID-19 experiences over six weeks following infection.

COVID-19's wide-ranging effects on patients' physical health are well-documented, but comparatively less research has explored the impact on patients' emotional and social experiences. We examined how patients across a multi-state health system experience the emotional and social aspects of COVID-19 during the first six weeks of recovery from infection. We leveraged the larger My COVID Diary project to capture open-ended journal data from an app-based platform available to patients who test positive for COVID-19 within the health system. Our sample was limited to participants with multiple journal entries during the first six weeks after infection, with one entry in the top 5% of all participants for word count to ensure sufficient journal content was available for analysis. We randomly selected 100 eligible participants and coded and analyzed all of their journal entries in weeks 1-6 after infection, utilizing a thematic analysis approach. Despite journal entry prompts' orientation towards physical symptoms, the majority of participants discussed emotional experiences (such as anxiety, depression, and gratitude) and social factors (such as work and family) when describing their COVID-19-related experiences. Physical, emotional, and social experiences related to COVID-19 infection and recovery were often interconnected and overlapping. These findings demonstrate that a holistic understanding of the patient experience that extends beyond physical symptoms is necessary to fully support patient care and recovery.

Outpatient advance care planning for patients with metastatic cancer: a pilot quality improvement initiative.

BACKGROUND: Despite American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines recommending that oncologists discuss advance care planning (ACP) with patients with stage IV cancer early in treatment, in standard practice ACP remains a late step of a terminal illness. ACP preserves comfort and dignity at the end of life, ensuring patients receive the care that they desire. METHODS AND MATERIALS: A feasibility study in patients with stage IV cancer was developed to test whether incorporating ACP immediately after a stage IV cancer diagnosis is feasible. Inclusion criteria were consecutive new gastrointestinal and thoracic oncology patients treated by one of two oncologists. The project included creation of new workflow; development of an ACP patient education guidebook; training seminars for oncology staff; and enhancements to the electronic health record (EHR) to improve ACP documentation. RESULTS: The oncologists recorded 33 of 48 (69%) advance directive notes (ADNs) and 22 of 48 (46%) code status orders (CSOs) in the EHR of patients newly diagnosed with stage IV cancer by following ACP protocol during the 6-month trial period. Twenty-one of 33 ADNs were entered within 7 days of first consultation. The median time to ADN placement was 1 day after consultation. Twenty-two of 33 patients with ADNs had CSOs placed, of which 16 were do-not-resuscitate (DNR) and 6 were full code. One year prior to the feasibility study, only 1 of 75 deceased patients of the two oncologists had outpatient ADNs and CSOs. CONCLUSIONS: Outpatient ACP is feasible early in the care of patients with stage IV cancer through systematic improvement in workflow and motivated providers. Education and infrastructure were pivotal to routine development of advance care plans.

A technology-based quality innovation to identify undiagnosed hypertension among active primary care patients.

PURPOSE: The goal of this study was to develop a technology-based strategy to identify patients with undiagnosed hypertension in 23 primary care practices and integrate this innovation into a continuous quality improvement initiative in a large, integrated health system. METHODS: In phase 1, we reviewed electronic health records (EHRs) using algorithms designed to identify patients at risk for undiagnosed hypertension. We then invited each at-risk patient to complete an automated office blood pressure (AOBP) protocol. In phase 2, we instituted a quality improvement process that included regular physician feedback and office-based computer alerts to evaluate at-risk patients not screened in phase 1. Study patients were observed for 24 additional months to determine rates of diagnostic resolution. RESULTS: Of the 1,432 patients targeted for inclusion in the study, 475 completed the AOBP protocol during the 6 months of phase 1. Of the 1,033 at-risk patients who remained active during phase 2, 740 (72%) were classified by the end of the follow-up period: 361 had hypertension diagnosed, 290 had either white-coat hypertension, prehypertension, or elevated blood pressure diagnosed, and 89 had normal blood pressure. By the end of the follow-up period, 293 patients (28%) had not been classified and remained at risk for undiagnosed hypertension. CONCLUSIONS: Our technology-based innovation identified a large number of patients at risk for undiagnosed hypertension and successfully classified the majority, including many with hypertension. This innovation has been implemented as an ongoing quality improvement initiative in our medical group and continues to improve the accuracy of diagnosis of hypertension among primary care patients.

Demonstration of the weighted-incidence syndromic combination antibiogram: an empiric prescribing decision aid.

OBJECTIVE: Healthcare providers need a better empiric antibiotic prescribing aid than the traditional antibiogram, which supplies no information on the relative frequency of organisms recovered in a given infection and which is uninformative in situations where multiple antimicrobials are used or multiple organisms are anticipated. We aimed to develop and demonstrate a novel empiric prescribing decision aid. DESIGN/SETTING: This is a demonstration involving more than 9,000 unique encounters for abdominal-biliary infection (ABI) and urinary tract infection (UTI) to a large healthcare system with a fully integrated electronic health record (EHR). METHODS: We developed a novel method of displaying microbiology data called the weighted-incidence syndromic combination antibiogram (WISCA) for 2 clinical syndromes, ABI and UTI. The WISCA combines simple diagnosis and microbiology data from the EHR to (1) classify patients by syndrome and (2) determine, for each patient with a given syndrome, whether a given regimen (1 or more agents) would have covered all the organisms recovered for their infection. This allows data to be presented such that clinicians can see the probability that a particular regimen will cover a particular infection rather than the probability that a single drug will cover a single organism. RESULTS: There were 997 encounters for ABI and 8,232 for UTI. A WISCA was created for each syndrome and compared with a traditional antibiogram for the same period. CONCLUSIONS: Novel approaches to data compilation and display can overcome limitations to the utility of the traditional antibiogram in helping providers choose empiric antibiotics.

Role of the extended alpha4 domain of Staphylococcus aureus gyrase A protein in determining low sensitivity to quinolones.

Fluoroquinolones target two bacterial type II topoisomerases, DNA gyrase and topoisomerase IV. Acquired resistance to quinolones occurs stepwise, with the first mutation occurring in the more sensitive target enzyme. To limit the emergence of resistance, quinolones should ideally possess dual activities against the two enzymes. For reasons that are as yet unclear, Staphylococcus aureus gyrase is less sensitive to quinolones than topoisomerase IV, counter to its greater sensitivity in Escherichia coli, thereby limiting the use of quinolones for the treatment of staphylococcal infections. Mutations in the alpha4-helix domain of the GyrA subunit of gyrase are important in determining quinolone resistance. We replaced an extended region encompassing the alpha4 domain in the E. coli GyrA protein with its homolog in S. aureus and tested for its ability to complement a thermosensitive gyrase and its catalytic and noncatalytic properties. Purified gyrase reconstituted with chimeric GyrA was more resistant to ciprofloxacin than wild-type gyrase at both inhibition of catalytic activity and stimulation of cleavage complexes, and this difference was more apparent in the presence of K+-glutamate. The chimeric GyrA subunit was able to complement thermosensitive gyrase, similar to wild-type GyrA. Without supplemental K+-glutamate the MICs of ciprofloxacin for thermosensitive E. coli complemented with chimeric DNA gyrase were equal to those for E. coli complemented with wild-type gyrase but were twofold higher in the presence of K+-glutamate. Our findings suggest that the extended alpha4 domain of S. aureus GyrA is responsible, at least in part, for the increased resistance of S. aureus gyrase to quinolones and that this effect is modulated by K+-glutamate.